Nella's At Autumn Lake Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure documentation that required transfer information was provided to the receiving hospital. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for care area of hospitalization. Resident identifier: #21. Facility census: 91. Findings included:a) Resident #21 Review of Resident #21's electronic medical records showed the resident was transferred to the hospital on [DATE] due to a fall, altered mental status, and an elevated blood glucose level. Further review of Resident #21's electronic medical records did not reveal documentation regarding what information was sent to the hospital to which the resident was transferred. On 08/04/2025 at 3:07 PM, the Director of Nursing (DON) provided a document titled Acute Care Transfer Document Checklist. The document had Resident #21's name written on it, along with the date 07/13/25. The document gave the following instructions: Copies sent with resident, check all…

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 record review and staff interview, the facility failed to accurately reflect the resident's diagnoses in the assessment. This was found to be true for one (1) of twenty-seven (27) residents reviewed during the annual survey process. Resident identifier: #9. Facility census: 91.Findings included: a) Resident #9 A review of the electronic health record reflects the Resident has the following diagnoses related to mental health:ANXIETY DISORDER, UNSPECIFIED 6/17/2024MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 6/17/2024POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED 6/17/2024 The most recent Minimum Data Set (MDS) assessment was completed on 06/26/25. Under Section I: Active Diagnoses, Psychiatric/Mood Disorder, the facility only marked Post Traumatic Stress Disorder. Anxiety disorder or depression were not marked. These findings were reviewed with the Director of Nursing (DON) on 08/04/25 at 1:00 PM. The DON acknowledged the error.

Based upon record review and staff interviews, the facility failed to update the Pre-admission Screening and Resident Review (PASARR) when new diagnoses were given. This was found to be true for two (2) of eight (8) residents reviewed during the annual survey process. Resident identifiers: #9, #42. Facility census: 91. Findings included: a) Resident #9 A review of the electronic health record reflected the Resident had the following diagnoses related to mental health:ANXIETY DISORDER, UNSPECIFIED 6/17/2024MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 6/17/2024POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED 6/17/2024 The resident's most recent Pre-admission Screening and Resident Review (PASARR) was completed on 09/25/24 by the facility. Under the section III, MI/MR, Current Diagnosis, None was marked. There is a box for Major Depression, but it was not selected. There is also a selection for Other Relation Conditions, and it was not marked. Post Traumatic Stress Disorder (PTSD) and Anxiety could have been specified in that section. The resident's Medical…

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 upon record review and staff interview, the facility failed to provide medically-related social services to assist the resident in attaining or maintaining their mental and psychosocial health. This was found to be true to one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #9. Facility census: 91. Findings included:a) Resident #9Upon admission to the facility on [DATE], the Resident had a diagnosis of Post Traumatic Stress Disorder (PTSD), Anxiety and Major Depressive Disorder, Recurrent and Severe. The diagnosis for PTSD was also found on her Pre-admission Screening and Resident Review Assessment. A review of her medical record documents revealed, a Social Service Assessment, was performed by the Director of Social Services on 06/20/24. Section G of this document consisted of a Trauma Screen. The resident responded No to all the questions, thus scoring negative for trauma. Resident #9's care plan document stated she had a communiction problem related to choosing…

