La Grande Post Acute Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure a clean, homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an environment that was not homelike. Findings include: On 10/2/23 between the hours of 12:10 PM and 2:52 PM the following environmental issues were observed: - room [ROOM NUMBER]'s walls had multiple thick gouges where the paint and sheet rock were missing and the plastic window blinds were broken and bent; - room [ROOM NUMBER]'s floor was sticky with built-up dark debris along the baseboard, the walls were scraped and gouged and the vertical blinds had missing slats; - room [ROOM NUMBER]'s large window had multiple strips of black, white and green tape adhered to various parts of the window. Do not open was hand written on one of the green strips of tape. Glue or adhesive residue was observed from top to bottom of the window and blue painter's tape outlined the entire window; - room [ROOM NUMBER]'s door…

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 consent was obtained prior to administering psychotropic medications to residents for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for being uninformed about their medications. Findings include: The facility's 9/2017 Informed Consent for Psychotropic Drugs Policy specified when the physician ordered an anti-depressant, the facility obtained informed consent from the resident before the drug was administered. Resident 15 was admitted to the facility in 2/2021 with diagnoses including depression. Resident 15's 9/30/23 Physician Order indicated the resident was prescribed trazodone 50 mg for sleep and depression. Resident 15's 9/2023 and 10/2023 MARs revealed the resident received trazodone daily. Review of Resident 15's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of trazodone nor given the opportunity to consent to the medication. On 10/4/23 at 1:46 PM Staff 3 (Social Services Director)…

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 assessed for self-administration of medications for 1 of 7 sampled residents (#10) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include: The facility's 6/2017 Medication Administration Policy specified medications were not to be left at the resident's bedside for the resident to take later. Resident 10 was admitted to the facility in 3/2020 with diagnoses including heart failure. Resident 10's 9/6/23 Quarterly MDS indicated the resident was cognitively impaired. On 10/5/23 at 8:19 AM Staff 4 (CMA) was observed for medication administration. Staff 4 dispensed the following medications into a plastic cup: - Colace 100mg (stool softener) - furosemide 20mg (diuretic) - losartan 25mg (blood pressure) - gabapentin 100mg (pain) - Jardiance 10mg (diabetes) - Urecholine 10mg (urinary retention) - Eliquis 2.5mg (blood clot prevention) - metformin 500mg (diabetes) - fiber powder, 1 scoop added to a cup of water…

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 complete a comprehensive assessment in activites for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unidentified care needs. Findings include: Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects one's ability to communicate) and dementia. Resident 19's 5/25/23 Annual MDS assessed her/him was unable to answer cognition questions, with memory problems and no recall of information. Section F, Activities Preferences, indicated she/he enjoyed the use of a phone in private, participating in her/his favorite activities and spending time outdoors. The assessment indicated her/his family or representative was not interviewed to obtain answers for the resident. Resident 19's 5/25/23 MDS CAAs for Activities revealed the resident has some cognitive issues that make it difficult for [her/him] to express [her/his] needs. [She/he] seems to have some understanding at times. [She/he] usually just smiles when spoken to…

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

Based on interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 5 sampled residents (#11) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: Resident 11 was admitted to the facility in 4/2023 with diagnoses including congestive heart failure. Resident 11's 7/18/23 Significant Change in Status MDS revealed the resident required extensive assistance from at least one staff in the areas of bed mobility, transfers, dressing, toilet use and personal hygiene. Resident 11's 8/16/23 ADL Self-Care Performance Deficit Care Plan revealed the following: - The resident required supervision with bed mobility. - The resident was able to transfer with supervision. - The resident was able to dress her/himself with supervision. - The resident required limited assistance from one staff person with toilet use. - The resident was able to independently perform personal hygiene tasks after set-up. On 10/5/23 at 9:42 AM Staff 9 (CNA) stated she found…

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 an ongoing program to support individual activity interests and preferences for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unmet psychosocial needs. Findings include: The facility's 7/2015 Activity Program Policy and Procedure indicated the facility provided an ongoing program of activities designed to meet the interests as well as physical, mental and psychosocial well-being of each resident. Activities included individual, small and large group, one-to-one, and independent activities to meet resident's needs, abilities and interests. For residents who remained in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests. Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects ability to communicate), depression, insomnia (sleeplessness) and dementia. Resident 19's 5/25/23 Annual MDS…

