Stillwater Creek Skilled Nursing And Therapy

Based on record review and interview the facility failed to update a care plan with smoking interventions for one #57) of one sampled resident reviewed for smoking. The Administrator identified 66 residents resided in the facility and the list of smoking residents documented eleven residents smoked. Findings: A Smoking Policy and Procedure revised 02/24/20, read in part .To offer the resident the ability to smoke free of danger to self and others .The resident may choose to utilize an electronic cigarette .physicians should be notified to appropriately update care plan and set goals for residents regarding smoking habits . Resident #57 had diagnoses which included, heart failure and type two diabetes mellitus. Resident #57's care plan did not have any interventions or safety measures implemented for smoking. On 03/11/24 at 12:59 p.m., Resident #57 was asked if they smoked. They stated that they were and was able to smoke when they wanted. On 03/12/24 12:44 p.m., the Administrator was asked if Resident #57 was a smoker. They stated the resident had signed a smoking contract, 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 a medication regimen review was responded to timely for one (#9) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility. Findings: Res #9 had diagnoses which included bipolar disorder, insomnia, and depression. A physician order, dated 09/07/23, documented to administer Zoloft oral tablet 50 mg one time per day for depression. A physician order, dated 09/07/23, documented to administer Abilify oral tablet 2 mg one time per day for bipolar disorder. A physician order, dated 10/18/23, documented to administer Trazodone HCL oral tablet 300 mg at bedtime for bipolar disorder. A monthly medication review, dated 12/18/23, documented the pharmacist request to attempt a gradual dose reduction of the residents Zoloft, Abilify, or trazodone. The medication review was not documented as responded to until 02/12/24 in which the physician declined the GDR. On 03/14/24 at 2:51 PM, Corporate consult RN #1 stated if there is not a response within 30 days 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.

Based on record review, observation and interview, the facility failed to ensure residents were treated with respect and dignity, and care in a timely manner for two (#23 and #26) of 24 residents reviewed for dignity and respect. The Resident Census and Conditions of Residents form documented 73 residents resident in the facility. Findings: 1. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they…

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, observation, and interview, the facility failed to maintain a safe, clean, comfortable, homelike environment regarding wheelchair maintenance and air temperatures. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. On 01/23/23 at 4:02 p.m., Res #13 stated she stayed cold all the time and had to wear multiple layers of clothing to stay warm. Res #13 was observed to have on two coats, two sock hats, the hood from one of her jackets, and a pair of gloves. The temperature was taken in the resident's bathroom and it was 68.2 degrees F. The temperature at the resident bed was 68.0 degrees F. There was a white blanket observed folded up on the window ledge but a draft was still felt coming through the window. On 01/24/23 at 11:44 a.m., Res #13's room temperature at the bed was 59.5 degrees and in the bathroom it was 63.1 degrees. On 01/25/23 at 10:40 a.m., the temperature in Res #13's room was 66.7 degrees at the bed and 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 record review and interview, the facility failed to ensure the OHCA was notified after a resident received a significant mental health diagnoses for two (#17 and #37) of three residents reviewed for PASRR. The Resident Census and Conditions of Residents report, documented 72 residents who reside in the facility. Findings: 1. Res #17 was admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 02/28/19, a new diagnosis of psychotic disorder with delusions due to known physiological condition was documented in the resident's diagnoses in the medical record. On 01/27/23 at 10:15 a.m., the DON and corporate nurse consultant #1 stated the OHCA should have been called after the new diagnoses was added on 02/28/19. 2. Res #37 admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 12/03/21, a new diagnosis of delusional disorder was documented in the resident's record. On 01/27/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for two (#6 and #11) of 23 residents whose care plans were reviewed. The facility failed to develop a care plan: a. related to wandering behaviors for Res #11 and b. related to ADL care including refusals to bathe for Res #6. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #6 was admitted to the facility on [DATE] and had diagnoses which included dementia, Parkinson's disease, and seizures. The admission MDS, dated [DATE], documented the resident's cognition was severely impaired, required assistance with ADLs, had not bathed in the last seven days, and had no rejection of care behaviors. On 01/23/23 at 3:53 p.m., Res #6 was observed in her room in bed. The resident was asked if they were getting their baths as scheduled. The resident stated they had not had a bath in five weeks. The resident's bathing record documented…

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

Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for six (#2, 17, 21, 23, 30, and #124) of six residents reviewed for ADL care. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included COPD, dementia, and depressive disorder. A care plan, last revised 11/11/22, documented bathing Tuesday, Thursday, Saturday on the 3-11 shift. Res #2 required one to two staff participation with bathing. Provide Res #2 with a sponge bath when a full bath or shower cannot be tolerated. Res #2 will often refuse showers. A five day assessment, dated 01/03/23, documented the resident was intact with cognition and required extensive assistance with bathing. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. The resident should have received 13 baths during the 30 day time frame. There were two documented baths, six refused…

