Als Woodstock INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of the medical record, review of the police report, review of the hospital documentation, and review of the facility's wandering and exit-seeking policy and procedure, the facility failed to provide a safe environment and adequate supervision to prevent Resident #8 from exiting the facility without staff knowledge. This affected one (Resident #8) of three residents reviewed for elopement. The facility identified six residents (Resident #8, #19, #20, #23, #25, and #33) at risk for elopement. The facility census was 39. Findings include: Review of Resident #8's medical record revealed he was admitted to the facility on [DATE] with diagnoses including pulmonary nodule, metastatic squamous cell carcinoma, and emphysema. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment, required contact guard assistance from staff with ambulation, exhibited wandering behaviors, and required an elopement…

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 resident and staff interviews, and record review, the facility failed to ensure resident concerns brought up at the resident council meeting were addressed timely and appropriately. This affected nine (#05, #07, #10, #13, #14, #18, #30, #32, and #36) residents in regular attendance of the resident council meetings. The Facility census was 39. Findings include: Review of the resident council meeting minutes dated 09/2023 revealed concerns related to the Administrator, needing to spend more time in the facility and concerns related to nursing and the staff taking too long to answer call lights. Review of the resident council meeting minutes dated 12/2023 revealed concerns related to the Administrator, messing things up, making promises that were not kept, and he couldn't remember what he was told. The meeting also brought up concerns related to agency nurses. Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility does not address resident concerns timely and revealed the Administrator was not seen often at the building fixing the concerns. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and record review, the facility failed to ensure resident's representatives were notified when a change in condition occurred. This affected two (#16 and #21) of three residents reviewed for change in condition. The facility census was 39. Findings include: 1. Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and required moderate assistance from staff with eating. Resident #16 was dependent on staff for mobility and transfers. Review a nurse's progress note dated 11/24/23 for Resident #16 revealed the nurse noticed a change in condition when the resident had an altered mental status, had dark foul-smelling urine and the physician 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, resident and interviews, and record review, the facility failed to maintain a home like environment for one (#16) of three residents reviewed for physical environment. The facility census was 39. Findings include: Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and was dependent on staff for activities of daily living (ADLS). Interview and observation on 01/22/24 at 12:15 P.M. with Resident #16 revealed an outlet cover above him was hanging out of the wall approximately eight inches and had a cable cord hanging from it. The resident reported it had been that way since he was moved to the room a few weeks ago. Interview on 01/22/24 at 12:34 P.M. with State Tested…

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 interviews, staff interviews and record review, the facility failed to ensure dependent residents received showers as scheduled. This affected two (#16 and #21) of three residents reviewed for activities of daily living (ADLs). The Facility census was 39. Findings include: 1. Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the shower preference document revealed Resident #16 was scheduled to get showers on Sundays and Wednesdays. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and the resident was dependent on staff for bathing. Review of the shower sheets from the past three months (10/15/23 to 01/23/24) for Resident #16, revealed the resident was offered showers on (Sunday) 10/15/23, (Sunday) 10/29/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and record review, the facility failed to ensure resident's call lights were answered timely. This affected one (#23) of the three residents reviewed for call lights. The facility census was 39. Findings include: Review of the medical record for the Resident #23 revealed an admission date of 02/19/18. Diagnoses included cerebral palsy, diabetes, somatization disorder, epilepsy, borderline personality disorder, dysphasia, paraplegia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required partial assistance from staff for mobility and activities of daily living (ADLs). Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility did not have enough staff to provide needed care for residents and had long waits for the call lights to be answered. Observation at the same time revealed Resident #23 activated his…

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 interviews, resident interview, and record review, the facility failed to ensure residents received their diet as ordered. This affected one (#35) of three residents reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record for the Resident #35 revealed an admission date of 11/26/20. Diagnoses included sepsis, morbid obesity, hyperlipidemia, gastro esophageal reflux disease (GERD), diabetes, intellectual disability, and muscle weakness. Review of a dietary note dated 10/03/22 revealed Resident #35 was recommended to receive half portioned meals for lunch and dinner. Review of a physician's order dated 10/04/22 revealed Resident #35 was ordered to receive half portioned meals. Review of a dietary note dated 12/20/23 revealed Resident #35 had stable weights and received half portion meals for lunch and dinner. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact with a Brief Interview Mental…

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 interviews, resident interview, and record review, the facility failed to ensure a resident was provided with the appropriate assistive devices for dining. This affected one (#16) of three residents reviewed for assistive devices for dining. The facility identified eight (#05, #7, #14, #16, #17, #19, #36, and #39) residents with orders for adaptive equipment. The facility census was 39. Findings include: Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the plan of care dated 12/17/23 for Resident #16 revealed the resident was at risk for altered nutrition and hydration with interventions to offer encouragement, assistance and cueing as needed at mealtime, encourage to dine in the dining room, provide diet as ordered and the Dietician and Speech Therapy to evaluate as needed, Review of the Minimum Data…

