Sage Post Acute

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure narcotic medications were signed out according to professional standards for 1 (Resident #209) of 2 sampled residents reviewed for pain management and failed to ensure narcotic reconciliation counts were completed for 1 of 1 medication room and 1 of 2 medication carts. Findings included: A facility policy titled, Controlled Substances, revised in 04/2019, revealed, 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The policy indicated, 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The policy further indicated, Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of…

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, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure enhanced barrier precautions (EBP) were implemented and catheter collection bags were kept off the floor for 3 (Residents #13, #5, and #50) of 3 sampled residents with indwelling urinary catheters. Findings included: CDC guidelines titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed Enhanced Barrier Precautions Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact…

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, record review, and review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. Specifically, the facility failed to accurately code the presence of an indwelling urinary catheter for 1 (Resident #5) of 3 sampled residents who had urinary catheters and failed to accurately code the use of an antiplatelet medication for 1 (Resident #19) of 1 resident reviewed for MDS discrepancies. Findings Included: 1. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, SECTION H: BLADDER AND BOWEL, revealed, Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube). The user's manual further indicated, for section H0300 Urinary Continence staff should, Code 9, not rated: if during…

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, record review, and facility policy review, the facility failed to complete a baseline care plan within 48 hours of admission for 1 (Resident #207) of 3 residents reviewed for baseline care plans. Findings included: A facility policy titled, Care Plans - Baseline, revised in 12/2016, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. An admission Record, indicated the facility admitted Resident #207 on 05/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of atherosclerotic heart disease, end stage renal disease, dependence on renal dialysis, chronic pain syndrome, and insomnia. Resident #207's Baseline Care Plan, dated 05/12/2024 at 6:36 PM, revealed a status of In Progress. The sections addressing Dietary/Nutritional Status, Therapy, Social Services, Comments [and preferences], Plan of Care, and signatures of staff completing the baseline care plan, the resident, and the resident's representative were 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 observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of anticoagulant medications for 1 (Resident #47) of 5 sampled residents reviewed for unnecessary medications and failed to develop a care plan addressing urinary catheters for 2 (Resident #13 and Resident #50) of 3 sampled residents with indwelling urinary catheters. Findings included: A facility policy titled, Anticoagulation - Clinical Protocol, revised in 11/2018, revealed, 1. As a part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. A facility policy titled, Catheter Care, Urinary, revised in 08/2022, revealed, Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 1. An admission Record revealed the facility admitted Resident #47 on 02/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of personal history of pulmonary embolism and heart failure. An admission Minimum Data Set (MDS), 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 2. An admission Record revealed the facility originally admitted Resident #13 on 04/12/2024 and readmitted the resident on 04/23/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident did not have an indwelling urinary catheter at the time of the assessment. Resident #13's care plan revealed a Focus area, initiated on 04/13/2024, that indicated the resident had bowel and bladder incontinence. The care plan did not address the presence of an indwelling urinary catheter. A hospital Discharge Summary, dated 04/23/2024, revealed the resident had renal failure and was being discharged from the hospital to a skilled nursing facility with hospice services. The Discharge Summary did not indicate the resident had an indwelling urinary catheter. Resident #13's Order Summary Report, listing active orders as of…

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, record review, and facility policy review, the facility failed to ensure 1 (Resident #47) of 5 sampled residents reviewed for unnecessary medications was monitored for potential side effects related to the use of a prescribed anticoagulant medication. Findings included: A facility policy titled, Anticoagulation - Clinical Protocol, revised in 11/2018, revealed, The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria [blood in the urine], hemoptysis [coughing up blood], or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. An admission Record revealed the facility admitted Resident #47 on 02/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of personal history of pulmonary embolism and heart failure. An admission Minimum Data Set (MDS), with an…

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, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 3 medication errors out of 32 total opportunities, resulting in a medication error rate of 9.38%, affecting 2 (Resident #15 and Resident #21) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. An admission Record revealed the facility originally admitted Resident #15 on 08/13/2021 and readmitted the resident on 02/15/2022. Resident #15's Order Summary Report, listing active orders as of 05/15/2024, revealed an order, dated 02/23/2024, for Multiple Vitamine-Minerals Tablet, one tablet by mouth one time daily for nutritional supplement. Observation of medication administration on 05/15/2024 at 8:07 AM revealed Licensed Vocational Nurse (LVN) #4 gave Resident #15 a multivitamin tablet without added minerals. During an…

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, record review, and facility policy review, the facility failed to ensure 1 (Resident #21) of 5 residents observed during medication administration was free of a significant medication error. Specifically, the facility failed to administer metoprolol to Resident #21. Findings included: The facility policy, Identifying and Managing Medication Errors and Adverse Consequences, revised April 2007 revealed, 1. The staff and practitioner shall strive to minimize adverse consequences by a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. An admission Record revealed the facility originally admitted Resident #21 on 11/01/2019 and readmitted the resident on 04/24/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hypertension (high blood pressure). Resident #21's Order Summary Report, listing active orders as of 05/15/2024, revealed an order, dated 05/16/2023, for metoprolol tartrate (medication used to treat…

