Ascension Living - Lakeshore at Siena

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6) R61 was admitted to the facility on [DATE] with diagnoses which include generalized anxiety disorder. R61 an activated Healthcare Power of Attorney (HCPOA). R61's admission Minimum Data Set (MDS), dated [DATE], indicates R61 has a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, has anxiety, depression, receives antianxiety and antidepressant medication. Surveyor reviewed R61's Facility provided document, titled Medication Record for 09/2025. Surveyor noted R61 has an order for Hydroxyzine 10 milligrams (mgs) (Atrax, can be used to treat anxiety, tension) by mouth, 3 times per day (8AM, 12PM, 4PM) with a start date of 9/16/2025 and end date 9/25/2025. The following dates and times are noted where R61 received the scheduled medication outside of the scheduled time frames, including the 1 hour before or 1 hour after standard of practice: *9/16/2025- 8 AM dose, given at 10:10 AM & 4 PM dose given at 5:49 PM. *9/17/2025- 8 AM dose given at 10:40 AM. *9/18/2025- 8 AM…

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

Based on observation, interview, and record review, the facility did not store medications in the proper temperature potentially affecting 25 of 53 residents. The medication refrigerators in one of two medication storage rooms were consistently colder than the recommended range for temperature. Findings include: On 1/26/2026 at 1:28 PM, Surveyor accompanied Registered Nurse Unit Manager (RNUM)-C into the medication storage room on the west side of the facility. The medication storage room had two refrigerators, a full-sized refrigerator with a freezer and a small compact refrigerator. Medications were stored in both refrigerators, such as insulin and intravenous medications. The temperature logs were located on the front of each refrigerator. The top of the temperature log documented: Temperatures are logged daily, temperatures out of range 2 degrees-8 degrees C (Celsius) and 36 degrees-46 degrees F (Fahrenheit) are re-checked and action is logged. The January temperature log for the full-sized refrigerator had temperature documentation for 17 out of 26 days. 16 out of 17 of those…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R17) of 14 residents reviewed received the right to self-determination through support of resident choice. The facility failed to accommodate R17's preference for a morning shower. Findings include:The facility policy titled Quality of Life - Self Determination and Participation dated 12/2016 with last revised date 12/2021 documents: . Our community respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. each resident chooses activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: . daily routine, such as sleeping and waking, eating, exercise and bathing schedules . include information gathered about the resident's preferences in the care planning process . R17 admitted to the facility 10/11/2022 with diagnoses including anxiety, unspecified dementia, depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R7) of 1 resident reviewed for grievances received corrective actions taken by the facility.R7 filed a grievance with the facility on 2/18/25, and there is no evidence that corrective action was taken by the facility to resolve the grievance. Findings include:The facility policy titled Complaints and Grievances dated 11/2017 with last revised date 6/2025 documents: It is the policy of [Facility Name] to provide residents and family members/legal representatives the opportunity to voice complaints and grievances free from restraint, interference, coercion, discrimination or reprisal. acknowledgment of grievance will be provided to complainant when available as soon as possible but no later than 5 working days from date or receipt . issuing of a final decision in writing on all grievances will be provided to the complainant when available within a reasonable time frame but not to exceed 30 days from date of receipt.R7 admitted to the facility on…

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

Based on interview and record review, the facility did not ensure 2 (R4, R41) of 3 residents with allegations of resident-to-resident abuse and injuries of unknown origin were reported to the State Agency.*On 10/1/2025, a resident-to-resident incident occurred. R41 entered R4's room, grabbed R4's forearm causing R4 to scream in fear and feel pain in R4's forearm.*On 11/8/2025, R41 was discovered to have an injury of unknown origin which was an abrasion to the head.Findings:Review of the facility policy titled Abuse Investigation and Reporting, last approved 12/2024, indicates, Reporting: A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: . B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or Serious Bodily Harm - immediately but not later than 2…

