George L Mee Memorial Hospital D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) for two of 12 residents' (Residents 3, and 40) clinical records, when Licensed Vocational Nurse (LVN) F computer screen was left open and unattended in the hallway near residents 3 and 40's room during medication pass. These failures had the potential to result in unauthorized access to the resident's health information.Findings 1a. During a medication administration observation on 1/22/26, at 11: 28 a.m., the Med cart CC containing an open laptop computer was left unattended in the hallway outside of Resident 40's room. The laptop computer was on, and the screen displayed residents' information and medication records when LVN F left to check the blood…

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 resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of 12 sampled residents (Resident 7) when the nursing facility/dialysis unit communication reports (NF/DUCR) were incomplete. This deficient practice had the potential for Resident 7's dialysis care not being properly communicated and could put Resident 7 at risk for complications.Findings: Review of Resident 7's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidney failure, kidney's no longer functioning on a permanent basis), hypertension (high blood pressure), Anemia in chronic kidney disease, Aortic stenosis (narrowing of the aortic valve opening),Chronic Obstructive Pulmonary Disease(COPD - a progressive incurable lung disease-primarily caused by smoking- that causes inflammation, destroyed air sacs, and restricted…

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 controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for on the electronic medication administration record (eMAR) to indicate they were given for one out of four residents (Residents 29) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors.Findings: During the review of the CDRs for one (1) random resident receiving PRN (meaning as needed) medications was requested for review during the survey. A review of Resident 29's eMAR indicated to give Acetaminophen -Codeine (used to treat severe pain) Oral tablet 300 MG -30 MG (milligram, unit of dose of measurement) by mouth three times daily as needed for severe pain with start date of 10/1/25. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) D on 1/21/26 at…

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

Based on observation, interview and record review, the facility failed to ensure food and nutrition services staff carried out the functions of food and nutrition service competently according to facility policy and standards of practice when: 1. Two kitchen staff were unable to properly test the dish machine sanitizer solution concentration. 2. Kitchen staff did not correctly verbalize the cool down process for cooked foods. 3. Kitchen staff did not wash melons prior to cutting. These failures had the potential to expose residents to bacterial contamination, that can result in food borne illnesses for all residents who consume food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 6/24/24 at 10:41 a.m. with Dietary Aide- Dishwasher (DSW) E demonstrated how to test the concentration of the sanitation solution for the dish machine. After DSW E washed multiple loads of dishes through the dish machine, DSW E dipped a test strip (used to detect the concentration of chemical sanitizing solution) in the dish machine solution tank. DSW E then compared…

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 food safety and sanitation methods were followed according to standards of practice and facility policy when: 1. The ice machine had visible pink slime and tan colored residue on the ice making parts. 2. Two drainage pipes did not have air gaps. 3. Three floor sink drains were visibly dirty with dark black and brown stains, crumbs, and food debris. 4. Expired sliced cheese, sliced pears, and cranberry juice were found in the reach-in and walk-in refrigerators. 5. [NAME] bell peppers had grayish and black spots resembling mold in the walk-in refrigerator. 6. Metal shelves on a dish drying rack and inside the walk-in refrigerator were rust. 7. A reach-in freezer door gasket was dirty with black and brown sticky grime and residue. 8. Serving scoops with food debris stuck in the scoop were stored with clean scoops. 9. Cutting boards were deeply worn with multiple cuts and tan stains in the center. These failures had the potential to expose residents to contaminants that could cause foodborne illness.…

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 follow their policy and procedure (P&P) for an advance directives (AD, a written instruction for healthcare when the individual is incapacitated) and for completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for 7 of 8 sampled residents (Residents 9, 22, 24, 26, 31, 32, and 184). These failures have the potential for delivery of medical services against residents' wishes. Findings: Review of Resident 9's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE]. Review of Resident 9's POLST form, dated 7/14/2016, indicated section D for AD's all three options were left blank, therefore not completed. Review of Resident 22's FS indicated Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's clinical record indicated, there 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 observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of thirteen sampled residents (Residents 15, 8, 3, 5, 1, and 29), when the activity care plans of Residents 15, 8, 3, 5, 1, and 29, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 15's clinical records (history of someone's health) indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease (CKD, when the kidneys have mild to moderate damage and are less able to filter waste and fluid out of the blood), dementia (loss of memory) with behavioral problem, and hypertension (high blood pressure). During an observation of Resident 15 on 6/24/24 at 12:40 p.m., Resident 15 sat reclined in her wheelchair with her head slightly elevated.…