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

Based on observation, interview and record review the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 residents (#22) reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Resident 22 admitted to the facility in 8/2023 with diagnoses including abnormalities of gait (manner of walking) and mobility, weakness and dementia. Residents 22's 10/2023 Physician Order, initiated on 8/10/23, directed staff to place the resident's bed against the wall on one side. Resident 22's 10/3/23 In-Room Care Plan directed staff to place the resident's bed against the wall on one side and a fall mat on the opposite side. Review of the 10/3/23 IDT (Inter Disciplinary Team) Review form revealed Resident 22 experienced a fall on 9/28/23 in her/his bedroom. The9/28/23 fall assessment indicated the contributing factor of the fall was the resident's lack of safety awareness. Observations on 10/3/23 at 10:16 AM and 10/4/23 at 9:48 AM and 12:56 PM Resident 22 was observed to sit on her/his bed while the bed was positioned…

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 identify, assess and monitor weight loss for 1 of 4 sampled residents (#11) reviewed for nutrition. This placed residents at risk for unidentified weight changes. Findings include: The facility's 12/2016 Procedure for Managing Weight Loss and Weight Gain indicated the following: - Report abnormal results to the Wellness Director or Community Director, Dietician, physician, and the resident's family if the resident is not their own person: a. A 5 percent or more decrease/increase in weight since the last recorded weight or within the past 30 days. b. A 7.5 percent or more decrease/increase in weight since the last recorded weight or within the past 90 days. c. A 10 percent or more decrease/increase in weight since the last recorded weight or within the past 180 days. - Report changes or differences in health status, service needs, or preferences to the Community Director, Wellness Director, Dietician, and/or designated staff. - Once the attending physician has been notified that their 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 ensure respiratory equipment was properly maintained and used as ordered for 1 of 2 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include: The facility's 1/2015 Maintenance Program-Oxygen Concentrators Policy included the following related to equipment maintenance: - Oxygen tubing, cannula (medical device used to provide supplemental oxygen therapy) and humidifier bottle to be cleaned daily. - Cabinet air filter to be cleaned weekly. Resident 11 was admitted to the facility in 4/2023 with diagnoses including congestive heart failure. Resident 11's 8/16/23 Congestive Heart Failure Care Plan revealed the following: - Oxygen via nasal prongs at two liters as needed to maintain saturation of oxygen over 90 percent and humidified. Resident 11's 8/23/23 Physician Orders included a PRN order for two liters of oxygen per minute via nasal cannula to keep O2 sats greater than 90 percent for hypoxemia. On 10/2/23 at 2:07 PM and 10/3/23 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.

Based on observation, interview and record review it was determined the facility failed to ensure safe and secure storage of medicated powder for 1 of 2 sampled residents (#15) reviewed for skin conditions. This placed residents at risk for receiving incorrect medication and treatment. Findings include: Resident 15 was admitted to the facility in 2/2021 with diagnoses including depression. Resident 15's 9/1/23 Significant Change in Status Assessment revealed the resident was severely cognitively impaired. Resident 15's 5/2023 Physician Order included nystatin powder (a medication used to treat fungal infections) bid to the groin area. On 10/2/23 at 11:30 AM two unlabeled, plastic medication cups filled with white powder were observed on Resident 15's nightstand. Resident 15 stated staff applied the powder from those cups to her/his groin area every day for her/his rash. On 10/5/23 at 12:39 PM Staff 12 (LPN) stated medicated powders were stored in a locked treatment cart. Staff 12 stated medicated powders, such as nystatin, should be applied by the nurse and not left in a resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control practices during medication administration for 4 of 5 sampled residents (#s 10, 17, 23 and 131) observed for medication administration. This placed residents at risk for spread of infection. Findings include: The facility's 3/2018 Handwashing/Hand Hygiene Policy specified hand hygiene was the primary means to prevent the spread of infection and should be performed before and after preparing medications. Resident 10 was admitted to the facility in 3/2020 with diagnoses including heart failure. Resident 17 was admitted to the facility in 8/2021 with diagnoses including stroke. Resident 23 was admitted to the facility in 5/2023 with diagnoses including lung disease. Resident 131 was admitted to the facility in 9/2023 with diagnoses including heart failure. On 10/4/23 at 11:14 AM Staff 4 (CMA) dispensed and administered Resident 131's medications. At 11:17 AM Staff 4 returned to the…

