Clinton Therapy & Living Center

Based on record review and interview, the facilty failed to transmit MDS assessment data to CMS in the required timeframe for two (#7 and #23) of 12 sampled residents reviewed for MDS assessments. The administrator identified 31 residents resided at the facility. Findings: A facility policy titled MDS Completion and Submission Timeframe's, revised July 2017, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframe's. 1. Resident #7's quarterly assessment, completion date 09/25/24, had a submitted date of 11/05/24. The accepted date was documented as 11/05/24. 2. Resident #23's quarterly assessment, completion date 09/25/24, had a submitted date of 11/05/24. The accepted date was documented as 11/05/24. On 11/07/24 at 10:42 a.m., MDS coordinator #1 was asked what was the policy to ensure MDS assessments were submitted in a timely manner. They stated they had 14 days from date of completion to be submitted. They were then asked to review Resident #7 and Resident #23's quarterly MDS assessments with 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 dish machine temperature and sanitizer concentration and refrigeration temperatures were monitored and logged daily to ensure safe operation and safe storage of potentially hazardous foods during two of two of two kitchen observations. The DON identified 29 residents received nutrition and hydration from the kitchen. Findings: The facility's Dishwashing Machine Use policy, revised 03/2010, documented the temperature and sanitizer concentrations should be monitored and recorded in the facility approved log. On 11/05/24 at 11:18 a.m., there were no logs observed where refrigeration equipment temperatures were to be monitored. On 11/05/24 at 11:26 a.m., [NAME] #2 was observed testing the dish machine temperature and PPM of the sanitizer. An October 2024 dish machine temperature document was observed on the wall and did not have any documentation it was being utilized. On 11/05/24 11:27 a.m., the dietary manager stated the dish machine should be tested and logged on the form before breakfast, lunch and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident and/or their legal representative was informed in writing of treatments and side effects of the use of psychotropic medications for one (#24) of five sampled residents who were reviewed for education, alternative treatments, and consents for psychotropic medication treatments. The DON identified 11 residents who had diagnosis of dementia and 18 residents who received psychotropic medications. Findings: Resident #24 was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective-bipolar type, delusional disorder, depression, and obsessive compulsive behavior. Resident #24's admission assessment, dated 04/25/24, documented they were taking antipsychotic, antianxiety, and antidepressants on a routine basis. The assessment documented the resident's cognition was severly impaired. Resident #24's physician orders, dated 11/05/24, documented the resident was prescribed the following psychotropic medications: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a clean, safe, and comfortable home like environment for residents. The administrator identified 31 residents resided in the facility. Findings: An undated facility Safe Environment policy, read in part, The facility will maintain comfortable and safe temperature levels between 71 and 81 degrees F(Fahrenheit). The policy also read, The facility will be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public. On 11/05/24 at 7:30 a.m., residents were observed in the common area and dining room wearing coats and covered in blankets. The temperature in the dining room was 68.3 degrees F. On 11/05/24 at 7:35 a.m., the corner wall leading into the dining room from the common area was observed. The sheetrock was missing and a metal strip was protruding from the wall. The metal strip was sharp to the touch. This was the main thoroughfare where all residents accessed the dining…

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 prevent sexual abuse for one (#13) of three sampled residents who were reviewed for abuse. The administrator identified 31 residents resided in the facility. Findings: An undated facility policy titled Abuse Policy and Procedure, read in part, Isolating If the accused person is agitated, [they] will be removed from the area and temporarily separated as a therapeutic intervention until [their] agitation is lowered. {name of facility with held} will implement steps aimed at preventing the accused person from visiting other peoples rooms unattended, until [their] behavior is stabilized. The policy also read, Nursing staff shall document the incident and interventions in the Medical Record. 1. Resident #13 had diagnoses which included cerebral aneurysm and muscle wasting with atrophy. Resident #13's quarterly assessment, dated 07/24/24, documented their cognition was intact. On 11/04/24 at 1:22 p.m., Resident #24 was observed to exit their…

