Thalia Gardens Rehabilitation And Nursing

Based on information obtained during the resident group meeting and a review of facility documents, the facility staff failed to ensure that 5 of 5 residents in the group meeting knew where the survey results binder was located without having to ask someone. The findings included:On 4/22/26 at 11:00 AM, a Resident Group meeting was held with the Resident Council President and four residents who regularly attend the group. There was consensus among all attendees that they were unaware they could review the survey book or even have access to it. No one could state where the book was located, and the president suggested that it must be behind the nurse's station. On 4/23/26 at 11:30 AM, an interview was conducted with the Director of Activities. The Activities director stated that the residents are educated in every resident council meeting on where to locate the survey results binder, and it was documented in the resident council minutes that they were provided with the information. No suggestions were offered on how the residents would be updated moving forward. On 4/28/26 at…

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

Based on a review of facility documents and staff interviews, the facility staff failed to thoroughly investigate prospective employees' histories before hiring.The findings included: A review of current and past employees hired over the last 2 years was conducted on 4/22/26. Eleven of 25 employee records are missing at least one of the following documents: the sworn statement, the state police criminal background search, or verification of a certificate or license. On 4/22/26 at 12:20 PM, an interview was conducted with the Human Resources Director. The HR Director stated that they had conducted an in-house audit of employee records, and they identified that specific documents were missing. The HR Director also stated that they had not taken action to correct the problem, nor had they referred the matter to the Quality Assurance committee. The HR Director stated that on 4/22/26, an employee was terminated before clocking in because, on the evening of 4/21/26, the sister facility had emailed the criminal background report indicating that the employee had barrier crimes. The HR…

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 interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure that one (1) resident (Resident #16) and their family members were able to attend their person-centered care plan meetings, and the facility staff failed to review and revise a care plan for one (1) resident (Resident #11) of 63 residents in the survey sample. The findings included: 1.The facility staff failed to invite resident #16 and her family member to care plan meetings. Resident #16 was originally admitted to the facility 4/30/24 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/13/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #16 cognitive abilities for daily…

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

Based on observation and staff interview, the facility staff failed to provide a resident environment free of accident hazards.The findings included: The facility staff failed to replace missing floor tiles in the kitchen, and replace a damaged dining room entry door which resulted in an accident hazard. On 4/21/26 at 11:30 AM during an observation tour of the kitchen, it was observed that floor tiles were missing on the floor when entering through the kitchen door. It was also observed that the missing tiles were placed on a pellet warmer next to the missing tiles. On 4/23/26 at 4:00 PM an interview was conducted with the Director of Maintenance. The Director of Maintenance stated that the floor tiles in the kitchen were removed a couple months ago. The Director of Maintenance also stated that due to the floor in the kitchen missing tiles, this could be an area that the staff could trip and fall. The Director of Maintenance further stated that this could be a hazard. On 4/21/26 at 11:45 AM during an observation tour of the dining room, it was observed that the entry door to the…

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

Based on observation, staff interview, resident interview and facility documentation, the facility staff failed to ensure staffing information was posted daily at the receptionist's desk and/or on three of three units in a prominent place and readily accessible to all residents, staff and visitors.The Findings included:During the initial tour of the facility on 04/21/2026, there was no observation of the daily posting of the nurse staffing information on the nursing units. There was no posting noted at the receptionist's desk.On 04/22/2026 (the second day of survey), no nurse staffing information was observed on the units nor at the receptionist's desk.On 04/22/2026 at 11:00 a.m., a group interview was conducted by another surveyor with five alert and oriented individuals. The surveyor reported that each resident stated that the residents did not know where to find information about the nurse staffing each day.On 04/22/2026 during rounds at 1:20 p.m., an interview was conducted with an alert resident sitting in the hallway who stated he did not know how to determine how many 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and Staff interview the facility staff failed to discard 2 bottles of expired insulin from 2 out of 3 medication carts. The findings included: On [DATE] at approximately 2:05 pm, a medication cart audit was conducted on the [NAME] unit, Front Hall medication Cart with Licensed Practical Nurse (LPN) #7. A bottle of Humulin R, 100 units of insulin, with an open date of [DATE]. LPN #7 said it should have been discarded after 28 days of opening.On [DATE] at approximately 2:27 pm, a medication cart audit was conducted on the Fine Unit, Cart #2, with LPN #8. Upon inspection, 1 bottle of Humulin R insulin with an open date of [DATE] was observed. LPN #8 said that it should have been discarded 28 days from the open date. LPN #8 also said that I have to get rid of it, it's no good.On [DATE] at 1:45 pm., a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Minimum Data Set Consultant. No further information…

