Sun City Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interviews and review of policy, the facility failed to ensure that two residents (#1 and #150) who were unable to carry out activities of daily living (ADLs) were consistently provided care regarding oral care and incontinence care. The sample size was 6. The deficient practice could result in residents with unmet ADL care. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, Parkinson's disease, Schizophrenia and need for assistance with personal care. During an observation of the resident conducted on November 28, 2022 at 11:11 am, the resident's teeth were observed to be black with white substance build up in between the teeth. Review of the baseline care plan dated November 11, 2022 revealed the resident required assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to recent illness, hospitalization…

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 clinical record review, staff interviews, and policy reviews, the facility failed to ensure proper skin assessment necessary to identify and treat lice infestation of one sampled resident (#69). The deficient practice could result in undetected lice infestation of residents. Findings include: Resident #69 was admitted on [DATE] with diagnoses that included schizophrenia, type 2 diabetes mellitus, dementia, gastroesophageal reflux disease, and age-related cataract. A care plan initiated on February 15, 2021 revealed that the resident was at risk for decreased ability to perform ADL(s) (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to diabetes, dementia. Interventions indicated to provide the resident with set-up to extensive assists for bathing, grooming, personal hygiene and dressing. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score…

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 clinical record review, staff interviews and facility policies and procedures, the facility failed to ensure pressure ulcer assessment was completed for one resident (#248). The sample size was 5. The deficient practice could result in the resident not receiving the appropriate pressure ulcer treatment. Findings include: Resident #248 was admitted on [DATE] with diagnoses of sepsis, anemia, hypomagnesemia, melena, difficulty in walking, and bacteremia. A nursing note dated August 6, 2022 indicated that the resident was alert and oriented to person, place, time, with modified independence in decision making skills for daily routine. The note also revealed a skin check was completed on the resident and no skin injury or wounds were noted. The Skin Check assessment dated [DATE] stated the resident did not have any skin injury and or wounds. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident 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 clinical record review, observations, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#63) was consistently provided meals and assistance to eat to maintain adequate nutrition. The sample size was 4. The deficient practice could result in nutritional needs of residents not being met. Findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, displaced intertrochanteric fracture of left femur, major depressive disorder, muscle weakness, and need for assistance with personal care. A care plan initiated on May 30, 2022 identified that the resident required assistance for ADL (activities of daily living) care which included eating. The goal was that the resident's ADL care needs will be anticipated and met. A physician's order dated May 30, 2022 stated regular diet, regular texture. Another care plan initiated on June 2, 2022 indicated that the resident has a nutritional risk and sign of weight loss for…

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 clinical record review, observation, resident and staff interviews, and the facility's policy and procedure, the facility failed to provide respiratory care in accordance with the professional standard of practice for one sampled resident (#54). The deficient practice could result in adverse effects to residents. Findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and atherosclerotic heart of native coronary artery without angina pectoris. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. During an observation conducted on November 28, 2022 at 10:37 a.m., a nebulizer machine was observed attached to nebulizer tubing sitting on top of an air conditioning unit. The nebulizer chamber contained unknown particles, beige in color, and the tubing was moist. The nebulizer tubing was not cleaned…

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 a clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#25) received pain medication as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #25 was admitted to the facility on [DATE], with diagnoses that included other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified affecting left dominant side, Chronic Obstructive Pulmonary Disease, unspecified, Fibromyalgia, and Systemic Lupus Erythematosus, unspecified. A review of the resident's care plan initiated on May 28, 2022 revealed the resident was at risk for alterations in comfort related to deconditioning and that the resident was prescribed an opioid medication for pain control. Review of the physician orders dated August 10, 2022, revealed an order for Percocet (opioid analgesic) 5-325 milligrams by mouth every 6 hours as needed for moderate to severe pain (pain levels…

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 -Resident #90 was admitted to the facility on [DATE] with diagnoses that included repeated falls, hemiplegia and hemiparesis following unspecified cerebrovascular diseases affecting left dominant side, and other symptoms and signs involving cognitive functions and awareness. A practitioner notes dated September 12, 2022 at 11:35 a.m., stated related to psychiatric, the resident is cooperative. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident had no cognitive impairment. The assessment included the resident's mood interview (PHQ-9) which indicated no symptoms, and no behavior or potential psychosis. Per the assessment, the active diagnoses included cerebrovascular accident and no psychiatric mood or disorder. Review of the nursing progress notes dated August 23 and 29, 2022; September 7, 2022; November 12 and 19, 2022 revealed the resident was found on the floor. A care plan with a revision date November 23, 2022 included a problem that the resident is at risk for…