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 implement their abuse policy by: a. not reporting abuse to the administrator and investigating immediately; and b. not taking steps to prevent further abuse for two (#13 and #82) of three sampled residents who were reviewed for abuse. The administrator identified 31 residents resided in the facility. Findings: An undated facility policy titled Abuse Policy and Procedure, documented residents had the right to be free from physical abuse, all incidents would be reported to the administrator and investigated immediately, and steps should be immediately implemented to prevent future abuse. 1. Resident #13 had diagnoses which include cerebral aneurysm and muscle wasting with atrophy. Resident #13's quarterly assessment, dated 07/24/24, documented their cognition was intact. On 11/04/24 at 1:22 p.m., Resident #24 was observed to exit their room and go into Resident #13's room. Resident #24 was naked. Resident #13 was observed to yell in a loud…

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 hospice services was care planned for one (#31) of three sampled residents reviewed for closed record review. The administrator identified 31 residents resided at the facilty. Findings: An undated Comprehensive Resident Centered Care Plans policy, read in part , The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's needs and will be complete and current. Resident #31 had diagnoses which included senile degeneration of the brain and dementia. An Order Summary Report, dated 11/05/24, documented Resident #31 had a physician order for hospice. There was no documentation hospice services was care planned. On 11/05/24 at 1:27 p.m., MDS Coordinator #1 was asked the policy and procedure regarding hospice services and where hospice services was documented. They stated the care plan. They were then asked when was hospice services added to a care plan. They stated immediately. They were asked to review Resident #31's careplan and asked if hospice…

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 medications were supplied as ordered for one (#5) of five sampled residents observed during medication administration pass. The administrator identified 31 residents resided in the facility. Findings: A Medication and Treatment Orders policy, revised July 2023, read in part, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. An undated Certified Med Aide job description, read in part, monitor medications to ensure adequate accountability measures were taken when medications are ordered. Resident #5 had diagnoses which included congestive heart failure, bipolar, depression, and hypertension. A Physician order, dated 06/17/24, documented Resident #5 received clonidine HCL (blood pressure medication) 0.2 mg by mouth three times a day. On 11/05/24 at 7:54 a.m., during an observation of a medication pass, CMA #1 stated Resident #5's clonidine 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.

Based on record review and interview, the facility failed to ensure a physician order was completed for one (#14) of five sampled residents reviewed for unnecessary medications. The DON identified 18 residents who received psychotropic medications. Findings: A Medication and Treatment Orders policy, revised July 2016, read in part, orders for medications and treatments will be consistent with principles of safe and effective order writing. A Medication Orders policy, revised January 2018, read in part, new handwritten orders by the prescriber while in the facility. The nurse on duty at the time the order is received enters it on the physician order sheet/telephone order sheet/electronic medical record. A Antipsychotic Medication Use policy, revised November 2023, read in part, The physician shall respond appropriately by changing or stopping problematic doses or medications. Resident #14 had diagnoses which included senile degeneration of brain, dementia with other behavioral disturbance, and bipolar type. A Note to Physician/Clinician pharmacy report, dated 09/27/24, documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update a care plan after an assessment for high risk of elopement and a documented event of a missing resident for one (#1) of four sampled residents reviewed for care plans. The DON identified the census was 32. Findings: Res #1 was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, delusional disorder, anxiety disorder, and bipolar type schizoaffective disorder. A Care Plan, initiated 06/11/24, documented the resident was an elopement risk/wanderer and had a history to leave the facility unattended. Interventions included: a. assess for fall risk, b. distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book, c. identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. d. monitor for fatigue and weight loss, e.…