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

Based on observation, interview and record review the facility failed to ensure reisdent rooms were designed and equipped for adequate privacy for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for lack of priviacy and dignity. Findings include: Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects ability to communicate) and dementia. On 10/2/23 at 2:52 PM Resident 19's window blinds were observed with three vertical slats missing and the common area to the soda machines was visible from her/his bed. On 10/3/23 at 11:49 AM the facility's written repair maintenance binder was reviewed and no repair for the missing blinds were reported. On 10/3/23 at 9:38 AM Staff 11 (CNA) stated when Resident 19 received personal care in her/his bed, the blinds covered the window for privacy. On 10/3/23 at 1:50 PM Staff 15 (Administer in Training/Temporary Maintenance) stated the condition of resident rooms and the building in general was audited weekly. At 2:06 PM Staff 15 walked through the…

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

Based on interview and record review it was determined the facility failed to provide a response rationale for Resident Council requests for 1 of 1 Resident Council reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being. Findings include: Resident Council Notes were reviewed from 8/2022 through 10/2022 and indicated the following concerns: *8/2022: Resident Council meeting canceled due to COVID-19 outbreak. *9/2022: Concerns regarding staff not wearing name tags and making name tags larger so residents could read them. *10/2022: Resident rooms were untidy, cleaning supplies were left piled on dressers, and there were missing pants for one resident and missing pajamas for another resident. There were no written responses or rationales provided for the resident council concerns and the forms for the Resident Council President's signature and Executive Director's signature were left blank. On 10/20/22 at 12:33 PM Staff 3 (Regional [NAME] President) stated there were no written responses for Resident Council concerns.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure physician orders were followed and notify the physician for delays in treatment for 4 of 7 sampled residents (#s 26, 30, 31 and 32) reviewed for unnecessary medications and following physician orders. This placed residents at risk for adverse side effects. Findings include: 1. Resident 32 admitted to the facility on [DATE] with diagnoses including hypothyroidism (under active thyroid). The resident discharged from the facility on 5/10/22. A 4/28/22 Physician Order indicated the resident was to receive levothyroxine (thyroid medication) once daily. The 4/2022 and 5/2022 MARs indicated Resident 32 did not receive the levothyroxine from 4/28/22 through 5/5/22, except the medication was marked off as given on 5/2/22. The dates reviewed indicated the following: *4/28/22 through 5/1/22: On order from pharmacy *5/2/22: Medication administered. *5/3/22 through 5/4/22: Left blank. *5/5/22: See Progress Note (There was no progress note…

