Majestic Care of Manchin

Based on observation, record review and staff interview, the facility failed to complete the daily staff posting. This was a random opportunity for discovery. Facility Census: 25. a) Daily Staff Posting On 04/22/25 at 9:00 AM, an observation of the daily staff posting which was hanging at the nurses' station was made. The staff posting dated 04/22/25 did not have the 7:00 AM to 7:00 PM shift completed with the census, nursing hours, actual nursing hours worked and staffing totals. On 04/22/25 at 9:12 AM, the Administrator was at nurses' station. The Administrator was notified the posting was not completed. The Administrator confirmed the posting was not complete.

Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #4's hospice notes and a nursing assessment regarding contractures for Resident #12. This was true for two (2) of 15 residents reviewed during the survey process. Resident identifiers: #4 and #12. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 8:45 AM, a review of the hospice notes was completed for Resident #4. During the review, Resident #9's hospice notes were found in Resident #4's medical record. On 04/22/25 at 8:50 AM, the Administrator was notified and confirmed the wrong resident's notes were scanned into Resident #4's medical record. The Administrator stated, We will get this taken care of immediately. b) Resident #12 On 04/22/25 at 4:00 PM, a record review was completed for Resident #12. The review found two (2) nursing assessments, dated 03/16/25 and 04/06/25, did not indicate the presence of bilateral hand contractures. On 04/22/25 at 4:30 PM, the Administrator was notified and confirmed the nursing assessments were incorrect.

Based on observation, policy review, and staff interview, the facility failed to ensure the environment was free from accident hazards over which it had control. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier: #5. Facility census: 32. Findings included: a) Sharps Container Overflowing with Disposable Razors in Shower Room Sharps is a term for objects with sharp points or edges that can puncture or cut skin, such as needles, syringes, lancets, and razors. Sharps disposal containers are made from rigid puncture-resistant plastic with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter. Sharps disposal containers are marked with a line to indicate when the container is about three-fourths (3/4) full, and it is time to dispose of the container. On 11/06/23 at 12:45 PM, a random observation made during a facility tour revealed a red, five (5) quart Sharps disposable container…

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 respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #27. Facility Census: #32 Findings included: a) Resident #27 On 11/06/23 at 11:40 AM observation was made of Licensed Practical Nurse (LPN) #5 assisting Resident #27 with her noon meal and was standing while feeding her. This was confirmed immediately with LPN #5, at which time and she told a co-worker, I need a chair. This was confirmed with the Administrator on 11/06/23 at 11:45 AM who stated you are right, she should be sitting.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to conduct an accurate initial minimum data set (MDS) assessment. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #32. Facility census: 32. Findings included: a) Resident (R) #32 Review of the medical record on 11/07/23 revealed R#32 was admitted to the facility on [DATE] with a terminal diagnosis of renal cell carcinoma. The admission medications included the following psychotropic medications: Buspirone (antianxiety), Effexor (antidepressant) and Seroquel (antipsychotic). The pharmacy review dated 10/23/23 notes no recommendations. The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/25/23 identified the administration of an antipsychotic drug and noted a gradual dose reduction (GDR) was last attempted on 10/23/23 per physician documentation. On 11/07/23 at 9:18 AM, MDS Nurse #3 confirmed R#32's MDS was incorrectly coded under section N…

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, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual and staff interview, it was determined that the facility failed to ensure that Resident 10's Quarterly MDS was submitted during the prescribed timeframe. This was a random opportunity for discovery. Resident identifier: #10. Facility census: 32. Finding Included: a) MDS 3.0 Resident Assessment Instrument (RAI) User's Manual Review of the MDS 3.0 RAI Manual (October 2019) Chapter 5 Submission and Correction of the MDS Assessments, subsection 5.2 revealed in part the following: Assessment Schedule: An OBRA (Omnibus Budget Reconciliation Act) assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. b) Resident #10 A brief record review, completed on 11/08/23 at 12:38 PM revealed Resident #10 was admitted to the facility on [DATE]. The last submitted MDS was a Significant Change MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to complete accurate Minimum Data Set (MDS) assessments. This was true for three (3) of 15 sample residents. Resident #1 was coded for a wrong diagnosis, Resident #16's assessment indicated there was a urinary tract infection (UTI) and Resident #32 had an incorrect gradual dose reduction (GDR) date. Resident identifiers: #1, #16, and #32. Facility census: 32. Findings included: a) Resident #1 A medical record review on 11/07/23 indicated the MDS assessment with an Assesment Reference Date (ARD) of 08/02/23 had Section I coded wrong for pneumonia under Active Diagnoses. During and interview with the Director of Nursing (DON) on 11/07/23 at 9:57 AM, reported the MDS assessment had been coded wrong and Resident #1 had not had a diagnosis of pneumonia thus far this year. b) Resident (R) #32 Review of the medical record on 11/07/23 revealed R#32 was admitted to the facility on [DATE] with a terminal diagnosis of renal cell carcinoma. The 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.

