Camden Postacute Care, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the safety of one of four residents (Residents 29) who smoke without oversight staff supervision. This failure had the potential to put Resident 29 at risk of harm. Findings: During a concurrent observation and interview on 5/16/25 at 10:413 a.m., Residents 29 was in the patio smoking and was not wearing a smoking apron. There was no facility staff in the patio providing supervision for Resident 29. without facility staff's supervision. Resident 29 stated facility staff was not supervising him when he was smoking except when staff provides his cigarette and light his cigarette. During a concurrent observation and interview on 5/16/25 at 10:14 a.m., with Activity Assistant (AA) J, she confirmed the above observation and stated that Resident 29 needs supervision from the facility staff while smoking for safety. During a concurrent interview and record review with Registered Nurse (RN) A, she reviewed Resident 29's clinical records 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was sufficient direct care nursing staff to provide nursing and related care and services to meet resident's needs safely for 24 hours a day during the weekend. This failure had the potential to compromise care, health, and well-being of the 55 residents residing in the facility. Findings: Review of facility's census and direct care service hours per patient day (DHPPD) form dated 5/10/25 (Saturday) indicated actual CNA (certified nursing assistant) DHPPD was 2.13, and actual total DHPPD (including CNA and license nurses) was 3.15. Review of DHPPD form dated 5/11/25 (Sunday) indicated an actual CNA DHPPD of 1.99, and actual total DHPPD of 2.99. During concurrent record review of DHPPD forms and interview with the facility's Director of Staff Development (DSD) on 5/15/25 at 10:52 a.m., the DSD reviewed the DHPPD forms above on both days. The DSD confirmed the above DHPPD for CNA and the total for both days. The DSD stated the facility did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP, a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported the lack of blood work related to use of anticoagulant (AC, used to treat prevent or delays blood clots forming in blood vessels) medication to the facility during the monthly medication regimen review (MRR, a thorough evaluation of resident's medications) for one of three sampled resident (Resident 10); and the facility failed to follow up MRR recommendations for one of two sampled resident (Resident 156). These failures resulted in Resident 10 not receiving a baseline and periodical blood work, and Resident 156's medication orders not clarified. Findings: Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 10/24/24 with diagnoses including atrial fibrillation (A Fib, an irregular, often rapid heart rate…

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 had a 5.56% medication error rate when two medication errors out of 36 opportunities were identified during medication pass for two residents (Resident 16 and 41). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident. Findings: 1. During a review of Resident 16 physician's orders dated 2/21/25, it indicated, Glipizide (is used to treat high blood sugar levels) tablet 5 milligrams (mg, unit of measurement), give 0.5 tablet by mouth in the afternoon related to type two diabetes mellitus (a chronic condition that happens with persistent high blood sugar levels), 0.5 tablet =2.5 mg. give 30 minutes prior to meals. During a medication administration observation on 5/12/25, at 4:04 p.m., Registered Nurse (RN) B prepared half tablet of glipizide in a medicine cup after verifying the medication orders then administered to Resident 16 with a cup of water. 2. During a review of Resident 41's minimum data set (MDS, an assessment tool) dated 3/14/25, it indicated his…

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 medications were labeled and stored accordance with currently accepted professional standards for two of 15 sampled Residents( 5 and 25) when: 1. A bottle of oral liquid lorazepam (a controlled medication used to relieve anxiety [persistent worry and fear about everyday situations]) without legible expiration date was stored in the medication room for Resident 25 to be used; and 2. An unlabeled normal saline solution (NSS, 0.9% sodium chloride in water ) in a bottle was found at Resident 5's bedside table unattended. These deficient practices could lead to unsafe and ineffective medication use for the residents. Findings: 1. During an observation on 5/12/25, at 7:30 a.m. to 7:50 a.m., in the medication storage room with Licensed Vocational Nurse (LVN) I, Resident 25's lorazepam medication did not have a legible expiration date. Review of Resident 25's controlled drug record indicated the last time the lorazepam medication was administered to Resident 25 was on 9/30/24. A further review of Resident 25'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 interview and record review the facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal. The transfer/discharge was improper and violated Resident 20's resident rights. Findings: During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning),…

