Avamere Health Services Of Rogue Valley

Based on interview and record review the facility failed to treat resident's pain in accordance with resident preference for 1 of 2 sampled residents (#10) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include: Resident 10 was admitted to the facility in 2017 with diagnoses including chronic pain. A 7/9/25 Progress Note revealed the resident requested she/he be prescribed lidocaine patches to manage her/his pain. The request was also documented in the Provider Communications Notebook by Staff 22 (former LPN-Resident Care Manager). A review of the 8/2025 Pain Level Summary revealed Resident 10 reported pain levels of 3 to 6 (moderate to severe) on 9 of 21 days reviewed. On 8/19/25 at 8:44 AM, Resident 10 stated she/he regularly experienced severe pain.On 8/21/25 at 12:22 PM, Staff 23 (Medical Director) stated she was not aware Resident 10 requested lidocaine patches. Staff 23 stated she and the nurse practitioner reviewed the Provider Communications Notebook during each visit to the facility. On 8/22/25 at 11:30 AM, Staff 2 (DNS) stated she was unable…

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 obtain routine dental services for 1 of 2 sampled residents (#27) reviewed for dental care. This placed residents at risk for unmet dental needs. Findings include: Resident 27 was admitted to the facility in 1/2025 with diagnoses including dementia.A 2/6/25 progress note revealed Resident 27's diet was downgraded due to loose dentures.A 2/13/25 progress note revealed Resident 27 did not want to get up for meals as she/he was having trouble with her/his dentures.A 3/21/25 progress note revealed Resident 27 did not want other people to see her/his top dentures because they always fell down while eating.A Care Plan revised 4/21/25 revealed Resident 27 wore upper dentures.A 5/27/25 social service progress note revealed an attempt to make a dental appointment for Resident 27. A 6/20/25 Care Conference Information evaluation revealed Resident 27 was concerned about her/his dentures not fitting and had a dental appointment coming up. On 8/19/2025 at 7:49 AM, Resident 27 was observed eating in…

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

Based on interview and record review it was determined the facility failed to address with resident council grievances for 1 of 1 resident council reviewed for grievances. This placed residents at risk for unmet needs. Findings include: An 4/17/24 review of resident council notes revealed a Bi-Monthly Resident Counsel Questions form was completed on 4/10/24 which revealed the following concerns: -Residents did not feel they were treated respectfully by staff. -Residents did not feel staff listened to their needs or responded timely. -Residents did not feel staff followed up with them when they had a concern or issue. -Residents felt staff retaliated when they expressed concerns. -Residents stated staff did not answer their call lights within 10 minutes. -Residents felt the noise level in the facility was unacceptable. -Residents stated the facility did not offer snacks at bedtime and when requested. -Residents stated the food did not taste good and it was cold. -Residents stated lost items were not replaced by the facility. -Residents did not feel there were enough activities 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 4/15/24 through 4/19/24 identified the following issues: -room [ROOM NUMBER] had a missing floorboard in the center of the room. -room [ROOM NUMBER] had a large chunk of the bathroom door missing which exposed the inside material of the door and there was missing paint. -room [ROOM NUMBER]-B had wall damage with missing paint behind the bed and along the wall where the bathroom was located. -room [ROOM NUMBER]-A had wall damage with missing paint along the wall to the left of the residents bed. -Lights were not working on the 200 hall outside rooms [ROOM NUMBERS]. -A small round table in the smoking area had sharp and jagged edges that were approximately 18 inches long. -The double doors at the end of…

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.

2. Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system). An 4/2024 MAR revealed Resident 52 was to be administered Folic Acid 400 micrograms QD for vitamin B12 deficiency. The MAR indicated the Folic Acid was not administered from 4/13/24 through 4/16/24. Progress Notes revealed the following: -4/13/24 Folic Acid-dose on order -4/14/24 Folic Acid-waiting on pharmacy to deliver -4/15/24 Folic Acid-waiting on pharmacy to dispense -4/16/24 Folic Acid-waiting on pharmacy to dispense On 4/17/24 at 3:50 PM Staff 10 (LPN Unit Manager) stated Folic Acid 400 micrograms was an over-the-counter medication which was available in the central supply closet and should have been administered. Based on interview and record review it was determined the facility failed to ensure residents received medications as prescribed, were monitored for medication side effects and provide wound care as ordered for 4 of 14 sampled residents (#s 8, 52, 58 and 59)…

