Marcella Post Acute

Based on staff interviews, clinical record reviews and facility document reviews, the facility staff failed to treat one resident with respect and dignity. Specifically, the facility failed to protect and promote the rights of one resident, Resident #181 (R181) by applying multiple briefs with incontinence care, out of a survey sample of 42 residents. The findings included:The facility staff failed to ensure one resident received individualized incontinence care by applying multiple briefs at one time for R181. On 5/18/26 at 3:45 pm, an interview was conducted with a certified nursing assistant, CNA13. She said, I didn't double brief him. CNA13 stated that when she went into the room R181 was doubled briefed and she told the daughter that she did not put two briefs on him. CNA13 stated she had never seen his daughter do incontinent care on R181 and the only supplies the daughter would ask for was a towel to wipe off his face at times. CNA13 said, when they came to me about this double brief it made me cry I don't do that but don't know how it was there I didn't put it on him. 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, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a clean, comfortable and homelike environment for 2 of 33 current sampled residents, Resident #3 and Resident #111.The findings included: 1. For Resident #3, the facility staff failed to repair the overbed light resulting in the light remaining on from 5/13/26 until 5/18/26 affecting the resident's sleep. An undated facility policy titled, Maintenance Service, specified The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. An admission Record indicated the facility admitted Resident #3 on 10/19/23. According to the admission Record, the resident had a medical history that included schizophrenia, post-traumatic stress disorder, panic disorder, and insomnia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/26, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated 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, clinical record review, and facility document review, the facility staff failed to maintain documentation that an alleged violation of neglect was thoroughly investigated for one (1) of 42 sampled residents, Resident #63. The findings included:A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 04/2021, specified, Residents have the right to be free from.neglect. Under the heading, Policy Interpretation and Implementation Item #1 specified, Protect residents from.neglect.by anyone including.a. facility staff. Item #2 read, .Implement policies and protocols to prevent and identify.b. neglect of residents. Item #6 specified, Provide staff orientation and training/orientation programs that include topics such as.identification and reporting of abuse. Item #8 read, Identify and investigate all possible incidents of.neglect. Item #9 specified, Investigate and report any allegations within timeframes required by federal…

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 provide written notification regarding the reason(s) for transfer and/or discharge to the resident and/or the resident's representative(s) and failed to offer a bed hold for 1 of 42 residents, Resident #175.The findings include: Resident #175 was transferred to a higher level of care on 06/24/2024. The facility staff were unable to provide documentation showing written notification of the reason(s) for transfer and/or discharge was provided to the resident and/or resident representative. In addition, the facility staff could not provide evidence that a bed hold was offered. This was a closed record review.Resident #175's diagnoses included pneumonitis, atrial fibrillation, acute kidney failure, alcohol dependence, clostridium difficile, gastro-esophageal reflux disease, benign prostatic hyperplasia, hypotension, gout, diabetes, and protein-calorie malnutrition. Section C (cognitive patterns) of Resident #175's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (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 Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for two (2) of 42 sampled residents, Resident #2 and Resident #36. Findings included: 1. For Resident #2, the facility staff coded the resident as having a limb restraint on the 03/21/2026 quarterly minimum data set (MDS), when the resident did not have a limb restraint. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to, bilateral osteoarthritis of knee, muscle weakness, morbid obesity, and abnormalities of gait and mobility. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/21/2026 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Section P (Restraints and Alarms) was coded to indicate the resident had a limb restraint used less than 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 clinical record review, the facility staff failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 of 33 residents, Resident #55. The findings include: The facility staff failed to fully complete a Level I PASRR, section 5 was left blank. A PASRR is a federally required screening process that screens individuals for mental illness and intellectual/developmental disabilities before they are admitted to a Medicaid-certified nursing facility. Resident #55's diagnoses included, dysphagia, diabetes, depression, and vascular dementia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The resident's admission date was 01/24/2022. Review of the clinical record revealed a Level I PASSR dated 01/24/2022. Section 5, titled RECOMMENDATION (Either a or b must be checked.) had not been completed. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, resident interviews, clinical record reviews, and facility document reviews, the facility staff failed to develop and implement a comprehensive person-centered care plan for four residents, Resident #28 (R28), Resident #36 (R36), Resident #8 (R8), and Resident #9 (R9) out of a survey sample of 42 residents. The findings included:1.The facility staff failed to develop a care plan to address the use for R28's CPAP (continuous positive airway pressure) machine and develop interventions related to R28's hoarding behaviors within the resident's room. On 5/17/26 at 10:30 am, an observation of R28's room was conducted. Observation of his room was like hoarding behaviors. He had personal items packed in bags and boxes that was stacked at the end of his bed and on both sides of his bed. He had metal racks that were placed at the side of his bed that was full of his personal belongings. His overbed table was in front of him while in the bed and he had personal items on the overbed…

