Arbor Hills Nursing Center

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained according to standards of practice when: 1. Two individual sized cereal containers were found on the floor under the food shelves of the dry pantry storage. 2. One large food can item was dented. 3. Food boxes stored above the red line (18 inch) mark from the ceiling from fire sprinkler clearance. 4. Five food seasonings was previously used without an opened date. 5. One dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids. 6. A red sanitation bucket was placed on top of a food production table. These failures had the potential to cause widespread food borne illness among all 86 residents who receive food from the kitchen. Findings: 1. During the initial kitchen tour on 10/29/24 at 8:38 A.M., an observation was conducted with the Dietary Supervisor (DS). Upon entry there were two shelves on the left of the dry storage food pantry with brown boxes on the top shelf and food items…

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, interviews, and record review, the facility did not develop and implement resident specific care plans related to PTSD (PTSD-an anxiety disorder that comes from a traumatic event) and limited range of motion (ROM) for 2 of 18 residents reviewed for care planning. (Resident 27 and Resident 294) Cross reference F688 and F699 As a result, Resident 27 did not receive care to address the decline in ROM in Resident 27's hands. In addition, Resident 294 had the potential to be retraumatized. Findings: 1.Resident 27 was admitted to the facility on [DATE] with diagnoses including osteoporosis (condition in which bones become weak and brittle) according to the facility's admission Record. During an initial tour of the facility on 10/29/24 at 9:40 A.M., an observation and interview of Resident 27 was conducted. Resident 27 was observed lying in bed in his room with a blanket. Resident 27 stated the facility staff Did not help me cut up my pancakes. Resident 27 stated he needed assistance cutting up…

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 a comprehensive care plan was revised and updated for one of five residents (Resident 15) reviewed for nutrition. As a result, the resident had the potential for further weight loss and health decline. Findings: According to the admission Record, Resident 15 was admitted on [DATE] with diagnoses that included protein-calorie malnutrition (not enough protein or calories eaten to meet nutritional needs). A review of Resident 15's Interdisciplinary (IDT) Note indicated Resident 15 had a significant, unplanned weight loss of 18.3 pounds in one month. On 10/31/24 at 2:59 P.M. an interview was conducted with the Registered Dietitian (RD). The RD stated Resident 15's weight loss .was not an intentional weight loss .She had sudden significant weight loss .its not desirable, it means you are not meeting [Resident 15's] nutritional needs. The RD acknowledged that Resident 15's nutritional care plan was not updated to reflect the recent weight loss. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide interventions (care) according to the comprehensive care plan to prevent foot injury for one of 12 residents (Resident 42) reviewed with diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). As a result, Resident 42 was hospitalized with a left foot swelling (buildup of fluid in the tissues caused by the body's defense response to injury or infection) due to abrasions with the potential for diabetic foot complications. Findings: A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included a history of diabetes and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) on the left second toe. A record review of Resident 42's MDS (Minimum data set: nursing facility assessment tool) dated 8/31/24 indicated that Resident 42 was rarely or unable to understand others or make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three resident's (Resident 86) pain medication order was clarified to include parameters (how much medication to give based on the residents stated pain level on a 0-10 scale) and frequency of administration. This failure had the potential for Resident 86 to have uncontrolled pain or to be over medicated. Findings: According to the admission record, Resident 86 was admitted to the facility on [DATE] with diagnoses including post laminectomy (back surgery). During a record review of Resident 86's Medication Administration Record (MAR), Resident 86 had an order for Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth as needed for Twice daily as needed for pain management. 2x daily as needed for pain. Start date 10/24/2024 0900. During an interview on 11/1/2024 at 9:50 A.M., with the Infection Preventionist (IP), IP stated a pain medication order needed to have the medication name, dose, route, frequency, length,…

