Orchards Of East Liverpool, The

Based on observation, record review and interview the facility failed to ensure Resident #11 received medication/treatment only while necessary by failing to discontinue an antibiotic medication cream after an area to the resident's back was healed. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/25/21 with diagnoses including Parkinson's disease, dysphagia and scoliosis. Review of the physician's orders revealed an order, dated 05/18/22 for Silvadene cream 1% silver (antibiotic cream) to affected areas topically every shift for purpura with drainage. Review of the Medication Administration Record and Treatment Administration Record from 05/18/22 to 11/22/22 revealed Resident #11 received this cream twice daily. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #11 had severe cognitive impairment with memory problems. The assessment revealed the resident required extensive two-person physical assistance…

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, facility policy review and interview the facility failed to ensure as needed (PRN) anti-anxiety medication (Xanax) ordered for Resident #33 was not ordered longer than 14 days, had a specific duration for use and stop date. The facility also failed to ensure an appropriate indication for use of the anti-psychotic medication (Seroquel) for Resident #26. This affected two residents (#26 and #33) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of Resident #33's physician's orders revealed an order, dated [DATE] for the anti-anxiety medication, Xanax 0.5 mg (milligrams) by mouth every twelve hours as needed for behaviors. Record review revealed the medication was discontinued on [DATE] Review of Resident #33's physician progress note, dated…

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, record review, facility policy review and interview the facility failed to ensure Resident #32's Levemir long-acting insulin was discarded once expired. This affected one resident (#32) of one resident identified during the medication storage review who had insulin stored in the medication storage cart on the East Wing. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type one diabetes, muscle weakness and need for assistance with personal care. Review of Resident #32's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #32's physician's orders revealed an order, dated [DATE] and discontinued [DATE] for Levemir (long acting insulin) inject 20 units subcutaneously at bedtime related to diabetes. Review of Resident #32's physician's orders revealed an order, dated [DATE] to inject Levemir 18 units subcutaneously at…

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, interview, and record review the facility failed to ensure medication was stored, labeled and disposed to meet professional standards. This had to the potential to affect all the residents at the facility. The facility's census was 45. Findings Include: Observation on [DATE] from 2:28 P.M. to 2:52 P.M. of the facility medication storage rooms, medication cart and refrigerator revealed, an open stock bottle of Calcium with vitamin D with an expiration date of 09/2019 in the medication room, an open bottle of eye drops being stored with an open bottle of ear drops, open nasal sprays being stored in the same bin as open eye drops in the top drawer of the medication cart, and an open undated vial of tuberculin that was dispensed on [DATE] in the medication refrigerator. Interview on [DATE] at 2:52 P.M. with Licensed Practical Nurse #400 confirmed the facility failed to remove the expired bottle of calcium, failed to store eye, ear, and nasal medication separately, and failed to label a vial 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.

Based on review of survey findings and staff interview, the facility failed to ensure corrective plans were initiated and/or comprehensively evaluated in regard to identified concerns. This had the potential to affect all 45 residents. Findings include: During the survey, deficient practices were identified regarding inconsistencies in code status records, pressure ulcer assessments and care, falls, and use of psychotropic medications. On 11/14/19 at 5:40 P.M., Registered Nurse (RN) #120 stated a concern was identified in a sister facility regarding advance directives not matching so an audit was completed at this facility and no issues were identified. RN #120 stated the facility had identified concerns with pressure ulcers in October 2019. The facility instituted weekly visits by a wound care nurse. Nurses were educated on how to complete and accurately document skin assessments. Continuing education regarding pressure ulcers was planned for nurses upon hire and annually. On 10/01/19, the Quality Assurance (QA) committee identified concerns with falls and addressed the concerns.…

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, record review, review of infection control monthly tracking sheets and interview, the facility failed to ensure accuracy and completeness of the logs and failed to monitor infections on an ongoing basis in order to identify patterns or trends in a timely manner. The facility also failed to implement appropriate infection control practices during cleaning of glucometers and during provision of incontinence care. This had the potential to affect all 45 residents and affected Residents #14, #19, and #242. Findings include: 1. On 11/13/19 at 11:27 A.M., infection control logs were reviewed with Registered Nurse (RN) #120. RN #120 stated the October 2019 surveillance logs had not been completed as she did not usually start the logs until the beginning of the following month. RN #120 verified the September 2019 log indicated Resident #19 had a urine sample 09/19/19 which tested positive for extended spectrum beta lactamase (ESBL), escherichia coli, and proteus mirabilis. The log indicated…

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, interview and record review the facility failed to implement the bowel protocol for Resident's #3, #8, #18 and #27 and failed to comprehensively assess a non-pressure skin area for Resident's #32 and #8. This affected four of five residents reviewed for unnecessary medications and two of two residents reviewed for non-pressure skin areas. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included constipation and Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 01/13/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff including toileting. Review of the bowel movement (BM) report revealed the resident had a BM in the morning of 09/20/19. Further review revealed the resident did not have another BM until the afternoon of 09/24/19. Review of the medication administration record (MAR) for September 2019…