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 ensure QAPI (Quality Assurance Performance Improvement) meetings were conducted quarterly for 3 of 4 quarters sampled.The Findings included:Throughout the survey conducted 04/21/2026 - 04/28/2026, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had failures and remained out of compliance in areas that had previously been cited as deficient during previous abbreviated surveys. The Maintenance logs and Pest control logs were reviewed by the survey team. There were issues identified.Review of the Resident Council minutes and Grievance logs revealed the facility's administration was aware of issues/concerns voiced by residents and families. The issues continued for several months without resolution.On 04/23/2026 at approximately 3:20 p.m., an interview was conducted with the Administrator who stated the facility was making improvements and renovations in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility's staff failed to have a functional emergency call system (Emergency Pull cord) available for a resident who ambulates to the bathroom frequently For 1 of 63 residents (Resident #16), in the survey Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/13/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated that Resident #16's cognitive abilities for daily decision-making were severely impaired.In section GG (Functional Abilities Goals), the resident was coded as requiring set-up or cleanup assistance with oral hygiene, upper- and lower-body dressing, and eating. The resident requires supervision or touching…

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 The facility staff failed to maintain an effective pest control program. Residents during the group meeting with the inspectors that represented all three nursing units, were in consensus that roaches were identified in their rooms.The findings included: On 4/22/26 at 11:00 AM, a Resident Council meeting was held with the President and four other residents who regularly attend the group meeting. All attendees agreed that the facility was not a safe, clean, comfortable, and homelike environment. 1. Resident #22 was admitted to the facility on [DATE]. The residents' diagnoses included high blood pressure and asthma. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/20/2026, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 22's cognitive abilities for daily decision-making were intact.On 4/22/26 at approximately 11:17 AM, an interview was conducted with Resident #22. Resident #22…

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 develop, implement, and maintain an effective training program for all staff, including training on Communication for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA) The Findings included:Substandard Quality of Care was identified by the survey team on resulting in extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/28/2026 at 10:12 a.m., an interview was conducted with the Staff Development Coordinator in her office. The Staff Development Coordinator was asked about the training schedules and to provide…

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 interviews, staff interviews, and clinical record reviews, the facility staff failed to ensure language interpreter services were available to allow effective communication for a Spanish-speaking resident for for 1 resident of 63 residents (Resident #16) in the survey sample. The findings include:Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/13/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated that Resident #16's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities Goals), the resident was coded as requiring set-up or cleanup assistance with oral hygiene, upper- and lower-body…

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 information obtained during the resident group meeting, and a review of facility documents, the facility staff failed to ensure that 5 of 5 residents in the group meeting knew the location of the list of contact names, addresses, and phone numbers of the State agencies, ombudsman and adult protective services.The findings included:On 4/22/26 at 11:00 AM, a Resident Group meeting was held with the Resident Council President and four residents who regularly attend the group. There was a consensus among all attending the meeting that they were unaware of how to contact the relevant agencies, such as the ombudsman, adult protective services, or other state offices. On 4/23/26 at 11:30 AM, an interview was conducted with the Director of Activities. The Activities director stated that residents are educated at every resident council meeting on the ombudsman and where to find the contact information, and that this was documented in the resident council minutes. The activities director stated she would invite the ombudsman to the resident group meeting going forward. On 4/28/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of facility documentation, the facility staff failed to inform the resident's representative of a change in condition and failed to update the resident representative's phone numbers for 1 of 63 residents (Resident #99) in the survey sample.The findings include: Resident #99 was originally admitted to the facility 3/07/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Allergic Rhinitis and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/12/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #99's cognitive abilities for daily decision-making were intact In section GG (Functional Abilities), the resident was coded as dependent in transfers, locomotion, dressing, toileting, personal hygiene, and Shower/bathe…

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, it was determined that facility staff failed to ensure a grievance was filed on missing items for 1 of 63 residents in the survey sample, Resident #12. The finings included: Resident #12 was originally admitted to the facility 2/14/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Malignant Neoplasm of the colon. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/17/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #12's cognitive abilities for daily decision making were moderately impaired. On 04/22/2026 at 12:30 pm, during the initial tour, Resident #12 said she's been missing 2 cases of cranberry juice, 1 case of Ensure Clear, bodywash, perfume, baby powder, bifocals (wearing new glasses now). I reported it to everyone, the Director of Nursing (DON) and Nurse's Aides. It's been 4 months. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility's staff failed to ensure that 1 of 63 residents (Resident #11) did not have as needed Lorazepam ordered for use for greater than 14 days. The findings included: Resident #11 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with aphasia and anxiety. The Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/24/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 4 out of 15. This indicated that Resident # 11's cognitive abilities for daily decision-making were severely impaired.A review of the resident's physician order summary revealed an order dated 4/06/2026 for Lorazepam Tablet 0.5 MG; give 0.5 mg via G-Tube every 4 hours as needed for anxiety. The order lacked a stop date, and in the clinical record, there was no documentation by the physician and/or prescribing practitioner that the resident had been evaluated…