Based on record reviews and staff interviews, the facility failed to develop comprehensive person-centered care plans. This was true for two (2) of 15 sample resident's care plans reviewed. Resident #16's care plan was not developed for anticoagulant therapy and Resident #32's was not developed for Hospice services. Resident identifiers: #16 and #32. Facility census: 32. Findings included: a) Resident #16 A medical record review on 11/07/23 of the current physician's orders for Resident #16 had an order for Apixaban (anticoagulant) tablet five (5) milligrams (mg) twice daily for anticoagulant therapy with a start date of 09/13/23. A review of the resident's care plan indicated anticoagulant therapy had not been developed. During an interview with the Director of Nursing (DON) on 11/08/23 at 8:45 AM, verified the care plan for Resident #16 had not been developed for anticoagulant therapy. b) Resident (R) #32 Review of the medical record on 11/07/23 revealed R#32 was admitted to the facility on Hospice services with terminal renal cell carcinoma. The facility care plan identifies 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 record review and staff interview, the facility failed to review and revise the care plan related to skin assessment/breakdown. This was true for one (1) of fifteen (15) care plans reviewed. Resident #12 Facility Census: 32 Findings Included: a) Resident #12 On 11/06/23 at 1:09 PM it was observed that Resident #12 had a small open area to the dorsum of her right foot. It was open to air. On 11/07/23 at 10:06 AM record review shows the Incident/Accident Report dated 11/04/23 at 10:00 AM, describes the injury as small open area to outer/lateral right foot measures 1.2 x 0.8, appears possible pressure from button on brown slipper socks. There was an order dated 11/04/23 which reads: Cleanse area to right outer lateral foot with wound wash, pat dry, apply thin layer of bacitracin and leave open to air twice a day (BID) until healed. The Physician documented his findings when he rounded to observe the resident on 11/07/23 at 11:35 AM. and described the wound as abrasion to the dorsum of the right foot. Upon review of the care plan on 11/07/23 at 11:55 AM, it was found that there…

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 nurse staffing information was posted and readily accessible. This was a random opportunity for discovery and had the potential to affect all residents and visitors wishing to view the information. Facility census: 32. Findings included: a) Daily Staff Posting During a walk-thru of the facility on 11/06/23 at 10:57 AM, it was noted there was no nurse staff posting anywhere throughout the second floor of the facility where residents reside. During an interview with Licensed Practical Nurse (LPN) #5, on 11/06/23 at 11:03 AM, when inquired about the location of the nurse staffing data LPN #5 reported there was a three (3) ring binder behind the nurses' station. This had the assignment sheet for nurse staffing so staff would know their assignments. When asked for a of the assignment sheet for review, LPN #5 stated she would transfer the information over to the Daily Nurse Staffing form. LPN #5 transferred the information on to the Daily Nurse Staffing form. When asked if the staffing information was always kept…

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 ensure a resident receiving psychotropic medications was monitored for behaviors and side effects of the medications. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #5. Facility census: 32. Findings included: a) Resident (R) #5 Review of the medical record on 11/07/23, revealed R#5 was recently admitted to the facility with a diagnosis of late onset Alzheimer's disease with aggressive dysphagia. Treatment included the administration of Seroquel (antipsychotic) and Zoloft (antidepressant). The Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/16/23 was coded for the presence of behaviors under section E0200. R#5 demonstrated physical behaviors towards others 4-6 days and verbal behaviors towards others 1-3 days. R#5 rejected care 4-6 days and wandered daily. The psychiatric consult note dated 10/18/23, notes prior to admission the resident was wandering the street, taking mail from other houses, verbally aggressive, 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.

Based on observation and staff interview, the facility failed to provide a locked permanently affixed compartment for storage of controlled drugs and other drugs subject to abuse. This practice had the potential to affect a limited number of residents. Facility Census: 32. Findings Included: a) Medication Storage Room On 11/07/23 at 9:00 AM during the medication storage room observation in the presence of Register Nurse (RN) #45 it was found that the medication refrigerator had no permanently affixed locked box for controlled drugs (narcotic/benzodiazepines) in the medication refrigerator. There was a sealed 30 milliliter (ml) bottle of Lorazepam (a benzodiazepine) 2 milligram (mg)/ml in the refrigerator which was not secured. This was confirmed on 11/07/23 at 9:00 AM by RN #45 and then with the Director of Nursing on 11/07/23 at 9:14 AM. The DON agreed with the rational and the need for the permanently affixed compartment and will have it put into place.