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 observation and interview, the facility failed to ensure the facility building was maintained. This had the potential to affect all the residents in the facility. The facility census was 45. Findings include: Observation on 11/14/19 at 9:05 A.M. with Maintenance Assistant (MA) #143 revealed the following: - the facility's shower room had eight two inch x two inch holes in the wall and one large hole, several feet long and six inches wide, from where a bath tub was removed in 2014; - the shower room mortar board, located on the wall to the right of the toilet, was separated from the wall from the floor up approximately 12 inches; - the heater in the bathroom had paint peeling away and visible rust; - Resident #32's room, the wall to the right side of the door had a moderate amount of paint missing with varies gouges approximately three feet in length; - Resident #14's light above her bed had not been in working order for some time according to the resident and since observation on 11/12/19, the light would not turn on; - Resident #28's room revealed rust above the door frame…

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 observation, record review, and interview, the facility failed to ensure an Advanced Directive was clearly and accurately represented on a resident's medical record. This affected one resident (Resident #28) of one resident reviewed for Advanced Directives. Findings include: Review of Resident #28's medical record revealed an admission date of 01/06/19 with diagnoses that included, chronic atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease. Review of physician's orders revealed a 02/04/19 order for a code status Do Not Resuscitate-Comfort Care (DNR-CC). Review of Resident #28's medical record revealed a Do Not Resuscitate Comfort Care-Arrest (DNR-CCA). An Advanced Directive that was signed by the physician on 01/03/19. Observation on 11/12/19 at 5:39 P.M. of Resident #28's room revealed a red sticker outside of her door, on her name plate. There were no markings on the red sticker. Review of the facility policy, Code Status Determination, dated 08/2019 stated, to assist with quick identification for timely interventions, the facility…

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, interview and record review the facility failed to ensure the physician was notified with a change in condition for Resident #8's bruising and Resident #39's development of a pressure ulcer. This affected two of 12 residents (Residents #8 and #39) reviewed for notification of change. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on on 10/10/19 with diagnoses which included fractured hip status post repair, multiple pressure ulcers and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the nurse practitioner wound care assessment dated [DATE] revealed the resident had an Stage II pressure ulcer to the left inner thigh, an unstageable pressure ulcer to the left heel and an unstageable pressure ulcer to the coccyx. Further review of the 10/29/19 nurse practitioner wound care assessment revealed the above areas were healed and after 10/04/19 the heel was to be left open to air. There were…

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 interview and record review the facility failed to implement the abuse policy when Resident #8, who was cognitively impaired, was found to have injuries of unknown origin (IUO). This affected one of one residents reviewed for abuse (Resident #8). Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated…

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 interview and record review the facility failed to report injuries of unknown origin (IUO) obtained by Resident #8, who was cognitively impaired, to the state agency as required. This affected one of one residents reviewed for abuse. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated 07/14/19…

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, interview and record review the facility failed to ensure Resident #8's injuries of unknown origin (IUO) were thoroughly investigated. This affected one of one residents reviewed for abuse. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated 07/14/19 revealed the resident was found 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to ensure nail and oral care were provided to a dependent resident. This affected one (Resident #191) of one resident reviewed for activities of daily living. Findings include: Review of Resident #191's medical record revealed the resident was admitted [DATE] with diagnoses including fractured left femur, severe protein calorie malnutrition, muscle wasting and atrophy, end stage renal disease with dialysis, and anemia. A comprehensive assessment was not due. Review of a 11/11/19 at 10:37 P.M. nurse note revealed the resident was having difficulty sucking from straw as well as difficulty swallowing, coughing on thin liquids and very weak. Observation 11/12/19 at 3:05 P.M. revealed the resident was in bed on his back, his nailbeds were dark with debris bilaterally. The resident's lips were dry and cracked. Resident #191's tongue was dry. His head was leaning against the side rail of the bed. He was unshaven. There was a water pitcher with…