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 maintain water temperatures below 120 F for 3 of 4 resident bathrooms (room [ROOM NUMBER], 108, 111) reviewed for hot water and follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 4 sampled residents (#6) reviewed for falls. This placed residents at risk for injury. Findings include: 1. On 4/17/24 from 10:55 AM through 12:02 PM with Staff 44 (Maintenance Lead) the following bathroom water temperatures were obtained: -room [ROOM NUMBER] 123 F -room [ROOM NUMBER] 125 F -room [ROOM NUMBER] 121 F Resident 26 and Resident 29 resided in room [ROOM NUMBER] and both required staff assistance for toileting transfers. Resident 20 and Resident 52 resided in room [ROOM NUMBER], both were cognitively intact. Resident 52 was independent for toileting and Resident 20 required one staff assistance for toileting…

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 have adequate staff available to timely meet the needs of residents for 3 of 18 sampled residents (#s 32, 60 and 160) and for 2 of 3 wings (Wings 1 and 2). This placed residents at risk for unmet needs. Findings include: 1. A 2/7/24 Quality Assurance Resident Council note indicated call light wait times were too long. The 2/12/24 Response Form indicated the facility followed the state minimum CNA staffing requirements. A 3/6/24 Resident Council Department Response Form indicated the residents felt they needed more nurses and there were not enough which affected their care. The facility's response was they staffed to meet the state minimum staffing requirements. An 4/10/24 Bi-Monthly Resident Counsel Questions form revealed the questions if residents felt staff answered call lights within a 10-minute time frame, and if the resident counsel felt the facility was staffed well enough to meet the needs of the residents, to which the answer to both was documented as no. An 4/10/24 Resident Council…

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 post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports (DCSDR) from 11/23/23 through 12/15/23 revealed no staff hours were documented on eight days, census was documented only one day, and the number of staff was not documented two days out of 23 days reviewed. On 4/19/24 at 7:39 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware of the issues with the DCSDR reports. Staff 2 stated the Staffing Coordinator was newer to the facility during the above reviewed time period.

Based on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food-borne illness. Findings include: On 4/17/24 at 8:24 AM the beverage carts for Wing 1 and Wing 2 were observed with dirty coffee pots which were used for the residents. Staff 28 (Dietary Services Manager) acknowledged the coffee pots needed deep cleaning. On 4/17/24 at 11:45 AM the following was observed during preparing and plating food from the kitchen's steam table for lunch: -Staff 31 (Dietary Aide) performed a temperature check on all food. The food was within normal limits except for the potato salad which was 51 degrees and needed to be 41 degrees. No further checking was performed for the potato salad. -Staff 31 was observed touching the food with utensils and his gloved hands, he then stepped away from the steam table to retrieve tongs and did not perform hand hygiene or don new gloves. Staff 31 left the steam table twice to retrieve food from 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 ensure residents were treated with dignity for 1 of 4 sampled residents (#52) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include: Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system). A 3/23/24 admission MDS revealed Resident 52 was cognitively intact. On 4/15/24 at 1:17 PM and 4/17/24 at 11:47 AM Resident 52 stated she/he took medication which was required to prevent her/his health from significantly declining. The side affects of the medication made her/him feel ill for up to four hours after it was administered and she/he preferred to take the medication in the morning. One Thursday morning Resident 52 asked the nurse when her/his medication could be administered. The nurse's response was that she had the medication in her pocket and would administer the medication when the nurse wanted to administer it. 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 treat residents with respect for 1 of 1 sampled resident (#63) reviewed for abuse and call lights. This placed residents at risk for lack of dignified treatment. Findings include: Resident 63 admitted to the facility in 2023 with diagnoses including kidney failure and difficulty walking. A 11/19/23 admission MDS indicated Resident 63 was cognitively intact. A 12/15/23 FRI indicated staff yelled at Resident 63, and refused to assist her/him with cares. The FRI included the resident had significant care needs and depended on staff for assistance. On 4/18/24 at 11:23 AM Witness 5 (Complainant) indicated Resident 63 stated staff yelled at her/him all the time. An Incident report dated 12/15/23 included the following: -Staff 7 (CNA) and Staff 48 (CNA) were bathing Resident 63's roommate. Resident 63 asked Staff 7 if she/he could have a shower later in the day. Staff 7 stated he would try to do a shower for her/him in the afternoon. Resident 63 stated later she/he asked Staff 48 for a shower and Staff 48 stated…