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 supervision to prevent an elopement for one (#3) of three sampled residents reviewed for elopement. The Administrator identified 31 residents resided in the facility. The MDS coordinator identified three residents who were at risk for elopement. Findings: An Elopement policy, revised 2007, read in part .Staff shall investigate and report all cases of missing residents . Resident #3 had diagnoses which included Alzheimer's, dementia and delusional disorder. A Wandering Risk Scale, dated 04/29/24 documented Resident #3 was a low risk to wander. A Behavior Note, dated 04/30/24 at 3:01 p.m., .Resident went outside to smoke and [the resident] started to walk off stating [they] was going home. Staff informed this nurse and was able to get [the resident] to come back inside . A Health Status Note, dated 04/30/24 at 9:51 p.m., read in part .does exit seek . A Release of Responsibility for Outside Activity, dated 05/01/24 at 2:30 P.M., had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an effective pest control for four (#1, #4, #6 and #7) of four sampled residents reviewed for pest control. The Administrator identified 31 residents resided in the facility. Findings: A Pest Control policy, undated, read in part .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . A Bed Bugs, Preventing and Managing Infestations of policy, revised August 2011, read in part .Staff will employ infection control strategies to prevent and manage infestation of bed bugs .Identification .check resident rooms at night when bed bugs are active .Remove and/or treat all infested materials using non-chemical methods, including: .Washing and drying bedding, linens, and clothing at a high temperature; vacuuming or steam cleaning floors, mattresses, and any porous surfaces that cannot be machine-washed:…

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 staff followed their policy to report an allegation of abuse to the Administrator for one (#10) of four sampled residents reviewed for abuse. The Administrator identified 31 residents resided in the facility. Findings: An Abuse Policy and Procedure policy, read in part .Immediate reporting. ALL allegations of maltreatment, including .verbal abuse .must be reported immediately to the Administrator by a Facility employee or immediate supervisor . Resident #10 had diagnoses which included acute respiratory failure and depressive disorder. On 06/12/24 at 8:40 a.m., CNA #2 was asked if they had ever heard staff curse or talk in a demeaning was to residents. They stated Yes. They were asked who and when. CNA #2 stated, This weekend by the nurses station there was a verbal altercation with [LPN #1] and [Resident #10]. I was coming down the hall heard [Resident #10] called [LPN #1] a bitch. then [LPN #1] stated 'Don't ever call me a bitch you look like a pig, you smell like a pig, and you breathe like a pig'. I looked at LPN…

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 resident rights were posted. This had the potential to affect 35 residents in the facility. LPN #1 identified the census was 35. Findings: On 03/11/24 at 6:05 p.m., and on 03/12/24 at 10:40 a.m., tours of the common areas that were accessible to residents was completed. The resident rights were not located. On 03/14/24 at 11:30 a.m., the Administrator was asked if the resident rights were posted in any of the common areas that were accessible to all residents. A tour of the halls and common areas were conducted with the Administrator. They stated, I guess they aren't posted.

Based on observation, record review, and interview, the facility failed to: a. assess a resident's physical limitations to prevent psychological abuse, and b. follow their abuse policy to fully investigate and report allegations of neglect for one (#5) of three residents reviewed for abuse. LPN #1 identified the facility census was 35. Findings: An undated, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention policy, read in parts, .Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .occurs when .staff fails .delivery of patient/resident care and service to assure care is provided as required .Mental abuse includes .humiliation, harassment, treats of punishment or deprivation .Residents .shall be protected .staff assigned have knowledge of the individual residents' care needs .identify .patterns, and trends .Investigate different types of incidents .Report all alleged violations .immediately .have evidence that all alleged violations are thoroughly investigated . Resident #5 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.

