Momentous Health At Vandalia

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive care plans to address residents' identified needs. This affected three (Residents (#42, #9, and #8) of four residents reviewed for care plans. The facility census was 108 residents.Findings include: 1.Review of the medical record for Resident #42 revealed an admission date of 12/03/25 with diagnoses including osteoarthritis, obstructive sleep apnea, and congestive heart failure. Review of the care plan for Resident #42 initiated 12/03/25 revised 12/31/25 revealed the resident was at risk for potential pain or discomfort. Further review of the care plan revealed it did not include interventions related to pain management. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 01/07/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #42 revealed an order dated 01/19/26 for Voltaren gel to be applied to the right shoulder topically every six hours as needed for pain. 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.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident care plans were revised to reflect changes in toileting needs. This affected one (Resident #4) of four residents reviewed for care plans. The facility census was 108 residents. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/02/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type two, and acquired absence of right and left leg below knee. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 12/16/25 revealed the resident did not have an indwelling catheter and was occasionally incontinent of urine. Review of care plan for Resident #4 dated 1/09/26 revealed the resident had indwelling foley catheter and requires catheter care per facility policy. Observation on 03/09/26 at 10:35 A.M. revealed Resident #4 was in bed and did not have a foley catheter. Interview on 3/16/26 at 10:59 A.M. with Registered Nurse (RN) #307 confirmed the resident no longer…

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

Based on review of the medical record, observation, and staff interview, the facility failed to ensure oxygen therapy was administered as ordered by the physician. This affected one (Resident #2) of three residents reviewed for oxygen therapy. The facility census was 108 residents. Findings include:Review of the medical record for Resident #2 revealed an admission date of 08/11/25 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (COPD) and respiratory failure. Review of the care plan for Resident #2 dated 08/11/25 revealed the resident was at risk for altered respiratory status, difficulty breathing, or potential for an alteration in respiratory status related to COPD. Interventions included provide oxygen per physician's order. Review of the physician's orders for Resident #2 dated March 2026 revealed there was no order for oxygen therapy. Observation on 03/10/26 at 1:48 PM revealed Resident #2 was receiving continuous oxygen therapy via nasal cannula per concentrator set at three liters per minute (LPM). Interview on 03/11/26 at 12:02 PM…

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, resident interview, and staff interview, the facility staff failed to provide pain management interventions as ordered by the physician and per resident request. This affected one (Resident #42) of six residents reviewed for pain management. The facility census was 108 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/03/25 with diagnoses including osteoarthritis, obstructive sleep apnea, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 01/07/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #42 revealed an order dated 01/19/26 for Voltaren gel to be applied to the resident's right shoulder topically every six hours as needed for pain. Review of the Medication Administration Record (MAR) for Resident #42 dated March 2026 revealed there was no record of administration of Voltaren gel on 03/07/26, 03/08/26, 03/09/26, and 03/10/26. Interview on 03/09/26 at 1:12 P.M. with Resident #42 confirmed he…

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 a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 99 residents in the facility who the facility identified as receiving food from the kitchen. The census was 99. Findings include: Observation of the kitchen with [NAME] #59, on 12/03/24 at 8:31 A.M. through 8:44 A.M., revealed the facility's dry food storage consisted of dry pancake mix, dry cake mix, instant potatoes, noodles, onions, brown sugar, two canisters of oats, frosting, 11 cans of fruit, six cans of vegetables, and 25 pounds of rice. The refrigerated food storage consisted of one opened gallon of milk, two five-pound logs of cheese, one bag of broccoli, one bag of carrots, and an opened bottle of salad dressing. Observation of frozen food items in the kitchen consisted of two bags of peas and carrot mix and approximately 60 breakfast sausage links. Interview at time of the kitchen tour with [NAME]…

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 and resident interviews, observations and policy review the facility failed to ensure prescription medications were appropriately stored in a secured manner. This had the potential to affect 17 residents (#69, #70, #73, #75, #78, #79, #80, #83, #85, #86, #88, #89, #91, #94, #95, #97 and #101) residing on the [NAME] Hall and eight resident (#6, #7, #11, #17, #21, #22, #23 and #29) residing on the East Hall who were cognitively impaired and independently mobile who could potentially access unsupervised and unsecured medications. Additionally, the facility failed to ensure refrigerated medications were appropriately stored. This had the potential to affect 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast unit. The facility census was 103. Findings include: 1. Medical record review for Resident #82 revealed an admission on [DATE] with diagnoses including but not limited 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.