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 review and revise the comprehensive person-centered care plan for 1 of 33 current sampled residents, Resident #4. The findings included; For Resident #4 (R4), the facility staff failed to revise the comprehensive person-centered care plan (CPCCP) following the discontinuation of a foley catheter.An admission Record indicated the facility admitted R4 on 10/02/25. According to the admission Record, the resident had a medical history that included heart failure unspecified and retention of urine unspecified. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/9/2026, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition.R4's medical provider orders included an order dated 1/06/2026, to remove foley catheter: void trial, bladder scan every 8 hours and as clinically indicated.On 5/19/2026, a review of R4's comprehensive care plan revealed a focus area dated 12/17/2025 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide activities of daily living care for 3 of 42 residents, Residents #55, #149 and #36. The findings include:1. For Resident #55, the facility staff failed to provide nail care. Resident #55 was observed to have fingernails that were excessively long and jagged. Resident #55's diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, and diabetes. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #55 was severely impaired in cognitive skills for daily decision making. Section GG (functional status) was coded to indicate the resident was dependent on staff for personal hygiene. Section I (active diagnoses) documented a contracture of the left hand. Resident #55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and facility policy review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests, and physical, mental, and psychosocial well-being for one (1) of 33 current sampled residents, Resident #25. Findings included:A facility policy entitled, Activity Programs with a revision date of June 2018 read in part, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Under the heading Policy Interpretation and Implementation item #1 read in part, The activities program is provided to support the well-being of residents. Item #2 read, Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Item #3 read in part, The activities program is ongoing and includes.individual activities and assisted individual activities. Item #5 read, Our activity…

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, clinical record review, and facility document review, the facility staff failed to provide appropriate services and/or treatment to prevent further decrease in range of motion for 1 of 42 residents, Resident #55. The findings include:Resident #55 was observed without the provider-ordered hand splint (palm guard) in place on the right hand. Resident #55's diagnoses included, dysphagia, diabetes, depression, and vascular dementia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. Section GG (functional abilities) was coded to indicate the resident had bilateral limitation in range of motion in the upper extremities. The Resident's comprehensive care plan identified the problem area activities of daily living (ADL) performance deficit. Interventions included applying bilateral palm guards during AM ADL's and doff…

