Elkins Rehabilitation & Care Center

Based on observation and staff interview, the facility failed to provide care and treatment in a dignified manner. Staff signed and dated a dressing after it was affixed to Resident #69's body. This is true for one (1) of one (1) reviewed for wound care. Resident identifier: # 69. Facility census: 103. Findings included: a) Resident #69 On 10/25/23 at 8:50 AM Nurse Practitioner (NP) #32 was observed performing wound care and a dressing change on Resident (R) #69's buttocks. After cleaning the wounds, NP #32 applied two clean dressings onto R #69's buttocks. NP #32 signed and dated both dressings after they were affixed to the resident's body. An interview was conducted immediately after this observation with the wound care team: NP #32, Licensed Practical Nurse (LPN) #74 and LPN #124. All three nurses reported they were unaware they should not sign and date a dressing after it is applied to a resident's body. During an interview on 10/25/23 at 9:00 AM the Director of Nursing (DON) agreed staff writing on a dressing after it is affixed to the resident's body is a dignity concern. 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 medical record review and staff interview the facility failed to notify the physician and resident representative of a change in condition. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long-Term Care Survey Process. Resident # 91 had a significant weight loss and the physician and resident representative was not notified. Resident identifier: #91 Facility census: 103 Finding included: a) Resident #91 A medical record review on 10/25/23 for Resident #91 indicated there was a significant weight loss. On 07/04/23 the resident's weight was 137 pounds and on 08/13/23 her weight was 115 pounds. This was calculated at a 16 percent weight loss of 22 pounds. There was no evidence the physician or the resident representative was notified regarding the change in condition. In an interview with the Nursing Home Administrator and the Director of Nursing on 10/25/23 at 9:40 AM, both verified the physician and the Resident Representative had not been notified of the significant weight loss for Resident #91.

Based on record review and staff interview the facility failed to follow Physicians order for medication administration and failed to have an order for pressure ulcer care. Resident Identifiers: #17 and #12. Facility Census: #103 Findings included: a) Resident #17 On 10/24/23 at 10:22 AM record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment. During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, record review, and staff interview, the facility failed to assist a resident in locating his lost hearing aide This was true for one (1) out of ( 2) residents reviewed for communication. Resident identifier #90. Facility census: 103. Findings included: a) Resident #90 During an initial interview on 10/23/23 at 11:15 AM, Resident #90 stated, Can you speak up, I can't hear without my hearing aide. Surveyor observed a hearing aide in Resident #90's left ear. Resident #90 stated, I am supposed to have hearing aides in both of my ears, they lost one of them. I haven't had it for a long time. When asked if he had reported it to anyone? Resident #90 stated, I have told all kinds of people I am not sure who they was. Resident #90 has a BIMS of 14 indicating he is cognitively intact. A record review on 10/24/23 at 9:00 AM, found on Resident #90's admission Nursing assessment dated [DATE] the resident was admitted with hearing aides in both ears. During a record review on 10/24/23 at 9:15 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 record review and staff interview the facility failed to provide care to a pressure ulcer injury in order to promote healing. Resident Identifiers: #17. Facility Census: #103 Findings included: a) Resident #17 On 10/24/23 at 10:22 AM, a record review of Resident #17's care plan found she had a stage IV pressure injury to her sacrum. Review of her current orders found no Physicians order for pressure ulcer treatment. During an interview on 10/25/23 at 10:00 AM Licensed Practical Nurse Wound Nurse Assistant #124 confirmed Resident #17 did have an open, stage IV pressure injury to her sacrum. She stated the wound care team failed to reassess a treatment order that was limited to fifteen (15) days for the pressure injury treatment. Wound care was provided on 10/18/23 and then the order fell off the Treatment Administration Record (TAR) due to the fifteen (15) day restriction on the antibiotic order. Therefore the pressure injury wound has not been treated for the last six (6) days. This was confirmed by documentation on the TAR for October. The pressure injury was being treated…

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 medical record review, resident interview, observation and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Morning medications were left in Resident #37's room unsupervised and not taken until hours later. Antifungal powder was left on R #90's dresser. These were random opportunities for discovery. Resident identifiers: R #37 and R #90. Facility census: 103. Findings included: a) Resident (R) #37 During an interview and observation on 10/23/23 at 12:22 PM, R #37 retrieved a medicine cup containing 12 pills/tablets from his desk. When questioned, R #37 reported they were his morning medications that the nurse left for him to take. R #37 stated he took one pill, the rest included psyche meds for his head so he didn't take them. On 10/23/23 at 12:27 PM, Licensed Practical Nurse (LPN) #179 acknowledged she left the pills in there this morning and added the resident stated he would take them. LPN #179 said she would go get the pills. Review of the medical record on 10/24/23 found LPN #179 signed out…