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

Based on record review and interviews, the facility did not ensure a thorough investigation was completed for 2 (R4 and R41) of 3 Residents reviewed for allegations of abuse/neglect and injury of unknown origin investigations.*On 10/1/2025, a resident-to-resident incident occurred. R41 entered R4's room, grabbed R4's forearm causing R4 to scream in fear and feel pain in R4's forearm.*On 11/8/2025, R41 was discovered to have an injury of unknown origin which was an abrasion to the head. The investigation was not started until 11/11/2025, 3 days later, and was not thorough. The investigation did not include statements from staff who first identified the injury and does not include determination of possible cause. Findings include: The Facility policy, titled, Abuse Investigation and Reporting, with a last approved date of 11/2024, documents in part, . Role of the Administrator or designee:A. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown sources reported, the Administrator or designee will assign the investigation to an appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R58 and R7) of 2 residents reviewed for transfer and bed hold notices were notified of the reason for transfer to the hospital and bed hold policy in writing to the resident and/ or their representative and the rate to reserve the resident's bed was not provided to the resident and/ or their representative. A bed hold rate is not provided to residents on Medicaid. *R58 was transferred and admitted to the hospital on [DATE] for further evaluation. A transfer notice and bed hold form were not provided in writing, and a bed hold rate was not provided to R58 and/or R58's representative. *R7 was transferred and admitted to the hospital on [DATE] and 11/11/2025 for further evaluation. A transfer notice and bed hold form were not provided in writing, and a bed hold rate was not provided to R7 and/or R7's representative. Findings include: The facility policy titled Bed-Holds and Returns last revised on 12/2017 with an approval date of 1/2026 documents:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did ensure a resident was provided the appropriate care and services with a mobility device. This was observed with 1(R5) of 3 residents reviewed with mobility devices.R5 was observed with a left palm guard device. There was not a documented assessment for use and care of this device.Findings include:The facility policy and procedure Restorative Nursing Splint/Brace Assistance Program dated 1/2026. The Policy Statement documents: residents who have been fitted for a splint or brace are assessed by nursing and or therapy for a Restorative Nursing Splinting Bracing Program to promote independence and quality of life by maintaining or improving a resident's correct alignment through application of splint/brace.The Policy Interpretation and Implementation documents:C. Care plan includes but is not limited to:1. measurable goals:a. Amount of self-performance encouraged;b. Increased resident independence with splint/brace application and care;c. Maintain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R67) of 4 residents reviewed received appropriate treatment and services related to catheter care.R67 was admitted to the facility on [DATE] with an indwelling catheter. R67 did not have a baseline catheter care plan initiated and observations were made of R67's catheter not having a privacy cover on it per R67's preference.Findings include:The facility policy titled Care Plans- Baseline last revised 7/2020 with an approval date of 1/2026 documents: A baseline plan of care that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care should be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation:A. A baseline care plan should be developed within forty eight (48) hours of the resident's admission to meet and maintain the resident's immediate care needs.B. The baseline care plan should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure a resident received appropriate oxygen services and administration. This was observed with 1 (R1) of 2 residents reviewed with oxygen services.* R1 was observed receiving oxygen per nasal cannula during the survey. R1 did not have a physician order for oxygen administration, nor was it documented as being administered.Findings include:The facility policy and procedure Oxygen Administration dated 12/2025, The Purpose is to provide guidelines for safe oxygen administration. The Preparation documents:A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration.B. Review the residents care plan to assess for any special needs of the resident.C. Assemble the equipment and supplies as needed.:Documentation: .C. The rate of oxygen flow, route, and rationale.1.) R1 was admitted to the facility on [DATE] with acute and chronic respiratory failure, mantle cell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not act upon the pharmacy medication review reports when received for 2 (R1 and R6) of 6 residents reviewed. *R1'S Medication Regimen Review Recommendations, dated 1/5/26, indicates they are receiving the antibiotic levofloxacin without a stop date. R1's Primary Care Physician signed the recommendation on 1/22/26 and referred to the prescribing Physician. This recommendation on 1/5/26 was not acted upon promptly. *R6's monthly pharmacy reviews noted a recommendation reported on 8/4/2025, 10/6/2025 and 10/7/2025. There was no documentation the attending physician acted upon the recommendations from the pharmacist. Findings include: The facility policy titled Procedure: Medication Regimen Review for Nursing last approved 12/2025 documents: Policy- The medication regimen of each resident is reviewed by a licensed Pharmacist according to Federal, State, and Local regulations as well as current standards of practice. The pharmacist reports any irregularities to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R1 and R67) of 7 residents drug regimen were free of unnecessary drugs. *R1's facility admission physician orders on 11/25/25 prescribe the following: Acyclovir 800 mg BID for pneumonia with no stop date, Levofloxacin 500 mg every day for pneumonia with no stop date and Bactrim-DS 800-160 mg 3 x week for Urinary Tract Infection (UTI) with no stop date. The diagnosis of these medications is listed on the Medication Administration Records for December 2025 and January 2026. The Physician Assistant (PA) Visit Note on 11/25/25 documents the Levofloxacin end of therapy is 11/25/25, and the Acyclovir and Bactrim-DS are prophylaxis for Mantle Cell Lymphoma which did not transfer to R1's MAR. *R67 did not have end dates ordered for an intravenous (IV) antibiotic (Vancomycin) or an oral antibiotic (Flagyl) when admitted to the facility on [DATE] until Surveyor brought to the facility's attention on 1/22/2026. R67 does not have a diagnoses or indication…

