Maple Springs Of Wasilla

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to ensure residents were free from accident hazards and/or received adequate supervision. Specifically, the facility failed to: 1) Ensure the care plan was followed regarding the total number of staff needed for safe bed mobility for 1 Resident (#6), out of 14 sampled residents; 2) Ensure neurological assessments, after unwitnessed falls, were conducted accurately for 1 Resident (#18), out of 14 sampled residents; and 3) Ensure 3 residents (#'s 11; 16; and 33), out of 3 residents reviewed for smoking, were assessed for safe storage of smoking paraphernalia (cigarettes and lighter or matches). These failed practices created a potential for accidents and injury to the residents. Findings: 1) Care Plan - Bed Mobility Resident #6 Record review on 6/17-21/24 revealed Resident #6 was admitted to the facility with diagnoses that included Type 2 Diabetes (chronic condition involving insulin resistance), osteomyelitis (bone infection), stage 4…

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 interview the facility failed to complete a comprehensive admission assessment using the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) for one resident (#204), out of 14 sampled residents. This failed practice had the potential to cause inaccurate health and functional status for the resident, of which placed the resident at risk for inconsistent care. Findings: Record review on 6/17-21/24, revealed Resident #204 was admitted to the facility with diagnoses that included Parkinsons disease (a progressive disorder that affects the nervous system and causes movement problems, such as shaking, stiffness, and difficulty with balance and coordination), and neurocognitive disorder with Lewy bodies (a form of dementia where abnormal amounts of protein deposits are located in the nerve cells of the brain affecting cognitive functioning). Review of Resident #204's MDS Summary, dated 6/11/24, revealed sections A (Identification), B (Hearing, Speech, and Vision), C (Cognitive Patterns),…

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, observation, and interview, the facility failed to complete a comprehensive reassessment within 14 days after the Resident was diagnosed with dementia for one resident (#28) out of 14 sampled residents. This failed practice had the potential to decrease the resident's quality of life and jeopardized potential for maintaining functional independence at the highest possible level. Findings: Resident #28 Record review from 6/17-21/24 revealed Resident #28 was admitted to the facility in April 2024 with diagnoses that included cardiac arrest, and hypertensive heart disease (prolonged unmanaged high blood pressure) with heart failure. Further review revealed on 5/13/24, an additional diagnosis was added by the facility's provider of severe vascular dementia with psychotic disturbance (a condition caused by restricted blood flow to parts of the brain characterized by impaired reasoning, planning, judgement, and memory). Behaviors: Record review of the MDS (Minimum Data Set, a federally…

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 interview, the facility failed to ensure range of motion (ROM) exercises were provided to 1 resident (#6), out of 14 sampled residents. This failed practice had the potential to place the resident at risk of not receiving the necessary care and therapy to maintain his/her level of mobility. Findings: Review on 6/17-21/24, revealed Resident #6 was admitted to the facility with diagnoses that included sepsis (an infection of the bloodstream) and quadriplegia (complete paralysis of the body from the neck down). During an interview on 6/17/24 at 2:19 PM, Resident #6 stated he/she had difficulty moving his/her arms. When asked if he/she had therapy, Resident #6 stated No. Review of Minimum Data Set (MDS- a federally required nursing assessment) admission Assessment, dated 4/22/24, revealed: Section GG. Functional Limitation in Range of Motion A. Upper extremity 2=impairment on both sides, B. Lower extremity 2=impairment on both sides. Review of Resident #6's Care Plan, dated 4/15/24, revealed: Focus: . [Resident #6] has limited physical mobility related 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 interview, the facility failed to review the drug regimen for 1 resident (#18), out of 14 sampled residents, for adequate parameters of a medication dose range order (orders in which there are dosing amount options over a prescribed range). This failed practice had the potential to expose the resident to unnecessary medications. Findings: Review on 6/17-21/24 revealed Resident #18 was admitted to the facility under hospice care for diagnoses that included dementia, unspecified severity, with agitation. Resident #18 had a history of stroke which had contributed to the decline of his/her dementia. Review of Resident #18's electronic medication administration record (eMAR), dated 6/2024, revealed the following pain medication: Morphine Sulfate (Concentrate) Solution [liquid form of morphine, a narcotic used to treat moderate to severe pain] 20 milligrams [mg] / [per] milliliter [ml] - Give 0.25ml [or 5mg] by mouth every 2 hours as needed for moderate to severe pain/shortness of breath. Further review of this order revealed the following instructions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to store food under proper sanitation and food handling practices in the central kitchen. This failed practice placed all residents (based on a census of 55) at risk for foodborne illnesses and communicable disease. Findings: An observation of the central kitchen on 3/20/23 at 9:26 AM, revealed: 1) Walk in refrigerator: - Soiled whipped cream can 13 oz.; - Opened sour cream container, unlabeled with no used by date; - Opened 10-pound box of breakfast sausage with inner bag opened. The sausages were exposed to air; - Dried brown substance dripping down outer container of 1 gallon Lea and [NAME] Worcestershire sauce; - Dried brown substance dripping down outer container of 1 gallon Kikkoman soy container; - Dried brown substance dripping down outer container of 169 oz [NAME] balsamic vinegar; - Carton of Dr Pepper labeled Em taped to the carton. - Plastic container labeled Em taped to the container, contained two Fast Twitch energy drink…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure State Laws were followed. Specifically, the facility failed to ensure individuals employed by the facility had a valid criminal history background check for 4 employees: 1) Certified Nursing Assistant (CNA) #4; 2) Neighborhood Helper (NH) #1; 3) [NAME] #2; and 4) Housekeeper #1. This failed practice violated State background check Alaska Administrative Code (AAC) and placed all residents (based on a census of 55) at risk for receiving care and services from individuals with barrier crimes and no valid variance. Findings: Review of the facility's State of Alaska license revealed an effective date of 7/1/22 through 6/30/24. Review of the Alaska Department of Health Division of Health Care Services website, accessed at https://dhss.alaska.gov/health/dhcs/Pages/hflc/Background-Check.aspx, revealed: Background checks are required for all individuals associated with the facilities overseen by the Health Facilities Licensing & Certification Program…

