Marquis Springfield

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 an insulin open date was documented for 1 of 1 sampled resident (#17) observed to receive insulin during medication administration observation. This placed residents at risk for ineffective medication regimen. Findings include: Resident 17 was admitted to the facility in 9/2025 with a diagnosis of diabetes. Resident 17's 12/31/25 Active Orders included staff were to administer Lispro (fast acting insulin) with meals. On 12/31/25 at 7:41 AM Staff 8 (LPN) was observed to prepare Insulin Lispro for Resident 17. The Lispro insulin did not have an open date, and Staff 8 stated all insulin was to be dated when first opened. On 12/31/25 at 8:41 AM Staff 9 (LPN Resident Care Manager) stated insulin should be dated when opened. Staff stated the 12/2025 pharmacy receipt binder did not have a receipt for Resident 17's Lispro insulin and she was not able to determine when the Lispro was potentially first used. On 12/31/25 9:00…

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 influenza vaccine was offered to residents for 1 of 5 (#13) sampled residents reviewed for vaccinations. This placed residents at risk for influenza infection. Findings include: The facility Vaccination of Residents policy with a 5/2021 revision date indicated all residents were to be offered vaccinations that helped in preventing disease and all vaccination information was to be recorded in the resident's medical record. Resident 13 was admitted to the facility in 11/2025 with diagnoses including diabetes and urinary tract infection. A 11/27/25 admission MDS indicated Resident 13 was cognitively intact.During a review of Resident 13's medical record no information was found to indicate the influenza (flu) vaccine was offered for the 2025 flu season (October 2025 through May 2026). On 1/5/26 at 1:50 PM, Staff 4 (DNS) stated the expectation for resident flu vaccinations was for all residents to be offered the flu vaccine each flu season. She acknowledged Resident 13 was not offered the influenza…

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 had an accessible bathroom call light for 2 of 3 sampled residents (#s 38 and 83) reviewed for accidents. This placed residents at risk for the inability to call for assistance. Findings include: 1. Resident 38 was admitted to the facility in 11/2024 with a diagnosis of dementia. On 12/29/25 at 12:42 PM Resident 38's bathroom was observed without a call light cord to access if she/her fell to the ground. On 1/2/26 at 10:32 AM Staff 6 (Maintenance) stated if a resident room did not have a call light cord the staff were to notify him, and he would provide a cord. Staff 6 stated he was not notified Resident 38 did not have a bathroom call light cord. On 1/5/26 at 10:28 AM Staff 1 (Administrator) stated she and Staff 4 (DNS) did audits to ensure residents' bathrooms had call light cords. Staff 1 stated the staff were to notify maintenance in person or via the facility online communication system if a resident needed a new call light cord. 2. Resident 83 was admitted 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 interview and record review it was determined the facility failed to protect residents' rights to be free from misappropriation of property by staff for 4 of 4 sampled residents (#101, 102, 103 and 104) reviewed for misappropriation of property. Findings include: 1. Resident 101 was admitted to the facility in 2024, with diagnoses including cancer of the colon and frontal lobe of the brain. A Police Department Incident/Investigation Report dated 10/28/24, indicated the department received a report from the facility regarding possible theft of narcotic medication. On the night of 10/23/24 Staff 3 (Agency LPN) oversaw resident medications on the facility's South Hall and a resident complained to day shift staff she/he did not receive her/his narcotic pain medication and was in pain. Several other residents also complained about not getting their medications. Staff 2 (DNS) began an investigation and multiple medication administration and documentation discrepancies were found specifically with narcotic medications. All the concerns involved Staff 3. A progress note by Staff 4…