Based on observations and staff interviews, the facility failed to maintain the building in a safe homelike manner. This had the potential to affect the 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast Unit of the facility. The facility census was 103. Findings include: Observation on 10/07/24 at 1:55 P.M. of the facility roof revealed areas over the Northeast unit, facing the south had an area of splintered/missing wood with rain gutters not attached to the roof exposing the soffit and sagging. Further observation of the roof in the same area revealed multiple rows of shingles sagging between the roof rafters. Observation on 10/07/24 at 1:59 P.M. of the facility roof revealed two areas over the Northeast Unit, facing north had areas of splintered/missing wood with rain gutters not attached and sagging exposing the soffit and roofing shingles sagging between the rafters. Additionally, there was a large blue tarp present over the shingles in the same area. Observation on 10/08/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and resident and staff interviews and policy review, the facility failed to ensure an adequate supply of paper towels and toilet paper for a resident's bathroom. This affected one (#84) out of three residents reviewed for the physical environment. The facility census was 103. Findings include: Medical record review for Resident #84 revealed an admission on [DATE] with diagnoses including but not limited to synovitis, hypertension, diabetes mellitus, depression and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 07/24/24 revealed an intact cognition. Resident #84 required supervision for eating, bed mobility and transfers. Resident #84 required moderate assistance with toileting. Interview on 10/08/24 at 8:10 A.M. with Housekeeper #21 stated the facility was out of toilet paper and paper towels today. Additionally, Housekeeper #21 stated that it happens often and they are just not ordering enough until the next order comes in.…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the online license verification system of the Bureau of Executives of Long-Term Services and Supports (BELTSS), review of the Administrator job description, and staff interview, the facility failed to ensure there was a licensed nursing home administrator (LNHA) with a valid license providing supervision and leadership to the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 106 residents. Findings include: Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing/license-lookup revealed Administrator #1 was issued an Ohio LNHA license on [DATE] with an expiration date of [DATE]. Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing/license-lookup revealed Administrator #2 was issued an Ohio LNHA license on [DATE] with an…

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

Based on observations and resident and staff interviews, the facility failed to ensure shower rooms were clean and ceilings were maintained. This had the potential to affect 60 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102 and #103) residents who receive showers in the [NAME] and Northeast shower rooms. The facility census was 101. Findings include: Interview with Resident #96 on 05/20/25 at 8:30 A.M. revealed the [NAME] shower room smelled like mold. Observation of facility on 05/20/24 at 8:35 A.M. revealed there was a black substance on the floor of the [NAME] shower room where the floor of the shower met the wall of the shower. There was also a black substance on the floor and caulk where the floor of the shower met the wall of the shower and a large round black spot on the ceiling of the shower in the Northeast shower room.…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and policy reviews, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was cognitively impaired with a history of wandering did not elope from the facility. This affected one (#53) out of three residents reviewed for elopements. The facility census was 101. Findings include: Review of Resident #53's chart revealed Resident #53 admitted to the facility on [DATE] with diagnoses including cardiac arrest cause unspecified, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, hypertension, encephalopathy, and malignant neoplasm of prostate. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #53 required set up assistance with eating, and oral hygiene. Resident #53…

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 review of personnel files and staff interview, the facility failed to ensure all licensed nursing staff had an active nursing license. This had the potential to affect all 96 residents residing in the facility. The census was 96. Findings include: Review of the personnel file for Assistant Director of Nursing - Registered Nurse (ADON -RN) #34 revealed she was hired on [DATE], and the department was listed as Assistant DON-RN. Further review of the personnel file revealed no evidence ADON-RN #34's license was verified with the board of nursing upon hire. Review of the license verification provided by the facility for ADON-RN #34 dated [DATE] at 1:14 P.M. revealed ADON-RN #34 had an inactive RN license. The verification indicated the license was effective [DATE] and expired [DATE]. Interview with Human Resources Director (HRD) #402 on [DATE] at 1:32 P.M. confirmed ADON-RN #34 was hired by the facility on [DATE]. HRD #402 further confirmed ADON-RN #34's nursing license was expired. HRD #402 stated ADON-RN…

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

Based on record review, staff interviewand policy review, the facility failed to conduct Quality Assurance and Performance Improvement meetings at least quarterly. This had the potential to affect all 103 residents in the facility. The census was 103. Findings include: Review of meetings for Quality Assurance and Performance Improvement, (QAPI), for the years 2023, and 2022, revealed no documentation of at least quarterly meetings. Interview on 04/20/23 at 2:00 P.M., with the Administrator verified there was no documentation of regular QAPI meetings for years 2023 and 2022. The Administrator stated she was newly hired and the documentation of previous QAPI meetings was missing. Review of the policy titled, QAPI Committee, dated 05/01/22, revealed the QAPI committee will meet at least quarterly to develop plans of action to correct issues.

