Daleville Health and Rehabilitation

Based on staff interview, clinical record review and facility document review the facility staff failed to review and act upon a monthly medication regimen review for 1 of 19 residents, Resident #234. The findings included: For Resident #234 the facility staff failed to follow-up on pharmacy recommendation from the monthly medication regimen review. Resident #234's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus. Resident #234's most recent minimum data set with an assessment reference date of 02/17/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #234's comprehensive care plan was reviewed and contained a care plan for Resident is as risk for complications associated with hyper or hypoglycemia related to: diabetes on insulin therapy. The director of nursing (DON) provided the survey team with a list of residents who had a medication regimen review with recommendations for the month of February 2024. Resident #234…

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, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 19 residents in the survey sample, Resident #46 and #21. The findings included: For Resident #46, the facility staff failed to document a change in the resident's condition resulting in an acute care hospital admission. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Acute Follicular Conjunctivitis, Chronic Pain Syndrome, Open-Angle Glaucoma, Type 2 Diabetes Mellitus, Schizophrenia, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 4/08/24 at 1:11 PM, surveyor spoke with Resident #46 who stated they were sent to the hospital in December after being sick for three to four days. The resident stated upon arrival at the hospital their temperature was 104.5…

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 ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of correction for the standard recertification surveys dated 4/11/19, 5/27/21, and 2/16/23 in order to maintain compliance as evidenced by repeated deficiencies in the area of Pharmacy Services. The findings included: The area of Pharmacy Services was previously cited with the 4/11/19, 5/27/21, and 2/16/23 standard surveys due to failure to provide evidence of the attending medical provider reviewing and acting upon monthly drug regimen reviews completed by the pharmacist. This deficiency was cited again on the current standard survey dated 4/10/24 due to failure to provide evidence of the attending medical provider review and action taken upon monthly drug regimen reviews completed by the pharmacist for 1 of 5 residents reviewed. On 4/10/24 at 2:45 PM, surveyor met with the Administrator to review the facility QAPI…

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

Based on observation, staff interview, and facility document review, the facility staff failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by a final rinse temperature below 180 degrees Fahrenheit (F) for a high temperature (heat sanitization) dishwasher in the facility kitchen. The findings included: The facility staff failed to consistently maintain a final rinse temperature at the manufacturer recommended minimum temperature of 180 degrees F for the facility high temperature dishwasher. On 2/13/23 at 2:10 pm, the surveyor observed the facility dishwasher in use. The dietary manager (DM) stated the machine was a high temperature dishwasher. Dishwasher wash and rinse temperature gauges were located on the front of the machine. The wash temperature reached a maximum of 150 degrees F, and the rinse temperature reached a maximum temperature of 170 degrees F. The DM stated the rinse temperature should be 180 degrees F and proceeded to empty and drain the machine and ran another cycle. At that time the wash temperature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document reviews, the facility staff failed to maintain complete and accurate clinical records for five (5) of 24 residents, Resident #50, Resident #68, Resident #70, Resident #125, and Resident #176. The findings include: 1. Resident #50's Medication Regimen Review (MRR) dated 12/30/22 failed to include documentation of the medical provider's reason for not attempting a Gradual Dose Reduction (GDR). Resident #50's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/9/23, was signed as completed on 2/3/23. Resident #50 was assessed as able to make self understood and able to understand others. Resident #50's Brief Interview for Mental Status summary score was documented as an 8 out of 15; this indicated moderate cognitive impairment. Resident #50 was assessed as being independent with bed mobility and eating. Resident #50 was assessed as requiring assistance with personal hygiene and bathing. The following information was found in a facility document titled…

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 representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the resident representative of significant changes in the resident's physical condition for 1 of 24 residents in the survey sample, Resident #61. The findings included: For Resident #61, the facility staff failed to notify the resident representative of significant weight loss in a timely manner and failed to notify of an episode of rectal bleeding. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #61 was coded as requiring limited assistance with bed mobility, transfers, dressing,…

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 interviews and document review, the facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment for one (1) of 24 residents, Resident #68. The findings include: The facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment when Resident #68 started receiving hospice care. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modifications to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68 had an order for consult for hospice care and to treat if approved dated 11/29/22. Documentation indicated the hospice admission was…