The facility failed have a system in place to ensure medications were available for one (#1) of three sampled residents reviewed for medication availability. LPN #1 stated the facility census was 35. Findings: Resident #1 had diagnoses to include ankylosing spondylitis, depressive episodes, and anxiety. Physician Orders, dated 05/26/23, documented Resident #1 was to be administered: a. Elderberry Immune Complex, two gummies one time a day, b. Turmeric 500 mg, two capsules one time a day, and c. Vitamin E, 1200 units one time a day. Physician Orders, dated 05/27/23 doucmented Resident #1 was to be administered: a. Vitamin C gummies 500 mg one time a day, and b. Vitamin D-3 extra strength, gummies 150 mcg one time a day; The MAR, dated 12/2023, documented the following medications were held and not administered: a. Elderberry Immune Complex from 12/29/23 to 01/01/24, b. Turmeric from 12/12/23 to 12/19/23, and c. Vitamin E from 12/12/23 to 12/19/23 and, from 12/29/23 to 01/01/24. The clinical record did not contain signed physician orders to hold the medication or an entry 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 coordinate care and services with mental health providers for one (#1) of three residents reviewed for mental health services. The facility census was 35. Findings: Resident #1 had diagnoses to include depression. A Physician Order, dated 05/26/23, documented staff were to complete behavior monitoring every shift for scratching, itching, biting, sexual inappropriate behavior, hitting, attention seeking, hand wrenching, cussing, elopement attempts, refusal of care or hallucinations. The behaviors were to be documented in the clinical record. A Care Plan, dated 06/26/23, documented Resident #1 had behavioral problems to make frequent, and false statements and allegations against others and threatens to call the state complaint department. A Physician Order, dated 07/23/23, documented mental health services were to evaluated and treat Resident #1 as indicated. A Progress Note, dated 07/23/23, documented Resident #1 was seen by mental health staff , on 07/21/23, and no changes in order or care plan were made at the time 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 observation, record review, and interview, the facility failed to ensure a resident receiving 1:1 supervision was free from confinement, restriction, or isolation for one (#1) of one sampled resident who was reviewed for involuntary seclusion. The administrator identified 35 residents resided in the facility. Findings: An Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention policy, undated, read in parts, .Involuntary Seclusion is defined as separation of a resident from other residents .or confinement to her/his room .against the resident's will . A Safety and Supervision of Residents policy, revised December 2023, read in parts, .Recommended timeframe below for safety monitoring .1:1 for 8 hours; 15 minute checks for 8 hours, 30 minute checks for 8 hours, Hourly checks for 8 hours and then return to regular routine monitoring if no further incidents .Monitoring the effectiveness of interventions shall include .Evaluating effectiveness of interventions .Modifying 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 be administered effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial being of each resident. The Administrator failed to ensure: a. resident assessments were completed and submitted in the required time frame, b. each resident had a completed comprehensive care plan to accurately reflect the needs and services of each resident, c. a safe and secure environment was provided to prevent cognitively impaired residents to wander or elope from the building, d. residents were free from abuse and neglect, allegations and known events were identified, victims were protected during investigation, thorough investigations were completed and reported the to required agencies within the required time frame, e. a system was in place for residents and representatives to report grievances, issues corrected, and a response to the parties involved, f. a facility risk assessment was completed and updated to determine the resources necessary to care for the residents on a day…

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 conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents completely both day-to-day operations and emergencies. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings. On 08/15/23 at 2:30 p.m., the Administrator and Corporate Nurse were provided an Entrance Conference Worksheet, and provided verbal instructions to provide a Facility Risk Assessment. On 08/28/23 at 1:50 p.m., the Corporate Nurse was asked to provide the Facility Risk Assessment. The Corporate Nurse stated, I have been looking for it because I knew you would ask. I cannot find one.

Based on observation, record review, and interview, the facility failed to ensure residents were provided dignity for: a. two (#5 and #21) of three sampled residents that required assistance with toileting needs and; b. one (#3) of three sampled residents reviewed for dignity. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility and documented eight residents were dependent on staff for toileting, 18 residents required assistance for toileting, and 22 residents were in a chair all or most of the time. Findings: 1. Resident #3 had diagnosis to include below the knee amputation. An Admission/readmission Screener assessment, dated 07/26/23, documented Resident #3 utilized a wheelchair for mobility. A BIMS assessment, dated 07/26/23, documented Resident #3 was cognitively intact for daily decision making. The clinical record did not contain a baseline care plan, a completed MDS assessment, or a comprehensive care plan. On 08/16/23 at 4:37 p.m., Resident #3 was observed to rest on top of their bed. A manual wheelchair was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and the interview, the facility failed to: a. ensure advanced directives were offered for one ( #13) of 16 sampled residents reviewed for advanced directives, and b. ensure code status for DNR or CPR was accurately documented in the clinical health record for two (#4 and #13) of 16 sampled residents reviewed for code status. The Resident Census and Condition of Residents report, dated [DATE], documented 37 residents resided in the facility. Findings: 1. Resident #4 had diagnosis of multiple sclerosis, muscle wasting, and abnormal weight loss. A quarterly assessment, dated [DATE], documented, Resident# 4 was not cognitively impaired. A physicians order, dated [DATE], read in part, .I have a DNR in place . A Care Plan, dated [DATE], read in part, . Anytime I am transferred out of the facility a copy of my DNR and Face sheet will be sent . A progress note, dated [DATE], read in part, .Informed hospice nurse of resident's wish to rescind DNR status . On [DATE] at 2:56 p.m., Resident # 4 stated…

