Bowling Green Health & Rehabilitation Center

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notification to the responsible party of a change in resident treatment for one of 33 residents in the survey sample, Resident #309. The findings include: For Resident #309 (R309), the facility staff failed to notify the responsible party of the Losartan (1) medication being held due to low blood pressure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/29/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The comprehensive care plan for R309 documented in part, Cardiac: the resident is at risk for cardiac complications secondary to hypertension r/t (related to) bilateral lower edema. Created on: 12/05/2023. Revision on: 12/18/2023. Review of R309's progress notes revealed the following: - 11/27/2023 0821 (8:21 a.m.) Note Text : Losartan Potassium Oral Tablet 100…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a pressure injury for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to clean a pair of scissors immediately before pressure injury wound care was provided. R97 was admitted to the facility with a stage four pressure injury (1) on the left buttock. R97's comprehensive care plan dated 1/18/24 failed to document information regarding sanitation during wound care. A review of R97's clinical record revealed a physician's order dated 3/12/24 to cleanse the left buttock with normal saline, pack with collagen particles, cover with moist gauze, and cover with bordered foam. On 3/27/24 at 1:55 p.m., during an observation of R97's pressure injury wound care, LPN (licensed practical nurse) #2 removed a pair of scissors from her pocket, placed the scissors on a clean field, picked up the scissors, cut a piece of collagen with the scissors, then placed the collagen…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide urinary catheter care and services for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to maintain the resident's urinary catheter (1) drainage bag in a sanitary manner. R97's comprehensive care plan dated 1/19/24 failed to document information regarding the placement of the resident's urinary catheter drainage bag. A review of R97's clinical record revealed a physician's order dated 2/21/24 that documented an order for a Foley (urinary) catheter related to a neurogenic bladder. On 3/27/24 at 8:26 a.m., R97 was observed lying in a low bed. The resident's urinary catheter drainage bag was attached to the bed frame and the bag was sitting on the floor. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated a urinary catheter drainage bag should not touch the floor for infection control reasons and also because someone's feet or…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide urostomy care and services for one of 33 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to obtain physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. R259's comprehensive care plan dated 2/27/24 documented, The resident has a Urostomy. Change wafer and provide site care as ordered . A review of R259's clinical record revealed physician's orders to monitor urostomy output every shift and monitor for signs and symptoms of infection every shift. Further review of the clinical record failed to reveal physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated residents with urostomies should have physician's orders to monitor for output and to monitor 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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial well-being for two of 33 residents in the survey sample, Residents #86 and #62. The findings include: For Resident #86 (R86) and Resident #62 (R62), the facility staff failed to evidence comprehensive medically related social service assessments for continued ability to consent to intimate relations. R86 and R62 shared a semi-private room in the facility, planned to be married and were currently sexually active. R86 most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/25/2024 assessed the resident as scoring 6 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. The 8/25/2023 MDS assessment documented R62 scoring 13 out…

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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of 33 residents, Resident #15. The findings include: The facility staff failed to evidence complete and accurate documentation for incontinence care for Resident #15. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #15's comprehensive care plan dated 6/29/23 revealed, FOCUS:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 33 residents in the survey sample, Residents #15, #38 and #54. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #15. Resident #15 was observed in bed with bilateral grab bars on 3/26/24 at 3:10 PM and 3/27/24 at 3:45 PM. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required notification, to the Ombudsman, for a facility-initiated transfer for one of 33 residents in the survey sample, Residents #92 (R92). The findings include: For R92, the facility staff failed to have evidence that written notification was provided to the ombudsman for a facility-initiated transfer on 12/04/2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 02/24/2024, R92 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R92 was cognitively intact for making daily decisions. The facility's progress noted for R92 dated 12/04/2023 documented, Resident transferred out to (Name of Hospital) ER (emergency room) r/t (related to) fluctuations in blood pressure readings @ (at) 2100 (9:00 p.m.) 12/4/23. This nurse called hospital and spoke with (Name of Registered Nurse) in ER who…