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 clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#24) received treatment and care in accordance with professional standards regarding wound/skin treatments and monitoring. The sample size was 18. The deficient practice could result in adverse outcomes for residents. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included fractures of the right fibula and right tibia, dysphagia, and altered mental status. Regarding the external fixator pin sites: Review of a nurse progress note dated March 13, 2020 revealed the resident was a new admission from the hospital and had an external fixation device to the right lower extremity with six pins into the skin with ace wraps from the knee to ankle. The nurse was unable to assess the skin underneath related to agitation by the resident when the nurse attempted to look. The care plan initiated on March 14, 2020 stated the resident required assistance…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure three of four sampled residents (#214, #33, and #17) were weighed per the physician's order. The deficient practice can result in residents' nutritional status not being monitored. Findings include: -Resident #214 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with diabetic chronic kidney disease, dependence on renal dialysis, acquired absence of right leg above knee and end stage renal disease. A care plan was initiated on July 19, 2021 that stated resident #214 was at nutritional risk due to end stage renal disease, diabetes, recent right above knee amputation and pressure ulcer on the sacrum. The goal was that the resident would maintain a stable weight. Interventions included monitoring unplanned weight loss/gain for changes in nutritional status. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview…

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 resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents. This deficient practice results in resident needs not being met. The census was 66. Findings include: During the initial phase of the survey 9 out of 25 sampled residents identified concerns of not having enough nurses and CNAs (certified nursing assistants). One resident reported waiting up to 6 hours for help and that it was worse at nights but was bad all the time. Multiple residents stated call light response times were between 2 minutes to an hour. Another resident stated that they were left in a shower chair for 45 minutes waiting for their turn in the shower. One resident stated that they were only showered once weekly and some scheduled showers were missed all together. Several residents stated medications were sometimes given late and that they have received their every 4-hour medication two hours late. Another resident stated it may take 20 minutes to have their briefs changed at night, 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 observations, facility documentation, clinical record review, staff interviews, policy review, and the manufacturer's instructions, the facility failed to ensure that quality control solution testing was consistently completed on a multi-use glucometer and failed to ensure the container for the glucometer test strips was dated when opened. The deficient practice could result in not being aware of glucometers that were not functioning properly which could result in inaccurate glucose levels for residents with diabetes. Findings include: -An observation of the medication cart (#1) on the memory care unit (station 3) was conducted on August 4, 2021 at 7:50 AM with a Licensed Practical Nurse (LPN/staff #44). Review of the blood glucometer daily quality control logs for February 2021, March 2021, April 2021, and May 2021 revealed multiple days that there was not documentation that the daily glucometer control testing for accuracy was completed. The LPN stated that was the only binder for that unit and that the testing is done by the night shift. The LPN stated that she did not…

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

Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure infection control standards were maintained during medication administration. The census was 66. The deficient practice could result in the transmission of infection. Findings include: -A medication administration observation was conducted on August 4, 2021 starting at 7:46 a.m. with a Licensed Practical Nurse (LPN/staff #102). At 7:54 a.m., the nurse was observed to use hand sanitizer at the cart then dispensed the medications for a resident. After entering the resident's room, the nurse handed the medication cup and water cup to the resident. After taking the medications, the resident handed the cups back to the nurse who disposed of the items. The nurse was not observed to perform hand hygiene after the medication administration. At 8:00 a.m., the nurse dispensed the medication for another resident. The nurse was not observed to perform hand hygiene prior to dispensing the medications or before entering the resident's room. The nurse handed the medication cup to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure two of six sampled residents (#33 and #119) and/or their representative were informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The deficient practice can result in the resident and/or the resident representative not being aware of the benefits and the potential adverse side effects of taking psychoactive medications. Findings include: -Resident #119 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances and essential hypertension. A physician order dated July 20, 2021 included for Mirtazapine (antidepressant) 15 milligrams (mg) by mouth at bedtime for depression as evidenced by ineffective sleep pattern. Review of the Psychotropic Medication Administration Disclosure form outlining the risks and benefits of receiving Mirtazapine/Remeron and Olanzapine/Zyprexa did not include the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure advanced directives were accurately documented for two of four sampled residents (#33 and #163). The census was 66. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: -Resident #33 was admitted to the facility on [DATE] with diagnosis that included fracture of unspecified part of neck of left femur, chronic obstructive pulmonary disease, dysphagia, post-traumatic stress disorder (PTSD), anxiety disorder and alcohol dependence with withdrawal. Review of the clinical record revealed an Advance Directive form signed by the resident's responsible party on [DATE] which revealed the resident code status was DNR (Do Not Resuscitate) indicating the resident did not want cardiopulmonary resuscitation (CPR). A baseline care plan dated [DATE] included the resident has an established advanced directive and chooses to be a DNR. The goal was 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 clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of one resident's (#33) significant weight loss. The sample size was 4. The deficient practice could result in physicians not being notified of changes in residents' conditions. Findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur, hereditary motor and sensory neuropathy, chronic obstructive pulmonary disease (COPD), dysphagia, post-traumatic stress disorder (PTSD), anxiety disorder and insomnia. Review of the clinical record revealed the weight recorded on June 8, 2021 was 152.8 pounds (lbs.). A physician order dated June 9, 2021 revealed an order to weigh the resident every month starting on the 10th and every Thursday for 4 weeks. The baseline care plan dated June 9, 2021 revealed the resident was at nutritional risk as evidenced by diagnoses of hereditary motor and sensory neuropathy,…