Based on record reviews, employee file review, staff interviews and policy reviews, the facility failed to implement and monitor the water system to prevent Legionella disease, and to ensure employees were screened or tested for tuberculosis. This had the potential to affect all 103 residents in the facility. The facility census was 103. Findings include: 1. Review of facility Legionella disease control program revealed no water temperature monitoring log for the months of September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, and April 2023. Interview on 04/20/23 at 12:00 P.M., Maintenance Director (MD) #81 verified the water temperature monitoring was a process identified in the facility Legionella Water Management plan for the prevention of Legionella disease. MD #81 verified the last water temperature monitoring occurred on 08/17/22. MD #81 verified he had been in the maintenance department since December 2022. Review of the policy titled, Legionella Water Management, dated 05/01/22, revealed the plan was to reduce the risk 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 record review, staff interview and policy review, the facility failed to notify Medicaid recipient residents when they had exceeded the Medicaid eligible personal fund limit. This affected 15 (#36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15) of 15 Medicaid residents with personal funds accounts reviewed. The facility census was 103. Findings include: Review of the facility census list revealed Residents #36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15 were Medicaid eligible recipients. Review of Resident Fund Log dated 04/19/23, revealed Residents #36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15 were over the Medicaid $2,000.00 limit in their personal fund account. Resident #72 was over the Medicaid eligibility limit by $10,624.17; Resident #86 was over the limit by $13,957.88 and Resident #88 was over the limit by $14,196.27. Interview on 04/20/23 at 11:30 A.M., with Business Office Manager (BOM) #9 verified the residents receiving Medicaid should be notified when reaching $200.00 of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Observation on 04/18/23 at 8:23 A.M., revealed on the wall behind Resident #30 bed board, a four foot by four-foot wall area with multiple half inch deep cuts in the wall. This exposed a non-cleanable wall surface. Interview on 04/18/23 at 8:23 A.M., with Resident #30 stated the wall had the exposed area and cuts since admission on [DATE]. He stated he did not like how the wall looked. Interview on 04/20/23 at12:00 P.M., with Maintenance Director #81 verified the wall behind Resident #30 bed board had large scrapes and deep cuts which was not a cleanable surface. The Maintenance Director #81stated he was unsure how long the wall had been in disrepair. Review of the policy titled Homelike Environment dated 05/01/22 revealed the facility will provide a safe, clean, comfortable and homelike environment. 4. Observation on 04/18/23 at 8:59 A.M., revealed Resident #39 to be in his bed. The left side of Resident #39's bed was observed to be up against the wall with a circular baseball sized hole in the wall next to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interviews, staff interview and policy review, the facility failed to ensure residents received showers per their preference. This affected four (#05, #40, #47 and #91) of five residents reviewed for activities of daily living. The census was 103. Findings include: 1. Review of Resident #05's medical record revealed an admission date of 12/15/22, with diagnoses including arthrogryposis multiplex congenita, low back pain, quadriplegia, and other reduced mobility. Review of Resident #05's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #05 required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. Resident #05 required total dependence with eating and two-person physical assistance with part of the bathing activity. Review of Resident #05's activities of daily living (ADL) care plan dated 12/15/22 revealed Resident #05 needed assistance with ADLs. Interventions…

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, resident interview, staff interview, and policy review, the facility failed to ensure medications were not stored at the bedside. This affected one (#21) of five reviewed for medications. The facility also failed to ensure insulin and inhaler was discarded when expired. This potentially could affect 15 residents identified as receiving insulin and/or inhaler. The census was 103. Findings included: Medical record review for Resident #21 revealed an admission date of [DATE]. Medical diagnoses included diabetes, heart failure, and Schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed the resident was cognitively intact. Review of the medical record from [DATE] through [DATE] revealed Resident #21 was not a self-medicate. Observation on [DATE] at 8:24 P.M., revealed Resident #21 had a bottle of refresh tears, Lotemacx eye drops, Advair inhaler, and an Atrovent inhaler lying on the bed in a baggie. Interview with…