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 staff interview, facility document review and clinical record review, the facility staff failed to follow physician's orders for three of 37 residents in the survey sample, Resident # 93 (R93), Resident #15 (R15) and Resident #75 (R75). The facility staff failed to monitor a fluid restriction for R93; and failed to provide care and services for a central venous access (central line) for R15 and R75. The findings include: 1. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/31/2022, R93 scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving dialysis. The physician order dated 4/11/2022, documented, Fluid Restriction (1200 ml [milliliters]) Give the following fluid volume with medication administration: 7-3 [7:00 a.m. to 3:00 p.m.] meds: (120 ml with morning meds and 120 ml afternoon meds) 3-11 [3:00 p.m. to 11:00…

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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow the menu for one of 37 residents in the survey sample, Resident #309; and for the dinner meal on 4/19/22. The findings include: 1. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/11/22, R309 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating she is cognitively intact for making decisions. On 4/19/22 at 11:34 a.m., R309 was interviewed. R309 stated she had concerns about not getting the food that was on the meal ticket for each meal. R309 stated it was rare for them to receive anything close to what they had repeatedly told staff they were able to eat. On 4/19/22 at 1:37 p.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: shrimp and vegetable stir fry, orange twist, buttered white rice, roll, margarine,…

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, staff interview, and facility document review, the facility failed to store food in a sanitary manner in one of two refrigerators in the main kitchen. The findings include: The facility kitchen was observed on 4/19/2022 at 10:10 a.m. A container of sliced American cheese was observed in a refrigerator with and open date of 3/6/2022 and a use by date of 3/10/2022. A second container with shredded cheddar cheese did not have a date when opened, but had a use by date of 3/10/2022. When asked if these containers of cheese should be still available for use, OSM (other staff member) #1, the culinary services manager, stated the staff probably put the wrong dates on it. When asked if it should be available for use with the dates on it, OSM #1 stated, No, I guess not. The facility policy, Food Storage: Cold documented in part, The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1,…

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 staff interview, the facility staff failed to maintain one of one dumpsters in a sanitary manner. The findings include: On 4/19/2022 at approximately 10:35 a.m. the facility dumpster was observed with OSM (other staff member) # 1, the culinary services manager. There were 11 used gloves around the dumpster area. A 12th used glove was found just outside the door to go back into the building. When asked who was responsible for maintaining the dumpster area, OSM #1 stated it is between dietary and maintenance. When asked if the gloves should be on the ground, OSM #1 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. A request was made for the policy on maintaining the dumpster area on 4/20/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on resident interview, facility document review and clinical record review, the facility staff failed to allow one of 37 residents in the survey sample to withdraw more than twenty dollars from their personal fund account at a time, Resident #99 (R99). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/1/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. An interview was conducted with R99 on 4/19/2022 at approximately 12:30 p.m. R99 stated the facility keeps changing the rules about getting my money out. R99 stated the facility is only allowing the resident to take twenty dollars at one time. An interview was conducted with OSM (other staff member) #5, the receptionist, on 4/20/2022 at 3:24 p.m. When asked the process for residents to access their money in the personal fund account, OSM #5 stated the residents come to the front desk and ask for their money, 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, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 2 of 37 residents in the survey sample, Residents #33 and #97. The facility staff failed to administer oxygen to Resident #33 (R33) per the physician prescribed rate of three liters per minute. The facility staff failed to store a nebulizer mask in a sanitary manner for Resident # 97 (R97). The findings include: 1. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 2/4/22, the resident scored 6 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. A review of R33's clinical record revealed a comprehensive care plan dated 8/12/21 that documented, The resident has altered respiratory status/difficulty breathing r/t (related to) pneumonia. R33's April 2022 physician's order sheet documented a physician's order dated 3/28/22 for oxygen at three liters per minute…

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 staff interview, facility document review and employee record review, the facility staff failed to perform annual performance evaluations on two of five CNA (certified nursing assistant) record reviews. The findings include: On 4/20/2022 at 9:23 a.m. OSM (other staff member) #7, the human resources staff member, presented the documentation of annual performance evaluations for three of the five CNAs; CNA #5, CNA #1, CNA #7. OSM #7 stated that CNA #4 and CNA #6 got an across the board raise so no performance evaluations were completed. The facility policy, Merit Increase documented in part, Policy: (Initials of company) will evaluate employees annually and reward eligible employees for performance through annual merit increases .Procedure: 1. Employees may earn merit increases for performance .4. Generally, all employees will receive a performance appraisals annually. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15…

