The Rehab Center At Bristol

Based on staff interview and clinical record review, the facility staff failed to provide evidence that they had obtained a provider ordered laboratory test for 1 of 6 residents, Resident #1. The findings include. The facility staff failed to provide evidence that they had obtained the provider ordered laboratory test urinalysis (UA). This was a closed record review. Resident #1's diagnoses included, but were not limited to, atrial fibrillation, traumatic brain injury, epilepsy, and anxiety disorder. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/22/24 included a brief interview for mental status (BIMS) score of 5. Per the MDS manual a score of 5=severe impairment in cognitive skills for daily decision making. Section GG (functional abilities) was coded to indicate a toilet transfer was not attempted with this resident due to medical conditions or safety concerns. Section H (bladder/bowel) was coded to indicate this resident was always incontinent of urine. Resident #1's comprehensive care…

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, clinical record review and facility document review, the facility staff failed to provide activities of daily living (ADL) care to one of six residents in the survey sample, resident # 5. This was a closed record review. The findings included: For resident # 5, the facility staff failed to provide scheduled bathing assistance for October 2022 through January of 2023. Resident # 5's diagnoses included but were not limited to, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, muscle weakness, difficulty walking, need for assistance with personal care. Resident # 5's minimum data set (MDS) assessment with an assessment reference date of 2/17/23 assigned the resident a brief interview for mental status (BIMS) score of 00 indicating severe cognitive impairment. Resident # 5 was coded as being dependent for bathing with assistance of one staff member. Resident # 5 's comprehensive person-centered care plan had a problem statement with an effective date of 11/4/22 that read, Resident's ability to perform ADL's has declined R/T…

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 and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan for one of six residents in the survey sample. The findings included: For resident # 1, the facility staff failed to administer oxygen as ordered by the physician and according to the residents comprehensive person-centered care plan. Resident # 1's diagnoses included but were not limited to, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), morbid obesity, right heart failure unspecified, essential hypertension, pulmonary hypertension. Resident # 1's most recent minimum data set (MDS) assessment assigned the resident a brief interview for mental status score of 15 indicating intact cognition. This surveyor observed the resident in their room on 3/25/23 at 11:52 AM and noted they were on oxygen via a nasal cannula. When asked how much oxygen they required they stated, I'm on 3 liters. Surveyor noted that the oxygen…

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, family interview, and facility document review the facility staff to ensure a clean, comfortable, homelike environment for 1 of 2 floors, and one of 19 residents, Resident #36. The findings included: 1. For the 2nd floor of the facility, the facility staff failed to ensure a clean environment. Throughout the course of the survey, the surveyor observed a pervasive odor of urine in the hallway of the second floor. The surveyor also observed debris in the floor, and inside the handrails. These observations were addressed with the maintenance director and housekeeping district manager on 10/26/22 at 11:10 am during a waking tour of the 2nd floor of the facility. Surveyor asked the housekeeping district manager how often the handrails were cleaned, and housekeeping district manager stated one time per week. Surveyor asked how many housekeepers were assigned to each floor and housekeeping district manager stated one on each floor. Surveyor asked how often each resident room is cleaned and housekeeping district manager stated each room should be cleaned daily.…

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 and facility document review, the facility staff failed to maintain an infection prevention and control program to include an antibiotic stewardship program. The findings included: The facility staff failed to safeguard and maintain documentation regarding the facility antibiotic stewardship program. On 10/26/22 at 12:39 pm, surveyor met with the administrator and director of nursing (DON) regarding the facility infection prevention and control program. The DON began employment with the facility on 6/27/22 and the administrator began on 9/20/22. The DON stated the previous assistant director of nursing (ADON), who also served as the Infection Preventionist, had the facility antibiotic stewardship documentation on their computer and current staff have been unable to retrieve this information following their departure from the facility. The administrator stated an FRI (Facility Reported Incident) was completed and submitted. Administrator provided a copy of an FRI dated 10/05/22 which stated in part The ADON/Infection Control, (name omitted) sent out an…

