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STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards
provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or
not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available
to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 1 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
§483.10(g)(15)
Admission to a composite distinct part. A facility
that is a composite distinct part (as defined in
§483.5) must disclose in its admission
agreement its physical configuration, including
the various locations that comprise the
composite distinct part, and must specify the
policies that apply to room changes between its
different locations under §483.15(c)(9).
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 2 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 3 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Resident #1
Family Interview
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 4 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 5 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Staff Interviews
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 6 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 7 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 8 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 9 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 10 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Staff Interviews
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 11 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Record Review
Staff Interviews
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 12 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Facility Follow-Up
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 13 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The resident did not have an minimum data set o All nurses on duty 2/13/2018 were
(MDS) assessment completed related to the in-serviced regarding “Services Provided
resident being in the facility less than 24 hours. Meet Professional
Standards/Comprehensive Care Plans”
The interim person centered care plan, initiated related to obtaining a written/signed
12/27/17, indicated the resident had an physicians orders to transfer patient to
alteration in cardiac or respiratory status. emergency room. Nursing staff were
Interventions included: educated on the following; 1. Physician
-Medications as ordered; Written Order signed and dated by
-Labs as ordered; physician, 2. Physician Written Order
-Treatments as ordered; displays discharge location, 3. Physician
-Oxygen as ordered; Written Order has Nurses’ signature.
-Vital signs daily;
-Weight weekly; o Systemic Changes:On 2/13/2018, all
-Monitor for signs and symptoms of cardiac or licensed nursing staff were in-serviced
respiratory exacerbation and report changes to and educated regarding “Services
the physician. Provided Meet Professional
Standards/Comprehensive Care Plans”
Record Review related to obtaining a written/signed
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 14 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 15 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Record Review
Resident #6
Record Review
According to a nursing progress note on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 16 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Resident #2
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 17 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Record Review
Staff Interviews
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 18 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 19 of 19