Ashland Post Acute

Based on interview and record review it was determined the facility failed to obtain a consent for use of a mood stabilizer prior to administration for 1 of 5 sampled residents (#54) reviewed for unnecessary medications. This placed residents at risk for lack of consent. Findings include: Resident 54 was admitted to the facility in 10/2024 with a diagnosis of a stroke. Resident 54's Physician Order Details revealed she/he was to be administered Depakote (anti-seizure medication which can be used to treat manic depression) for her/his mental health diagnosis. Resident 54's 2/1/25 Quarterly MDS revealed she/he was cognitively intact. Review of Resident 54's clinical record did not reveal a consent for the use of Depakote to treat her/his mental health diagnosis. On 5/9/25 at 9:09 AM Staff 4 (Resident Care Manager) stated on 1/31/25 Resident 54 was started on Depakote as a mood stabilizer. Staff 4 stated Depakote was classified as an anti-seizure medication. Therefore, she did not obtain a consent and did not review the risks and benefits of the medication with Resident 54. On 5/9/25…

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

Based on observation, interview, and record review it was determined the facility failed to ensure a resident had a bed to accommodate her/his needs, a room had adequate room for transfers, and a resident's call light was within reach for 3 of 4 sampled residents (#s 17, 26, and 54) reviewed for environment. This placed residents at risk for lack of a homelike environment and inability to call for assistance. Findings include: 1. Resident 17 was admitted to the facility in 6/2021 with a diagnosis of shoulder surgery. Resident 17's 4/4/25 Quarterly MDS revealed she/he was cognitively intact and was at risk for pressure ulcers. On 5/5/25 at 10:50 AM Resident 17 stated her/his bed was not comfortable and she/he reported her/his concerns to staff. On 5/7/25 at 3:29 PM Resident 17 was observed on an air mattress on her/his back with her/his arms resting at her/his side. Residents 17's arms were at the edge of the bed. Resident 17 stated she/he needed a bigger bed. On 5/8/25 at 9:30 AM Staff 1 (Administrator) stated Resident 17 always had a 36 inch wide bed and was not aware of concerns…

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 ensure a resident was offered information to formulate an advance directive (AD) for 1 of 3 sampled residents (#54) reviewed for AD. This placed Residents at risk for end-of-life choices not being honored. Findings include: The facility's Advance Directives policy last revised on 9/2022 revealed if a resident did not have an AD the resident or representative was given the option to accept or decline assistance in establishing ADs. Nursing staff would document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Resident 54 was admitted to the facility in 10/2024 with a diagnosis of a stroke. Resident 54's care plan revised on 12/16/24 revealed Resident 54's Advance Directive indicated a POLST [physician orders for life sustaining treatment] indicated she/he was to be treated if found without a pulse and respirations and the residents AD and/or POLST for treatment would be in the resident's medical record at all times. Resident 54's 1/30/25 Quarterly Social…

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 have a grievance policy which included a reasonable time frame to complete review of grievances and timely resolution for a resident's grievance for 1 of 2 sampled residents (#26) reviewed for oxygen. This placed residents at risk for unaddressed concerns and grievances. Findings include: Resident 26 was admitted to the facility in 4/2025 with diagnoses including respiratory failure and chronic pain. The facility's 8/1/2024 Grievance Policy and Procedure indicated to complete grievances with appropriate action and follow-up. The 4/12/25 admission MDS indicated Resident 26 had a BIMS score of 13 (cognitively intact) and required assistance with eating. A 4/9/25 physician order indicated Resident 26 was to receive continuous oxygen at 2.5 liters per minute. A 4/23/25 Grievance/Complaint Report, submitted by Witness 3 (Family), indicated there were concerns related to Resident 26's oxygen, meal assistance, pressure ulcer interventions, and missing items. The grievance report indicated Resident 26's 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 ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#31) reviewed for medications. This placed residents at risk for adverse side effects of medication. Findings include: Resident 31 was admitted to the facility in 9/2023 with diagnoses including PTSD (Post Traumatic Stress Disorder) and insomnia. The 4/16/25 clinical psychologist management plan indicated Resident 31 should transition from Ambien (sedative) to an alternative sleep aid and indicated Resident 31 was open to try something else. The 4/2025 and 5/2025 MAR indicated Resident 31 received Ambien nightly from 4/1/25 through 4/30/25, and 5/1/25 through 5/7/25. On 5/8/25 at 4:01 PM Staff 3 (Regional Nurse) acknowledged Resident 31 had not stopped her/his Ambien and her expectation was for staff to follow-up with the psychologist's recommendation.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into her/his care plan for 1 of 5 sampled residents (#54) reviewed for unnecessary medications. This placed residents at risk for unmet behavioral health needs. Findings include: Resident 54 was admitted to the facility in 10/2024 with a diagnosis of a stroke. Resident 54's PASRR II was completed on 1/8/25. The evaluation indicated Resident 54 was assessed due to a history of mental health disorders, suicidal ideations, and aggressive behavior toward staff. Recommendations included: -Environmental and social structuring to assist with Resident 54's behaviors. Encourage the resident to engage with staff and peers and spend time in the fresh air. -Memory cues: place photos of loved ones in her/his room and/or create a memory book with the resident. -Provide art supplies at the bedside to allow her/his ability for creative self expression. -Given Resident 54's reports of being an avid…