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 trauma-informed care (care that involves recognizing and responding to the effects of all types of traumas) to one of six sampled residents (Resident 294). This deficient practice had the potential for Resident 294 to experience re-traumatization that could lead to severe psychosocial harm and affect the resident's quality of life. Findings: A review of Resident 294's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included PTSD (PTSD, a disorder in which a person has difficulty recovering after experiencing a terrifying event), depression, and alcohol use. A review of Resident 294's Minimum Data Set (MDS, an assessment tool) dated 10/16/24 indicated Resident 294 had intact cognitive skills (the ability to think, remember, and reason). On 10/29/24 at 11:04 A.M., an interview was conducted with Resident 294. Resident 294 stated he was a military veteran and had been stationed in Iraq. Resident…

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 controlled medications (medications with high abuse potential) reconciled with the medication administration record (MAR) for one of three residents (Resident 86). This failure had the potential for drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). Findings: According to the admission record, Resident 86 was admitted to the facility on [DATE]. During a record review of Resident 86's Medication Administration Record (MAR), Resident 86 had an order for: Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth two times a day for pain management Start Date 09/11/2024 0900 [9 A.M.] (D/C Date (ending date) 10/23/2024 2046 [8:46 P.M.]. This same order was then restarted on 10/23/2024 at 2100 [9 P.M.] and D/C [discontinued] date of 10/24/2024 0857 [8:57 A.M.] when it was replaced with the order Norco Oral Tablet 5-325 mg…

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 resident (Resident 68) who received a psychotropic medication (a medication that affects brain activity associated with mental processes and behavior) had accurate monitoring for use of the medication. As a result of inaccurate monitoring, there was a potential the facility would not be able to determine if the medicine was effective or if a gradual dose reduction was beneficial which put Resident 68 at risk for receiving unnecessary psychotropic medication. Findings: According to the admission record, Resident 68 was admitted on [DATE]. Resident 68's admitting diagnosis was unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture routine healing (a break in the hip joint that did not require surgery to heal). Resident 68 had a diagnosis of dementia (a long term condition that causes a decrease in brain function) and a diagnosis of depression (a mental health condition that impacts how a person feels,…

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 outdoor facility garbage and refuse (recyclable and non-recyclable trash) was not overflowing and was secure with the dumpster's lids closed, for one of three facility dumpsters located outside the kitchen by the parking lots. This had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: On 10/29/24 at 9:30 A.M., an observation and interview was conducted with the Dietary Supervisor (DS). Dietary Aide (DA) 2 was observed pushing a blue wheeled kitchen trash barrel with no lid outside the kitchen towards the facility's garbage and refuse area. The three blue facility dumpsters were located by the parking lot area outside of the kitchen. The first dumpster did not have one of the two lids securely closed and the third dumpster had several bags of trash overflowing to the top of the dumpster that prevented the lids to fully close and secured. The DS stated DA 2 should have had a lid on the kitchen trash…

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 five residents (Resident 15) reviewed for weight loss had a completed Interdisciplinary Note and SBAR (Situation, Background, Assessment, and Recommendations) Communication Form in the resident's electronic health record (EHR). This deficient practice had the potential for Resident 15's condition not to be communicated to all healthcare providers. Findings: According to the admission Record, Resident 15 was admitted on [DATE] with diagnoses that included protein-calorie malnutrition and type 2 diabetes. On 10/29/24, a review of Resident 15's EHR was conducted. Resident 15's Interdisciplinary (IDT) Note indicated resident had an unplanned weight loss of 18.3 pounds in one month. The IDT note indicated an effective date of 10/4/24. The IDT note indicated Late Entry and was entered into Resident 15's chart on 10/29/24. On 10/31/24 at 2:41 P.M., an interview was conducted with the Registered Dietitian (RD). The RD stated Resident 15's weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to assure the full understanding of an arbitration agreement was explained to three reviewed residents (Resident 68, Resident 72, and Resident 34) when: 1. Resident 68 entered into a legal agreement when they did not have the capacity to understand what they were signing. 2. Resident 72's family member who was not the responsible party (RP) or legal representative signed the agreement without explaining to Resident 72 what the agreement was about. 3. Resident 34 was not given a copy of the signed arbitration agreement and did not fully understand that they had 30 days from the date they signed to cancel the agreement. As a result, the residents (Resident 68, Resident 72 and Resident 34) entered into a legal agreement when they did not fully understand what they were signing and posed the risk for the residents to give up their judicial (judgments made in a court) rights for any medical malpractice. Findings: 1. A review of Resident 68'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 interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify areas of improvement and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), complaints identified in resident council meetings and by surveyors during the recertification survey concerning food served to the residents. Cross reference F804 and F806 This failure resulted in unresolved issues affecting the residents' quality of life. Findings: On 11/1/24 at 4:20 P.M. an interview with the Director of Nurses (DON) and a review of the QAPI program was conducted. The DON stated the issues discussed in the QAPI meetings were falls, diabetic care, inaccurate orders from the hospital, unsafe discharges, and weight loss. The DON stated the issues in the resident council meetings pertaining to food from the months of May, June, July, August, and September 2024 were not addressed in the QAPI meetings. The DON stated she…