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 NOMNC and ABN was provided for a facility initiated discharge from Medicare Part A services with days remaining for three (#15, 24, and #58) of three sampled residents reviewed for beneficiary notices. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. The Entrance Conference Worksheet, undated, documented 12 residents were discharged from Medicare Part A services with days remaining in the last six months. Findings: 1. Resident #15 was admitted to Medicare Part A Skilled Services on 06/15/23. The last covered day of services was on 07/15/23. The SNF Beneficiary Protection Notification Review form documented NOMNC and ABN were provided to the resident at the time of discharge from skilled services. 2. Resident #24 was admitted to Medicare Part A Skilled Services on 03/11/23. The last covered day of services was on 04/14/23. The SNF Beneficiary Protection Notification Review form documented NOMNC and ABN were provided to the resident at the time…

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 interview, the facility failed to maintain a safe homelike environment to ensure: a. blue painters tape was not used to repair a broken toilet in room [ROOM NUMBER]'s bathroom, b. tiles in the common area were not missing, cracked, stained, and buckled from water damage in common areas accessed by residents, and c. electrical outlets were covered in room [ROOM NUMBER]'s bathroom next to the sink The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: A Safe Environment, policy, undated, read in parts, .The facility will maintain all essential, mechanical, electrical .in safe operating condition .The facility will provide a safe, clean, comfortable, and home like environment .The facility will provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . On 08/16/23 at 4:02 p.m., room [ROOM NUMBER]'s bathroom was observed to not have a electrical outlet cover on an outlet 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.

Based on record review and interview, the facility failed to complete comprehensive resident assessments within 14 days of admission to the facility for three (#14, 21, and #151) of three sampled residents reviewed for comprehensive assessments. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. Resident #14 was admitted to the facility, on 05/20/23, with diagnoses to include dementia, emphysema, respiratory failure, alcohol dependence, and bipolar disorder. The resident assessment logs, documented: a. an entry to the facility was initiated on 05/20/23; and b. an admission assessment was initiated on 05/20/23 and remained in progress. 2. Resident #21 was admitted to the facility, on 07/18/23, with diagnoses to include bacteremia, diabetes mellitus, encephalopathy, and respiratory failure. The resident assessment logs, documented: a. an entry to the facility was initiated on 07/18/23 and remained in progress; and b. an admission assessment was initiated on 08/21/23 and remained in progress. 3. Resident #151 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.

Based on record review and interview, the facility failed to ensure the resident assessments were transmitted within 7 days of completion for three (#17, 13, and #9) of three sampled residents reviewed for the transmission of resident assessments. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. The Resident Assessment and Transmission Logs for Resident #17, documented: a. On 03/28/23, a Medicare 5-day Assessment had been exported but not accepted, and b. On 04/03/23, an End of Medicare Part A Stay Assessment had been exported but had not been accepted. 2. The Resident Assessment and Transmission Logs for Resident #13, documented: a. On 03/24/23, a Medicare 5-day Assessment had been exported but not accepted, and b. On 04/20/23, an End of Medicare Part A Stay Assessment had been exported but not accepted. 3. The Resident Assessment and Transmission Logs for Resident #9, documented: a. On 04/20/23, an Annual Assessment had been exported but not accepted, and b. On 08/15/23, a Quarterly Assessment was 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 record review and interview, the facility failed to ensure baseline care plans were completed for two (#14 and #21) of three sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. Resident #14 had been admitted to the facility, on 05/20/23, with diagnosis to include dementia, cerebral vascular disease, bipolar disorder, alcohol dependence, emphysema and respiratory failure. The clinical record did not contain a baseline care plan. On 08/24/23 at 2:25 p.m., the Administrator was asked what interventions were placed for Resident #14 on the baseline care plan. They stated there is not a baseline care plan. 2. Resident #21 was admitted to the facility, on 07/16/23, with diagnoses to include bacteremia, diabetes mellitus-type 2, encephalopathy, and respiratory failure. The clinical record did not contain a baseline care plan. On 08/25/23 at 9:58 a.m., the ADON was asked what concerns were identified and interventions placed on the resident's baseline care…