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

Based on interview and record review it was determined the facility failed to ensure grievances were resolved or resolutions sustained for 2 of 3 sampled residents (#s 7 and 29) reviewed for grievances and care planning. This placed residents at risk for unresolved concerns. Findings include: The facility's Grievance Policy dated 5/2000 stated: It is the policy of this facility to ensure that all residents and their family members are afforded the opportunity to express their concerns and suggest changes in facility policy formally, in writing if they desire without the fear of restraint, interference, coercion, discrimination or reprisal. Additionally, the nursing facility will listen to and act promplty upon grievances and recommendations received from resident, family and advocacy groups. 1. Resident 7 admitted to the facility in 10/2017 with diagnoses including type 2 diabetes and major depressive disorder. On 10/12/23 a public complaint was received which indicated Resident 7 expressed concerns about nursing staff throwing her/his food away and the facility administration…

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 free from abuse for 1 of 1 sampled resident (#19) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 19 was admitted to the facility in 8/2020 with diagnoses including post laminectomy syndrome (a condition in which a person continues to feel pain after back surgery). An 8/22/23 MDS indicated Resident 19 was cognitively intact. A 9/9/23 Progress Note stated Resident 19 was subjected to physical aggression when she/he ignored Resident 1. Resident 1 yanked on Resident 19's hair. Both residents were separated, and Resident 19 was placed on alert charting. A review of a 9/9/23 care plan revealed Resident 1 had a resolved care plan for physical aggression toward another resident. A 9/13/23 Brief Interview for Mental Status (BIMS) Evaluation indicated Resident 1 was cognitively intact. On 4/18/24 at 8:05 AM Resident 1 stated, when asked about the 9/2023 incident with another resident, I do not remember the incident, but it sounds like…

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 for a significant change in condition for 1 of 4 sampled residents (#6) reviewed for falls. This placed residents at risk for unmet care needs. Findings include: Resident 6 admitted to the facility in 8/2023 with diagnoses including infection and pressure ulcer of the lower spine. Resident 6's 12/14/23 Physician Order indicated the resident was referred to hospice services. Resident 6's Census log indicated the resident started hospice services on 12/20/23. A review of Resident 6's MDS records indicated a Significant Change MDS was not completed after the resident started hospice services. On 4/18/24 at 11:06 AM Staff 19 (LPN Unit Manager) reviewed Resident 6's MDS records. Staff 19 stated a Significant Change MDS was required if a resident started hospice services. Staff 19 confirmed a Significant Change MDS was not completed for Resident 6.

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 care plans were revised to accurately reflect the needs of residents for 1 of 1 sampled resident (#7) reviewed for care plans. This placed residents at risk for unmet needs. Findings include: Resident 7 admitted to the facility in 10/2017 with diagnoses including diabetes and major depressive disorder. A Care Plan initiated on 9/20/23 revealed the resident was to use her/his call light, walkie talkie or to call the nurses' station by phone if staff assistance was needed. A 2/9/24 Quarterly MDS revealed Resident 7 was cognitively intact. A [NAME] (brief overview of each resident) dated 4/15/24 revealed staff were to encourage Resident 7 to use her/his call light for her/his needs and to ensure all staff were able to attend to her/his needs. A 3/18/24 Alert Note revealed Resident 7 was reminded staff could not hear or see the call light from the hall the resident was on and for Resident 7 to use her/his call bell…

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 maintain healthy parameters of nutritional status for 3 of 6 residents (#s 32, 60 and 358) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: 1. Resident 32 admitted to the facility in 2023 with diagnoses including stroke and dementia. An 10/3/23 MDS indicated Resident 32 had moderate cognitive impairment. No dietary issues were noted, and she/he was working with ST and currently weighed 142 pounds. An 10/2023 MAR instructed staff to administer a nutritional supplement three times a day with a discontinuation date of 10/30/23. An 10/28/23 Order Note indicated the supplement appeared to cause gastrointestinal upset. A Weight Summary Review revealed Resident 32 weighed 148 pounds on 9/29/23 and 135 pounds on 10/30/23. (Eight percent weight loss) No documentation was found in Resident 32's clinical record for a Nutritional Assessment after an eight percent weight loss. On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated there was usually a report which was…