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 staff interview, the facility failed to ensure complete and accurate medical records. Resident #204's capacity status was incorrect in PointClickCare (the facility's electronic medical record software.) Resident #37's code status order was incorrect and did not match resident's Care Plan or resident's preference. This is true for two (2) of four (4) residents reviewed for Advanced Directives. Resident identifiers: Resident #204 and Resident #37. Facility census: 103. Findings included: a) Resident #204 When first opening Resident #204's electronic medical record, on 10/23/23 at 4:09 PM, the viewer immediately saw resident's name, gender, date of birth , age, physician, allergies, and code status. The code status was listed as DNR (Do Not Resuscitate), HAS Capacity. The Physician Determination of Capacity, dated 10/13/23, reflected Resident #204 LACKS capacity. During an interview on 10/24/23 at 1:22 PM, Licensed Practical Nurse (LPN) Clinical Supervisor #16 confirmed the error in the medical record and stated she felt it must have happened because two (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . e) Resident #47 On 07/25/22 at approximately 1:20 PM, an observation was made during incontinence care for Resident #47. Nurse Aide (NA) #72 and NA #78 were observed throwing dirty linen and a soiled brief on the floor without a barrier leaving a wet spot directly on the floor. On 07/25/22 at 1:27 PM, NA #78 stated, I forgot, when asked about using a barrier during incontinence care. NA #72 made no statement. Licensed Practical Nurse (LPN) # 77 confirmed the dirty linen and the soiled brief should not be put directly on the floor and the items were not discarded into a designated container. The facility policy entitled Perineal Care, step #11 states, Discard disposable items into designated containers . On 07/25/22 on 1:44 PM, the Director of Nursing (DON) was notified. The DON stated I'm embarrassed .I'm sorry. No further information was obtained during the survey process. f) Resident #20 On 07/25/22 at 11:26 AM, Resident #20 was found to be in a transmission-based precaution room for droplet precautions for…

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

Based on observation and staff interview, the facility failed to ensure two (2) of 28 sampled residents had a dignified dining experience. Staff stood over residents while assisting them to eat. Resident identifiers: #70 and #57. Facility census: 86. Findings included: a) Resident #70 Observation at 11:42 AM on 07/26/22, found the resident received his noon meal. The resident was in his room, in bed when the meal was served. Nurse Aide (NA) #118 was standing beside the bed looking down on Resident #70 while feeding him. NA #118 was asked if she should sit down when feeding the Resident? NA #118 replied, he's a feeder and I stand up when I feed him. b) Resident #57 On 07/26/22 at 11:45 AM, NA #17 was observed standing by Resident #57's bed looking down on the resident while feeding him the noon meal. Resident #57 was in bed. NA #17 said she usually doesn't sit down when feeding Resident #57. On 07/26/22 at 1:25 PM, the administrator said a nursing assistant should sit down when feeding a resident. The administrator asked if the residents were eating in their rooms? The surveyor…

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 failed to recognize the resident's right to formulate an advance directive. This was true for one (1) of seven (7) residents reviewed for the care area of advance directives. Resident identifier: #136. Facility census: 86. Findings included: a) Resident #136 Review of the electronic medical record found the Resident was a full code. Review of the current care plan found the following focus: Resident elects to be a Full Code, dated 07/13/22. The Resident was admitted to the facility on [DATE]. The Resident's daughter, the Medical Power of Attorney (MPOA) completed the resident's admission paperwork on 07/13/22. On 07/15/22, the Resident's physician completed a History and Physical (H&P) and hand wrote the following: Here for long term care. He is a full DNR (Do Not Resuscitate) per his request but cannot make other health decisions without help from MPOA. The physician also checked the following Code Status on the H&P, Do Not Resuscitate. On 07/25/22 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 observation, staff interview and record review the facility failed to implement their abuse policy by reporting all injuries of unknown origin and thoroughly investigating all injuries of unknown origins to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) resident reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86. Findings included: a) Resident #42 Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color. A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which was 5.0 centimeters X…