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 interviews and record reviews it was determined the facility failed to report a reasonable suspicion of a crime to the State Survey Agency for 4 of 4 sampled residents (#s 101,102, 103 and 104) reviewed for misappropriation of property. This placed residents at risk for further misappropriation of property and incomplete investigations. Findings include: A Police Department Incident/Investigation Report dated 10/28/24 indicated they received a report from the facility regarding possible theft of narcotic medication. A Complaint Form dated 10/23/24 at 10:00 PM to 10/24/24 at 6:00 AM (the night shift) submitted by the facility to the Oregon State Board of Nursing indicated a possible diversion of medications had occurred. On the morning of 10/24/24 the medication aides reported several narcotics had been incorrectly signed out and medications were signed out of the narcotic book but not documented as administered on the eMAR (electronic MAR) by Staff 3 (LPN). There were discrepancies in Staff 3's charting of narcotics. Interviews with residents determined some residents had…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#137) reviewed for dignity, 3 of 15 residents (#s 2, 15 and 39) reviewed for assisted dining. This placed residents at risk for lack of dignity. Findings include: 1. Random observations on 7/30/24 from 12:20 PM through 12:50 PM (30 minutes) revealed Staff 19 (CNA) was in the Willamette dining room and Residents 2, 15 and 39 were all seated at the same table for lunch. Staff 19 stood or walked around the table to assist each each of the residents with their lunch meal. On 7/30/24 at 1:13 PM Staff 19 stated the three residents in the Willamette dining room needed assistance and cueing when eating their meals. Staff 19 acknowledged she stood and should have been seated to assist Residents 2, 15 and 39 with their meals. On 8/1/24 at 4:30 PM Staff 2 (DNS) stated she expected all staff to sit with residents who required assistance with eating. Staff 2 stated Staff 19 spoke with her regarding the 7/30/24 dining incident and…

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

Based on observation and interview it was determined the facility failed to ensure resident dining environments were homelike, and resident shower rooms were clean for 1 of 2 dining rooms and 5 of 5 shower rooms reviewed for environment. This placed residents at risk for lack of homelike environment and an unsanitary environment. Findings include: 1. Observations on 7/30/24 at 9:25 AM and 8/1/24 at 10:01 AM revealed five individual shower rooms for residents. All five shower rooms were observed to have a heater vent, a small heater unit on the wall, and a ceiling fan. All of them were covered in cobwebs and had dust particle build-up on the exterior and inside (approximately quarter-inch thick dust particles) for each of the three separate components (ceiling fan, heater vent and small heater). On 8/1/24 at 9:32 AM Staff 20 (Housekeeper) stated housekeepers were responsible for cleaning all five shower rooms, which included dusting the ceiling fans, vents and heaters. Staff 20 stated she was unable to clean the accumulated dust particles inside the heater, vent and ceiling fan and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determine the facility failed to ensure a residents call light was within reach for 1 of 2 sampled residents (#25) reviewed for physical environment. This placed residents at risk for lack of ADL assistance. Findings include: Resident 25 was admitted to the facility in 11/2017 with diagnoses including dementia and depression. The Quarterly MDS dated [DATE], revealed Resident 25 had a BIMS score of 15, which indicated the resident was cognitively intact. On 7/29/24 at 1:07 PM Resident 25 stated she/he needed assistance to move her/himself in bed and was not sure where the call light was located. Observations on 7/29/24 from 1:08 PM through 3:09 PM revealed Resident 25's call light was on the left side of her/his bed, on the floor, out of reach. Staff entered Resident 25's room at 1:18 PM, repositioned her/him, and took the resident's lunch tray, but did not ensure her/his call light was within reach. On 7/29/24 at 3:09 PM Staff 16 (CNA) entered the room and…