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

Based on observation, interview, and record review, the facility did not ensure the medication error rate was not 5 percent or greater. 2 (R49 and R21) of 3 residents observed during medication pass were affected. The medication error rate was 30 percent, 9 errors out of 30 opportunities. Findings include: The facility policy and procedure titled Administering Medications dated 12/2025 documents: . C. Medications shall be administered in accordance with the orders ad within the allowable time frame per best practice/regulatory guidelines (60 minutes before the due time and 60 minutes after the due time). On 1/21/2026 at 8:00 AM, Surveyor observed Registered Nurse (RN)-K prepare R49's medications. RN-K administered tramadol 50 mg (milligrams) and omeprazole 40 mg at 8:27 AM. The medications were scheduled to be given at 7:00 AM. The medications were administered after the allowable time frame. On 1/21/2026 at 10:55 AM, Surveyor observed RN-Y prepare R21's medications. RN-Y administered atorvastatin 20 mg, Vitamin D3 200u, sertraline 50 mg, Tylenol 1000 mg, propranolol 60 mg,…

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 interviews, the facility did not ensure a thorough investigation was completed for allegations of abuse/neglect for 1 (R7) of 2 Residents reviewed for alleged abuse. *The Facility did not ensure a thorough investigation was completed related to the allegation of neglect of R7 which was reported by Adult Protective Services on 6/24/25. Findings include: The Facility policy, titled, Abuse Investigation and Reporting, with a last revised date of 11/2023, documents: .Role of the Administrator or designee:A If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown sources reported, the Administrator or designee will assign the investigation to an appropriate individual. B. The administrator or designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation.C. The administrator or designee will keep the resident, and his/her representative informed of the progress of the investigation. Role…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not ensure residents received adequate fluid intake for 1 (R1) of 1 Residents reviewed for nutrition. R1was transferred from the facility to the hospital on [DATE] due to weakness, encephalopathy (a disturbance of brain function causing confusion, and abnormal lab values). The facility did not ensure R1 received adequate fluid intake to maintain acceptable parameters of hydration as evidenced by failing to total and assess daily fluid intake, accurately assess and complete on-going assessments for signs and symptoms of dehydration when R1 was assessed to be at risk for dehydration and had a history of poor oral intakes. Findings include:R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Dementia, Delirium and Acute Kidney failure. R1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference) of 11/11/24 documents R1 has a BIMS (Brief Interview for Mental Status) score of 07, indicating R1 was severely…

