Smiths Mill Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of facility policy, the facility failed to maintain a proper containment system for soiled personal protective equipment for a resident. This affected one (Resident #26) of five residents reviewed for infection control. The facility census was 49. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included severe sepsis with septic shock, recurrent enterocolitis due to clostridium difficile, and encounter for attention to colostomy. Review of the comprehensive Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #26 required substantial to maximal assistance from staff with toileting hygiene. Review of Resident #26's hospital record dated 04/15/26 revealed Resident #26 had clostridium toxin B detected, but not active infection, and she was a carrier of clostridium toxin. In response, Resident #26 was on oral vancomycin, an antibiotic. Review of Resident #26's care…

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, medical record review and interviews, the facility failed to ensure one resident who was dependent on staff for eating was provided a dignified dining experience when his meal tray was left for an extended period of time before staff returned to feed him. This affected one resident (#22) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #22 revealed an initial admission date of 02/06/25 with the diagnoses including but not limited to Guillain-Barre syndrome, dysphagia, retention of urine, diabetes mellitus, hyperlipidemia, hypertension and functional quadriplegia. Review of the plan of care dated 02/20/25 revealed the resident required staff dependence to complete self-care and mobility functional tasks completely and safely. Review of resident's functional abilities dated 02/10/26 revealed the resident was dependent on staff for eating. On 02/11/26 at 11:55 A.M., an interview/observation with Resident #22 revealed the resident's lunch tray was sitting untouched on the resident's bedside table. 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, open and closed medical record review, hospital record review, and interview, the facility failed to ensure physician ordered treatments were provided to non-pressure skin impairments. Additionally, the facility failed to identify a change in condition timely. This affected one resident (#19) of three residents reviewed for skin breakdown and one resident (#50) of three residents reviewed for change in condition. The facility census was 49. Findings Include:1. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign…

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, interview, hospital summary review, review of staffing schedules and facility policy review, the facility failed to provide adequate supervision and /or assistive devices to prevent falls and/or injury for those residents with a cognitive deficit. Additionally, the facility failed to ensure one resident was assisted in bed mobility in a manner to prevent falls from bed. This affected three residents (#19, #50 and #51) of three residents reviewed for falls. The facility census was 49. Findings Include:1. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and daily assignment sheet review, the facility failed to ensure sufficient levels of staffing to supervise to prevent falls. This affected one resident (#50) of three residents reviewed for falls. The facility census was 49. Findings Include:. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. Review of the fall risk assessment dated [DATE] revealed a score of 22 indicating the resident was at high risk for falls. Review of the plan of care dated 01/29/26…

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, interview and review of after care summary, the facility failed to ensure physician orders were implemented in a timely manner. This affected one resident (#19) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate cognitive deficit. Review of the resident's after visit summary dated 02/13/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to ensure a complete and accurate electronic medical record (EMR). This affected two residents (#19 and #50) of six sampled residents. The facility census was 49. Findings Include:1. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate 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 observation, medical record review, interview and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection during a pressure ulcer dressing change. This affected one resident (#16) of three residents reviewed for skin breakdown. The facility census was 49. Findings Include:Review of the medical record for Resident #16 revealed an initial admission date of 11/19/25 with the diagnoses including but not limited to sepsis, urinary tract infection, osteomyelitis of vertebra, stage four pressure ulcer to sacral region, moderate protein calorie malnutrition, hypertension, congestive heart failure, encounter for palliative care, neuromuscular dysfunction of bladder, dementia, hyperlipidemia, hypothyroidism, cerebral infarction, adult failure to thrive and dysphagia. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident 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 staff interview, record review, review of facility policy and review of drug labels, the facility failed to have appropriate diagnoses to support the use of an antipsychotic medication. This affected one (Resident #10) out of three residents reviewed for antipsychotic medication administration. The facility census was 44. Findings Include:Review of the medical record for Resident #10 revealed an admission date of 03/17/24, with diagnoses including Parkinson's disease and dementia (without behavioral, psychotic, mood, or anxiety disturbances), altered mental status, and depression.Review of the care plan dated 10/16/24 revealed Resident #10 exhibited altered behaviors, including hallucinations. Interventions included identifying behavioral triggers, notifying the physician of changes, redirecting the resident when needed, and administering medications as ordered.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident was severely cognitively impaired, displayed 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, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure residents who had recent weight loss received their nutritional supplements and weighed according to physician orders. This affected one (Resident #18) of three residents reviewed for weight loss. The facility census was 39. Findings include: Review of the medical record for Resident #18 revealed a re-entry date on 02/05/25. Diagnoses included pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact, weighed 133 pounds (lbs), was on a physician prescribed weight gain, and on a therapeutic diet. Review of the physician orders for Resident #18 revealed she had an active orders for weights to be obtained monthly on the fifth (dated 10/19/24); Ensure Clear (high calorie nutritional supplement) once…

