Meadowbrook Nursing Center

Based on observation and interview, the facility failed to:a. ensure medications were secured for 1 (nurse treatment cart) of 3 medication/treatment carts observed for secured medications;b. ensure medications were dated when opened and not expired for 1 (nurse treatment cart) of 3 medication/treatment carts observed for medication storage; andc. ensure discontinued narcotics were stored in a separately locked, permanently affixed compartment for 1 (DON medication/treatment cart) of 3 medication/treatment carts observed for medication storage.RN #1 identified three medication/treatment carts in the facility and one medication/treatment cart for discontinued narcotic storage.Findings:1.On 03/09/26 at 11:16 a.m., the nurse treatment cart was observed to be unlocked and unattended by the nurse's station. On 03/09/26 at 11:18 a.m., RN #1 was observed to lock the nurse treatment cart.On 03/13/26 at 1:13 p.m., the nurse treatment cart was observed to be unlocked and unattended at the nurse's station. On 03/13/26 at 1:16 p.m., the administrator was observed to walk by the nurse treatment…

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

Based on observation and interview, the facility failed to ensure eggs, served over easy, were pasteurized for 1 (breakfast meal) of 2 meals observed and failed to ensure left over foods were labeled and dated in the refrigerator for 1 of 1 refrigerators in the kitchen. The dietary manager identified 8 residents who ate eggs over easy and 34 residents who ate food from the kitchen. Findings: On 03/09/26 at 11:29 a.m., the cold storage refrigerator was observed to have sliced cheese in an unlabeled open zip close bag that was dated 02/26/26. An undated, unlabeled clear plastic container with a lid was observed in the refrigerator. The container was observed to have an unknown liquid. Two flats of unpasteurized eggs were observed in the refrigerator. No other eggs were observed. On 03/10/26 at 8:26 a.m., three residents in the dining room were observed to eat eggs over easy. No policy for storage of food or the use of pasteurized/unpasteurized eggs was provided by the end of the survey. On 03/09/26 at 11:30 a.m., the DM stated the cheese should have been zipped closed. They stated 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.

Based on record review and interview, the facility failed to ensure allegations of abuse were reported to OSDH for 1 (#4) of 1 sampled residents who were reviewed for abuse.The administrator identified 34 residents who resided at the facility. Findings:The undated policy titled Abuse Prohibition Procedure, read in part, PURPOSE: To assure that any or all suspected abuse is reported, investigated and that the residents of this facility are kept in a safe environment at all times .If any person(s) see or suspects abuse to a resident or group of residents or Finds any unexplained injury this should be reported immediately to the charge nurse, DON, or Administrator.The Administrator or designees will immediately initiate an investigation And notify the OSDH.A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of schizophrenia. A progress note, dated 02/22/26 at 11:42 p.m., read in part, Resident telling other residents during smoke break today that [they had]…

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

Based on record review and interview, the facility failed to ensure allegations of abuse were investigated for 1 (#4) of 1 sampled residents who were reviewed for abuse.The administrator identified 34 residents who resided in the facility.Findings:An untitled and undated policy, read in part, Purpose: To assure that any or all suspected abuse is reported, investigated and that the residents of this facility are kept in a safe environment at all times.The Administrator or designees will immediately initiate an investigation and notify the OSDH.A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of schizophrenia. A progress note, dated 02/22/26 at 11:42 p.m., read in part, Resident telling other residents during smoke break today that [they had] been getting beaten and has bruises on [their] arms and back. The progress note was signed by LPN #3.A progress note, dated 02/28/26 at 4:56 p.m., read in part, Resident called 911 from resident phone in living…

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 the clinical record contained documentation for a discharge for 1 (#36) of 1 sampled residents who were reviewed for discharge.Regional nurse #2 identified 13 residents who had discharged from the facility in the past 3 months. Findings: A discharge return-not anticipated assessment, dated 12/29/25, showed Resident #36 was admitted to the facility on [DATE], and discharged from the facility to home on [DATE]. Review of the clinical record, dated 12/23/25 through 12/29/25, did not show the reason for the discharge, the status of the resident upon discharge, a physician order for discharge, or what resources were required/provided upon discharge. On 03/16/26 at 9:37 a.m., LPN #2 stated Resident #36 had returned to their apartment upon discharge from the facility with hospice services and left with medication and personal belongings. On 03/16/26 at 9:39 a.m., the DON stated the physician had provided an order that Resident #36 could be discharged…