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 complete a thorough fall investigation and ensure interventions were in place to prevent falls for 4 of 4 falls (Resident #s 12, 34 and 35) reviewed for accidents. This placed residents at risk for injury. Findings include: 1. Resident 34 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and adult failure to thrive. The 8/28/21 Fall Assessment indicated the resident was at high risk for falls. The 9/3/21 admission MDS indicated the resident was severely cognitively impaired and the resident's fall history was unable to be determined. A 9/7/21 Fall Investigation indicated Resident 34 was found on the floor laying on the right side with her/his head at the foot of bed. There were no witnesses, and the resident was unable to be interviewed. There was no information related to when the resident was last seen. Resident 34 sustained no injuries. The initial root cause was noted to be related to Resident 34'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 observation and interview it was determined the facility failed to ensure food was labeled, stored appropriately and was discarded in a timely manner, and a resident refrigerator was properly cleaned and maintained for 1 of 1 kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and cross contamination. Findings include: 1. On 10/17/22 at 2:20 PM during the initial tour of the facility's walk-in refrigerator, walk-in freezer, and dry storage room the following were observed: Walk-in refrigerator *An unsealed and undated bag of shredded cheese *An unsealed and undated bag of sliced cheese *An unsealed, partially consumed one-gallon container of yellow mustard dated 2/22/22 *An unsealed, partially consumed and undated plastic bottle of teriyaki glaze *An undated zip lock plastic bag of hamburger buns *An unlabeled to go box containing an employee's lunch Walk-in freezer *An undated plastic bag containing five unbaked cinnamon rolls with freezer burn *An undated plastic bag containing frozen egg and cheese omelets 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 treatment and services to maintain vision abilities were received for 1 of 3 sampled residents (#5) reviewed for communication and sensory care. This placed residents at risk for unmet vision needs. Findings include: Resident 5 admitted to the facility in 2/2022 with diagnoses including cerebral infarction (stroke). A 5/6/2022 progress note revealed Resident 5 requested an appointment for a vision exam related to complaints of blurred vision. This progress note also stated the request for an appointment was forwarded to social services. The 5/25/22 Quarterly Social Service Evaluation noted vision concerns but did not explain how the facility addressed the resident's needs. On 10/17/22 at 4:47 PM Resident 5 stated she/he was supposed to wear glasses but did not have a pair. Resident 5 said she/he previously expressed this concern to social services. During interviews with Staff 6 (SSD) on 10/18/22 at 2:21 PM and 10/20/22 at 8:45 AM, she stated she usually called to schedule resident appointments 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 pressure ulcer wounds were accurately and routinely assessed for healing for 1 of 1 sampled resident (#15) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing; - Document the results of all wound assessments; - Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor; - Select a uniform, consistent method for measuring wound length, width, depth or wound area to facilitate meaningful comparisons of wound measurements across time; - Ensure pressure ulcers are correctly…

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 respiratory equipment was properly maintained for 2 of 3 sampled residents (#s 21 and 30) reviewed for respiratory care. This placed residents at risk for infection. Findings include: 1. Resident 21 admitted to the facility in 2022 with hospice services. The Resident's 6/8/22 care plan indicated oxygen therapy with the use of three liters of continuous oxygen. On 10/17/22 at 4:41 PM Resident 21 was observed to have oxygen in place. The oxygen concentrator filter was observed to be dirty, completely covered in dust and the oxygen tubing was not dated. Resident 21 indicated she/he used the oxygen continuously. On 10/18/22 at 11:55 AM Resident 21's oxygen filter was still visibly dusty. Staff 2 (DNS) acknowledged the filter was dusty, needed to be cleaned and the resident's oxygen tubing was not dated. 2. Resident 30 admitted to the facility in 3/2020 with diagnoses including chronic obstructive pulmonary disease (COPD). A 1/8/21 Physician Order indicated the resident was to receive two…

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 irregularities identified by the pharmacist were addressed by a physician for 1 of 5 sampled residents (#5) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications and adverse side effects. Findings include: Resident 5 admitted to the facility in 2/2022 with diagnoses including schizoaffective disorder, depression, and insomnia. A review of Resident 5's 10/2022 MAR revealed she/he received three antidepressants: Cymbalta, Zoloft, and trazodone. Pharmacist recommendations from 3/17/22, 4/21/22, and 7/21/22 documented the need for Resident 5's physician to assess the risks versus benefits of these medications and to provide documentation to support their use. No documentation existed in Resident 5's record indicating these recommendations were acted upon. On 10/19/22 at 3:29 PM Staff 2 (DNS) confirmed no rationale was provided for Resident 5's concurrent use of three antidepressants.

Based on interview and record review it was determined the facility failed to obtain dental services for 1 of 2 sampled residents (#5) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include: Resident 5 admitted to the facility in 2/2022 with diagnoses including cerebral infarction (stroke). The 2/23/22 admission Dental CAA explained Resident 5 experienced dental pain and she/he was interested in scheduling a dental appointment. This assessment further indicated social services was notified. A 3/18/22 progress note indicated Resident 5 had a dental appointment scheduled on 3/18/22 but it was not completed as Resident 5 was transferred from the dental office to the emergency department prior to the start of her/his appointment. A 5/6/22 progress note revealed Resident 5 requested to see a dentist related to complaints of dental pain. The progress note indicated the request for an appointment was forwarded to social services. The 5/25/22 Quarterly Social Service Evaluation noted dental concerns but did not explain how the facility addressed…

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.