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 develop a resident centered care plan for 3 of 4 sampled residents (#s 17, 47, and 62) reviewed for hospice, smoking and incontinence. This placed residents at risk for unmet care needs. Findings include: 1. Resident 17 was admitted to the facility in 6/2021 with a diagnosis of arthritis. Resident 17's 7/2/24 Annual MDS revealed Resident 17 did not refuse care, required substantial assistance with toileting hygiene, and was frequently incontinent. Resident 17's Care Plan last revised 10/12/24 revealed she/he was occasionally incontinent of urine, and staff were to provide incontinence care. Resident 17's care plan also indicated she/he was depressed and behaviors exhibited could include false accusations made against staff, refusing basic care, and increased anxiety with new staff. The care plan instructed staff to re-approach the resident at a later time. Resident 17's 4/4/25 Quarterly MDS revealed she/he was cognitively intact and did not have behaviors, including refusing cares. On 5/5/25 at 11:01 AM…

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

Based on observation, interview and record review it was determined the facility failed to ensure a dependent resident received assistance with ADLs for 1 of 2 sampled residents (#26) reviewed for oxygen. This placed residents at risk for unmet needs and injuries. Findings include: Resident 26 was admitted to the facility in 4/2025 with diagnoses including respiratory failure and chronic pain. A 3/26/25 Hospital Encounter note indicated Resident 26 had a lumbar spinal fusion (surgical procedure that joins two or more sections in the lower back) in 2011 and cervical spine (neck area) surgery in 2015. A 4/10/25 through 5/9/25 CNA Bathing Task indicated Resident 26 refused her/his shower on 4/17/25 and received one shower on 4/21/25. All additional shower opportunties were identified as no (not scheduled for this shift). The 4/12/25 admission MDS indicated Resident 26 had a BIMS score of 13 (cognitively intact), the resident required one staff to assist with bathing and bed mobility, and a shower was not attempted during the seven day review period due to medical concerns. A 4/23/25…

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

Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 2 of 2 sampled residents (#s 2 and 62) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: 1. Resident 2 was admitted to the facility in 3/2025 with diagnoses including anxiety and sepsis (extreme immune response to an infection). The 3/12/25 Activity Assessment indicated Resident 2 liked easy crossword books, painting, and it was very important to do activities with others. The 3/14/25 admission MDS indicated Resident 2 had a BIMS score of 14 (cognitively intact), was at risk for lack of socialization, and required two staff to transfer the resident out of bed. Resident 2 had no activity care plan related to her/his interest in activities. The 4/5/25 through 5/6/25 CNA Activities Task indicated Resident 2 participated in no activities for 30 days. On 5/5/25 at 2:19 PM Resident 2 was observed in bed watching television. Resident 2 stated art activities were not offered…

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 and failed to follow physician orders for a follow-up doctor's appointment for 2 of 3 sampled residents (#s 17 and 24) reviewed for catheter care and hospitalization. This placed residents at risk for tooth decay and delayed care. Findings include: 1. Resident 17 was admitted to the facility in 6/2021 with a diagnosis of arthritis. A 4/4/25 Quarterly MDS revealed Resident 17 was cognitively intact. On 5/5/25 at 10:51 AM Resident 17 stated in 2/2025 she/he had a lung x-ray at 9:00 AM but the physician was not notified of the results until late in the evening. Resident 17 stated she/he was really sickwhen she/he was admitted to the hospital. Progress Notes revealed the following: -2/3/25 the facility physician assessed Resident 17 and an order was obtained for a chest x-ray which was scheduled for 2/4/25. Resident 17's Progress Notes did not have a nursing assessment of her/his respiratory status or the physical condition which warranted a chest X-ray. A radiology results report revealed…

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 ensure a fall investigation was completed timely for 1 of 1 sampled resident (#54) reviewed for falls. This placed residents at risk for a delay in implementing new interventions. Findings include: Resident 54 was admitted to the facility in 10/2024 with a diagnosis of a stroke. Resident 54's 11/1/24 admission MDS revealed she/he was cognitively intact, required assistance with ADLs, did not have a history of falls but was at high risk for falls due to her/his diagnosis of stroke and weakness. Resident 54 required two staff and the use of a mechanical lift for transfers. Resident 54's care plan initiated on 10/25/24 revealed she/he was at risk for falls. Interventions included Resident 54 was to call for assistance for transfers, her/his call light was to be kept within reach, and appropriate footwear was to be worn. A 12/27/24 Progress Note revealed Resident 54 completed working with therapy and was sitting in her/his wheelchair in her/his room. Staff left the room to find additional staff to assist with…