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

Based on interviews and document reviews, the facility staff failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' conditions for two (2) of 24 residents, Resident #68 and Resident #70. The findings include: 1. Resident #68's Minimum Data Set (MDS) assessment (with an Assessment Reference Date (ARD) of 1/11/23) had the resident assessed as both able to make self understood and as being rarely/never understood. Resident #68's MDS assessment, with an ARD of 1/11/23, was signed as completed on 1/11/23. Resident #68 was assessed as able to make self understood and as able to understand others. Resident #68 was also assessed not to have the Brief Interview for Mental Status completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 2/14/23 at 4:04 p.m., the surveyor discussed Resident #68's conflicting MDS data with the facility's Administer. On 2/16/23, the survey team was provided with a modified MDS assessment that had…

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. The facility staff failed to develop a care plan to address Resident #68's hospice needs. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68 had an order for consult for hospice care and to treat if approved dated 11/29/22. Documentation indicated the hospice admission was delayed until 12/7/22 at the request of one of the resident's family members. On 2/15/23 at 2:10 p.m., Registered Nurse (RN) #1 was interviewed about Resident #68's care plan. RN…

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 interviews and document review, the facility staff failed to ensure clinical documentation supported new diagnoses for two (2) of 24 residents, Resident #68 and Resident #50. The findings include: 1. Resident #68's clinical documentation included the diagnosis of Schizoaffective disorder, unspecified dated 12/21/22. Resident #68's clinical documentation failed to include assessment information to support the addition if this diagnosis. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. The following information was found in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review and clinical record review, and staff interview facility staff failed to provide treatment as ordered for one of 24 current residents in the survey sample (Resident # 176). Resident #176 was admitted to the facility on [DATE]. The resident's diagnoses included primary adrenocortical insufficiency, ployneuropathy, chronic obstructive pulmonary disease, polymyalgia rheumatica, common variable immunodeficiency, morbid obesity type 2 diabetes mellitus, chronic pancreatitis, depression, anxiety, muscle spasms, nausea, allergies, edema, primary adrenocortical insufficiency, hypertension, and insomnia. At the time of the survey, the resident did not yet have a minimum data set assessment. The surveyor interviewed the resident on 2/13/2023 and found the resident knowledgeable about diagnoses and treatment and able to answer questions about the time in the facility. The resident expressed no concerns other than lack of medication availability and not having received a fentanyl patch (due…

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, facility staff failed to provide pressure ulcer treatment as ordered for one of 24 current residents in the survey sample (Resident #5). Resident #5 was admitted to the facility with diagnoses including hypertension, peripheral vascular disease, gastroesophageal reflux, muscle weakness, major depression, osteoarthritis, cognitive communication deficit and polyneuropathy. On the minimum data set assessment with assessment reference date 12/8/2022, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting treatment. The resident was assessed as having one unhealed stage two pressure ulcer and application of non-surgical dressing. During clinical record review, the surveyor noted an order to Cover pressure area to buttock with Mepilex change daily until healed dated 11/25 and discontinued on 12/03/2022. The Treatment Administration Record indicated the treatment N=not administered, other, see note on 11/27-11/29/2022. The nurse's notes did not…

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

Based on staff interview and clinical record review, the facility staff failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 24 residents in the survey sample, Resident #61. The findings included: For Resident #61, the facility staff failed to administer the nutritional supplement Ensure as ordered by the physician and failed to follow the registered dietician's (RD) recommendations to increase the amount of Ensure or add the nutritional supplement Magic Cup. The facility staff also failed to ensure the resident's weight loss was addressed by the provider in a timely manner. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident 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.

2. The facility staff failed to assess respiratory status for Resident #125. Resident #125 was COVID-19 positive at the time of admission. On the afternoon of 2/13/23, Resident #125 was observed to be resting in bed, coughing. Resident #125's Minimum Data Set (MDS) assessment had yet to be completed at the time of the survey. Review of Resident #125's clinical documentation failed to reveal evidence of a respiratory exam until approximately 38 hours after the resident's arrival to the facility. The following information was found in a facility policy titled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents (with a revised date of September 20212): - Residents are monitored daily for signs of respiratory infection and/or symptoms of COVID-19, including: a. fever (temperature (greater than or equal to) 100.0 (degrees Fahrenheit) and/or chills; b. cough; c. shortness of breath or difficulty breathing; d.fatigue; e. muscle or body aches; f. headache; g. new loss of taste or smell; h. sore throat; i. congestion or runny nose; j. nausea or vomiting; and/or k.…

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 ensure that residents who require dialysis receive services consistent with the comprehensive person-centered care plan for 1 of 24 residents in the survey sample, Resident #42. The findings included: For Resident #42, the facility staff failed to monitor the resident's hemodialysis access site for adequate blood flow and complications. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Hypertensive Heart Disease, Chronic Kidney Disease, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, and Schizoaffective Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/21/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #42 was coded as receiving dialysis within the past 14 days. Resident #42's comprehensive person-centered care plan included a care plan description…

