Waterview Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility document review, and clinical record review, the facility staff failed to afford a Resident the ability to make decisions in concerning their care for 1 of 64 residents (Resident #87), in the survey sample. The findings included: The facility staff failed to transfer Resident #87 to an acute care setting even after a significant change had been observed. Resident #87's Responsible Representative (RR) called non-emergent transportation who transported the resident to the local hospital on [DATE]. Resident #87 was transferred to another acute care setting on 02/03/23. Resident #87 was readmitted to the nursing facility on 02/08/23. Resident #87 was originally admitted to the nursing facility on 01/24/23. Diagnosis for Resident #87 include but are not limited to rectal prolapse, Atrial Fibrillation (A-Fib), and lymphedema. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief…

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

Based on interview, clinical record review and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident's choice, for 1 Resident in a survey sample of 64 Residents. The findings included: For Resident #98 the facility staff failed to schedule the appointments that the Resident had ordered by his physician. On 8/23/23 at approximately 9:58am, an interview was conducted with Resident #98. Resident #98 stated he needs psych services but has not had them since arrival at facility. He stated that his physician had written an order for him to be seen by a back specialist he had been to in the past when he had back issue. He stated the facility was supposed to be making an appointment with the specialist and he has not received a date and time of appointment yet either. A review of the clinical record revealed that the physician wrote the following orders that read: 7/31/23 - Refer to [facility name redacted] clinic for neuropathy and back pain. 8/10/23 - Refer to [psych services name redacted] On the afternoon 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 interviews, clinical record review and facility documentation review, the facility staff failed to ensure 1 of 64 residents (Resident #87) had an accurate medical record for an advanced directive. The finding included: Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of [DATE] coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. Resident #87's person-centered comprehensive care plan revised on [DATE] documented the resident is a Full Code. The goal set for the resident by the staff was that the resident's code status will be honored through the next review date of [DATE]. The interventions/approaches the staff would use to accomplish this goal is for the resident's code status to be reviewed and updated as needed. A review of Resident #87's Physician Order Sheet (POS) for [DATE] revealed the following order: Cardiopulmonary resuscitation (CPR)…

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

Based on observation, Resident interview, staff interview and facility documentation review, the facility staff failed to maintain a homelike environment for one Resident (Resident #32) in a survey sample of 64 Residents. The finding included: For Resident #32, the facility staff failed to provide a homelike environment as evidenced by multiple ceiling tiles in his room were discolored and one in the bathroom was off the track, and appeared as though it may fall. On 8/22/23, in the late morning, during a Resident interview, Resident #32 told the surveyor to look at the ceiling tiles. He pointed out how multiple tiles were stained and said they had been like that for several weeks. Resident #32 said, I've told them for 3 weeks, but it goes in one ear and out the other. The resident then asked the surveyor to look in the bathroom. A ceiling tile in the bathroom was noted to be off the track and appeared as though it could fall. Resident #32 said, It's going to fall, I've told them, they do nothing. On 8/22/23, before going to lunch, Surveyor C shared the above findings with 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 2. For Resident #98 the facility failed to accurately assess Resident #98 in the MDS (Minimum Data Set) with an ARD (assessment reference date of 8/2/23. On 8/23/98 at approximately 9:58 AM Resident #98 was observed sitting in his wheelchair watching the TV. Resident #98 was asked about his mobility, and he stated I cannot feel my legs other than the spasms I get from my back to my legs and then from the legs down with the neuropathy pain too. When asked if he could safely transfer on and off the toilet he stated, I manage ok, some days I need more. When asked if he could walk unassisted, he stated that he could not. The Resident stated that anything involving the legs down he needed assistance with. When asked does he get the assistance he needs when he requests it, he stated that he needs help with shower because if he bends over to wash his feet, he will fall out of the shower chair. A review of the MDS dated [DATE] Section G-0110 ADL (Activities of Daily Living) Assistance: B. Transfer- Resident 98 was coded…