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, facility document review, and resident interviews, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for 1 of 63 residents in the survey sample, Resident #12. The findings included: Resident #12 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: malignant neoplasm of the colon. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/17/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #12's cognitive abilities for daily decision making were moderately impaired. On 04/22/2026 at 12:30 pm, during the initial tour, Resident #12 said that she had informed the Veterans Administration staff that she had almost fallen out of bed but was shoved back into bed by staff. The resident said that she has not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interviews and a review of the clinical record, the facility staff failed to provide discharge information for 2 of 63 residents in the survey sample (Residents #114 and #120). The findings included: 1. For Resident# 114, the facility failed to provide any discharge instructions to the resident at the time of discharge AMA (against medical advice.) Resident # 114 was admitted to the facility on [DATE] with the diagnoses of but not limited to: sepsis, hypertension, diabetes, pneumonia and Chronic Obstructive Pulmonary Disease. It was too soon for the completion of an Minimum Data Set (MDS) assessment because Resident left within 3 days of admission. There was documentation that coding of Resident #114's BIMS (Brief Interview for Mental Status) Score was 12 out of 15, indicating moderate cognitive impairment. Review of the clinical record was conducted on 04/24/2026-04/28/2026. Review of the clinical record revealed that Resident # 114 left the facility against medical advice (AMA) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record and staff interviews, the facility staff failed to ensure that the Minimum Data Set (MDS) assessment was accurately completed for 1 of 63 residents (Resident #39) in the survey sample. The findings included: Resident #39 was admitted to the facility on [DATE]. The resident's current diagnoses included liver cirrhosis, diabetes, and status post right foot trans metatarsal amputation. The admission MDS assessment, with an assessment reference date (ARD) of 4/6/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 39's cognitive abilities for daily decision-making were intact. In section N0415. High-Risk Drug Classes: Use and Indication, the resident was coded as taking an anticoagulant, and the indication for use was documented. A review of the resident's Physician's Order Summary (POS) failed to reveal an order for an anticoagulant. A review of the resident's care plan also failed 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 observations and staff interviews, the facility's staff failed to ensure that 1 of 63 residents (Resident #11), who were unable to perform activities of daily living (ADL), received all necessary services.The findings included:Resident #11 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with aphasia and anxiety. The Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/24/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 4 out of 15. This indicated that Resident # 11's cognitive abilities for daily decision-making were severely impaired. In section GG0130 (Functional Abilities), the resident was coded as dependent with all ADL care. On 4/21/26 at approximately 2:40 PM, the resident was observed asleep in bed. The resident's fingernails were observed to be approximately 1.75 inches beyond the tips of the fingers, and they were discolored. Observations were also made of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and clinical record review, the facility staff failed to follow the physician's order for the oxygen flow rate for 1 of 63 residents (Resident # 99) in the survey sample. The findings included: Resident #99 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: allergic Rhinitis and Type 2 Diabetes Mellitus with diabetic chronic kidney disease, morbid obesity, hypoventilatory syndrome, functional quadriparesis, bedbound, chronic respiratory failure with oxygen dependence, COPD, hypertension, CAD, chronic pain syndrome, GERD, asthma, anemia, and neuropathy. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/12/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #99's cognitive abilities for daily decision-making were intact In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and a review of the clinical record, the facility staff failed to ensure proper technique was utilized to achieve the ordered dose of medication for 1 of 63 residents (Resident 23) in the survey sample. The findings included: Resident #23 was admitted to the facility on [DATE]. The residents' current diagnoses included cataracts and anxiety. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/6/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 9 out of 15. This indicated that Resident #23's cognitive abilities for daily decision-making were moderately impaired. During the medication pass on 4/23/2026 at approximately 7:56 AM, the Assistant Director of Nursing (ADON) brought a single-dose package of Ativan 1 milligram (mg) to the medication cart for Registered Nurse (RN) #4 to administer to Resident #23. RN #4 opened the package and, using gloves, broke the tablet in half; one half was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, facility record reviews, and facility policy, the facility staff failed to provide a safe, sanitary, comfortable homelike environment on 3 of 3 units ([NAME] Hall, [NAME] Hall, and Fine Hall), which represented a widespread deficient practice, Substandard Quality of Care. The findings included: 1. [NAME] Hall a. In room [ROOM NUMBER] B a progressive wall crack was observed in the corner above the B bed. The wall with the crack attaches to the facility's outside wall and the crack had moved midway the length of the window. Resident #120 was observed in bed and an interview was conducted with him on 10/19/23 at 12:45 PM. The resident stated the crack in the wall had been there for a while. The resident's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the resident Brief Interview for Mental Status (BIMS) score as 14 out of 15. This indicated his daily decision-making ability was intact. On 10/20/23 at 10:04 AM, an observation of 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 a review of facility documents and a staff interview, the facility staff failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies and to ensure the physical environment and other physical plant considerations that are necessary to care residents living in their Center. The Findings Included: An extended survey was conducted from 10/19/23 through 10/20/23 because Substandard Quality of Care was identified in the area Resident Rights, Safe/Clean/Comfortable/Homelike Environment. An interview was conducted with the Interim Administrator on 10/20/23 at approximately 10:45 AM. The Interim Administrator stated the facility had not conducted a Facility Assessment since 5/13/21 and there were no other documents available to support a facility-wide assessment was conducted. The Facility Assessment provided by the facility was last reviewed and updated on 5/31/2021 and reviewed by the Quality Assurance Committee on 6/18/21. As a result of not reviewing…