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 Administrator (ADMN) failed to provide consistent administrative oversight to ensure that the Social Services Department and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) implemented the facility's policy and procedure (P&P) for safe transfer and discharge for one of three residents (Resident 20) when Resident 20 was discharged to a board and care facility (smaller more intimate living option for residents who need assistance with daily activities but not nursing care 24/7). This failure had resulted in Resident 20's having eloped (run away secretly) from the board and care facility. Findings: During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental…

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 perform a thorough investigation and report for six of six residents (Residents 1, 2, 3, 4, 5, and 6). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety. Findings: During a review of the 5-day investigation summary of an alleged abuse by a certified nursing assistant (CNA) to Residents 1 and 2, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the alleged abuse by the CNA did occur, or not. During an interview on 4/25/25 at 3:49 p.m., with the administrator (ADM), the ADM stated that he tried to send the 5-day follow-up investigations for Resident 1 and 2 but failed. He was not able to verify if the allegations were substantiated or not. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse policy and procedure (P&P). During a review of the 5-day investigation…

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 assist one of three residents (Resident 1) with getting insurance when their insurance stopped. This failure had the potential to compromise Resident 1's ability to obtain quality of care and admission. Findings: Resident 1 was admitted to the facility with diagnoses which included heart failure, malnutrition, and pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and sepsis (a serious condition in which the body responds improperly to an infection). During an interview on 8/15/24 at 9:12 a.m. with the administrator (ADM), he stated Resident 1 had been taken off from MediCal (state insurance) on 7/31/24. During an interview on 8/15/24 at 11:44 a.m. with the ADM, he stated the facility did not discuss private pay with Resident 1. During an interview on 8/15/24 at 11:57 a.m. with the ADM, he stated the facility never applied for MediCal for Resident 1. During an interview on 8/21/24 at 2:24 p.m. with the social services (SS), she stated the previous…

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 provide care and services in accordance with professional standard of practice for one of one resident (Resident 1) when the Licensed Vocational Nurse (LVN) did not follow the physician order regarding out on pass (leave the premises) for therapeutic therapy. This failure had the potential to compromise the resident's safety. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), neuralgia (severe, sharp, or burning pain that follows the path of a damaged or irritated nerve) and neuritis (inflammation of one or more nerves caused by injury, infection, or an autoimmune disorder causing pain, tenderness, numbness, weakness, or changes in sensation), hypertensive heart (heart problems that occur because of high blood pressure that is present over a long time) and chronic…

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 one of three sampled residents (Resident 1) was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1. Findings: Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage caused by multiple strokes [occurs when blood supply going to the brain is blocked or reduced] and cognitive communication deficit (trouble participating in conversations). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/21/24 indicated her Brief Interview for Mental Status (BIMS, a tool used to have a snapshot of a resident cognitive function) was 00 (score of 0 to 7 indicates severe cognitive impairment). Review of Resident 2's admission record indicated he was admitted to the facility on…

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 provide supervision to prevent one out of three residents (Resident 1) from leaving the facility without staff's knowledge and permission. 1. The facility did not implement the care plan to provide enough supervision for Resident 1's mobility; 2. The facility did not update Resident 1's care plan to provide adequate supervision post-event. These failures compromised Resident 1's health and safety, as he was found by the police and, was admitted to the acute hospital for treatment and evaluation on 9/20/23, and had a potential risk for Resident 1's elopement in the future. Findings: 1. Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and unspecified Dementia (impaired ability to remember, think, or make decisions that interfere…

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 maintain sanitary conditions in the kitchen when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. The uncleaned fan blew air directly onto the clean meal trays, plates, plate covers and food preparation area (area to prepare for hot food); 3. There were opened liquid eggs stored with other food items in the refrigerator; 4. Toaster had multi-colored substances; 5. The can opener had multi-colored substances; 6. Kitchen staff did not correctly check the sanitizer concentration level; 7. Dietary manager (DM) did not wash his hands or perform the hand hygiene when he was in the kitchen. These failures had the potential to cause food-borne illness for the residents. There were 49 of 51 residents consuming the food from the kitchen. Findings: 1a. During an initial kitchen tour on 5/17/21 at 8:46 a.m., [NAME] G and dietary aide H (DA H) worked in the kitchen, their hair on the sides and the back were not completely covered with a hairnet. Their hair on the sides and the back were sticking…