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 staff interviews, the facility failed to staff a registered nurse eight hours a day, seven days a week. The facility census was 42. Findings include: Review of staffing sheets and the staffing tool from 02/11/25 to 02/17/25, there was no registered nurse scheduled for 02/16/25. Interview on 02/24/25 at 10:30 A.M. with the Administrator confirmed there was no registered nurse on the assignment sheet for Saturday 02/16/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview and policy review, the facility failed to provide transportation to a scheduled medical appointment. The affected one Resident ( #17), of three residents reviewed for transportation to medical appointments. The facility census was 42. Findings include: Resident #17 was admitted on [DATE] with diagnoses that included acute embolism and thrombosis of femoral vein, acute respiratory failure with hypoxia, Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction, pneumonia, sepsis, pressure ulcer of sacral region, atherosclerotic heart disease, chronic kidney disease, lymphedema, neutropenia, metabolic encephalopathy, chondrocalcinosis of left knee, urinary tract infection, tachycardia, dysphagia, altered mental status, and localized edema. Review of quarterly minimum data set (MDS) 3.0 dated 01/23/25 revealed Resident #17 was cognitively intact with a brief interview of mental status score (BIMS) of 13 out 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, staff interviews, and policy review, the facility failed to keep one, Resident (#23), of three reviewed for fall risk, free from a fall during care. The facility census was 42. Findings Include: Resident #23 was admitted [DATE] with the most recent re-admission date of 12/07/24, diagnoses included metabolic encephalopathy, dysphagia, severe protein-calorie malnutrition, hyperosmolality and hypernatremia, hypokalemia, adult failure to thrive, low back pain, major depressive disorder, anxiety disorder, neurocognitive disorder with Lewy bodies, Vitamin D deficiency, and hallucinations. Review of the admission minimum data set (MDS) 3.0 dated 11/11/24 revealed the resident was unable to be interviewed, Resident #23 is rarely understood. Staff reported Resident #23 had both short-term and long-term memory problems. Resident #23 was dependent on staff for eating, personal hygiene, all activities of daily living and mobility. Resident #23 received no high-risk medications and no special…

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 records review, shower sheet review, and staff interview, this facility failed to ensure residents received a bath or shower as scheduled and failed to provided supporting documents for provided shower sheets. This affected one (Resident #49) of the five residents reviewed for hygiene care. The facility census was 46. Findings include: Review of the medical record for Resident #49 revealed an initial admission date of 10/18/2024 and a reentry date of 01/02/2025. Diagnoses included acute embolism and thrombosis of femoral vein bilateral, pulmonary embolism, stage two pressure ulcer of sacral region, and a history of urinary tract infections. Review of Resident #49's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #49 was noted to have an impairment to one lower extremity and required the use of a wheelchair for mobility. 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 medical record review, wound clinic order review, and staff interview, this facility failed to ensure orders for lymphedema pumps were implemented as ordered. This affected one (Resident #49) of the five residents reviewed for physician orders. The facility summary was 46. Findings include: Review of the medical record for Resident #49 revealed an initial admission date of 10/18/2024 and a reentry date of 01/02/2025. Diagnoses included acute embolism and thrombosis of femoral vein bilateral, pulmonary embolism, stage two pressure ulcer of sacral region, and a history of urinary tract infections. Review of Resident #49's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #49 was noted to have an impairment to one lower extremity and required the use of a wheelchair for mobility. Resident required setup or clean up assistance for eating, oral…