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 review of facility documents, the facility staff failed to maintain an effective pest control program so that the facility is free of pests in 3 of 3 units and the dining room. The findings included: On 8/15/23 at approximately 4:00 PM an inspection, of the facility was conducted related to a concern that rats and roaches were throughout the facility. After an inspection of the kitchen for rats and rodents the dining room was inspected, no evidence of them including droppings were identified. In the dining room on the back wall directly behind the kitchen wall, many dried insects of various sized were observed beside and behind the portable popcorn machine. At 4:07 PM the dining room observations were shared with the Maintenance Assistant (MA). The MA looked at the insects near and behind the popcorn machine and identified them as dead and dried roaches. On 8/15/23 at approximately 4:16 PM accompanied by the MA and the Administrator observations were made in room…

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

Based on observations, staff interviews, and a review of facility documents, the facility staff failed to ensure the drainage pipes connected to the three-compartment sink did not allow overflow onto the floor as the water was draining from the compartments. The findings included: On 8/15/23 at approximately 3:39 PM an inspection of the kitchen was conducted because a concern was voiced that the local health department had closed the facility's kitchen due to sanitation, floor drains in the kitchen failing to drain, and standing water on the kitchen floors. The kitchen was observed to be operational to include food preparation for facility residents at the time of the current survey, 8/15/23. An inspection of the stated concerns was completed on 8/15/23 at 3:39 PM. The inspection revealed that pipes leading from the three-compartment sink dumped into a pipe that carried the water out to the sewer system. The pipe which carried the water out to the sewer system was unable to manage the rapid flow from the three-compartment sink therefore, water overflowed onto the kitchen floor and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the provisions of quality care for the residents using the Quality Assessment and Assurance (QA&A) committee to identify and implement action plans for the physical environment for 3 out of 3 units ([NAME], [NAME], and Fine) of the facility. The findings included: A review of the quarterly QAPI dated 9/19/23 read: In the maintenance section, the discussion was left blank. In the Environmental section, discussed Janki Line Shortage. A review of the monthly QAPI dated 10/17/23 read: In the maintenance Section-5 yr. sprinkler inspection completed. Under the Environmental services section, the discussion was left blank. On 10/20/23 at approximately 1:15 PM, an interview was conducted with the SDC/Staff Development Coordinator. She said that she was present at the QAPI meeting held on 10/17/23 and on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of facility documents, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facility residents. The findings included: On 8/15/23 observations were made of the facility's 3 of 3 shower rooms with the Maintenance Assistant (MA). On [NAME] Hall were shower rooms [ROOM NUMBERS]. Shower room [ROOM NUMBER] was totally out of service because of drainage concerns, shower room [ROOM NUMBER] had one operational shower stall and the other stall in shower room [ROOM NUMBER] was without a hose and had drainage issues. Observations were made of the spa shower room [ROOM NUMBER] on the refurbished hall, ([NAME]) with the MA at approximately 5:15 PM and with the Administrator at approximately 5:55 PM. The room appeared to be a storage room for it contained two recliner chairs, four bedside commodes, multiple shower chairs, and a trash can three-fourths full of clothing and used depends. There were also cracked tiles on the floor in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility policy, the facility staff failed to maintain an effective pest control program. The findings included: During the days of the survey 06/07/22 through 06/09/22 fruit fly's and gnats were observed in the kitchen, facility conference room, [NAME] Hall, Fine Hall, [NAME] Hall, The Physical Therapy Gym, and dining room. During an interview on 06/09/22 at 2:33 P.M. the Maintenance Director stated, our pest control company was just in the building two weeks ago. As the weather has warmed up the fly's have started to come out more. A facility Pest Control Policy revised 10/01/21 indicated: Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). 4. Facility will utilize a variety of methods in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a resident council meeting, staff interviews and facility document review the facility staff failed to provide an environment for resident, staff and visitors that was safe, sanitary and comfortable. The findings included: On 6/7/22 at 3:57 p.m. a Resident Council meeting was held with 6 residents present. During the meeting the resident's expressed that housekeeping was not occurring on a daily basis. There were complaints of torn and dirty floors, torn wallpaper, and dirty PTAC (packaged terminal air condition) room units. During the survey the following observation were made: Resident room [ROOM NUMBER]: A one foot long tear in the linoleum was observed between the two resident beds. Also there was a six inch linoleum tear under the resident's bed near the door. Resident room [ROOM NUMBER]: There were clumps of black hair on the floor behind the window bed and white paint missing for the baseboards in the room. Resident room [ROOM NUMBER]: The resident room was noted with torn wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide evidence that two out of 51 residents were invited to attend a care plan meeting, Resident #68 and Resident #59. The findings included; 1. Resident #68 was originally admitted to the facility 3/30/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Major Depressive Disorder and Anxiety Disorder. The Quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/10/22 coded the resident coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #68 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two person for bed mobility and toileting. Requiring extensive assistance of one person with eating.…

