Salem Health & Rehabilitation

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the medical provider's orders for 1 of 10 sampled residents (Resident #10). The findings included: For Resident #10, the facility staff administered Vitamin D3 10 mcg instead of the provider ordered Vitamin D 50 mcg. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Osteoarthritis of Knees and Right Shoulder, Congestive Heart Failure, and Moderate Protein-Calorie Malnutrition. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 2/26/25 at 8:33 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #10's medications. The administered medications included a Vitamin D3 10 mcg tablet. A review of Resident #10's medical provider orders revealed no order for Vitamin D3; however, the resident did have an order for…

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, the facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment and help prevent the development and transmission of infections for 1 of 10 residents (Resident #10). The findings included: For Resident #10, the nurse dropped an oral medication tablet on top of the medication cart and then administered the medication to the resident. On 2/26/25 at 8:37 AM during a medication pass and pour observation, surveyor observed Licensed Practical Nurse (LPN) #2 remove a Finasteride 5 mg tablet from a blister pack and the tablet inadvertently landed directly on top of the medication cart. LPN #2 donned a glove and picked up the tablet from the medication cart and placed it in the medication cup along with the resident's other medications. LPN #2 then administered the medications, including the Finasteride to Resident #10. On 2/26/25 at 1:45 PM, the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff…

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, interviews, and the review of documents, the facility staff failed to ensure menus were followed for two (2) of approximately 11 - 13 resident tray carts (each tray cart was used to transport multiple residents' trays to nursing units); this observation occurred for the lunch meal on 5/30/24. (The dietary staff members working on the food service line during the lunch meal on 5/30/24 indicated the last two (2) resident tray carts were the smallest carts to be sent out; the dietary staff members indicated each cart contained trays for approximately 20 residents.) The findings include: The facility staff failed to ensure all residents had the opportunity to receive the schedule menu items for the lunch meal on 5/30/24. The facility staff ran out of two (2) menu items prior to all the residents receiving their meals. The facility staff ran out of the pork loin with garlic and fresh herbs and the facility staff ran out of the roasted red potatoes. On the afternoon of 5/30/24, the facility's food service staff were observed to be preparing trays to be sent 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 observation facility staff failed to ensure hand rails were intact on 4 of 4 nursing units. During initial tour and throughout the course of the facility, surveyors observed residents utilizing hand rails for stabilization while ambulating and as an anchor to pull themselves down the halls while in wheelchairs. On 6/3/24, the surveyor checked handrails throughout the building and found a number of missing handrail segments or end caps which left sharp edges exposed posing a risk of injury: On the front hallway, there were no end caps between the elevator and dining room and no end cap or corner segment by the ladies' restroom. On Unit 1, a segment of the hand rail was missing near the door to the unit manager's office. End caps were missing by rooms 14, 17, 23, 25, and 26. On unit 2, the rail by the pantry was missing an end cap. On Unit 3, end caps were missing by the MDS office and room [ROOM NUMBER]. On 6/3/24, the administrator, director of nursing, MDS corporate consultant, regional nurse…

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 screen for a mental disorder or intellectual disability prior to admission for 1 of 38 sampled residents. Resident #154. The findings include: For Resident #154 (R154), the facility staff failed to obtain a Level I Screening for Mental Illness, Intellectual Disability (ID), or Related Conditions, to determine if the resident had or may have had a MD (Mental Disorder), ID, or related condition prior to admission. R154's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Legal Blindness, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Parkinson's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/27/24, 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. On 5/30/24, during the clinical record review, surveyor could not locate a PASARR (Preadmission…