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

Based on interview, document review, and review of facility policy, the facility failed to ensure that there was evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within two hours for one of two residents (Resident (R) 5) reviewed for abuse from a total sample of 13 residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents. Findings include: Review of the facility policy titled Abuse Investigation and Reporting, last approved 12/2024, revealed: Reporting A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: . B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or Serious Bodily Harm - immediately but 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 interview and record review the facility did not ensure 1 (R2) of 3 residents reviewed had a complete and accurate medical record. R2 had a diabetic wound ulcer and was being followed by Wound MD-C for four weeks. The facility changed their contract with Wound MD-C and obtained a new contract with Wound MD-D. The facility did not obtain Wound MD-C documentation of R2 wounds assessments. Surveyor asked to review R2's wound assessments from Wound MD-C and Nursing Home Administrator (NHA)-A stated the facility has no access to those records because they ended the contract with Wound MD-C. Findings include: R2 was admitted to the facility on [DATE] with diagnoses of right hip pining, type 2 diabetes, right diabetic foot ulcer. R2 was discharged home on [DATE]. The admission MDS (minimum data set) dated 10/29/24 indicates R2 is cognitively intact. The facility's documentation indicates Wound MD-C was assessing and ordering treatments to R2's diabetic foot wound. The medical record indicates the facility 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 interview and record review, the facility did not ensure that 2 (R1, R2) of 3 residents reviewed were kept safe from accidents or hazards. *R1 sustained 3 falls while residing at the facility. The facility did not ensure that fall risk assessments were completed for each fall. The facility did not implement appropriate fall interventions for R1. *R2 was hit in the lip during a hoyer lift transfer on 11/25/24. The facility did not ensure staff reported the incident so that the facility was able to evaluate the circumstances on how the accident occurred and how to prevent future similar accidents from occurring. Findings include: On 12/30/24 at 9:30 AM, Surveyor reviewed the facility's Fall Policy with an initiation date of 12/2017 and a revision date of 07/2023 which documented: Policy Detail: The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process should be completed quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medication administration records were complete and accurate for 1 (R2) of 4 residents reviewed for medication administration. * R2's Medication Administration Record (MAR) indicated R2 was given R2's prescribed narcotic pain medication twice in the month of November 2024. The Facility's controlled drug log indicated R2's prescribed narcotic medication was signed out six times in the month of November 2024. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnosis that include Alzheimer's Disease, chronic pain, and dementia. The facility policy, titled Administering Medications dated 12/2024, documents: . Policy Interpretation and Implementation. The individual administering the medication to document on the MAR or eMAR after giving each medication and before administering the next ones. S. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: 1.…

