Crestwood Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Specifically, a medication cart was observed unlocked and unattended outside of resident rooms. Findings included: On 4/19/26 at 8:05 AM, an observation was made of the medication cart on the second floor between room [ROOM NUMBER] and 204. The cart was unlocked and unattended by nursing staff. On 4/19/26 at approximately 8:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 was observed exiting room [ROOM NUMBER]. RN 1 confirmed that he had left the medication cart unlocked and unattended. On 4/22/26 at 8:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when staff walk away from the medication cart and no other staff were present it should be locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain a Basic Metabolic Panel (BMP) when ordered by the provider. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 4/15/26, resident 8's physician ordered a BMP to be obtained. No documentation could be found of the laboratory results in resident 8's medical records. On 4/27/26 at approximately 8:00 AM, the Director of Nursing (DON) was asked to provide the results for the BMP that was ordered on 4/15/26. On 4/27/26 at 8:40 AM, the Regional Nurse Consultant (RNC) communicated via email that they were still looking for the results of resident 8's BMP. On 4/27/26 at 9:40 AM, the DON stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 40 residents sampled, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's urinalysis laboratory report was not located in the medical records. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 3/21/26, resident 8's physician ordered a urinalysis to be obtained. No documentation could be found of the laboratory results in resident 8's medical records. On 4/27/26 at approximately 8:00 AM, the Director of Nursing (DON) was asked to provide the results for the urinalysis that was ordered on 3/21/26. On 4/27/26 at 8:40 AM, the Regional Nurse Consultant (RNC) provided via email the laboratory results for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, the resident's chest x-ray report was not located in the medical records. Resident identifier: 6. Findings included: Resident 6 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included contracture right and left hand, dysphagia, hypothyroidism, dementia, atrial-fibrillation, pain, hypertension, chronic pain, deformity of left lower leg, peripheral vascular disease, and idiopathic neuropathy. On 4/19/26, resident 6's medical records were reviewed. On 1/10/26 at 9:37 AM, resident 6's progress note documented, Resident has productive cough and crackles bilaterally, MD [Medical Doctor] notified and STAT [immediate] CXR [chest x-ray] ordered.No documentation of the chest x-ray was found in resident 6's medical records. On 4/22/26 at 9:49 AM, an interview was…

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

Based on interview and record review it was determined the facility did not employ a full-time, designated person to serve as the director of food and nutrition services. Specifically, the facility did not have a qualified food service director. Findings included: On 4/22/26 at 1:20 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not have a certification. The DM stated she had been the DM for 3 years. The DM stated the Registered Dietitian (RD) was at the facility weekly for the nutrition at risk meeting and was available by phone anytime. The DM stated she had registered for the course a few times but then staffing was low in the kitchen and she was pulled to work in the kitchen. On 4/22/26 at 4:05 PM, an interview was conducted with the Administrator. The Administrator stated that he did not know if the DM had a certification. The Administrator stated the RD worked 1 day a week at the facility. (Cross refer to F804 and F812)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for 1 of 40 sampled residents, the facility did not arrange timely services for outside resources that met professional standards and principles that applied to professional providing services. Specifically, a resident was not scheduled for a pain clinic appointment when pain was identified and the resident requested. Additionally, resident records were not secured, left unattended, and visible to any passerby. Resident identifier: 8. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included stage 4 pressure ulcers, paraplegia, osteomyelitis, spastic hemiplegia and injury of root of cervical spine. On 4/19/26 at 3:27 PM, an interview was conducted with resident 8. Resident 8 stated he was in a lot of pain and when he was admitted the house physician decreased his pain medication. Resident 8 stated he requested to be sent to a pain clinic because his pain medications were decreased when he was 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 interview and record review, for 1 of 40 sampled residents, the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident had an order for 12 tablets of an antidepressant when the physician ordered 1 tablet. Additionally, the medication cart had the computer open to resident records and left unattended and a nurse report sheet with resident medical information was visible. Resident identifier: 4. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, altered mental status, dementia, bipolar and pulmonary hypertension. A physician's order dated 2/27/25 and discontinued 3/4/25 revealed Wellbutrin XL [extended-release] oral tablet extended release 24 hours 150 milligrams [MG]. The directions were to give 12 tablets by mouth one time a day for depressive symptoms. A nursing progress note dated 2/26/25 at 10:38 AM revealed, .I received new orders and reviewed them with the facility NP…

