Focused Care At Clarksville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Residents #17). 1.CNA A and CNA B failed to use enhanced barrier precautions by donning a gown when performing foley care on Resident #17 on 12/03/2024. 2.CNA A and CNA B failed to change their gloves after performing foley care on Resident #17 and touched the resident and clean surfaces on 12/03/2024. These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections. Findings included: Record review of the face sheet, dated 12/04/2024, revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 19 residents (Resident #14) reviewed for physical environment. The facility failed to ensure Resident #14's bathroom toilet was functioning properly. The facility failed to ensure Resident #14's bathroom toilet was not briskly running or leaking water for her to use safely. This failure could place residents at-risk of falls and further injuries due to an unsafe environment. The findings were: Record review of Resident #14's face sheet dated 12/04/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses high blood pressure, arthritis, seasonal allergies, and abnormal posture. Record review of Resident #14's admission MDS assessment dated [DATE] indicated she was able to make herself understood and able to understand others. The MDS also indicated she had a BIMS score of 14 which…

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, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 (Resident # 1) residents reviewed for misappropriation of resident property. The facility failed to prevent a drug diversion (misappropriation) of Resident #1's-controlled medications on [DATE], Hydrocodone-Acetaminophen 7.5-325MG (narcotic pain reliever), Hydrocodone-Acetaminophen10-325MG, and Lorazepam (controlled anti-anxiety medication) 0.5 MG, after she expired on [DATE]. The medications were not found. The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] 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, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the facility's only kitchen The facility failed to ensure that kitchen staff appropriately restrained their hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: 1. During an observation on 10/30/2023 starting at 09:03 AM revealed: two dented cans of Campbell's Cream of Mushroom Soup in the kitchen pantry. the [NAME] was not wearing the hairnet appropriately to restrain the sides and back of hair. the Dishwasher was not wearing the hairnet appropriately to contain facial hair, approximately one half inch mustache. During an observation on 10/30/2023 at 09:11 AM, revealed the dishwasher was in the kitchen without a hairnet on appropriately. The dishwasher was not wearing a hair net to contain facial hair approximately one half inch mustache. During an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 3 of 20 residents (Residents #4, #16 and #24) reviewed for advanced directives. 1. The facility did not ensure Resident #4's OOH-DNR included the physician signature and physician date the document was signed. 2. The facility did not ensure Resident #16's OOH-DNR included the witness 2 signature, physician license number, and physician date the document was signed. 3. The facility did not ensure Resident #24's OOH-DNR included the witness 1 signature. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's physician order…

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 observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 6 of 20 residents (Resident #8, Resident #13, Resident #19, Resident #25, Resident #47, and Resident #52) reviewed for accidents and supervision. The facility did not ensure Resident #52 smoked in the designated smoking area while being supervised during the smoke break. The facility did not ensure PTA F used the gait belt appropriately while ambulating Resident #25. The facility failed to ensure the safety of Resident #13 by not moving the Resident to another location/bed prior to removing/working on the bed. The facility failed to properly store aerosol can with a labeled Lavender Scent Deodorizer Spray leaving them on Resident #47's dresser. The facility failed to properly store 3 air freshener sprays and 1 container of disinfectant wipes leaving them…

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 the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 20 residents (Residents #4, #9 and #24) reviewed for medical records. 1. The facility did not ensure Resident #4's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #4's side effects were adequately monitored regarding her antianxiety, antidepressant and antipsychotic medications. 2. The facility did not ensure Resident #9's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #9's side effects were adequately monitored regarding her antianxiety and antidepressant medications. 3. The facility did not ensure Resident #24's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #24's side effects were adequately monitored regarding her…

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 ensure that residents were free of significant medication errors for 1 of 9 residents reviewed for insulin administration. (Resident #52) The facility did not ensure LVN P and RN Q administered Resident #52's Humalog (insulin lispro) KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 20 residents (Resident #8, Resident #9, and Resident #40) and 1 of 1 empty resident's room reviewed for drugs and biologicals. The facility failed to ensure Resident #8's Afrin (nasal spray medication) was stored properly. The facility failed to ensure Resident #40's Azelastine (nasal spray medication) was stored properly. The facility did not ensure a Plavix pill (antiplatelet) was stored in a locked container and original packaging. The facility did not ensure Resident #9's multivitamins, ear drops, and triple antibiotic ointment were properly safe and secured. These failures could place residents at risk of medication misuse and diversion. Findings included: 1. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] 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 observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature 1 of 1 lunch meal reviewed for palatability and temperature. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #41, Resident #28, and Resident #19 who complained the food was served cold and did not taste good. The facility failed to ensure the Dietary Manager followed the recipe for pureeing the Swiss steak and California Blend Vegetables (the lunch menu). This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. During an interview on 10/30/2023 beginning at 9:25 AM, Resident #41 stated the food was cold and bland at times. During an interview on 10/30/2023 at 4:11 PM, Resident #28 said sometimes the food smelled like dogfood, and she could not eat it. She stated the food was cold. During an interview on 10/30/2023 at 1:07 PM, Resident #19 said the food was bland 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, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for 2 of 2 meals (Lunch on 10/30/2023 AND 10/31/2023) observed for frequency of meals. The facility failed to serve the 10/30/2023 and 10/31/2023 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings include: Record review of the facility's mealtimes indicated breakfast at 7:15 AM, Lunch at 12:00 PM, and Supper 5:15 PM. During an observation on 10/30/2023 at 12:42 PM, revealed the residents in the dining room were served lunch. During an observation on 10/31/2023 at 12:48 PM, revealed the residents on 600 hall were served lunch. During an interview on 10/31/2023 at 12:42 PM, Resident #42 said lunch…

