Crestpark Stuttgart, LLC

Based on an interview and record review, the facility failed to thoroughly prevent possible further abuse for 1 Resident (Resident #34) who was involuntarily secluded and possible abuse for all other 44 residents who reside in the facility. The findings are: Resident # 34 was admitted to the facility with a diagnosis of Displaced intertrochanteric fracture of left femur and Alzheimer's Disease. On 01/08/24 at 3:59 PM Surveyor notified the family member by phone for a family interview. During the interview the daughter stated, last week on Wednesday it was reported a staff member locked him (Resident #34) in his room. She was fired and an investigation is under way. She also said she has a meeting with the Administrator tomorrow 1/9/24. On 01/09/24 at 8:10 AM the Administrator provided the 3 reportables that showed the following: On 12/29/23 form 7734/762 was reported to DPSQA (Division of Provider Services and Quality Assurance) documented that an x-employee was found to have involuntary secluded Resident # 34. This x-employee was terminated. On 01/12/24 at 2:50 PM the Administrator…

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 a residents ' s representative was notified in writing of resident's transfer to the hospital and/or discharge and failed to notify the Ombudsman required for 1 (Resident #34) of 7 (Residents #6, #14, #16, #23, #34, #46 and #148) sampled residents who were transferred to the hospital in the last three months. The findings are: 1. Resident #34 had a diagnosis of Alzheimer's Disease. a. An Incident and Accident (I&A) form dated 12/6/23 at 1515 (3:15) PM documented Resident #34 tried to transfer self and landed on his left side. He had an abrasion to the (L) (left) temple and complained of (L) hip pain. The intervention was Resident #34 was transferred to the ER (Emergency Room) and PT (Physical Therapy) will work on transfers. b. The nurse's notes dated 12/6/23 at 1620 (4:20) PM documented the Physician ordered Resident #34 be transferred to the ER for evaluation due to complaints of pain in the left hip. At 1600 (4:20) PM, Resident #34 left 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the bed hold policy was provided for a transfer to the hospital for 1 Resident #34. This had the potential to affect 45 residents. The findings are: 1. The nurse's notes dated 12/6/23 at 16:20 4:20 PM documented the Physician ordered Resident #34 be transferred to the ER (Emergency Room) for evaluation due to complaints of pain in the left hip. At 16:00 (4:00) PM the resident left the facility by way of EMS (Emergency Medical Services). 2. On 1/10/24 at 1:01 PM, the Business Office Manager provided a list of residents who were transferred to the hospital from [DATE] to 01/03/24 and Resident #34 was not listed. 3. 01/11/24 10:05 AM, the Assistant Administrator was asked if there was documentation of notification when Resident #34 was admitted and no documentation of bed hold policy. She stated, Resident #34 got dropped in a crack. We didn't send it to the family or Ombudsman because he wasn't on the list that he went out. 4. On 01/11/24 at 1:11…

