Parkside Nursing And Rehabilitation Center

Based on medical record review, observation, and staff interview, the facility failed to identify and initiate prompt treatment for non-pressure wounds. This affected one (Resident #5) of one resident reviewed for skin conditions. The facility census was 67 residents. Findings include:Review of the medical record for Resident #5 revealed an admission date of 12/20/24 with diagnoses including hypoxic ischemic encephalopathy, cerebral infarction, congestive heart failure (CHF), schizoaffective disorder, and hidradenitis suppurativa. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 04/15/25 revealed the resident had impaired cognition and was dependent on staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #5 dated 07/14/25 at 1:50 P.M. revealed the nurse identified blood on the resident pillow and an open wound behind the resident's right ear. The nurse applied A&D ointment to the area.Review of the progress notes for Resident #5 dated 07/23/25 at 11:39 A.M. revealed there was an open area behind the resident's right…

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, resident interview, staff interview, and review the facility policy, the failed to appropriately assess and treat resident pain. This affected one (Resident #62) of three residents reviewed for pain management. The facility census was 67 residents Findings include:Review of the medical record for Resident #62 revealed an admission date of on 5/29/25 with diagnoses including traumatic subdural hemorrhage, cerebral infarction, heart failure, and spinal stenosis. Resident #62 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE].Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 7/09/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.)Review of the Medication Administration Record (MAR) for Resident #62 dated July 2025 for Resident #62 revealed there was an order for oxycodone 5 milligrams (mg) every six hours with a start date of 07/02/25 and a stop 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.

Based on medical record review, observation, staff interview, review of manufacturer's guidelines, and review of the facility policy, the facility failed to ensure insulin pens were properly labeled and stored. This affected two (Residents #15 and #65) of four residents who received insulin stored in the 200-medication cart. The facility census was 67 residents. Findings include:1. Review of the medical record for Resident #15 revealed an admission date of 1/07/24 with diagnoses of diabetes mellitus type and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 05/16/25 revealed the resident had severe cognitive impairment and was dependent on staff for assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #15 revealed an order dated 07/02/25 for insulin Glargine inject seven units subcutaneously at bedtime for diabetes mellitus. Observation on 07/23/25 at 9:21 A.M. of the 200-hall medication cart with Licensed Practical Nurse #66 revealed Resident #15's insulin Glargine…

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, resident interview, and staff interview, the facility failed to provide residents with food that was appealing and palatable. This affected Resident #26 and#62 and had the potential to affect all residents at the facility. The facility identified ten (Residents #1, #5, #15, #16, #35, #38, #46, #53, #64, #84) who did not receive food from the kitchen. The facility census was 67 residents. Findings include: 1.Review of the medical record for Resident #26 revealed an admission date of 12/18/24 with diagnoses including chronic atrial fibrillation, major depressive disorder, hypothyroidism, vascular dementia, heart failure, anorexia. Review of the Minimum Data Set (MDS) assessment for Resident #26 dated 06/27/25 revealed the resident had impaired cognition and required set up assistance from staff with her meals. Review of the physician's orders for Resident #26 revealed an order dated 01/09/25 for a regular diet, mechanical soft texture.Observation on 07/23/25 at 12:30 P.M. revealed Resident #26 was propped up in her bed and her meal was in 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.

Based on observation, staff interview, and review of the facility policy, the facility failed to provide privacy curtains in resident rooms. This affected four (Residents #26, #28, #59, #62) four residents reviewed for privacy. The facility census was 67 residents.Findings include: Observation on 07/24/25 at 8:42 A.M. with Assistant Director of Nursing (ADON) #56 revealed there were no privacy curtains in the rooms of Residents #26, #28, #59, and #62.Interview 07/24/25 at 8:46 A.M. with ADON #56 confirmed the facility had not provided proper privacy curtains to ensure full visual privacy in the rooms of Residents #26, #28, #59, and #62.Review of the facility policy titled Resident Rights dated 06/01/24 revealed residents had the right to be treated with dignity and respect and had a right to privacy during personal care.

Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to provide an effective pest control program. This affected three (Residents #3, #26, #44) of three residents reviewed for pest control. The facility census was 67 residents.Findings include: 1.Review of the medical record for Resident #3 revealed an 04/30/24 with diagnoses including atherosclerotic heart disease, osteoarthritis, and asthma.Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 6/14/25 revealed the resident had impaired cognition.Observation on 07/21/25 at 11:04 A.M. revealed there were multiple large black flying insects in Resident #3's room. Interview on 07/21/25 at 11:19 A.M. with Unit Manager (UM) #140 confirmed there were multiple large black flying insects in Resident # 3's room.2. Review of the medical record for Resident #26 revealed an admission date of 12/18/24 with diagnoses including chronic atrial fibrillation, major depressive disorder, vascular dementia, and anorexia. Review of the MDS assessment for…

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 interviews, the facility failed to ensure all residents were treated with respect and dignity. This affected one (#77) out of three residents reviewed for respect and dignity. The facility census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on 01/12/24. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident #77 was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed…

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, review of facility self-reported incidents (SRI's), review of staff timesheets, staff interviews, and policy review, the facility failed to report an allegation of staff to resident abuse to the state surveying agency as required. This affected one (#77) out of three residents reviewed for abuse. The census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on 01/12/24. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident…

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, review of facility self-reported incidents (SRI's), review of staff timesheets, staff interviews, and policy review, the facility failed to conduct a thorough investigation following an allegation of staff to resident abuse. This affected one (#77) out of three residents reviewed for abuse. The census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on 01/12/24. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident #77…

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, staff interview, review of the facility policy, and review of medication information from Medscape (online resources), the facility failed to ensure a resident was free from unnecessary medications by failing to implement adequate blood sugar monitoring in conjunction with insulin administration. This affected one resident (#57) of three residents reviewed for diabetes management. The census was 73. Findings include: Review of the medical record for Resident #57 revealed an admission date of 03/03/22 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #57, revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two with activities of daily living (ADL's). Review of the care plan dated 03/03/22 for Resident #57, revealed the resident was at risk for hyper/hypoglycemia due to diagnosis of DM. Interventions included the following: administer medications as ordered, be alert for…

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, record review, and policy review, the facility failed to complete quarterly care conferences. This affected four residents (#07, #16, #43, and #57) out of 24 residents sampled for care conferences. The facility census was 73. Findings include: 1. Resident #57 admitted to the facility on [DATE], was readmitted [DATE], with diagnoses that included but were not limited to dependence on respirator, type II diabetes, chronic diastolic congestive heart failure, morbid obesity, unspecified anxiety disorder, major depressive disorder - single episode, and chronic respiratory failure with hypoxia. Review of the most recent annual Minimum Dat Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact, had no behaviors, did not wander, and frequently refused care. Resident #57 was a two-person assist and required extensive assistance with bed mobility, dressing, and personal hygiene, total assistance with transfers, toileting, and bathing, and was independent with eating and…

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 and staff interview the facility failed to fill out the Notice to Medicare Provider Non-coverage (NOMNC-form CMS-10123), for two residents (#70 and #373) out of three residents reviewed and complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for all three residents reviewed. This affected three residents (#68, #70, and #373) out of three residents reviewed for Beneficiary Notification. The facility census was 73. Findings include: 1. Review of the medical record for Resident #68 revealed an admission date of 05/18/22 and a discharge date of 06/02/22. Diagnoses included chronic respiratory failure, pneumonia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, Insomnia, chronic kidney disease, and constipation. Further review of the medical record for Resident #68 revealed a NOMNC was issued and signed by the resident with the appropriate time period. There was no SNFABN issued and presented to the resident. 2. Review of the medical record for Resident #70 revealed an admission date of 03/9/22 and a discharge 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 record review, interview, and policy review, the facility failed to complete a significant change pre-admission screening and resident review (PASARR) after identifying new mental health diagnoses. This affected one (Resident #33) of three residents reviewed for PASARR program. The facility census was 73. Findings include: Review of medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included hemiplegia/hemiparesis following cerebral infarction, unspecified seizures, and hypertensive heart disease without heart failure, and major depressive disorder. Additional diagnoses identified on 04/13/19 included unspecified anxiety and unspecified psychosis. Review of the most recent quarterly Minimum Data Set (MDS) assessment completed on 04/13/22 revealed Resident #33 was severely cognitively impaired, had physical and verbal behaviors, did not wander, and occasionally rejected care. Resident #33 was a two-person assist and required extensive assistance with bed mobility, total…