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, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to honor a resident's preferences for one of 37 residents in the survey sample, Resident #309 (R309). The findings include: 1. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/11/22, R309 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating she is cognitively intact for making decisions. On 4/19/22 at 11:34 a.m., R309 was interviewed. R309 stated she had concerns about not getting the food that was the meal ticket for each meal. R309 stated it was rare for them to receive anything close to what they had repeatedly told staff they were able to eat. On 4/19/22 at 1:37 p.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: shrimp and vegetable stir fry, orange twist, buttered white rice, roll, margarine, frosted carrot cake,…

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, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control practices for one of nine residents during the medication administration observation, Resident #105. The facility staff failed to administer oral medication to Resident #105 (R105) in a sanitary manner. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/31/22, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. On 4/20/22 at 7:55 a.m., an observation of LPN #1 preparing and administering medications was conducted. LPN #1 popped a pill out of a blister pack and the pill dropped on top of the medication cart. LPN #1 scooped the pill into the medication cup then administered the pill to R105. LPN #1 had not disinfected the cart prior to the medication pass or dropping the pill on the cart. On 4/20/22 at 1:14 p.m., an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, facility document review and clinical record review, it was determined the facility staff failed to meet the requirements for advanced directives for four of 59 residents in the survey sample, (Residents #24, #116, # 84, and #40). The facility staff failed to obtain a copy of Resident #24's Appointment of Agent to Make Healthcare Decision as documented on the resident's admission paperwork. The facility staff failed to periodically review, Resident 116's, Resident #84's and Resident #40's decisions regarding advance directives. The findings include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score,…

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 4. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS and had both short and long-term memory difficulties. The physician's note 12/27/19 documented in part the resident presented with recurrent episodes of coffee ground emesis and moderate amount of dark brown drainage from the G -tube (gastrostomy tube), and Resident #89 was sent to the emergency room after giving IV (intravenous) fluids and lab [laboratory tests] work. Further review of the clinical record failed to evidence documentation that Resident #89'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 3. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS (brief interview for mental status) and had both short and long-term memory difficulties. The physician's note 12/27/19 documented in part the resident presented with recurrent episodes of coffee ground emesis and moderate amount of dark brown drainage from the G -tube (gastrostomy tube), and Resident #89 was sent to the emergency room after giving IV (intravenous) fluids and lab [laboratory tests] work. Further review of the clinical record failed to evidence…

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 resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 59 residents in the survey sample, (Residents #4, #40, #15, #62, and #61). The facility staff failed to implement the comprehensive care plan to offer non-pharmacological interventions prior to the administration of pain medication for Resident #4, failed to develop a comprehensive care plan to address Resident #40's PICC (peripherally inserted central catheter) and failed to implement Resident #40's comprehensive care plan for palm guards. The facility staff failed to develop a comprehensive care plan to address the care of Resident #15's PICC. The facility staff failed to develop a comprehensive care plan to address Resident #62's prescribed anticoagulant medication Eliquis, and failed to develop a comprehensive care plan for Resident #61's use of a urinary catheter. The findings include: 1. Resident #4…

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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for eight of 59 residents in the survey sample, Resident #24, #4, #25, #31, #28, #21, #13 and #38. The findings include: 1. The facility staff failed to review and revise the comprehensive care plan to address Resident #24's prescribed and administered anti-anxiety medication Xanax. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions. The physician order dated, 9/23/19 documented, Xanax [used to treat…

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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice to clarify physician orders for two of 59 residents in the survey sample, Residents #111 and Resident #23. The facility staff failed to clarify a physician order for Lorazepam for Resident #23, which lead to the resident receiving more than double the prescribed dose of medication. The facility staff failed to clarify physician orders for multiple as needed pain medications for Resident #23 to determine which and when each medication should be administered. The findings include: 1. Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C- [inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described. (1)], high blood pressure, diabetes, fractured hip and cirrhosis of the liver [chronic…

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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services consistent with professional standards of practice and in accordance with physician orders for two of 59 residents in the survey sample with a central venous access, (Residents #40 and #15). Resident #40 had a PICC (peripherally inserted central catheter) (1) in place in her right arm during the time of the survey. There were no orders or documentation for the maintenance and care of the PICC. The dressing on the PICC was dated 1/29/2020, and had not been changed in 14 days. Resident #15 had a PICC in place in her right arm during the time of the survey. The dressing on the PICC was dated 1/30/2020; the dressing had not been changed in 13 days. The findings include: 1. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (2),…