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 interview, the facility failed to ensure nail care services were regularly provided to promote good personal hygiene and grooming for 1 (Resident #18) of 9 (Residents #6, #12, #18, #23, #30, #34, #35, #40 and #148) sampled residents who required assistance for nail care, as documented on a list provided by the Administrator on 1/12/24 at 12:27 pm. The findings are: 1. Resident #18 had diagnoses of Vascular Dementia without Behavioral Disturbances, Altered Mental Status. a. A Care Plan with a review date of 11/14/23 documented Resident #18 had an ADL (Activities of Daily Living) self-care deficit and needs supervision/limited assistance with personal hygiene. No nail care was addressed on the resident's care plan. b. On 01/08/24 at 10:45 AM, Resident #18 had dark substance observed underneath his fingernails. c. On 01/08/24 at 4:31 PM, Resident #18 had a dark substance observed underneath the fingernails on both hands. d. On 01/09/23 at 08:23 AM, resident #18 had a dark substance underneath his fingernails. e. On 01/12/24 at 6:55 PM, 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, record review and interview, the facility failed to ensure oxygen tubing was dated to reduce the potential for respiratory complications and failed to ensure Oxygen in Use signage was in place to promote oxygen safety for 1 (Resident #23) of 1 sampled resident that had orders for oxygen therapy. This failed practice had the potential to affect 4 residents that had physician orders for oxygen therapy. The findings are: a. A Physician Order dated 10/30/22 documented, .Oxygen PRN (when necessary) 2 LPM (liters per minute) per /nasal Cannula PRN saturations . On 01/08/24 11:37 AM, Resident #23 was lying in the bed with oxygen in use at 2 liters per nasal cannula. There was no date on oxygen tubing or an Oxygen in Use sign on the door. On 01/08/24 4:50 PM, Resident #23 was lying in bed with oxygen in use at 2 liters per nasal cannula. There were no dates on the oxygen tubing or an oxygen in use sign on the door. On 01/09/24 8:41 AM, Resident #23 was lying in bed with oxygen in use at 2 Liters per minute per nasal. There were no dates on oxygen tubing or an oxygen 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 record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with medication error rates. This failed practice had the potential to affect all 45 residents who resided in the facility. The findings are: 1. A Recertification and Complaint Survey was conducted on 01/06/2023 at the facility. During this survey, the team identified concerns with medication errors during medication observations. 2. The Plan of Correction for medication errors, with a completion date of 02/04/2023 indicated all residents were evaluated, no negative findings were found. A designated Licensed Practical Nurse (LPN) will monitor Medication Pass twice per week to ensure liquid meds are given at the correct time and will correct negative findings immediately and report to Quality Assurance (QA) weekly to ensure effectiveness. 3. A Recertification survey was conducted on 01/12/2024. During the survey the team identified concerns with medication…

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 foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; spices were used in a timely manner to maintain flavor and potency, foods were discarded prior to use by date, 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages, and kitchen ceilings and vents were cleaned to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 60 residents who received meal trays and beverages from the kitchen as documented on the Diet Physician's Orders Report provided by the Dietary Manager (DM) on 01/05/23. The findings are: 1. On 01/03/23 at 10:25 AM, during the tour of the kitchen with Dietary Employee (DE) #1 the following observations were made: a. At 10:26 AM, dust particles were hanging from the ceiling 1 to 1 1/2 feet on each side of the vents above the steam table, stove, and puree prep…

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 Physician Ordered medication with specific times were administered as ordered for 1 (Resident #13) of 1 sampled resident. The findings are: 1. Resident #13 had a diagnosis of Parkinson's Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The January 2023 Medication Administration Record (MAR) for the 7:00 AM and 8:00 AM medication pass documented, .Sodium Chloride, Hypertonic, Ophthalmic 5% Solution 1 GTT [drop] OU [both eyes] TID [three times per day 0800 [8:00 AM], 1200 [12:00 PM], 1600 [4:00 PM] . Cholecalciferol 1000 Intl [international] Units Oral Tablet 1 Tab [tablet] PO [by mouth] QD [every day] 8A [8:00 AM] . Vitamin B [cyanocobalamin] l2 500 MCG [micrograms] Oral Tablet 1 Tablet PO QD 8A . ELIQUIS [apixaban] 5 MG [milligrams] Oral Tablet (APIXABAN) 1 Tablet PO BID [Two times per day] 0800 and 1600 . Pramipexole 0.5 mg Oral Tablet (Mirapex) 1…

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 ensure floor tiles were maintained and free from cracks and chips and the glue leaking out from under and around the floor tiles was cleaned in a timely manner to maintain a clean homelike environment. The findings are: 1. On 01/03/23 at 2:00 PM, a puddle of grey liquid was observed under the table in the Conference Room. Medical Records Employee #1 stated, That is the glue from the tiles. It does that when it rains. My mom said it's because they didn't put plastic down when they poured the concrete for this building. I use a baby wipe and clean 2 tiles a day because the lanolin keeps the glue from leaking out so much. 2. On 01/04/23 at 10:06 AM, a floor tiled in room [ROOM NUMBER]B had a wet grey liquid that had seeped up between the cracks. 3. On 01/03/23 at 7:28 PM, the floor in room [ROOM NUMBER] had uneven tiles, a wet grey liquid seeping out of the cracks between tiles. 4. On 01/03/23 at 7:38 PM, the floor in room [ROOM NUMBER] had…