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

Based on observation, interview, and record review it was determined the facility failed to ensure ongoing communication with the dialysis center for 1 of 2 sampled residents (#63) reviewed for rehab. This placed residents at risk for dialysis complications. Findings include: Resident 63 admitted to the facility in 2023 with diagnoses including chronic kidney disease and was dependent on dialysis (a procedure to remove waste products from the blood when the kidneys stop working). Resident 63's care plan for renal failure dialysis, revised on 11/15/23, indicated the resident's scheduled dialysis days were Monday, Wednesday, and Friday. A review of the resident's clinical record revealed a 11/21/23 document related to dialysis communication. There were no forms from 11/22/23 through 12/15/23 between the facility and the dialysis provider. On 4/19/23 at 8:39 AM Staff 10 (LPN Unit Manager) indicated there was one dialysis communication form in Resident 63's clinical record. Staff 10 stated the form was an important document and used for communication between the dialysis center and the…

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

Based on interview and record review it was determined the facility failed to ensure a resident's medication was available for administration for 1 of 4 sampled residents (#52) reviewed for dignity. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system). A 3/23/24 admission MDS revealed Resident 52 was cognitively intact. Resident 52 had a severe degeneration of her/his spinal cord due to a vitamin B12 deficiency. On 4/15/24 at 1:17 PM and 4/17/24 at 11:47 AM Resident 52 stated she/he took vitamin B12 daily, which was required to prevent her/his health from significantly declining. Resident 52 stated it was like life or death to her/him if she/he missed the medication. Resident 52 stated the facility did not have her/his vitamin B12 available to administer. An 4/2024 MAR revealed vitamin B12 was not administered on 4/15/24. An 4/15/24 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.

Based on interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 7% with two errors in 27 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: 1. Resident 303 admitted to the facility in 2024 with a diagnosis of a low functioning thyroid. Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily. Resident 303's 4/6/24 admission MDS indicated she/he was cognitively intact. On 4/16/24 at 7:30 AM Staff 15 (LPN) was observed to administer levothryoxine to Resident 303. Resident 303 was observed eating breakfast and stopped to take her/his medications including the levothyroxine. On 4/16/24 at 2:58 PM Resident 303 stated when she/he was at home, she usually did not take levothyroxine with food. Resident 303 stated she/he took the levothyroxine as soon as she/he woke up, even before she/he drank…

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 menus were followed for 2 of 4 sampled residents (#s 8 and 40) reviewed for food. This placed residents at risk for unmet food preferences. Findings include: 1. Resident 8 admitted to the facility in 2018 with diagnoses including diabetes. An 4/17/24 breakfast menu ticket revealed poached eggs, toast, link sausage, cream of wheat, and two percent milk. On 4/17/24 at 7:51 AM Resident 8 stated she/he received scrambled eggs instead of poached eggs and did not receive any drinks. On 4/19/24 at 7:54 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected the kitchen to provide Resident 8 what was on her/his menu ticket. 2. Resident 40 was admitted to the facility in 2023 with diagnoses including adult failure to thrive. An 4/17/24 breakfast menu ticket revealed Resident 40 circled hash brown patty, grapes, two eggs over easy, and coffee. The lunch menu ticket indicated a hamburger on a bun. The bun portion was crossed out and a handwritten English muffin was in place of the bun.…

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 assistive devices for 1 of 5 sampled residents (#8) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 8 admitted to the facility in 2018 with diagnoses including diabetic neuropathy (damage or disease affecting the nerves). An 4/3/24 care plan indicated Resident 8 was at nutritional risk with interventions including adaptive equipment of a two-handle cup and a lip plate. An 4/17/24 breakfast menu ticket revealed the following adaptive equipment: a lip plate and a two-handle cup. On 4/17/24 the following occurred: -7:46 AM Staff 4 (CNA) brought out a small plastic cup with a white liquid out of Resident 8's room. -7:51 AM Resident 8 stated she/he did not know where her/his milk was, and she/he did not receive any drinks with breakfast. -7:55 AM Staff 4 stated she took Resident 8's milk because her/his cup did not have an adaptive handle on it. -7:58 AM Staff 4 came out of the kitchen with Resident 8's cup with adaptive handles on it.…