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 clinical record review, the facility staff failed to follow physicians' orders for one of 42 residents in a survey sample, Resident #8. The Findings Include: Resident #8 (R8) did not have pressure dressing supplies in place as ordered for dialysis access port. Diagnoses for R8 included diabetes, congestive heart failure, chronic pain, and end stage renal disease on dialysis. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/16/26. R8 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R8's physician orders documented Keep pressure dressing supplies at bedside. The order was dated 5/19/26. On 5/20/2026 at 10:32 a.m. R8's room was observed along with license practical nurse (LPN #7) LPN #7 searched throughout R8's room (closet, drawers, under bed, window ledge, and behind furniture) and was unable to find a pressure dressing kit/supplies and verbalized that the supplies would be put in place. On 5/20/2026 at 11:25 a.m. the director of nursing (DON) 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 observation, clinical record review, staff interviews, and facility document reviews the facility staff failed to follow a physician's order for a therapeutic diet for one resident, Resident 36, (R36) out of a survey sample of 42 residents. The findings included:The facility staff failed to serve R36's therapeutic diet ordered by the physician. On 5/19/26 at 1:36 pm, an observation was made of R36's lunchtime meal. R36's meal was served mechanical soft, but he had salt packet on his lunchtime meal tray. R36's meal ticket read, [Facility name and Resident's name redacted] - Mechanical Soft Tuesday (W4-D24) Lunch 5/19/2026 Ground Cheeseburger for Bun* - 1 Hamburger Bun - 1 Ea [each] Mayonnaise (oz) - 2 Oz Baked Beans - 1/2 Cup CHOP Broccoli Salad - 1/2 Cup Scalloped Apples. R36's meal ticket was not accurate, 2-gram sodium not observed on the meal ticket. 5/19/26, a clinical record review was conducted. During the review, the physician's orders were reviewed and R36 had an order written on 3/11/26, which read in part, . CCD [consistent carbohydrate] 2g [grams] Na [sodium]…

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, clinical record review, and facility document review, the facility staff failed to maintain a infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of diseases and infections for 2 of 3 nursing units ([NAME] and [NAME]) and 1 of 33 current sampled residents (Resident #36). The findings included: 1. On [NAME] nursing unit, a stocked clean linen cart was being stored in a resident's soiled bathroom. An observation on 5/20/26 at 9:50 AM revealed a covered linen cart stocked with clean linen stored inside Resident #170's bathroom beside an unflushed toilet containing feces. The bathroom had a strong odor of fecal matter. Certified Nursing Assistant (CNA) #10 was immediately notified of the observation and stated the linen cart should not be in the resident's bathroom and the staff needed the cart. CNA #10 removed the cart from the resident's bathroom and placed it 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 staff interview, policy review, and clinical record review, the facility staff failed to ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for one of five residents sampled for immunizations, resident #134.The findings included: A facility policy entitled, Pneumococcal Vaccine with a revision date of August 2025 read in part, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. An admission Record for resident #134 indicated the facility admitted the resident on 10/30/25. According to the admission Record resident #134 had a medical history that included the diagnoses of stroke, end stage renal disease, chronic obstructive pulmonary…

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 policy review, the facility staff failed to implement policies and procedures to ensure each resident or resident representative receives education regarding the risks, benefits and potential side effects associated with the COVID-19 vaccine for two of five residents in the immunization review sample, resident #134 and #163.The findings included:1. For resident #134, the facility staff failed to provide education of the risks, benefits and potential side effects of the COVID-19 vaccine. A facility policy entitled, Coronavirus Disease (COVID-19)- Vaccination of Residents with a revision date of August 2025 was reviewed and read in part, 8. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. 9. The resident (or representative) is provided with the most current vaccine information statement (VIS) prior to vaccine administration. Current VIS for all recommended vaccines are available at:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the resident's interview, observations, family interview, staff interviews, and clinical record review, the facility's staff failed to obtain emergency dental services for one resident (Resident 7), in the survey sample. The findings included: Resident #7 was not provided dental services who presented with a broken and severely painful left upper tooth for which the facility's staff could not provided documentation of extenuating circumstances that resulted in the delay of treatment by a dentist. Resident #7 was originally admitted to the facility 1/11/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included diabetes, high blood pressure and heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were moderately impaired. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 2 of 7 residents (Resident #1 and Resident #2), in the survey sample. The findings included: 1. Resident #1 was originally admitted to the facility 5/25/24 after an acute care hospital stay. The admission diagnoses included; cardiogenic shock, chronic congestive heart failure, pulmonary hypertension, muscle weakness, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. On 5/29/24 during an observation tour for room [ROOM NUMBER], it was observed that the air conditioning unit was not functioning. On 5/29/24 at 3:05 PM an interview was conducted with Resident #1. Resident #1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review the facility staff failed to provide toileting hygiene/toileting assistance for 2 of 7 residents (Resident #6 and 5), in the survey sample. The findings included: 1. The facility's staff failed to provide toileting hygiene to Resident #6 when requested on 5/29/24 before and during the supper meal. Resident #6 was originally admitted to the facility 4/1/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included dementia, high blood pressure and diabetes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/5/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired. In section GG (Functional Abilities and Goals) the resident was coded as dependent for toileting hygiene. On 5/29/24 at 5:23 PM Resident #6 stated…