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 a discharge summary was completed and the State Ombudsman office was notified of discharge for 1 (#36) of 1 sampled resident reviewed for discharge.Regional nurse #2 identified 13 residents who had been discharged in the past 3 months. Findings: A discharge return-not anticipated assessment, dated 12/29/25, showed Resident #36 was admitted to the facility on [DATE] and discharged from the facility to home on [DATE]. Review of the clinical record, dated 12/23/25 through 12/29/25, did not show a discharge summary had been completed or the State Ombudsman office had been notified of the discharge for Resident #36. On 03/16/26 at 9:37 a.m., LPN #2 stated Resident #36 had returned to their apartment upon discharge from the facility with hospice services and left with medication and personal belongings. On 03/16/26 at 9:39 a.m., the DON stated discharge summaries were completed by the MDS coordinator and placed in the clinical record under 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.

Based on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed for 1 (#10) of 1 sampled residents who were reviewed for dialysis.Regional nurse #2 identified two residents who received dialysis at the facility.Findings: An admission assessment, dated 12/15/25, showed Resident #10 had a BIMS score of 11, which indicated the resident was moderately impaired in cognition for daily decision making, and received dialysis. A physician order, dated 02/20/26, showed Resident #10 received dialysis weekly on Monday, Wednesday, and Friday. A care plan, dated 03/05/26, showed Resident #10 had a diagnosis of end stage renal disease and received dialysis. Dialysis Communication forms and progress notes, dated 03/02/26 through 03/13/26, did not show nurses had conducted a pre or post dialysis assessment on 03/02/26 or 03/09/26. On 03/13/26 at 4:32 p.m., LPN #2 stated pre and post dialysis assessments were documented on Dialysis Communication forms or in the progress notes. On 03/16/26 at 1:17 p.m., the DON stated they could not locate…

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, interview, and record review, the facility failed to ensure assessments were conducted for bedrails for 1 (#1) of 1 sampled residents who were reviewed for bedrails.CNA #1 identified six residents who had bedrails.Findings: On 03/10/26 at 8:44 a.m., Resident #1 was observed in bed. An enabler style bedrail was observed on the right side of the bed, in the up position. A physician order, dated 12/22/25, showed Resident #10 may use an enabler style bedrail to assist with positioning. A care plan, revised 12/27/25, read in part, 12/22/2025-Transfer bar evaluation with demonstration completed for safety of repositioning while in bed and transferring in and out of bed safely. Review of the observation section and the progress notes, dated 12/25/25 through 03/13/26, did not show the resident had been assessed for safety with the use of the bedrail. On 03/10/26 at 8:44 a.m., Resident #1 stated they used the enabler style bedrail to assist them in getting out of bed. On 03/13/26 at 3:33 p.m., the DON stated residents with bedrails were to be assessed when bedrails 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 record review and interview, the facility failed to ensure TB testing, Flu, and Pneumonia immunizations were performed annually for 2 (#16 and #26) of 5 sampled residents reviewed for immunizations. The administrator identified 34 residents resided at the facility.Findings: 1. An admission assessment, dated 09/28/25, showed Resident #15 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included dementia. The assessment showed Resident #15 admitted to the facility 09/21/25. Review of the immunization record for Resident #16 showed they had not received their TB test on admission or their flu and pneumonia vaccinations annually. 2. A quarterly assessment, dated 02/12/26, showed Resident #26 had a BIMS of 15 and was cognitively intact for daily decision making. The assessment showed diagnoses which included lung cancer of the right lower lobe. The assessment showed Resident #26 re-admitted to the facility on [DATE]. Review of the…

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

Based on observation, record review, and interview, the facility failed to have an effective pest control program for the kitchen and failed to maintain the kitchen environment in an effort to promote an effective pest control program for the kitchen. The ADON stated 20 residents resided in the facility. Findings: The pest control service notification, dated 07/17/24, read in part, .Technician looked in pest control. [sic] Log and roaches were reported in break room and in dining room technician inspected, see no dead, no feces or live activity at time of service. Technician treated entryways, common areas. Offices, break room, dining room, nurses station, and kitchen with liquids. Inspected exterior bait stations, updated cards and replaced bait . On 08/04/24 at 9:17 a.m., an initial tour of the kitchen was performed and the following observations were made: - roaches in and around the low temperature dish machine; - missing baseboards in the dish room, dry storage room, and main kitchen areas; - standing water under the dish machine when not in use; - missing floor tiles in the…