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

Based on record review, meal spreadsheet review, observation, staff interviews and policy review, the facility failed to provide food portions as planned by a Registered Dietitian. This affected 16 (#3, #54, #53, #20, #47, #12, #73, #38, #83, #22, #41, #11, #95, #26, #69, and #52) of 16 residents who received a consistent carbohydrate diet and all 101 residents who received food from the kitchen did not receive a bread portion at the lunch meal on 04/19/23. Residents #29 and #59 do not receive food from the kitchen. The census was 103. Findings include: 1. Record review revealed Residents #3, #54, #53, #20, #47, #12, #73, #38, #83, #22, #41, #11, #95, #26, #69, and #52 were on consistent carbohydrate diets. Review of the 04/19/23 lunch meal spreadsheet revealed residents with physician orders for a consistent carbohydrate diet were listed to receive a number 10 size portion of rice. Observation on 04/19/23 at 11:13 A.M., revealed [NAME] #2 had mixed the rice portion with the meat portion. There was no separate rice portion for the consistent carbohydrate diet. Interview on 04/19/23…

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, observation, staff interviews and policy review, the facility failed to label stored foods, discard expired foods, and maintain food equipment in a sanitary manner. This had the potential to affect 101 residents who received food from the kitchen. Residents #29 and #59 do not receive food from the kitchen. The facility census was 103. Findings include: Observation on 04/17/23 at 6:15 P.M. of the kitchen, revealed the following sanitation violations: 1. In the hand washing area, there were no paper towels. 2. In the walk-in refrigerator, there was a large container, identified as pudding, with no label or date. A large container, identified as cooked vegetable, with no label or date. A container, identified as cheese, with no label or date. A container of identified chicken soup dated 04/13/23. 3. In the walk-in freezer, there was no thermometer. 4. In the food preparation area, the was an undated bottle of opened lemon juice. There were two opened undated bread bags. There were two bulk food containers of white substances with no label. 5. In the reach in…

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

Based on observation and staff interviews, the facility failed to maintain essential equipment in operating condition. This had the potential to affect 101 residents who received food from the kitchen. Residents #29 and #59 do not receive food from the kitchen. The facility census was 103. Findings include: Observation on 04/19/23 at 10:19 A.M, revealed in the kitchen the following food equipment in disrepair and or not operational: 1. The food plate warmer was not operation and not heating meal service plates. 2. The left door of the reach in refrigerator was no able to open. It was taped closed on the exterior surface. There was noted food debris on the shelves of the refrigerator and around the exterior surface of the taped areas. 3. The garbage disposal near the three-compartment sink was not operational. There was noted food debris around the trash cans. Interview on 04/19/23 at 9:20 A.M., with [NAME] #2 verified the plate warmer had not been operational for several weeks. The meal plates were not heated, causing loss of meal food temperatures. [NAME] #2 stated the door of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident interview, staff interviews and policy review, the facility failed to ensure a resident was assessed to self-administer medications. This affected one (#78) of one random resident observed. The census was 103. Findings include: Medical record review for Resident #78 revealed and admission on [DATE], with diagnoses including pneumonia, chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, anxiety disorder, solitary pulmonary nodule, and dementia with other diseases. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #78 revealed an impaired cognition. Resident #78 was coded with delusions during the assessment period. Resident #78 required limited assistance for bed mobility, supervision for transfers, eating and toileting. Review of the plan of care for Resident #78 revealed I have potential for altered respiratory status, difficulty breathing related to congestive obstructive pulmonary disease.…

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, staff and resident interview, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#47) of 25 residents reviewed for care and treatment. The census was 103. Findings included: Review of Resident #47's medical record revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), Schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance or bed mobility and toilet use. She was dependent on staff for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 10/05/22 revealed Resident #47 has a behavior problem and will make false allegations towards staff to get them in trouble. Interventions were to approach her…