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 record review, interview, and facility document and policy review, the facility failed to ensure nursing staff documented the administration of as needed (PRN) pain medication for 1 (Resident #209) of 2 sampled residents reviewed for pain management. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, revealed, 22. The individual administering the medication initials the resident's MAR [medication administration record] on the appropriate line after giving each medication and before administering the next ones. An admission Record revealed the facility admitted Resident #209 on 05/11/2024. According to the admission Record, the resident had a medical history that included a diagnosis of pain to left hip. Resident #209's care plan included a Focus area, initiated on 05/12/2024, that indicated the resident was at risk for pain. An intervention dated 05/12/2024 directed staff to administer analgesics per physician's orders. Resident #209's Order Summary Report, listing active orders as of 05/14/2024, contained an order, dated 05/11/2024,…

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 supervision for one (Resident 12) to ensure the safety of all residents. Resident 12 had a history of striking out at other residents and staff. This failure resulted in an unsafe environment for all residents due to a lack of continued supervision. Findings: Record review on 5/25/21 of the document, admission Record showed the facility admitted Resident 12 with diagnoses that included Dementia (decline in mental ability severe enough to interfere with daily life) with behavioral disturbances (agitation which can include verbal and physical aggression). Review of the nurse's Progress Notes dated 12/20/2020, showed Resident 12 was found in another resident's room, and asked Resident 12 to come out. Resident 12 was found holding the nursing assistant's face shield. When the CNA (certified nursing assistant) asked for the face shield, Resident 12 hit her arm several times. Resident 12 was escorted back to his room by nurse and CNA. Resident 12 came out of his room and resumed pacing. Review of 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, interview, and record review, the facility failed to follow proper sanitation and food handling practices safety for 51 of 51 residents who were residing at the facility. Multiple items were found in the kitchen that were not dated or had expired. This deficient practice had the potential health risk of foodborne illness because of their compromised health status. Findings: During an observation on 05/24/21 at 10:23 a.m., the following items in the freezer were undated: 16 bags of pancake containing 8 pancakes each, 16 pieces of pizza in a bag, 2 bags of 3 lbs (pounds) diced potatoes, 21 muffin pieces in bags, 24 pieces of biscuits, 2 bags of cream puffs, 5 plates of pies, 6 French toasted bread items, each one included 6 pieces, dinner rolls 1 bag, 15 whip cream bags, each one 1 lb, 1 gallon of thousand island dressing, cooked 5 lb Italian sausage, one bag of diced chicken 2 lb, bag of fried ham 2 lb, 1 bag of beef hot dogs, 5 boxes of concentrated juice (each one 55 lb),(grapes, apple, orange, cranberry, pineapple), 3 gallons of opened vanilla ice cream, feta…

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, for one (Resident 46) of 17 sampled residents, the facility allowed Resident 46 to self-administer medication without a physician's order or assessment of the resident's ability to self-administer medications safely. This failure has the potential for Resident 46 to not take the medications as prescribed. Findings: During the initial tour observation and concurrent interview, on 5/24/2021 at 10:10 a.m., Resident 46's Proventil HFA (hydrofluoroalkane) Aerosol Solution (anti-asthmatic and bronchodilator agents to treat a disease that affects the lungs) and Naphcon eye drops (used for redness, puffiness, itching that commonly occur with allergies) were at the bedside table. The Director of Staff Development (DSD) confirmed Resident 46's medications were at the bedside table. During an interview with the Licensed Vocational Nurse 1 (LVN 1), on 5/24/2021 at 10:30 a.m., LVN 1 stated the albuterol (fast acting medication for shortness of breath) inhaler and eye drops were put on the bedside table a few days ago. For patient's safety, they…

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 skilled nursing facility's staff did not maintain an environment free from abuse for two, Residents 9 and 353 of 17 sampled residents. Resident 353 and 9 were engaged in verbal abuse and not separated by staff as soon as possible. This failure resulted in unnecessary verbal abuse. Findings: During an interview with Resident 353 on 5/25/21 at 9 a.m., Resident 9 (roommate) was observed yelling out, Nurse, nurse! Resident 353 said to Resident 9 Shut up. Resident 9 then stated, No, you shut the h### up! In an interview, on 5/25/21 at 9:10 a.m. Licensed Vocational Nurse 3 (LVN 3) stated she was not aware of any issues between Residents 353 and 9, but she would Let the social worker know. LVN 3 did not initiate separating the roommates. In an interview on 5/25/21 at 9:12 a.m., the Certified Nursing Assistant 5 (CNA 5) stated, Sometimes his roommate (Resident 353) is in a bad mood. In an interview on 5/25/21 at 9:15 a.m., Resident 353 stated, Did you hear him yell? Did you hear that? See what I have to put up with? I want him to move to another room.…