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

Based on facility staff interviews, clinical record review and facility documentation review, the facility staff failed to incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care planning for one Resident (Resident #10) in a survey sample of 64 Residents. The findings included: For Resident #10, who had a level II PASARR, the facility staff were unaware until requested by the survey team, that the Resident had a level II screening and failed to incorporate the recommendations into the Resident's assessment and care planning. On 8/22/23-8/23/23, a clinical record review was conducted of Resident #10's electronic health record. Surveyor C was unable to find a PASARR. The care plan did not address a PASARR or any recommendations. On 8/24/23, the facility Administration was asked to provide the PASARR for Resident #10. On 08/24/23 at 02:19 PM, the Director of Nursing (DON) provided Surveyor C with a copy of the Level I PASARR for Resident #10. The level 1 PASARR indicated a level II was needed. On 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 record review, interview and facility policy review, the facility failed to ensure one of seven residents (Resident (R) 91) reviewed for Preadmission Screening and Resident Review (PASARR) had a Level One PASARR completed prior to admission. This failure had the potential for R91 to not receive services necessary for mental health and psychosocial well-being. Findings include: Review of R91's hard (paper) chart and EMR record (tabs labeled Assessments, Progress Notes, and Misc [Miscellaneous]) showed no PASARR screening documentation. On 08/23/23 at 5:30 PM, the Director of Nursing (DON) was asked to provide R91's PASARR documentation. During an interview on 08/24/23 at 1:24 PM, the DON stated R91 did not have a PASARR. When asked to clarify if that was a PASARR level I or level II, the DON responded, There is no PASARR period. In an interview on 08/24/23 at 2:00 PM, the Social Services Director (SSD) also confirmed R91 did not have a PASARR. In a follow-up interview on 08/24/23 at 3:15 PM, the DON was asked if it was her expectation that all residents have a PASARR prior…

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 record review, the facility staff failed to follow physician orders for the application of ace wraps to the bilateral lower extremities. The findings include Resident #87 was originally admitted to the nursing facility on 01/24/23. Diagnosis for Resident #87 included but not limited to lymphedema. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #87 total dependent of two with bathing, extensive assistance of two with bed mobility, extensive assistance of one with transfer, dressing, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. Resident #87's person-centered care plan with a revision date of 05/11/23 documented resident with impaired circulation related to lymphedema. The goal set for the resident by the staff was that the resident will be free from…

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

Based on Resident interview, facility staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that Residents were free from accident hazards, affecting one Resident (Resident #29) in a survey sample of 64 Residents. The findings included: For Resident #29, who went to an off-site dialysis clinic three days per week, the Resident was unable to gain entry to the facility for extended periods of time upon her return, resulting in her being left to sit outside, alone and at times in the dark. On 08/23/23 at 10:39 AM, during an interview with Resident #29, the Resident verbalized that frequently she waits 30 minutes or more when she arrives back at the facility at night because the facility staff won't answer the phone or doorbell. Resident #29 reported it is usually around 8:30-9 PM or later when she returns from dialysis, three days a week. The Resident said, she uses her cell phone and will call the facility before they ever arrive back at the facility, but facility staff do not answer the phone. Then, once she arrives, she and/or…

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

Based on observation, interview, record review, and facility documentation review, the facility staff failed to A) coordinate services to ensure she arrived at dialysis timely and B) provide meals and snacks for one (Resident #29) in a survey sample of 64 Residents. Findings include: For Resident #29, who received dialysis treatments at an outside dialysis center, the facility staff failed to A) coordinate transportation so that she would be at dialysis on-time to receive her full session and B) failed to send a meal and snacks with the Resident to accommodate her while she was out of the facility. On 08/23/23 at 10:39 AM, an interview was conducted with Resident #29. Resident #29 reported that she goes to dialysis three days per week on Monday, Wednesday, and Fridays. Resident #20 said she is scheduled to leave the facility at 3 PM and doesn't return until usually 8:30-9 PM, at night. The Resident said they do not send any food or snacks with her; they just save the evening meal tray for when she returns. The Resident went on to say that she is late often, and her treatments have…