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 and facility document review, the facility staff failed to provide copies of notice of resident transfers and discharges to a representative of the Office of the State Long-Term Care Ombudsman. The findings included: The facility staff failed to provide evidence of notification of resident transfers and discharges to the Office of the State Long-Term Care Ombudsman. On 10/26/22 at approximately 12:00 pm, surveyor spoke with the administrator who stated they were unable to locate documentation of notice of resident transfers and discharges being sent to the ombudsman's office. The administrator stated they were reaching out to the ombudsman to find out when the facility last provided resident transfer and discharge information. Surveyor requested and received the facility policy entitled Notice Requirements before Transfer/Discharge which read in part: 1. Before the facility transfers or discharges a resident, the facility will: b. Notify the resident and, if known, a family member or the resident's representative(s) of the transfer or discharge and 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, family interview, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for 3 of 18 Residents, Resident #52, #36, and #252. The findings include: 1. Resident #52's toenails were observed to be long, thick, and jagged. Resident #52 was unable to cut/trim their toenails. Resident #52's diagnoses included but were not limited to, Alzheimer's disease and need for assistance with personal care. Section C (cognitive patterns) of Resident #52's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/22/22 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Resident #52's comprehensive care plan included the problem area Activity of Daily Living. Approaches included, but were not limited to, provide assistance for completion of ADL tasks. 10/24/22 3:20 p.m., Resident #52 was observed ambulating in room. Resident #52 was observed with open toed shoes and their toenails were observed to be long, thick, and jagged.…

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 and clinical record review the facility staff failed to follow-up on pharmacist recommendations for 2 of 19 residents, Resident #36 and Resident #47 and failed to complete pharmacy reviews for 1 of 19 residents, Resident #44. The findings included: 1. For Resident #36 the facility staff failed to follow-up on pharmacist recommendations. Resident #36's face sheet listed diagnoses which included, but not limited to Autistic disorder, liver disease, anxiety, hypertension, hypothyroidism, disorder of urea cycle metabolism, and age-related osteoporosis. Resident #36's most recent quarterly minimum data set with an assessment reference date of 08/16/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #36's comprehensive care plan was reviewed and contained care plans for Resident has liver disease, Resident has hypothyroidism and Resident is prescribed anticoagulant therapy d/t (due to) hx (history) of DVT (deep venous…

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 resident interview, staff interview, clinical record review, facility document review, and during a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. There were 3 errors in 32 opportunities for a medication error rate of 9.38%. These medication errors affected Resident #55. The findings include: During a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. The medication error rate was 9.38%. LPN #2 did not administer Resident #55's Aspercreme, Colace, or Magnesium Hydroxide. 10/25/22 beginning at approximately 7:38 a.m., the surveyor observed Licensed Practical Nurse (LPN/agency nurse) #2 prepare and administer Resident #55's morning medications. LPN #2 was observed to pick up a bottle of Magnesium Hydroxide from the cart and state it did not have the residents name on it and they would have to find out the facility procedure. LPN #2 placed the medication back into the medication cart. Resident #55's diagnoses included, but were not limited to, pain…