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

Based on resident interview and staff interviews the facility staff failed to have an agreement with a dentist to provide emergency dental services for 1 of 7 residents (Resident #7), in the survey sample. The findings included: On 5/29/24 at 4:20 PM Resident #7 stated she had a broken tooth, and the pain was so severe it was causing pain in her eyes. Resident #7 stated the tooth broke off on Thursday 5/23/24 or Friday 5/24/24 and she reported it to a nurse on Saturday 5/25/24. The resident stated she was told that a dental appointment had been scheduled but she was not provided details. On 5/30/24 at 11:21 AM and interview was conducted with SW #1. SW #1 stated the resident required stretcher transport and an escort to the dentist office and there was no local dentist to accommodate any residents who required stretcher transport. SW #1 also stated the Medical Assistant (MA) attempted to make an appointment for Resident #7 on 5/29/24 at a dental school's clinic in another city but the MA was informed that a call would need to be made to the dental school's clinic on 6/1/24, which…

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, record review, staff interview, resident interview, interview with the facility's Pest Control Company staff, and facility policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This affected three of three units, common areas, and the dining rooms in the facility, and had the potential to affect all 126 residents residing in the facility. Findings include: Observation in the dining room on 10/26/21 at 8:58 AM revealed four small white boxes on the floor in each corner of the room. The boxes were observed to have more than 10 dead bugs in each one of them. Some of the bugs were one and a half inches in length and were noted to be sticking out the end of the boxes. These four boxes were in the same room where the door was observed to be propped open with a rock. Interview with the Pest Control Company staff on 10/26/21 at 2:50 PM while he was in the building revealed he sprays for bugs in the building every two weeks. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of maintenance records, and review of facility policy, the facility failed to ensure maintenance services to maintain clean and orderly environment for residents' rooms on three of three units in the facility. Findings include: The following observations were made during an environmental tour with the Maintenance Director (MD) on 10/29/21 that began at 10:11 AM and concluded at 11:00 AM: 1. In Room (RM) 109 the bathroom door was observed to have a large amount of white substance along the bottom on the inside of the door. The MD identified the substance as being material used to fill holes and was unaware aware of why there was no further repair such as painting the door. 2. In RM [ROOM NUMBER] the heating/air conditioning unit was attached only on the top corner and was hanging crooked off the wall. The base cove molding was observed to be coming away from wall and there was crumbling plaster underneath the heating/air conditioning unit. 3. In RM [ROOM NUMBER] the wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to ensure the resident, his or her family, and/or the resident representative was provided information related to the benefits and risks to the residents for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for five of five residents reviewed for unnecessary medications (Resident (R) 17, 31, 55, 86, and 97). Findings include: 1. Review of R17's Face Sheet located in the Electronic Medical Record (EMR) under the Resident Info tab, revealed an admission date of 04/02/21 and included diagnoses of dementia with behavioral disturbance and anxiety disorder. Review of R17's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/25/21 revealed a diagnosis of dementia and Brief Interview for Mental Status (BIMS) score of 05/15, indicating the resident was severely cognitively impaired. Review of R17's October 2021 Physician…