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 records were accurate for 1 of 6 sampled residents (#44) reviewed for unnecessary medications. This placed residents at risk for inaccurate treatment. Findings include: Resident 44 was admitted to the facility in 12/2023 with diagnoses including high blood pressure. Resident 44's 12/19/23 Physician Order indicated the resident was to receive lisinopril (medication to treat high blood pressure) one time a day and the medication was to be held for systolic blood pressure (pressure in the arteries when the heart beats) below 110 and diastolic blood pressure (pressure in the arteries when the heart rests between beats) below 60. Resident 44's 3/2024 and 4/2024 MARs indicated the resident's blood pressure was documented as NA on 3/27/24, 4/1/24, 4/5/24, 4/8/24, 4/9/24, 4/15/24 and 4/16/24. On 4/18/24 at 10:32 AM Staff 19 (LPN Unit Manager) and Staff 22 (CMA) reviewed Resident 44's physician order and 3/2024 and 4/2024 MARs. Staff 19 stated Resident 44's blood pressure readings needed to be documented 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 interview and record review it was determined the facility failed to monitor antibiotic use for 1 of 1 resident (#1) reviewed for antibiotic stewardship. This placed residents at risk for unnecessary medications. Findings include: Resident 1 admitted to the facility in 7/2013 with diagnoses including infection due to urinary catheter, and a history of multi-drug-resistant organisms (MDRO). An 4/16/24 review of Resident 1's care plan revealed a 2/9/23 care plan for enhanced barrier precautions related to a history of MDRO infections and a 2/18/24 care plan for chronic urinary tract infections. A review of Resident 1's 2/2024 MAR revealed an order for cephalexin (an antibiotic) for a urinary tract infection which started on 2/17/24 and ended on 2/25/24. A 2/16/24 urine analysis lab indicated Resident 1 had a small number of bacteria in her/his urine. On 4/16/24 Staff 2 (DNS) acknowledged there was no culture and sensitivity completed with the urinalysis to determine the correct antibiotic for Resident 1. On 4/19/24 at 8:41 AM Staff 2 acknowledged Resident 1 completed 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 ensure residents were assessed prior to prescription and use of psychotropic medications for 1 of 6 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for over-sedation. Findings include: Resident 29 admitted to the facility on [DATE] with a diagnosis of mild dementia without behaviors. Progress Notes revealed the following: -1/19/24 Resident 29 admitted to the facility and was noted to have some short-term memory loss. -1/20/24 Resident 29 was alert, oriented, followed commands, had some forgetfulness, no unwanted behaviors, and slept through the night. The resident was noted to be adjusting well. -1/20/24 at 11:50 PM Resident 29 was found on the floor. The resident was at her/his baseline mental status. -1/21/24 and 1/22/24 Resident 29 was assessed to have no injury from her/his fall. -1/22/24, 1/23/24, and 1/25/24 Resident 29's mood was pleasant with no unwanted behaviors.…

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 grievances were resolved for residents in a timely manner for 2 of 3 sampled residents (#s 1 and 9) reviewed for grievances. This placed residents at risk for unresolved concerns. Findings include: A Lost Item Policy last revised 9/2004 revealed the facility would make every effort to ensure resident belongings were protected and to recapture lost items or to make restitution should a lost item not be recovered. After the lost item was reported as missing and not recovered, within three business days, the form was to be forwarded to the administrator to determine if further action was needed. The facility was to communicate with the resident within five business days after the social service staff received the form back from the administrator. 1. Resident 1 was admitted to the facility in 2022 with diagnoses including diabetes. A 3/12/23 Complaints/Grievance form revealed Resident 1 reported a full pack of cigarettes was missing. Staff went to the store for the resident and bought cigarettes 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 was not abused for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for injury. Findings include: Resident 3 was admitted to the facility in 2016 with diagnoses including dementia. A FRI dated 4/13/23 revealed Staff 2 (CNA) used force while she assisted Resident 3 with incontinent care. Resident 3 did not turn when Staff 2 requested the resident to turn, therefore Staff 2 reported she used the sheet to roll the resident hard. At the time of the incident Staff 2 stated she was irritated and frustrated and knew it was wrong. Resident 9 was interviewed at the time of the incident and reported a staff person threw her/him over several times and it was upsetting but denied ongoing fear. On 7/28/23 at 9:50 AM Staff 2 acknowledged she used force to turn Resident 3 during incontinent care by using a turn sheet. Staff 2 stated it was during last rounds, she was not able to find anyone to help her and she tugged hard on the turn sheet. Staff 2 stated it was wrong 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 report an allegation of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including diabetes. A Significant event form dated 2/27/23 revealed Resident 1 reported a staff member stated the only way Resident 1 would leave the facility would be in a body bag. Resident 1 did not find the comment funny. The form did not indicate the state agency was notified of the incident. On 7/26/23 at 11:14 AM Staff 3 (LPN Resident Care Manager) stated if a resident made a comment which could potentially be verbal abuse, the incident should be reported to the state agency. Staff 3 indicated the resident was not able to identify who made the comment and it could have been a resident. Staff 3 stated the resident had dark humor and often joked with staff and other residents and a comment could have been made in a joking manner, but it was not determined who made the comment. Staff 3 acknowledged…

