Meadow Brook Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide or obtain laboratory (lab) services only when ordered by a physician. Specifically, for 1 out of 29 sampled residents, a resident did not have a physician's order for an ammonia level, Complete Blood Count (CBC), and magnesium. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, diabetes mellitus, pseudobulbar, generalized anxiety disorder, and dementia. Resident 15's medical record was reviewed on 9/22/25 through 9/59/25. An ammonia level was drawn on 7/7/25, a CBC was drawn on 7/9/25, and a Magnesium and CBC were drawn on 9/15/25. There were no physician's orders for the labs drawn. On 9/29/25 at 1:00 PM, an interview was conducted with the Director or Nursing (DON). The DON stated that all laboratory draws need to be ordered by the physician. The DON stated she did not know why there…

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 did not ensure each resident received food prepared in a form designed to meet individual needs. Specifically, for 1 out of 29 sampled residents, a resident with a physician order for thickened liquids was not provided the appropriate thickened liquids. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, pneumonia, dementia, and moderate oropharyngeal dysphagia. On 9/22/25 at 12:35 PM, an observation was made of resident 15 during the lunch meal. Resident 15 was observed to be fed by Certified Nursing Assistant (CNA) 2. CNA 2 was feeding resident 15 a pink frozen substance and resident 15 was coughing after each bite. Resident 15 was observed to have thickened milk and juice which were observed to have a nectar consistency and resident 15 was coughing after drinking the liquids. CNA 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 13 sampled residents, that the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, staff were not monitoring oxygen levels for a resident who had a diagnosis of pneumonia. Resident identifier: 1. Findings include 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included aneurysm, hypertensive heart disease, heart failure, moderate protein-calorie, gout, obstructive and reflux uropathy, muscle weakness, unsteadiness on feet, obstructive sleep apnea, urinary tract infection, prediabetes, and dysphagia. On 10/22/24 resident 1's medical record was reviewed. On 8/15/24 at 11:40 am a Nurses Note documented that resident 1 was sent to the hospital due to a blocked nasogastric (NG) tube. On 8/15/24 at 7:00 pm a Nurses Note documented that resident 1 had returned 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 record review and interview, the facility did not promptly act upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. In addition, the facility was not able to demonstrate their response and rationale for resident concerns. Specifically, recurring concerns were voiced by the resident council over the period of approximately 14 months with no follow up to or resolution of the concerns. Findings include: The resident council notes for the previous 14 months were reviewed and revealed the following concerns voiced by the residents: a. On 1/25/23: i. The parking lot is hard to maneuver, it's dangerous. People keep falling and hard to maneuver with a wheelchair. ii. Agency staff don't always understand specific needs. High turn over rate. Affecting care. iii. Dietary: I like him [name of staff member] he's doing better. Tray transfer needs to be thought over, need to use second cart so dirt/grime does not get on the bottom trays. Larger…

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 did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility did not have a full time maintenance worker, resident areas were dirty, there was a lack of hot water in resident bathrooms and communal shower room, a resident bathroom door was in disrepair, a resident had missing items which had not been replaced and a column from the gazebo area outside had a loose metal base which caused a resident to fall resulting in a laceration. Resident identifiers: 4, 21, 26, 30, 31, 33, and 34. Findings Include: MAINTENANCE AND HOUSEKEEPING 1. On 2/7/24 at 9:32 AM, an interview was conducted with resident 4. Resident 4 stated that the dining room tables and table linens were filthy and the dining room usually had a bad odor. Resident 4 stated that the drinking fountain in the dining room had a sewer smell. Resident 4 stated that they ran out of toilet paper a week ago and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 out of 40 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident threw a can of food at another resident and struck them in the leg. Additionally, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident cut another resident with a razor. In addition, multiple areas of neglect were identfied during the survey. Resident identifiers: 7, 19, 31, and 36. Findings included: ABUSE 1. A. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, cirrhosis, type II diabetes mellitus, excoriation (skin picking) disorder, major depressive disorder, stimulant abuse, chronic pain, gout, polyneuropathy, hepatitis C, chronic kidney disease,…