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 upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order for 2 of 3 dishwashing machines located in the on unit kitchens. The machines were leaking water onto the floor. 1 of 3 dishwashers did not display temperatures. This deficient practice has the potential to affect 24 of 24 residents total on the 2 units. *Surveyor observed 2 of 3 dishwashing machines in the on the unit kitchens, to be leaking water onto the floor, causing a potential hazard. *Surveyor observed 1 of 3 dishwashing machines in the on unit kitchen, did not have a temperature display to properly identify the dishwasher is reaching required water temperature. Findings include: On 09/16/2024, at 11:39 PM, Surveyor observed the dishwasher on the Fairview Unit, on the floor next to the dishwasher were soaked towels and water. Dietary Manager-N informed Surveyor this started happening this morning, a maintenance request has already been submitted and maintenance will be looking at it this afternoon. On 09/16/2024, at 11:47 PM, Surveyor observed 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 interviews and record review, the facility did not ensure the right of a Resident to receive visitors and at the time of their choosing for 1 (R36) of 1 Resident reviewed for visitation rights. The facility restricted a family member immediate access to R36 without developing any strategies to continue safe and enjoyable visits for R36. Findings include: R36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anxiety Disorder, and Alzheimer's Disease. R36's medical record indicates R36 has an Activated Power of Attorney for Health Care (HCPOC). R36's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/5/24 documents R36's Brief Interview for Mental Status (BIMS) not able to be completed due to severe cognitive deficits. On 9/17/24, a Facility Reported Incident dated 8/16/24 was reviewed and indicated on 8/15/24 it was reported that R36's family member was observed to say shut up to R36 in a loud voice. During the investigation a statement from 8/17/24 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure advanced directives were in the resident's medical record for 2 (R6, R19) of 13 residents reviewed. R6 did not have a Do Not Resuscitate consent form placed in R6's medical record. The facility was unable to locate the signed form. R19 did not have a Do Not Resuscitate consent form place in R19's medical record. The facility was able to locate the signed form. Findings include: The facility policy entitled Do Not Resuscitate Order last approved on 6/2022 documents: . Policy Interpretation and Implementation- A. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. B. A Do Not Resuscitate (DNR) order form must be obtained from the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law) and placed in the resident's medical record. 1. Use State-required DNR forms as applicable. 1) R6 was admitted to the facility 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 interview and record review the facility did not ensure residents were free from abuse/neglect for 1 (R19) of 4 residents reviewed for abuse/neglect. R19 was transferred using a Hoyer lift and assist of 1 staff member instead of 2 staff members per R19's care plan resulting in a bruise to R19's right forearm. Findings include: The facility policy entitled Abuse Prevention last approved on 6/2022 documents: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. PREVENTION- A. The community will develop and implement policies and procedures to aid our community in preventing and prohibiting all types of abuse, neglect, or mistreatment of our residents. C. Implement preventative measures to address factors that may lead to abusive situations. 9. Identification, ongoing assessment, care planning, and appropriate interventions and monitoring of residents with needs and behaviors that may lead to conflict and neglect. The facility policy entitled…

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

Based on interview and record review the facility did not report 3 allegations of abuse/neglect for 1 Resident (R36) of 4 residents reviewed for allegations of abuse, neglect, misappropriation, or injury of unknown origin allegations, immediately to the Nursing Home Administrator or to the State Agency within the required timeframe. *An allegation of verbal abuse was observed between R36's family and R36 which was alleged to have occurred on 08/11/2024. This incident was not reported to Nursing Home Administrator (NHA)-A until 08/15/2024. NHA-A reported the allegation of verbal abuse on 08/16/2024 at 03:06 PM to the State Agency. *An allegation of physical abuse was alleged to have occurred between R36's family and R36 on 08/10/2024 and 08/11/2024. It was not reported to NHA-A until 08/17/2024. The allegation of physical abuse was not reported to the State agency, law enforcement, or APS until 09/18/2024 during survey. *On 6/2/24, an allegation of neglect was reported to Registered Nurse (RN)-G related to R36. The allegation was not reported to NHA-A or the State Agency within…