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, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for eight of 59 residents in the survey sample, (Residents #267, #21, #24, #116, #55, #8, #317 and #320). The facility staff failed to review risks and benefits, failed to obtain informed consent for the use of bed rails and failed to evidence that appropriate alternatives were attempted prior to the resident's use of bed rails for Resident #267, Resident #21, Resident #24, Resident #116, Resident #55, Resident #8, Resident #317 and Resident #320. The findings include: 1. Resident #267 was admitted to the facility on [DATE]. Resident #267's diagnoses included but were not limited to bronchitis, high blood pressure and history of falling. Resident #267's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/21/20, coded the resident's cognition as severely impaired. Section G coded…

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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of unnecessary psychotropic medications for one of 59 residents in the survey sample, Resident #111. Based on the comprehensive assessment the facility staff failed to ensure duplicate antianxiety medication was not administered to Resident #111. The findings include: Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C-(inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described.) (1), high blood pressure, diabetes, fractured hip and cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and normal function of the organ) (2). The resident is on hospice care. The most recent MDS (minimum…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #111) of 59 sampled residents was free of a significant medication errors. The facility staff administered both Lorazepam tablet (1 mg) twice daily and Lorazepam concentrate three times a day resulting in Resident #111 receiving a total of two milligrams of Lorazepam per day from 2/1/2020 through 2/7/2020, and a total of 5 mg per day, from 2/8/2020 through 2/12/2020. The findings include: Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C-(inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described.) (1), high blood pressure, diabetes, fractured hip and cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood…

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, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature. The facility staff failed to provide food at a palatable temperature during lunch on 2/12/20. The findings include: Resident #96 was admitted to the facility on [DATE]. Resident #96's diagnoses included but were not limited to paralysis and diabetes. Resident #96's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/23/20, coded the resident as being cognitively intact. On 2/11/20 at 12:52 p.m., an interview was conducted with Resident #96. The resident stated the facility food was cold. Resident #84 was admitted to the facility on [DATE]. Resident #84's diagnoses included but were not limited to major depressive disorder and high blood pressure. Resident #84's quarterly MDS assessment with an ARD of 1/16/20, coded the resident as being cognitively intact. On 2/11/20 at 1:03 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for three of 59 residents in the survey sample, (Residents #40, #15, and #318); and in one of two dining rooms, (Dining Room B); and in two of 62 resident rooms, (Rooms #35 and #36). The facility staff failed to ensure PICC (peripherally inserted central catheter) care was provided including dressing changes, to prevent infection for Resident #40 who had a PICC in place in her right arm, and Resident #15, who had a PICC in place in her right arm. The facility staff failed to store Resident #318's nebulizer mask with a protective covering, to prevent infection on 2/12/2020. The facility staff placed ungloved thumbs on the eating surfaces of dishes being served to the residents in Dining Room B of the facility during lunch on 2/11/2020. The facility staff removed a straight-back chair from room [ROOM NUMBER] and placed it in room [ROOM NUMBER], without…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure three of 59 sampled residents, (Residents #25, #21 and #13) were free from abuse. On 11/15/18, Resident #25 was hit in the chest by Resident #31. On 12/22/19, Resident #21 was hit in the face by Resident #28 and on 7/5/19, Resident #38 was observed with his hand inside Resident #13's brief and was caressing Resident #13's buttocks. The findings include: 1. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to diabetes, chronic kidney disease and repeated falls. Resident #25's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/26/19, coded the resident's cognition as moderately impaired. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to paralysis, heart disease and difficulty swallowing. Resident #31's quarterly MDS with an ARD of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. The facility policy documented impart, The Administrator will provide to the State Agency an initial report for occurrences of alleged or reasonably suspected abuse, neglect, exploitation, mistreatment or crime against a patient of the Center…