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 9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. The facility staff became aware that resident 93 had not returned to the facility at 6:00 PM on [DATE]. The facility administration was notified that resident 93 had not returned to the facility at 6:30 AM on [DATE]. 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 9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], Resident 93 was admitted to the facility. Resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, Resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. The facility staff became aware that Resident 93 had not returned to the facility at 6:00 PM on [DATE]. The facility administration was notified that Resident 93 had not returned 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, the facility did not have evidence that all allegations of abuse were thoroughly investigated for 3 of 40 sampled residents. Resident identifiers: 16, 33, and 97. Findings included: 1. Resident 97 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, severe protein-calorie malnutrition, viral hepatitis C, generalized anxiety disorder, muscle weakness, adjustment disorder with anxiety, major depressive disorder, dysphagia, and insomnia. Resident 97's medical record was reviewed from 2/5/24 through 2/22/24. Resident 97's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Resident 97's progress notes indicated the following: a. On 9/28/22 at 4:00 PM, a nurses note read, Resident approached nurses' station and resident informed nurse that he was going to look at apartments with a friend. Resident had walker with him…

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 40 sampled residents, that the facility did not incorporate the recommendations from the pre-admission screening and resident review (PASRR) level II determination and the PASRR evaluation report into the resident assessment, care planning, and transitions of care. Specifically, residents had PASRR level II recommendations for mental health services and none were provided. Resident identifiers: 21, 29, and 34. Findings included: 1. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, insomnia, migraine, schizoaffective disorder, and history of suicidal behavior. On 6/22/23, resident 29's Patient Health Questionnaire (PHQ)-9 depression assessment documented a score of 17, which indicated moderately severe depression. On 9/21/23, resident…

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 did not provide the appropriate treatment and services to 5 of 40 sampled residents to maintain or improve his or her ability to carry out the activities of daily living. Specifically, multiple residents did not receive showers as desired or scheduled. Resident identifiers: 7, 8, 28, 31, and 34. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:21 AM, an interview was conducted with resident 7. Resident 7 stated that his scheduled shower days were…

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, observation and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents voiced concern about the staffing level both individually and in a group setting, showers were not provided as scheduled, pain medication was not provided timely, incontinence care was not provided timely, and a nurse left the facility to retrieve the keys to the medication cart from the Director of Nursing. Resident identifiers: 1, 4 6, 7, 8, 16, 30, 31, and. Findings included: 1. On 2/5/24 at 1:47 PM, an interview was conducted with resident 31. Resident 31 stated that approximately one month prior, she was left in the shower for 10 to 15 minutes alone. She stated that she had the emergency light on because she needed to go to the bathroom, but because no…

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 used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, three Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified. Findings include: On 2/13/24, the files of 3 Nursing Assistants (NAs) were reviewed and revealed the following: a. NA 2 had a hire date listed as 9/25/23. b. NA 3 had a hire date listed as 9/1/23. c. NA 7 had a hire date listed as 8/7/23. The facility staff schedule for the week of 2/4/24 through 2/10/24 was reviewed. NA 2, NA 3 and NA 7 were all scheduled and assigned a section of the facility to provide cares for residents during that week. On 2/7/24 at 9:55 AM, an interview was conducted with Nurse Assistant (NA) 2. NA 2 stated that he had worked at the facility for 2 months and he was working on getting his certificate. On 2/14/24 at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she had not taken the test to become certified yet. NA 3 stated that she was training…

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 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. Resident 31's physician orders revealed the following: a. On 6/21/23, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. The order was discontinued on 1/30/24. b. On 1/30/24, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. c. On 6/21/23, an order was initiated for Escitalopram Oxalate Oral Tablet, give 20 mg by mouth one time a day for depression. The order was discontinued on 1/30/24. d. On 1/31/24, an order was initiated for Escitalopram Oxalate Oral Tablet, give 20 mg by…