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

Based on interview and record review it was determined the facility failed to provide information related to financial responsibilities for 1 of 3 sampled residents (#14) reviewed for Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This placed residents at risk for unforeseen financial responsibilities. Findings include: Resident 14 admitted to the facility in 4/2024 and received Medicare services from 4/26/24 through 6/28/24. Resident 14 received and signed the NOMNC (Notice of Medicare Non-Coverage) on 6/26/24. Although the resident remained in the facility, there was no evidence the resident received a SNFABN providing information on the resident's financial liability. On 7/31/24 at 4:16 PM Staff 5 (Social Service Director) acknowledged Resident 14 did not receive the SNFABN form and did not receive information about financial responsibilities after discharging from Medicare services while remaining in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to comprehensively assess a resident's needs related to nutrition for 2 of 3 sampled residents (#s 17 and 42) reviewed for nutrition. This placed residents at risk for unmet nutritional needs and weight loss. Findings include: 1. Resident 17 admitted to the facility in 5/2024 with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis. The 5/15/24 admission MDS Nutritional Status CAA did not include Resident 17's history, current nutritional status, or plan of care. On 8/1/24 at 1:15 PM Staff 2 (DNS) acknowledged the 5/15/24 admission MDS Nutrition CAA was not comprehensive and did not include Resident 17's history, current nutritional status, or plan of care. 2. Resident 42 was admitted to the facility on [DATE] with the diagnoses including fracture of the right femur, malignant neoplasm of the lung and type 2 diabetes. Resident 42's admission MDS dated [DATE], Section V: Care Area Assessment (CAA)…

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 implement a mobility device for 1 of 2 sampled residents (#37) reviewed for positioning and mobility. This placed residents at risk for functional decline. Findings include: Resident 37 was admitted to the facility in 10/2021 with diagnoses including a stroke and dementia. The Quarterly MDS, dated [DATE], revealed Resident 37 had an upper extremity impairment and lower extremity impairment to one side of her/his body. A physician order dated 1/9/24 indicated Resident 37 was to have an InterDry (skin protector) cloth placed into her/his right hand daily. Random observations from 7/29/24 through 7/31/24 revealed Resident 37 was either up in her/his wheelchair or in bed with no skin protecting device in the right palm of her/his hand. On 7/31/24 at 2:20 PM Staff 12 (CNA) stated Resident 37 was alert but had confusion and limitations to her/his right arm and hand. Staff 12 stated an InterDry cloth was to be placed in 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 the facility failed to evaluate the potential risk of choking related to altered swallowing ability for 1 of 3 sampled residents (#430) reviewed for nutrition. This placed residents at risk for choking. Findings include: Resident 430 was admitted to the facility on [DATE] with diagnoses including stroke and dysphagia (difficulty swallowing). A 7/24/24 Speech Therapy Assessment completed while the resident was in the hospital identified medications crusted in either thin liquids or puree. The Evaluation indicated swallow deficits including a delayed swallow response, moderately impaired ability to swallow, and a mild deficit in protecting the airway during swallow. These swallowing deficits increased the risk of aspiration. admission orders dated 7/25/24 did not include information related to safe medication administration (or alternatively, did not indicated safe swallowing precautions related to medication administration). No evidence was found in 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 dialysis services were in place including transportation, monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at increased risk for complications associated with dialysis treatment. Findings include: Resident 17 admitted to the facility in 5/2024 with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis. The 5/14/24 care plan indicated Resident 17 was to receive dialysis on Tuesdays, Thursdays and Saturdays. a. On 7/29/24 at 2:01 PM Resident 17 stated transportation failed to pick her/him up from the facility for a dialysis appointment recently and she/he missed dialysis. Resident 17 further stated she/he was fluid overloaded due to missing the appointment. Progress notes indicated the following: -7/20/24 7:08 PM the provider was notified that transportation did not show up to take Resident 17 to dialysis on the morning of 7/20/24. Transportation staff stated Resident 17 did not have…