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 policy review, record review and staff interview, the facility failed to provide specialized rehabilitation services for speech therapy. This failed practice was found to be true for two (2) of two (2) residents during the annual survey process and had the potential to affect a limited number of residents. Resident Identifiers: #6 and #84. Facility Census: 91. a) Resident #84 A record review on 08/04/25 at 11:45 AM, revealed that Resident #84 was ordered a regular diet, regular texture, thin liquids diet on 02/07/25. The diet was changed on 07/25/25 to a regular diet, puree texture, thin liquids. A record review of Resident #84's weights shows that her actual admission weight, taken the day after admission was 116.4 pounds (lbs.) and her current weight taken on 07/07/25 was 110 lbs. Further record review revealed that Resident #84 had ordered supplements throughout the weight loss but had not had any Speech Therapy Consults before her diet was downgraded to the puree texture. During a telephone…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow appropriate infection control practices during medication administration. The facility also failed to follow enhanced barrier precautions. These were random opportunities for discovery. Resident Identifiers: #27 and #6. Facility Census: 91.Findings included:a) Resident #27 The facility's policy titled Medication Administration, with no date of implementation or revision documented, gave instructions to take care not to touch medications with bare hands while removing the medications from their source. On 07/31/2025 at 9:23 AM, Registered Nurse (RN) #33 was observed administering medications to Resident #27. The medications were contained in blister packs. Each dose was individually sealed within the pack and needed to be pushed through the package by the nurse.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interviews and staff interviews, the facility failed to ensure resident room temperatures were maintained between 71 to 81 degrees Fahrenheit (F). This failed practice has the potential to affect more than a limited number of residents. Facility census: 87. Findings include: An unannounced complaint investigation was conducted. Upon entering the building, an interview was conducted with Registered Nurse (RN) # 42 at 9:20 AM. When asked if the building was hot on 06/29/24. RN # 42 answered it was hot especially on B side of the building. I understand parts have been ordered. After meeting with the Nursing Home Administrator (NHA) and providing a request of documents and electronic medical record access, a tour was conducted on the A Hall at 12:22 PM. The outside temperature was 77 degrees F at the time. Observations of the resident rooms on the A Hall found the following concerns: 110 No air conditioning (AC) 104 Resident #49 complained the room was too hot and the AC unit was 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 observation, resident interview and staff interview, the facility failed to maintain a functioning room air conditioner when water was leaking from the air conditioning unit in room [ROOM NUMBER] on A Hall. Facility census: 87. Findings include: a) room [ROOM NUMBER] On 07/02/24 at 12:46 PM Resident #50 stated, the air conditioning unit had been leaking into the floor from the time she was admitted which was about a year ago. She stated, they put towels around it because the water runs down the floor. Resident #50 stated, she was afraid she could fall with the water in the floor. An observation of the unit found the filter was partially pulled out and was wet. The unit fan would not turn on. NHA was told about the leak at 1:40 PM on 07/02/24. An interview with the Maintenance Director on 07/03/24 at approximately 9:30 AM confirmed he didn't have a work order regarding the unit leaking. He stated, the drain tube was plugged up and had been opened. An additional observation found the floor dry and the…

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

Based on observation, policy review, resident council meeting minutes, and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility also failed to make grievances forms accessible to all residents and/or residents' family/representatives residing in the facility. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 79. Findings Included: A review of the facility policy titled Grievances/Complaints Filing with a revision date of 10/2019 read as follows: .Policy Interpretation and Implementation .Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. During the Long-Term Care Survey Process from 11/06/23 to 11/08/23, many observations throughout the facility revealed no evidence of grievance forms were made accessible to the residents and/or resident representatives. During an interview on 11/07/23 at 1:15 PM, the Licensed Practical Nurse (LPN) #22 stated if someone has a grievance or concern I give them the Ombudsman…

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 ensure residents were free from sexually aggressive behavior (such as making sexually explicit comments and forced observation of masturbation and exposure ) from Resident #59. The lack of action from the facility to address and protect the other residents resulted in an immediate jeopardy situation for more than an isolated number of residents. The facility was notified of the immediate jeopardy on 11/07/23 at 5:01 PM. The plan of correction, as follows, was accepted at 6:57 PM on 11/07/23: -Resident #59 will be placed on 24 hour, one on one supervision effective 5:00 pm on November 7, 2023, to protect all residents. Documentation will be done q (every) 15 minutes as to what the resident is doing, and log will be maintained. (Log attached) -An immediate report will be submitted to OHFLAC, APS, and the Regional Ombudsman on November 7, 2023. -Resident #132 will be moved over to B-Side of facility at his request. This will be…

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

Based on record review and staff interview the facility failed to ensure an accurate assessment for five (5) of 19 residents whose Minimum Data Sets (MDS's) were reviewed. Resident identifiers: #31, #15, #56, #36 and #26. Facility census 79. Findings included: a) Resident #31 During a review of medical records found Resident #31 was coded in the Minimum Data Set (MDS) to have Physical Restraints (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.) Observation on 11/06/23 at 12:45 PM, found Resident #31 was seen in his room in the bed sleeping, no physical restraints were being used. On 11/07/23 at 3:20 PM, the Director of Nursing (DON) was asked what type of physical restraints does Resident #31 have? DON said Resident # 31's restraints were discontinued in January. The DON was shown that the resident was coded for having side rails, used daily as a physical restraint. However, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review, and staff interview the facility failed to medicate for pain in a timely manner and failed to evaluate pain using a pain scale to measure the level of pain a resident was experiencing. This is true for two (2) of two (2) reviewed in the care area of pain. Resident identifiers: #132 and #181. Facility census 79. Findings included: a 1) Resident # 132 Observation of the physical condition of the resident found his left leg was very large, with gauze wrapped around the lower part of the leg between the knee and ankle. His left arm and hand appear to have contractures. He was sitting in a wheelchair. On 11/06/23 at 3:04 PM, Resident # 132 said he was admitted on [DATE] and did not get his pain medication for several days. Resident #132 went on to say he had to make the staff send him to a local hospital to get some medicine for his pain in his left leg, groin area and abdomen. He said the facility doctor told him that he ordered pain medication before he went to the…