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

Based on record review, observation, and interview, the facility failed to ensure 5 residents (#'s 1; 24; 50; 155; and 305), out of 16 sampled residents, were assessed to determine safety prior to self-administration of medications. This failed practice placed the residents at risk of medication errors, and potential drug interactions. Findings: Review on 3/24/23 of the facility's policy Self-Administration of Medications, dated 12/2022, revealed: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident .In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension for the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medication from a container and to ingest and swallow (or otherwise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set- A federally required nursing assessment) accurately reflected the resident's status at the time of assessment. Specifically, the facility failed to: 1) complete a discharge assessment for 1 unsampled resident (#3), out of 1 reviewed for resident assessment; 2) assess for hearing aids for 2 residents (#'s 2 and 37), out of 16 sampled residents; 3) ensure oxygen therapy and/or CPAP (continuous positive airway pressure) use were identified for 2 residents (#'s 37 and 50), out of 16 sampled residents; and 4) ensure a broken denture was identified for 1 resident (#304), out of 16 sampled residents. These failed practices placed the residents at risk for receiving an inaccurate care plan, interventions, and recieving less than optimal care. Findings: Resident #3 Record review on 3/20-24/23 revealed Resident #3 was admitted to the facility with diagnosis that included heart failure. Review of the Interdisciplinary Discharge…

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

Based on record review, interview, and observation, the facility failed to ensure care plans were individualized to meet the medical and psychosocial needs for 6 residents (#'s 2; 13; 34; 37; 50; and 304) out of 16 sampled residents. This failed practice placed the residents at risk for not receiving necessary services to address their individual needs. Findings: Resident #2 Record review on 3/20-24/23 revealed Resident #2 was admitted to the facility with diagnoses that included cerebral palsy and seizure disorder. During an interview on 3/21/23 at 1:11 PM, Resident #2 stated he/she had hearing aids, but they needed to be cleaned (of ear wax). Review of Admission/readmission Evaluation-V 5, dated 1/18/23 at 3:27 PM, revealed Resident #2 was admitted to the facility with hearing aids for both ears. Review of Resident #2's current care plan revealed no documentation of hearing deficit or hearing aids. During an interview on 3/23/23 at 2:14 PM, the Minimum Data Set (MDS) Coordinator stated the Resident's care plan should have included hearing and tasks with hearing aids so that staff…

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 interview, the facility failed ensure respiratory care was consistent with professional standards of practice for 3 residents (#'s 37; 50; and 304), out of 16 sampled residents. This failure had the potential to place the residents at risk for inconsistent care, and potential respiratory complications. Findings: Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery with acute cor pulmonale (a large blood clot gets stuck where the main pulmonary artery branches off into a Y-shape to go into each lung causing the right side of the heart to fail), and diabetes. An observation on 3/20/23 at 2:54 PM, revealed a CPAP (continuous positive airway pressure) machine (a machine to help with obstructive sleep apnea, to ensure a person continues breathing while asleep) placed on Resident #37's bedside cabinet. The CPAP's mask was connected to an oxygen…