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 develop a baseline care plan reflective of mobility needs for 1 of 4 sampled residents (#6) reviewed for transfer status. This placed residents at risk for falls. Findings include: Resident 13 was admitted to the facility 7/24/23 with diagnoses including a history of falls. A [NAME] (CNA guide to resident specific care) revealed the resident's transferring status required two staff with all transfers and the resident required one staff with transfers using a walker. On 7/26/23 at 4:37 PM Staff 5 (CNA) stated she was assigned to work with Resident 13 and was told the resident required one person stand by assist for transfers. Staff 5 reviewed the [NAME] and confirmed the resident's transfer status had conflicting information and she would need to clarify with the nurse. On 7/26/23 at 4:49 PM Staff 4 (LPN Resident Care Manager) reviewed the resident's [NAME] and acknowledged the resident's transferring status had conflicting information…

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 care plans were revised for 1 of 3 sampled residents (#4) reviewed for ADLs. This placed residents at risk for care plans not reflective of current care needs. Findings include: Resident 4 was admitted to the facility in 2017 with diagnoses including diabetes. Resident 4's Care Plan indicated she/he was to have enhanced barrier precautions related to wound care. The care plan was initiated on 12/22/22. The goal was to prevent the spread of infections. Gloves and gowns were to be worn during care including toileting. On 7/26/2023 at 10:25 AM Staff 6 (CNA) was observed to provide Resident 4 incontinent care. Staff 5 wore gloves but did not wear a gown. On 7/27/23 at 10:23 AM Staff 3 (LPN Resident Care Manager) stated at one time Resident 4 had an open wound and was on enhanced barrier precautions. The resident's wound healed and the care plan was not updated to reflect the resident's current status.

Based on interview and record review it was determined the facility failed to ensure residents were monitored after allegations of abuse for 2 of 3 sampled residents (#s 1 and 5). This placed residents at risk for unidentified psychosocial harm. Findings include: 1. Resident 1 was admitted to the facility in 2022 with diagnoses including depression. A Significant incident report form dated 2/27/23 revealed Resident 1 reported a staff member told her/him the only way the resident was going to leave the facility was in a body bag. The resident did not feel the comment was funny. Progress notes revealed the resident was not monitored for behavioral or mood changes after the 2/27/23 reported incident. A 3/3/23 psychological progress note revealed the resident was assessed for depression and for reports that a staff member made a comment to the resident about leaving the facility in a body bag. The resident was upset about the comment but the comment did not contribute to increased depression. On 7/26/23 at 11:14 AM Staff 3 (LPN Resident Care Manager) stated if staff were to monitor…

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 qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet activity needs. Findings include: On 2/23/23 at 10:39 AM Staff 16 (Activity Director) stated she had been in the activities position since 8/2022 and did not have an activities certificate. She reported working with Staff 1 (Administrator) to initiate the appropriate certification for her position. A review of the 11/2022 through 2/2023 resident council minutes and the 2/2023 activity schedule revealed Resident 16 was the Activity Director. On 2/23/23 at 3:06 PM Staff 1 stated Staff 16 was hired for activities and had been in the position since 8/2022. Staff 1 acknowledged Staff 16 was not currently certified.