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the trash can at the hand washing sink was not operational, and two (2) freezer floors were heavily soiled. This deficient practice had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 32. Findings included: a) Kitchen tour During the kitchen tour on 11/06/23 at 10:30 AM, it was discovered the hand washing sink did not have a trash can with an operational step lid. Also, there were two (2) reach-in freezers, which required a deep cleaning of the floors. In an interview with the Dietary Manager on 11/06/23 at 10:45 AM, verified the trash can step lid was not working and both the freezers floors needed to be cleaned. .

Based on record reviews and staff interviews, the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician's Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for two (2) of 15 residents reviewed. Resident Identifiers: #16 and #15. Facility Census: 32. Findings included The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals states, The patient (or incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. a) Resident #16 A 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.

Based on observation, policy review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible. A medication cart was left unlocked during medication pass. Resident identifiers: #13 and #16 Facility census 27. Findings included: Facility policy named Medication Administration with no effective date or signature, found the following: .Medication Cart: The medication cart is to remain locked when not in use . a) Resident # 13 On 04/26/22 at 8:00 AM, observed Registered Nurse (RN) #12 take Resident #13's medications into the room for administration. The medication cart was left unlocked and unattended. RN #12 came out of Resident # 13's room and proceed down the hallway to the next Resident's room. On 04/26/22 at 8:48 AM, the Unit Manager acknowledged the medication cart is to be locked when staff were not in attendance. On 04/26/22 at 9:22 AM, the DON confirmed it is facility policy to keep the medication cart locked when not in sight or use. c) Resident #16 On 04/26/22 at 8:10 AM, an observation of RN #12 give Resident #16's…

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

Based on observation, staff interview and record review, the facility failed to ensure the medication error rate was not five% (5 percent) or greater. There was no order to crush medications, an extended release capsule was opened and administered and bare hands touched a medication. This was discovered for nine (9) of the 28 medications observed during medication pass. Resident identifiers: #21, #16 and #26. Facility census: 27. Findings Included: a) Resident # 21 On 04/26/22 at 8:00 AM Registered Nurse (RN) #12 was observed crushing the following medications for Resident #21: 1. Tramadol 50 milligrams (mgs) 2. Lisinopril 10 mgs 3. Amlodipine 5 mgs 4. Sertraline 50 mgs 5. Diclofenac 50 mgs 6. Metoprolol 25 mgs 7. Feosol 65 mgs On review of Resident #21's medical record, found no order for allowing medications to be crushed. On 04/26/22 at 9:22 AM, the Director of Nursing (DON) confirmed Resident #21 had no order to crush medications. b) Resident #16 Facility drug book titled Nursing 2022 Drug Handbook found the following: .memantine hydrochloride extended-release (ER) capsules must…

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 the Dishwasher Temperature Log was completed. This was a random opportunity for discovery. The failed practice had the potential to effect more than an unlimited number of Residents. Facility census: 27. Findings included: a) Dishwasher Temperature Log An observation on 04/25/22 at 11:00 AM, showed a Dishwasher Temperature Log that was incomplete with missing dishwasher water temperature checks. The following dates had blank spots on the log with missing temperatures: 04/08/22- Dinner time incomplete 04/09/22- Dinner time incomplete 04/10/22- Dinner time incomplete 04/11/22- Dinner time incomplete 04/12/22- Dinner time incomplete 04/13/22- Dinner time incomplete 04/14/22- Dinner time incomplete 04/15/22- Dinner time incomplete 04/16/22- Dinner time incomplete 04/24/22- Dinner time incomplete 04/25/22- Breakfast time incomplete During an interview on 04/25/22 at 11:20 AM, Dietitian stated that the dishwasher log was incomplete and should have been completed. .

Based on observation, interview, and record review, the facility failed to ensure a resident's right to self-determination, and reassessment of mental capacity was completed once it was clear the resident's cognition had improved. This was true for one (1) of 27 residents reviewed during the long-term care process. Resident identifier: #18. Facility census: 27. Findings included: a) Resident #18 During an interview on 04/25/22 at 11:43 AM, Resident #18 reported having a cerebrovascular accident (CVA) prior to being admitted to the facility three (3) years ago. Resident reported she has come a long way since admission a few years ago. In addition Resident #18 has regained a lot of her physical abilities as well as experiencing a marked increase in cognitive abilities. Resident #18 reported the facility deferred to her appointed Medical Power of Attorney (MPOA) when she was admitted . A review of Resident #18's medical record was completed on 04/25/22 at 1:19 PM. --There was a Physician Determination of Capacity, dated 07/31/19, which reflected Resident #18 demonstrated incapacity 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 observation, interview, and review of medical records, the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not administering skin protective devices as ordered by a physician. This was true for one (1) of 27 residents reviewed in the annual long-term care survey process. Resident identifier: #5. Facility census: 27. Findings included: a) Resident #5 An observation on 04/25/21 at 1:40 PM, noted two (2) very dark colored bruises in the center of resident's left forearm. Each bruise was approximately the size of a quarter. Review of the resident's medical record found a physician's order for geri-sleeve left arm to maintain skin integrity. Additionally, there was an order for ace wraps to lower extremities for dependent edema. The order stated staff should apply the ace wraps from the base of toes to knees before getting up in chair daily and remove at bedtime daily. A second observation on 04/26/21 at 10:30 AM, found Resident #5 in the facility's day room participating in a group activity. Resident #5 did…