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 interviews, the facility did not ensure a thorough investigation was completed for 3 allegations of abuse/neglect for 1 (R36) of 4 residents reviewed for alleged abuse investigations. *The Facility did not ensure a thorough investigation was completed related to the allegation of verbal abuse of R36 by R36's daughter which was to have occurred on August 11, 2024. *The Facility did not ensure a thorough investigation was completed related to the allegation of physical abuse of R36 by R36's daughter which were identified during the investigation of the August 11, 2024, alleged verbal abuse. *On 6/2/24, Registered Nurse-G documented R36's daughter expressed a concern R36 was left up for 40 hours continuously and the Facility did not investigate the allegation of neglect. Findings include: The Facility policy, titled, Abuse Investigation and Reporting, with a last revised date of 11/2023, documents in part, . Role of the Administrator or designee: A If an incident or suspected incident 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 interview and record review the facility did not ensure that 1 (R36) of 13 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. * R36's family member was denied regular visitation and the facility implemented appointment only supervised visitation with R36's family member. An assessment and monitoring of how the decision was affecting R36 was not completed. No meetings with R36's Family member and Power of Attorney for Healthcare (HCPOA) were conducted to establish how visits with R36's family would continue in the future. Findings include: R36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anxiety Disorder, and Alzheimer's Disease. R36's medical record indicates R36 has an Activated Power of Attorney for Health care (HCPOC). R36's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/5/24 documents R36's Brief Interview for Mental Status (BIMS) not able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not make a prompt effort to resolve grievances for 4 (R4, R5, R6, & R7) of 4 residents reviewed for grievances. *On 11/13/23, R4 voiced concerns to the facility that R4 was not dressed or gotten out of bed until 2nd shift and did not receive a shower. The facility did not follow up with R4 to ensure that after speaking with staff there were any further concerns regarding not getting dressed, getting out of bed, or being showered. R4's grievance does not include the date the written decison was issued. * On 11/13/23, R5 voiced a concern to the facility that R5 was not dressed until 2nd shift. R5's grievance does not include a summary of findings or a conclusion. After interviewing staff, the facility did not follow up with R5 to see if there were any further concerns regarding not getting dressed. R5's grievance does not include the date a written decision was issued. * On 1/24/24, R7's representative filed a grievance about R7 not receiving a shower, that R7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility did not ensure that 1 (R1) of 2 Residents reviewed received required assistance with their ADL's (activities daily living). R1 did not receive their weekly showers/baths consistently per their plan of care. Findings include: R1 was admitted to the facility on [DATE] & discharged on 2/3/24. R1's diagnoses includes Parkinson Disease, status post Left Hip Fracture, CKD (Chronic Kidney Disease) and CLL (Chronic Lymphocytic Leukemia). The admission MDS (minimum data set) with an assessment reference date of 1/10/24 has a BIMS (brief interview mental status score of 15) which indicates that R1 is cognitively intact. R1 is assessed as requiring substantial/maximal assistance for showering/bathing self. The ADL (activities daily living)/rehabilitation potential care plan with a start date of 1/5/24, includes an intervention dated 1/5/24 that documents BATHING: I need extensive assistance with 2 person staff support. I prefer a shower. R1's progress notes from 1/5/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents received needed care and services based on professional standards of practice for 1 (R2) of 2 residents reviewed. R2 was determined to be at risk for weight loss and had a physician's order for weekly weights. The facility failed to obtain weekly weights per R2's physician's order for eleven weeks. As evidenced by: The facility's weight monitoring policy dated as last reviewed on January 2023 and titled, Weight Monitoring documents under the Policy Interpretation and implementation section A. Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter. R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia following Cerebral Infarct (stroke) affecting Left side, Diabetes Mellitus Type II, Dysphagia, and Obesity. R2's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 8, indicating R2 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that necessary treatment and services were provided, consistent with professional standards of practice, to prevent and promote healing of pressure injuries for 1 (R3) of 3 residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE], the facility did not thoroughly assess R3's wounds until 1/4/2024. Assessments included measurements but did not include a thorough assessment of the wound. R3 did not have clarification orders for R3's right buttock and left gluteal wounds on admission. Findings include: The facility policy entitled Skin Identification, Evaluation and Monitoring revised 11/2022 states: The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings. Procedure: Licensed nursing associate will evaluate 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, interview and record review the facility did not ensure 2 (R2 and R4) of 3 residents received the necessary services to prevent falls/accidents. The Facility did not thoroughly investigate R2's and R4's falls to identify a root cause and implement preventative interventions to prevent falls/accidents in the future. Findings include: On 1/23/24 the facility policy titled Accidents and Incidents-Investigating and Reporting dated 01/24 was reviewed and read: The following information shall be included in the investigation, as applicable. The circumstances surrounding the accident or incident. The names of the witnesses and their accounts of the accident or incident. Follow up information. Other pertinent data as necessary. 1.) R4 was admitted to the facility on [DATE] with diagnosis that included osteoporosis and dementia. R4's initial Minimum Data Set (MDS) dated [DATE] indicated R4 was totally dependent on 2 or more staff with transfers. R4's MDS also indicated a score of 6 (severe cognitive…