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

Based on observation, interview, and record review it was determined, for 3 of 19 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not attractive or palatable, and there were complaints in the resident council meetings. Resident identifiers: 2, 16, and 17. Findings include:On 12/29/25 at 11:51 AM, an interview was conducted with resident 17. Resident 17 stated the food tasted like shit. Resident 17 stated They could starve a bird with the food they serve here. Resident 17 stated he was served only a piece of toast and coffee for breakfast yesterday. On 12/29/25 at 1:39 PM, an interview was conducted with resident 2. Resident 2 stated the food was served cold. On 12/30/25 at 11:07 AM, an interview was conducted with resident 16. Resident 16 stated the food was not good and she did not eat lunch on 12/29/25. Resident 16 stated it was popcorn chicken with all breading and it looked horrible. Resident 16 stated she did not…

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

Based on observation, interview, and record review, it was determined the facility did not provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, a sign was hung in the elevator instructing residents that water was the only beverage available between meals and coffee was served at specific times. Findings include: On 12/30/25, a sign was observed in the resident elevator. The sign revealed UPCOMING CHANGES!!! COFFEE WILL NOW START BEING SERVED AT 7 am AT THE EARLIEST COFFEE AND JUICE WILL ONLY BE SERVED AT MEAL TIMES AND WE ARE NO LONGER FILLING UP MUGS WITH JUICE OR COFFEE! IF YOU WANT TO HAVE ANY BEVERAGES BESIDES WATER BETWEEN MEAL TIMES YOU WILL HAVE TO PROVIDE YOUR OWN (WE ARE IN THE PROCESS OF GETTING VENDING MACHINES). THIS WILL BEGIN ON MONDAY NOVEMBER 17TH!!! On 12/30/25 at 12:28 PM, an interview was conducted with the Dietary Supervisor (DS). The DS stated recently there was a policy change that residents were not provided beverages other than water between meal times.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure that each resident received supervision to prevent accidents. Specifically, a resident who was assessed as high risk for exit seeking and had a wanderguard alarm system placed on his body eloped from the facility and was missing for multiple hours. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia, alcohol dependence, Wernicke's encephalopathy, osteoarthritis left knee, and chronic pain. On 12/29/25 at 9:53 AM, an interview was conducted with resident 1. Resident 1 stated that he exited the building from the door located inside his room, and the alarm on the inside of the door did not work. The resident was observed to ambulate independently and open the door to the outside courtyard. The courtyard was enclosed by a fence with locked gates on both sides of the courtyard. Resident 1 stated that a long…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to report the results of all investigations to the State Survey Agency (SSA), within 5 days of the incident. Specifically, for 2 out of 7 sampled residents, the facility did not thoroughly investigate an allegation of abuse from misappropriation of funds and an allegation of neglect from a fall with serious injury. Resident Identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included quadriplegia, muscle weakness, chronic obstructive pulmonary disease, sepsis, and cellulitis. On 5/1/24, resident 1's medical record was reviewed. Exhibit 358 Initial Report dated 2/28/24 at 4:49 PM, indicated that the facility reported an incident to the SSA. The initial report indicated an allegation of misappropriation of funds and exploitation when resident 1's money from his wallet went missing. On 5/1/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, a resident desired to return to the community through the New Choice Waiver (NCW) program and the facility did not submit the required paperwork for a whole year. Resident identifier: 6. Findings Included: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of malignant neoplasm of right renal pelvis, atrial fibrillation, generalized anxiety disorder, major depressive disorder, unsteadiness of feet, and difficulty in walking. On 5/1/24 at 10:02 AM, an interview was conducted with resident 6's Family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility did not ensure that the medication error rates was not 5 percent or greater. Observations of 31 opportunities revealed 2 medication errors which resulted in a 6.45 percent medication error rate. Specifically, a resident was administered a multivitamin supplement instead of the ordered multivitamin with mineral, and a resident was administered a fiber suppliment when the order did not specify the dosage to be administered. Resident identifiers 23 and 218. Findings included: 1. On 1/24/24 at 7:31 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration. LPN 1 was observed to administer a Multivitamin one tablet orally to resident 23. Resident 23 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of, but were not limited to, schizophrenia, hypo-osmolality and hyponatremia, iron deficiency anemia, and adult failure to thrive. Resident 23's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, a resident had an order for a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a Thyroid Stimulating Hormone (TSH) level that was not obtained, a resident had an order for an iron level to be drawn every six weeks and a lipid panel every six months that was not obtained, and a resident had an order for a CBC to be drawn monthly that was not obtained. Resident identifiers: 3, 35, and 37. Findings included: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, unsteadiness on feet, adult failure to thrive, muscle weakness, suicidal ideation, malignant neoplasm of larynx, tracheotomy status, presence of artificial larynx, chronic kidney disease, and hypothyroidism. On 1/23/24, resident 35's medical records were reviewed. On 10/16/23, the…