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #28) and 4 of 4 staff (CNA G, CNA H, Community Cleanliness Provider O and Clinical Reimbursement Coordinator) reviewed for infection control. 1. The facility failed to ensure CNA G and CNA H changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure CNA G and CNA H did not touch the multi-use wipes container with their dirty gloves. 2. The facility failed to ensure the Clinical Reimbursement Coordinator sanitized her hands between each resident meal tray while passing meal trays on Hall 1. 3. The facility did not ensure Community Cleanliness Provider O kept the personal linen cart covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings…

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, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 3 of 3 residents (Residents #13, #36, and #44) reviewed for antibiotic use. The facility failed to ensure Residents #13, #36, and #44 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #13's face sheet, dated 11/01/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting,…

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 follow their own established smoking policy for the facility's only smoking area and 1 of 12 residents (Resident #52) reviewed for smoking policies. 1. The facility did not ensure Resident #52 smoked in the designated smoking area with appropriate supervision. 2. The facility did not ensure cigarette butts were disposed of in metal containers in the smoking area. 3. The facility did not ensure plastic trash was placed in the appropriate trash containers in the smoking area. These failures could place residents at risk of an unsafe smoking environment. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable…

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 observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #25 and Resident #159) reviewed for resident rights. 1. The facility did not ensure CNA B knocked, introduced herself, and explained the procedure prior to entering Resident #25's room and providing care. 2. The facility did not ensure CNA B knocked prior to entering Resident #159's room. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema (complication of high blood sugar where blood vessels in the eye are damaged causing swelling), legal blindness (unable to see), unsteadiness of feet, difficulty in walking, ataxia (loss of coordination 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 residents (Resident #10) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #10's call light was within reach. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 11/01/23, revealed Resident #10 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, heart failure (progressive heart disease that affects pumping action of the heart muscles), cerebrovascular disease (umbrella term for conditions that impact the blood vessels in your brain), and chronic kidney disease, stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant; Kidney…

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 provide a safe, clean, and comfortable homelike environment for 1 of 20 residents (Resident #28) reviewed for environment. The facility failed to ensure Resident #28's door was properly functioning. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes…

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 interviews and record review the facility failed to ensure an accurate MDS was completed for 1 of 20 residents (Resident's #14) reviewed for MDS assessment accuracy. 1. The facility did not ensure Resident #14's most recent MDS assessment reflected his hospice services during the 14-day look-back period. This failure could place residents at risk for not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #14 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), alcoholic liver disease (spectrum of alcohol-induced liver dysfunction ranging from mild, reversible fatty liver to irreversible liver fibrosis and cirrhosis), and type 2 diabetes mellitus without complications (high blood sugar). Record review of the MDS assessment, dated 09/15/2023,…

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, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 20 residents reviewed for care plans. (Resident #5 and Resident #13) 1. The facility did not implement Resident #5's care plan or accurately reflect her diet preferences. 2. The facility failed to develop and implement a care plan for Resident #13's Hospice care services. These failures could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #5 was a [AGE] year-old female who admitted initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (happens when another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), COPD…

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 observations, interviews, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 5 residents reviewed for ADLs. (Resident #41 and Resident #210) 1. The facility did not ensure Resident #41 received nail care. 2. The facility failed to ensure Resident #210 received his shower as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #41 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute on chronic congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), essential hypertension (high blood pressure), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with numbness in hands and feet). Record review of the MDS assessment, dated 09/29/2023, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 20 residents (Residents #28) reviewed for pharmacy services. The facility failed to ensure Resident #28 received insulin as prescribed. The facility failed to ensure Resident #28's blood sugar was rechecked in an hour. These failures could place residents at risk for hospitalizations, not receiving services to meet their needs, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent…

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.