Legend Healthcare And Rehabilitation - Greenville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for four (Resident #66, Resident #250, Resident #73, Resident #1) of 24 residents reviewed for dietary services. The facility failed to honor Resident #250's preference for no pork. The facility failed to provide snacks for dialysis for Resident #66 and Resident #73. The facility failed to provide Resident #1 with food that accommodated his preferences. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life. Findings include: 1- Resident #66 Record Review of Resident #66s face sheet revealed she was admitted to facility with initial admission date of 8/12/2023. Her relevant diagnoses include Diabetes Mellitus (increased blood glucose), Hypothyroidism (low thyroid hormone levels), Hypertension (high blood pressure), Dependence on Renal Dialysis (involves relying on 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.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were dated or labeled. 2. The facility failed to ensure dented cans were stored away from the main dry storage area. 3. The facility failed to ensure Dietary manager checked food temperature before serving during lunch meal service on 5/29/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings included: Observation in the facility's kitchen on 5/28/24 at 10:54 AM revealed one-gallon Ziplock bag of orange mashed food. Observation in Facility's dry storage on 5/28/2 at 10:44 AM of kitchen dry storage area revealed 3 cans of canned butterbeans and 1 can Chicken Broth were dented and stored within the storage area with other canned goods.…

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 based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 21 residents (Resident #44) reviewed for quality of care. The facility staff failed to ensure Resident #44's splint was placed on his right arm and hand on 06/04/24 and 06/05/24 per physician orders. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in decreased Range of Motion and worsening of contractures. Findings included: Record review of Resident #44's face sheet dated 06/06/24 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of aphasia (loss of ability to understand or express speech caused by brain damage), hemiplegia right side (paralysis), and cerebral vascular accident (stroke). 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #52, Resident #70, and Resident #85) reviewed for catheter care. 1. The facility failed to ensure CNA D and CNA E maintained the foley catheter drainage bag below Resident #52's bladder during a mechanical lift transfer. 2. The facility failed to ensure RN P maintained Resident #70's foley catheter drainage bag below the bladder level during wound care on 06/03/24. 3. The facility failed to ensure Resident #85's catheter bag did not had contact with the floor. This failure placed residents at risk for not receiving care appropriate to address their incontinence. Findings included: 1. Record review of Resident #52's face sheet dated 06//06/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included obstructive and reflux uropathy (a disorder 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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (300 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure the 300 Hall medication cart had: 1- 1 insulin pens with no label and with an expired opened date. 2- 1 insulin pen for Resident #250 with no opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Observation on [DATE] at 12:48 PM revealed the 300-hall nurse's medication cart had a pen of Novolin R insulin pen 100 unit/ml, had no label an opened date of [DATE]. The label revealed discard after 28 days. 2- Record review of Resident #250's Comprehensive MDS, dated [DATE],…

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 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 three of sixteen residents (Resident #78, Resident #13 and Resident #51) observed for infection control. 1. The facility failed to ensure that CNA D performed hand hygiene while providing incontinence care to Resident #78 on 06/04/24. 2. The facility failed to ensure that CNA F changed his gloves and performed hand hygiene while providing incontinence care to Resident #13 on 06/04/24. 3. The facility failed to ensure that CNA L changed her gloves and performed hand hygiene while providing incontinence care to Resident #51 on 06/04/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #78's Face sheet dated 06/06/24 reflected 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 observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that established a system of records of receipt and disposition of all controlled drugs in sufficient detail to ensure an accurate reconciliation for 4 of 5 carts (Carts 1, 2, 3, and 4) reviewed for securing controlled drugs. The facility failed to ensure all controlled drugs were received and counted according to facility procedure when nursing staff failed to document the count of controlled drugs on the medication carts. MA A failed to secure controlled drugs on cart #3. This failure could place residents at risk for misappropriation of their medications or not receiving the therapeutic benefits from medications because there are not available. Findings included: Cart 1: Review of a narcotic count sheet dated September 2023 for the nursing medication cart for the 100-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 16 cards which indicated…

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 complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 20 residents (Resident's #7, #23, #27, and #129) reviewed for comprehensive assessments and timing. 1. The facility failed to ensure Resident #129's cognitive status was assessed. 2. The facility failed to ensure Resident #7, #23, and #27's cognitive and mood statuses were assessed. This failure could place residents at risk of not having their needs identified and met. The findings included: 1. Record review of Resident #129's face sheet dated 3/20/23 revealed he was a [AGE] year-old, male, and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disruption of blood flow to the brain which can parts of the brain to die off, also known as a stroke), hemiplegia and hemiparesis of right dominant side (weakness or inability to move the right side of the body), aphasia (loss of ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 8 of 20 residents reviewed for palatable food. (Resident #239, Resident #240, and 6 residents in a confidential group). The facility failed to provide palatable food served at an appetizing temperature for Resident #239, Resident #240, and 6 residents in a confidential group. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of Resident #239's face sheet dated 3/21/23 revealed she was an [AGE] year-old, female, and admitted to the facility on [DATE] with diagnoses of fracture of right ischium (broken right pelvis), history of falls, diabetes (disease of too much sugar in the blood), pain, and history of lung cancer. Record review of Resident #239's MDS revealed it had not been completed. Record review of Resident #239's BIMS…

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 safety in the facility's only kitchen. The facility failed to ensure: 1. The juice machine spigot was clean 2. The microwave was clean and free of food debris. 3. The cooking grease in the deep fryer was kept clean. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation in the kitchen on 03/20/2023 at 10:15 a.m., revealed yellow build up inside the microwave, a red gooey substance was observed in the juice machine spigot and dark brown grease noted inside the deep fryer. Record review of the daily cleaning schedule indicated [NAME] R was responsible for changing the grease in the deep fryer on 3/19/2023. The cleaning schedule indicated Dietary Aide S was responsible for cleaning the microwave. The cleaning schedule did not address the juice spigot. Record review of a dining services and sanitation audit dated 02/27/2023 completed by the Dietician indicated…