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

Based on interview and record review it was determined the facility failed to ensure a resident's medication was available to administer for 1 of 1 sampled resident (#17) reviewed for pharmacy services. This placed residents at risk for pain. Resident 17 was admitted to the facility in 6/2021 with a diagnosis of arthritis. Resident 17's Encounter Note revealed a Nurse Practitioner visit for her/his medication review and to refill her/his Norco (narcotic medication) prescription. Resident 17's 1/2025 MAR revealed Resident 17 was to be administered Norco every four hours for pain. The MAR revealed it was not administered on 1/30/25 at 4:00 AM, 1/30/25 at 8:00 AM, 1/30/25 at 12:00 PM or 1/30/25 at 4:00 PM. Progress notes revealed the following: -1/30/25 at 5:40 AM waiting for Norco delivery. Physician notified of missed dose. -1/30/25 at 8:39 AM physician was faxed for a new prescription for Norco. -1/30/25 at 3:45 PM Norco-not applicable, nurse notified. Resident 17's 4/4/25 Quarterly MDS revealed she/he was cognitively intact. On 5/8/25 at 8:09 AM Staff 38 (CMA) stated if a resident…

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

Based on interview and record review it was determined the facility failed to provide dental services for 1 of 1 sampled resident (#24) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include: Resident 24 was admitted to the facility in 12/2023 with diagnoses including heart failure and kidney disease. The 3/26/25 Care Conference notes indicated Resident 24 requested a dental appointment. The 4/15/25 care plan revealed Resident 24 had oral/dental health problems and staff were to coordinate arrangements for dental care and transportation as needed. On 5/7/25 at 3:47 PM Resident 24 stated she/he asked staff to schedule her/him a dental appointment for a while but staff had not scheduled one. On 5/9/25 at 12:32 PM Staff 5 (Social Services) stated she was in charge of making dental appointments for residents. Staff 5 acknowledged Resident 24 asked during the 3/26/25 Care Conference for a dental appointment and the appointment was not scheduled. On 5/9/25 at 1:41 PM Staff 3 (Regional Nurse) stated her expectation was for staff to follow-up…

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

Based on observation, interview, and record review it was determined the facility failed to ensure food was served at palatable temperatures for 1 of 5 sampled residents (#56) and 1 of 1 kitchen. This placed residents at risk for food that was not palatable, safe, or appetizing. Findings include: 1. Resident 56 was admitted to the facility in 12/2024 with diagnoses including stroke and heart disease. The 12/23/24 admission MDS indicated Resident 56 was assessed with a BIMS score of 13 (cognitively intact) and required supervision for eating. A 3/26/25 Nutritional Risk Assessment indicated Resident 56 was at risk for decreased food intake because she/he was unable to feed herself/himself. A 4/22/25 revised care plan indicated Resident 56 required one person to assist her/him with meals. A 5/8/25 Diet Slip for Resident 56 indicated no information related to her/his need for dining assistance. On 5/5/25 at 8:29 AM Resident 56 was observed in bed with a meal in front of her/him on the bedside table. Resident 56 stated she/he was waiting for a CNA to return and her/his food was getting…

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 treat residents with dignity and respect for 1 of 3 (#19) sampled residents reviewed for dignity and respect. This placed residents at risk for loss of dignity. Findings include: Resident 19 admitted to the facility in 1/2024, with diagnoses including palliative (end of life) care. Resident 19's 1/11/24 MDS admission Assessment revealed a BIMS score of 8, indicating moderate impairment. Resident 19's care plan dated 1/9/24 revealed she/he was incontinent of bowel and bladder and required two persons to assist her/him with a bedpan. On 1/11/24, the facility reported to the State Survey Agency (SSA), which noted on 1/11/24 at 2:05 PM, Resident 19 requested assistance as she/he needed to use the bathroom. She/he was told by Staff 10 (Former CNA) to go in her/his incontinence brief rather than use the bedpan. Staff 1 (Administrator) had walked by the resident's room and overheard the conversation. Staff 1 intervened, asked Staff 10 to exit the room and requested Staff 3 (RCM) and another aide to assist 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 interview and record review it was determined the facility failed to accurately assess MDS assessments for 1 of 3 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for unassessed pressure ulcer care needs. Findings include: Resident 16 admitted to the facility in 7/2024, with diagnoses including diabetes and heart failure. The 7/3/24 admission Assessment indicated Resident 16 admitted to the facility with a coccyx pressure ulcer. The 7/2024 TARS revealed physician orders to treat Resident 16's coccyx wound from 7/5/24 through the resident's discharge on [DATE]. The 7/9/24 admission MDS indicated Resident 16 did not have a pressure ulcer. The 7/24/24 Discharge MDS indicated Resident 16 did not have a pressure ulcer. On 8/29/24 at 2:00 PM, Staff 2 (DNS) verified the 7/9/24 admission MDS and the 7/24/24 Discharge MDS were coded inaccurately.