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

Based on observation and staff interview the facility failed to store utensils in a sanitary manner. This practice had the potential to affect all residents that receive nourishment from the facility kitchen. Facility Census: 79. a) Kitchen Utensils The Certified Dietary Manager (CDM) was not present upon entering the facility. Dietary Aide (DA) #37 oversaw the building on the initial tour of the kitchen on 11/06/23 beginning at 10:54 AM. Tour revealed the following: The three (3) drawer utensils cabinet revealed all utensils were not turned the same way. When someone went to find a serving utensil, they would have had to touch the utensils by the serving part to remove it from the cabinet. During an immediate interview the Dietary Aide (DA) #37 acknowledged the utensils handles should all be turned in the same direction.

Based on resident interview, observation and staff interview, the facility failed to provide residents with furniture in good repair. This was a random opportunity for discovery. Resident identifiers: Resident #17. Facility Census: 79. Findings included: a) Resident #17 During an initial tour of the facility on 11/06/23 at 11:53 AM, Resident #17's over the bed table's trim was loose and hanging off the table on the floor. While Licensed Practical Nurse (LPN) #66 was moving the table, the trim that was loose was on the floor and the LPN was pulling the strip while moving the table. During another observation on 11/07/23 at 11:57 AM, Resident #17's over the bed table's trim was still broken. Resident #17 stated the table has been like this for two months and keeps getting worse. During an interview on 11/08/23 at 9:57 AM, Maintenance #93 acknowledged the table needed to be replaced and should have been when the trim started to come loose.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and record review, the facility failed to report an alleged allegation of sexual abuse to the State Survey Agency, Adult Protective Services, and the Ombudsman. This was a random opportunity for discovery. Resident identifier: #132. Facility census: 79. Findings included: a) Facility Policy- Abuse, Neglect and Exploitation VII. Reporting/Response Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframe's: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . b) Resident #132 Review of the facility's narrative of complaints filed in the last six (6) months on the morning of 11/7/23, provided to the survey team by the Social Worker (SW) #2 found the summary dated 11/04/23: (Typed as written): (Name of Resident #132) reported…

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 interviews, the facility failed to ensure the resident's Pre admission Screening and Resident Review (PASRR) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASRR. Resident #26 was diagnosed with Schizophrenia . The lack of pre-screening resulted in the resident's condition not being evaluated through the Level II PASRR process. Resident identifier: Resident #26. Facility Census: 79. Findings Included: a) Resident #26 During a record review, on 11/07/23 at 10:18 AM, Resident #36's medical record revealed admitting diagnoses included unspecified psychosis and schizophrenia. Further review of the medical record revealed a PASRR dated 03/10/23, Section 30 Current Diagnosis, was coded D. Seizure Disorder, G schizophrenic Disorder was not coded. During an interview on 11/07/23 at 10:29 AM Social Services #2 stated, I did not complete the PASRR, that was a previous facility. SS #2 acknowledged the PASRR was not coded correctly for the Schizophrenia diagnosis on admission.

Based on record review and staff interview, the facility failed to complete neuro checks after an unwitnessed fall. This was a random opportunity for discovery and has the potential to affect a limited number of residents that currently reside in the facility. Resident identifier: #350. Facility census 77. Findings included: a) Resident #350 During a review of reportable made by the facility, Resident #350 had an unwitnessed fall on 11/28/23 at 6:15 AM in the bathroom. Facility policy titled, Neurological Assessment/Evaluation Policy: The nurse performs neurological checks, whenever there is the possibility of a head injury. A neurological evaluation will be performed on any un-witnessed fall. Purpose: Accurate assessment/evaluation, and monitoring for changes in resident's neurological status to allow prompt medical notification/treatment. After the initial assessment, the neurological exam is repeated every 15 minutes x 3 (1hour), every 30 minutes times two (2) hours, every hour for four (4) hours, then every shift for six (6) days. A review of the facility forms named AUTM NEURO…