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, and facility document review, the facility staff failed to dispose of expired specimen tubes in 1 of 2 medication rooms (floor 2) and failed to ensure medication(s) were secure on 1 of 2 floors (floor 1). The findings include: The facility staff failed to dispose of expired specimen tubes and left the keys to the medication cart on top of the medication cart and out of view. [DATE] 4:25 p.m., the surveyor checked the medication room on floor 2 with Licensed Practical Nurse (LPN) #1. The cabinet in this medication room included 2 opened containers of purple top blood specimen tubes with an expiration date of [DATE] and 1 bag (17) of white top tubes used for urine collection with an expiration date of [DATE]. [DATE], LPN #1 stated they had spoken with the unit manager and they would be disposing of the expired specimen tubes. [DATE] 8:05 a.m., during a medication pass and pour observation with LPN #2 (agency nurse). LPN #2 was observed to leave their medication cart keys 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 staff interview and clinical record the facility staff failed to obtain a physician ordered laboratory test for 1 of 19, Resident #36. The findings included: For Resident #36 the facility staff failed to obtain physician ordered laboratory blood tests. Resident #36's face sheet listed diagnoses which included, but not limited to Autistic disorder, liver disease, anxiety, hypertension, hypothyroidism, disorder of urea cycle metabolism, and age-related osteoporosis. Resident #36's most recent quarterly minimum data set with an assessment reference date of 08/16/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #36's comprehensive care plan was reviewed and contained care plans for Resident has liver disease, Resident has hypothyroidism and Resident is prescribed anticoagulant therapy d/t (due to) hx (history) of DVT (deep venous thrombosis [blood clot]) Interventions for these care plans included Monitor lab work as ordered. 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.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure food was stored under safe and sanitary conditions in 2 of 2 unit nourishment rooms. The findings include: The facility staff failed to ensure resident food was appropriately stored/labeled. The following information was found in a facility polity titled Food: Safe Handling for Foods from Visitors (with a revised date of July 2019): - Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. - When food items are intended for later consumption, the responsible facility staff member will: . Ensure that foods are in a sealed container to prevent cross contamination . Label foods with the resident's name and the current date. - Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: . Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for (greater than or equal to) 7 days. (Storage of frozen foods and shelf stable items…

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

Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and/or infections, including COVID-19, for 2 of 19 residents in the survey sample, Resident #153 and Resident #55. The findings included: 1. On 10/24/22 and 10/25/22, the surveyor noted a sign on the door leading into Resident #153's room which included the statement WARM ROOM - DROPLET PRECAUTIONS. This sign indicated anyone entering this room was required to use the following personal protective equipment (PPE): mask, face shield, gown, and gloves. h On 10/24/22 at 3:17 p.m., the surveyor observed licensed practical nurse (LPN) #4 and certified nurse aide (CNA) #2 in Resident #153 without using a gown or eye protection. The surveyor interviewed LPN #4 and CNA #2 when they exited the room. Both LPN #4 and CNA #2 stated they should have worn a gown but indicated they were not required…

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, clinical record review, and facility document review, the facility staff failed to offer and provide the resident and/or resident representative education regarding the benefits and potential side effects of the pneumonia vaccine for 1 of 5 sampled residents (Resident #97) reviewed for immunizations. The findings included: For Resident #97, the facility staff failed to offer the pneumonia vaccine and provide education regarding the benefits and potential side effects of the vaccine. Resident #97's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3b, and Chronic Diastolic Heart Failure. The admission minimum data set (MDS) with an assessment reference date (ARD) of 9/21/22 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Surveyor reviewed Resident #97's clinical record 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 and clinical record review, the facility staff failed to ensure medications were available to be administered to 3 of 5 residents in the survey sample (Resident #1, #3 and #4). The findings included: 1. The facility staff failed to ensure medications were available to be administrated to Resident #1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, paraplegia, low potassium levels, Ankylosing spondylitis and osteoarthritis. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #1 was also coded as requiring extensive assistance of 1-2 staff members for dressing and personal hygiene and being totally dependent on 1-2 staff members for bathing. During the clinical record review for Resident #1 on 5/10/19, the surveyor noted on the MAR (Medication…

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 clinical record review, the facility staff failed to ensure the medication error rate was less than 5% on 1 of 2 units in the nursing facility. (Unit 2, second floor) The medication error rate was noted to be 8.69%, which included 2 medication errors out of 23 opportunities for errors. The findings included: The facility staff failed to ensure the medication error rate was less than 5% on Unit 2, second floor. The medication error rate was noted to be 8.69%, which included 2 medication errors out of 23 opportunities for errors. Resident #4 and Resident #1 were the residents in which the nurse made the errors on. On 5/9 and 5/10/19, the surveyor performed the facility task for medication administration observation. On 5/10/19 at 8 am, the surveyor observed LPN (licensed practical nurse) #2 administrated Symbicort inhaler to Resident #4. LPN #2 gave the resident water after the use of the inhaler and the resident swallowed the water. LPN #2 did not give instructions to the resident not to swallow the water that she was being given nor did she have another cup…