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

Based on observation and interview it was determined, for 9 of 33 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, residents sitting at the same table in the dining room were not served meals at the same time and food was served in disposable cups. Resident identifiers: 25, 28, 29, 31, 50, 54, 55, 61 and 165. Findings include: 1. On 1/22/24 11:59 AM, a dining observation was conducted in the 100 hallway dining room. The following residents were sitting at the same table: a. At 12:21 PM, resident 165 was served lunch and was observed to feed himself. b. At 12:22 PM, resident 50 and resident 55 were observed to be served lunch. c. At 12:25 PM, resident 29 was observed to be served lunch. d. At 12:29 PM, resident 61 was observed to be served lunch. e. At 12:30 PM, resident 28 was served lunch. Resident 28 was observed to give resident 61 a bottle of ensure. f. At 12:31 PM, resident 54 was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment. Specifically, for 1 of 33 sampled residents, the facility did not notify the Medical Director (MD) when blood sugar results were outside of the physician ordered parameters for notification. Resident identifier 49. Findings included: Resident 49 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included fracture of left femur, acquired absence of right and left leg below the knee, peripheral vascular disease, chronic kidney disease, neuromuscular dysfunction of the bladder, iron deficiency anemia, major depressive disorder, anxiety disorder, type II diabetes mellitus, hypertension, chronic pain, and personality disorder. Resident 49's January Medication Administration Record (MAR) revealed the following: a. On 1/17/24, in the morning the blood sugar (BS) was 442…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 2 of 33 sampled resident, that the facility did not ensure that residents remained free from abuse, neglect, and misappropriation of property. Specifically, there were residents in a relationship that had not been evaluated to have the capacity to consent. Resident identifier: 3 and 55. Findings included: On 1/22/24 at 9:16 AM, an observation was made of resident 3 and resident 55 in the 100 hall dining room. Resident 3 and resident 55 were sitting close to each other holding hands with their heads together at the dining room table. On 1/23/24 at 1:50 PM, an observation was made of resident 55 walking past resident 3 and touches her on the right shoulder with a patting motion. On 1/24/24 at 12:02 PM, an observation was made of resident 55 entering the dining area. Resident 55 then approaches resident 3, who was sitting at the dining room table. Resident 55 then touched with a patting motion resident 3 on the left shoulder. Resident 55 then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that when the facility transferred a resident the facility did not ensure that the transfer was documented in the resident's medical record and the information communicated to the receiving provider included: the basis for the transfer, the contact information of the practitioner responsible for the care of the resident, the resident representative information, the Advanced Directive information, all special instructions for ongoing care, the comprehensive care plans, and a copy of the resident's discharge summary. Specifically, for 2 of 33 sampled residents, the facility did not document a transfer or discharge assessment/note or what documentation was provided to the receiving provider to ensure a safe and effective transition of care. Resident identifiers 35 and 37. Findings included: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, unsteadiness on feet, adult failure to thrive, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not ensure that services provided by the facility met professional standards of quality and care. Specifically, for 2 of 33 sampled residents, a Licensed Practical Nurse (LPN) was observed to attempt to change a physician medication order without direction by the medical provider and the LPN confirmed that another medication order was modified without direction by the medical provider. Resident identifier: 23 and 218. Findings included: 1. On 1/24/24 at 7:31 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration. LPN 1 was observed to administer a Multivitamin one tablet orally to resident 23. Resident 23 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of, but were not limited to, schizophrenia, hypo-osmolality and hyponatremia, iron deficiency anemia, and adult failure to thrive. Resident 23's medical records were reviewed. On 10/14/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 33 sampled resident, that the facility did not provide necessary services to maintain good nutrition for a resident who was unable to carry out activities of daily living. Specifically, a resident waited 35 minutes to be fed by staff after her meal was served to her. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance, lack of coordination, muscle weakness, cognitive communication deficit, type 2 diabetes mellitus, and traumatic subdural hemorrhage without loss of consciousness. On 1/22/24 at 12:22 PM, an observation was made of resident 13. Resident 13 was observed to be served her lunch tray. The plate was observed to be in front of her with a dome over it. There were 2 disposable cups with lids in front of her. At 12:46 PM, resident 13 was observed with eyes closed with her chin on chest and 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 it was determined, for 1 of 33 sampled residents, that the facility did not provide adequate supervision to prevent accidents. Specifically, a resident was observed to be yelling for help from a staff bathroom located by the therapy department. Staff were not aware there was a call light for the bathroom. Resident identifier 51. Findings included: Resident 51 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, abnormalities of fait and mobility, muscle weakness, adult failure to thrive, suicide attempt, major depressive disorder, and acquired absence of right leg below knee. On 1/25/24 at 1:34 PM, a resident was heard in the staff only bathroom calling for help multiple times. The resident was later identified as resident 51. Resident 51 was observed to open the bathroom door and yell for help. The Director of Therapy (DOT) was observed to answer resident 51's calls for help. Resident 51 could be heard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 out of 33 sampled residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, lab results for a iron level, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Hemoglobin A1c, and a lipid panel were obtained but the reports were not filed in the residents medical records. Resident identifier: 3 and 37. Findings included: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses which consisted of cerebral infarction, asthma, testicular hypofunction, anxiety disorder, polyneuropathy, benign prostatic hyperplasia, chronic pain, type II diabetes mellitus, reduced mobility, muscle weakness, difficulty walking, hyperlipidemia, cognitive communication deficit, tremor, aphasia, mood disorder, dysphagia, and post-traumatic stress disorder. On 1/24/24, resident 37's medical records were reviewed. Resident 37's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, a resident's chest x-ray (CXR) results were not filed in their medical records. Resident identifier 4. Findings included: Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included pneumonitis, metabolic encephalopathy, fibromyalgia, asthma, pneumonia, hypertension, major depressive disorder, anxiety disorder, charcot's joint, scoliosis, hyperthyroidism, and obstructive sleep apnea. On 1/23/24, resident 4's medical records were reviewed. On 1/9/24, the physician ordered a chest x-ray one time for a non-productive cough. No documentation of the chest x-ray results could be found in resident 4's medical records. On 1/29/24 at 12:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not keep confidential information contained in the resident's medical record. Specifically, a residents name was used in another resident's medical record. Resident identifiers: 6 and 53. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, convulsions, intellectual disabilities, dysphagia, adult failure to thrive and lack of coordination. Resident 6's medical record was reviewed 1/22/24 through 1/29/24. A nursing progress note dated 1/12/24 at 7:20 PM, This nurse was called to dining room with urgency by another resident, [Resident 53's name]. [Resident 53's name] reports she put a whole string cheese in her mouth. It is not clear where or how she got the string cheese. On 1/29/24 at 2:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated other resident names should not be in other residents medical records. The…