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 the facility failed to ensure residents did not receive unnecessary steroid medication for 1 of 6 sampled residents (#15) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 37 was admitted to the facility in 10/2021 with diagnoses including stroke and dementia. A physician's order dated 7/9/24 revealed an order for prednisone (a steroid medication) at 40 mg. Staff were to administer one tablet (40 mg) by mouth daily for five days and then administer half a tablet (20 mg) by mouth daily for four days for gout (inflammatory arthritis). A Medication Error Report dated 7/22/24 revealed Staff 10 (Agency LPN) mistakenly administered 40 mg of prednisone on 7/16/24 instead of the prescribed 20 mg. Staff 9 (LPN) discovered the error on 7/17/24. Staff 9 notified the physician and followed the directive to monitor Resident 37 for any severe reactions while continuing to administer the prednisone per the physician's order. On 7/29/24 Witness 3 (Complainant) stated Resident 37…

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

Based on interview and record review it was determined the facility failed to have a dialysis contract in place for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for not receiving appropriate dialysis services. Findings include: Resident 17 admitted to the facility in 5/2024 with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis. The 5/14/24 Care Plan indicated Resident 17 received dialysis three times a week. On 8/1/24 at 1:15 PM Staff 2 (DNS) acknowledged Resident 17 received dialysis from an outside provider and the facility did not have a signed contract with Resident 17's dialysis provider.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5% (5 errors in 31 opportunities resulting in a 16.13% error rate) for 3 of 4 sampled residents (#s 6, 9 and 55) observed for medication administration. This placed residents at risk for medication errors. Findings include: 1. Resident 6 admitted to the facility in 2022 with diagnoses including diabetes. A review of Physician Orders revealed a 7/31/22 order for Miralax Powder (a laxative) one time a day mixed with 4 to 8 ounces (120 to 240 milliters(ml)) of fluid. On 4/6/23 at 8:11 AM Staff 21 (CMA) was observed administering medication to Resident 6 including Miralax (a bowel medication) mixed with approximately 120 ml water. The Miralax mixed with water was left with Resident 6 with approximately 50 ml of fluid remaining. On 4/6/23 at 8:30 AM Staff 21 stated she would check on the resident later to validate if Resident 6 drank all the Miralax mixed with water. A 4/6/23 review of Resident 6's medical record revealed no evidence of an assessment or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to accurately assess dental status for 1 of 2 sampled residents (#58) reviewed for dental. This placed residents at risk for lack of dental services. Findings include: Resident 58 was admitted to the facility in 2021 with diagnoses including heart failure. An Annual MDS dated [DATE] documented no broken or loosely fitting full or partial dentures. A Quarterly MDS dated [DATE] documented no broken or loosely fitting full or partial dentures. On 4/3/23 at 3:50 PM Resident 58 was observed in her/his room with some missing teeth on the bottom and a lack of upper teeth. Resident 58 stated she/he had upper dentures that were loose and the bottom partial was broken. On 4/7/23 at 1:28 PM dental concerns for Resident 58 were discussed with Staff 2 (DNS) who agreed the MDS was not accurate.