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, observations, and staff interview the facility failed to obtain treatment orders for Resident #02 and failed to continue medication orders for Resident #56. This affected two residents (#02 and #56) out of three residents reviewed for continuity of care. The facility census was 73. Findings included: 1. Review of medical record for Resident #02 revealed readmission date of 5/24/22 with a no cognitive deficits. The resident was admitted with diagnoses of chronic small [NAME] obstruction status post decompressive gastrostomy continue with decompression to gravity, rectal cancer, and type two diabetic. Review of Resident #02's care plan last updated on 11/22/21 revealed no instructions of taking care of the decompressive gastrostomy. Review of Resident #02's physician orders last updated on 5/24/22 revealed no care instructions for the decompressive gastrostomy. Review of the physician progress notes for 05/04/22, 05/07/22, 05/27/22, and 05/27/22 revealed no care instructions for 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 record review, interviews and policy and procedure review the facility failed to obtain weights for residents as per physician orders . This had the potential to affect three residents (#07, #42 and #58) out of three residents who were reviewed for possible weight loss. The facility census was 73. Findings include: 1. Review of medical record for Resident #42 revealed admission date of 12/03/21 with mild cognitive deficits . He was admitted with a diagnoses of arteriovenous fistula, repeated falls, diabetic and chronic kidney disease. A review of Resident #42 physician orders from 05/1/22 to 06/23/22 revealed on 05/22/22 an order for weights to be done for three days and then weekly on Sunday for three weeks. A review of Resident #42 weights for 04/01/22 to 06/30/22 revealed weights were not recorded on 05/23/22, 05/24/22, 05/25/22 or on Sunday 06/03/22. On 06/23/22 at 1:00 P.M. interview with the DON confirmed weights for Resident #42 were not done on 5/23/22, 5/24/22, 5/25/22 , or on Sunday 06/03/22.…

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 pass medications as ordered resulting in significant medication errors. This affected two residents (#56 and #71) out of three residents reviewed for medications. The facility census was 73. Findings included: 1. Review of the medical record for Resident #56 revealed an original admission date of 01/12/22. The resident had hospital stays from 01/13/22-01/20/22, 01/22/22-02/02/22, 02/11/22-02/15/22, and 06/07/22-06/09/22. Diagnoses included dependence on respirator, viral pneumonia, type 2 diabetes mellitus, muscle weakness, urinary tract infection, and schizoaffective disorder. Review of the quarterly minimum data set (MDS) assessment for Resident #56 dated 06/10/22 revealed the resident had an intact cognition. No hallucinations, delusions, or rejections of care were noted by the assessment. Resident #56 required total dependence from at least one staff member for hygiene, toileting, dressing, locomotion on/off unit, and transfers. The resident…

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, staff interview, and review of refrigerator rules, the facility failed to ensure food being held in a snack refrigerator used for residents were not past its specified expiration date. This had the potential to affect 49 of 54 residents who consumed food from the refrigerator. The facility identified five residents (#25, #10, #21, #13, and #15) who received nothing by mouth. Findings include: Review of the posting on the resident refrigerator in the Activity Room titled, Resident Refrigerator Rules revealed the refrigerator was for resident use only, staff items should not be stored inside; any items put in the refrigerator need to be labeled and dated with the resident's name and date; any food/drink item that is not labeled (name and date) or is more than 3 days old will be thrown away immediately. On 11/13/19 at 11:10 A.M. observation the resident snack refrigerator in the Activity Room with the Dietary Manager (#45) revealed the following spoiled and/or outdated food items: a) There was a 1/2 gallon plastic carton of chocolate milk which was visibly curdled…