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 interview, the facility failed to ensure a catheter drainage bag was maintained off the floor and in a privacy bag to prevent the risk for infection and to maintain resident dignity for 1 (Resident #257) of 2 (Residents #256 and #257) sampled residents who had physician orders for an indwelling catheter as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:07 AM. The findings are: 1. Resident #257 had diagnoses of Pressure Ulcer of Sacral Region, Stage 4, and Paraplegia. The MDS with an Assessment Reference Date (ARD) of 12/19/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and had an indwelling catheter and an ostomy. a. The Physicians Orders dated 12/13/22 documented, .Foley catheter care Q [every] shift clean with soap and water or wet wipe Q shift . Foley catheter: 10-6 change Q month, + [plus] PRN [as needed] leakage-change monthly on the first . b. The Care Plan dated 12/12/22 documented, .Resident has a . Foley catheter present…

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 interview, the facility failed to ensure physician ordered pain medications with specific times were administered as ordered for 1 (Resident #19) of 25 (Residents #5, #8, #13, #14, #16, #17, #19, #22, #23, #29, #30, #32, #34, #37, #40, #44, #45, #51, #55, #155, #255, #256, #257, #305 and #307) sampled residents with physician orders for as needed and scheduled pain medications. The findings are: 1. Resident #19 had diagnoses of Chronic Pain, Neuropathy and Restless Leg Syndrome. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was on a scheduled pain medication regimen and received opioids 7 of the 7 day lookback period. a. The Care Plan dated 10/28/22 documented, . Pain - Related to: Osteoarthritis and Diabetic Neuropathy . Administer and monitor for effectiveness and for possible side effects from: Routine pain medication (see MAR [Medication Administration 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 of the 4:00 PM medication pass on 01/05/23 with Licensed Practical Nurse (LPN) #1, record review, and interview, the facility failed to ensure a medication error rate of less than 5% was maintained. The facility had 5 medication errors in 25 opportunities, resulting in a medication error rate of 20%. This failed practice had the potential to affect 34 residents who received their medications from the South Medication Cart as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:33 AM. The findings are: 1. On 01/05/23 at 3:30 PM, LPN #1 administered medications to Resident #34. She was given instructions by the Surveyor and obtained the following medication from the medication cart: Lasix 20mg (milligrams) 1 tab (tablet). She stated, I am not going to give the Med Pass or the UTI [Urinary Tract Infection] Stat until tonight at bedtime. She did not circle the Medication Administration Record (MAR) space provided for 1600 (4:00 PM). a. Resident #34's Physician…

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 resident preferences were followed to encourage the amount residents consume for 2 (Residents #30 and #37) of 27 (Resident #5, #8, #11, #13, #14, #16, #17, #19, #22, #23, #28, #29, #30, #32, #34, #37, #38, #40, #44, #45, #46, #52, #54, #255, #256, #257 and #307) sampled residents whose likes and dislikes were listed on their tray cards per the list provided by the Dietary Manager (DM) on 01/06/23, and failed to ensure pureed foods were prepared to maintain nutritive value for 4 (Residents #16, #17, #37 and #255) of 4 sampled residents who received pureed diets per the list provided by the DM on 01/05/23 at 8:20 AM. The findings are: 1. On 01/03/23 at 3:31 PM, Dietary Employee (DE) #2 pureed chicken and dressing casserole. DE #2 added cold half and half from the refrigerator to the food processor. The Surveyor asked the DM, Should a cold liquid be added to a hot or warm food? The DM stated, No ma'am. Warm milk or warm stock should be added. The DM informed DE #2, as she re-pureed the casserole to make…