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 approved menus were followed and emergency menus were developed to properly feed residents in an emergency. These failures had the potential for the facility to not meeting Residents' nutritional needs. Findings: 1. During an interview on 6/24/24 at 10:00 AM in the kitchen with the Dietary Manager (DM), a copy of the facility's therapeutic menu spreadsheet was requested but the DM stated they did not use a therapeutic menu spreadsheet. The DM stated the Cooks use a daily production tally sheet with the serving size amounts for each food item and total number of diet meals to make on it. A review of the facility's Regular menu titled Season's Harmony Week 5 Menu 6/23/24-6/29/24, indicated, .Tuesday .Lunch- Garden salad with cherry tomatoes, salad dressing, Pesto grilled salmon, Orzo with lemon & herbs, Italian vegetable blend, tartar sauce, snickerdoodle cookies . A review of kitchen's Daily Production Tally, dated 6/24/24 indicated, . Meal: Lunch .Orzo with lemon and herbs, ½ cup . (cup, a unit 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 observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when hot foods were served cold and cold foods were served hot, and when pureed food recipes was not followed, which resulted in lumpy foods for three residents. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status. Findings: During the initial kitchen tour observation and interview on 6/24/24 at 10:04 a.m., an uncovered metal sheet pan with cooked green peas was resting on warm water on the trayline. A [NAME] (CK A) stated the green peas were prepared around 9:15 a.m. for that day's lunch. Another large metal sheet pan with cooked chili (a type of stew that typically contains ground meat, beans, and tomatoes) was resting inside the food warmer with other sheet pans of cooked foods. CK A stated the chili was for dinner. The DM stated the daily mealtimes when the trayline started were breakfast 7:30 AM, lunch 11:30 A.M., and dinner 5:30 P.M. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 2 of 3 sampled Residents (Residents 31 and 32) when Residents 31 and Resident 32's foley catheter (F/C, a semi-flexible plastic tube, inserted into a person's urinary bladder [a body organ that stores urine] one end and the other end attached to a bag that collects urine) drain bags were left uncovered. This failures had the potential to negatively affect the psychosocial well-being and health of Residents 31 and 32. Findings: 1. Review of Resident 31's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's admission diagnoses included neurogenic bladder (lack of bladder control), and renal cell carcinoma (kidney cancer). Review of Resident 31's physician order, dated 5/1/2024, indicated F/C. Review of Resident 31's minimum data set (MDS, a clinical and functional assessment tool)…

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 follow their policy and procedure (P&P) for oxygen (gas that supports life) therapy for 1 of 3 sampled residents (Resident 31), when oxygen was administered to Resident 31 without a physician's order for it. This failure resulted in Resident 31 receiving oxygen without a physician's order. Findings: Review of Resident 31's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 31 admitted to facility on 3/25/2024. Review of Resident's admission diagnoses included renal cell carcinoma (type of kidney cancer), metastatic cancer of spine (cancer cells spread to spine [back bone] from elsewhere in the body), severe anemia (a condition when decreased red blood cells cannot provide sufficient oxygen to body), and palliative care (specialized form of care that provides symptom relief, comfort, and support to residents living with serious illnesses). Review of Resident 31's current physician's orders…

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 to accommodate food dislikes and preferences for one out of three sampled resident (Resident 30). This failure had the potential for negative effects on health secondary to decreased food intake for Resident 30. Findings: During lunch observation in facility's dining room on 6/24/2024 at 12:17 p.m., cut carrot pieces mixed with Italian vegetables was served, and soup was not served, for Resident 30's lunch meal. Review of Resident 30's lunch tray card dated 6/24/2024 indicated under dislikes, No Carrots, and under preferences, it indicated, soup daily at lunch & dinner. Review of facility's lunch menu for 6/24/2024 indicated, Italian vegetable blend, along with other food items. During a concurrent interview, and record review of Resident 30's lunch tray card, dated 6/24/2024, with certified nursing assistant H (CNA H) on 6/24/2024 at 12:21 p.m., CNA H acknowledged carrots were indicated under dislikes and soup daily at lunch and dinner were under preferences for Resident 30. CNA H stated dietary staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement proper infection prevention and control practices for one out of five residents observed for medication administration, (Resident 16), when the registered nurse did not perform hand hygiene; such that, after throwing used gloves in the trash bin, she proceeded to prepare medications of Resident 16. This failure had the potential to spread infections, and compromise residents' health and safety in the facility. Findings: During the medication pass observation with registered nurse G (RN G), on 6/26/24 at 9:10 a.m., RN G threw away her used gloves in the trash bin that was attached to the side of the medication cart, and then proceeded to prepare medications to administer to Resident 16 without performing hand hygiene. During another medication pass observation with RN G, on 6/26/24 at 9:50 a.m., RN G again threw away, her used gloves in the trash bin that was attached to the side of the medication cart, and then proceeded to…

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

Based on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Undated food, food past their used-by date, and rotten lettuce were found in the refrigerators and on the shelves in the kitchen; 2. Dietary Aid A (DA A) did not cover his beard with a hair net; and, 3. [NAME] B (CK B) did not cover the hair in the back of her head in a hair net. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 31 residents eating at the facility. Findings: 1. On 6/13/22 at 10:15 a.m., during an observation of the refrigerators and the storage shelves in the kitchen, with the dietician (DT), the following were observed: a. Two cans of nacho cheese with a used-by date of 12/26/21 b. Eight burger buns with a used-by date of 6/2/22 c. Nine english muffin with a used-by date of 6/12/22 d. Eleven hoagie rolls with a used-by date of 6/12/22 e. Four bags of 12 burger buns in each bag with a used-by date of 6/12/22 f. One…