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 records review, incident investigation review, and staff interview, this facility failed to ensure residents were free from injury when receiving assistance and transportation from facility staff. This affected one (Resident #49) of the five residents reviewed for accidents and injuries. The facility census was 46. Findings include: Review of the medical record for Resident #49 revealed an initial admission date of 10/18/2024 and a reentry date of 01/02/2025. Diagnoses included acute embolism and thrombosis of femoral vein bilateral, pulmonary embolism, stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without bruising or slough) of sacral region, and a history of urinary tract infections. Review of Resident #49's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. 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 medical record review, staff interview, and review of the resident assessment instrument (RAI) guidelines, the facility failed to ensure that minimum data set assessment (MDS) were completed within required timeframe's. This affected eight (Resident #1, #4, #19, #20,#30, #31, #44 and #299. The census was 41. Findings included 1. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, dysphasia, major depression, diabetes, incontinence, and atrial fibrillation. Review of the quarterly MDS dated [DATE] revealed her cognition is not intact. She had impairment to the upper and lower extremities on both sides, always incontinent of bowel and bladder, and no weight loss or wounds identified. Review of the MDS's revealed the following were completed late: Review of the quarterly MDS with the ARD (Assessment Reference Date) of 07/11/24 was not completed until 07/26/24 Review of the quarterly MDS with the ARD date of 06/28/24 was not completed…

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, review of the medication administration record, staff interview, and facility policy review, the facility failed to ensure medications were available to be administered for one (Resident #20) resident and failed to ensure medication was administered timely as prescribed for four (Resident #12,#20,#30, and #22) residents. This affected four (Resident #12,#20,#30, and #22) residents out of 19 residents reviewed for medications. The facility census was 41. Findings include: 1. Resident #20 was admitted to the facility on [DATE]. Diagnoses included acute cystitis, Chronic Kidney Disease Stage III, diabetes, anxiety, depression, high blood pressure, and obesity. Review of the admission minimum data set (MDS) dated [DATE] revealed his cognition was intact. He is dependent on staff for toileting, requires substantial assistance for shower/bathing,and personal hygiene. He is always incontinent of his bowel. Review of the physicians orders revealed an order dated 07/30/24 for Soliqua…

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 interviews, and facility policy review, the facility failed to ensure proper parameters were identified for anticoagulant, as needed (PRN) pain, and blood pressure medications. The deficient practice affected five residents (Residents #12, 28, 96, 98, and 146) of eight residents reviewed for unnecessary medications. The facility census was 41. Findings Include: 1. Review of the medical record for Resident #96 revealed an admission date on 09/14/24 and a discharge date on 10/01/24. Medical diagnoses included displaced intertrochanteric fracture of right femur, periprosthetic fracture around internal prosthetic right hip joint, paroxysmal atrial fibrillation, unspecified cirrhosis of liver, and anxiety disorder. Review of the census revealed Resident #96 was hospitalized from [DATE] to 09/25/24. There was not a comprehensive Minimum Data Set (MDS) 3.0 assessment completed for Resident #96. Review of the physician orders dated September 2024 revealed Resident #96 had an 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 record review, resident representative and staff interviews, and facility policy review, the facility failed to timely notify one resident's representative (Resident #34) and certified nurse practitioner (CNP) of changes in condition. The deficient practice affected one resident (Resident #34) of three reviewed for changes in condition. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. Medical diagnoses included abdominal aortic aneurysm without rupture, urinary tract infection (UTI), severe protein-calorie malnutrition, complication of surgical and medical care of abdominal wound, acute posthemorrhagic anemia, acute kidney failure, dysphagia, bacteremia, colostomy, peripheral vascular disease, and pressure ulcers of sacral region, buttock, and heel. Review of the resident profile for Resident #34 revealed the resident's girlfriend (Girlfriend #700) 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 record review, staff interview, and facility policy review, the facility failed to provide written notice of transfer to a hospital to one resident (Resident #34) and/or the resident's representative. The deficient practice affected one resident (Resident #34) of three reviewed for transfer and discharge. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. Medical diagnoses included abdominal aortic aneurysm without rupture, urinary tract infection (UTI), severe protein-calorie malnutrition, complication of surgical and medical care of abdominal wound, acute posthemorrhagic anemia, acute kidney failure, dysphagia, bacteremia, colostomy, peripheral vascular disease, and pressure ulcers of sacral region, buttock, and heel. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition and scored 15 out…