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, record review, interview, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for three of 28 residents reviewed for respect and dignity (Resident (R) 36, R77, and R119). Findings include: 1. During dining observation on 10/26/21 at 12:27 PM, R77 was sitting at the table in the dining room and Certified Nursing Assistant (CNA) 2 walked over to the resident and fed her two spoonfuls of food, while standing at the table next to R77. During an interview on 10/26/21 at 12:34 PM, CNA2 confirmed she assisted R77 with eating while standing beside the resident. 2. Observations on 10/26/21 at 9:34 AM, 10/27/21 at 8:31 AM, and 10/27/21 at 2:14 PM revealed R119 lying in bed supine (on his back) with his urinary catheter bag hanging from the left side of his bed uncovered and exposed to the view of his roommate and others that may enter his room. During an observation on 10/27/21 at 8:31 AM, Nursing Assistant (NA)2 was standing to the right of R119,…

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, interview, record review, and policy review, the facility failed to provide documented evidence assistance with activities of daily living (ADLs) was given to three of four residents reviewed for ADLs (Residents (R)20, R32, and R95) out of a total sample of 28 residents. Specifically, there was no documented evidence residents received showers/tub baths in accordance with the bath schedule and their needs. All three residents resided on the [NAME] unit. Findings include: Review of the paper Tub or Shower Bath policy dated 03/01/15 revealed Residents should receive a tub or shower bath at least twice weekly. The purpose was To provide cleanliness and comfort to the resident. To assist the resident in bathing. To prevent body odors. To stimulate circulation and provide a mild form of exercise. To observe the resident's skin condition. To alleviate skin conditions. 1. Review of the Face Sheet undated, in the electronic medical record (EMR) under the admission tab, revealed R20 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to provide services to ensure two (Residents (R)63 and R4) of four residents reviewed for limited of Motion (ROM) and mobility, maintained or improved function unless reduced ROM/mobility was unavoidable based on the resident's clinical condition. Findings include: 1. Review of the Face Sheet in the Electronic Health Record (EMR) for R4 revealed an admission date of 07/02/19 with a current diagnosis of arthritis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/21 revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated R4 had functional limitation in ROM to her upper extremities to include her shoulder, elbow, wrist, and hand with impairment of both sides. Review of the Comprehensive Care Plan, located in the EMR under the Care Plan tab revealed R4 had the potential for health and safety concerns related to activities of daily living…

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, record review, interview, and review of facility policy, the facility failed to ensure one (Resident (R) 83) of four residents reviewed for nutrition maintained to the extent possible, acceptable parameters of nutritional status and did not experience a significant weight loss. Findings include: Review R83's Face Sheet located in the Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with a diagnosis of glaucoma, blindness of the right eye, low vision in left eye and Vitamin D deficiency. Review of the admission Minimum Data Set (MDS) in the EMR under the MDS tab with an assessment reference date (ARD) of 03/09/21 revealed R83 was able to understand and to be understood and his vision was noted to be highly impaired. R83's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The MDS indicated R83 required supervision, oversite and cueing for meals by staff. Review of the current Nutrition Person Centered Comprehensive Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a resident received timely pain medication for one of 28 sampled residents (Resident (R) 62). Findings include: Review of the facility's policy titled, Pain Management, revised 06/15/12, revealed pain should be assessed and documented at regular intervals to ensure residents receive optimal pain management. Assessments should include the onset, location, frequency, quality, and intensity of pain with the resident self-report as primary indicator of pain. Pain assessments should be ongoing, and if interventions are not effective, the treatment plan and plan of care should be revised accordingly. Pain should be coded at the most severe level when the assessment does not determine the exact frequency or intensity of pain. Review of R62's Face Sheet found in R62's Electronic Medical Record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] and had diagnoses 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 Based on observation, interview, record review, and policy review, the facility failed to attempt use of alternatives prior to installing bed rails, failed to obtain informed consent, and failed to ensure bed rails were maintained to ensure safety for one of one sampled resident (Resident (R)20) reviewed for bed rails out of a total sample of 28 residents. Findings include: Review of the Face Sheet undated, in the electronic medical record (EMR) under the admission tab, revealed R20 was admitted to the facility on [DATE]. Diagnoses included intellectual disability, epilepsy, aphasia (loss of ability to understand or express speech), and seizure disorder. R20 received all nutrition via a gastrostomy feeding tube. Review of the Annual Minimum Data Set (MDS), dated [DATE], in the EMR under the MDS tab, revealed the resident had no speech during the assessment period, she was rarely understood, and rarely understood others, and was highly impaired in vision. A Brief Interview for Mental Status test was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to develop person-centered comprehensive care plans to meet resident preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for dementia for two (Residents (R)31 and R55) of two residents reviewed with a diagnosis of dementia. Findings include: 1.Review of R31's Face Sheet located in the Electronic Medical Record (EMR) located under the Resident Info tab revealed R31 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R31's Minimum Data Set' (MDS) located in the EMR under the MDS tab with an assessment reference date of 08/16/21 revealed a diagnosis of dementia. Review of the Comprehensive Care Plan in the EMR located under Care Plan tab revealed there was no evidence of a person-centered comprehensive care plan to address the residents' preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for dementia.…