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

Based on staff interview and facility documentation review, the facility staff failed to perform annual performance reviews for 2 (CNA's) Certified Nursing Assistants (CNA B, and CNA C) to provide regular education based upon the review outcome. The findings included: On 8-24-23 at 5:00 p.m., the Administrator was notified that the annual reviews for CNA (B), and CNA (C) had not been completed for the employees as per regulation. On 8-25-23 at 3:00 p.m., the Human Resources Director stated no reviews could be found for the employees. At approximately 5:00 p.m. the Administrator stated they had no further information to provide. No further information was provided by the facility staff.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure a resident who diagnosed with mental disorder or a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment for 1 Resident (#98) in a survey sample of 64 Residents. The findings included: For Resident #98, the facility staff failed to assess and provide mental health services for a Resident who was admitted with a diagnosis of PTSD (Post Traumatic Stress Disorder). On 8/23/23 at approximately 9:58 an interview was conducted with Resident #98 who stated that he feels that some staff and Residents in the facility are intimidated by his appearance and shy away from him. He stated that he felt that there was only 1 or 2 staff members he could trust. On 8/23/23 at approximately 9:58 an interview was conducted with Resident #98 who discussed his diagnosis of PTSD (Post Traumatic Stress Disorder). Resident #98 stated that he had been institutionalized for many years and he does not relate well to the staff and Residents. When asked if he 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.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 64 residents (#34 and #85) in the survey sample were free of significant medication errors. The findings included: 1. For Resident # 34 the facility staff failed to discontinue the order for Metoprolol 50 mg (blood pressure medication) daily, when the order was increased to 100 mg every day, thus Resident #34 was given 150 mg of Metoprolol instead of 100 mg on two occasions. On 8/24/23 a review of the clinical record revealed that Resident #34 had the following orders for Metoprolol: Metoprolol 50 mg. Give 1 Tablet two times per day for HTN [Hypertension]. HOLD for SBP [Systolic Blood Pressure] of 100 or pulse below 60. On 8/22/23 at 2:48 PM the following orders were put in the system: 8/22/2023 2:48 PM-Note Text: Resident received new orders for increase metoprolol to 100mg BID, give metoprolol 50mg one time r/t elevated blood pressure, start Lasix 20mg daily for edema. On 8/23/23 at approximately 10:00 AM a review of the clinical record revealed the following…

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

Based on observation, Resident interview, staff interview and facility documentation review, the facility staff failed to provide beverages in accordance with Resident's preferences for one Resident (Resident #85) in a survey sample of 64 Residents. The findings included: For Resident #85, the facility staff failed to provide coffee with meals as per her preference. On 8/23/23 at approximately 12:45 PM, during an interview with Resident #85, the Resident said, I really miss my coffee, I don't like juice. I want milk, especially with breakfast. Resident #85's lunch tray was in the room and observations revealed that there was a cup of juice on the tray, no coffee or milk was noted. Review of the meal/tray ticket on the lunch tray indicated Resident #85 was to have Whole Milk- 8 oz and Hot Coffee or Hot Tea- 6 oz. On 8/23/23, a clinical record review of Resident #85's chart was conducted. This review revealed a care plan that Resident #85 is at nutritional risk due to diagnose of cardiovascular disease [sic]/HTN [hypertension] and diabetes . Interventions for this care plan focus area…

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

Based on observation, interview, and record review, the facility failed to ensure all staff followed neutropenic precautions for one of one resident (Resident (R)163) by not donning personal protective equipment (PPE) prior to entering the R163's room. This failure had the potential of exposing R163 to an infectious disease. Findings include: Review of R163's Electronic Medical Record (EMR) under the Face Sheet tab indicated R163 was admitted to the facility with the diagnoses myelodysplastic syndrome, acute and chronic respiratory failure, sever sepsis, heart disease, spinal stenosis, and acute embolism and thrombosis of deep veins of lower extremities. During an observation on 08/24/23 at 10:00 AM, R163 was located in a private room on the first floor of the facility. There were two signs placed on R163's door stating, STOP Neutropenic Precautions (In addition to standard precautions) Visitors, Staff, and Physicians Mask for all room entry if recovering from a respiratory illness. Visitors ask nursing for mask instructions. When you enter and each time you leave the room you must…