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

Based on record review, observation, and interview, the facility failed to ensure there was sufficient nursing staff to provide care in accordance with resident care plans for eight (#2, 13, 17, 21, 23, 30, 49, and #124) of 24 residents reviewed for staffing. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #124's admission MDS assessment, dated 12/08/22, documented the resident was cognitively intact, required the assistance of two people with bathing, and had no rejection of care behaviors, The resident's bathing record documented the scheduled times for bathing were Tuesdays, Thursdays, and Saturdays. The record documented for the last 30 days, the resident had 14 opportunities for bathing. The record documented the resident received three showers, refused eight times, and missed three showers. On 01/23/23 at 5:27 p.m., the resident was asked if she received her baths as scheduled. The resident stated sometimes they skip her. She stated she has not had a bath in two weeks. The resident's hair was observed to be…

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

Based on record review, observation, and interview, the facility failed to obtain blood pressures for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. A physician order, dated 05/29/20, documented prazosin 5 mg at bedtime related to hypertensive heart disease with heart failure. Hold if systolic BP <110. A physician order, dated 05/25/21, documented metoprolol ER 50 mg one time a day related to hypertensive heart disease with heart failure. Hold if systolic BP is <110, diastolic BP <60, or pulse <60. A physician order, dated 06/03/21, documented isosorbide 10 mg two times a day related to angina pectoris. Hold for systolic BP <110, diastolic BP <60, or pulse <60. A physician order, dated 11/24/21, documented ranolazine ER 500 mg two times a day related to angina pectoris. Hold if systolic BP < 110 or diastolic BP < 60. An annual 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, observation, and interview, the facility failed to ensure resident call lights were in reach for one (#23) of 24 residents observed for call lights. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequelae of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to his sheet above his shoulder. At that time the resident stated he wanted to be moved because he was hurting and his nose itched. The resident was asked if he could use his call light. He looked over at it and shook his head no. At that time the surveyor initiated…

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

Based on record review, observation, and interview, the facility filed to ensure an allegation of abuse was reported to the State Survey Agency no later than two hours after the allegation was made for one (#21) of one resident reviewed for abuse. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy and procedure, revised 11/01/22, read in part, .C. Director of Nursing/Administrator do initial state report, send in any staff to Nursing/CNA Board Immediately but no later than 2 hours* - If the alleged violation involves abuse or results in serious bodily injury .'' Res #21 had diagnoses which included diabetes mellitus, depressive disorder, and anxiety disorder. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required extensive assistance with bed mobility and total assistance with toilet use and bathing. An incident report, dated 07/17/22 at 4:45 a.m., documented an allegation of neglect. The initial report fax…

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, observation, and interview, the facility failed to ensure a resident received adequate supervision and/or failed to implement interventions to prevent wandering into other resident rooms for one (#11) of one resident reviewed for wandering. The Resident Census and Conditions of Residents report documented 73 residents residing in the facility. Findings: 1. Res #11 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, bipolar disorder, and unspecified anxiety disorder. A quarterly assessment, dated 12/03/22, documented the resident was cognitively impaired, had behavioral disturbances, was independent with walking, and had wandering behaviors which occurred daily. A care plan, last reviewed 12/12/22, was completed and there was no care plan for wandering. On 01/23/23 at 1:00 p.m., Res #11 was observed wandering throughout the facility. On 01/24/23 at 7:48 a.m., Res #11 was observed wandering in room [ROOM NUMBER]…

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, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated for one (#15) of two sampled residents who were reviewed for thorough investigations. The resident census and condition report identified 76 residents resided in the facility. Findings: Resident #15 had diagnoses which included schizophrenia. A quarterly assessment, dated 07/05/19, documented the resident was moderately impaired in cognitive skills for daily decision making, required limited assistance from staff for ambulation and was independent with transfers. A care plan, dated 07/12/19, documented the resident had impaired cognition, due to schizophrenia and his behaviors and mood could fluctuate. He used psychotropic medications related to behavior management. Interventions included to offer the resident reassurance, redirection and one to one supervision as needed. Staff was to monitor and record behaviors of refusing care, hoarding and anxiety exhibited by restlessness. A nurse's note, dated 08/29/19 at 3:03 p.m., documented the resident was…