Based on interview and record review it was determined the facility failed to provide necessary information to continuing care providers pertaining to the coccyx pressure ulcer treatment for 1 of 3 sampled resident (#16) reviewed for skin conditions. This placed residents at risk for unmet treatment care needs after discharge. Findings include: Resident 16 admitted to the facility in 7/2024, with diagnoses including diabetes. The 7/2024 TARS revealed Resident 16 had a coccyx pressure ulcer. The 7/30/24 Discharge Summary indicated Resident 16 had macerated skin to the coccyx. There was no treatment listed for the care of Resident 16's pressure ulcer to her/his coccyx. On 8/29/24 at 2:00 PM, Staff 2 (DNS) verified Resident 16's Discharge Summary did not include information about Resident 16's coccyx pressure ulcer and treatment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to bathe residents for 1 of 5 sampled residents (#2) reviewed for ADL assistance. This placed residents at risk for lack of hygiene. Findings include: Resident 2 admitted to the facility on [DATE], with diagnoses including heart failure. Resident 2's 4/2023 ADL Bathing documentation revealed from 4/14/23 through 4/30/23, staff did not offer the resident the opportunity to bathe. On 8/27/24 at 9:27 AM, Staff 2 (DNS) verified Resident 2 was not offered the opportunity to bathe from 4/14/23 through 4/30/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to properly assess and treat a pressure ulcer for 1 of 4 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The National Pressure Injury Advisory Panel defines pressure ulcers as: *Stage I: Non-blanchable erythema (redness) of intact skin. *Stage II: Partial-thickness skin loss with exposed dermis. *Stage III: Full-thickness skin loss in which adipose (fat) tissue is visible. Slough and/or eschar may be visible. *Stage IV: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. *Unstageable: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. When slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed.…

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 accurately document in the medical record for 1 of 3 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical records. Findings include: Resident 16 admitted to the facility in 7/2024, with diagnoses including diabetes and heart failure. Review of Resident 16's medical record found the following inaccurate records related to the resident's pressure ulcer staging: -The 7/3/24 admission Assessment indicated the resident admitted to the facility with a Stage III, measuring 1.5 cm x 2.2 cm. -The 7/3/24 Skin Assessment indicated the resident had a Stage II pressure ulcer to her/his coccyx, measuring 1.5 cm x 2.2 cm x 0.5 cm. -The 7/2024 TARS revealed treatment orders for a DTI (Deep Tissue Injury - purple or maroon localized area of discolored intact skin or a blood-filled blister) coccyx wound. -The 7/6/24 Care Plan did not indicate the resident had a pressure ulcer to her/his coccyx. -The 7/9/24 admission MDS indicated the resident did not have any pressure…

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 ensure residents were free from misappropriation of controlled (medications that are counted and stored in a locked area) narcotic and sedative medications for 2 of 2 sampled residents (#s 4 and 6) reviewed for drug diversion. This placed residents at risk for unmet medication care needs. Findings include: Correction of noncompliance related to misappropriation of resident medications was completed on 2/2/22 after the facility conducted an investigation including staff interviews, review of the incident by QAPI and training for staff who monitored and administered medications. On 1/28/22 the facility submitted a FRI to the State Agency related to Witness 1 (Agency Nurse) who was observed by other facility nursing staff to appear impaired. Staff 2 (DNS) and Staff 4 (Resident Care Manager - LPN) checked the controlled medications and discovered two bottles of Resident 6's methadone (used to treat opiod dependence) were missing from a locked container. Staff 2 and Staff 4 further discovered Resident 4's…

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 ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 10, 11, 12, and 13) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 1/11/24 indicated the following employees did not receive their annual performance evaluations: -Staff 10 (CNA), hired on 11/18/21, no evaluation on file for 11/18/22 through 11/18/23. -Staff 11 (CNA), hired on 1/4/22, no evaluation on file for 1/4/23 through 1/4/24. -Staff 12 (CNA), hired on 1/3/17, no evaluation on file for 1/3/23 through 1/3/24. -Staff 13 (CNA), hired on 1/4/13, no evaluation on file for 1/4/23 through 1/4/24. On 1/11/24 at 12:29 PM and 2:10 PM Staff 9 (Infection Control Nurse) stated she would review information and stated no additional annual performance reviews were found for the above staff.