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, record review and staff interview the facility failed to immediately report an injury of unknown origin to appropriate State agencies within the appropriate time frames. Resident #42 had a deep purple bruising to the left side of the head and to both sides of her neck. There was no indication the facility knew how this injury occurred and there was no evidence this injury was reported. This was true for one (1) of one (1) reviewed for the care area of skin conditions non -pressure related. Resident Identifier: #42. Facility Census: 86. Findings Included: a) Resident #42 Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color. A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which 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, staff interview and record review the facility failed to ensure all injuries of unknown origin are thoroughly investigated to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) residents reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86. Findings included: a) Resident #42 Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color. A review of Resident #42's medical record on 07/26/22 found a Non Pressure Skin Report which indicated the resident had bruise to the left side of face which was 4.5 centimeters X 1.8 centimeters X 0 centimeters depth, a bruise to the right side of the neck which was 5.0 centimeters X 3.0 centimeters X 0 centimeters depth. and a bruise to the left…

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 staff interview the facility failed to review and revise the care plan when Resident #73 chose not to continue Hospice Care. This was true for 1 (one) of 28 sampled residents. Resident identifier: 73. Facility Census: 86. Findings Included: a) Resident #73 On 7/25/22 at 11:15 AM while reviewing medical records for Resident #73, it was noted the Resident was receiving Hospice Care. After reviewing the current orders, there was no order for the Resident to receive Hospice Care. Review of the current care plan found the resident was receiving Hospice Services. An interview on 7/26/22 at 1:14 PM, with the Administrator, confirmed Hospice Care was declined on 7/15/22 and the care plan was not revised. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure Resident #75 only received medications when ordered by the attending physician. Resident #75 received Tramadol on an as needed basis (PRN) from 02/13/22 through 02/20/22. Resident #75's attending physician indicated he never gave the facility an order to administer Tramadol. This was true for one (1) of one (1) resident reviewed for the care area of pain management. Resident Identifier: #75. Facility Census: 86. Findings Included: a) Resident #75 A review of Resident #75's medical record found a nursing progress note dated 01/11/22 (Resident was admitted to the facility on [DATE]) which read as follows, Received Fax from (Name of Attending physician) New orders as follows: Change Isosorbide mononitrate 10 mg tid (three times a day) to isosorbide mononitrate ER 30 mg by mouth dialy in am. Also stop Tramadol PCC (point click care) orders updated. Resident #75 was admitted from hospital with a prescription for Tramadol which was discontinued…

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 failed to ensure two (2) of eight (8) residents review for the care area of pressure ulcers received care consistent with professional standards of practice to heal or prevent pressure ulcer development. Resident Identifiers: #57 and #70. Facility Census: 86. Findings included: a) Resident #57 While reviewing medical records it was noted Resident #57 was admitted on [DATE]. He was assessed as having a Stage III pressure ulcer upon admission. It was noted by the admitting Licensed Practical Nurse (LPN) #124 on 5/20/22 that the resident was admitted to facility with an open area to the coccyx. According to the wound evaluation completed by Facility Nurse Practioner (FNP)/Wound Nurse #176 on 05/24/22 with treatment orders included, the resident had a Stage III pressure ulcer, it was 4 (four) days old from admission and present on admission to the right buttock. The FNP wrote the following order for treatment: Cleanse stage III PI (pressure injury) to coccyx…

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 staff interview the facility failed to ensure the residents environment over which it had control was as free from accident hazards as possible. This has the potential to effect more than an isolated number of residents. For Resident #70 the facility failed to investigate bruising on the Residents forearms to possibly identify any hazards/risks, implement interventions to reduce any hazards/risks and monitor for the effectiveness of any interventions. Resident #69 had medication in the room. In addition, medication was left unattended on top of the medication cart. Resident identifiers: #70 and #69. Facility census: 86. Findings included: a) Resident #70 Review of the Skin/Wound notes in the electronic medical record found the following: -05/09/2022 at 11:21 AM Skin/Wound Note Note Text: Bruising on back of left hand is resolving well. Faded red in color. Resident denies pain to area. -05/16/2022 at 7:11 AM Skin/Wound Note Note Text: Bruising back of left hand is faded…

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 staff interview the facility failed to ensure a resident with an ileostomy had physician orders for ileostomy care. This was a random opportunity for discovery. Resident Identifier: #1. Facility Census: 86. Findings included: a) Resident #1 On 7/25/22 at 11:30 AM, during the initial survey interview process Resident #1 stated she didn't feel well because she recently returned from the hospital and her stomach was upset. She proceeded to inform the surveyor she had an ileostomy due to surgery last year. While reviewing her current medical records and orders it was noted there are no orders for ileostomy care to be provided by staff. This was confirmed with the Administrator on 7/27/22 at 9:34 AM. .