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 clinical record review, staff interviews, and policy review, the facility failed to ensure the Level 1 Pre-admission Screening and Resident Review (PASRR) was updated for one sampled resident (#33), after the resident's stay in the facility was over 30 days. The deficient practice could result in specialized services needed not being identified and provided for residents. Findings include: Resident #33 was admitted to the facility on [DATE] with diagnosis that included post-traumatic stress disorder (PTSD) and anxiety disorder. A review of the Level 1 PASRR dated June 22, 2021 included the resident was admitted to the facility from the hospital, and met the criteria for a 30-day convalescent stay at the facility. The PASRR also included a statement that the nursing facility must update the Level 1 PASRR at such time that it appears the resident's stay will exceed 30 days. Further review of the clinical record revealed the resident returned to the facility from hospital on June 23, 2021 and continued 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one of 18 sampled residents (#214). The deficient practice may result in residents not being provided the services and person-centered care necessary to meet their needs. Findings include: Resident #214 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with diabetic chronic kidney disease, dependence on renal dialysis, acquired absence of right leg above knee and end stage renal disease. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment included the resident had received dialysis. A physician's order dated July 15, 2021 stated to monitor the hemodialysis site for signs/symptoms of complications, and to notify the physician and dialysis center immediately with…

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 clinical record review, staff interviews, and review of policy and procedure, the facility failed to revise the care plan for one of 18 sampled residents (#24). The deficient practice could result in care plan not being revised. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included fractures of the right fibula and right tibia, dysphagia, and altered mental status. Regarding the external fixator device: A nurse progress note dated March 13, 2020 revealed the resident was a new admission from the hospital and had an external fixation device to the right lower extremity with six pins into the skin with ace wraps from the knee to the ankle. Review of the care plan initiated on March 14, 2020 revealed the resident required assistance for mobility related to an external fixator to the right lower extremity. Interventions included head of bed elevated as a mobility enabler and therapy screening. A physician's order dated March 17, 2020 revealed an order for daily…

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 clinical record reviews, observation, staff interviews, and review of policies and procedures, the facility failed to ensure services met professional standards of quality, by failing to ensure a physician order was clarified for one resident (#13) and that a physician order for one resident (#17) was followed. The sample size was 18. The deficient practice could result in medication errors and physician orders not being followed. Findings include: -Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, fall, and history of traumatic brain injury. Review of a prescription dated July 28, 2021 for resident #13 revealed for Phenytoin Sodium Extended Capsule, give 230 milligrams (mg) by mouth in the morning for seizures with an effective date of July 30, 2021. Review of the physician's order report revealed two orders dated July 29, 2021: -Phenytoin Sodium (Dilantin) Extended Capsule give 200 mg by mouth in the morning for seizures; and -Phenytoin Sodium Extended Capsule…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure pre and post dialysis assessments were consistently completed for one sampled resident (#214). The deficient practice could result in dialysis related complications not be being readily identified and treated timely. Findings include: Resident #214 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with diabetic chronic kidney disease, dependence on renal dialysis, acquired absence of right leg above knee and end stage renal disease. Multiple physician's orders dated July 15, 2021 regarding dialysis were noted. These included: -Monitor dialysis site for signs/symptoms of complications and notify the physician and dialysis center immediately with any urgent problems. -Dialysis Tuesday, Thursday, Saturday - Early breakfast meal at 0530 due to dialysis schedule - Hemodialysis Dressing changes may be performed by the Center staff if accidental removal of transparent…

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 observations, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to two residents (#27 & #13). The error rate was 8%. The deficient practice could result in further medication errors. Findings include: -Resident #27 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and amputation between left hip and knee. A physician order dated August 2, 2021 included for a chewable Lanthanum Carbonate (phosphate binding agent) 500 milligrams (mg) tablet by mouth with meals for phosphorus binding. On August 4, 2021 at 8:06 a.m., a Licensed Practical Nurse (LPN/staff #102) was observed to administer resident #27 medications during a medication administration observation. Review of the medication blister pack for Lanthanum Carbonate 500 mg included instructions to chew the medication before…

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 county COVID-19 positivity rates, facility documentation, staff interviews, policy review, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule requirements, the facility failed to ensure one Registered Nurse (RN/staff #75) was tested for COVID-19 at the required frequency. The deficient practice could lead to the spread of COVID-19. Findings include: Facility Documentation of testing frequency requirements according to community transmission was reviewed and included the following: For the week of June 27 through July 4, 2021, the staff were required to test every two weeks. For the week of July 4 through July 11, 2021, the staff were required to test every week. For the week of July 11 through July 18, 2021, the staff were required to test every week. For the week of July 18 through July 25, 2021, the staff were required to test every week. For the week of July 25 through August 1, 2021, the facility began outbreak testing, and the staff were required to test every 3-7 days. Review of the facility's COVID-19 testing log revealed staff #75, 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.