Based on observation, interview, and record review it was determined the facility failed to ensure food for menus were available for 1 of 1 un-sampled resident (#12) observed during kitchen observations. This place residents at risk for lack of honored preferences and nutrition. Findings include: The 11/29/23 Resident Council Minutes revealed group concerns related to the kitchen running out of things including: bacon, sausage, butter, hamburger, and baked potatoes. A 11/29/23 Resident Council Grievance/Concern indicated a concern related to small portions with a response on 12/8/23 by Staff 21 (Dietary Manager) for residents to ask for an additional serving after all residents were served if residents were still hungry. The 12/28/23 Resident Council Minutes revealed the kitchen was always out of stuff and there were no additional servings available if residents requested additional food after all residents were served. 1. Resident 12 was admitted to the facility in 2022 with diagnoses including diabetes and heart failure. On 1/9/24 at 8:33 AM Staff 16 (CNA) stated over the last few…

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

Based on observation, interview, and record review it was determined the facility failed to ensure meals were served at appriopriate temperatures for 2 of 4 sampled residents (#s 38 and 53) reviewed for food. This place residents at risk for lack of meal palatability and satisfaction. Findings include: The 10/26/23 Resident Council Minutes indicated group concerns of cold food including the temperature of food delivered to rooms. The 12/28/23 Resident Council Minutes indicated meals were cold in the dining room. 1. Resident 38 was admitted to the facility in 2023 with diagnoses including UTI and failure to thrive. On 1/8/24 at 1:24 PM Resident 38 was observed in her/his bed with a hamburger on her/his meal plate located on her/his bedside table. Resident 38 stated the food was often too cold to eat. On 1/8/24 during the evening meal the following occurred: -5:23 PM the meal cart arrived to the hall and no staff were observed to assist with the distribution of resident meals until 5:32 PM (nine minutes later). -5:50 PM a meal tray was delivered to Resident 38's room by an…

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

Based on interview and record review, it was determined the facility failed to have a system in place to ensure CNA staff received the required 12 hours of in-service training annually for 3 of 5 sampled CNAs (#s 10, 11, and 13) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 10 (CNA), hired 11/18/21, had 10 hours of documented training from 11/18/22 through 11/18/23. -Staff 11 (CNA), hired 1/4/22, had two hours of documented training from 1/4/23 through 1/4/24. -Staff 13 (CNA), hired 1/4/13, had two hours of documented training from 1/4/23 through 1/4/24. On 1/11/24 at 12:29 PM and 2:10 PM Staff 9 (Infection Control Nurse) stated she would review information and later stated no additional training hours were found for the above staff.

Based on observation, interview, and record review it was determined the facility failed to accommodate resident needs for 1 of 7 sampled residents (#13) reviewed for environment. This placed residents at risk for not being able to call for assistance. Findings include: 1. Resident 13 was admitted to the facility in 2018 with diagnosis including contractures. A 12/23/24 Quarterly MDS revealed Resident 13 had impairment to one side of the upper extremities. A revised 10/8/23 care plan indicated Resident 13 had a contracture of the left hand, was at risk for falls with interventions including to anticipate and meet her/his needs. Resident 13's call light was to be within reach for fall prevention, and staff were to respond promptly to all requests for assistance. On 1/8/24 at 1:15 PM Resident 13 was in bed with her/his call light pad clipped to the upper part of her/his mattress above her/his head on her/his left side. On 1/10/24 the following was observed: -9:30 AM Resident 13 was in bed with bedside table in front of her/him with a cup lying on its side, a reddish liquid was spilled…

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 protect the resident's right to be free from physical abuse for 1 of 1 sampled resident (#21) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 21 was admitted to the facility in 2023 with diagnosis including cellulitis (infection involving the inner skin layer). A 12/2/23 care plan for ADL care indicated Resident 21 required one staff to provide extensive assistance for toileting. A 12/23/23 FRI investigation included a statement by Staff 25 (former CNA) indicating she requested assistance from Staff 15 (CNA) to reposition Resident 21 in bed. Resident 21 hit her/his head on the headboard in the process, and Staff 25 was asked to go home three hours later. The investigation indicated abuse was substantiated for Resident 21. On 1/8/23 at 4:19 PM and 1/10/24 at 1:15 PM Resident 21 stated she/he filed a complaint related to Staff 25 who was rough during her/his care for toileting and when Staff 25 was asked to stop she did not. Resident 21 further stated Staff 25 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 interview and record review it was determined the facility failed to accurately assess 3 of 9 sampled residents (#s 2, 15 and 43) reviewed for medications and ROM. This placed residents at risk for unmet and unidentified needs. Findings include: 1. Resident 2 was admitted to the facility in 2023 with diagnoses including UTI and Parkinson's disease (degenerative disease of the nervous system). The 12/21/23 admission MDS indicated Resident 2 received no antibiotic medication during the last seven days. The 12/2023 MAR indicated Resident 2's last dose of Ciprofloxacin (antibiotic medication) was administered on 12/19/23. On 1/11/24 at 4:36 PM Staff 3 (Resident Care Manager-LPN) acknowledged Resident 2's MDS assessment for antibiotic medication was incorrectly coded. 2. Resident 15 was admitted to the facility in 2022 with diagnoses including muscle weakness, hemiplegia, and hemiparesis (weakness or inability to move one side of the body). The 8/18/23 care plan indicated staff were to apply Resident 15's splint to her/his right hand and right leg. The ROM care plan, last…