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

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to remedy identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. Findings included: Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of Coronavirus disease (COVID-19). Specifically, the facility failed to ensure that staff members were screened for COVID-19 prior to entering the facility to work. The facility failed to ensure a symptomatic staff member, who subsequently tested positive for COVID-19, was screened accurately and notification and evaluation was completed per the facility protocol. The failure resulted in 3 residents being exposed to COVID-19. After the staff member tested positive for COVID-19, the facility did not…

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 Resident medical records were reviewed. 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity due to excess calories, cirrhosis of liver, essential hypertension, generalized anxiety disorder, asthma, pain in right hip, post traumatic stress disorder, cognitive communication deficit, liver disease, irritable bowel syndrome without diarrhea, and major depressive disorder. Resident 50's medical record was reviewed on 4/19/22. No documentation of resident or family notification of a positive COVID-19 test within the facility on 4/16/22 was located within the medical record. 2. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, atrial fibrillation, vascular dementia with behavioral disturbance, malignant neoplasm of bladder, generalized anxiety disorder, major depressive disorder, acute ischemic heart disease, metabolic encephalopathy, and cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, for 6 of 34 sample residents, that the facility did not ensure that the resident's medical records were secure and confidential. Specifically, observations were made of computer screens left unattended and displaying resident's personal information. Resident identifier: 17, 25, 29, 33, 46 and 51. Findings included: On 4/18/22 at 8:40 AM, Licensed Practical Nurse (LPN) 1 was observed to walk away from the medication cart and walk to the nurses station. The laptop computer on the medication cart was open to resident 51's medical record. The computer was visible from the hallway. On 4/18/22 at 9:00 AM, LPN 1 was observed to have left the medication cart unlocked and walked into resident 33's room. The computer on the medication cart was left open to resident 33's medical record. The computer was visible from the hallway, resident 25 was in the hallway. On 4/19/22 at 9:30 AM, an interview was conducted with LPN 1. After preparing medications for resident 51, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 4 of 34 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, two residents did not have updated care plans for pressure sores, and two residents had care plans that did not address their dental needs. In addition, a residents was not evaluated for a bowel and bladder program. Resident identifiers: 5, 41, 49, and 56. Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, convulsions, dysphagia, intellectual disabilities, constipation, edema, pain, muscle weakness and nutritional deficiency. On 4/25/22 resident 41's medical record was reviewed. A Physician's Order dated 3/25/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 3 of 34 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not changing the residents oxygen tubing and humidifier bottles per physician's order. Resident identifiers: 34, 38 and 55. Findings included: 1. Resident 34 was admitted to the facility on [DATE] with diagnoses which included human immunodeficiency virus (HIV) disease, stage 4 pressure ulcer, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder, pain, and adult failure to thrive. On 4/18/22 at 2:36 PM, an observation was made of an oxygen concentrator next to resident 34's bed. The disposable humidifier bottle was a quarter of the way full of water. Neither the humidifier bottle nor the oxygen tubing were dated. A gallon sized plastic bag was taped to the side of the oxygen concentrator. The bag…