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 medical record review and interview the facility failed to ensure all residents received or were offered an influenza and pneumococcal vaccinations for two (Resident (R) 80 and R97) out of five sampled residents. Findings include: 1. Review of R80's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R80 was admitted to the facility on [DATE]. Review of R80's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/16/23 , located under the Resident Assessment Instrument(RAI) tab indicated R80 was independent with bed mobility, toileting, dressing, and transfers. The MDS showed Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R80 was severely cognitively impaired. Review of R80's EMR under the Vaccination tab indicated R80 had not received or been offered a pneumococcal vaccination since his admission to the facility. 2. Review of R97's Face Sheet located under the Profile tab of the electronic medical record (EMR)…

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 and facility staff interviews, the facility staff failed to maintain equipment in a safe operating condition for one Resident (Resident #82 ) in a survey sample of 64 Residents. The findings included: For Resident #82 the facility staff failed to maintain his wheelchair, it had no arm rests and then several days later wash clothes were wrapped on the frame and taped to provide a barrier from the wheelchair frame and the Resident's arm. On 08/22/23 at 02:49 PM, during an interview with Resident #82, the Resident reported that he needed a new wheelchair because what he has been provided is not comfortable. Observations of the wheel chair revealed the chair had no arm rests and it was just bare metal for the Resident to rests his arms on. On 8/25/23, observations were made of Resident #82's wheelchair at the bedside. It was observed that washcloths had been put over the metal where arm rests would go and were taped with a medical tape. The Resident reported facility staff had done this but the Resident was not able to identify who had done this.…

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

Based on interview, observation, record review, and facility policy review, the facility failed to ensure two of a sample of 64 residents (Resident (R) 27 and R81) were provided with a functional call light for use when assistance could be needed. This failure had the potential to adversely affect the timeliness of care or response time in case of an urgent or emergent need. Findings include: 1. Review of R27's Order Summary Report from the electronic medical record (EMR) Orders tab showed diagnoses that included blindness, hemiplegia and hemiparesis (paralysis) following a cerebral infarction (stroke). Observation of R27's call light on 08/23/23 at 3:10 PM, showed after being pushed, no light appeared on the wall unit or above the door. During an observation of R27's call light on 08/23/23 at 3:22 PM with Licensed Practical Nurse (LPN) H she confirmed R27 had no call light function at all, but that he could call out. LPN H continued to explain that R27 did not usually use the call light but usually waits until he hears someone in the room and then ask for what he needs. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure five of 49 sampled residents; Resident #62, #40, #72, #86, and 1 closed record resident; Resident #191, who were unable to carry out Activities of Daily Living (ADLs) received showers. The findings included: 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included but were not limited to stroke, atrial fibrillation, heart failure, diabetes mellitus, and renal insufficiency. Resident #62's most recent Minimum Data Set (MDS) assessment was an admission assessment with an assessment reference date (ARD) of 7/14/21. Resident #62 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the Brief Interview For Mental Status (BIMS) exam. Resident #62 was coded as requiring total dependence on two plus persons with transfers and bathing. On 8/31/21 at 2:03 p.m., an interview was conducted with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure that 1 of 44 residents (Resident #32) in the survey sample was provided ongoing resident centered activity services based on the resident's activity preferences from May through August of 2021. The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, Major Depressive Disorder and Anxiety Disorder. Resident #32's most recent comprehensive Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 4/21/21. The Brief Interview for Mental Status (BIMS) was coded as a 15 out of a possible 15 indicating Resident #32 was cognitively intact and capable of daily decision making. Under Section F Preferences for Customary Routine and Activities, F0500 Interview for Activity Preferences Resident #32 was coded as follows: While you are in the facility .B. how important is it to you to listen 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 resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to maintain a complete and accurate clinical record for four of 49 sampled residents, Resident #18, #1, #391 and #90. The findings included: 1. For Resident #18, facility staff failed to obtain all after visit summaries from her outside pain management provider and file them in her clinical record. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to anemia, coronary artery disease, diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD) and hyperlipemia. Resident #18's most recent Minimum Data Set (MDS) Assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 6/25/21. Resident #18 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status Exam (BIMS). On 8/31/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure access to resident funds for one of 49 sampled residents; Resident #49. The findings included: On 8/31/21 at approximately 4:30 p.m., an interview was conducted with Resident #18 (another sampled resident). Resident #18 stated that other residents had come to her crying because they did not have access to their resident fund account. Resident #18 stated that their 30 dollars that they are supposed to receive every month was not available or able to be accessed. Resident #18 stated that even though she did not have a resident fund account, she brought this concern to the attention of the facility administrator. Resident #18 stated that she was told by the facility administrator that the facility had used the residents' monies to pay for overhead things such as a printer and ink etc. Resident #18 stated that she heard that the facility's corporate card 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 Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure that the care plan or care plan goals were sent with two of 49 sampled residents at the time of an acute care transfer for Resident #62 and #18. The findings included: 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included but were not limited to stroke, atrial fibrillation, heart failure, diabetes mellitus, and renal insufficiency. Resident #62's most recent Minimum Data Set (MDS) assessment was an admission assessment with an assessment reference date (ARD) of 7/14/21. Resident #62 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the Brief Interview For Mental Status (BIMS) exam. Review of Resident #62's clinical record revealed that she had been sent out to the hospital on 8/2/21. The following nursing note was documented on 8/2/21: When resident returned from dialysis resident (sic) appeared to have…