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 pureed food items were blended to a smooth, lump-free, pudding-like consistency to minimize the risk of choking or other complications for residents who required pureed diets. This failed practice had the potential to affect 5 residents who received pureed diets as documented on a list provided by the Dietary Manager (DM) on 01/05/23. The findings are: 1. On 01/03/23 at 3:31 PM, Dietary Employee (DE) #2 pureed chicken and dressing casserole. DE #2 poured and scraped the puree into a stainless steam table pan and informed the Surveyor it was done. The Surveyor dipped a plastic spoon into the puree and rubbed the puree between her fingers. The Surveyor asked the DM to feel the puree and asked her to describe the texture. The DM stated, It has small lumps, and it needs pureed more. The Surveyor asked the DM, What should the consistency of puree be like? The DM stated, It should be very smooth, almost like pudding. 2. On 01/03/23 at 4:01 PM, DE #2 pureed dinner rolls. DE #2 poured the bread puree into 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 interview, and record review, the facility failed to ensure all required members of the QAA (Quality Assessment and Assurance) committee attended required quarterly Quality Assessment and Assurance/Quality Assurance & (and) Performance Improvement (QAA/QAPI) meetings. The findings are: 1. On 01/03/23 at 11:26 AM, the Surveyor asked the Physician, Do you attend the QAA meetings? The Physician stated, No, not all of them. I just review the minutes. 2. On 01/03/23 at 11:59 AM, the Administrator provided the facility's QAPI Plan and Facility Assessment. 3. On 01/03/23 at 1:07 PM, Medical Records Employee #1 provided the QA Committee Member List. 4. On 01/05/23 at 10:46 AM, the Administrator provided the QA (Quality Assurance) meeting minutes dated October 25, 2022, November 1, 2022, November 8, 2022, November 15, 2022, November 22, 2022, and November 29, 2022. 5. The QAPI Plan titled, 2017 QAPI Plan, provided by the Administrator on 01/03/23 at 11:59 AM, had a date range on page 9 of 8/1/18 to 10/31/18 and the Facility Assessment documented, .reviewed with Quality Assessment…

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 all laundry was handled, transported, and processed wearing non-contaminated personal protective equipment (PPE) to help minimize the spread of potential contaminants. The findings are: 1. On 01/04/23 at 8:34 AM, the Surveyor accompanied Laundry Employee (LE) #1 on her rounds to retrieve laundry. LE #1 put on gloves and a visibly used, blue, disposable gown that was hanging on a thumb tack on a door on the dirty side. Upon returning to the dirty side of the laundry room, LE #1 proceeded to dump all of the bags of dirty clothes into the large, grey, wheeled cart LE #1 had used to obtain bags of laundry. LE #1 sorted soiled clothing, some covered in feces, into a white and colored load in two washers. LE #1 removed gloves and blue disposable gown. LE #1 put gloves in the trash and hung the blue disposable apron on the thumb tack. The Surveyor asked LE #1 how often the apron was used. LE #1 stated, The three of us have to share the apron between us because there are three of us and because there are not enough aprons.…

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 the facility's Antibiotic Stewardship Program was maintained to include protocols to ensure residents who required antibiotics received the correct antibiotic to treat their infection and residents who did not require antibiotics did not receive them to prevent potential development of antibiotic-resistant organisms and facilitate each resident's ability to achieve their highest practicable level of physical well-being and failed to ensure antibiotic use was monitored for appropriateness and signs and/or symptoms of infection and effectiveness or ineffectiveness of antibiotic therapy were evaluated and documented for 3 (September, October, November 2022) of 4 months reviewed. The failed practice had the potential to affect all 60 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/03/23 at 1:57 PM. The findings are: 1. On 01/03/23 at 11:59 AM, the Antibiotic Stewardship Program logs were provided by 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 staff avoided placing signs that included residents' care information regarding personal care needs, in areas where they could be seen by other residents or visitors, to promote dignity and respect for 1 (Resident #51) sampled resident. This failed practice had the potential to affect 60 residents as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/23/23 at 1:57 PM. The findings are: 1. Resident #51 had a diagnosis of Hemiplegia, Hemiparesis following a Cerebral Infarction. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with bed mobility, was totally dependent on one person physical assistance for transfer and toilet use. a. On 01/03/23 at 10:40 AM, Resident #51 was sitting in her recliner in her room. The call light was laying…