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

Based on observation, interview, and review of facility policy, the facility failed to ensure metal boxes containing Schedule IV (controlled substances) medication located in the refrigerators in one of three medication rooms were secured in permanently affixed compartments. Findings include: The facility was identified to have three medications rooms. One medication room on each unit to include 100 Unit, 300 Unit and 400 Unit. Observation of the 100 Unit medication room on 10/29/21 at 8:25 AM with Licensed Practical Nurse (LPN)5 revealed the medication room door was locked and the refrigerator within the medication room was locked. There was an unlocked metal box in the refrigerator containing two unopened vials of Ativan 2 milligram (mg), an anti-anxiety Schedule IV medication. The box was able to be removed from the refrigerator as it was not permanently affixed. There was a chain attached to the inside of the refrigerator, but the chain was not attached to the metal box containing the Scheduled IV medications. LPN5 indicated the chain had been broken for a long time and she 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 clinical record review, staff interviews and facility document review, the facility staff failed to convey the summary and goals of the comprehensive plan of care upon transfer/discharge for 2 of 46 Residents in the survey sample, Resident #74 and #73. 1. The facility staff failed to include in the transfer summary the resident's comprehensive care plan goals at the time of discharge/emergency department, or as soon as possible to the actual time of transfer for Resident #74 on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18. 2. The facility staff failed to ensure Resident #73's comprehensive care plan goals were included in the hospital transfer documentation when the resident was transferred to the hospital on 8/20/18 and 10/8/18. The findings include: 1. Resident #74 was originally to the nursing facility on 1/28/15 with a diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 2 of 46 residents in the survey sample (Resident #74 and #73). 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #74's discharges to the hospital/emergency room on [DATE], 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #73's transfer to the hospital on 8/20/18 and 10/8/18. The finding include: 1. Resident #74 was originally admitted to the nursing facility on 1/28/15 with diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/25/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, resident interviews and facility documentation, the facility staff failed to issue a written notice of the bed hold policy upon transfer to the local hospital for 2 of 46 residents (R #74 and #73) in the survey sample. 1. The facility staff failed to ensure Resident #74 was issued a written notice of the bed hold policy upon transfer to the local hospital/emergency department (ED) on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to provide Resident #73 or the resident representative with a written notice of the bed hold policy prior to transfer to the hospital on 8/20/18 and 10/8/18. The findings include: 1. Resident #74 was originally to the nursing facility on 1/28/15 with diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/25/18 and coded the resident on the Brief Interview…