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, clinical record review, staff interviews and facility document review the facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) was conducted prior to admission or within 30 days of admission to the nursing facility for 1 of 44 residents in the survey sample, Resident #23 with diagnoses of mental disorders. The finding included: Resident #23 was admitted to the nursing facility on 5/10/13 with diagnoses that included Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. Resident #23's most recent Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 6/30/21. The Brief Interview for Mental Status (BIMS) was coded as a 14 out of a possible 15, indicating Resident #23 was cognitively intact and capable of daily decision making. Under Section A1500 Preadmission Screening and Resident Review (PASARR): Is the resident currently considered by the state level II PASRR process to have mental illness and/or intellectual disability or a related condition? Resident #23 was coded:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure an accurate oxygen therapy care plan for one of 49 sampled residents; Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic respiratory failure with hypoxia (1), alcoholic cirrhosis of the liver with out ascites, anemia, chronic diastolic heart failure, and generalized edema. Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of 8/24/21. Resident #1 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam. Resident #1 was coded in Section O (Special Treatments, Procedures and Programs) as receiving oxygen therapy. Review of Resident #1's clinical record revealed the following oxygen orders: 1) Oxygen at 3 lpm (liters per…

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, resident interviews, staff interviews, and clinical record reviews, the facility's staff failed to ensure care and services were provided to meet professional standards of quality for 2 residents (Resident #30 and Resident #1) in the survey sample. The facility staff failed to obtain a physician's order prior to use of a seat belt for Resident #30, and to obtain daily weights as ordered by the physician for Resident #1. The findings included: 1. Resident #30 was originally admitted to the facility 7/1/21 and has not been discharged from the facility since this admission. The current diagnoses included; cerebral palsy with spastic hemiplegia and bilateral impairment of the upper and lower extremities. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/12/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #30's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to clarify orders for the use of oxygen AND failed to follow oxygen orders for one of 49 residents in the survey sample, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic respiratory failure with hypoxia (1), alcoholic cirrhosis of the liver with out ascites, anemia, chronic diastolic heart failure, and generalized edema. Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of 8/24/21. Resident #1 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam. Resident #1 was coded in Section O (Special Treatments, Procedures and Programs) as receiving oxygen therapy. Review of Resident #1's clinical record revealed the following oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to coordinate care with the dialysis center for one of 49 sampled residents; Resident #62. The findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses that included but were not limited to stroke, atrial fibrillation, heart failure, diabetes mellitus, and renal insufficiency requiring hemodialysis (1). Resident #62's most recent Minimum Data Set (MDS) assessment was an admission assessment with an assessment reference date (ARD) of 7/14/21. Resident #62 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the Brief Interview For Mental Status (BIMS) exam. Review of Resident #62's August 2021 Physician Order Summary (POS) documented the following order: Dialysis - M,W,F .chair time 6 a.m. Review of Resident #62's care plan dated 7/27/21 documented in part, the following: (Name of Resident #62) needs hemodialysis r/t…