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 did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, the temperature in both medication fridges was not within a safe temperature range for medication storage, medications did not have resident information, and medication was available for use past the expiration date. Resident identifiers: 6, 9, 14, 21, 26, 28, 31, and 33. Findings included: On 2/21/24 at 9:35 AM, an observation was made of the facility medication refrigerators. Two mini fridges were observed at the nurse's station located under the desk. The first fridge temperature gauge measured 49 degree Fahrenheit (F). The first fridge was observed with a large block of ice in the freezer section of the fridge that was partially melted and was obstructing the door from closing properly. The locked medication box was located on the shelf directly below the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide food that was palatable for 10 of 40 residents. Specifically, residents voiced concerns regarding the food quality in individual interviews, as well as resident council minutes. Resident identifiers: 1, 4, 8, 21, 26, 30, 31, 33, 34 and 36. Findings included: 1. On 2/5/24 at 11:13 AM, an interview was conducted with resident 8. Resident 8 stated that the food is fair. I don't care for it. Sometimes its warm, but not always. 2. On 2/5/24 at 10:09 AM, an interview was conducted with resident 34. Resident 34 stated that the food is not very good. 3. On 2/6/24 at 10:36 AM, an interview was conducted with resident 21. Resident 21 stated that the food was edible, but that's all . we all get the same slop. Resident 21 stated that he felt he had lost weight due to the poor quality of the food. 4. On 2/5/24 at 1:43 PM, an interview was conducted with resident 31. Resident 31 stated that the food was nasty. Sometimes it was good depending on who cooked.…

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 did not store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, the kitchen was not clean or sanitary and resident meal trays were subject to physical contamination while being served. Findings Included: On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. Hotel pans were stored on visibly soiled white painted shelves. There were metal colanders stored on top of the ice machine. There was a carafe stored upside down on a chipped laminate shelf. The carafe was not dry, and a watery pink liquid was dripping from the carafe into the chips on the laminate shelf. Inside of the shelf was made of particle board. The chips in the laminate indicate that the storage space cannot be fully sanitized. The laminate counter where the coffee machine was stored was covered with multiple coffee stains. A window air conditioning unit was observed to be blowing cold air across two trays with uncovered cake slices on the trays. 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 interview and record review it was determined that the facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility infection control tracking and trending was not complete. Findings included: On 2/12/24 at 1:24 PM, the facility infection control tracking and trending log was requested. A review of the log revealed no mapping, tracking, trending or analysis of the data for June, July, August, and September of 2023. A review of the Infection Prevention policy and procedure documented, goals of the infection prevention and control program which included: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection prevention and control practices. D. Maintain compliance with state and federal regulations relating to infection prevention and…

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

Based on interview and record review it was determined that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not complete. Findings included: On 2/12/24 at 1:24 PM, the facility infection control tracking and trending log was requested. A review of the log revealed no mapping, tracking, trending or analysis of the data for June, July, August, and September of 2023. A review of the Infection Prevention policy and procedure documented, goals of the infection prevention and control program which included: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection prevention and control practices. D. Maintain compliance with state and federal regulations relating to infection prevention and control. There is on-going monitoring for infections among residents, employees . and…

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

Based on observation and interview, it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility. Findings Included: On 2/13/24 at 10:43 AM, an observation was made of the facility shower room. It was noted that there was a strong odor of both feces and urine in the shower room. On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. A vent on the wall in the dry storage was visibly covered in dust. On 02/14/24 at 1:33 PM, an interview was conducted with the Corporate Maintenance (CM). The CM stated he was temporary and had only been here for 3 days. The CM stated that he got a text from the admin to replace the toilet and that was why he was here. The CM stated he was responsible for project management and helped with the building. The CM stated he came to the building depending on how big the project was. The CM stated they oversaw big projects such as replacing toilets, working on AC units, doing floor repairs,…