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

Based on observations, record review and interview, it was determined the facility failed to ensure assistance with activities of daily living was provided in a timely manner for three (#44, #59 and #61) of three sampled residents who were reviewed for activities of daily living. The facility identified 69 residents who required assistance with bathing and 49 residents who required assistance with toileting. Findings: 1. Resident #59 had diagnoses which included transient cerebral ischemic attack and overactive bladder. A quarterly assessment, dated 08/26/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of one person for toileting and bathing. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/14/19, documented a focus related to having bowel and bladder incontinence due to overactive bladder. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check the resident frequently for…

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

Based on observation, record review and interviews, it was determined the facility failed to ensure: ~ supervision was provided to prevent elopements for one (#33) of one sampled resident who was reviewed for eleopements; ~ smoking assessments were completed and supervision was provided to ensure residents did not smoke in their rooms for one (#3) of one sampled resident who smoked; and ~ safe transfers with a lift were provided with the assistance of two staff members for one (#23) of one sampled resident who was reviewed for transfers using a lift. The facility identified 15 residents who smoked and 76 residents who resided in the facility. Findings: 1. Resident #33 had diagnoses which included end stage renal disease and type 2 diabetes mellitus. An admission elopement assessment, dated 07/30/19, documented the resident was a low risk for elopement. An admission assessment, dated 08/08/19, documented the resident was moderately impaired in cognition for daily decision making skills and required limited assistance from staff with activities of daily living. A behavior note, 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 observation, record review and interview, it was determined the facility failed to ensure pain medication was administered in a timely manner for one (#27) of three sampled residents who were reviewed for pain. The facility identified 76 residents who resided in the facility. Findings: Resident #27 had diagnoses which included fracture of the tibia. A discharge assessment, dated 08/10/19, documented she was independent in cognitive skills for daily decision making and had frequent pain rated a four on a scale of 0-10. A care plan, last revised on 09/19/19, documented a focus of acute/chronic pain related to fracture to the shaft of the right tibia, wedge compression fractures to thoracic and lumbar vertebra and spinal stenosis of the lumbar region. The goal was to not have an interruption in normal activities due to pain through the review date. Interventions included to administer Percocet every four hours as needed as ordered; respond immediately to any complaint of pain; monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; 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.

Based on observation, record review and interview, it was determined the facility failed to provide sufficient nurse staff to ensure care was provided in a timely manner for three (#44, #59 and #61) of 14 sampled residents who were reviewed for staffing. The facility identified 76 residents who resided in the facility. Findings: 1. Resident #59 had diagnoses which included transient cerebral ischemic attack and overactive bladder. A quarterly assessment, dated 08/26/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of one person for toileting and bathing. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/14/19, documented a focus related to having bowel and bladder incontinence due to overactive bladder. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check the resident frequently for incontinence and provide incontinent care as needed. On 10/07/19 at 10:13 a.m., the resident was…

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

Based on observation, record review and interview, it was determined the facility failed to ensure a sufficient amount of bedtime snacks were available and offered to residents. The facility identified 75 residents who received meals from the kitchen, and 25 residents were identified as diabetic. Findings: On 10/09/19 at 10:05 a.m., a group meeting with 13 residents was conducted. The residents stated snacks had been available at the nurse's station for those who were capable to help themselves. They stated snacks were not passed on a regular basis to the dependent residents. The residents stated the staff had not been putting out enough snacks for all the residents and some residents would take multiple snacks if they were able to get to the tray first. At 1:50 p.m., the dietary staff was observed preparing the bedtime snacks. DA #1 was asked what was being prepared. He stated 20 bologna and cheese sandwiches were made and cut in half to make 40 servings. The staff would then wrap the half sandwiches individually for the bedtime snacks. The DA stated they would also set out fruit,…

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 interview and record review, it was determined the facility failed to notify the physician and the family in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible…

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, it was determined the facility failed to develop a care plan related to smoking for one (#33) of four sampled residents who smoked. The facility identified 15 residents who smoked. Findings: Resident #33 had diagnoses which included end stage renal disease and type 2 diabetes mellitus. A progress note, dated 09/12/19 at 5:19 p.m., documented the SSD was notified by a CMA that the resident had been smoking in the resident's room. When the SSD went to the resident's room, the pack of cigarettes was observed next to the resident and the lighter was on the bedside table. The resident was reminded of the smoking policy and the SSD requested the staff keep the cigarettes and lighter but the resident refused. According to the admissions coordinator the resident was caught smoking earlier in the day. A behavior note, dated 09/16/19 at 4:05 p.m., documented the resident had been smoking two times that day in the resident's room during the day shift. The resident was informed that smoking in the facility was not ever allowed. There was no care plan…

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 interview and record review, it was determined the facility failed to assess a resident in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible party stated he 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 interview and record review, it was determined the facility failed to document a fall in the clinical record in a timely manner for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible party 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.