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, staff and resident interview and policy review, the facility failed to ensure a resident was free from verbal abuse. This affected one (#47) of four residents reviewed for potential abuse. The census was 103. Findings included: Review of Resident #47's medical record revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), Schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance or bed mobility and toilet use. She was dependent on staff for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 10/05/22 revealed Resident #47 has a behavior problem and will make false allegations towards staff to get them in trouble. Interventions were 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 medical record review, resident interview, staff interview, facility investigation review, and policy review, the facility failed to report resident to resident altercation. This affected four residents (#80, #5, #4 and #77) of five reviewed for potential abuse. The census was 103. Findings include: 1. Medical record review for Resident #80 revealed an admission date of 10/04/22, with diagnoses including schizoaffective disorder, dementia with behaviors, depression, anxiety disorder, weight loss, psychosis bipolar disorder, visual hallucinations, and auditory hallucinations. Review of the Minimum Data Set assessment dated [DATE] for Resident #80 revealed a brief interview mental status was completed by staff with severe cognitive impairment. Resident #80 revealed physical and verbal behavioral symptoms director towards others, behaviors such as hitting, scratching self, pacing rummaging, occurs 4-6 days during the assessment period. Resident #80 requires limited assistance for bed mobility, transfers,…

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 interview, staff interview and policy review, the facility failed to ensure residents had a care plan for hearing loss and antipsychotic medications. This affected two (#82 and #92) of 25 residents reviewed for care plans. The facility census was 103. Findings include: 1. Review of Resident #92's medical record revealed an admission date of 01/25/23, with diagnoses including metabolic encephalopathy, sepsis, osteomyelitis, anemia, hematuria, hyperlipidemia, major depressive disorder, and other symbolic dysfunctions. Review of Resident #92's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #92 required extensive assistance with bed mobility, dressing, and toileting. Resident #92 also required total assistance with personal hygiene and supervision with eating. Resident #93 had adequate hearing with the use of a device. Review of Resident #92's care plans dated 04/18/23 revealed Resident #92 did not…

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, staff interview, the facility failed to ensure a resident experiencing pain was provided timely pain management. This affected one (#47) of one reviewed for pain management. The census was 103. Findings included: Medical record review for Resident #47 revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance for bed mobility, personal hygiene, and toilet use. She was a total dependence for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 06/22/22 revealed Resident #47 had the potential for pain discomfort. Interventions were to anticipate my need for pain relief and respond as soon…

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 ensure pharmacy recommendations were reviewed by the physician timely and monthly medication reviews were completed by the pharmacy. This affected two (#83 and #89) of five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #83's medical record revealed an admission date of 04/19/21, with diagnoses including schizophrenia, other pneumonia, muscle weakness, dysphagia, type two diabetes, major depressive disorder, necrotizing fasciitis, unspecified atrial fibrillation, osteomyelitis, schizoaffective disorder, and delusional disorder. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #83 required supervision with bed mobility, dressing, personal hygiene, eating and toileting. Review of Resident #83's physician order dated 04/23/22 revealed Resident #83 was ordered Sertraline…

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 policy review, the facility failed to ensure a resident received a gradual dose reduction or contraindication for a gradual dose reduction of an antidepressant. The facility also failed to ensure a resident that received an antipsychotic medication had an appropriate diagnosis and indications for use. This affected two (#82 and #83) residents of five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #83's chart revealed an admission date of 04/19/21, with diagnoses including schizophrenia, other pneumonia, muscle weakness, dysphagia, type two diabetes, major depressive disorder, necrotizing fasciitis, unspecified atrial fibrillation, osteomyelitis, schizoaffective disorder, and delusional disorder. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #83 required supervision with bed mobility, dressing, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews and policy review, the facility failed to provide dental services. This affected one (#33) of one resident reviewed for dental services. The facility census was 103. Findings include: Medical record review for Resident #33 revealed an admission on [DATE], with diagnoses including schizophrenia, Addisonian crisis, toxic encephalopathy, kidney failure, major depressive disorder, acute respiratory failure, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 revealed an impaired cognition. Resident #33 requires extensive assistance for bed mobility, transfers, toileting, and supervised eating. Resident #33 was assessed and coded for no dental problems. Review of the plan of care for Resident #33 revealed a nutritional risk related to diagnoses of schizophrenia with potential for altered oral intakes related to behavior, history of refusing meals. Interventions include assessing signs and symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, hospice staff interview and policy review, the facility failed to ensure the hospice provider and the facility collaborated to develop a plan of care. This affected one (#79) of one resident reviewed for hospice services. The census was 103. Findings include: Medical record review for Resident #79 revealed an admission date on 11/01/22, with diagnoses including metabolic encephalopathy (brain damage), pulmonary embolism (blood clot), deep vein embolism, hypoxemia (low oxygen), kidney failure and kidney disease, history of covid-19, vascular dementia with behavioral disturbances, major depressive disorder, diabetes mellitus type two, adult failure to thrive, Alzheimer's disease and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #79 revealed severe cognitive impairment. Resident #79 requires total assistance from two staff members for bed mobility, transfers, and toileting. Resident #79 requires total assistance…