Based on observation, interview and record review it was determined the facility failed to ensure residents' environment remained free from accident hazards and smoking materials were stored securely for 5 of 5 sampled residents (#s 10, 12, 22, 27 and 39) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 10 was admitted to the facility in 2018 with diagnoses including diabetes and weakness. A 2/23/21 comprehensive care plan indicated Resident 10 was at moderate risk for falls and she/he had a history of falls. Interventions included fall mats on both sides of Resident 10's bed. On 2/20/23 at 11:01 AM, 2/22/23 at 7:36 AM and 11:15 AM Resident 10 was in bed with one fall mat up against the wall and the other mat was in the middle of the room approximately five feet away from her/his bed. On 2/22/23 at 11:25 AM Staff 8 (CNA) stated Resident 10's care plan interventions for fall prevention were to have her/his bed in the lowest position and to have fall mats on both sides of the bed. Staff 8 stated Resident 10 had not fallen for a long…

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 the required annual CNA training and annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 12, 13, and 14) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: On 2/21/23 at 10:47 AM Staff 15 (HR and Payroll) provided the most recent performance reviews for Staff 12 (CNA), Staff 13 (CNA) and Staff 14 (CNA). - Staff 12 was hired on 4/21/18, the provided performance review was dated 1/17/22. - Staff 13 was hired on 7/19/21, the facility was unable to provide a performance review. - Staff 14 was hired on 3/26/14, the facility was unable to provide a performance review. On 2/21/23 at 10:51 AM Staff 15 acknowledged the performance evaluations were not completed annually for Staff 13 and stated she would look for additional documentation for performance reviews and records to show training requirements were met. On 2/24/23 at 10:50 AM Staff 15 (Human Resources and Payroll) provided training certificates for Staff 11, Staff 12, Staff 13 and Staff 14.…

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 ensure food was labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for the kitchen refrigerator and ensure dishwasher chemical solution was maintained at correct concentration for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include: 1. On 2/20/23 at 8:37 AM the walk-in refrigerator and walk-in freezer in the facility's kitchen were observed to contain the following improperly stored items and unsanitary conditions: -15 to 20 individual 1-ounce cups filled with mayonnaise, covered with lids not dated -Three cake deserts individually wrapped not dated. -One chocolate pudding covered not dated. -Three individually wrapped sandwiches not dated. -Three ketchups, three mustards, one barbeque sauce (approximately eight ounces half full) and one Italian dressing with a fill date of 1/18/22 but no discard date found. -The walk-in refrigerator ceiling had multiple dust particles (gray and black all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure there was a functioning and audible call light system for 1 of 3 wings (Wing 2) reviewed for call lights. This placed residents at risk for unmet needs. Findings include: 1. During an observation on 2/21/23 at 7:10 AM Resident 36 activated her/his call light but the display outside the room did not activate. Resident 36 stated she/he requested Resident 32 activate her/his call light because her/his call light was not working. At 7:10 AM Staff 1 (Administrator) had Resident 36 activate her/his call light and was observed outside the room and revealed a red flashing light which indicated the call light in the bathroom was activated. Staff 1 stated when Resident 36 activated her/his call light the white light should activate outside of the room even if the bathroom light was activated. 2. On 2/20/23 at 1:19 PM room [ROOM NUMBER]'s call light was activated and the audible sound at the nurses' station was heard at a low level when…

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 by a resident for 1 of 2 sampled residents (#36) reviewed for resident-to-resident abuse. This placed residents at risk for abuse and psychosocial harm. Findings include: Resident 36 admitted to the facility in 6/2022 with diagnoses including blood clot to the lungs and weakness. A 12/21/22 Quarterly MDS revealed Resident 36 had a BIMS score of 15, indicating she/he was cognitively intact. Resident 13 admitted to the facility in 5/2015 with a diagnosis including schizophrenia and had a BIMS score of 15, indicating she/he was cognitively intact. The facility's 1/17/23 investigation revealed Resident 36 reported to Staff 18 she/he was kicked in the left shin by Resident 13. Staff 18 (CMA) assessed Resident 36 for injury and immediately reported the incident to Staff 26 (LPN/charge nurse). There were no witnesses. Upon re-assessment by Staff 26, it was indicated Resident 36 had a slight bruise on her/his left shin. Resident 36 stated she/he had no…