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

Based on resident interview, staff interview, and facility document review it was determined that the facility staff failed to ensure nurses were competent in calibrating their recently acquired Blood Glucose Monitoring System (1) (glucose meter) per policy and manufacturers recommendations. The findings included: On 8/31/21 at approximately 4:30 p.m., an interview was conducted with Resident #18, a current sampled resident. Resident #18 had stated that the glucometer machines were cheap and not accurate. Resident #18 stated that approximately one month ago, a nurse was taking her blood sugar reading (2) when it read at a level of 200 (milligrams per deciliter (mg/dL). Resident #18 stated that she did not eat that much that day and her blood sugar never ran that high. Resident #18 asked the nurse to go get a different glucometer (glucose meter). Resident #18 stated that her second reading with the new glucometer read at a level of 97 mg/dL. Resident #18 could not recall the day or the nurse who had obtained her blood sugar levels. Resident #18 stated that she asked the nurse how…

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, record review and staff interviews, the facility staff failed to procure medications (hydrocortisone cream and scheduled topical pain relief medication) timely for one resident (Resident #23) in a survey sample of 49 residents. The findings included: Resident #23 was admitted to the facility on [DATE] and never discharged from the facility. Diagnosis for Resident #23 included but not limited to; Major Depressive Disorder and Anxiety Disorder. The current Minimum Data Set (MDS), an Annual assessment with an Assessment Reference Date (ARD) of 06/30/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15 indicating resident is cognitively intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility. Requiring extensive assistance of one person with dressing, toilet use and personal hygiene. Requiring limited assistance of one person with eating. Requiring total…

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 during medication pour and pass, staff interviews, and clinical record review, the facility's staff failed to ensure a resident didn't experience a significant medication error (blood sugar orders were duplicated and insulin was administered outside of parameters, too close to the next possible dose) for 1 of 44 residents (Resident #10), in the survey sample. The findings included: Resident #10 was originally admitted to the facility 10/13/16 and had never been discharged from the facility. The current diagnoses included; dementia and diabetes. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/9/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bathing, limited assistance of one person with dressing, supervision of one person with…

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

Based on general observations, staff, resident and group interview, the facility staff failed to ensure the resident who have authorized the facility to manage their personal funds have ready and reasonable access to those funds. The findings include: On 3/21/19 at 11:30 a.m. a group interview was conducted with seven residents that represented the facility's units. When the standard group question was asked if they had access to their money seven days a week, it was a consensus of the group that responded they had access and knew they could get money Monday through Friday from 10:00 am to 2:00 p.m., but not on the weekends. The group stated they knew by word of mouth that 10:00 a.m. to 2:00 p.m. Monday through Friday were the only banking hours. The posting of the banking hours for the residents was located in the front lobby on a table sitting up in a 8 x 10 Plexiglas frame that read Banking Hours Monday through Friday 10:00 a.m.-2:00 p.m. Saturday and Sunday request by 10:00 a.m. Resident #86 stated, I am barely up and finished breakfast before I can request money by 10:00 a.m.…

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 facility document review, it was determined that facility staff failed to implement abuse policies and report an allegation of abuse to the appropriate state agencies for one of 38 residents in the survey sample, Resident #75. For Resident #75, facility staff failed to implement abuse policies and report an allegation of verbal abuse reported to the administrator on 3/20/19 to the appropriate state agencies. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia without behavioral disturbance, depressive disorder, diabetes mellitus, seizures, and muscle weakness. Resident #75's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 9/11/18. Resident #75 was coded as being moderately impaired in cognitive function scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #75…