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

Based on record reviews, staff interviews and policy reviews, the facility failed to ensure residents were offered and received pneumococcal and influenza vaccines. This affected two (#89 and #55) of five residents reviewed for vaccinations. The facility census was 103. Findings include: 1. Review of Resident #89's medical record revealed an admission date of 11/17/22, with diagnoses including polyneuropathy, encephalopathy, type two diabetes mellitus with diabetic polyneuropathy, vascular dementia, asthma, metabolic encephalopathy and generalized abdominal pain. Review of Resident #89's medical record from 11/17/22 to 04/20/23, revealed no documentation that Resident #89 received a consent for the pneumococcal vaccine, refused the pneumococcal vaccine or received the pneumococcal vaccine. Interview on 04/19/23 at 5:45 P.M., with the Director of Nursing (DON) verified Resident #89 did not have any documentation indicating Resident #89 had received a consent for the pneumococcal vaccine, refused the pneumococcal vaccine or received the pneumococcal vaccine. 2. Review of 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 record review, staff interview and policy review, the facility failed to ensure a resident was offered a COVID-19 vaccine. This affected one (#89) of five residents reviewed for vaccinations. The facility census was 103. Findings include: Review of Resident #89's medical record revealed an admission date of 11/17/22, with diagnoses including polyneuropathy, encephalopathy, type two diabetes mellitus with diabetic polyneuropathy, vascular dementia, asthma, metabolic encephalopathy and generalized abdominal pain. Review of Resident #89's medical record from 11/17/22 to 04/20/23 revealed no documentation that Resident #89 received a consent for the coronavirus (COVID-19) vaccine, refused the COVID-19 vaccine or received the COVID-19 vaccine. Interview on 04/19/23 at 5:45 P.M., with the Director of Nursing (DON) verified Resident #89 did not have any documentation indicating Resident #89 had received a consent for the COVID-19 vaccine, refused the COVID-19 vaccine or received the COVID-19 vaccine. Review of the policy titled COVID-19 Precautions and Prevention, dated 10/05/22…

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.

Based on record review, observation and staff interview, the facility failed to store in a sanitary manner. This had the potential to affected 107 of 108 residents who receive food from the kitchen. The facility identified Resident #2 did not receive food from the kitchen. Findings include: Observation of the dry storage area with Dietary Manager #506 on 11/04/19 at 8:10 A.M. revealed there were items on the shelves for use without dates they were put on the shelves and the items did not have expiration dates on the packaging or use by dates on the packaging. The food items included: • Five, five pound dry milk mix bags; • Five, eighty ounce, pancake mix boxes; • One, 14 ounce chicken gravy mix; • Fourteen bags of 24 ounce country gravy mix; • Nine boxes of marshmallow pies, eight pies each box, • Five boxes of fudge rounds 24 rounds in each box, • Five bags of 15.5 ounce Monterey jack flavored cheese sauce. During an interview with Dietary Manager #506 on 11/04/19 at 8:15 A.M. it was verified the use by date and expiration dates were not on the above listed items. The manager…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview; the facility failed to develop baseline care plans. This affected four (#9, #43, #52 and #110) of 11 residents reviewed for the development of the baseline care plan. The facility census was 108. Findings include: 1. Review of the medical record for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis, muscle weakness, dysphagia, chronic respiratory failure with hypoxia, dementia with behavioral disturbances, colitis, gastrointestinal hemorrhage, coagulation factor deficiency, thrombocytopenia, osteoarthritis, heart failure, major depressive disorder and suicidal ideation. Further review of the medical record for Resident #52 revealed there was no baseline care plan. Interview on 11/06/19 at 7:52 A.M. with the Director of Nursing (DON) verified there was no baseline care plan developed for Resident #52. 2. Review of the medical record for Resident #9 revealed the resident was admitted to the facility on [DATE].…

