Siena Woods Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, policy review and records reviews, the facility failed to ensure the residents received their adaptive feeding equipment with meals as physician ordered. This affected three (#10, #57, and #79) of three residents reviewed for adaptive equipment. The facility census was 91. Findings include: 1. Record review for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atherosclerosis, diabetes, dementia, and osteoarthritis left shoulder and unspecified pain. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #79 had intact cognition and required set up assistance for feeding. Review of the physician orders revealed Resident #79 was to receive a two handled cup with spout lid for liquids.Review of the meal ticket for Resident #79 revealed the resident should have received a two handled cup with a spouted lid.Observation and interview on 02/11/26 at 1:30 P.M. revealed Resident #79 received a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, policy review, review of Centers for Disease Control and Prevention (CDC) guidance, and record review, the facility failed to ensure staff were following Enhanced Barrier Precautions (EBP) for high contact care activities with the residents. This affected three (#65, #77, and #84) of three residents reviewed for EBP precautions. The facility census was 91.Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 09/06/23. Diagnoses included multiple sclerosis, stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.), morbid obesity, and open wound to left lower leg. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. Review of the physician orders dated 06/02/25 revealed EBP were ordered for Resident #65 related to colostomy and wound care. Personal Protective Equipment (PPE) was to be worn during high contact care activities with a start date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a thorough assessment of a pressure ulcer was completed upon discovery. This affected one (#25) of three residents reviewed for wounds. The facility census was 82. Findings include: Review of the medical record for Resident #25 revealed an admission date of 06/27/24 with diagnoses of dysphagia, oropharyngeal phase, chronic obstructive pulmonary disease, chronic venous hypertension (idiopathic) with ulcer of the bilateral lower extremity, peripheral vascular disease, and acquired absence of the left leg below the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and required supervision assistance with eating, partial assistance with oral hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and bed mobility. Review of Resident #25's physician order dated 02/03/25 revealed an order to reduce pressure to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure medications were secured in a safe manner. This affected one (#33) of three residents reviewed for medications. The facility census was 82. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/26/16 with diagnoses of chronic obstructive pulmonary disease, schizoaffective disorder, anemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment. Resident #33 was independent with oral hygiene, toileting hygiene, dressing, bed mobility, and ambulation. Resident #33 required set-up assistance with eating, bathing, and personal hygiene, and required supervision assistance with transfers. Review of the care plan dated 08/11/22 revealed Resident #33 had impaired cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents received food in a form to meet individual needs. This affected one (#101) of three residents reviewed for dietary status. The facility census was 82. Findings include: Review of Resident #101's medical record revealed an admission date of 02/13/25 with diagnoses of acute respiratory failure with hypoxia, aphasia, morbid (severe) obesity due to excess calories, and type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was assessed with severe cognitive impairment. Resident #101 was dependent on staff assistance for all activities of daily living (ADLs). Resident had a percutaneous endoscopic gastrostomy (PEG) feeding tube and was not on a mechanically altered or therapeutic diet. Review of Resident #101's admission orders dated 02/13/25 revealed no dietary order was noted. Review of Resident #101's physician order dated 02/13/25 revealed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and review of the Influenza Vaccine Report, the facility failed to offer the annual influenza vaccines to residents. This affected three (#47, #14 and #39) out of three residents reviewed for influenza vaccines and had the potential to affected 80 out of 82 residents residing in the facility, the facility identified two (#16 and #79) residents who were not eligible for the influenza vaccine. The facility census was 82. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, spondylosis without myelopathy or radiculopathy, lumbosacral region, and unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #47's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to ensure medications were administered as physician ordered. This affected four (#47, #66, #80, and #91) out of four residents reviewed for medication administration. Facility census was 93. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 12/23/22 with diagnoses of seizures, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and chronic kidney disease, stage 3 unspecified. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #47 with severe cognitive impairment. Resident #47 required partial assistance with eating and oral hygiene. Resident # 47 required substantial assistance with toileting hygiene, bathing, dressing, bed mobility, and wheelchair mobility. Review of the September 2024 Medication Administration Record (MAR): Levothyroxine Sodium Oral Capsule 25 micrograms (MCG)-give 25 mcg by mouth one time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and policy review, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#08) of three residents reviewed for wound care and treatment. The facility census was 81. Findings include: Review of the medical record for Resident #08 revealed an admission date of 05/04/24 with medical diagnoses of moderate protein calorie malnutrition, diabetes mellitus with neuropathy, hypertension, anxiety, and chronic kidney disease. Review of the medical record for Resident #08 revealed a significant change Minimum Data Set (MDS) assessment, dated 09/06/24, which indicated Resident #08 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. The MDS assessment indicated Resident #08 had a stage four pressure ulcer (full-thickness skin and tissue loss) that was not present upon admission. Review of a wound observation assessment, dated 05/30/24, revealed Resident #08 had an unstageable pressure ulcer (obscured full-thickness skin and tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy, the facility failed to provide timely incontinence care. This affected one (#53) of three residents reviewed for incontinence care. The facility census was 81. Findings Included: Review of medical record for Resident #53 revealed an admission date 11/02/23. Diagnosis included dementia, psychotic mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was severely cognitively impaired, required partial to moderate assistance for meals, and substantial to maximal assistance for personal hygiene and oral hygiene. Resident #53 was dependent for transfers, bathing, toileting, dressing upper and lower body, and placing shoes on and off. Review of the plan of care dated 08/08/24 revealed Resident #53 was at risk for alteration in elimination due to incontinence. Interventions included to assist with toileting needs daily, keep the call light within reach during toileting, provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control precautions when providing wound care. This affected one (#53) of three residents reviewed for wound care. The facility census was 81. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/02/23 with medical diagnoses of dementia, chronic obstructive pulmonary disease, severe protein calorie malnutrition, and hypertension. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, which indicated Resident #53 had severe cognitive impairment and required partial to moderate staff assistance with meals and was dependent upon staff for transfers, bathing, toileting, and dressing. The MDS assessment indicated Resident #53 was always incontinent of bladder and bowel and Resident #53 had two stage four pressure ulcers (full-thickness skin and tissue loss). Review of Resident #53's medical record revealed a physician order dated 11/03/23 for enhanced barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observations, staff and family interviews, and review of facility policy, the facility failed to provide podiatry services to a resident. This affected one (#70) of three reviewed for activities of daily living (ADL's). The census was 79. Findings include: Review of Resident #70's medical record revealed an admission dated of 07/29/22. Diagnoses listed included type two diabetes mellitus, stage three chronic kidney disease, anxiety disorder, major depressive disorder, psychotic disturbance, and macular degeneration. Review of a quarterly Minimum Data Set (MDS) assessment dated revealed staff has assessed Resident #70 as being severely cognitively impaired. Review of a plan of care dated revised 10/23/23 revealed Resident #70 needed assistance with ADL self-performance care due to confusion, dementia, and visual disturbance. Resident #70 was dependent for personal hygiene. Further review of Resident #70's medical record revealed a physician order dated 05/13/21 for may see podiatrist, dentist, audiologist, and ophthalmologist. Review of facility forms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview and policy review, the facility failed to monitor the water supply to ensure the water could not be contaminated with the Legionella bacterium. This had the potential to affect all 92 residents in the facility. Findings include: Review