Based on observation, interview and record review it was determined the facility failed to provide ADL care for 1 of 3 sampled residents (#5) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 5 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease. Resident 5's care plan revised 8/2/22 indicated the resident required assistance with ADL care. Staff were to clean the resident's hands and fingers after eating with a warm washcloth and nail care was to be performed by a licensed nurse only. Observations on 4/3/23 through 4/5/23 during day and evening shifts revealed Resident 5 had a dark brown substance under her/his fingernails and around the nails. On 4/5/23 at 12:26 PM Staff 3 (Resident Care Manager), Staff 17 (Resident Care Manager) and Staff 25 (Resident Care Manager) verified Resident 5's nails were dirty and needed to be cleaned.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 3 of 6 sampled residents (#s 55, 182, and 189) reviewed for medications and notification. This placed residents at risk for unmet needs. Findings include: 1. Resident 55 was admitted to the facility in 2021 with diagnoses including diabetes. A review of 2/2023 progress notes revealed Resident 55 was sent to the hospital on 2/19/23 and was readmitted on [DATE]. A review of Resident 55's 2/2023 and 3/2023 Blood Sugar Summary revealed Resident 55 had CBG checks on 2/19/23 and 3/19/23 only. A review of 2/23/23 admission Orders revealed orders for CBG checks before meals and at bedtime. A review of Resident 55's 2/2023 through 4/4/23 medical record revealed no evidence indicating CBG checks were performed before meals and at bedtime. A review of a 3/2/23 Physician Progress Note revealed CBG checks were discontinued per resident preference. On 4/7/23 at 9:56 AM Staff 17 (Resident Care Manager) confirmed 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 prevent and accurately and comprehensively assess pressure ulcers for 2 of 5 sampled residents (#s 2 and 186) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers. Findings include: 1. Resident 186 was admitted to the facility in 2019 with diagnoses including Parkinson's disease and rheumatoid arthritis. A review of Resident 186's Skin and Wound Evaluations from 2/6/22 through 7/1/22 revealed the resident had numerous wounds on the left and right feet. The assessments inaccurately described the wounds or were incomplete. On 4/7/23 at 11:54 AM Staff 2 (DNS) verified the assessments were not accurate or complete. 2. Resident 2 was admitted to the facility in 2022 with diagnoses including dementia. A 3/17/23 care plan indicated Resident 2 was at risk for skin impairment and pressure ulcers. Resident 2 developed a facility acquired Stage 2 pressure ulcer (partial thickness loss of dermis) to her/his right buttocks. The 9/12/22 through 10/17/22 Skin and Wound Evaluation Reports…

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 the environment was free of accident hazards for 3 of 3 sampled residents (#s 31, 51 and 182) reviewed for accidents and smoking. This placed residents at risk for injury. Findings include: 1. Resident 51 was admitted to the facility in 2021 with diagnoses including lung cancer and paraplegia (paralysis of the legs). An observation on 4/3/23 at 1:34 PM revealed a small table, folding chair and a broom and dustpan outside in the parking lot of the facility. The area had trees with foliage surrounding the area. There was no ashtray or fire extinguisher. On 4/3/23 at 2:54 PM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility was a non-smoking facility but there was one resident who smoked. Staff 1 stated Resident 51 went to an area in the parking lot which had a table, chair, broom and dustpan and smoked by herself/himself or with friends and family. Staff 1 stated there was also a covered area by the entrance which Resident 51 used when the weather was bad. On 4/5/23 at 4:21 PM…

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 oxygen therapy according to physician's orders for 1 of 1 sampled resident (#283) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 283 was admitted to the facility in 2023 with diagnoses including pneumonia. An Order Audit Report printed on 4/7/23 revealed an order summary from 3/27/23 for oxygen up to two L/M (liters per minute) every shift and to wean off as tolerated. A 4/2023 TAR instructed staff to administer oxygen up to two L/M. From 4/2/23 through 4/5/23, documentation showed Resident 283 received above two L/M nine times out of 10 opportunities. On 4/4/23 at 8:07 AM, Resident 283 was in bed with nasal cannula in place. The oxygen concentrator for Resident 283 was on and set at five L/M. On 4/7/23 at 9:20 AM Staff 2 (DNS) stated she expected staff to contact the physician and obtain an updated order and document the change in Resident 283's clinical record.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#55) observed for medication administration. This placed residents at risk for medication complications or adverse side effects. Findings include: Resident 55 was admitted to the facility in 2018 with diagnoses including anxiety. A review of the 7/2019 FDA duloxetine (an antedepressant) delayed-release sprinkles prescribing information revealed duloxetine delayed released sprinkle capsules may be swallowed whole or opened and sprinkled over applesauce. If duloxetine sprinkles were not taken as instructed the medication would be released too quickly and at a high concentration which increased the risk for mild and severe adverse side effects and overdose. A review of Resident 55's Physician Orders revealed a 2/28/23 order for duloxetine delayed release sprinkles daily by mouth with instructions to open the capsule and mix the sprinkles inside the capsule with 30 ml applesauce or apple juice at room…

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.