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 each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 24 resident (Resident #12) reviewed for self-determination. The facility failed to ensure CNA E assisted Resident #12 with a bed bath when he requested it. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of a face sheet dated 03/22/2023 revealed Resident #12 was a [AGE] year old male initially admitted [DATE] and re-admitted [DATE], with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive…

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 environment for 1 of 24 resident room (room [ROOM NUMBER]A) reviewed for a homelike environment. The facility failed to repair deep scratches that exposed the sheetrock and dents with cracks on the wall behind the head of the bed in room [ROOM NUMBER]A. This failure could place residents at risk for a diminished quality of life and a diminished clean well-kept environment. Findings included: During an observation on 03/20/23 at 2:39 PM, room [ROOM NUMBER]A behind the head of the bed had deep scratches to the wall that exposed the sheetrock and dents with cracks. During an interview on 03/22/2023 at 3:55 PM, MA N stated she was aware of the deep scratches and dents with cracks behind the head of the bed in room [ROOM NUMBER]A. MA N stated if there was damage in the rooms it was supposed to be put in the maintenance book for the maintenance director to fix it. MA N stated she did not put room [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 3 residents (Resident #12) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #12's black blanket when it was not returned from the laundry. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 03/22/2023 revealed Resident #12 was a [AGE] year old male initially admitted [DATE] and re-admitted [DATE], with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic (systolic)…

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 an accurate MDS was completed for 2 of 20 residents (Resident's #38 and #76) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document oral status for Resident #38 on the MDS assessment. 2. The facility failed to accurately complete a nursing home discharge MDS assessment for Resident #76. These failures could place residents at risk for not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #38's face sheet, dated 03/20/2023, revealed Resident #38 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbances (group of symptoms that affects memory, thinking and interferes with daily life), PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar…

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 coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 2 of 21 residents (Resident #52 and Resident #2) reviewed for PASRR. The facility failed to indicate on the PASRR level 1 screening completed by the facility that Resident #52 had a mental illness. The facility failed to coordinate Resident #2's annual IDT PASSR meeting. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: 1.Record review of Resident #52's consolidated physician orders dated 03/22/23 indicated she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident #52 had a diagnosis of type 2 diabetes (chronic condition that affects the way the body processes blood sugar), bipolar (episodes of mood swings ranging from depressive lows to manic highs) and hypertension…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents reviewed for care plans. (Resident #38) The facility failed to ensure Resident #38's oral or dental status was care planned. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. The findings included: Record review of Resident #38's face sheet, dated 03/20/2023, revealed Resident #38 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbances (group of symptoms that affects memory, thinking and interferes with daily life), PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance 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 interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident representative was invited to participate in developing the care plan and making decisions about his or her care for 1 of 24 resident reviewed for care plan timing and revision. The facility failed to ensure Resident #26's resident representative was invited to participate in the development, review, and revision of her care plan. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 03/22/2023, revealed Resident #26 was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety(loss of memory, language,…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 27.78%, based on 10 errors out of 36 opportunities, which involved 1 of 6 residents (Resident #231) reviewed for medication administration. The facility failed to ensure Resident #231 received Eliquis (prevent blood clots), escitalopram (treat depression), Namenda (treat dementia), Protonix (treat acid reflux), potassium chloride (mineral supplement), vitamin B12 (supplement), cholecalciferol (supplement), calcium (supplement), ocuvel (supplement), and magox (supplement). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #231's order summary report, dated 03/22/2023, indicated Resident #231 was an [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 1 (Resident #38) residents reviewed for dental services. The facility failed to ensure Resident #38 received dental services when she had carious, missing, loose, and broken teeth. These failures could place residents at risk of not receiving needed dental care and a decreased quality of life. The findings included: Record review of Resident #38's face sheet, dated 03/20/2023, revealed Resident #38 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbances (group of symptoms that affects memory, thinking and interferes with daily life), PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations), and schizoaffective disorder (mental health…

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 food was prepared in a form designed to meet individual needs and as prescribed by the physician for 2 of 3 residents (Resident #48 and Resident #26) reviewed for therapeutic diets. The facility failed to ensure Resident #48 received a pureed diet as ordered by the physician. The facility failed to ensure Resident #26 received a mechanical soft diet as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs). Findings Included: 1.Record review of a face sheet dated 03/22/2023, revealed Resident #26 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other…

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 safe and sanitary storage of resident's food items for 2 of 7 residents reviewed for personal food safety. (Resident's #2 and Resident #23) The facility did not implement the personal food policy related to personal refrigerators for Resident's #2 and #23. These failures could place the residents at risk for food borne illness. The findings included: 1. Record review of Resident #2's face sheet, dated 03/22/2023, revealed Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of bipolar disorder (serious mental illness characterized by extreme mood swings), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and anxiety disorder (group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats).…

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 maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 2 of 5 meetings (November 2022, and December 2022) reviewed for QAPI. The facility did not ensure the Administrator attended their QAPI meetings in November 2022, and December 2022. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets indicated the Administrator did not sign in for their meetings from November 2022 and December 2022. The sign-in-sheets did not indicate the owner, or a board member attended the meetings in November 2022 and December 2022. During an interview on 03/22/2023 at 9:56 a.m., Administrator C stated he was the interim Administrator for November 2022 and December 2022. Administrator C stated the Administrator, DON, MDS nurse and the DOR were supposed to be present at the QAPI…

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.