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

Based on interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#15) reviewed for pressure ulcers. This placed residents at risk for unmet care needs. Findings include: Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease (a brain disorder that affects movement). In 2019 Resident 15's family provided a document which contained information related to a mental health diagnoses. The document was scanned into Resident 15's electronic health record. An ankle wound was identified on 6/24/22. Orders were received for treatment. The care plan was to be revised to include the nurses were to ensure Resident 15 wore protective boots at all times and discouraged the use of shoes. A review of the 2/2023 comprehensive care plan identified interventions for daily weights, weights per physician order, an air mattress, pressure ulcer care and cognitive problems due to dementia. The care plan was not revised to include any interventions related to an ankle ulcer and the need for protective boots 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 interview and record review it was determined the facility failed to reassess causes and interventions and provide medications for 1 of 1 sampled resident (#15) reviewed for pressure ulcers. This placed residents at risk for inappropriate wound care and infections. Findings include: 1. Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease (a brain disorder that affects movement) and diabetes. a. Medical records indicated Resident 15 had interventions in place in 2021 to avoid shoes, wear protective boots and instructed licensed nurses to ensure the boots were in place at all times due to previous foot wounds. On 6/24/22 a new wound to Resident 15's ankle was identified and determined to be caused by a shoe. The wound was noted to have a scab. An order dated 6/24/22 instructed staff to apply Betadine (an iodine solution used to protect against infection) twice a day until resolved and to notify the physician if the wound worsened. On 9/14/22 a Skin/Wound note identified an open area on Resident 15's right ankle previously observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to monitor and assess weight loss for 1 of 2 sampled residents (#24) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 24 was admitted to the facility in 2022 with diagnoses including (sepsis) a blood infection. Resident 24's hospital records indicated a weight of 297 pounds. A facility admission weight dated 9/22/22 indicated Resident 24 weighed 295 pounds. Another weight dated 9/22/22 of 265 pounds was recorded in the medical record and the previous weight of 295 pounds was crossed out by a nurse on 1/23/23 which indicated an error in the electronic record. An RD assessment dated [DATE] indicated Resident 24's intake was meeting her/his caloric needs and recommended a no added salt diet. Additional weights recorded: -9/30/22 295 pounds -10/4/22 295 pounds -10/5/22 295 pounds -10/15/22 241 pounds -12/19/22 234 pounds No additional weights recorded until: -1/22/23 208 pounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview it was determined the facility failed to have adequate staff available to meet the needs of residents for 1 of 3 wings (Wing 2). This placed residents at risk of unmet needs. Findings include: 1. On 2/22/23 at 11:25 AM Staff 8 (CNA) stated a couple of residents complained of long call light wait times. Staff 8 stated at times answering call lights in a timely was difficult such as during shift changes and meal times. During observations on 2/23/22 at 10:09 AM room [ROOM NUMBER] A's call light was on. The call light monitor at the nurses' station indicated the light was on for 23 minutes and 41 seconds. The call light monitor was observed cotinuously until 10:25 AM whenthe light was on for 35 minutes. At 10:26 AM the call light monitor indicated room [ROOM NUMBER]'s call light was on for 19 minutes. Staff 1 (Administrator) also observed 217's call light time of 19 minutes. In an interview on 2/24/23 at 10:05 AM with Staff 1, Staff 2 (DNS) and Staff 3 (Regional…

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 medical records were complete, accurate and readily accessible for 1 of 5 sampled residents (#15) reviewed for medications. This place residents at risk for unmet care needs. Findings include: Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease and dementia. In 2019 information was provided to the facility about Resident 15's mental health diagnosis. The information was not included or readily accessible in the record. Resident 15 had orders dated 2/1/23 for Seroquel and Abilify (anti-psychotic medications). The 2/2023 MAR indicated Resident 15 received one dose of Abilify for the month and the Seroquel was administered daily. On 2/21/23 at 2:39 PM Staff 4 (Social Services) acknowledged she was involved in behavior and psychotropic medication review. Staff 4 stated the Seroquel was new and Resident 15's family wanted her/him to take it for bipolar disorder. Staff 4 added Resident 15 had dementia without behavioral disturbances but she was not aware of…

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.