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 the ombudsman (an official appointed to advocate and investigate resident complaints) was notified before discharging one (Resident 52) of three sampled residents from the facility. This deficient practice had the potential to deny protection and advocacy rights from the Ombudsman on behalf of Resident 52 from a possible inappropriate discharge or explore other available options. Findings: During a review of Resident 52's discharge records, the facility was unable to find the ombudsman notification of Resident 52's discharge from the facility. During an interview on 05/27/21 at 10 AM with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated They (staff) need to inform the Ombudsman for residents who are going to be discharged , and for Resident 52, they did not do that. LVN 2 she did not know why staff forgot to inform the Ombudsman about Resident 52's discharge as required. During a review of the facility's policy and procedure, Notice Requirements Before Transfer/Discharge (undated) indicated, . c. the facility…

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 that staff consistently used available methods to communicate with Resident 36. The certified nursing assistant 1 (CNA 1) did not know the resident's primary language (Russian) and spoke Spanish to Resident 36. For Resident 10, staff failed to assist in positioning the resident appropriately for eating breakfast. These failures resulted in staff not communicating in Resident 36's preferred language with the use of a communication board (symbols in primary language) to enable Resident 36 to communicate needs. Resident 10 ate his breakfast at a 30 degree lying position which did not promote digestion. Findings: During an observation and interview on 5/25/2021, at 10:30 a.m., Resident 36, was not speaking in English. Resident 36 did not have a posted communication board or visible communication binder in Resident 36's room. During a record review of Resident 36's admission record dated 10/12/2020,which reflected the resident's primary language is Russian. During a concurrent observation and interview, 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.

Based on observation, interview, and record review, the facility failed to provide personal hygiene assistance for two (Residents 2 and 3) of 17 sampled residents. Residents 2 and 3 had long, chipped and dirty fingernails containing a black substance underneath the nails. This failure had the potential for the development of infection and /or skin injuries for Residents 2 and 3. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 2/11/2021 indicated, Resident 2 required extensive assistance for all personal hygiene activities, including cleaning of the face and hands. During an observation on 5/24/2021 at 11:30 a.m. , the chipped fingernails on Resident 2's contracted right hand extended beyond the end of the fingertips, with brown substances visible underneath the fingernails and were folded inside his palm. During an interview with the Certified Nursing Assistant 5 (CNA 5) on 5/25/2021 at 8: 45 a.m., CNA 5 stated their daily CNA routine is to cut or trim the resident's fingernails. CNA 5 further stated she had no time to trim Resident 2'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.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for one (Resident 2) of 17 sampled residents when Resident 2 did not have interventions in place to prevent the loss of function/mobility of Resident 2's right hand. This failure had the potential for Resident 2's contractures (a condition of shortening and hardening of muscles, tendons or other tissues, often leading to deformity and rigidity of joints) to worsen. Findings: During an observation on 5/25/2021 at 11: 48 a.m., Resident 2 was sitting in his wheelchair next to the nurses Station with his right contracted hand resting on his lap. Resident 2 was unable to move his right hand and his fingers were folded inside his palm. During an interview on 5/25/2021 at 12: 45 p.m., the Certified Nursing Assistant 5 (CNA 5) stated Resident 2 had a contracture on his right hand and was unable to open his fingers and did not do anything for his hand because Resident 2 has a restorative nursing assistant (RNA) program (certified nursing assistant with specialized training 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 interviews and record review, the facility failed to ensure one resident (Resident 23) was seen at least once, every 60 days by the physician. The Attending Physician (MD) did not personally conduct alternate visits with Resident 23 as required. This failure had the potential for inadequate medical care and treatment when the physician did not evaluate Resident 23. Findings: During a review for of the face sheet for Resident 23, Resident 23 had a diagnoses that included schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal, from reality or fantasy). Record review of the physician's progress notes dated 1/3/21, 1/8/21, 2/6/21, 2/11/21, 2/20/21, 2/28/21, 3/6/21, 3/21/21, 3/27/21, 4/3/21, 4/10/21, 4/19/21, 4/21/21, 5/15/21 and 5/22/21 reflected the visits were all performed and documented by the nurse practitioner (NP). The NP documented on 4/10/21, That nurses informed that patient refuses to take pills. Will DC (discontinue) certain…