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

Based on record review and interview, the facility failed to ensure comprehensive care plans were completed for two (#14 and #21) of three sampled residents reviewed for comprehensive care plans. The Resident Census and Condition of Residents, report, dated 08/16/23, documented 37 residents resided in the facility. Findings: 1. Resident #14 had been admitted to the facility, on 05/20/23, with diagnosis to include dementia, cerebral vascular disease, bipolar disorder, alcohol dependence, emphysema and respiratory failure. The clinical record contained a comprehensive care plan, dated 08/17/23, two days after Resident #14 had been discharged from the facility. On 08/24/23 at 3:30 p.m., in the presence of the Administrator, and DON was asked to review Resident #14's nursing care plan and identify the nurse that had completed the care plan. There was no response from the DON. The Administrator stated, That has my name, but I did not do it. They were asked if Resident #14 was admitted , on 05/20/23, why did the resident not have or need a care plan until two days after discharged to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure ADL care was provided for dependent residents for three (#5, 6, and #9) of five sampled residents reviewed for ADL's. The Resident Census and Conditions of Residents report, dated 08/16/23, documented the 37 residents resided in the facility. Six residents were dependent for bathing and 18 required assistance. Eight residents were dependent for assistance with toileting and eleven required assistance. Findings: An undated, Activitied of Daily Living (ADLs)/Maintain Abilities policy, The facility will provide care and [NAME] for the following activities of daily living .bathing, dressing, grooming,,,toileting .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming, and personal and oral hygiene . 1. Resident #5 had diagnoses which included muscle wasting and atrophy, paralytic gait, hemiplegia, and hemiparesis following a stroke. A Quarterly Assessment, 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.

Based on record review and interview the facility failed to monitor for side effects related to the use of psychotropic and opioid medications for three (#53 7, and #21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated on 08/16/23, documented 37 residents resided in the facility, and 18 residents received psychoactive medications. Findings: 1. Resident #53 had diagnoses which included pain, quadriplegia, schizoaffective disorder, anxiety, schizophrenia, major depressive disorder and muscle spasms. A Physician Order, dated 02/02/22, documented to administer trazadone 50 mg one tablet by mouth at bedtime. A Physician Order, dated 02/04/22, documented to administer Sertraline 50 mg one tablet by mouth one time a day. A Physician Order, dated 02/24/22, documented to administer Depakote tablets 250 mg one tablet by mouth two times a day. A Physician Order, dated 05/09/22, documented to administer Lorazepam 0.5 mg one half tablet by mouth two times a day. A Physician Order, dated 09/13/22, documented to administer…

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 psychotropic medication was not prescribed on an as needed bases for greater than 14 days without a physician documented rationale for two (#3 and #21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility, and 18 residents received psychoactive medications. Findings: 1. Resident #3 had diagnosis to include bipolar depression with psychotic features, major depressive disorder and anxiety. Physician Orders, dated 07/26/23, documented Resident #3 was to be administered: a. Lorazepam every 8 hours as needed for anxiety and restlessness, and b. Zyprexa [Olanzapine] 5 mg every 12 hours as needed for a psychotic disorder. The clinical record contained no documentation Resident #3 had been re-evaluated every 14 days, a physician had documented a rationale for the continued use of prn psychoactive medications, or a stop date to no longer administer the as needed psychotropic medications. 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: a. vaccinations were not beyond the expiration date, and b. controlled medications that were to be destroyed were stored in a double lock. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: A Receiving Controlled Substances, dated January 2018, read in part, .Medications listed in Schedules II, III IV, and V are stored under double lock. On 08/23/23 at 2:10 p.m., medications were observed in the refrigerator in the mediation room. Twenty-nine fluzone influenza vaccines were dated with an expiration date of 06/30/23, and two pneumonia vaccinations were observed with an expiration date of 09/11/22. On 08/23/23 at 2:20 p.m., the DON was asked to observe the vaccination syringes and review the expiration dates. They were asked if the vaccinations should have been disposed of. They stated, Yes. They were asked if any resident had received a pneumonia vaccination since 09/11/22. They stated they would look. On 08/23/23 3:05 p.m.,…

