Knopp Nursing & Rehab Center INC

Based on observation, interview, and record review, the facility failed to ensure medication error rates are not 5 percent or greater for 2 of 4 Residents (Residents #36 and #37), and 2 of 25 medication administration observations, resulting in an error rate of 8%. The facility failed to ensure Resident #36 received medication Donepezil at 7:00 AM on 1/19/2026, as ordered by the physician.The facility failed to ensure Resident #37 received medication Pantoprazole at 8:00 AM on 1/19/2026, as ordered by the physician. This failure could result in residents not receiving correct and timely medications.Findings included: Record review of Resident #36's medication administration record for January 2026, dated 1/19/2026, reflected the following order:Donepezil HCl Oral Tablet 5mg (Donepezil Hydrochloride) Give 1 tablet my mouth one time a day related to Alzheimer's disease [a progressive neurological condition causing deterioration of memory, thinking, and daily function] with late onset . start date 11/08/2025 07:00 [AM]A check mark symbol and initials of LVN G were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective se rvices where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 8 residents (Residents #5, #17, and #140) reviewed for reporting allegations of abuse, neglect, and exploitation. 1. The administrator failed to report an allegation of neglect, with serious injury, when Resident #140…

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 reviews the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action were taken, for 3 of 8 residents (rResidents #5, #17, and #140) reviewed for allegations of abuse, neglect, and exploitation. 1. The administrator failed to investigate and report an allegation of neglect, with serious injury, when Resident #140 was assisted with a mechanical lift transfer by 1 staff member, CNA A. Resident #140 fell during the transfer, suffered a broken right leg, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities which involved 2 of 6 residents (Resident #8 and #24) reviewed for crushed medication administration and medication errors. 1. RN G administered Resident #8's medications: a. ranolazine 500mg extended-release tablet by crushing the tablet. Ranolazine is used to treat heart related chest pain. 2. RN G administered Resident #24's medications: a. duloxetine 30mg delayed-release capsule by opening the capsule. Duloxetine is used to treat depression and anxiety. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #8's admission record dated 10/17/2024 revealed an admission date of 10/01/2024 with diagnoses which included dysphagia oropharyngeal 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 interview and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #28) reviewed for care plans. The facility failed to invite and include the input of Resident #28 and/or residents' representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in Care Plan Conference meetings. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnosis including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #18) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #18's diagnoses of mental illness including depression. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #18's face sheet, dated 10/18/2024, reflected a [AGE] year-old resident, initially admitted on [DATE], with diagnoses including pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe), depression, and dysphagia (difficulty swallowing). Record…

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 residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #28) reviewed for personal hygiene. The facility failed to provide Resident #28, 18 of 30 scheduled showers between 7/2/2024 and 10/15/2024. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body after a stroke causing…

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 that residents who had not used psychotropic drugs were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #13) reviewed for unnecessary medications. The facility failed to ensure Resident #13 was taking a psychotropic medication (Mirtazapine (an antidepressant)), to treat a specific diagnosed condition. This deficient practice could place residents at risk for receiving medications that were not necessary for their care. The findings include: Record review of the admission Record reflected Resident #13 was a [AGE] year-old resident who was initially admitted to the facility on [DATE]. Resident #13 had diagnoses which included essential hypertension (abnormally high blood pressure), and a pressure ulcer of the sacral region, stage 4. A diagnosis of depression was not documented. Record review of the comprehensive 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 interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 4 of 6 residents (Residents #10, 11, 12, and 13) reviewed for pharmacy services. 1. The facility failed to dispense the correct number of pills for Resident #10 per physician orders for diazepam (controlled medication used to treat anxiety, muscle spasms, and alcohol withdrawal). 2. The facility failed to ensure Resident #11 blister pack (packaging used for pharmaceuticals) of 5-325 mg of hydrocodone acetaminophen (medicine used to relieve moderate to severe pain.) was not tampered with and replaced with a 10-235 mg hydrocodone acetaminophen by RN K. 3. The facility failed to ensure nursing staff who documented they dispensed 10-235 mg hydrocodone acetaminophen 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 interview and record review, the facility failed to ensure that residents had orders and followed physician's orders for the resident's immediate care for 1 of 13 Residents (Resident #1) reviewed for admission orders. The facility failed to ensure Resident #1's admission orders for insulin administration and blood sugar checks were entered on admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result in a deterioration of their condition. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected he was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus, Resident #1's face sheet did not list his code status. Record review of Resident #1's nursing notes revealed was admitted to the facility after dinner service on [DATE] and expired on [DATE] around midnight. Record review of Resident #1'admission assessment dated [DATE] reflected he had intact…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 (RN K) of 13 nurses reviewed for competent nursing care. RN K failed to administer Resident #12's 10-235 mg hydrocodone acetaminophen one hour before or after the scheduled time according to the facility's policy. These deficient practices could places residents at risk of not receiving medications timely . The findings included: Record review of Resident #12's face sheet, dated 9/7/24, revealed an [AGE] year-old female was admitted on [DATE], with diagnosis that included Parkinson's disease with dyskinesia with fluctuations (is a progressive disorder that affects the nervous system and causes tremors, stiffness and slow movement.), migraine without aura (genetically-influenced complex…

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 residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 34 of 38 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) whose records were reviewed for pharmacy services. The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen review This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified (paralysis of the legs and lower body), epilepsy, unspecified, not intractable, without status epilepticus (disorder characterized by recurrent seizures), 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 interview and record review, the facility failed to ensure it was administered in a manner than enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 34 of 34 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) reviewed for pharmacy, nursing, and physician cooperation with Administration oversight, in that: The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen reviews for 3 reviewed monthly pharmacist recommendations (June, July, and August 2023). This failure placed residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified…