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 staff interview, review of timecard punches, and review of facility schedule, the facility failed to ensure Registered Nurse (RN) coverage was maintained for eight consecutive hours, seven days a week. This had the potential to affect all 39 residents. The facility census was 39. Findings include: Review of the timecard punches for Saturday 12/16/23 revealed no RN coverage for the day. Review of the daily written schedule for Saturday 12/16/23 revealed no RN scheduled for the day. Interview on 12/26/23 at 1:36 P.M. with Director of Nursing (DON) revealed she worked Monday through Friday and is on-call everyday, seven days a week. DON verified no RN was scheduled or worked on Saturday 12/16/23. This deficiency represents non-compliance investigated under Complaint Number OH00149061.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview with staff and residents, and review of daily menus, the facility failed to follow menus plan to provide nutritious and well-balanced meals. This had the potential to affect all 39 residents who the facility identified as receiving food from the kitchen. The facility census was 39. Findings include: Observation on 12/26/23 at 11:48 A.M. of test tray revealed sloppy joe sandwich, mixed vegetables, and cantaloupe served. The food was palatable. The menu revealed lunch was to be a hamburger, French fries, tossed salad, and cantaloupe. Review of medical record for Resident #03 revealed an admission date of 02/19/18 with diagnoses including but not limited to cerebral palsy, chronic obstructive pulmonary disease, dysphagia, anxiety, type two diabetes, epilepsy, borderline personality disorder, and major depression. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #03 was cognitively intact and required limited assistance for personal hygiene and 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.

Based on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide a clean and sanitary environment for the residents. This affected Resident #36 and #43 and had the potential to affect all 39 residents who resided in the facility. Findings include: Observation on 10/05/23 from 8:30 A.M. through 11:30 A.M. revealed there were four halls where residents resided and traveled throughout the facility. All the halls in the facility were carpeted. The carpeting in all halls was embedded with black dirt, grime, food, and fluid spills. The carpeting was soiled from the beginning of each carpeted area through the end. Many areas on each hall had large, discolored areas with stained like areas. In the dining area, there was visible food residue under the tables and throughout the floor. On the walls in the dining area and in the four resident hallways, there were visible cobwebs containing insects in multiple corners and, on the keypads, leading to the outside of the facility were a large number of dead insects on top of the keypads.…

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 interviews, review of facility policy, and record reviews, the facility failed to maintain full and complete accounting records for the residents. This affected one (#45) of four resident reviewed for facility management of funds. The facility identified 24 residents that the facility manages residents funds. The facility census was 39. Findings include: Review of Resident #45's medical record revealed an admission date 05/09/16. Diagnoses included schizoaffective disorder- bipolar type. Resident #45 has a court appointed guardian of person only. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #45 had cognitive impairment with episodes of delusions and daily behavioral symptoms not directed at others. Review of Resident #45's fund management service authorization and agreement to handle resident funds signed by Resident #45's court appointed guardian on 03/24/23, stated that they authorized the facility to establish and manage an Federal Deposit Insurance…

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 and staff interviews and record reviews, the facility failed to provide residents a diet order to meet their daily nutritional needs. This affected two (Residents #30 and #45) of four residents reviewed for therapeutic diets. The facility census was 39. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/15/2023 with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and emphysema. Review of the admission Minimum Data Set (MDS) 3.0 assessment indicated Resident #30 had no cognitive impairment. Resident #30 had verbal behavioral symptoms which occurred one to three days during the assessment period and had no rejection of care. Resident #30 was independent with eating. Review of Resident #30's physicians orders revealed they were silent for a diet order. Interview on 10/05/23 at 10:28 A.M., with Resident #30 stated he should be receiving a diet that was consistent with his diagnosis, that did not contain any…

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 resident and staff interviews, review of facility policy, and record reviews, the facility failed to provide a written physicians order for specialized rehabilitative services for a resident. This affected one (Resident #30) of four residents reviewed for specialized rehabilitative services. The facility census was 39. Findings include: Review of the medical record for Resident #30 revealed an admission date of 08/15/23. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and emphysema. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23 revealed Resident #30 had no cognitive impairment. Review of Resident #30's physician orders for 08/15/23 to 09/15/23 revealed there were no physician orders for specialized rehabilitative services for Resident #30. Records of the therapy service records revealed their records were kept in a separate electronic medical record system for therapy. Review of Resident #30's service log summary of physical therapy revealed a 60-minute evaluation was provided 08/22/23. 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 Based on resident record review, staff interview, and review of Centers for Medicare and Medicaid Services (CMS) waiver guidance; the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon transfer to the hospital. This affected one (#30) of one residents reviewed for hospitalization. The census was 34. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnosis include acute respiratory failure. Review of an annual minimum data set (MDS) assessment dated [DATE], revealed Resident #30 had severely impaired cognitive function. Review of a progress note dated 08/26/21 at 11:28 P.M., revealed a chest x-ray was completed for Resident #30. The x-ray findings were consistent with interstitial pulmonary edema, atypical/viral infectious etiology may be considered as less likely alternative etiology in the appropriate clinical setting. The progress note revealed the physician was made…