Based on record review and staff interview the facility failed to have an accurate and completed staff posting. This failed practice had the potential to affect a limited number of residents that reside in the facility. Facility census 86. Findings included: a) Staff posting The staff posting form for 07/13/22, found Only the day shift section was completed for 7a-3p. The facility census, evening and night shifts were not completed. During a review of the facility postings for the last four weeks the following postings were not corrected to reflect the actual hours worked: *07/23/22 staff posting had 3.81, the typed report provided by Administrator had 3.77 Hours Per Patient Day (HPPD). *07/21/22 staff posting had 4.8 HPPD, the typed report provided by Administrator had 4.5 HPPD. *07/20/22 staff posting had 4.54 HPPD, the typed report provided by Administrator had 4.20 HPPD. *07/19/22 staff posting was 3.93 HPPD, the typed report provided by Administrator had 3.83 HPPD. On 07/27/22 at 2:37 PM, Administrator was shown the inaccurate staff posting. No further information was provided.…

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 failed to ensure pharmaceutical services were provided to each resident to meet their needs and to ensure an accurate reconciliation of each controlled substance. Resident #75 was administered tramadol after the medication was discontinued in part because the medication was not removed from the medication cart in a timely manner after the discontinuance of the drug. In addition when the remaining tramadol were destroyed the licensed pharmacist was the only person to sign the Disposition of Drug section. This was a random opportunity for discovery and was true for Resident #75. Resident Identifier: #75. Facility Census: 86. Findings Included: a) Resident #75 A review of Resident #75's medical record found a nursing progress note dated 01/11/22 (Resident was admitted to the facility on [DATE]) which read as follows, Received Fax from (Name of Attending physician) New orders as follows: Change Isosorbide mononitrate 10 mg tid (three times a day) 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.

Based on record review and staff interview the facility failed to ensure medication irregularities identified by the Pharmacist, and accepted by the physician were implemented. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #1 Facility Census: 86. Findings Included: a) Resident #1 On 7/27/22 at 9:00 AM while reviewing medical records it was noted on the October, 2021 Consultation Report from the pharmacist, the Physician accepted the recommendation to change the timing on a medication (Bumex) from 9:00 PM to earlier in the evening due to this being a diuretic. This was not completed. On the 06/2022 Consultation Report from the pharmacist, the Physician accepted the recommendation to have the Residents Hemoglobin A1C laboratory level checked and monitored. This was not completed and there are no orders to monitor the A1C in the future. These two findings were confirmed with the Administrator on 7/27/22 at 9:34 AM. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 86. Findings included: a) Initial tour of the kitchen During the initial tour of the kitchen on 07/25/22 at 10:48 AM, with the dietary manager, observation found a large silver tray containing strips of uncooked bacon in the walk - in refrigerator. There was no date on the tray of bacon to determine when the bacon was removed from the original packaging or when the bacon would expire and need to be discarded. In addition a plastic bag containing at least 10 hot dog [NAME], removed from the original packaging, was present on a storage cart in the walk- in refrigerator. There was no date to determine when the hot dog [NAME] were opened or would the [NAME] would need to be discarded. The Dietary Manager provided no explanation for the above observations. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the medical records for Resident's #136 and #42 were accurate and correct. This was true for three (3) of 28 resident records reviewed during the long term care survey. Resident identifiers: #136 and #42. Facility census: 86. Findings included: a) Resident #136 Medical record review found the resident was admitted to the facility on [DATE]. On 07/13/22 a nursing admission assessment was completed indicating the resident had no pressure ulcers. The only skin issue was healed scratches to the feet. On 7/16/22 a pressure ulcer assessment, noted a Deep Tissue injury (DTI) to the left buttock. On 07/26/22 at 1:00 PM, the wound treatment nurse, Licensed Practical Nurse (LPN) #14 said the resident never had a pressure ulcer. A weekend nurse wrote that but I came in and looked on Monday and there is no pressure ulcer. I guess I should have clarified that somewhere in the medical record. The nurse surveyor observed the resident and found 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.