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, and staff interviews the facility staff failed to treat a resident's clothing with respect and dignity for 1of 51 residents (Resident #48), in the survey sample with laundry concerns. The findings included: Resident #48 was originally admitted to the facility 02/19/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; stroke, peripheral vascular disease and bilateral above the knee amputations. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/21/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #48's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with personal hygiene, physical help of one person with bathing, supervision of one person with bed mobility, locomotion,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. For Resident #68 the facility staff failed to execute the opportunity to provide an advance directive. Resident #68 was originally admitted to the facility 3/30/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Major Depressive Disorder and Anxiety Disorder. The Quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/10/22 coded the resident coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #68 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two person for bed mobility and toileting. Requiring extensive assistance of one person with eating. Requiring Total dependence of one person with dressing, personal hygiene and bathing. A review of the clinical record on revealed there were no advance directives in the clinical record 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 clinical record review, staff interview and facility documentation, the facility staff failed to ensure 1 of 3 residents reviewed for Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued the notices per the requirement. The findings included: The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #305 who was discharged from skilled services with Medicare days remaining. Resident #305 was admitted to the nursing facility on 02/24/22. Diagnosis for Resident #305 included but not limited to muscle weakness. Resident #305's Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) date of 03/03/22 coded Resident #305, a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment. Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #305 was not issued a SNF ABN letter. Resident #305 started Medicare Part A stay on 02/24/22 and the last covered day was on 03/25/22. Resident #305 was…

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

Based on observation, resident interview, staff interview and facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment for 1 of 51 residents in the survey sample, Resident #8. The findings included: Resident #8 was originally admitted to the facility 12/04/2021 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; COGNITIVE COMMUNICATION DEFICIT and APHASIA FOLLOWING CEREBRAL INFARCTION. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/05/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #8 cognitive abilities for daily decision making were moderately impaired. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing and personal hygiene. Total dependence of one person with toilet use and bathing. Set-help only with eating.…

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 record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 51 residents (Resident #79 and Resident #36) in the survey sample. The findings included; 1. Resident #79 was originally admitted to the facility on [DATE] and discharged on 2/23/2022 to an acute care facility. The current diagnoses included; HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/17/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #79 cognitive abilities for daily decision making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility and transfers. Requiring total dependence of two persons…

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 information obtained during a closed record review, staff interviews, and a clinical record review, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 51 residents (Resident #103 and #10), in the survey sample. The findings included: 1. Resident #103 was originally admitted to the facility 4/15/2022 and she was discharged from the facility on 5/10/2022. The diagnoses included; rheumatoid arthritis, left above the knee amputation with phantom pain. The discharge MDS with an assessment reference date (ARD) of 5/10/2022 coded the resident as discharged return not anticipated to the community and the staff interview was coded for short term memory problems as well as modified independence with daily decision making. A nurse's note dated 5/10/22 at 5:04 p.m., read the resident's daughter called 911 to have the resident go to the emergency room against medical advice and the resident left the facility 911 via stretcher with no new skin issues noted. The nurse's note…

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, resident interviews, staff interviews and facility document review the facility staff failed to ensure that 2 of 51 residents in the survey sample who were unable to carry out grooming activities of daily living (ADL) were provided showers, Resident #37 and Resident # 69. 1. The facility staff failed to ensure Resident #37 who was unable to carry out activities of daily living was offered and received a scheduled twice-weekly shower to maintain good personal hygiene since admission. Resident #37 was admitted to the facility on [DATE] with diagnoses to include but not limited to Stroke, Left Hemiparesis, Hypertension and Depression. Resident #37's most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 3/24/22. The Brief Interview for Mental Status (BIMS) was coded as a 13 out of a possible 15 for Resident #37, indicating she was cognitively intact and capable of daily decision making. Under Section G Functional…

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, resident interview, staff interviews, and clinical record review the facility staff failed to provide necessary respiratory care and services for 1 of 48 residents (Resident #11), in the survey sample for the use of a BiPap machine. The findings included: Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but are not limited to Obstructive Sleep Apnea. Resident #1's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 03/06/22 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section O (Special Treatment and Programs) was not coded for the use of a CPAP or BiPap machine. Resident #11's person-centered care plan created on 04/22/21 identified the resident has potential for respiratory distress due to history of respiratory failure with hypoxia, obstructive sleep apnea with the use of Bi-pap…

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.