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 diagnoses were accurate for the use of antipsychotic medications and failed to ensure adverse side effects from said medications were monitored. This affected one (Resident #4) of five residents reviewed for unnecessary medications and four review. The facility also failed to ensure adverse side effects from psychotic medications were monitored for four (Residents #30 #34, #25 and #15) of four residents reviewed for psychotropic drug use. The facility census was 37. Findings include: 1. Medical record review for Resident #4 revealed an admission date of 01/27/17. Medical diagnoses included hypertension, diabetes, hyperlipidemia, seizure disorder, depression, anxiety, and Alzheimer's Disease. Review of quarterly Minimum Data Set (MDS) assessment, dated 04/05/19, revealed Resident #4 was cognitively impaired. Review of a physician order dated 10/03/17 revealed Zyprexa, an anti-psychotic medication, ten milligrams (mg) by mouth at bedtime for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment with all current diagnoses. This affected one (Resident #30) of three residents reviewed for accurate assessments. The facility census was 37. Findings include: Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including osteoporosis, chronic obstructive pulmonary disease, pacemaker, Vitamin D deficiency, low back pain, dementia, disc degeneration, major depressive disorder with psychosis, atrial fibrillation and wedge compression fracture of third lumbar. Review of the comprehensive admission MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision with personal hygiene and ambulation in the corridor. The resident was independent for bed mobility, transfers, dressing, eating, toileting and ambulation in room. Review of the diagnoses revealed the assessment was not coded as having depression with psychosis and dementia.…

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 interview, the facility failed to ensure that care plans were developed for activities. This affected one (Resident #20) of two residents reviewed for activities. The facility census was 37 Findings include: Medical record review for Resident #20 revealed an admission date of 09/20/18. Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition. Review of the MDS dated [DATE] revealed interview for activity preferences was coded as somewhat important to have books, newspapers and magazines to read, have music to listen to, be around animals, keep up with the news and attend religious services. The resident identified that it was very important to him to do things with groups of people, to do his favorite activities and go outside when the weather was good. Review of the record revealed no plan of care related to activities. Interview with MDS Coordinator #18 on 04/25/19 09:11 A.M. verified that a plan of care for activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an assessment for activities and an activity calendar were provided for residents. This affected two (Resident #1 and Resident #20) of two residents reviewed for activities. The census was 37. Findings include: 1. Medical record review for Resident #4 revealed he was admitted on [DATE]. Medical diagnoses included Alzheimer's Disease, depression and seizure disorder. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. Review of Resident #4's plan of care for activities, dated 02/01/18, revealed the resident had decreased orientation. Activities were needed that promoted a pleasant social environment that he could enjoy and observe. The resident enjoyed staying in his room the majority of the time and coloring books in his room. The interventions were to adapt activity as needed to ensure resident was able to enjoy the activity. Assure activities are compatible with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of recommendations and manufacturer's guidelines for side rails and motorized wheelchairs, the facility failed to ensure there was safe distance between the side rail and the mattress on a bed and failed to ensure a motorized wheelchair was set at a safe speed . This affected one (Resident #1) of three residents reviewed for side rails and one (Resident #2) of five residents who operated a motorized wheelchair. The facility identified there were 22 ambulatory residents of which the speed of the motorized wheelchair could potentially affect. The census was 37. 1. Medical record review for Resident #1 revealed an admission date of 12/30/09. Medical diagnoses included anxiety, depression and Schizophrenia. Review of annual Minimum Data Set (MDS) assessment, dated 01/02/19, revealed he was cognitively intact. His functional status was independent for bed mobility, transfers, and eating. He was a limited assistance for toilet use. On this MDS, bed rails were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure side rail assessments were completed for two (Residents #1 and #10) of eight residents reviewed for side rails. The census was 37. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 12/30/09. Medical diagnoses included anxiety, depression and Schizophrenia. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. His functional status was independent for bed mobility, transfers, and eating. He was a limited assistance for toilet use. On this MDS, bed rails were coded as not being used. Review of the care plan, dated 01/22/15, revealed the resident had a activities of daily living self performance deficit related to postural kyphosis, difficulty walking, and muscle wasting. Interventions were to keep left side of bed against the wall and an enabler to right side of the bed to aid in transfers and repositioning. Review of the most recent…

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

Based on observation, record review and interview, the facility failed to ensure side rails were properly installed. This affected three (Residents #1, #5 and #7) of three residents who had reviewed for side rails. The census was 37. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 12/30/09. Observation of the side rail on 04/22/19 at 1:00 P.M. revealed the side rail was attached to the right side of the resident's bed with zip ties. 2. Medical record review for Resident #5 revealed an admission date of 02/11/16. Observation of the side rail on 04/22/19 at 1:30 P.M. revealed the side rail was attached to the left side of the resident's bed with zip ties. 3. Medical record review for Resident #7 revealed an admission date of 02/19/18. Observation of the side rail on 04/22/19 at 1:40 P.M. revealed the side rail was attached to the right side of the resident's bed with zip ties. Interview with the Maintenance Supervisor (MS) #7 on 04/22/19 at 2:10 P.M. revealed he used zip ties to attach the rails because he did was not provided with installation…

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.