of the Legionella documentation provided by the facility revealed it contained no documentation related to the Centers for Disease Control (CDC) toolkit, completion of a water risk assessment or completion of any water flow diagrams. Interview on 11/14/19 at 1:45 P.M. with Maintenance Supervisor #112 confirmed the facility does not have a water flow diagram, did not complete the CDC toolkit or complete a water risk assessment. Review of the facility policy titled Legionnaires' Disease: Detection, Response, Prevention Policy, undated, revealed the facility will utilize sound clinical and infection control practices to quickly identify and treat any potential Legionnaires' related illnesses. Sound engineering, preventive maintenance and housekeeping practices will be utilized to minimize the risk of exposing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview; the facility failed to ensure advanced directives being stored in the hard chart and electronic health record (EHR) were consistent. This affected three (#26, #40, and #49) of 25 residents reviewed for consistency of advanced directives. The census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. Review of the hard chart for Resident #26 revealed a do not resuscitate (DNR) form dated 06/17/17, which identified the residents code status was DNR comfort care (CC) arrest (A). Review of the EHR for Resident #26 revealed the resident's code status was DNR. 2. Review of the medical record of Resident #40 revealed the resident was admitted to the facility on [DATE]. Review of the hard chart for Resident #40 revealed a DNR form dated 12/06/17,which identified the residents code status was DNR CC A. Review of the EHR for Resident #40 revealed the residents code status was DNR. 3. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately to reflect the resident's current status. This affected four (Residents #3, #53, #58 and #71) of 22 resident MDS reviews completed. The facility census was 92. Findings include: 1. Record review for Resident #71 revealed an admission date of 10/09/19. Review of the admission MDS assessment, dated 10/16/19, documented the resident was receiving an anticoagulant medication. Her oral assessment stated she had obvious or likely cavities or broken natural teeth. Review of the Medication Administration Record (MAR) and physician orders for October 2019 revealed the resident was receiving an anti-platelet medication, Plavix, not an anti-coagulant. On 11/12/19 at 11:08 A.M. interview with Resident #71 verified she did not have any teeth and had a full set of dentures observed on her bedside table. 2. Record review for Resident #53 revealed an admission date of 10/24/19. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based record review and staff interview, the facility failed to ensure a Preadmission Screen and Resident Review (PASARR) was accurate upon admission to the facility. This affected one (Resident #71) of three residents reviewed for PASARR assessments. The facility census was 92. Findings include: Review of the medical record for Resident #71 revealed an admission date of 10/09/19 with diagnoses including major depression, anxiety and bipolar disorder. Review of PASARR dated 09/19/19 documented the resident had a diagnosis of dementia and no current diagnoses of mental health disorders or psychiatric services received in the past two years. Review of admission Minimum Data Set (MDS) assessment, dated 10/16/19, documented the resident did not have any indications of serious mental illness. She was cognitively intact and had no active diagnosis of dementia. On 11/12/19 at 11:08 A.M. interview with Resident #71 revealed she does not have a diagnosis of dementia and she received psychiatric service prior to admission to the facility by a physiatrist and a therapist. On 11/13/19 at 2:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview and policy review, the facility failed to ensure laboratory tests were completed as ordered per the physician. This affected one (Resident #34) of one resident reviewed for dialysis. The facility census was 92. Findings include: Review of medical record for Resident #34 revealed an admission date of 08/03/19 with diagnoses including sepsis, cerebral infarction, aphasia, dysphasia, muscle weakness, abnormal posture, anemia in chronic kidney disease, diabetes type two, need for assistance with personal care, vascular dementia, hypertension, hyperlipidemia, pressure ulcer of the sacral region, end stage renal disease (ESRD), dependence on renal dialysis. Review of physician order dated 08/04/19 documented an order for dialysis treatments every Tuesday, Thursday and Saturday. Review of comprehensive care plan documented Resident #34 has an alteration in kidney function related to ESRD. The goal was to keep lab values within therapeutic range with intervention of the resident's specific dialysis schedule of a chair time of 7:30 A.M. on every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure the physcian addressed pharmacy recommendations. This affected