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, staff interview, and record review, the facility failed to identify expired narcotics (medications used to relieve pain) in the e-kit (emergency kit: a locked box which contains a limited supply of medications for the facility to use during emergency situations, and after pharmacy hours). This failure had the potential for residents to experience inadequate pain control. Findings: During a tour of the medication room with the Director of Nursing (DON), on 5/25/21, at 9:45 a.m , the narcotics e-kit had a yellow lock tag. Further inspection of the narcotics e-kit contained 2 vials of Hydromorphone (Dilaudid) 2mg/ml (milligram/milliliter) 1 ml injectable and expiration date of 5/21. During an interview with the Director of Nursing (DON) on 5/25/21 at 9:55 a.m., DON stated the pharmacy consultant is supposed to check the e-kits during the monthly pharmaceutical reviews. The pharmacy consultant had not visited the facility since the start of the COVID-19 pandemic. DON confirmed the 2 vials of Hydromorphone were expired and DON is responsible for checking the e-kits…

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 maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize adverse consequences related to medication therapy, for three of three sampled residents, (Resident 30, Resident 37 and Resident 3) when the facility did not inform the physicians about the pharmacist's recommendation of changing the medication dosages for Resident 30. The drug regimen review was not done within 30-days by the licensed pharmacist for Residents 3 and 37. These failures had the potential to receive unnecessary medication for Resident 30. For Resident 37 and Resident 3, this had the potential of adverse side effects of the medications. Findings: 1. During a review of the Consultant pharmacist's Medication Regimen Review (MRR) for Resident 30 dated 3/31/21, showed the pharmacist recommended a gradual dose reduction of venlafaxine (antidepressant medication) 75 milligrams daily for Resident 30. During an interview 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.

Based on interview and record review, for one (Resident 37) of 17 sampled residents, the facility failed to accurately monitor, document, and communicate the effects of anti-psychotic (Seroquel) medication therapy. This failure had the potential for adverse side effects of Seroquel and possible need to adjust the medication dosage. Findings: Review of the clinical record indicated Resident 37 was admitted to the facility with diagnoses that included schizophrenia (a mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior) and major depressive disorder, recurrent (repeated episode of depression). During a review of Resident 37's physician orders dated 4/28/2021, indicated Seroquel (also called Quetiapine) ER (extended release) 400 milligrams (mg), two tablets by mouth at bedtime and Seroquel 50 mg, one tablet by mouth at bedtime related to schizophrenia. During an interview with Resident 37 on 5/25/2021 at 11:55 a.m., Resident 37 stated, I mentioned to the nurse that maybe the reason I had multiple falls is because of my medications.…

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 one (Resident 46) of 17 sampled residents was free of significant medication error when Licensed Staff administered Omeprazole (reduces the amount of acid in the stomach) after the medication was discontinued. This failure had the potential for Resident 46 to be exposed to more side effects from taking the medication longer than expected. Findings: Review of the admission Record indicated Resident 46 was admitted to the facility with multiple diagnoses that included malignant neoplasm of unspecified part of the bronchus or lung (cancerous abnormal mass of tissue). Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) for Resident 46 dated 4/30/2021, indicated this Resident has been receiving the proton pump inhibitor Omeprazole, could the ongoing need for this therapy be re-assessed at this time? MRR indicated the physician wrote an order Ok to Discontinue. During an interview and concurrent record review on 5/26/2021 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1) , LVN 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.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly after they have been discontinued. This failure had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy. 1. Two Glucagon (medication for low blood sugar) kits were found at the bottom drawer of the refrigerator in the medication room. 2. The refrigerator freezer in Station 2's medication room had a thick layer of frost. 3. Narcotic medications that were discontinued were kept stored in Medication Cart B. Findings: 1. During an inspection of the Station 2 medication room and concurrent interview with the Director of Nursing (DON), on 5/25/21 at 10 a.m., two Glucagon kits were found in the bottom drawer of the refrigerator. The two Glucagon kits did not have resident names nor expiration dates on them. DON stated the two Glucagon kits should have been destroyed after their original labels were removed. 2. During a concurrent tour and interview in the medication room on 5/25/21, at 10:05 a.m., an inspection of…

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, interviews and record review, the facility failed to maintain the infection control program. The Restorative Nursing Assistant (RNA-trained to assist residents with strengthening muscles and range of motion) entered an isolation room without wearing personal protective equipment (PPE) and performing hand hygiene. For Resident 10, a half-filled urinal containing yellow urine was not removed from the meal tray while Resident 10 ate breakfast. These failures had the potential to result in the spread of infection. Findings: During an observation on 5/24/21 at 10:47 a.m., RNA 1 entered Resident 23's isolation room without performing hand hygiene and wearing a disposable gown. During an interview on 5/24/21 at 10:47 a.m., RNA 1 stated she was sorry she did not wear the gown or perform hand hygiene. During an interview on 5/24/21 at 10:47 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated RNA 1 was required to perform hand hygiene and wear a gown to enter an isolation room. Review of the care plan initiated 5/19/21 indicated Resident 23 was placed on isolation due…

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.