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 develop a comprehensive care plan for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of medical interventions. Findings include: Resident 2 was admitted to the facility in 2023 with diagnoses including UTI and Parkinson's disease (degenerative disease of the nervous system). The 12/2023 MAR indicated Resident 2 was administered Lamictal (medication to treat seizures) daily since admission for Parkinson's Disease. A 12/14/23 admission Nursing [Database] had no indication Lamictal was used for Resident 2. The 12/14/23 initial care plan did not indicate Resident 2 had Parkinson's disease. On 1/10/24 at 3:38 PM Staff 15 (CNA) stated she was not aware Resident 2 had Parkinson's disease and thought her/his occasional shakiness was due to lack of food. Staff 15 confirmed information related to Resident 2's Parkinson's disease was not in her/his care plan. On 1/11/24 at 9:22 AM Resident 2 stated her/his symptoms of Parkinson's disease included occasional shaking 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 interview and record review it was determined the facility failed to revise care plan interventions for 1 of 5 sampled residents (# 29) reviewed for hearing and ROM. This placed residents at risk for unmet needs. Findings include: 2. Resident 29 was admitted to the facility in 2023 with diagnoses including diabetes and heart failure. A 12/11/23 Alert Note indicated Resident 29 complained of hearing loss, dizziness and the physician was notified. The 12/2023 MAR revealed Resident 29 had orders for meclizine (medication for motion sickness) as needed for dizziness since 12/19/23 and none was provided. A 1/10/24 revised care plan had no indication Resident 29 had dizziness or hearing loss. On 1/8/24 at 3:37 PM and 1/11/24 at 2:11 PM Resident 29 stated she/he had little assistance with loss of her/his hearing and vertigo (sensation of movement not cause by the physical environment) since she/he arrived to the facility. Resident 29 stated her/his vertigo often impacted her/his success with therapy, her/his ability to move and was unaware of any available medication. On 1/9/24 at…

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

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#18) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 18 was admitted to the facility in 2023 with diagnoses including diabetes. The 12/2023 and 1/2024 TARs instructed staff to have a licensed nurse check Resident 18's fingernails on bath days and trim as needed every Friday for diabetic nail checks. Staff were to document (+) for nails trimmed and (-) for nail trim not needed. The 12/2023 TAR was documented as a check mark completed every Friday. The 1/2024 TAR was documented as a check mark on 1/5/24. There were no + or - documented as instructed. On 1/9/24 Resident 18 was observed to have approximately one-half inch long fingernails with dark debris under her/his index fingers and middle fingers. Resident 18 stated she/he would like to have her/his nails trimmed. On 1/11/24 at 9:32 AM Staff 19 (CNA) stated he observed Resident 18 with long fingernails…

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

Based on observation, interview, and record review it was determined the facility failed to provide a restorative program to prevent decline in range of motion for 1 of 4 sampled residents (#15) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities. Findings include: Resident 15 was re-admitted to the facility in 2022 with diagnoses including muscle weakness, hemiplegia, and hemiparesis (weakness or inability to move one side of the body). The ROM care plan, last revised on 9/5/20, indicated staff were to provide the resident with active and passive ROM. -Active ROM, set up bike in PT gym three times a week. -Passive ROM, right ankle stretches along calf to manage contractor for 30 to 60 seconds. -Apply splint to her/his right hand and right leg. -Set up at the pull bar in the room for five minutes. Restorative Program Notes reviewed from 12/12/23 through 1/10/24 revealed the following: - Staff were instructed to stretch Resident 15's right ankle for 30 to 60 seconds to manage contraction. The documentation indicated Resident 15 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, interview, and record review it was determined the facility failed to ensure interventions for smoking safety were followed for 1 of 1 sampled resident (#30) reviewed for smoking. This placed residents at risk for smoking accidents. Findings include: Resident 30 was admitted to the facility in 2022 with diagnoses including stroke and anxiety disorder. A 6/21/23 Smoking Safety Evaluation indicated Resident 30 was safe to smoke independently and acknowledged understanding of the facility's smoking expectations. An 10/19/23 revised care plan indicated Resident 30 smoked unsupervised, signed in and out at the nurse's station prior to leaving the facility and returned all smoking items to the nurse's station upon her/his return. A 11/11/23 Quarterly MDS revealed Resident 30 was cognitively intact. On 1/10/24 at 4:20 PM Resident 30 was observed in her/his room. Staff 31 (LPN) stated Resident 30 last signed out of the facility on 10/31/23 based on the observation of the log and she could not locate Resident 30's cigarettes and lighter at the East Nurse's station. On…