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, interview and record review revealed the facility failed to ensure Resident #39's multiple pressure areas were comprehensively assessed with ongoing tracking to ensure interventions were in place to prevent re-occurrence of the pressure area specifically the left heel. This affected two of two residents reviewed for pressure ulcers (Residents #39 and #191). Findings include: 1. Record review revealed Resident #39 was admitted to the facility on on 10/10/19 with diagnoses which included fractured hip status post repair, multiple pressure ulcers and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the nursing data collection tool dated 10/11/19 revealed the resident was admitted to the facility without any pressure areas. Review of the nursing note dated 10/11/19 revealed the resident was sent to the hospital, was admitted for dehydration and urinary tract infection and returned to the facility on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #91 was properly assessed and had proper interventions in place when the resident was determined to be at risk for falls. After the resident sustained falls the facility failed to implement further interventions in an attempt to prevent the resident from further falls and injuries. This affected one of two residents reviewed for falls. Findings include: Record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included a history of falls and malnutrition. Review of the current fall care plan, initiated 11/05/19 revealed the resident was at risk for falls due to weakness and otitis media. The goal was to decrease the risk for falls. Interventions included to anticipate and meet the resident's needs, encourage the resident to use her call light for assistance, ensure the resident was wearing the appropriate footwear and have physical therapy evaluate and treat as needed. There had been 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 observation, interview and record review the facility failed to ensure a comprehensive nutritional plan was in place including accurate weights, monitoring/offering supplements and ensuring the resident's meal consumption was optimal for Resident #39, who sustained severe weight loss and developed multiple pressure ulcers. This affected one of three residents revealed for nutrition. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included fractured hip status post repair, dehydration and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the resident's weight on 10/11/19 was 242 pounds which was not determined to be an error until 10/16/19. Review of the 10/11/19 nutritional data collection tool form revealed there was no evidence the resident was interviewed but the liquid nutritional supplement, Ensure, was to be started (there was no documented evidence the Ensure was…

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 interview, the facility failed to maintain a record of fluid intakes for a resident receiving dialysis who had orders for fluid restriction. This affected one (Resident #36) of one resident reviewed for dialysis. The facility identified three residents as receiving dialysis. Findings include: Review of Resident #36's medical record revealed an initial admission date of 09/26/19. Diagnoses included end stage renal disease, cardiomegaly, heart failure, and chronic pulmonary edema. A physician's order was written 10/04/19 indicating a 1000 milliliter (ml) fluid restriction according to the power of attorney (POA). Notify dialysis if resident intake was greater than 1000 ml in 24 hours. A five day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was severely cognitively impaired. A nursing note dated 10/17/19 at 12:10 P.M. indicated a state tested nursing assistant (STNA) reported she observed the speech therapist provide Resident #36 with several cups 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 2. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, dementia with behaviors and brief psychotic disorder which was diagnoses on 02/04/18. Review of the quarterly minimum data set (MDS) 3.0 dated 01/13/19 revealed the resident was severely cognitively impaired. The resident had no concerns with mood or behaviors and the resident needed extensive assistance of one to two staff for activities of daily living (ADL). Review of the nursing note dated 05/03/19 revealed the resident was exit seeking. There was no evidence of non-pharmalogical interventions. Review of the nursing note dated 05/04/19 revealed the resident was rocking back and forth in her chair and was spitting out half chewed food. Review of the 05/06/19 psychiatric nurse practitioner (PNP) note revealed the resident was on Buspar, an anti-anxiety (AA) medication at five milligrams (mg) twice a day, Remeron, an anti-depressant (AD) medication at 15 mg at night and Dispersal, 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 observation, record review and interview, the facility failed to ensure an accurate resident medical record. This affected two of 17 records reviewed (Residents #32 and #191). Findings include: 1. Review of Resident #191's medical record revealed the resident was admitted [DATE] with diagnoses including fractured left femur, severe protein calorie malnutrition, muscle wasting and atrophy, end stage renal disease with dialysis, and anemia. Review of the admission Data Collection Tool included a Sacral pressure ulcer 0.75 cm x 0.75 cm x 0.2 cm and a left buttock pressure ulcer 2.0 cm x 2.0 cm x 0.1 cm both listed Stage 1. The pressure ulcers were inaccurately Staged I when they had a depth, indicating the skin was broken. The Weekly Skin Integrity Review for 10/29/19 stated Sacral wound, 0.75 cm x 0.75 cm depth none and a left buttock 2.0 cm x 2.0 cm depth none with no other description. A 11/05/19 at 1:41 P.M. nurses note included the State Tested Nurse Aide (STNA) reports that resident now has an opened…

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 observation and interview the facility failed to ensure wheelchairs were maintained in good condition. This affected two (Resident's #21 and #36) out of 16 residents in the initial pool. The facility's census was 45. Findings include: Observation on 11/12/19 at 9:30 A.M. revealed Resident #21's armrest on his wheelchair had a large rip. Observation on 11/14/19 at 9:05 A.M. with Maintenance Assistant (MA) #143 of the facility revealed the following; The arm rest of Resident # 21 wheelchair had a six-inch tear exposing the foam and various cracked plastic on the front half of the arm rest. Resident #36's wheelchair cushion was ripped; the inside of the cushion was visible and approximately one third of the surface material was off the cushion. Interview on 11/14/19 at the time of the observations with MA #143 confirmed that the arm rest on Resident #21 wheelchair had a six-inch chair exposing the foam, and Resident #36 wheelchair cushion was ripped with the inside of the cushion exposed.