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, and staff interview, the facility failed to provide feeding assistance in a manner that preserved a resident's dignity. This affected one (Resident #104) 24 observed during meal time. The facility census was 54. Findings include: Medical record review revealed Resident #104 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbance. Review of Minimum Data Set (MDS) assessment for Resident #104 dated 10/04/19 revealed was cognitively impaired and required supervision with eating. Observation of the lunch meal on 11/12/19 at 12:00 P.M. revealed Resident #104 was up in a chair in his room with the door open. He was being assisted with his lunch by State Tested Nursing Assistant (STNA) #65. STNA #65 remained standing through the entire lunch meal as she assisted Resident #104. Interview on 11/12/19 at 12:08 P.M. with Licensed Practical Nurse (LPN) #440 confirmed STNA #65 was standing over Resident #104 during the entire lunch meal…

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 review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete quarterly assessments for residents in a timely manner. This affected two (Residents #2 and #8) of 24 residents reviewed for assessments. The facility census was 54. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 09/19/17 with diagnosis of cerebral infarction (stroke). Review of the comprehensive Minimum Data Set (MDS) assessment revealed it was completed on 07/08/19. Review of the quarterly MDS for Resident #2 had been started with an assessment reference date of 10/08/19, however the MDS had not been completed, or submitted. 2. Review of the medical record for Resident #8 revealed an admission date of 08/02/18 with a diagnosis of hemiplegia following cerebral infarction. Review of the comprehensive MDS assessment revealed it was completed on 07/24/19. Review of the quarterly MDS assessment revealed it had been started on 10/24/19, however had not been completed or submitted. Interview on…

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 interview, and review of facility policy, the facility failed to ensure a resident with a gastrostomy tube (g-tube) had orders and treatments in place to potentially prevent complications related to the g-tube. This affected one (Resident #12) of one reviewed for tube feeding. The facility census was 54. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnosis of quadriplegia. Review of the care plan for Resident #12 dated 08/20/12 revealed the resident had a g-tube used for medication administration. Interventions included to flush the g-tube per physician's order, dressing change to the g-tube per physician's order, and to check placement of the g-tube per physician's order. Review of Minimum Data Set (MDS) assessment for Resident #12 dated 08/13/19 revealed resident was cognitively intact, was totally dependent on staff with activities of daily living, and had a g-tube. Review of November 2019 physician…

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 an as needed anti-anxiety medication order included a duration for the medication. This affected one (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/19/17 with a diagnosis of cerebral infarction (stroke). Review of Resident #2's physician order dated 06/14/19 revealed an order for Ativan (anti-anxiety) every four hours, as needed for shortness of breath and agitation. There was no stop date for the medication. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Interview on 11/13/19 at 4:37 P.M. with Registered Nurse (RN) #270 confirmed the as needed Ativan ordered for Resident #2 on 06/14/19 did not have a stop date or duration for the order. Interview with Physician #55 on 11/14/19 at 2:58 P.M. confirmed when he wrote the order for…

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, resident and staff interview, the facility failed to arrange for timely dental services for one resident (#22) of two reviewed for dental care. The facility census was 54. Findings include: Medical record review revealed Resident # 22 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, schizoaffective disorder, and history of respiratory failure. Review of Resident #22's nurse's note dated 08/30/19 at 3:47 P.M., revealed Resident #22 had been out to a Dental Clinic and returned with a molar removed. Resident #22 was scheduled to return to the clinic on 09/25/19 at 8:45 A.M., for a consultation. Review of Resident #22's nurse's note dated 09/25/19 revealed Resident #22 returned from the Dental Clinic with a plan to be scheduled for a surgery procedure. The Dental Clinic note revealed the clinic would call the facility no later than 10/02/19 to schedule the appointment. However, if they had not, the facilty should follow up with them to schedule 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.