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 follow the medical provider orders for 2 of 38 sampled residents (Residents #84 and #160). The findings included: 1. For Resident #84, the facility staff failed to follow the recommendations of the orthopedic specialist for compression stockings. Resident #84's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Asthma, Chronic Kidney Disease Stage 3, Heart Failure, Paroxysmal Atrial Fibrillation, and Displaced Bicondylar Fracture of Left Tibia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 5/30/24 at 3:20 PM, surveyor spoke with Resident #84 who complained of swelling in their feet stating it was painful while participating in physical therapy. The resident removed their left sock revealing a large amount 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.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident who is fed by enteral means receives the appropriate provider ordered hydration for 1 of 4 sampled residents dependent on enteral feeding (Resident #160). The findings included: For Resident #160, the facility staff failed to provide water flushes as ordered on seven (7) separate occasions during the month of May 2024. Resident #160's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Vascular Dementia, Dysphagia, Heart Failure, Cerebral Infarction, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #160 was coded for the presence of a feeding tube in which they received 501 cc/day or more of average fluid intake. Resident #160's current…

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 ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications for 1 of 4 sampled residents dependent on enteral feeding (Resident #384). The findings included: For Resident #384, the facility staff failed to follow the medical provider orders for enteral feeding. Resident #384's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Malignant Neoplasm of Brain, Malignant Neoplasm of Lung, Pneumonitis, Dysphagia, Cerebral Edema, and Seizures. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/28/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #384 was coded for the presence of a feeding tube. Resident #384's current comprehensive person-centered care plan included a focus area stating, the resident is at risk for complications related to the need for an enteral tube feeding…

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 respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 38 sampled residents (Resident #84). The findings included: For Resident #84, the facility staff failed to administer supplemental oxygen as ordered by the provider. Resident #84's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Asthma, Chronic Kidney Disease Stage 3, Heart Failure, Paroxysmal Atrial Fibrillation, and Displaced Bicondylar Fracture of Left Tibia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #84's comprehensive person-centered care plan included a focus area stating, the resident is at risk for respiratory complications secondary to respiratory failure with an intervention to administer…

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

2. The facility staff failed to document detailed assessments: (a) when Resident #185 experienced a fall on 10/27/23 which resulted in a medical provider ordering left leg and left hip x-rays and (b) when Resident #185 was provided pain medications which were ordered to be administered as needed. Resident #185's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/17/23, was signed as completed on 10/18/23. Resident #185 was assessed as able to make self understood and as able to understand others. Resident #185's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact and/or borderline cognition. Resident #185's clinical record included a Fall Note with an effective date of 10/27/23 at 7:11 p.m. This Fall Note indicated a left hip x-ray and a left leg x-ray were ordered. No documentation was found to indicate what change in the resident's condition/assessment resulted in the medical provider ordering the left leg and left hip x-rays. Resident #185's clinical record indicated the resident was…

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

2. For Resident #160, the facility staff failed to obtain a STAT CBC (complete blood count) and BMP (basic metabolic panel) and failed to perform flu and COVID-19 testing timely. Resident #160's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Vascular Dementia, Dysphagia, Cerebral Infarction, Heart Failure, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. A review of Resident #160's clinical record revealed a telehealth evaluation progress note dated 4/14/24 4:24 PM CT which read in part .resident seen at the request of nursing for T [temperature] +100.4 F .Currently on 4 L [liters] O2 [oxygen] (chronically) O2 sat [oxygen saturation] 86% .STAT BMP and CBC ordered .Suspect underlying developing aspiration pneumonia . A provider order dated 4/14/24 at 4:24 PM was received for a STAT BMP and…

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

2. The facility staff failed to timely obtain Resident #185's medical provider ordered left leg x-ray and left hip x-ray. Resident #185's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/17/23, was signed as completed on 10/18/23. Resident #185 was assessed as able to make self understood and as able to understand others. Resident #185's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact and/or borderline cognition. Resident #185's clinical record included a Fall Note with an effective date of 10/27/23 at 7:11 p.m. This Fall Note indicated a left hip x-ray and a left leg x-ray were ordered. No documentation was found to indicate what change in the resident's condition/assessment resulted in the medical provider ordering the left leg and left hip x-rays. No evidence was found of Resident #185's x-rays being obtained until 10/30/23. On 6/3/24 at 12:08 p.m., the facility's Medical Director was interviewed via telephone. The Medical Director reported that ideally radiology reports would be…