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, and facility policy review, the facility failed to provide a written notice of discharge to one resident (Resident #34) or the resident's representative prior to discharging the resident from the facility. The deficient practice affected one resident (Resident #34) of three reviewed for transfer and discharge. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. Medical diagnoses included abdominal aortic aneurysm without rupture, urinary tract infection (UTI), severe protein-calorie malnutrition, complication of surgical and medical care of abdominal wound, acute posthemorrhagic anemia, acute kidney failure, dysphagia, bacteremia, colostomy, peripheral vascular disease, and pressure ulcers of sacral region, buttock, and heel. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had…

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 completed accurately. This affected one resident (Resident #22) out of nine residents reviewed for MDS assessments. The facility census was 41. Findings included: Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses that included dementia, atrial fibrillation, chronic kidney disease stage three, hypothyroidism, type two diabetes mellitus, major depressive disorder, anxiety disorder, dysphagia, dysphagia, and muscle weakness. Review of the quarterly minimum data set (MDS) 3.0 dated 08/24/24 revealed Resident #22 is severely cognitively impaired. Resident #22 received antidepressant, diuretic, and hypoglycemic medications with indications noted. Resident #22 is receiving hospice care. Review of orders revealed Resident #22 was taking warfarin 2.5 milligrams (mg) once a day and the order was written on 08/01/24. Review of the August medication administration record…

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 Resident #299 received timely treatment for a urinary tract infection. This affected one resident (#299) of 21 residents reviewed for medication administration. The facility census was 41. Findings include: Review of medical records for Resident #299 revealed and admission date of 09/16/24. Diagnoses include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, diabetes mellitus and hypertension. Review of Resident #299's progress noted revealed she complained of discomfort with urination on 09/21/24 and a urinalysis was ordered. Further review of the resident's medical record revealed the resident had a urine sample collected on 09/23/24 with a urinalysis and culture and sensitivity to be completed. The results of the urinalysis and culture and sensitivity were completed on 09/26/24. Review of the physician's orders revealed no order for an antibiotic to treat Resident #299's urinary tract infection until 10/02/24 at 4:20 P.M. An interview with Regional Support…

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 reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one resident (#147) identified by the facility as having PTSD/trauma. The facility census was 41. Findings include: Record review for Resident #147 revealed the resident was admitted to the facility on [DATE] and had diagnoses including PTSD, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 10/02/24, revealed an ongoing assessment that was not completed. Review of an assessment dated [DATE] for Resident #147 revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. Review of the active care plans for Resident #147 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to ensure two residents (Residents #20 and #98) were free from significant medication errors. The deficient practice affected two residents (Residents #20 and #98) of two reviewed for medication errors. The facility census was 41. Findings Include: 1. Review of the medical record for Resident #98 revealed an admission date on 09/13/24 and a discharge date on 10/02/24. Medical diagnoses included unspecified cirrhosis of the liver, celiac disease, chronic kidney disease, and charcot's joint for unspecified foot and ankle. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #98 received daily insulin injections. Review of the Medication Administration Record (MAR) dated September 2024 revealed Resident #98 had an order for Humulin N insulin (a long acting insulin that…

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 staff and resident interview and review of facility arbitration agreement the facility failed to fully explain the arbitration agreement and the right to rescind the agreement within 30 days of signing. This affected two residents (#297 and #150) of three residents whose arbitration agreements were reviewed. The facility census was 41. Findings include: 1. Review of the medical record for Resident #297 revealed an admission date of 09/11/24. Diagnoses include fractures of the right fibula, muscular dystrophy, osteoarthritis, morbid obesity, depression and scoliosis. Review of the Minimum Data Set, dated [DATE] revealed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of the form titled Trilogy Voluntary Binding Arbitration Agreement dated 09/16/24 revealed Resident #297 signed the form as agreeing to the facility's binding arbitration agreement on 09/19/24. The agreement stated that the resident had 30 days to revoke the agreement after…