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

Based on observation, interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#6) reviewed for PASRR. This placed residents at risk for unmet trauma needs and a decrease in their quality of life. Findings include: Resident 6 was admitted to the facility in 2021 with diagnoses including PTSD (Post-Traumatic Stress Disorder), depression, and anxiety. The 10/14/23 Quarterly MDS revealed Resident 6's BIMS score was 14 indicating she/he was cognitively intact, and she/he had a diagnosis of PTSD. The 10/20/21 behavior care plan indicated Resident 6 had a history of anxiety, depression, and PTSD. Interventions indicated staff were to monitor for changes in behavior, and effectiveness of interventions. The care plan also included in the intervention portion self-isolation, threatening statements, agitated/aggressive behavior, upset from loud noises, and difficulty with sleeping. The care plan did not describe the history of trauma, or triggers. On 1/8/24 at 1:05 PM Resident 6…

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 address pharmacy recommendations for 1 of 5 sampled residents (#29) reviewed for medications. This placed residents at risk for inappropriate medication dosing. Findings include: Resident 29 was admitted to the facility in 2023 with diagnoses including diabetes and cardiac disease. On 11/8/23 a pharmacy review identified Resident 29 had an order for Isosorbide (a cardiac medication) extended release formula (ER) 30 mg twice a day. The pharmacist noted this extended release medication should be dosed one time a day and recommended the dose be changed to 60 mg once a day. On 1/10/24 a review of current physician orders included Isosorbide ER 30 mg twice a day for cardiac disease. On 1/11/24 at 3:31 PM Staff 3 (Resident Care Manager-LPN) was asked about the recommendation for Isosorbide. Staff 3 stated she could not locate information the recommendation was addressed with the provider.

Based on interview and record review it was determined the facility failed to monitor psychotropic medications for adverse side effects, monitor for medication effecacy, and receive a consent prior to administration for 2 of 9 sampled residents (#s 6 and 15) reviewed for psychotropic medications and ROM. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 6 was admitted to the facility in 2021 with diagnoses including PTSD (Post-Traumatic Stress Disorder), depression and anxiety. a. A 7/19/23 physician order indicated the resident received Lorazepam (to treat anxiety) daily and trazodone (to treat depression) daily. A 7/26/23 Psychoactive Drug Consent indicated Resident 6 received trazadone. There was no indication of use related to behaviors, actions and thoughts. Resident 6 also received Lorazepam and hydroxyzine (to treat PTSD). Indication of use was for fidgeting. The form indicated the following: -Resident 6 accepted the use of the medication. -Written consent was given by Resident 6. The form did not include Resident…

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

Based on observation, interview and record review it was determined the facility failed to provide a clean and sanitary kitchen and food service related to floors, surfaces, refrigeration, beverage service and food storage and failed to provide a system for nutritionally appropriate food substitutions for 1 of 1 kitchen and 1 of 1 dining room. This placed residents at risk for food borne illnesses and compromised nutrition. Findings include: On 10/3/22 at approximately 2:00 PM the kitchen walk-in refrigerator was observed with the following: -A tub of fruit mixed with a white dressing labeled with a date of 9/26/22 and a pull date of 9/30/22. -A tub of butterscotch pudding labeled with a pull date of 9/30/22. -A metal container of chopped meat and bag of meat links with no label or date. -The floor at the entrance to the refrigerator had an area approximately 12 inches by eight inches without flooring and the flooring edges were rough. The exposed surface was black and bumpy. On 10/3/22 at 2:11 PM a large box of barley was open in the dry storage room and the contents were fully…

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 it was determined the facility failed to provided finished and cleanable window sills in 4 of 34 rooms. This place residents at risk for lack of a sanitary and homelike environment. Findings include: Review of the 5/2018 facility floor plan revealed the facility had 34 resident rooms. On 10/4/22 random observations revealed the window sills in rooms four and five were unfinished and unpainted. In Resident 30's room a line of caulking and water rings were observed on the window sill. On 10/4/22 at 10:49 AM Resident 30 stated her/his window sill was unfinished for some time and remarked that the window sill should be painted to feel more like home. On 10/4/22 at 12:12 PM Staff 16 (Maintenance Director) stated a painter was contracted to finish and paint window sills in residents' rooms during the summer. Staff 16 stated he completed weekly visual audits of rooms and believed all window sills were now finished and painted. On 10/5/22 at 10:31 AM Staff 17 (Housekeeper) stated she told Staff 16 routinely about unpainted window sills in residents' rooms…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were evaluated prior to receiving an antipsychotic medication, had appropriate indications for use, consented to the medication, had behaviors monitored, medications monitored for effectiveness and all psychotropic (drugs that effect brain chemistry) medications were evaluated for 4 of 6 sampled residents (#s 23, 30, 34 and 38) reviewed for medications. This placed residents at risk for lack of consent, indications for use, monitoring of behaviors, evaluation for effectiveness as well as risk for medication side effects. Findings include: 1. Resident 23 was admitted to the facility in early 2022 with diagnoses including stroke and mood disorder. A pharmacist review dated 8/2/22 indicated the need for an AIMS (a scale used to assess the presence of abnormal involuntary movements as a side effect of antipsychotic medications) test to be completed as a result of starting Seroquel (an antipsychotic). A pharmacist review dated 9/6/22 repeated the request to complete an AIMS test.…