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

Based on observation, interview, and record review it was determined that the facility menus were not prepared in advance, followed, and reviewed by the facility dietitian for nutritional adequacy. Specifically, menu items were changed without notifying the facility dietitian and the portion sizes were not served according to the menu. Resident identifiers: 15, 39 and 56. Findings included: On 4/18/22 at 11:35 AM, an interview was conducted with resident 56. Resident 56 stated there was a situation over the weekend. Resident 56 stated that there was no cook and the kitchen was short handed, so everyone was served a dollar coin size of meat loaf, a salad with no dressing, and a very small amount of potatoes. Resident 56 stated that a family member had to bring more food to her. On 4/18/22 at 1:24 PM, an interview was conducted with resident 15. Resident 15 stated that he was provided baby sized food portions. Resident 15 stated he had to request more food. On 4/18/22 at 1:49 PM, an interview was conducted with resident 39. Resident 39 stated it felt like there was not enough food…

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

Based on observation and interview, it was determined that the facility did not distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a refrigerator and multiple freezers were not dated or were past the use by date, logs on refrigerators and freezers were not completed, and there were cracked tiles in the dish machine area. Findings included: 1. On 4/18/22 at 9:35 AM, an interview was conducted with the Dietary Manager (DM) who stated the resident refrigerator in the lower-level storage area was for resident food only. The DM stated there was a log on the door of the refrigerator to keep track of what was inside, the date it was placed in the refrigerator, and when it was to be removed. On 4/18/22 at 9:37 AM, an observation was made in the 100 level storage area where the resident refrigerator and three other freezers were located. The following observations were made: a. For the resident refrigerator, the log on the side of the refrigerator was from March 2022. There were two entries, one from 3/2/22 and one from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not have adequate outside ventilation by means of window, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility during the survey. Findings included: On 4/18/22 at 8:40 AM, on initial entry into the facility there was a strong feces odor noted. On 4/18/22 at 9:37 AM, an observation was made of 2 residents sitting in the lower level dining area watching television. A strong odor of urine was observed in the dining area at that time. On 4/18/22 at 9:40 PM, an observation was made in the elevator. There was a strong urine odor. On 4/18/22 at 9:45 AM, an observation was made of the 100 hallway. There was a strong urine and feces odor. On 4/18/22 at 9:53 AM, a fecal odor was observed in the hallway leading from the therapy gym to the 200 hall. On the 200 hall, there was a fecal odor observed throughout the entire 200 hall. On 4/18/22 at 10:00 AM, an observation was made of strong urine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 of 34 sample residents, a resident was observed to have medication in a lock box available for use in the resident's room and the resident was not evaluated to determine if she was safe to self administer medications. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, morbid obesity due to excess calories, cirrhosis of liver, essential hypertension, generalized anxiety disorder, asthma, pain in right hip, post traumatic stress disorder, cognitive communication deficit, liver disease, irritable bowel syndrome without diarrhea, and major depressive disorder. On 4/18/22 at 1:23 PM, an interview was conducted with resident 50. Resident 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility did not ensure that each resident received an accurate assessment that reflected the status, needs, strengths, and areas of decline for each resident. Specifically, for 2 of 34 sample residents, the facility did not provide an accurate assessment of the resident's dental status resulting in the resident's dental needs not being identified. Resident identifiers: 5 and 56. Findings included: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of lateral malleolus of right fibula, displaced fracture of lateral malleolus of left fibula, muscle weakness, difficulty in walking, foot drop (left foot), morbid obesity, post-traumatic stress disorder, generalized anxiety disorder, personal history of other venous thrombosis and embolism, and unspecified convulsions. On 4/18/22 at 12:06 PM, an interview was conducted with resident 5. Resident 5 stated she had dentures that did not fit correctly.