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 staff implemented proper infection control practices when: 1. Licensed vocational nurse A (LVN A) did not follow infection control practice during residents' wound treatment for sampled Residents 8 and 28; 2. The janitor/Housekeeper did not know the environmental disinfectant contain time (wet time, disinfectant maintain wet on the surface in order to kill the micro-organism) when cleaning the resident's room; 3. The facility did not implement the effective infection control practice when Resident 8 refused to do the wound treatment and shared the room with four residents; 4. Multiple residents did not wear mask or did not properly wear masks when leaving their room; multiple residents did not keep social distancing of at least six feet apart in the hallway; 5. COVID-19 screen concerns for visitor/staff; 6. LVN C did not perform hand hygiene and change gloves before starting a new task; 7. The facility failed to educate staff regarding proper cohorting (group of residents with the same infection are…

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 respect and dignity was maintained for five of 13 sampled residents (46, 7, 31, 33, and 198) when: 1. Resident 46's urinary catheter drainage bag (urinary catheter a thin, flexible tube used to drain urine from the bladder) was left uncovered; 2. Residents 7 and 31's body parts were exposed to public view; 3. Resident 33's name were written on the back of his clothes and 4. Resident 198 wore only an incontinent brief while walking in the hallway. This failure resulted to residents rights not being maintained. Finding: 1. During an observation on 5/17/21 at 12:38 p.m., Resident 46 was observed with an uncovered urinary catheter drainage bag hanging from his wheelchair while in the hallway outside his room. During a concurrent observation and interview on 5/17/21 at 12:40 p.m., with the director of staff development (DSD)/infection preventionist (IP), she confirmed the above observation. She further stated that if the urinary…

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 submit the completed Minimum Data Set (MDS, an assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for one of three sampled (Resident 2). This failure resulted in non-compliance with regulatory requirements. Findings: During a concurrent interview and record review with the MDS Coordinator (MDSC) on 05/21/21 at 9:20 a.m., MDSC reviewed the MDS and stated that Resident 2's quarterly MDS dated [DATE] was completed. She acknowledged after the 14 days of completion date there was no record of transmission or submission electronically to CMS for the quarterly MDS. Review of Resident 2's CMS Submission Report dated 5/21/21 indicated Resident 2's quarterly MDS dated [DATE] was submitted to CMS more than 14 days after the MDS assessment completion date. A review of the CMS website (https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October-1-2018-R.pdf) indicated, The quarterly 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 interview and record review, the facility failed to ensure an interdisciplinary team (IDT) meeting was held to start the discharge planning of four of four residents. This failure could potentially affect the residents' health and wellness upon discharge from the facility. During the initial tour on 5/17/21 at 10:23 a.m., Resident 40 stated the facility staff wanted to send him home, but he said he was not ready. Resident 40 stated he just started to walk a few days ago. Resident 40 stated he had filed an appeal, because his insurance ran out. During an interview on 5/20/21 at 3:04 p.m. with the social services staff (SS), the SS stated there was not an IDT note about Resident 40's future discharge. The SS stated no IDT meeting was held to discuss Resident 40's discharge plan. During an interview on 5/20/21 at 3:08 p.m. with the SS, the SS stated there was no IDT meeting yet for Resident 97's discharge. She also stated neither Residents 100 nor 101 have had IDT meetings for discharge planning either. The SS stated IDT meetings for discharges should be held within 24 to 48…