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 interview, the facility failed to ensure medications were available for administration for two (Residents (R)1 and R2) upon readmission to the facility following a hospitalization out of a sample of nine residents. This had the potential to have adverse health issues for both residents. Findings include: 1. Review of R1's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an original admission date of 09/17/21 and a readmission date of 09/30/23. Review of R1's Physician's Orders located in the EMR under the Orders tab, revealed a physician's order to admit resident to skilled level of care, dated 09/30/23. Review of R1's 10/2023 Medication Administration Record (MAR) provided by the facility revealed the following medications were not administered to R1 on 10/01/23: 0600 [6:00 AM] Diclofenac 1% topical gel every 6 hours bilateral knees, for pain 0800 [8:00 AM] Metamucil Fiber Gummy Chew, 3 gummies, for constipation 0800 [8:00 AM] Sodium chloride…

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 10. R15 was admitted to the facility on [DATE] with diagnoses including, major joint replacement, infection following a procedure, weakness, unsteadiness on feet, depression and Alzheimer's disease. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15 required extensive assist of 1 staff for toileting and transfers. Section D which assesses Mood documented R15 should have a mood interview conducted however the assessment is blank besides a 0 documented for trouble sleeping. Section G which assesses function status documented an 8, meaning activity did not occur during the lookback period for dressing, eating and personal hygiene and documented a 7, meaning occurred once during the look back period, for toileting. A review of progress notes during that time did not indicate these activities did not occur. R15's Quarterly MDS, dated [DATE], documented a BIMS should be conducted for R15 however…

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

Based on observation, interview and record review the facility did not ensure 2 of 3 medication rooms were free from expired medications. Surveyor observed the 2nd floor medication room and 1st floor rehab unit medication room. Expired medications were observed in both medication rooms. This had the ability to affect total of 38 residents. Findings include: On 6/22/23 at 9:15 a.m. Surveyor observed 2nd floor medication room with Director of Quality C. Surveyor noticed a bottle of chewable antacid 500 mg that expired June 2022 and a bottle of polyethylene glycol that expired 2/2023. Director of Quality C stated she would dispose of it. On 6/22/23 at 9:26 a.m. Surveyor observed the rehab medication room with Director of Quality C. Surveyor noticed 3 bottles of 60 tables of melatonin 3 mg that expired 1/2023. Director of Quality C stated she would dispose of it. Director of Quality C stated the nursing staff is responsible for disposing of expired medications.

Based on interview and record review the facility's Quality Assurance Committee did not ensure a system was in place to measure the success of implemented performance improvements, and track performance to ensure that improvements are realized and sustained for the accurate completion of 11 of 14 Minimum Data Set Assessments reviewed for R10, R16, R29, R31, R17, R20, R34, R13, R2, R15, and R303. * During the recertification survey from 06/19/23 - 06/22/23, the Survey team identified concerns with inaccurate and incomplete Minimum Data Set (MDS) Assessments which were partly a result of a lack of Certified Nursing Assistant (CNA) charting. The facility had identified an issue with the lack of CNA charting and implemented improvements, but did not have a plan to measure the success of the improvements nor a plan to track the performance. (Cross Reference F641) Findings include: Facility policy entitled, Quality Assurance and Performance Improvement Program (QAPI), last approved date of 09/2022 documented, The primary purpose of the Quality Assurance and Performance Improvement Program…