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined for 1 of 34 sample residents, that the facility did not ensure the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident was observed not being supervised during smoking and dropped cigarettes and ashes onto his lap. Resident identifier: 54. Findings included: Resident 54 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease, essential hypertension, major depressive disorder, dependence on renal dialysis, muscle weakness, difficulty walking, nicotine dependence and difficulty walking. On 4/19/22 at 9:27 AM, an observation was made of resident 54. Resident 54 was observed to be alone under a gazebo outside. Resident 54 was observed to be smoking. Resident 54 was observed to have long ash on his cigarette. Resident 54's ash was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 out of 34 sampled residents, that the facility did not ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. Specifically, the facility did not assess a resident for possible bowel and bladder retraining. Resident identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] with diagnoses which included alcoholic liver disease, rheumatoid arthritis, fibromyalgia, hypothyroidism, chronic obstructive pulmonary disease, post-traumatic stress disorder, and anxiety disorder. On 4/18/22 at 10:35 AM, an interview and observation was made of resident 56. Resident 56 stated she had fallen because she tried to get to the bathroom by herself. Resident 56 stated that staff told her not to get up to the bathroom without staff assistance or she might…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 out of 34 sampled residents, that the facility did not offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, the facility was not offering fortified diets for residents. Resident identifier: 49. Findings included: Resident 49 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, hypertension, dementia, dysphagia, and Gilbert Syndrome. On 4/25/22 at 12:20 PM, an observation was conducted of resident 49 during the lunch meal. Resident 49 had broccoli, pasta, and ice cream on his tray. Resident 49's medical record was reviewed on 4/21/22. A quarterly Minimum Data Set assessment dated [DATE], revealed resident 49 required supervision while eating with set up help only and no swallowing problems. There was no information regarding resident 49's diet. A care plan dated 9/18/19 and updated on 3/16/22, revealed [Resident 49] has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 34 sampled residents, a resident's medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, morbid obesity due to excess calories, cirrhosis of liver, essential hypertension, generalized anxiety disorder, asthma, pain in right hip, post traumatic stress disorder, cognitive communication deficit, liver disease, irritable bowel syndrome without diarrhea, and major depressive disorder. On 4/18/22 at 1:23 PM, an interview was conducted with resident 50. Resident 50 stated the staff kept losing her AirDuo medication. Resident 50 was observed to reach for a lock box that was on a shelf above her bed. The lock…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that for 1 out of 34 sampled residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, a resident was provided medications when their blood pressure was outside of the physician's ordered parameters. Resident identifier: 49. Findings included: Resident 49 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dementia, hyperlipidemia, and Gilbert Syndrome. Resident 49's medical record was reviewed on 4/25/22. A physician's order dated 9/6/19, revealed Lisinopril 2.5 milligrams by mouth in the morning. The instructions revealed that the medication was to be held if the systolic blood pressures was less than 110 or the diastolic blood pressure was less than 60. Resident 49's Medication Administration Record (MAR) for March 2022 was reviewed. The following dates revealed when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, an expired medication was administered to a resident. Resident identifier: 29. Findings included: Resident 29 was admitted to the facility on [DATE] with diagnoses which include metabolic encephalopathy, acute respiratory failure, pulmonary hypertension, pleural effusion, dysphasia, major depressive disorder, and alcohol abuse. On [DATE] at 8:42 AM, a medication that was in a bubble pack card from a local pharmacy was observed to be removed from the medication cart by the Assistant Director of Nursing (ADON). There were two bubbles, which held medication, that remained in the bubble pack card. The ADON was observed to place the medication from bubble #2 into a medication cup for resident 29. The bubble pack card…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility did not ensure that each resident obtained needed dental services. Specifically, for 2 of 34 sample residents, the facility did not provide needed dental services for a resident with dentures that did not fit experiencing mouth pain and a resident with missing teeth experiencing mouth pain. Resident identifiers: 5 and 56. Findings included: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of lateral malleolus of right fibula, displaced fracture of lateral malleolus of left fibula, muscle weakness, difficulty in walking, foot drop (left foot), morbid obesity, post-traumatic stress disorder, generalized anxiety disorder, personal history of other venous thrombosis and embolism, and unspecified convulsions. On 4/18/22 at 12:06 PM, an interview was conducted with resident 5. Resident 5 stated she had dentures that did not fit correctly. Resident 5 stated her dentures did not fit…

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.