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

Based on observation and interview, the facility failed to store medications appropriately when: 1. Two of three medication carts were left unlocked and unattended; and 2. Residents 9's sevelamer (medication used to control high blood levels of phosphorus in people with chronic kidney disease) 800 milligrams (mg, a metric unit of mass) was left on the medication cart unattended. These failures had the potential to result in the access of medications by unauthorized personnel or residents. Findings: 1. During an observation on 6/14/22 at 2:09 p.m., licensed vocational nurse G (LVN G) was sitting inside the nurse station. Her medication cart was parked on the side of the nurse station, and it was unlocked. During and observation on 6/16/22 at 5:20 p.m., the director of staff development (DSD) was sitting inside the nurse station. Her medication cart was parked outside of the nurse station, and it was unlocked. During the interviews with LVN G and the DSD on 6/14/22 at 2:09 p.m. and on 6/16/22 at 5:20 p.m., LVN G and the DSD stated the medication carts should be locked when they were…

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 16% error rate when four medication errors out of 25 opportunities were observed during a medication pass for 3 of 14 residents (16, 17, and 31). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications (in the case of underdosing) or had the potential to for preventable side effects for the residents (in the case of overdosing). Findings: 1. During a medication pass observation on 6/14/22 at 11:46 a.m., with licensed vocational nurse C (LVN C), LVN C checked Resident 17's blood sugar and it was 321. However, LVN C recorded 231 on Resident 17's Medication Administration Record (MAR) as Resident 17's blood sugar, and she administered 12 units of aspart insulin (used to treat high blood sugar) to Resident 17 instead of 16 units according to the sliding scale (a method used to determine the dose of insulin based on the blood sugar level just before the meal). 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 observation and interview, the facility failed to ensure: 1. Two expired medications and 46 expired 8-oz boxes of renal supplement were made unavailable for resident use; and, 2. Two opened multi-dose eye medications were dated with an open and discard date (to ensure they were not used beyond the discard date). These failures had potential for residents to receive medications with reduced potency from being used past their discard date. Findings: 1. During an observation of medication cart #2 on 6/16/22 at 3:23 p.m., with the director of staff development (DSD), an 100 units/milliliter (ml, a metric unit of volume) insulin degludec (a long-acting insulin, medication to lower blood sugar level) pen (injection pen, prefilled with insulin degludec) for Resident 16 was found with an expiration date of 6/8/22. On 6/17/22 at 4:15 p.m., during an observation of medication cart #2 with licensed vocational nurse G (LVN G), Resident 16's insulin degludec pen with an expiration date of 6/8/22 was still in the cart. During an interview with the DSD on 6/20/22 at 10:46 a.m., the DSD…

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 send a copy of Resident 35's notice of discharge to the Long Term Care Ombudsman. This failure had the potential of not providing Resident 35 with access to an advocate who could inform him of his options and rights and from being inappropriately discharged . Findings: Review of Resident 35's Discharge Summary indicated he was discharged on 4/8/22 to a boarding care facility since his functional status improved. During an interview with the manager of regulatory, quality assurance, and risk (MRQAR) on 6/20/22 at 5:34 p.m., she was unable to locate the record that indicated the Long Term Care Ombudsman was notified regarding Resident 35's discharge. The MRQAR stated she also confirmed with the skilled nursing facility manager (SNFM), and there was no notification to the Long Term Care Ombudsman found regarding Resident 35's discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 12 residents (16) was free of a significant medication error when Resident 16 received insulin degludec (a long-acting insulin, medication to lower blood sugar level) nine times (doses) past the expiration date. This failure had the potential for ineffective use of the insulin (secondary to degraded potency of expired medication), resulting in uncontrolled high blood sugar for the resident. Findings: Review of Resident 16's admission Record indicated she was admitted to the facility on [DATE] with diabetes (a disease that occurs when the blood sugar is too high) diagnosis. On [DATE] at 3:23 p.m., during an observation of medication cart #2, with the director of staff development (DSD), an 100 units/milliliter (ml, a metric unit of volume) insulin degludec pen (injection pen, prefilled with insulin degludec) for Resident 16 was found with an expiration date of [DATE]. Review of Resident 16's Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to notify residents' representatives and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of a confirmed infection of COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) and scabies (an intensely itchy skin condition that spreads quickly through close physical contact) for two of 12 residents (14 and 16). These failures had the potential to result in residents' representatives and families, not receiving timely notification regarding the status and impact of COVID-19 and scabies in the facility. Findings: 1. During an interview on 6/20/22 at 3:35 p.m., with the brother of Resident 14, he verified that he was not informed by the facility when there were cases of COVID-19 and scabies in the facility, last January, 2022. During an interview on 6/20/22 at 12:50 p.m., with the Manager of Regulatory, Quality Assurance and Risk (MRQAR), she confirmed that they 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.