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 interviews, the facility did not always ensure that 2 out of 2 residents ( (R302, R51) who were discharged from the facility had a discharge summary that included all the pertinent information, a final summary of the resident; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. * R302 was discharged back into the community and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition of moving back into the community. * R51 was discharged from the facility on 5/9/23. The facility's Universal Transfer form which documents a recapulation of R51's stay was incomplete. R51's medical record did not include a recapitulation of R51's stay, nor did R51's medical record include information pertaining to R51's discharge. This is evidenced by: Surveyor reviewed the facility's policy: Transfer or Discharge,…

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 interviews, the facility did not always ensure that they provided care and treatment, based on a comprehensive assessment, for 1 out of 4 residents (R17) reviewed who had a pressure ulcer. * R17 was readmitted to the facility, after being at the hospital for 6 days, and staff stated that R17 had a stage #3 pressure injury to the coccyx. The facility staff did not comprehensively assess the wound upon readmission and did not verify treatment orders with the physician. This wound was discovered on 4/11/23 and the facility did not provide a comprehensive assessment of the wound until 4/18/23. This is evidenced by: Policy Review; Skin Identification, Evaluation and Monitoring revised 11/2022 Purpose: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion. Procedure: ( includes) Upon admission:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident received needed supervision and assistance to prevent accidents for 2 (R303 and R15) 6 residents reviewed for accidents. *R303 sustained a fall and the facility did not provide an individualized fall intervention. *R15 sustained multiple falls and the facility did not thoroughly investigate the falls to determine a root cause and to establish and provide individualized person centered interventions to prevent potential further falls from occurring. Findings include: The facility policy entitled, Fall Policy with a last approved date of 01/2022 documented, The purposes of this procedure is to provide guidelines for the evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall .The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates .The falls should be reviewed at 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, record review and staff interviews, the facility did not always ensure that 2 out of 2 residents ( R17, R34) who were at nutritional risk had a nutrition risk assessment received the proper assessment and care planning to help maintain acceptable parameters of nutritional status. * The facility conducted a nutritional risk assessment for R17 upon re-admission on [DATE]. The assessment indicated R17 weighed 94.2 pounds and weights were stable. The assessment indicated R17 was at risk for unintended weight loss and should be weighed weekly. R17 was noted to have a 7.7 % weight loss in 1 month (May 11- June 13, 2023). The facility did not update R17's plan of care to reflect the significant weight loss and provide additional interventions to avoid further weight loss from occurring. * The facility conducted a nutritional risk assessment for R34 upon her admission dated 3/23/23. The assessment indicated R34 weighed 141.2 pounds and was at risk for unintended weight loss, there were no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure the physician reviewed the pharmacy recommendation timely for 1 (R15) of 5 residents reviewed for pharmacy recommendations. * R15's pharmacy recommendation from 02/11/23 recommended discontinuing R15's Tylenol PM. The same recommendation was made on 2/25/23, 3/6/23, 4/3/23, 5/1/23 and 6/5/23. R15's medical record did not contain documentation the physician was made aware of this recommendation. Findings include: Facility policy entitled, Procedure: Medication Regimine [sic] Review for Nursing, last approved on 09/2022, documented, .The pharmacist reports any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports are acted upon in a manner that meets the needs of the residents .C. For non-urgent recommendations, the facility and the Attending Physician must address the recommendations in a timely manner that meets the needs of the resident-but no later than their next routine visit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R15) of 5 residents on psychotropic medications received the necessary behavior monitoring. * R15 received two anti-depressants without monitoring for effectiveness. Findings include: Facility policy entitled, Behavioral Assessments, Intervention and Monitoring, last approved on 01/2022 documented, .Residents with behavioral expressions and those on a psychotropic medication will have their behaviors monitored routinely. R15 was originally admitted to the facility on [DATE] and then returned to the hospital on [DATE]. R15 was re-admitted to the facility on [DATE] with diagnoses including, Major Joint replacement, infection following a procedure, Alzheimer's disease and depression. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15's mood was not assessed and R15 received an antidepressant seven out of the last seven days.…

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.