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 record review and interview, the facility did not ensure that nursing assistants received training to ensure ongoing competence, and include dementia management training. Findings included: 1. A list of inservices provided to staff for the previous 12 months was requested and revealed the following: a. On [DATE] an inservice was provided on Wandering Residents. However, only 8 staff members' signatures were listed on the signature sheet. b. On [DATE] an inservice was provided on Elopements, garbage bags, CNA duties. However, only 10 staff members' signatures were listed on the signature sheet. c. On [DATE] an inservice was provided on Resident issues, Infection Prevention, PHI (protected health information). However, only 7 staff members' signatures were listed on the signature sheet. d. On [DATE] an inservice was provided on Behavioral interventions, abuse training [and] reporting requirements, dignity and customer service. However, only 13 staff members' signatures were listed on the signature sheet.…

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 2 of 40 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 lift, recognizing each resident's individuality. Specifically, residents were provided cowbells as an alternative to a broken call light and a resident was not provided privacy during a brief change. Resident identifiers: 6 and 26. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia, type 2 diabetes mellitus, major depressive disorder, generalized anxiety disorder, dementia, repeated falls, vitamin b12 deficiency, extrapyramidal and movement disorder, and overactive bladder. On 2/21/24 at 9:16 AM, an observation was made of Certified Nursing Assistant (CNA) 2 assisting resident 6 with a brief change. CNA 2 was observed to leave resident…

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 40 sampled residents, that the facility did not ensure that the resident received services in the facility with reasonable accommodation of needs and preferences. Specifically, the resident requested a bed cane be provided for his bed to aid in mobility and the facility did not provide the assistive device. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:12 AM, an interview was conducted with resident 7. Resident 7 stated…

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 40 sampled residents, that the facility did not consult with the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status, or when there was a need to alter treatment. Specifically, a resident had uncontrolled pain and the physician was not notified, and a resident's Trulicity was not administered for two consecutive weeks due to unavailability and the physician was not notified. Resident identifiers: 29 and 31. Findings include: 1. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diffuse traumatic brain injury, hemiplegia and hemiparesis following a cerebral infarction, major depressive disorder, panic disorder, anxiety disorder, low back pain, acute hepatitis C, seizures, overactive bladder, benign prostatic hyperplasia, insomnia, migraine, schizoaffective disorder, lymphangioma, and a history of suicidal behavior. On 2/6/24 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 out of 40 sampled residents, that the facility did not ensure that the comprehensive care plan was prepared by the interdisciplinary team that included the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services, the resident or representative, and any other appropriate staff as determined by the resident's need; and that the plan was reviewed and revised by the Interdisciplinary team (IDT) after each assessment including quarterly review assessments. Specifically, nursing staff were not present at the resident's quarterly care conference. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose…

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 40 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, the resident desired to return to the community through the New Choice Waiver (NCW) program and the facility did not submit the required paperwork. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral…

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 for 2 of 40 sampled residents, that the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, the facility did not provide or maintain documentation of one on one activities for residents that had care plans for one on one activities and did not provide activities for residents on weekends. Resident Identifiers: 21 and 22. Findings include: 1. Resident 21 was admitted on [DATE] with diagnoses including unspecified cirrhosis of liver, generalized anxiety disorder, unspecified dementia moderate without behavioral disturbance psychotic…

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 40 sampled residents, that the facility did not ensure that residents received proper treatment and care to maintain mobility and good foot health. Specifically, a resident was not provided care with trimming his toenails and appointments to podiatry services were not made. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:21 AM, an interview was conducted with resident 7. Resident 7's toenails were observed to extend past the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 1 of 40 sampled residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, a resident was not provided their ordered supplement for 3 days. Resident identifier: 33. Findings Include: Resident 33 was initially admitted to the facility on [DATE] and readmitted with the following diagnoses that included severe protein calorie malnutrition, alcoholic cirrhosis of liver without ascites, dementia, opioid dependence, esophageal obstruction, gastrointestinal hemorrhage, generalized anxiety disorder, and alcohol dependence. Resident 33's medical record was reviewed on 2/6/24 through 2/22/24. On 2/6/24, resident 33's documented weight was 86 pounds. A nutrition care plan initiated on 10/22/23 documented resident 33 had Potential for/actual alteration in nutrition related to cachexia, hospital diagnosis of severe malnutrition, hx [history] of esophageal strictures, alcohol…