The facility staff failed to ensure RN coverage for 8 consecutive hours for 24 days. The findings included: On 06/09/22 at approximately 7:32 PM., the facility's actual as worked schedule was reviewed with Other Staff Member (OSM/ Staffing Coordinator) #3 and revealed there was no RN coverage for the following days: 5/09/2021 and 12/25/21. On 6/09/22 at approximately 7:45 PM., the above findings were shared with the Administrator, and the DON (Director of Nursing). No comments were voiced at this time.

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 ensure the PRN (as need) psychotropic medication Lorazepam was not administered for more than 14 days for 1 of 51 residents in the survey sample, Resident #37. The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses to include but not limited to Stroke, Left Hemiparesis, Anxiety and Depression. Resident #37's most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 3/24/22. The Brief Interview for Mental Status (BIMS) was coded as a 13 out of a possible 15 for Resident #37, indicating she was cognitively intact and capable of daily decision making. Resident #37's Physician Orders were reviewed and are documented in part, as follows: Lorazepam tablet 0.5 mg (milligrams) give 1 tablet every 8 hours as needed for Anxiety. Start Date: 3/21/22 D/C (discontinue date) 5/11/22. Resident #37 Medication Administration Records (MAR)…

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

Based on observations, staff interview,and in the course of a complaint investigation, the facility staff failed to maintain equipment to include an ice dispenser in the kitchen and a washing machine in safe operating conditions. The findings included: During the Kitchen Inspection on 8/28/19 at 11:45 A.M. the ice dispenser located in the kitchen was observed to be in poor repair. The ice dispenser was noted not able to dispense ice. During an interview on 8/28/19 at 12:45 P.M. with the Dietary Manager, he was asked how long the ice dispenser had been inoperable. The Dietary Manager stated, the ice dispenser had not operated properly for several weeks. During a complaint investigation indicating the facility was without linens it was determined that one of two facility washing machines had been inoperable. A review of a facility email dated June 24, 2019 indicated that a request for the purchase of a washer was instituted on June 24, 2019 at 7:48 A.M. by the Administrator. During an interview with the Housekeeping Director on August 28, 2019 at 2:15 P.M. he stated, The washer 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 resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 2 (Resident #37 and 64) of 66 residents in the survey sample, to attend their person centered care plan meeting. The findings included: 1. The facility staff failed to invite Resident #37 to participate in her person centered care plan meeting. Resident #37 was originally admitted to the facility on [DATE]. Diagnosis for Resident #37 included but not limited to, Cerebral Palsy. The current Minimum Data Set (MDS), a 30-day PPS assessment with an Assessment Reference Date (ARD) of 06/14/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. During the initial tour of the facility on 08/26/19 at approximately 3:04 p.m., an interview was conducted with Resident #37 who stated when asked about care plan meetings, No one has ever given me a care plan letter or invited me to attend a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, complaint investigation and staff interviews the facility staff failed to ensure the environment was safe, clean and comfortable for potentially all residents in the facility and specifically for 3 of 66 residents in the survey sample, Residents #14, #40, #109). The findings included: 1. During a complaint investigation indicating the facility was without linens it was determined that one of two facility washing machines became inoperable. A review of a facility email dated June 24, 2019 indicated that a request for the purchase of a washer was instituted on June 24, 2019 at 7:48 A.M. by the Administrator. The washer was not installed until 8/30/19. During an interview with the Housekeeping Director on August 28, 2019 at 2:15 P.M. he stated, The washer had been out for about two months. When asked what out meant he stated The washer was not operating properly and was not in operating condition. When asked how he was keeping up with the linen and resident clothing, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide the required documentation upon transfer to the hospital for five of 66 residents in the survey sample, Residents #15, #78, #102, #37 and #71. The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia, HIV (Human Immunodeficiency virus), and weakness. Resident #15's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 5/31/19. Resident #15 was coded as being severely impaired in cognitive function scoring 02 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he went out to the hospital on 6/27/19. The following in part, was documented: At 9:25 p.m. resident was in bed throwing up x 2 (two times) and continued to state that he did not…

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

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 provide written bed hold notification upon transfer to the hospital for five of 66 residents in the survey sample, Residents #15, #78, #102, #37, & #71. The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia, HIV (Human Immunodeficiency virus), and weakness. Resident #15's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 5/31/19. Resident #15 was coded as being severely impaired in cognitive function scoring 02 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he went out to the hospital on 6/27/19. Further review of the clinical record revealed that Resident #15 arrived back to the facility on 6/28/19 with diagnoses of a UTI (urinary…