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 food items in the refrigerator were labeled with the date for one of three refrigerators observed. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. The Corporate Nurse #1 identified 37 residents received nutrition from the kitchen. Findings: A Infection Control-Food Handling policy, undated, read in part, .Food should be properly labeled . On 08/15/23 at 2:30 p.m., during a tour of the kitchen, the following items were observed in a refrigerator: a. a plastic bag containing cooked bacon with no date label, b. a plastic bag containing cooked scrambled eggs with no date label, c. a pan containing tuna salad covered in a plastic wrap with no date label, d. two plastic bags of shredded white cheese with no date label, and e. a pan of cream of wheat covered in plastic had no date label. On 08/15/23 at 2:38 p.m., [NAME] #1 was asked what the policy was on labeling left overs in the refrigerator. [NAME] #1 stated, We label them with 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 QAPI program was in place to identify areas of concerns or deficient practice, implement plans of correction, or improve the identified concerns with resident care. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. On 08/15/23 at 2:30 p.m., the Administrator and Corporate Nurse were provided an Entrance Conference Worksheet, and given verbal instruction to provide information regarding the QAA committee and the facility's QAPI plan. On 08/28/23 at 4:08 p.m., the Corporate Nurse, DON, and ADON were asked what members are included on the QAPI committee. The Corporate Nurse stated, the medical director, social services, Administrator, DON, DM, maintenance, and MDS coordinator. The Corporate Nurse was asked how often the QAPI committee meet. They stated the committee meets quarterly, but also have a monthly QAPI to review triggers for residents, and have a stand up meeting every morning with nursing, the administration and all department head. 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 Tuberculin tests were administered according to policy for four (#55, 21, 3, and #7) of five sampled residents reviewed for immunizations. The Resident Census and Condition of Residents report, dated 08/16/23 documented 37 residents resided in the facility. Findings: A Policy for TB Infection Control Program policy, dated 12/30/05, read in parts, .It shall be the policy and procedure of [Name of Facility] that all new residents .will receive a two-step tuberculin skin test (TST). This testing will be completed within 30 days of admission to .this facility .The TST will be separated by at least 1-3 weeks. Results of the TST will be read within 48-72 hours from the time of administration . 1. Resident #55 had diagnoses which included high blood pressure, congestive heart failure, type two diabetes mellitus and atrial fibrillation. A Clinical Immunizations documented Resident #55 was administered a TB test on 07/26/23, and documented results were pending. On 08/24/23 at 10:00 a.m., the Corporate Nurse was asked what…

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 Residents were offered the pneumococcal vaccination for four (#55, 21, 3, and #7) of five sampled residents reviewed for pneumococcal vaccinations. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility, and 10 residents had received the pneumococcal vaccination. Findings: A Influenza and Pneumococcal Disease Prevention policy, revised January 2018, read in part, .Residents should be offered a pneumococcal vaccine in accordance with the CDC recommended immunizations schedule . 1. Resident #55 had diagnoses which included high blood pressure, congestive heart failure, type two diabetes mellitus and atrial fibrillation. The clinical health record did not document Resident #55 had been assessed and offered the pneumococcal immunization. 2. Resident #21 had diagnoses which included type two diabetes mellitus and cerebrovascular disease. The clinical health record did not document Resident #21 had been assessed and offered the pneumococcal immunization. 3.…