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 1 of 40 sampled residents that the facility did not ensure intravenous (IV) therapy was administered consistent with professional standards of practice as well as implement prevention of infection at the IV site to the extent possible. Specifically, a resident was observed to have IV fluid lying on a flat surface while being administered and no alcohol caps were observed on the IV hub. Resident Identifier: 26 Findings Include: Resident 26 was admitted to the facility on [DATE] with the following diagnoses of osteomyelitis of right ankle and foot, generalized muscle weakness, polyneuropathy, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis, and necrotizing fasciitis. On 2/5/24 at 10:41 AM, an observation was made of resident 26's dual lumen peripherally inserted central catheter (PICC) line. One of the ports was observed to have been hooked up to 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 that for 1 of 40 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the the resident's goals and preferences. Specifically, the facility did not have physician's orders in place for a resident's oxygen tubing to be changed or documentation that the resident's oxygen tubing had been changed. Resident identifier: 7. Findings include: Resident 7 was originally admitted [DATE], readmitted [DATE], with diagnoses including chronic respiratory failure unspecified whether with hypoxia or hypercapnia, morbid (severe) obesity with alveolar hypoventilation, chronic obstructive pulmonary disease unspecified, interstitial pulmonary disease unspecified, and dependence on supplemental oxygen. On 2/5/24 at 10:25 AM, an observation was made of Resident 7 in his room. It was noted that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not submit and follow-up on the application process for the New Choice Waiver (NCW) program that provided support services to enable residents to reside in their own home or other community-based settings. Resident identifiers: 4 and 31. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive…

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 40 sampled residents, the facility did not ensure that each resident was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, a resident's blood pressure was not monitored before being administered pain medication as ordered by the physician. Resident Identifier: 16. Findings Included: Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses that included type 2 diabetes mellitus, stage 4 pressure ulcer of sacral region and stage 4 pressure sore of left heel, generalized anxiety disorder, post-traumatic stress disorder, personal history of adult physical and sexual abuse, suicidal ideation, vitamin D deficiency, moderate protein…

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 40 sampled residents, that the facility did not ensure that residents were free from any significant medication errors. Specifically, a resident's Trulicity medication was omitted for two consecutive weeks due to unavailability from the pharmacy. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type II diabetes mellitus, asthma, morbid obesity, anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx left great toe, chondromalacia left knee, and dementia. On 2/10/24 resident 31's medical records were reviewed. On 11/3/23, resident 31 had an order initiated for Trulicity Subcutaneous Solution Pen-injector 0.75 milligram (mg)/0.5 milliliter (ml), Inject 0.75 mg subcutaneously one time a day every Friday related to type II diabetes mellitus. On 1/12/24 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 40 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, a resident had orders for labs that were not obtained by the facility. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. On 2/10/24 resident 31's medical records were reviewed. Resident 31's physician laboratory orders revealed the following: a. On 1/19/24, an order was initiated to obtain a Hemoglobin A1c (HbA1c) and a Glomerular Filtration Rate (GFR). b. On 2/1/24, an order was initiated to obtain a HbA1C and a Basic…

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 did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the facility dishwasher spilled water onto the floor whenever a dishwashing cycle was run. Findings included: On 2/12/24 at 12:35 PM, an interview was conducted with the Dietary Manager (DM). The Dietary Manager stated that the dish machine was serviced by Ecolab once a month. On 2/12/24 at 12:36 PM, the facility's mechanical dishwashing machine was tested. While the dishwashing machine was running, water flowed from the bottom of the machine onto the floor. On 2/14/24 at 9:21 AM, an interview was conducted with the Custodial Staff (CS). The CS stated that it was not normal for the dish machine to flood water onto the floor. The CS stated that either he or the facility maintenance staff usually mopped any spills from the machine. The CS stated that there was currently no maintenance staff at the facility. On 2/20/24 at 2:40 PM, an interview was conducted with the Registered Dietitian…