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

Based on observation, interview, and record review, the facility failed to ensure patient care equipment was monitored to ensure it was in a safe operating condition. Specifically, the facility failed to: 1) complete daily maintenance checks on 2 emergency code carts (emergency cart/equipment used for resuscitation); and 2) maintain and monitor a unit freezer. This failed practice: 1) placed residents residing in the facility, that were a full code, at risk for adverse outcomes in the event of malfunctioning emergency equipment, and 2) placed residents at risk for receiving food not stored at appropriate temperatures which increased the chance of food borne illnesses. Findings: Emergency Code Cart: Observations conducted 3/20-24/23 revealed incomplete daily code cart maintenance logs on 2 code carts (Hatchers code cart and Main code cart). - Hatchers code cart log for the month of March revealed it was checked 14 out of 23 days total. - Main code cart log for the month of March revealed it was checked 9 out of 23 days total. During an interview on 3/23/23 at 5:18 PM, the MDS…

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 interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 1 resident (#1), out of 5 sampled residents for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use. Findings: Record review from 3/20-24/23 revealed Resident #1 was admitted to the facility with diagnoses that included major depressive disorder, recurrent moderate and schizoaffective disorder (a combination of schizophrenia and mood disorder symptoms), depressive type. Review of Resident #1's current Physician Orders revealed an order for Duloxetine HCI Capsule [antidepressant] Delayed Release Particles 60 MG [;] Give 60 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE . with a start date of 10/22/22. Further review revealed no psychotropic medication informed…

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 interview, the facility failed to ensure resident rights to self-determination were honored. Specifically, the facility failed to provide a method for storing perishable food brought in by family or visitors. This failed practice denied the residents the right to store perishable food brought into the facility. Findings: During a collaborative group meeting on 3/22/23 at 1:30 PM, residents of the facility voiced their concern that there was no way to store perishable food brought into the facility by family or visitors. The residents stated there was no refrigerator to store their food. During an interview on 3/23/23 at 2:06 PM, the Kitchen Manager stated that when residents asked for food to be stored/refrigerated it was a hard no and that no resident-owned food was kept in the kitchen. During an interview on 3/23/23 at 3:41 PM, the Director of Nursing (DON) stated there was not a specific resident refrigerator maintained for resident food, as this would have required recording of temperatures and everyone having access. Review of the facility's policy…

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 interview, the facility failed to resolve a grievance for 1 resident (#24) out of 16 sampled residents. Specifically, the resident's complaint was not fully resolved, and the resident did not receive a written grievance decision which included the steps taken to investigate the grievance and a summary of pertinent finding or conclusions regarding the resident's concerns. This failed practice denied the resident information regarding a resolution of the grievance. Findings: Record review from 3/20-24/23 revealed Resident #24 was admitted to the facility with diagnoses that included hemiplegia (weakness on one side of the body) and seizure disorder. Further review revealed the Resident had a BIMS (brief interview for mental status) score of 15, indicating the Resident was cognitively intact. During an interview on 3/21/23 at 8:40 AM, Resident #24 stated he/she had $800.00 (eight hundred dollars) go missing out of his/her wallet last month. When asked who he/she reported the missing money to, the Resident stated he/she reported this to the front desk 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 record review, interview, observation and document review, the facility failed to ensure safety equipment was checked per manufacturer's instructions for 1 resident (#36) out of 1 resident sampled for wandering. Specifically, the wanderguard tag device (worn by the resident to alert the facility if the resident eloped) was checked monthly instead of weekly. This failed practice had the potential to cause harm if the resident wandered outside during a time the equipment was not functioning. Record review from 3/20-24/23 revealed Resident #36 was admitted to the facility with diagnoses that included dementia, depression, and diabetes. During an interview on 3/20/23 at 2:47 PM, Resident #36's POA (power of attorney) stated he/she was called by the facility in the past because the Resident had wandered outside. The POA stated the Resident now has a wanderguard device in place. An observation on 3/22/23 at 9:30 AM revealed Resident #36 seated at the dining room table upstairs, wearing a wanderguard tag device on his/her ankle. During an interview on 3/23/23 at 11:43 AM, Licensed…