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

Based on observation, record review, and interview, the facility failed to ensure the development of care plans to meet the residents' needs for three (#10, 13, and #26) of 13 residents whose records were reviewed. The facility failed to ensure a care plan was developed related to: a. schizoaffective disorder for Res #10 and #13. b. the use of diuretics, antianxiety, and anticoagulant use for Res #26. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: 1. Res #26 had diagnoses which included permanent atrial fibrillation, generalized anxiety disorder, and hypertension. A physician order, dated 08/06/22, documented the facility was to administer 2.5 mg of Eliquis (an anticoagulant medication) once daily for a diagnosis of permanent atrial fibrillation. A physician order, dated 09/14/22, documented the facility was to administer 40 mg of furosemide (a diuretic medication) once daily for a diagnosis of secondary hypertension. A quarterly assessment, dated 05/07/23, documented the resident was severely impaired in cognition;…

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 a resident's care plan was revised with new interventions to prevent falls and offered the resident's representative to participate in the care plan meetings for one (#22) of three residents reviewed for falls. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: Res #22 had diagnoses which included dementia and DM. A care plan, dated 04/04/22, documented Problem: I am at increased risk for falls r/t my confusion, forgetfulness, impaired judgement and safety awareness, potential vision impairment. The documented interventions on the 04/04/22 care plan were for staff to keep the resident's bed in lowest position when they were in it, keep personal items and frequently used items within reach, ensure the resident was wearing their glasses when they were out of bed, and for staff to ensure the resident was wearing appropriate footwear when they were out of bed. An Event Report, dated 01/13/23 at 10:41 p.m., documented the resident was found on 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.

Based on observation, record review, and interview, the facility failed to ensure residents received the care and adequate supervision to prevent falls for one (#22) of three residents reviewed for falls. MDS coordinator #1 documented 12 residents had fallen during the previous six months. Findings: Res #22 had diagnoses which included dementia, diabetes, benign prostatic hyperplasia, and diarrhea. A care plan, dated 04/04/22, documented the resident at increased risk for falls r/t confusion, forgetfulness, impaired judgement and safety awareness, potential vision impairment. The care plan, read in part, .DX Alzheimer's, glaucoma 02/08/22, I bumped my arm in the shower and obtained a skin tear. Tx orders written. 06/24/22 fall without injury. 06/30/22 I was found in my room, on my left side, laying next to my fall mat. No injury. 07/01/22 Witnessed fall in living room. No injury. 07/05/22 Unwitnessed non-injury fall. 07/7/22 I was found laying on my fall mat next to bed. I wanted to use the BR. No injury. 07/10/22 Unwitnessed non-injury fall. 07/16/22 Found on fall mat by bed. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to attempt appropriate alternatives prior to installing side or bed rails; conduct a thorough assessment for the need of a side/bed rail; failed to ensure the resident and/or resident representatives were educated related to risk of side rails; and the informed consent documented the required components for two (#7 and #13) of two residents whose beds were equipped with side/bed rails. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: 1. Res #7 was admitted on [DATE] at 5:19 p.m., and had diagnoses which included sequelae of cerebral infarction, abnormal finding of lung field, and hypertensive heart disease with heart failure. The EHR documented the resident was receiving hospice services from admission. A side rail assessment in the resident's EHR, dated 05/11/23, did not document the resident's size and weight, sleep habits, existence of delirium, cognition, communication, or…

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 a resident's medication was administered and not held without an order to hold based on blood pressure readings for one (#26) of five residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: Res #26 had diagnosis which included hypertension. A physician order, dated 08/06/22, documented the facility was to administer valsartan-hydrochlorothiazide 160-12.5 mg (a medication used to treat high blood pressure) two tablets daily for a diagnosis of hypertension. A quarterly assessment, dated 05/07/23, documented the resident was severely impaired with cognition and required limited to extensive assistance with most ADLs. A care plan, dated 08/18/22, documented the resident was at risk for decline or adverse consequences related to medications for hypertension. The care plan documented an approach to conduct an monthly pharmacy review. A pharmacist review, dated 09/09/22, documented a request for the physician 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 observation, record review, and interview, the facility failed to ensure monthly consultant pharmacist were acted on for two (#8 and #26) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Resident's form documented 28 residents resided in the facility. Findings: 1. Res #8 had diagnoses which included diabetes mellitus with diabetic neuropathy, recurrent depressive disorders, and hypertension. A physician order, dated 07/12/19, documented the facility was to administer five mg of amlodipine (a medication used to treat hypertension) daily for a diagnosis of hypertension. A Extended DRR Report, dated 09/10/22, documented a pharmacist recommendation to add hold parameters for blood pressure to the amlodipine order. The facility was not able to provide a physician response to the recommendation and the order remained unchanged. An Extended DRR Report, dated 10/07/22, documented Sliding scale insulin use is on the Beers Criteria List, no longer recommended in LTC setting due to higher risk of hypoglycemia without improvement 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 observation, record review, and interview, the facility failed to obtain the following information from the hospice services, the hospice care plan, election form, physician certification, hospice medication specific to the resident, the hospice physician orders, for one (#7) of one resident reviewed for hospice services. The Resident Census and Conditions of Residents form documented three residents who resided at the facility received hospice services. Findings: Res #7 was admitted on [DATE] and had diagnoses which included sequelae of cerebral infarction and nonspecific abnormal finding of lung field. A physician order, dated 05/15/23, documented to admit the resident to hospice care. An admission assessment, dated 05/17/23, documented the resident was severely impaired in cognition, required extensive to total assistance with ADLs, and was receiving hospice care. On 07/25/23 at 11:23 a.m., Res #7 was observed lying in bed. The resident appeared to be without pain and was unable to be interviewed. A…