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 interviews it was determined, for 2 of 40 sampled residents, that the facility did not adequately equip each resident with a communication system that was relaying calls directly to staff or a centralized work area. Specifically, residents call lights were not functioning properly. Resident identifiers: 26 and 30. Findings Included: On 2/8/24 at 1:52 PM, an observation was made of the maintenance log located next to the nurse's station. The maintenance log dated 2/4/24 documented there was a repair/safety concern that needed to be fixed for room [ROOM NUMBER] b and c. It documented the following issue, Light needs fixed please. Call light stays on. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26 who resided in room [ROOM NUMBER] B. Resident 26 stated the call light had not been working for the last two days. Resident 26 stated their call light outside of the room had been on for the last two days, so staff were unsure when they needed assistance. On 2/6/24 at 8:44 AM,…

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 record review and interview it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, multiple entity reports of abuse allegations were not submitted to the State Survey Agency in a timely manner. Resident identifiers: 3, 9, 12, 14, 22, 24, 25, and 27. Findings include: 1. The Facility Reported Incidents (FRIs) filed with the State Survey Agency (SSA) were reviewed and revealed the following: At around 7:30 AM on Monday 3/21/22, [CNA 2). got frustrated with [resident 12] . because he had been difficult through…

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 have evidence that all alleged violations were thoroughly investigated. Resident identifiers: 3, 12, 22, 25, 27, and 82. Findings include: 1. The Facility Reported Incidents (FRIs) filed with the State Survey Agency (SSA) were reviewed and revealed the following: At around 7:30 AM on Monday 3/21/22, [CNA 2). got frustrated with [resident 12] . because he had been difficult through the weekend and he seemed to be starting in again on the same behaviour (sic). At that point she yelled at him using the F word saying that she wasn't going to put up with it that day and that he better F'ing stop it. [It should be noted that this FRI was not submitted until 3/22/22 at 4:57 PM, approximately 33 hours after the incident occurred). Review of the facility's investigation into the incident between CNA 2 and resident 12 revealed that the Administrator (ADM)…

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 did not ensure that 3 of 23 sample residents were free from abuse. Specifically, a resident was determined to have been verbally abused by a staff member. In addition, a resident hit another resident on the head. It should be noted that based on the victims' reactions in both of these cases, the deficiency was not cited at a harm level. Resident identifiers: 3, 12, and 22. Findings include: 1. Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Parkinson's disease, epilepsy, diabetes mellitus, multiple sclerosis, chronic viral hepatitis C, and anxiety disorder. On 5/22/22 at 2:05 PM, an interview was conducted with resident 12. When asked how staff had been treating him, he stated It wasn't [Certified Nursing Assistant (CNA) 2's] fault what happened, and that CNA 2 had been fired for how she had treated him. When asked to describe the incident, resident 12 stated that CNA 2 would yell at me all…

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 that the facility did not have an effective system to record the disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Findings include: On 5/24/22 at 8:34 AM, observation was made of nurse 1 (N 1) preparing and passing medications to residents. N 1 was observed to obtain a narcotic for a resident. On 5/24/22 at 2:32 PM, observations were made of the narcotic record sheets at the nurses' carts. One resident's record for the month of May 2022, revealed an order for hydrocodone/APAP (acetaminophen) 7.5 mg (milligrams)-325 mg, one tablet by mouth every 6 hours as needed for pain. On the narcotic sheet, there was one administration on 5/1/22 that was crossed out without a second nurse's signature. There was no noted reason for the line through. The narcotic count was decreased by one tablet. A different resident's controlled drug record for oxycodone 5 mg tablet, take 1/2 tablet by mouth every 4 hours as needed for pain was observed. The medication was received on 4/10/22, and included 60…

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.