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 facility document review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for one of 38 residents in the survey sample, Resident #75. For Resident #75, facility staff failed to report an allegation of verbal abuse reported to the administrator on 3/20/19 to the appropriate state agencies. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, depressive disorder, diabetes mellitus, seizures, and muscle weakness. Resident #75's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 9/11/18. Resident #75 was coded as being moderately impaired in cognitive function scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #75 was coded in section G (Functional Status) as needing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to evidence that all the required information was provided to the receiving provider for a facility-initiated transfer for 3 of 38 residents in the survey sample; Resident #82, #60, and #28. 1. For Resident #82, facility staff failed to send care plan goals at the time of a facility-initiated transfer to the hospital on 2/26/19. 2. The facility staff failed to ensure that Resident #60's Plan of Care Summary Goals were sent upon discharge to the hospital on [DATE], 2/6/18, and 3/2/19. 3. The facility staff failed to convey Resident #28's Individual Plan of Care summary upon discharge to the local acute care hospital on [DATE] The findings include: 1. Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, anemia, high blood pressure, alcoholic cirrhosis, and oral (mouth) cancer. Resident #82's most recent 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 issue bed-hold notices and policy at the time of discharge for 1 of 38 residents (Resident #28) in the survey sample. The facility's staff failed to provide written information to the resident or resident representative which specifies the duration of the bed-hold policy upon transfer to the local acute care hospital on [DATE] for Resident #28. The findings included: Resident #28 was originally admitted to the facility 7/29/16, and was readmitted to the facility 12/28/18, after an acute care hospital stay. The current diagnoses included; diabetes, chronic kidney disease and malnourishment. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated Resident #28's daily decision making abilities were intact. In section G (Physical functioning) 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 clinical record review, staff interview and review of the facility's policy, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 38 residents (Residents #21), in the survey sample. The facility staff failed to accurately code Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE], at section N0350 (Insulin Injections). The findings included; Resident #21 was originally admitted to the facility 2/1/11 and was readmitted to the facility 10/4/18, after an acute care hospital stay. The current diagnoses included; diabetes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/8/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 1 out of 15. This indicated Resident #21's daily decision making abilities were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care two people with transfers, personal hygiene, bathing, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to review and revise the care plan for one of 38 residents in the survey sample, Resident #98. For Resident #98, facility staff failed to revise the care plan when his code status changed to DNR (Do Not Resuscitate) and was ordered for comfort care measures. The findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscle weakness, hypoxic ischemic encephalopathy (1), fractured femur and pelvis post motor vehicle accident, and psychosis. Resident #98's most recent comprehensive MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/10/18. Resident #98 was coded as being severely impaired in cognitive function scoring 00 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #98 passed away in the facility on 12/22/18. Review of Resident #98'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.

Based on observations, resident interview, clinical record review, and staff interviews, the facility staff failed to ensure residents received necessary foot care to maintain good foot health, for 1 of 38 residents (Residents #76), in the survey sample. The facility staff failed to ensure Resident #76's toe nails were not overgrown, thick and discolored. The findings included: Resident #76 was originally admitted to the facility 11/30/18 and has never been discharged from the facility. The current diagnoses included; stroke, hemiparesis venous insufficiency and diabetes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/26/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated Resident #76's daily decision making abilities were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility and transfers, extensive assistance of one person with 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.

Based on observation and staff interview it was determined that facility staff failed to dispose garbage and refuse properly for one of three facility dumpsters, the third facility dumpster. Facility staff failed to ensure one of three facility dumpsters was free from surrounding debris. The findings include: On 3/22/19 at 11:15 a.m., an observation of the facility dumpster area, located outside the building behind the kitchen, was conducted with OSM (other staff member) #4, the Dietary Manager. Three used gloves were observed on the ground in close proximity to the third facility dumpster. OSM #4 was then asked which department was responsible for ensuring the dumpster area was clean. OSM #4 stated that it was a shared responsibility between dietary and the environmental department. When asked how long the gloves were on the ground, OSM #4 stated that he was not sure but that he did not want his staff picking up the gloves with their bare hands. OSM #4 stated that the environmental department had a device they used to clean up debris (gloves) around the dumpsters. When asked how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and clinical record review the facility staff failed to ensure infection control measures were utilized to prevent the spread of infections, illnesses and diseases for 1 of 38 residents in the survey sample, Resident #51. Licensed Practical Nurse (LPN) #6 failed to don (to put on) gloves and gown (PPE/Personal Protective Equipment) before entering a contact precaution room and failed to perform proper hand hygiene after completing wound care on Resident #51. The findings included: Resident #51 was originally admitted to the facility on [DATE], discharged from the facility to an acute hospital on [DATE] and returned to the facility on [DATE]. The current diagnoses included; cancer, hypertension, thyroid disorder, seizure disorder, depression and (VRE) Vancomycin Resistant Enterococcus. The Quarterly Review Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/12/19 coded Resident # 51's cognitive abilities for daily decision making as moderately…

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.