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

3. For Resident #31, facility staff failed to accurately document medication administration for the 9:00 p.m. doses on 05/12/24 and 05/17/24. Resident #31's admission Record listed diagnoses which included but were not limited to, metabolic encephalopathy (an underlying condition affecting metabolism), osteoarthritis, anxiety, depression, hypertension, chronic peripheral venous insufficiency, and congestive heart failure. The most recent annual minimum data set (MDS) with an assessment reference date of 05/01/24 assigned the resident a brief interview for mental status summary score a 15 out of 15. Resident #31's medication administration record for May 2024 was reviewed. There was no documentation for the 9:00 p.m. dose for seven medications on two dates, 05/12/24 and 05/17/24. The medications were: 1. Atorvastatin 20mg one tablet for hyperlipidemia, 2. Gabapentin 100mg two tablets for pain, 3. Melatonin 5mg for insomnia, 4. Mirtazapine 45mg one tablet for depression, 5. Carvedilol 25mg one tablet for hypertension, 6. Mycophenolate 500mg one tablet for DMARD (Disease-Modifying…

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 maintain an infection prevention and control program designed to help prevent transmission of communicable diseases and infections for 1 of 38 sampled residents (Resident #90). The findings included: For Resident #90, facility staff failed to don the required personal protective equipment (PPE) prior to entering the resident's room. Resident #90 was on transmission-based precautions due to ESBL (extended spectrum beta-lactamase) present in the urine. Resident #90's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Borderline Personality Disorder, Chronic Kidney Disease, and Retention of Urine. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/08/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. On 5/29/24 at 3:15 PM, surveyor observed a posted contact precautions sign, and a caddy of PPE…

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 offer a pneumococcal immunization in accordance with nationally recognized standards for 1 of 5 sampled residents reviewed for immunizations, Resident #90. The findings included: For Resident #90, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine (PPSV23) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 9/22/23, read in part, that adults 65 years or older who have received a PCV13 (pneumococcal conjugate vaccine 13) at any age and a PPSV23 under [AGE] years old, should receive a PCV20 or PPSV23. Resident #90's diagnosis list indicated diagnoses, which included, but not limited to Type 2 (two) Diabetes Mellitus, Chronic Kidney Disease and Asthma. The most recent minimum data set…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment in accordance with the provider orders to promote pressure ulcer wound healing for 1 of 38 sampled residents (Resident #184). The findings included: For Resident #184, the facility staff failed to treat an unstageable/Stage 4 pressure ulcer to the mid back as ordered. Resident #184's diagnosis list indicated diagnoses, which included, but not limited to Sepsis due to Methicillin Susceptible Staphylococcus Aureus, Sacral Pressure Ulcer, Generalized Muscle Weakness, Osteoarthritis, and Macular Degeneration. The minimum data set (MDS) with an assessment reference date (ARD) of 11/11/23 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating Resident #184 was severely cognitively impaired. The resident was coded as having one unstageable pressure ulcer with slough and/or eschar present upon admission. Resident #184's comprehensive person-centered care plan included a focus area stating the resident has a skin…

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

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to properly sanitize items used for food preparation and serving, stacked wet pans together, and failed to discard an out of date food item. The findings included: The facility staff failed to properly prepare sanitizing rinse solution used following manual washing of items used to prepare and serve food on two separate occasions. The facility staff nested (stacked) wet pans together and failed to discard a container of apple cider vinegar with a best by date of 7/22/22. On 10/31/22 at 4:08 pm, during the initial tour of the facility kitchen, surveyor observed the three-section sink with the first section filled with soapy water, second section with clean water, and the third section with a clear liquid solution. The Dietary Manager (DM) verified the third sink contained the sanitizing rinse. There were no items in the sanitizing solution at the time 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.