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, observation and staff interview the facility failed to place heel protectors on a Resident to promote the prevention of pressure ulcer development. The failed practice was true for one (1) of one (1) Residents reviewed for pressure ulcers. Resident identifier: #13. Facility census: 27. Findings included: a) Resident #13 A review of Resident # 13's medical record showed a physician order that stated, Heel Protectors at all times while in bed. An observation on 04/26/22 at 9:10 AM, showed Resident #13 in bed with no heel protectors in place. During an interview on 04/26/22 at 9:10 AM, Nurse Aide (NA) # 49 stated the heel protectors were supposed to be in place while Resident # 13 was in bed but was not. .

Based on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. An oxygen humidifier bottle was not changed as ordered. This observation was a random opportunity for discovery. Resident identifier: #5. Facility census: 27. Findings included: a) Resident #5 An observation on 04/25/22 at 12:21 PM found an oxygen humidifier bottle dated 02/24/22 connected to the oxygen source on the wall in Resident #5's room. A brief record review revealed the following order: Oxygen (O2) Orders: Change 02 tubing & humidifier bottle once weekly on Sundays 11-7. During an interview, on 04/27/22 at 10:15 AM, Unit Manager #17 confirmed the humidifier bottle was dated 02/24/22 and the bottle should have been changed. Unit Manager #17 then stated, I will address it now. .

Based on observation, record review and staff interview, the facility failed to post accurate and detailed nurse staffing information on a daily basis. This was true for eleven (11) out of 26 daily nurse staffing postings reviewed. The postings either were lacking the facility census, or the hours worked. This was a random opportunity for discovery. Facility census: 27. Findings included: a) Daily Nurse Staff Postings On 04/25/22 at 4:00 PM, observation found the daily nurse staff postings was incomplete and lacked hours worked by the nursing staff. Further review of the nurse staff postings in the month of April 2022 found the following: --04/02/22 Daily Nurse Staffing Posting missing the facility census --04/04/22 Daily Nurse Staffing Posting missing the facility census --04/06/22 Daily Nurse Staffing Posting missing the facility census --04/07/22 Daily Nurse Staffing Posting missing the facility census --04/09/22 Daily Nurse Staffing Posting missing the facility census --04/22/22 Daily Nurse Staffing Posting missing the facility census --04/23/22 Daily Nurse Staffing Posting…

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 that a Resident w free of a significant medication error. This was done by allowing an extended release capsule to be opened and administered. This was true for one (1) of 28 medications reviewed during the Long Term Care Survey Process. Resident Identifier #16 Facility Census 27 Findings Included: a) Resident #16 Facility drug book named nursing 2022 Drug Handbook found the following: Page 931 .memantine hydrochloride extended-release capsules must be swallowed whole and never crushed, divided or chewed . On 04/26/22 at 8:10 AM this surveyor observed RN #12 open Resident #16 Memantine ER 28 mg capsule and place the contents of the capsule in the with the rest of the morning crushed medications. RN #12 preceded to administer the medications to Resident #16 in the hallway. 04/26/22 at 8:48 AM, the unit manager acknoaswledged Resident # 16 had a decline in condition recently and would need a different order for extended release medications. On 04/26/22 at 9:22 AM, the DON confirmed extended release…

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 accurately document nursing services in a Resident's medical record. The failed practice was true for one (1) of 12 sampled Residents. Resident identifier: #3. Facility census: 27. Findings included: a) Resident #3 Review of Resident #3's medical record showed a nursing note dated 02/26/22 that stated, Resident exhibited signs of confusion, hallucinations and decreased fluid intake. Doctor was notified and said send resident out to UHC by transport at 7:54 PM for further evaluation. Continued review of Resident 3's medical record showed a Nursing Assistant Flowsheet dated 02/26/22 at 10:56 PM that stated, preventive skin care services provided included reposition/turn and check/change. During an interview on 04/26/22 at 3:55 PM, Unit Manager (UM) and Director of Nursing (DON) confirmed Nursing Assistant Flowsheet should have been completed prior to Resident #3's discharge. UM stated that because the Flowsheet was not completed and dated before Resident #3's discharge the Flowsheet looked as if services were 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.