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, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for five of 66 residents in the survey sample; Residents #67, #15, #218, #31 and #102. The findings included: 1. For Resident #67, facility staff failed to provide fingernail care. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure, difficulty walking, chronic kidney disease, and altered mental status. Resident #67's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/23/19. Resident #67 was coded as being severely impaired in cognitive function scoring 02 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #67 was coded as requiring extensive assistance from one person with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, record review and staff interviews it was determined that the facility staff failed to ensure medications for the treatment of scabies was available from the pharmacy for 10 of 66 residents in the survey sample, Residents #43, #75, #82, #219, #56, #224, #66, #115, #92, and #22 The findings included: The facility staff failed to obtain medications to treat residents during a Scabies outbreak. Two residents were initially identified as having Scabies on 11/8/18 and admitted to the hospital. On 11/8/18 the Director of Nursing received a call from the hospital informing the confirmation of Norwegian Scabies. The facility identified ten active residents on two different living units and three active staff between 11/6/18 through 11/15/18. The first order was placed to the pharmacy on 11/7/18 which included 20 tubes of permethrin cream and 480 tablets of Ivermectin 3 mg each. The local Health Department recommended Ivermectin po (by mouth-tablet) weekly, times 4 weeks, and topical…

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, and staff interview it was determined that the facility staff failed to store and prepare food under sanitary conditions. The findings included: During the kitchen inspection conducted on 8/28/19 at 11:45 A.M. the facility staff was observed to take clean steam table tray tops from the bottom of the steam table. The bottom shelf of the steam table was observed to have copious amounts of debris and dried food particles. The tray tops were observed to be stored face down with the tops outer surface contacting the debris and dried food particles. The back kitchen wall extending from the three compartment sink to the free standing refrigerator in the kitchen was observed to have dirt, debris, and black-green substance not easily removed, on the floor and on the wall. The soiled utility room utilized to store soiled aprons and towels was observed to be dirty and having a black-green substance on the floor. The floor was observed to have an open drain with trash, debris and a black gooey substance in it. The drain was noted to have a pungent order emitting from it.…

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 facility staff failed to ensure a complete and accurate clinical record for five of 66 residents in the survey sample, Resident #114, #418, #86, #87 and #31. The findings included: 1. For Resident #114, the facility staff failed to document treatments that were performed. Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, chronic respiratory failure, type two diabetes, and bipolar disorder. Resident #114's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/15/19. Resident #114 was coded as being intact in cognitive function scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #114's clinical record revealed that she had obtained a DTI (deep tissue injury) (1) on 5/30/19. 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 observations, staff interviews, facility documentation and clinical record review, it was determined that facility staff failed to implement effective infection control practices for 4 of 66 residents in the survey sample. For Resident #31, the facility staff failed to prevent the indwelling catheter drainage bag from touching the floor. The facility staff failed to follow infection control practices as evidenced by not performing hand hygiene before and after medication administration for three residents in the medication administration observation, Resident #114, #24, and #113. The findings included: 1. Resident #31 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Central Cord Syndrome at C4 Level of Cervical Spinal Cord, sequela, and Neuromuscular Dysfunction of Bladder, Unspecified. Resident #31's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 06/12/2019 was coded with a BIMS (Brief Interview for Mental Status) score 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 observations and staff interview it was determined that the facility staff failed to maintain an effective pest control system. The findings included: During the kitchen inspection on 8/28/19 at 11:45 A.M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies were observed in the conference room. Mice dropping's were observed in the kitchen area under the three compartment sink and in the dry storage room area. During an interview on 8/29/19 at 12:50 P.M. with the Dietary Manager, he stated, the drain flies have been a concern and there is a new pest control company that is servicing the facility. The pest control company came monthly and as needed. A review of the Pest Management policy indicated: Mission-We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional manner. The facility staff failed to maintain and effective pest control program. Complaint deficiency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility document review the facility staff failed to ensure 1 of 66 residents in the survey sample (Resident #78) had footwear and clothing other than the facility's hospital gowns to wear. The findings included: Resident #78 was originally admitted to the facility 3/5/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses include anemia, and a seizure disorder. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/26/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #78's cognitive abilities for daily decision making was moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, extensive assistance of one person with dressing, eating, toileting, personal and hygiene and total care with bathing. Resident #78 was…