Based on observation, staff interview, clinical record review facility staff failed to ensure the resident maintained acceptable nutrition status as evidenced by failure to assess the resident's condition on admission for one of 35 residents in the survey sample (Resident #175). Resident #175 was admitted to the facility with diagnoses including muscle weakness, unsteadiness on feet, unspecified fracture of occiput, subsequent encounter for fracture with routine healing, anemia, and dysphagia, oropharyngeal phase. On the minimum data set assessment with assessment reference date 10/19/2022, the resident scored 10/15 on the Brief Interview for Mental Status and was assessed as lacking signs of delirium, psychosis, or behaviors affecting care. Height 63 inches and weight 87 pounds with recent gain or loss unknown was documented. During initial tour on 10/31/2022, the surveyor observed the resident looked thin. The resident reported being well-fed and treated well by staff. Clinical record review revealed: The Malnutrition Universal Screening Tool (MUST) dated 10/17/2022 documented the…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 35 residents in the survey sample, Resident #53. The findings included: For Resident #53, the facility staff failed to document the treatment application of Z-paste to the resident's sacrum. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Paranoid Schizophrenia, Generalized Muscle Weakness, Alzheimer's Disease, and Transient Cerebral Ischemic Attack. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/26/22 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Resident #53's current physician's orders included an order dated 10/26/22 for Z-paste to the sacrum every shift for protection for two weeks. Resident #53's clinical record included an assessment entitled Skin Observation Tool -V2 dated 10/25/22 which documented in part Seen by (name…

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 and staff interview, facility staff failed to conduct initially a comprehensive, accurate, standardized reproducible assessment of the resident's functional capacity as evidenced by failure to reflect receipt of hospice care for 1 of 38 residents in the survey sample (Resident #216). Resident #216 was admitted to the facility for end of life care. Diagnoses included hypertension, diabetes mellitus, dysphagia, oropharyngeal stage, bacteremia, methicillin staphylococcus aureus infection, pulmonary hypertension, and spinal stenosis. On the Minimum Data Set assessment with assessment reference date 8/12/2019, the resident scored 3/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis. The resident was not coded as receiving hospice services. The resident was admitted for hospice per the admission assessment. The resident's pay source was Medicaid Hospice. The discharge planning admission assessment dated [DATE] documented intent to remain 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.

Based on resident interview, staff interview and clinical record review, facility staff failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan as evidenced by failure to administer medications per physician's order for 1 of 38 residents in the survey sample (Resident #61). The findings included: For Resident #61, the facility staff failed to administer Lexapro (antidepressant), Magnesium Oxide (mineral supplement), Nepro (nutritional supplement), Spiriva (bronchodilator), Multivitamin (vitamin and mineral supplement), Venlafaxine (antidepressant), Ferrous Sulfate (iron supplement), Hydralazine (antihypertensive) Metoprolol (beta blocker), Cranberry Juice Capsule (supplement), Gabapentin (anticonvulsant), Humalog (rapid acting insulin), and Renvela (phosphate binder) as ordered by the physician on 12/03/19 and 12/12/19. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Type 2 Diabetes Mellitus, Heart Failure, Chronic Obstructive Pulmonary Disease, Essential…

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

Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record evidenced by an inaccurate physician's order summary and electronic medication administration record for 1 of 38 residents, Resident #190. The findings included: For Resident #190 the facility staff failed to ensure the correct route of medication administration was included on the physician's order summary and elctronic medication administration record for the medications levofloxacin and quetiapine. Resident #190's diagnosis list contained diagnoses, including but not limited to acute and subacute endocarditis, subarachnoid hemorrhage, chronic obstructive pulmonary disease, alcohol abuse, and acute respiratory failure with hypoxia. Resident #190's admission MDS (minimum data set) with an ARD (assessment reference date) of 11/25/19 assigned the resident a BIMS (brief interview for mental status) score of 5 out 15 in section C, cognitive patterns. Section K, swallowing/nutritional status, coded the resident as having a feeding tube. Resident #190'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.