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, observation, and interview, the facility failed to ensure 1 resident (#8) out of 2 residents sampled with a foley catheter (a hollow tube inserted into the bladder to drain urine) was assessed timely for discontinuation of the catheter. This failed practice had the potential to keep the device in place for longer than clinically necessary and increased the potential for the resident to develop a urinary tract infection. Findings: Record review from 3/20-24/23 revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the lower end of the right tibia (shinbone), diabetes, and chronic kidney disease. Further review revealed the resident admitted to the facility with a foley catheter in place. During an observation on 3/20/23 at 3:14 PM, Resident #8 was observed lying in bed with a foley catheter hanging from the lower frame of his/her bed. During an interview on 3/20/23 at 3:17 PM, Resident #8 stated he/she was admitted to the long…

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 interview, the facility failed to ensure administration of enteral nutrition (a liquid diet delivered by way of tube feeding) was free of possible complications for 1 resident (#29), out of 2 residents observed for enteral nutrition. Specifically, the facility failed to ensure the resident's head of the bed was positioned no lower than 30 degrees in elevation during enteral feedings. This failed practice had the potential to cause aspiration (liquid entering the lungs). Findings: Record review from 3/20-24/23 revealed Resident #29 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (paralysis or weakness of one side of the body) following cerebral infarction (lack of blood flow to the brain) affecting right dominant side and severe protein-calorie malnutrition (lack of proper nutrition). An observation on 3/20/23 at 10:02 AM, revealed Resident #29 lying in bed with an enteral feeding being administered at 80 milliliters per hour. Further observation revealed the head of the bed to be almost flat in…

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

Based on interview and observation, the facility failed to ensure reconciliation of a controlled drug (narcotic medication for pain) was accurate. Specifically, the facility failed to ensure liquid narcotic medication volume was accurately reconciled for 1 resident out of 8 residents sampled during medication cart review. This failed practice had the potential for inaccurate narcotic reconciliation. Findings: Narcotic Medication Reconciliation During an interview on 3/22/23 at 11:02 AM, the Director of Nursing (DON) stated the narcotics (controlled drugs) were kept in the medication cart on each unit. The DON further stated the nurses would have reconciled the controlled drugs at shift change. The DON stated the oncoming nurse and the outgoing nurse would have reconciled (counted) the amount of medication in the blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) and the data was entered into the narcotic log book. During an interview on 3/22/23 at 1:30 PM, Licensed Nurse (LN) # 1 stated the controlled drugs were kept in a…

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 interview, the facility failed to ensure duplicative medications ordered for constipation, were written with adequate indications for use for 1 resident (#37), out of 16 sampled residents. Specifically, the facility failed to ensure: 1) clear guidance on when to use Senna (medication used for constipation) in the bowel protocol; and 2) the as needed bowel medication orders included sequence for use. These failed practices had the potential to inadequately medicate the resident. Findings: Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included chronic kidney disease and diabetes. During an interview on 3/20/23 at 2:56 PM, Resident #37 stated he/she received a stool softener every day, however he/she still struggled with constipation. Resident #37 described his/her bowel movements as hard stool and difficult to pass. Review of the facility's Bowel Protocol, undated, revealed the purpose of the protocol was To provide timely interventions to assist with prevention of constipation and other complications. 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 interview, the facility failed to ensure drugs used in the facility were labeled in accordance with accepted professional practices. Specifically, the facility failed to ensure the label on the Melatonin (a supplement used for insomnia) blister pack for 1 discharged resident was not re-labeled as stock medication and put into use within 1 medication cart out of 3 medication carts observed. This failed practice placed all residents that received this medication from this cart at risk of misuse of prescribed medication. Findings: During an observation and concurrent interview on 3/22/23 at 12:15 PM, Licensed Nurse (LN #2) showed the contents of the medication cart on his/her unit. Further observation revealed a bubble pack for Melatonin 1 MG tabs had a resident's name crossed out. Further observation revealed a handwritten note on the pack which read stock. When asked about the melatonin bubble pack label, LN #2 stated that resident was discharged , and the left-over medication was used as floor stock for other residents. During an interview on 3/24/23 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 record review and interview, the facility failed to ensure menus were accurate for 2 residents (#s 37 and 304), out of 16 sampled residents. This failed practice caused the residents to receive an incorrect diet which could have affected their overall health and wellbeing. Findings: Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery (a large blood clot), and diabetes. Review of Resident #37's dietary card, dated 3/22/23, revealed: Diet: 2 Gm Na (low sodium). Review of Resident #37's electronic diet order, dated 3/16/23, revealed: NAS (No Added Salt) diet. Review of Resident #37's Order and Communication forms, dated 2/28/23, 3/4/23, and 3/7/23, all revealed a No Added Salt diet was checked as the diet order. Resident #304 Record review on 3/20 -24/23 revealed Resident #304 was admitted to the facility with diagnoses that included hypertensive heart (heart conditions…

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.