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 treatment for limited range of motion (ROM, the full movement potential of a joint) was implemented consistently for one of 13 sampled (Resident 197) when a carrot/hand roll was not applied to both of Resident 197's hands every shift. This failure had the potential to decrease the range of motion and function of Resident 197's hands. Findings: During multiple observations on 5/17/21 at 9:53 a.m., 12:00 p.m., and 2:30 p.m., Resident 197 had no carrot/hand roll in her hands. During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 5/18/21 at 9:55 a.m., she confirmed that Resident 197 had no carrot/hand roll in either hand. LVN B further stated that Resident 197 should have a carrot/hand roll in both hands applied every shift. Review of Resident 197's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), cerebral…

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 the gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply food, fluids, and medications) placement was checked prior to administering medications for one out of 28 opportunities (Resident 20). This failure had the potential to compromise the residents's care and could cause health complications. Findings: During a medication pass observation on 5/17/21 at 4:33 p.m., while at Resident 20's bedside, licensed vocational nurse C (LVN C) inserted a syringe in the GT. Then pulled the plunger and obtained 50 ml (ml, a metric unit of volume) of gastric residual (volume of fluid remaining in the stomach). After instilling the gastric residual, he poured 50 ml of water into the syringe, then proceeded with the medication administration. LVN C did not check the GT placement. During an interview shortly after the medication pass observation, LVN C acknowledged that he did not check the GT placement prior to administering Resident 20's medication. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure communication with the dialysis facility was properly coordinated when dialysis communication records (DCR) for one of four (Resident 46) was not completed. This failure may affect the quality of dialysis care being provided to the resident. Findings: Review of Resident 46's clinical record indicated he was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function). He was scheduled for dialysis every Monday, Wednesday and Friday. During concurrent interview and record review with the registered nurse supervisor (RNS) on 5/20/21 at 10:30 a.m., she reviewed Resident 46's clinical record and confirmed that DCR's dated 2/1/21, 2/18/21, 2/25/21, 3/1/21, and 4/29/21…

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 residents were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processess and behavior) for two of five residents (21 and 5) who receives psychotropic medications when: 1. Resident 21 received Ambien (prescription medicine for the short-term treatment of adults who have trouble falling asleep) 2.5 mg (mg, unit of measurement of mass) without monitoring hours of sleep, as indicated in the care plan; and 2. Resident 5 received prn (as needed) Lorazepam Intensol (used to treat anxiety) beyond 14 days without documentation of its rationale and specific duration in the resident's clinical record. These failures resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the resident's physical, mental, and psychosocial well being. Findings: 1. Review of Resident 21's physician's order, dated 4/6/21,…

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 had a 7.14 percent medication error rate when two medication errors out of 28 opportunities were identified during medication pass for one resident (Resident 30). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident. Findings: 1. During a medication pass observation on 5/17/21 at 9:53 a.m., licensed vocational nurse B (LVN B) was preparing and administering multiple medications, including a tablet of Protonix (blocks the production of acid in the stomach) 20 milligrams (mg, unit of measurement) to Resident 14. During the observation, LVN B said the internet was down so she used the resident's paper physcian orders to check for scheduled medications to administer to the resident. On 5/17/21, a review of Resident 14's medical record indicated a physician's order, dated 8/29/20, for Protonix 20 mg 1 tab one time a day for gastroesophageal reflux disease (a digestive disorder in which stomach acid or bile irritates the food pipe lining). On 5/17/21, a review…

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 store and label medications in accordance with the manufacturer's instructions when: 1. Resident 14's Incruse Ellipta (an oral inhaler, used to prevent airflow obstruction and reduce flare-ups in adults with chronic obstructive pulmonary disease) was opened without an open date; 2. Two of two Xalatan (or Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Residents 13 and 23 were being used past the discard date; and 3. Lorazepam Intensol (medication used to treat anxiety) 2mg/ml (mg/ml, measurement of a solution's concentration) bottle for Resident 5 did not have an open date and was being used past the discard date. These deficient practices had the potential for residents to receive medications from two out of two medication carts. Medications that are unlabeled and past their discard date could lead to unsafe and ineffective medications for the residents. Findings: 1. During an inspection of medication cart #2 on 5/17/21 at 9:53 a.m., with licensed vocational nurse (LVN) B,…

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.