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

Based on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices were issued in accordance with applicable Federal regulations to 2 of 3 residents (Resident #7 and #93) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #7 who was discharged from skilled services with Medicare days remaining. Resident #7 was admitted to the nursing facility on 05/17/19. Diagnosis for Resident #7 included but not limited to Dementia without behavior disturbances. Resident #7's Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 05/24/19 coded Resident #7 with short and long-term memory problems and with severe cognitive impairment - never/rarely made decisions. During review of the Beneficiary Notification Checklists provided by the facility it was noted that Resident #7 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure an accurate MDS (Minimum Data Set) assessment was completed for one of 66 residents in the survey sample, Resident #220. The findings included: Resident #220 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to chronic respiratory failure, pneumonia, stroke, tracheostomy status, quadriplegia (paralysis all four limbs), and gastrostomy status (feeding tube). Resident #220's most recent comprehensive MDS assessment was an admission assessment with an ARD (assessment reference date) of [DATE]. Resident #220 was coded as being severely impaired in cognitive function on the Staff Interview for Mental Status exam. Review of Resident #220's clinical record revealed that she had gone into cardiac arrest on [DATE] in between the 11 PM-7 AM and 7 AM-3 PM shift. The following was documented by the unit manager: Charge nurse on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility stafff failed to develop a baseline care plan for 2 of 66 residents in the survey sample, Resident #418 and #419. The findings included: 1. The facility staff failed to develop a baseline care plan within forty-eight (48) hours of Resident #418's admission. Resident #418 was admitted to the facility on [DATE] with diagnoses to include but not limited to, end stage renal disease requiring hemodialysis and liver failure. At the time of the survey the admission MDS (Minimum Data Set) required by day 14 had not been completed as the resident was still in the look back period. On 8/28/19 at 5:30 p.m., the clinical record failed to evidence that the baseline care plan was developed. The [NAME] Hall unit manager was interviewed. She stated the baseline care plan is initiated upon admission by the admission nurse. She stated the baseline care plan has to be signed by a registered nurse. When asked if Resident #418's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to develop the comprehensive care plan for 2 of 66 residents in the survey sample, Residents #67 and 98. The findings included: 1. For Resident #67, facility staff failed to develop an ADL (activities of daily living) care plan that was a triggered area on his CAA (care area assessment) worksheet from his annual MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of 2/28/19. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure, difficulty walking, chronic kidney disease, and altered mental status. Resident #67's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/23/19. Resident #67 was coded as being severely impaired in cognitive function scoring 02 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. 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 staff interview, facility document review and clinical record review, it was determined that facility staff failed to review and revise the care plan for two of 66 residents in the survey sample, Resident #15, and 37. 1a. For Resident #15, facility staff failed to revise his care plan after he was admitted back to the facility on 6/29/19 with a diagnosis of a urinary tract infection requiring antibiotic therapy. 1b. For Resident #15, facility staff failed to revise his care plan after a fall on 1/20/19. The findings included: 1a. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia, HIV (Human Immunodeficiency virus), and weakness. Resident #15's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 5/31/19. Resident #15 was coded as being severely impaired in cognitive function scoring 02 out of possible 15 on the BIMS (Brief Interview for Mental Status)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to ensure appropriate care and services were provided to 1 of 66 residents in the survey sample, Resident #86. The facility staff failed to assess the resident's self inflicted wound to the left buttock on a weekly basis and failed to apply dressing changes as ordered. The findings included: Resident #86 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include but not limited to, paraplegia (paralysis of the lower portion of the body and of both legs). The current MDS (Minimum Data Set) was an annual with an assessment reference date of 7/24/19. The MDS coded the resident as a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the resident's cognition was intact. The comprehensive person-center care plan, revised on 7/24/19, evidenced the resident had an alteration in skin integrity related to a self inflicted excoriation to the left buttock. The goals…

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 follow orders and the comprehensive care plan for oxygen administration for one of 66 residents in the survey sample, Resident #114. The findings included: Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, chronic respiratory failure type two diabetes, and bipolar disorder. Resident #114's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/15/19. Resident #114 was coded as being intact in cognitive function scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #114 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy. Review of Resident #114's POS (physician order summary) dated August 2019, revealed the following oxygen orders: Oxygen @ 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that facility staff failed to provide medically related social services following the loss of a loved one for one of 66 residents in the survey sample, Resident #64. The findings included: Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to cardiovascular disease, high blood pressure, adult failure to thrive, and Alzheimer's disease. Resident #64's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/23/19. Resident #64 was coded as being severely impaired in cognitive function scoring 00 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 8/27/19 at 2:12 p.m., an interview was attempted with Resident #64's emergency contact, her sister. The phone number was disconnected. On 8/28/19 at 9:49 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the unit…

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 the facility staff failed to ensure one resident (Resident #110) in the survey sample of 66 residents was provided with a gradual dose reduction (GDR) of the psychotropic medication Seroquel. The finding included: Resident #110 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses for this resident included Bipolar disorder, delusional disorder, major depression, dementia without behavioral disturbance, psychosis not due to a substance or known physiological condition and anxiety. A 8/19/19 Significant Change Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns (Brief Interview for Mental Status) BIMS as a (15). In the area of Mood this resident was assessed as having little interest in activities. In the area of behaviors this resident assessed as not having any behaviors. In the area of Medications this resident was assessed as receiving Antipsychotic and Antianxiety medications. A revised care…

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