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 the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include: All personnel, including managers, staff as well as their education and/or training and any competencies related to resident care, for 1 of 1 facility reviewed for the facility assessment, in that; The facility assessment was developed without complete assessment data and solely by the MDS nurse without training to complete the facility assessment. This failure could place residents at risk for not having their needs met. The findings included: A record review of the facility's CMS 802 Resident Matrix dated 09/11/2023 revealed the facility census to be 38 residents. A record review of the facility's facility assessment tool dated 08/01/2023, revealed Persons involved in completing assessment; Administrator: [The Administrator]; DON: [The DON]; Governing Body Rep [The Administrator]; Medical…

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 reviews, the facility failed to have the interdisciplinary team, review, and revise the comprehensive care plan after each assessment and quarterly, for 2 of 18 residents (Residents #23 and #138) reviewed for care plans, in that. 1. The facility failed to revise Resident #23's refusal to wear a right foot boot while in bed. 2. The facility failed to have a quarterly care plan meeting for Resident #138. These failures could have placed residents at risk for not having their needs met. The findings included: 1. A record review of Resident #23's admission record, dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes [a condition where the body does not make enough insulin, or it does not respond to it effectively. Insulin is a hormone that helps the cells use glucose (sugar) for energy. Symptoms include feeling tired, hungry, or thirsty, and passing more urine] and atherosclerosis of native arteries of right leg ulceration of ankle [a…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 19 of 38 residents (Residents #2, #6, #10, #12, #15, #16, #17, #19, #21, #25, #26, #27, #28, #29, #30, #35, #39, #40, and #138) reviewed for pharmacy services, in that; 1. Resident #2 was administered a diabetic medication 24 minutes late by RN E on 09/13/2023. 2. Resident #6 was administered injectable insulin 1 hour and 23 minutes late by LVN D on 09/13/2023. 3. Resident #10 was administered 3 drugs, a blood thinner medication, a probiotic, and breathing treatment medication, 32 minutes late, by RN E on 09/13/2023. 4. Resident #12 was administered a stool softener medication 47 minutes late, by LVN D on 09/13/2023. 5. Resident #15 was administered 6 medications, a gastro-esophageal reflux medication, a vitamin, 2 pain relief medications,…

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 a medication error rate below 5%, for 32 medication administration opportunities with 7 errors resulting in a 21.88% medication error rate, for 2 of 5 residents (Resident #10 and #26) and 2 of 2 staff Nurses (LVN D and RN E) reviewed for medication pharmacy services, in that: 1. LVN D administered 4 late medications to Resident #26. 2. RN E administered 3 late medications to Resident #10. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #26's admission record dated 09/15/2023 revealed an admission date of 07/20/2023 with diagnoses which included hypertension [high blood pressure], constipation, glaucoma [a serious eye disease that can damage the optic nerve and cause vision loss or blindness], and polyneuropathy [a condition in which multiple peripheral nerves are damaged]. A record review 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 observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication rooms and 1 of 38 residents (Resident #40) reviewed for medication storage, in that: 1. LVN F failed to store unadministered medications for Resident #40. 2. The facility failed to secure the medication storage room. These failures could place residents at risk for misappropriation of property and harm by not receiving the therapeutic effects of the medications prescribed by the physician. The findings included: 1. During an observation on 09/11/2023 at 09:03 AM revealed the facility sole medication storage room door was ajar and unsecured. Further observations revealed the room to be unsupervised and unattended. During an observation and interview on 09/11/2023 at 09:15 AM LVN D stated she and LVN F were the nurses on duty and the only staff with keys to the medication storage room. LVN D stated the room was unlocked 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 interviews and record reviews the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for 1 of 1 facility reviewed for QAPI performance improvements, in that; The facility failed to develop quality improvement measures and or interventions after recognizing a failure to have the resident's physician address the pharmacists monthly drug regiment review recommendations. This failure could place residents at risk for harm by not receiving the benefits of the physician and the pharmacist's review. The findings included: Record review of documents titled Consultant Pharmacist's Monthly Report for [The Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review revealed 33 residents of the 33 sampled had no interventions to support the pharmacist recommendations. Interview 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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 8 (Resident #20) reviewed for abuse and neglect, in that: The facility failed to report an allegation of neglect to the State Survey Agency within 24 hours of being made by Resident #20. This deficient practice could place residents at risk of allegations not fully being investigated, and abuse, neglect, misappropriation, or exploitation. The findings included: Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted…

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 reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #3) reviewed for care plans, in that. The facility failed to develop a care plan to support Resident #3's need for a spinal cord stimulator. These failures could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #3's admission record, dated 05/15/2023, revealed an admission date of 08/18/2023, with diagnoses which included post-laminectomy status [after a surgery to fuse some spinal vertebrae], chronic pain, and the presence of neurostimulator [a device which stimulates nerves]. A record review of Resident #3's admission MDS assessment, dated 08/24/2023, revealed Resident #3 was an [AGE] year-old female…

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, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 day (08/20/2023) of 90 days reviewed for nursing services, in that: The facility failed to have a registered nurse working on Sunday 08/20/2023. This failure could place residents at risk for harm by denying residents the advanced nursing skill level a registered nurse is supposed to provide. The findings included: A record review of the facility's Facility Assessment Tool dated 08/08/2023 revealed the facility's average daily census was projected to be 30-50, with an average of residents who have specialized care needs: 14 who need oxygen therapy, 1-3 residents who need a BiPaP / CPaP [BiPAP and CPAP machines have a lot in common. They both deliver positive air pressure (PAP) via a tabletop device connected to a tube and a mask], 1-7 residents who have behavioral health needs, 2-5 residents who need injectable medications, and an average of 7 residents who have hospice care needs. A record review of the facility census…

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.