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

Based on record review and interview, the facility failed to follow their QAPI program policy. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: A facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February 2020, read in part, .Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurements; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed . On 07/31/23 at 6:12 p.m., the administrator was asked how the facility came up with areas of improvement to work on. The administrator stated the facility utilized areas of concern brought up in morning meetings, resident complaints, and environmental issues occurring in the facility. When asked about how data for QAPI issues was attained, 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.

Based on record review and interview, the facility failed to ensure a DNR form was signed by an individual who was authorized to sign for a resident in the event the resident could no longer speak for themselves for one (#15) of one resident sampled for advanced directives. The Resident Census and Conditions of Residents form documented 20 residents who resided in the facility had advanced directives. Findings: Res #15 had diagnoses which included diabetes, cerebrovascular disease, and depressive episodes. Res #15's DNR form, dated 10/04/19, was signed by an individual without POA authority to sign for Res #15. A quarterly assessment, dated 06/19/23, documented the resident was intact in cognition and required set up and supervision with most ADLs. On 07/27/23 at 12:30 p.m., the BOM stated Res #15 had been admitted to the facility prior to their starting employment at the facility. The BOM stated the resident was in their right mind and could sign for themselves. The BOM stated the individual who signed the DNR form was not the resident's POA.

Based on observation, record review, and interview, the facility failed to ensure a resident with mental illness diagnoses was referred to OHCA for a PASRR II evaluation on admission to the facility for one (#10) of two residents reviewed for PASRR II. The Resident Census and Conditions of Residents form documented 10 residents residing in the facility had documented psychiatric diagnoses. Findings: Res #10 had diagnoses which included schizoaffective disorder, recurrent depressive disorders, conversion disorder, and mixed anxiety disorders. A physician order, dated 02/01/21, documented the facility was to administer five mg of aripiprazole (an antipsychotic medication) daily for a diagnosis of schizoaffective disorder. An annual assessment, dated 09/06/22, documented the resident currently was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The assessment documented the resident was intact in cognition and received an antipsychotic, antianxiety, and antidepressant medication daily during 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.

Based on record review and interview the facility failed to initiate and maintain an infection prevention and control program designed to help prevent the development Legionellosis and Pontiac fever caused by Legionella bacteria. The Resident Census and Conditions of Resident form documented 28 residents resided in the facility. Findings: An undated policy, titled Reducing the Risk of Legionella in Facility Water Systems Policy, read in part, .The facility will complete the following steps to implement a Water Management Program that considers the ASHREA industry standard and the CDC toolkit. Establish a Water Management Program Team that will meet monthly as needed to address any issues that arise that could pose a threat to water safety. Describe the building water systems using text and flow diagrams. Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits…

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 regular inspection of all bed frames, mattresses, and bed rails, if any, were conducted as part of a regular maintenance program to identify areas of possible entrapment. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: 1. An admission assessment for Res #7, dated 05/17/23, documented the resident was receiving hospice care. A care plan approach, dated 05/22/23, documented the resident's bed would have side rails in place in bed to aide in repositioning and to define the edges of the bed. On 07/25/23 at 11:23 a.m., the resident was observed in their room in bed. The resident was awake and unable to be interviewed. The resident's bed was observed in the high position and full bed rails were observed in the up position on both sides of the resident's bed. The bed was observed to be equipped with a low air loss mattress. 2. A quarterly assessment for Res #13, dated 03/14/23, documented the resident was receiving hospice services. On 07/25/23…

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.