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 and clinical record review, the facility staff failed to follow infection control guidelines for 2 of 3 residents during the medication administration observation (Resident #1 and #2). The findings included: 1. The facility staff failed to follow infection control guidelines concerning the cleaning of a stethoscope during the medication administration observation for Resident #1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, paraplegia, low potassium levels, Ankylosing spondylitis and osteoarthritis. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #1 was also coded as requiring extensive assistance of 1-2 staff members for dressing and personal hygiene and being totally dependent on 1-2 staff members for bathing. During 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 staff interview, facility document review and new employee file review, the facility staff failed to obtain a criminal background check on 1 of 25 newly hired employees of the facility (Employee #20). The findings included: The surveyor performed a review of the newly hired employees on 5/10/19 and it was noted that Employee # 20 had been hired as the administrator for the facility on 9/10/18. The criminal background check was not completed until 10/24/18, which was 44 days after the hire date. The surveyor notified the administrator of the above documented findings on 5/10/19 at 1 pm. The administrator stated, I was hired back in September but the building was not opened until February. I was being paid out of a different account then in October. I was switched to being paid from this facility. The surveyor requested to speak to the corporate human resource staff to clarify this. At 1:30 pm, the surveyor spoke to the corporate human resource employee that stated that Employee #20 had been hired on 9/10/18 as the role of administrator for the Bristol building. 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 staff interview and clinical record review, the facility staff failed to follow physician's orders for administration of a blood pressure medication for 1 of 5 residents in the survey sample (Resident #3). The findings included: The facility staff failed to obtain a blood pressure to determine if the blood pressure medication should be given to Resident #3 as ordered by the physician. Resident #3 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, dementia, Alzheimer's disease, anemia, adult failure to survive and major depressive disorder. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/7/19, the resident was coded as having short term and long term memory problem, and being moderately impaired in daily decision making. Resident #3 was also coded as requiring extensive assistance of 1-2 staff members for dressing, personal hygiene and being totally dependent on 1 staff member for bathing. During the…

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

Based on observation and staff interview, the facility staff failed to have narcotic box in the medication refrigerator permanently affixed for 1 of 2 units in the nursing facility (Unit 2 on second floor). The findings included: The facility staff failed to have a permanently affixed narcotic box in the medication refrigerator on Unit 2, which is on the second floor of the nursing facility. On 5/9/19, the surveyor observed that in the medication refrigerator located on Unit 2, second floor of the facility, did not have a permanently affixed narcotic box. This box would be where narcotics that needed to be refrigerated would be stored. Unit Manager #2 was with the surveyor when the above finding was noted. Unit manager #2 stated, I will bring this to the director of nursing's attention. At approximately 10:20 am, the director of nursing (DON) came to the surveyor and stated, We knew we needed one but because we didn't have any narcotics at the present time to be stored in the refrigerator it was not put into place. We had a backup plan for the time that this would be needed to be…

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 staff failed to date spices after they have been opened in the facility kitchen. The findings included: The surveyor went into the facility's kitchen and conducted an initial tour on 5/9/19 at 11 am. At this time, the surveyor noted that the following spices had not been dated after they were opened: Ground Mustard 15 oz. (ounce) container Ground Cinnamon 18 oz. container The surveyor asked the dietary manager when these opened spices should be discarded. The dietary manager stated, I have a list in my office that is from the manufactory and I go by those recommendations. The surveyor asked how would kitchen staff know when these spices were opened so staff would know when to discard the spice if the recommendation stated it should be discarded 6 months after it had been opened. The dietary manager stated, The containers should have a date written on it when it was opened. The surveyor asked if there were any dates on these 2 spice containers. The dietary manager stated, No, but I can write it on them…

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 and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 5 residents in the survey sample (Resident #5). The findings included: The facility staff failed to ensure a complete and accurate clinical record in regards to the post monitoring documentation of a fall for Resident #5, which occurred on 2/19/19. Resident #5 was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia with behaviors, palliative care and kidney disease. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/18/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #5 was also coded as requiring extensive assistance of 1-2 staff members for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review on 5/10/19, the surveyor noted that Resident #5 had a fall on 2/19/19…

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.