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 Enhanced Barrier Precautions (EBP) were followed during gastric-tube medication administration. This affected one resident (Resident #11) out of one resident observed for medication administration via a gastric - tube. The facility census was 41. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, Dementia, acute respiratory disease, complication of indwelling urethral catheter, cardiomegaly, Schizophrenia, anxiety disorder, and cognitive communication deficit. Review of the quarterly minimum data set (MDS) 3.0 dated 08/26/24 revealed Resident #11 has severe cognitive impairment, is on a mechanically altered diet with a gastric feeding tube and urinary catheter in place. Resident #11 is on anticoagulant, antipsychotic, and opioid medications with indications in place. Resident #11 is on hospice care with isolation…

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, staffing schedule review, review of the facility assessment, and family, resident, and staff interviews, the facility failed to ensure there was adequate staffing to provide activities of daily living (ADL) care for Residents #5, #12, #19, and #39. This affected four residents (#5, #12, #19, and #39) of seven residents reviewed for ADL care with the potential to affect all 46 residents. The facility census was 46. Findings include: 1. On 08/05/24 at 5:40 A.M., observation of staff revealed there were three licensed nurses, four State Tested Nursing Assistants (STNAs) and two STNAs in training on duty to provide care for 46 residents currently residing in the facility. The facility identified 15 residents that required assistance or were dependent on staff for feeding and 29 residents that required the assistance of two staff for toileting and transfers. 2. The following family and resident concerns were lodged during the investigation related to facility staffing. 2a.…

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, family interview, resident interview, and staff interviews, the facility failed to provide residents that required assistance from staff with activity of daily living (ADL) with the care and services with nail hygiene and dressing. This affected four (Residents #5, #12, #19, and #39) of seven residents reviewed for ADL care. The facility census was 46. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included abdominal aortic aneurysm, gangrene bilateral toes, and peripheral vascular disease. Review of Resident #5's profile care guide revealed the care included showers scheduled Monday and Thursday on day shift and use of a mechanical lift with two staff assist for transfers. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact and was dependent on staff for bathing. Review of the plan of care dated 07/03/24 revealed Resident #5 required staff assistance 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 observations, resident and staff interviews, medical record review, review of shower sheets, and facility policy review, the facility failed to provide showers as scheduled for one resident (Resident #29). This affected one resident (Resident #29) of three reviewed for showers. The facility census was 46. Findings Include: Review of the medical record for Resident #29 revealed an admission date on 04/28/24. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage III, adjustment disorder, depression, legal blindness, unsteadiness on feet, abnormalities of gait and mobility, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident had impairments on both sides of both the upper and lower extremities. Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review the facility failed to ensure residents were free from significant medication errors. This affected two residents (#8, #19) of three residents reviewed for medication errors. The facility census was 46. Findings Include: Review of Resident #8 revealed Resident #8 was admitted on [DATE] with the diagnoses including Alzheimer's Disease, depressive disorder, anxiety disorder, and high blood pressure. Resident #8 required extensive assistance from staff for activities of daily living (ADL) tasks including medication administration. Resident #8 had severely impaired cognition and was receiving hospice services for end stage Alzheimer's Disease. Review of Resident #8's progress notes dated 05/11/24 at 11:00 P.M. authored by the Director of Health Services (DHS) revealed Resident #8 had been administered the wrong medication. Resident #8 was assessed; vitals were stable and did not exhibit any adverse effects. Review of Resident #8's Interdisciplinary Team…

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, medical record review, interview, and review of the manufacture guidelines the facility failed to ensure the glucometer was properly disinfected after use. This affected one resident (Resident #4) of five residents observed for medication administration. The facility census was 46. Findings include: Review of Resident #4's medical record revealed an admission date of 11/16/20 with diagnoses including type two diabetes mellitus, unspecified dementia, and anxiety. Resident #4 required assistance from staff to complete activities of daily living (ADL) tasks including obtaining blood glucose readings and medication administration. Review of Resident #4's physician orders dated 04/15/24 revealed an order to obtain blood glucose readings before meals and at bedtime. Observation on 06/27/24 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #200 was completing morning medication administration for Resident #4. LPN #200 removed the glucometer from a drawer in the medication cart and placed it on the top of the medication cart (the glucometer was stored loosely in 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, staffing schedule review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, review of the facility assessment, and interviews, the facility failed to ensure there was adequate staffing to provide bathing for residents. This affected five residents (Residents #3, #23, #26, #87, and #187) of six residents reviewed for bathing with the potential to affect all 36 residents. The facility census was 36. Findings include: 1. On 07/03/23 at 7:30 A.M. three surveyors entered the facility to conduct an annual and complaint investigation. Observation revealed there were two licensed nurses, one licensed nurse in training, and three State Tested Nurse Aides (STNA's) on duty to proved care for 36 residents currently residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 37 residents. The ADL…