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 interviews and document review, the facility staff failed to ensure Medication Regimen Reviews (MRRs) were addressed by a medical provider for two (2) of 24 residents, Resident #68 and Resident #61. The findings include: 1. The facility staff failed to ensure two (2) of Resident #68's Medication Regimen Reviews (MRRs) were documented and addressed by a medical provider. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68's clinical documentation included the following notes: - On 8/29/22 at 1:40 p.m., 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 resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of any significant medication errors for 1 of 24 residents in the survey sample, Resident #61. The findings included: For Resident #61, the facility staff failed to provide three antibiotics as ordered for severe bilateral conjunctivitis and failed to hold the anticoagulant, Eliquis, as ordered by the provider following an episode of rectal bleeding. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #61 was coded as requiring limited assistance with bed mobility,…

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 laboratory services to meet the needs of the resident for 1 of 24 residents in the survey sample, Resident #61. The findings included: For Resident #61, the facility staff failed to obtain a complete blood count (CBC), iron saturation level, ferritin level, total iron binding capacity level, and failed to check stool for occult blood as order by the medical provider on 12/22/22 due to rectal bleeding. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #61 was coded as requiring limited assistance with bed mobility,…

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.

7. For Resident #11, the facility staff failed to provide assistance with showers per the resident's preference of twice weekly. Resident #11's diagnosis list indicated diagnoses, which included, but not limited to Spondylolisthesis Lumbar Region, Bipolar II Disorder, Hereditary Motor and Sensory Neuropathy, Muscle Wasting and Atrophy, and Epilepsy Unspecified not Intractable without Status Epilepticus. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #11 was coded as being totally dependent in bathing. On 5/26/21 at 9:19 am, surveyor spoke with Resident #11 who stated that they did not get their shower on Monday because there was not enough staff. Resident further stated that this happens often on Mondays. The next morning at 8:58 am, surveyor again spoke with Resident #11 concerning their showers and asked if they receive showers two times per week and the resident stated it depends if there's enough…

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 accurately code a MDS (minimum data set) assessment to reflect the resident's status for 1 of 22 residents, Resident #61. The findings include: For Resident #61, facility staff failed to code the resident's most recent weight on the 4/23/21 quarterly MDS assessment. Resident #61's diagnosis list indicated diagnoses, which included, not limited to Parkinson's Disease, Unspecified Dementia with Behavioral Disturbance, Schizoaffective Disorder Bipolar Type, Major Depressive Disorder Recurrent Moderate, Agoraphobia with Panic Disorder, and Chronic Pain Syndrome. The most recent quarterly MDS assessment with an ARD (assessment reference date) of 4/23/21 assigned the resident a BIMS (brief interview of mental status) score of 14 out of 15 in section C, Cognitive Patterns. In section K, Swallowing/Nutritional Status, Resident #61's most recent weight in the last 30 days was coded with a -. Resident #61 was also coded as no or unknown for a weight loss 5% or more in the last month or loss of 10% or more in…

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 ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 2 of 22 residents, Residents #31 and #19. The findings included: 1. For Resident #31, facility staff failed to follow physician's orders for the administration of Acidophilus (a probiotic supplement), Baclofen (a skeletal muscle relaxant used to treat pain and certain types of spasticity), Diazepam (a benzodiazepine used to relieve anxiety and control muscle spasms and spasticity), Gabapentin (an anticonvulsant used to control seizures, restless leg syndrome, and relieve nerve pain), and Simethicone (an anti-gas medication). Resident #31's diagnosis list indicated diagnoses, which included, but limited to Muscle Wasting and Atrophy not Elsewhere Classified Other Site, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Functional Quadriplegia, Generalized Anxiety Disorder, and Major Depressive Disorder Recurrent Mild. The most recent quarterly MDS (minimum data set) with 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.

2. For Resident #31, the facility staff failed to report the February 2021 drug regimen review to the attending physician, the facility medical director, and the DON (director of nursing). Resident #31's diagnosis list indicated diagnoses, which included, but limited to Muscle Wasting and Atrophy not Elsewhere Classified Other Site, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Functional Quadriplegia, Generalized Anxiety Disorder, and Major Depressive Disorder Recurrent Mild. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/27/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive patterns. Upon review of Resident #31's clinical record on 5/26/21, surveyor was unable to locate the February 2021 drug regimen review completed by the pharmacist. On 5/27/21 at 10:54 am, surveyor spoke with the DON who stated they have just spoken with the pharmacist and they did not send the February drug regimen review recommendations to the facility. DON stated the pharmacist is…

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.