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 follow up regarding Advance Directives for 1 of 2 sampled residents (#30) reviewed for Advance Directives. This placed residents at risk for not having their healthcare wishes honored. Findings include: 1. Resident 30 was admitted to the facility in 2022 with diagnoses including diabetes and post-traumatic stress disorder. A 3/23/22 care plan indicated Resident 30 did not want to execute an Advance Directive. Review of the medical record revealed no information related to Resident 30's education or follow up regarding an advance directive. On 10/6/22 at 10:25 AM Resident 30 stated she/he did not have an Advance Directive and the information she/he received about an Advance Directive was provided to her/him at the hospital. On 10/6/22 at 5:19 PM Staff 5 (Social Services Coordinator) confirmed there was no evidence education related to Advance Directives was provided to Resident 30.

Based on interview and record review it was determined the facility failed to notify the physician of blood sugar levels outside of parameters and insulin refusals for 2 of 6 sampled residents (#s 30 and 34) reviewed for medications. This placed residents at risk for physicians being uninformed. Findings include: 1. Resident 34 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 34 had an order for blood sugar level parameters of under 70 or over 400 to notify the physician. A review of the 8/2022 diabetic administration record (DAR) identified 12 times when blood sugar levels were outside of acceptable parameters and the physician notification was noted to be no six times. A review of the 9/2022 DAR identified 31 times when blood sugar levels were outside of acceptable parameters and the physician notification was noted to be no 24 times. On 10/7/22 at 12:29 PM Staff 2 (DNS) stated she expected the physician to be contacted if blood sugars were outside of acceptable parameters. Staff 2 added Resident 34 had orders for parameters for blood sugars over…

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 address respiratory care recommendations and to document oxygen use and care for 1 of 2 sampled residents (#38) reviewed for respiratory care. This placed residents at risk for complications from improper respiratory management. Findings include: Resident 38 admitted to the facility in 6/2022 with diagnoses including sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and restarts) and congestive heart failure. a. The 9/6/22 Quarterly MDS Assessment indicated the resident did not use a continuous positive airway pressure (CPAP) machine (a machine used to keep breathing airways open while asleep). On 6/6/22 Resident 38 was admitted to the hospital. According to the 6/10/22 hospital Discharge Summary the resident was treated for acute on chronic hypoxic (too little oxygen) respiratory failure likely due to being non-compliant with the continuous positive airway pressure (CPAP) machine (a machine used to keep breathing airways open while asleep) for her/his sleep apnea. 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, interview and record review it was determined the facility failed to provide dialysis services for 1 of 1 sampled resident (#13) reviewed for dialysis. This placed residents at risk for lack of dialysis services. Findings include: Resident 13 was admitted to the facility in 2022 with diagnoses including end stage renal disease (ESRD). a. An admission order dated 7/14/22 indicated Resident 13 was to receive a renal diet and a 2000 ml fluid restriction. On 9/9/22 Resident 13 was readmitted to the facility and was to the continue her/his current diet including a 2000 ml fluid restriction. On 10/4/22 at 10:07 AM Resident 13 was asked about fluid restriction and stated she/he was not on a fluid restriction. On 10/6/22 at 1:36 PM Staff 7 (CNA) stated Resident 13 was not on a fluid restriction. On 10/6/22 at 3:16 PM Staff 8 (CNA) was asked about fluid restriction and stated she was not aware of Resident 13 having a fluid restriction and offered to review the [NAME] (CNA care directives). Staff 8…

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 address pharmacy recommendations timely for 1 of 6 sampled residents (#23) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: Resident 23 was admitted to the facility in early 2022 with diagnoses including stroke and mood disorder. On 6/9/22 an order was received for Seroquel (an antipsychotic). On 8/2/22 a Consultant Pharmacist's Medication Regimen Review instructed staff to complete an AIMS (abnormal involuntary movement scale) test as a result of the Seroquel order. On 9/6/22 a Consultant Pharmacist's Medication Regimen Review repeated the request to complete an AIMS test. The medical record indicated an AIMS test was completed for Resident 23 on 9/12/22. On 10/7/22 at 12:04 PM Staff 2 (DNS) was asked about the delay in completing the AIMS test for Resident 23. Staff 2 stated it was completed on 9/12/22 because that was when she realized it was not completed.