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 residents were offered the COVID-19 vaccination for five (#55, 56, 21, 3, and #7) of five sampled residents reviewed for COVID-19 vaccinations. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: A COVID-19 Vaccine policy, dated 04/08/22, read in parts .COVID-19 Vaccinations and boosters will be offered to .all Residents .The Information to be Documented .Resident or Representative was provided education .Resident/Representative Consented to the Vaccine Which Vaccine was Administered .Which Dose was Administered .Date of Vaccination .If no, reason for Refusal .Contraindication .refusal . 1. Resident #55 had diagnoses which included high blood pressure, congestive heart failure, type two diabetes mellitus, and atrial fibrillation. The clinical health record did not document Resident #55 had been offered the COVID-19 vaccination. 2. Resident #56 had diagnoses which included type one diabetes mellitus, systolic congestive heart failure and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a functioning call light system for two (#5 and #4) of sixteen sampled residents reviewed for a functioning call light system. The Resident Census and Condittion of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: An undated Safe Environment policy, read in part .The facility will be adequately equipped to allow resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities . 1. Resident #5 had diagnoses which included, muscle wasting and atrophy, paralytic gait, hemiplegia and hemiparesis following a stroke. A Quarterly Assessment, dated 08/15/23, documented the resident had no cognitive impairment and needed extensive assistance with two staff for bed mobility, transfers, dressing, toileting and personal hygiene. On 08/23/23 at 07:58 a.m., Resident #5 triggered…

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 develop, implement, and maintain a staff education plan for six (CNA #1, CNA #4, CNA #5 ,CNA #7, the CDM, and the Administrator) of six sampled employees for staff education. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: A Staff Education Plan policy, undated, read in parts, .it is the policy of the facility to provide a staff education plan in accordance with state and federal regulations .The facility will develop, implement, and maintain a written staff education plan .The facility will ensure the staff education plan includes both pre-service and annual requirements .The staff education plan shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas; a. Prevention and control of infection, b. Fire prevention, emergency procedures - life, safety, and disaster preparedness, c. Abuse, neglect, and exploitation d. Accident prevention and safety awareness programs e. Resident rights 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 record review and interview, the facility failed to honor the resident's choice of bathing for one (#18) on one sampled resident reviewed for preference of bathing. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings: Resident #18 had diagnoses to include chronic respiratory failure, morbid/severe obesity, diabetes mellitus, need for assistance with personal care, and depression. An Annual Assessment, dated 11/18/22, documented Resident #18 was cognitively intact, participated in the assessment, and preference to choose clothing, care of personal belongings and to choose the type of bathing was very important. An ADL care plan, last revised on 11/30/21, read in parts, .ADL self care performance deficit .bathing/showering .able to bathe self with limited assist .provide sponge bath when a full bath or shower not tolerated .transfers .independently .requires limited assist from 1 staff member at times . Documentation was provided to support Resident #18 had been bathed. The documentation 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.

Based on observation, record review, and interview, the facility failed to have information posted through out the facility on how to file a grievance, who the contact person was and have grievance forms readily available for residents or representatives to obtain. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility Findings: An undated, Grievance Program policy, read in parts, .Right to file Grievances: residents and visitors have the right to present grievances on behalf of himself or herself or others to the staff or administrator of the facility whether verbally or in writing .Grievance forms will be sporadically placed in easy to find locations in the facility such as nurses' station, Social Service office, to encourage independent usage unless assistance is requested . The Activities Director provided five grievances, dated 04/17/23, out of their grievance book that they had received from Residents. Resident #101 had diagnoses which included diabetes mellitus, COPD, hypertension, GERD, and anxiety. On 08/29/23…

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.

Based on record review, and interview, the facility failed to complete an accurate comprehensive assessment, maintain comprehensive care plans to include personal interventions, and follow physician order for a psychology referral for one (#14) of two sampled residents reviewed for behavioral health. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility, 18 residents had behavioral healthcare needs, and none of the 18 residents had an individualized care plan to support the resident. Findings: Resident #14 was admitted to the facility, on 05/20/23, with diagnoses to include dementia with psychotic disturbance, cerebral vascular disease, tobacco use, hypo-osmolality and hyponatremia, alcohol dependence, and bipolar disorder. Physician Orders, dated 05/20/23, documented Resident #14 was to be administered Chlorpromazine HCl [Thorazine] 50 mg two times a day, and 100 mg at bedtime for dementia with psychotic disturbance. A Progress Note, dated 05/20/23 at 4:30 p.m., read in parts, .Received a call from [local police…

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.