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 facility failed to ensure adequate supervision was maintained to ensure safety during medication administration for Resident #55. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of Residents. Resident identifier: #55. Facility census: 79 Findings included: On 11/08/23 08:57 AM, observation was made of Licensed Practical Nurse (LPN) #22 briskly walking into the A Hall dining room with a cup of medications and a small cup of water. LPN #22 tapped Resident #55 on the shoulder to wake him. LPN #22 set the cup of mediations on the dining room table, called the Resident by his first name, and told him, Here is your meds. LPN #22 then turned and briskly walked off, leaving the cup of medications on the table in the dining hall. Resident #55 was accompanied by Resident #24 at the table. Resident #55 dumped out the pills onto the dining room table and began to push them around on the table, unsupervised by any staff. During an interview on 11/08/23 at 9:10 AM, LPN…

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 training to all staff (direct and indirect care) that included activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, the procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property and Dementia management and resident abuse prevention. This was true for two (2) of five (5) staff reviewed. Staff identifiers: #81 and #60. This had the potential to affect more than a limited number of Residents at the facility. Facility census: 79. Findings included: On 11/08/23 starting at 8:39 AM, five employee files were reviewed with the Human Resources/Payroll manager, HR #65. a) Dietary Aide #60 Dietary Aide #60 was employed on 10/23/23. The time card report was reviewed with HR #65. DA #60 worked on 10/23/23, 10/24/23, 10/26/23, 10/28/23, 10/29/23, 10/30/23, 11/01/23, 11/02/23, and 11/05/23. HR #65 confirmed DA #60 did not have training in activities that constitute abuse, neglect, exploitation, and misappropriation of…

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

Based on record review and staff interview the facility failed to provide required in-service training for nurse aides which included dementia management training and resident abuse prevention training. This was true for one (1) of two (2) nurse aides reviewed and had the potential to affect more than a limited number of residents. Staff identifier: #81. Facility census: 79. Findings included: a) Nurse Aide #81 On 11/08/23 starting at 8:39 AM, the employee file of NA #81 was reviewed with the Human Resources/Payroll manager, HR #65. Nurse Aide (NA) #81 was employed on 10/12/23. NA #81 had worked the following shifts since her employment: 10/12/23, 10/13/23, 10/14/23, 10/15/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/27/23, 10/28/23, 10/29/23, 11/02/23, 11/03/23, 11/04/23 and 11/05/23. HR #65 confirmed NA #81 did not receive training in activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, the procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property and Dementia management and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, observation, record review and staff interview, the facility failed to ensure that each resident had the opportunity to exercise autonomy regarding preferences that are important to their life. The facility failed to provide meal preferences to a resident who desired to be served eggs for meals. This was true for one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier #59. Facility census: 67. Findings included: a) Resident #59 An interview with Resident #59, on 06/01/21 12:47 PM revealed weight loss. Resident stated, I don't eat much. They said they would serve me breakfast foods all day. This happened for a few days but not anymore, look I got potato soup, pimento sandwich and fruit cocktail. That is a nasty sandwich. An immediate observation of Resident #59's food tray, on 06/01/21 at 12:47 PM revealed a bowl of cream soup, a pimento sandwich and a bowl of fruit cocktail. A brief record review, on 06/01/21 at 1:30 PM, revealed a weight record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with current accepted professional standards. Medications stored in two (2) of (2) medication storage rooms were expired and one (1) of two (2) medication carts inspected did not have medications dated when opened when put in to use. This practice had the potential to effect more than a limited number of residents. Facility census: 67. Findings included: a) Medication Cart (B Side) Observation An observation of the B side Medication cart, on [DATE] at 3:01 PM revealed a stock medication, Ferrous Sulfate 324 mg (milligrams), opened with no date noted. An interview on [DATE], at 3:01 PM, with Licensed Practical Nurse (LPN) #14, revealed the bottle of Ferrous Sulfate was opened and being used. In addition, LPN #14 verified there was no date when the bottle was opened and put in to use. LPN #14, stated further, the facility policy is for stock medications to be…

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

Based on record review and staff interview, the facility failed to ensure one (1) of 18 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifier: #60. Facility census: 67. Findings included: a) Resident #60 A record review, on 06/01/21 at 2:17 PM, found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form on Resident #60's chart. The POST form was signed by Resident #60's Health Care Surrogate (HCS). Under Section E, no information about Resident #60's HCS was provided, leaving the name, address, and telephone number blank. The 2016 edition of Using the POST Form - Guidance for Healthcare Professionals, compiled by the [NAME] Virginia Center for End-of-Life, states: For situations when the person loses or has lost decision-making capacity, the name, address, and phone number of the person legally authorized to make healthcare…

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.