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, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, policy review, and interviews, the facility failed to ensure residents unable to carry out activities of daily living including bathing received the necessary services. This affected five residents (Residents #87, #187, #26, #3, and #23) of six residents reviewed for bathing. The facility census was 36 Findings include: Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 37 residents. The ADL information revealed the facility identified 21 residents who required the assist of one or two staff for bathing and 16 residents that were dependent for bathing. 1. Review of medical record revealed Resident #87 was admitted on [DATE] and discharged on 06/03/23 with diagnoses that included but not limited to non-traumatic spinal cord dysfunction, atrial…

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, medical record review, and policy review, the facility failed to notify the physician and families of significant weight changes for Residents #3 and #27. This affected two residents (#3 and #27) of four residents reviewed for nutrition. The facility census was 36. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. She lost weight and was not on a physician-prescribed weight loss plan. Review of Resident #3's weight history revealed she weighed 122.8 pounds on 11/09/22, 123.1 pounds on 12/09/22, 121.2 pounds on 01/19/23, 121 pounds on 02/18/23, 119.3 pounds on 03/03/23, 120.4 pounds on 03/09/23, and 109.6 pounds on 05/09/23. Her 05/09/23 weight was a 10.7% weight loss over 180 days.…

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 activities were provided for one resident (#3). This affected one resident (#3) of two residents reviewed for activities. The facility census was 36. Findings include: Observation on 07/03/23 at 9:20 A.M. and 11:27 A.M. and on 07/05/23 at 9:05 A.M. and 3:41 P.M. revealed Resident #3's television was on but muted. Interview on 07/03/23 at 10:58 A.M. with Resident #3's daughter revealed she was concerned about her mother's activities. She reported they did not do activities with Resident #3, and nobody visited her. She reported she had been told Resident #3 gets 30 minutes of activities a week, but she had not seen it. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 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 observation, interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place for one resident (#23) who was at risk for falling. This affected one resident (#23) of four reviewed for accidents. The facility census was 36. Findings include: Observation on 07/03/23 at 8:33 A.M., 9:32 A.M., 12:08 P.M., and 12:30 P.M. revealed Resident #23 in bed. No fall mats were observed. Interview on 07/03/23 with Certified Resident Care Associate (CRCA) #72 verified no fall mats were in place. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. Review of the plan of care dated 08/29/22 revealed Resident #23 was at risk for falling related to impaired cognition, poor safety awareness,…

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 supplements were provided as ordered and weights were obtained as ordered for Residents #3 and Resident #23. This affected two residents (#3 and #23) of four reviewed for nutrition. The facility census was 36. Findings include: 1. Observation on 07/03/23 at 12:30 P.M. revealed Resident #23 did not have a magic cup on her lunch tray. This was verified by Certified Resident Care Associate (CRCA) #72 at that time who reported she would get the resident one after she was done eating. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She required the supervision of one person for eating. She had no weight indicated and was on a mechanically altered diet. Review…

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 ensure pharmacy recommendations were followed for Resident #23. This affected one resident (#23) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She received an antidepressant seven days during the look back period. Review of the pharmacy recommendation dated 08/23/22 revealed Resident #3 had orders for Depakote and as needed lorazepam, which could be used for multiple purposes. The pharmacist recommended specifying a reason for use and adding side effect monitoring. The physician agreed with all recommendations. Review of the pharmacist recommendation dated 10/19/22 revealed…

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 ensure as needed psychotropics were limited to 14 days or that the physician documented a rationale for extending the use and provided a duration for use for Resident #9 and Resident #23 and failed to ensure a psychotropic had an indication of use for Resident #9. This affected two residents (#9 and #23) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. Review of Resident #23's physician order dated 12/01/22 revealed an order for Lorazepam 2.0 milligrams (mg) per milliliter (ml) 0.5 ml to be administered every four hours as needed for anxiety there was no end date specified.…

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.