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 #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. A review was conducted of the Facility reported Incidents (FRIs) and the grievance logs, The review failed to evidence any documentation of Resident #24 being called a bitch by Resident #41. Resident #41 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence written notification was provided or sent to the resident and/or responsible party regarding the reasons for a transfer to the hospital for three of fifty nine residents in the survey sample, (Residents #74, #89 and #66). The facility staff failed to evidence written notification was provided to Resident #74 or the responsible party (RP) for the residents 12/12/19, hospital transfer, failed to evidence written notification to Resident #89 or the RP for the residents 12/27/29 hospital transfer and to Resident #66 or the RP for the residents 12/20/19 hospital transfer. The findings include: 1. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, nonreversible lung disease which is a combination of emphysema and chronic bronchitis) (1), left femur fracture (break in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to develop a baseline care plan for Resident #318's physician-ordered TED (thromboembolic-deterrent) hose. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (2), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed; both feet were observed and the resident was not wearing TED (1) hose. On 2/13/20 at 9:07 a.m., Resident #318 was observed sitting in a wheelchair by the nurses' station. The 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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment and care in accordance with professional standards of practice and the plan of care for one of 59 residents in the survey sample, Resident #318. The facility staff failed to apply TED (thromboembolism deterrent) hose to Resident #318's on 2/12/2020, as ordered by the physician. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (2), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed; both feet were observed and the resident was not wearing TED (1) hose. On 2/13/20 at 9:07 a.m., Resident #318…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries, and to promote healing of a pressure injury for two of 59 residents in the survey sample, Residents #267 and #40. The facility staff failed to assess Resident #267's pressure injuries from 1/16/20 until 2/11/20. The facility staff failed to ensure Bilateral palm guards were in place for Resident #40, per the comprehensive plan of care. The findings include: 1. Resident #267 was admitted to the facility on [DATE]. Resident #267's diagnoses included but were not limited to bronchitis, high blood pressure and history of falling. Resident #267's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/21/20, coded the resident's cognition as severely impaired. Section M coded Resident #267 as having two stage two…

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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to store a nebulizer mask with a protective covering for Resident #318 on 2/12/2020. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (1), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed. During both observations, a nebulizer mask was lying directly on the bedside table. The mask was uncovered, 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a complete pain management program for one of fifty nine residents in the survey sample, Residents #23 and Resident #4. The facility staff failed to document the location of pain, pain scale and if any non-pharmacological interventions were provided prior to the administration of a narcotic pain medication for Resident #4. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder, peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1), and amputation of his toes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score,…

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 resident interview, staff interview and clinical record review, it was determined the facility staff failed to ensure a drug regimen free of unnecessary medications for one of 59 residents in the survey sample, (Resident #4). The facility staff administered a physician prescribed as needed narcotic pain medication to Resident #4 for a pain level rating of zero and failed to document non-pharmacological interventions attempted prior to administering the as needed pain medication on 1/13/2020 and 2/9/2020. The findings include. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder, peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1), and amputation of his toes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 coded the resident as scoring a 15 on…

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

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to store milk in a safe manner in the A unit nourishment room. Two eight ounce cartons of skim milk with a sell by date of 2/4/20 was observed in the refrigerator. The findings include: On 2/12/20 at 12:12 p.m., observation of the A unit nourishment room refrigerator was conducted. Two eight ounce cartons of skim milk with a sell by date of 2/4/20 were observed in the refrigerator. On 2/12/20 at 12:45 p.m., an interview was conducted with OSM (other staff member) #7 (the dining services director). OSM #7 stated the dietary staff checks and restocks the unit refrigerators daily and usually several times a day. OSM #7 was asked if the dietary staff is supposed to check the dates on food and beverages. OSM #7 stated, Uh huh. OSM #7 was made aware of the above concern. OSM #7 stated the cartons of skim milk should not have been in the refrigerator because this date was past the sell by date. On 2/12/20…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for two of 59 residents in the survey sample, Residents #25 and #21. Resident #31 hit Resident #25 in the chest on 11/15/18 and Resident #28 hit Resident #21 in the face on 12/22/19. The facility staff failed to document these incidents in Resident #25's and Resident #21's clinical records. The findings include: 1. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to diabetes, chronic kidney disease and repeated falls. Resident #25's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/26/19, coded the resident's cognition as moderately impaired. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to paralysis, heart disease and difficulty swallowing. Resident #31's quarterly MDS…

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