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 clinical record review, staff interview and facility documentation the facility staff failed to administer a significant medication (*Dimethyl Fumarate) as ordered for 1 out of 46 residents (Resident #387) in the survey sample. The facility staff failed to administer forty doses of the *Multiple Sclerosis (MS) medication Dimethyl Fumarate as ordered by the physician. The findings included: Resident #387 was admitted to the facility on [DATE] and discharged home on [DATE]. Diagnoses for Resident #387 included, but not limited to, Multiple Sclerosis. Resident #387's Minimum Data Set (an assessment protocol) with an Assessment Reference date (ARD) of 05/17/18 coded Resident #387 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #387's comprehensive care plan effective on 05/21/18 documented Resident #387 with the potential for impaired quality of life related to new environment and change in health status. The goal: 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 observations, record review and staff interview, the facility staff failed to maintain an effective pest control program. The findings included: During the kitchen tour on 12/04/2018 at 11:37 A.M., roaches were observed in the kitchen area. Roaches and water bugs were observed in the kitchen area under the three-compartment sink area. The area was observed with water and food particles on the floor. A live roach was observed alongside the walk-in refrigerator next to the dry cooking pan racks. Dead roaches were observed in six overhead light covers. On 12/06/18 at 11:00 A.M., one dead roach was observed in the dry storage area under the food with bread and napkins. Dry corn flakes and cereal were observed on the floor. During a review of the Pest Control Log on 12/04/18 at 2: 33 P.M. the Pest Control Service Inspection Report noted date of service 11/14/18 in at 11:51 AM and time out 11/14/18 at 12:29 PM. The report indicated: applied Alpine Cockroach Gel-Area-Kitchen-target German Roaches. A Pest Control Long dated 11/28/18 Service Inspection Report indicated: date 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 Based on staff interview and clinical record review the facility staff failed for 1 resident (Resident #65) of 46 residents in the survey sample to ensure an accurate annual resident assessment. The facility staff failed to ensure that the Annual Minimum Data Set (MDS-an assessment tool), was accurately coded to reflect Resident #65 Bladder and Bowel incontinence. The findings included: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Diabetes Mellitus, Other sequelae of other Cerebrovascular Disease, and Anxiety Disorder. Resident #65's most recent MDS was an annual assessment with an Assessment Reference Date (ARD) of 10/12/18. The MDS coded Resident #65 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #65 requiring total dependence, on staff, for Activities of Daily Living care. The clinical record for Resident #65 was reviewed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to provide personal care to include showers for one resident in the survey sample (Resident #387) who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #387 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. The findings included: Resident #387 was admitted to the facility on [DATE]. Diagnosis for Resident #387 included but not limited to *Multiple Sclerosis (MS). Resident #387's Minimum Data Set (an assessment protocol) with an Assessment Reference date (ARD) of 05/17/18 coded Resident #387 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #387 requiring total dependence of one with bathing, extensive assistance of two and toilet use, extensive assistance of one with transfer, dressing, eating and personal hygiene.…

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 failed for 1 resident (Resident #65) of 46 residents in the survey sample to provide foot care and/or ensure that Podiatry services were provided. For Resident #65, who was a Diabetic, the facility staff failed to ensure toenail care was provided. Podiatry services had not been provided since 7/31/17. The findings included: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Diabetes Mellitus, Other sequelae of other Cerebrovascular Disease, Anxiety Disorder. Resident #65's most recent Minimum Data Set (MDS-an assessment tool) with an Assessment Reference Date (ARD) of 10/12/18. The MDS coded Resident #65 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #65 as requiring total dependence, on staff, for Activities of Daily Living (ADL) care. On 12/04/18 at 12:24…

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 documentation review, the facility staff failed to ensure an opened refrigerated medication included the opened date in one of two medication rooms. The facility staff failed to date a multidose vial of influenza vaccine when opened. The findings include: On 12/06/18 the facility's medication storage review of 3 medication carts and 2 medication rooms was conducted. On 12/6/18 at approximately 12:12 PM, the medication refrigerator was inspected with Licensed Practical Nurse (LPN) #4. Stored inside the medication refrigerator was an opened multidose vial of *Influenza Vaccine with a manufacturer's expiration date of 05/20/2019. The date the multidose vial of influenza vaccine was opened was not written on the vial or the medication storage box. On 12/06/18 at approximately 3:20 PM, Licensed Practical Nurse # 3 was interviewed. She stated that if she observed a multidose vial of medication in the refrigerator not labeled with the opened date she would discard the medication. On 12/06/18 at approximately, 3:30 PM. Licensed Practical…

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.