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, review of facility policy and staff interview, the facility failed to ensure the medication storage carts were secured. This affected two of six medication carts. This had the potential to affect 30 of the 40 residents residing on the units who were independently mobile. The facility census was 108. Findings include: 1. Observation on 11/04/19 at 2:28 P.M. revealed the medication storage cart on the male secured unit was unlocked and unsupervised in the hallway. The Licensed Practical Nurse (LPN) #502 was observed leaving the medication cart unattended. LPN #502 exited the unit for five minutes. Interview with LPN #502 on 11/04/19 at 2:33 P.M. verified the medication cart was left unlocked and unattended. The LPN verified the medication cart should have been locked. 2. Observation on 11/06/19 at 4:15 P.M. revealed the medication storage cart on the female secured unit was unlocked and unsupervised in the hallway. Interview with LPN #503 at 4:22 P.M. verified the medication cart was unlocked and unattended. LPN stated she went to the nurses station to get an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain the resident's room in safe and sanitary operating condition. This affected seven rooms and had the potential to affect all 108 residents residing in the facility. Findings include: Observation and interview of the environment in resident rooms on 11/06/19 from 9:50 A.M. through 10:05 A.M. with Facility Maintenance Director #540 revealed the following identified concerns: • There were multiple holes in the closet door in room [ROOM NUMBER] bed B. • The call light was not working in room [ROOM NUMBER] bed A. • The bedside table was soiled with enteral feeding solution in room [ROOM NUMBER] bed A. • There was a ripped arm rest on the left side of a wheelchair in room [ROOM NUMBER] bed A. • The closet door was broken on the railing and leaning on the wall in room [ROOM NUMBER] bed A. • The foot board on the bed was not attached in 306 bed B. • There were holes in the walls behind the bed and a wall had been repaired but not painted in room…

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 update care plans to meet the needs of a resident. This affected two (Resident #31 and #47) of 25 residents reviewed during the final investigation stage of the annual survey. The facility census was 108. Findings include: 1. Review of Resident #47's medical record revealed an admission date 12/14/10. Diagnoses included Alzheimer's disease, diabetes mellitus type two and diabetic neuropathy. Further review of Resident #47's medical record revealed she acquired a unstageable pressure ulcer (an ulcer covered in slough or eschar) to her right heel on 10/28/19. Review of the care plan, dated 06/21/16, revealed it was not updated to include the pressure ulcer to her right heel. Interview on 11/07/19 at 9:38 A.M. with Registered Nurse (RN) #512 confirmed Resident #47's care plan was not updated to include the right heel unstageable pressure ulcer. RN #512 stated it was her expectation that Resident #47's care plan would have been…

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 observation, the facility failed to ensure nail care was completed for a resident who required assistance with personal hygiene. This affected one (#18) of one resident reviewed for nail care. The facility census was 108. Findings include: Review of the medical record for Resident #18 revealed the resident had an admission date of 07/16/19. Diagnoses included abnormal heart beat, heart failure, major depressive disorder and vascular dementia with behavioral disturbances. Review of the plan of care for activity of daily living (ADL), dated 07/18/19, revealed the resident may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Interventions included to report any changes in ADL self-performance to nurse. Review of the Minimum Data Set (MDS) assessment, dated 07/27/19, revealed the resident had intact cognition. The resident required extensive assist with personal hygiene. Observation on 11/05/19 at 2:30 P.M. of Resident #18 revealed her nails on both fingers…

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 accurately document care given to a resident. This affected one (Resident #47) of 25 residents reviewed during the final investigation stage of the annual survey. The facility census was 108. Findings include: Review of Resident #47's medical record revealed an admission date 12/14/10. Diagnoses included Alzheimer's disease, diabetes mellitus type two and diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 08/23/19, revealed Resident #47 was cognitively intact. Review of the wound nurse practitioner notes revealed Resident #47 obtained a unstageable pressure ulcer (a localized area covered in eschar or slough) to to the right heel on 10/28/19. Review of the facility wound assessments, dated 10/28/19 and 11/04/19, revealed that the right heel unstageable pressure ulcer was not identified in these assessments. Review of the physician orders revealed an order dated 03/07/19 for a head-to-toe skin check every night shift every Monday and Thursday for routine assessment. An order dated…

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