one Resident (#3) of five residents reviewed for unnecessary medications. The census was 92. Findings include: Record review revealed Resident #3 was admitted on [DATE]. Review Resident #3's electronic medical record review revealed pharmacy reviews were completed on 08/20/19, 09/16/19, and 10/02/19. The reviews contained no documentation of what the pharmacist was recommending, just that a review was done. Transition Nurse Specialist (TNS) #130 presented copies of pharmacy recommendations dated 08/20/19, 09/16/19, and 10/02/19 on 11/14/19 at 3:50 P.M. that had been sent form the consultant pharmacy. Review of these pharmacy recommendations revealed on 08/20/19 pharmacy had recommended aspirin be discontinued due to an allergy. On 09/16/19 pharmacy recommended Prozac (anti-depressant) be addressed for an improper diagnosis of insomnia. On 10/0219 pharmacy recommended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to monitor a resident's weights as ordered by the physician. This affected one (Resident #24) of five residents reviewed for unnecessary medications. The facility census was 92. Findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of hypertension and stage three chronic kidney disease. Review of a care plan, dated 10/23/18, revealed the resident had impaired cardiovascular status related to the diagnosis of hypertension. The goal was for the resident to be free of symptoms and not have a decline in function related to cardiac condition. Interventions included: daily weights as ordered, notify physician of a two-pound weight gain in one day or five-pound weight gain in three days. Observe and report signs of hypertension such as headaches, flushing, fatigue, blurred vision, shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, dated 08/09/19, revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and review of Medscape (online medical resource), the facility failed to ensure an appropriate diagnosis for use of an anti-psychotic medication. This affected one (Resident #58) of five residents reviewed for unnecessary medications. The census was 92. Findings include: Review of Resident #58's medical record revealed an admission date of 02/25/19. Diagnoses included major depressive disorder, dementia without behavioral disturbance , Alzheimer's disease, generalized anxiety disorder, and cognitive communication deficit. Review of physician orders revealed an order dated 02/25/19 for Zyprexa, anti-psychotic medication, five milligrams (mg) by mouth daily. The diagnoses listed for the use of the medication was depression. Noted with the order was a request for a supporting diagnosis for use of the medication or recommendation for discontinuation of the medication. Review of medication administration records from 02/15/19 through 11/13/19 revealed Resident #58 had received Zyprexa daily since admission. During an interview on 11/13/19 at 3:29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that after an inadequate blood sample was obtained for a laboratory test, a second blood draw was completed timely. This affected one (Resident #34) of one resident reviewed for dialysis. The facility census was 92. Findings include: Review of medical record for Resident #34 revealed an admission date of 08/03/19 with diagnoses including sepsis, cerebral infarction, aphasia, dysphasia, muscle weakness, abnormal posture, anemia in chronic kidney disease, diabetes type two, need for assistance with personal care, vascular dementia, hypertension, hyperlipidemia, pressure ulcer of the sacral region, end stage renal disease (ESRD), dependence on renal dialysis. Review of laboratory report dated Saturday, 11/02/19 revealed a laboratory blood test was not completed as the phlebotomist unable to obtain an adequate blood sample. The laboratory was to send another phlebotomist out to draw the blood again. Review of the physcian orders revealed no order for the laboratory test. Review of the nursing notes revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and interview, the facility failed to provided dental services in a timely manner. This affected one (Resident #66) of three resident reviewed for dental services. The census was 92. Findings include: Review of the medical record for Resident #66 revealed the resident was admitted to the facility on [DATE]. Review of a dental consult progress note dated 05/17/19 revealed the resident's lower teeth were all decayed. Documentation revealed the resident refused extraction at this time. Review of the care plan updated 05/20/19, revealed Resident #66 was at risk for dental problems related to natural teeth. Documentation revealed the resident complained of mouth pain, was seen by a dentist but refused to have decayed lower teeth extracted. Interventions include refer to dental services as needed. Review of a general progress note dated 09/17/19 at 1:01 P.M., documented by social services, revealed Resident #66 reported complaints of his teeth hurting. The resident was in agreement to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.