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 of the 8:00 AM Medication Pass on 01/05/23, interview, and record review, the facility failed to ensure the Medication Administration Record (MAR) binder was closed when out of the Nurse's line of sight to maintain privacy of resident medical records. This failed practice had the potential to affect 10 residents who received their medications from the [NAME] Hall Medication Cart, as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/06/23 at 9:37 a.m. The findings are: 1. On 01/05/23 at 7:45 a.m., Licensed Practical Nurse (LPN) #2 was observed performing the 8:00 AM Medication Pass. She knocked on a resident's room door, entered the room and did not lock the cart or close the MAR binder. The medication cart was outside of the nurse's line of sight while she was in the resident's room. 3. On 01/05/23 at 8:11 AM, the Surveyor asked LPN #3, When you have finished gathering a resident's medicines and you are preparing to take the medicine into the resident's room, what should you do before entering the resident's room? LPN #3 answered, You…

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 1 (Resident #45) of 1 sampled resident was free from physical restraints, as evidenced by her wheelchair being physically locked at the dining room table during lunch. This failed practice had to potential to affect 60 residents as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/03/23 at 1:57 PM. The findings are: 1. Resident #45 had diagnoses of Transient Ischemic Attack related to an Embolism and Alzheimer's. The Annual MDS with an Assessment Reference Date (ARD) of 10/06/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and was independent with no set up or physical help for bed mobility and locomotion on the unit, required supervision with no set up or physical help with locomotion off the unit and did not require restraints. a. The Care Plan dated 10/07/22, did not address restraints. b. The January 2023 Physician Orders did not address restraints. c.…

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 of the 8:00 AM Medication Pass on 01/05/23, record review, and interview, the facility failed to ensure a Medication Cart was locked to prevent accidents when the cart was out of the nurse's line of sight. This failed practice had the potential to affect 10 residents who received medications from the [NAME] Hall Medication Cart as documented on a list provided by the Director of Nursing (DON) on 01/06/23 at 9:37 AM. The findings are: 1. On 01/05/23 at 7:45 a.m., Licensed Practical Nurse (LPN) #2 was observed performing the 8:00 AM Medication Pass. She knocked on a resident's room door, entered the room and did not lock the cart or close the Medication Administration Record (MAR) binder. The medication cart was outside of the nurse's line of sight while she was in the resident's room. 2. On 01/05/23 at 8:11 AM, the Surveyor asked LPN #3, When you have finished gathering a resident's medicines and you are preparing to take the medicine into resident's room, what should you do before entering the residents room? LPN #3 answered, You should knock on the door 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, interview, and record review, the facility failed to ensure physician ordered diets were followed for 1 (Resident #29) of 6 (Residents #11, #23, #29, #32, #38 and #305) sampled residents who received mechanically altered diets per the Physicians Orders Report provided by the Dietary Manager (DM) on 01/05/23 at 8:20 AM. The findings are: 1. Resident #29 had diagnoses of Diverticulitis of Small Intestine, Disorientation, Depressive Episodes and Constipation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and received a mechanically altered diet. a. The Physicians Order dated 04/09/19 documented, .Diet: Mechanical MT [meal time] Ground Meat with Gravy/Sauce . b. The Care Plan dated 12/09/22 documented, .Resident is at risk for altered nutrition related to mechanical diet with ground meat with gravy/sauce . Provide diet as ordered (see physician orders) c. The Tray Card dated 01/05/23 documented,…

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.