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 infection control procedures were followed when: 1. Certified Nursing Assistant (CAN) 11 provided care to a resident, Resident 65, who was on Enhanced Barrier Precautions (EBP-stronger infection control requirements requiring gowns and masks in addition to gloves) without wearing appropriate personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). 2. Licensed Nurse (LN) 4 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves. In addition, LN 4 wore bandages on both hands and fingertips which prevented her hands from being fully cleaned. These failures had the potential to result in the spread of infection among residents, staff, and visitors. FINDINGS: 1. During an observation on 11/1/2024, at 10:25 A.M. in the hallway outside of room A, CAN 11 was observed transferring (assisting a patient with movement) Resident…

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 clarify a physician ' s order for a medication for one of two residents reviewed for plan of care (Resident 1). This failure resulted in Resident 1 not receiving the medication for 12 days, with the potential for blood clots or other complications. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses to include atherosclerosis of coronary artery bypass graft (a build-up of plaque in the arteries of the heart, which can cause blockage, or heart attack), per the facility admission Record. On 8/12/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). Per the DON, Resident 1 went out of the facility to many types of doctor appointments. The DON stated the process for communicating with the doctors was for the doctor to write any prescriptions or progress notes to send back from their office to the facility. The facility Licensed Nurse (LN) who received the orders should document the order in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide communication in the native language of one resident, Resident 1, in his native Arabic dialect when: 1. The facility had a policy for communication which was not implemented A review of the facility policy entitled Facility Services - Translation and/ or Interpretation dated 7/1/20 indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.6. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting; b. A staff interpreter who is trained and competent in the skill of interpreting; c. Contracted interpreter service; d. Voluntary…

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 implement their infection control program when two staff members did not wear proper full personal protective equipment (PPE- consisted of gown, gloves, N-95 [highly particulate-filtering facepiece] mask, and face shield/goggles) while providing care to residents who were tested with COVID-19 (highly infectious disease), and one staff member failed to properly discard used N95 mask. These failures had the potential for contamination of supplies and spread of infection among staff and residents. Findings: On 4/4/24, the Department received a facility reported incident related to infection control. On 4/9/24, an unannounced onsite to the facility was conducted. During an observation on 4/9/24 at 9:26 A.M. in the east hall was conducted. There was a poster on the wall indicated, all staff should be wearing full PPE: gown, gloves, N-95 mask, a face shield or goggles while inside the residents' rooms. Outside the residents' room, there were PPE carts (cart which contained the PPE supplies for the staff to wear…

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 who required assistance with toileting, were provided assistance when requested and in a timely manner for six residents (Residents 39, 163, 162, 20, 10 and 8) and for six out of seven confidential residents (CR). This failure had the potential for residents to not have their toileting needs met and to experience a health decline or to lose the ability to control bowel and or bladder. Findings: 1. A review of Resident 39's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic subdural hemorrhage with loss of consciousness (bleeding in or around the brain), fall from bed, and abnormalities of gait and mobility. A review of Resident 39's MDS assessment (minimum data set, an assessment tool) dated 2/16/22, indicated the resident required extensive assistance from two or more staff for toileting. On 4/12/22 at 12:41 P.M., an interview was conducted with Resident…

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 19 sampled resident's (Resident 13) Physician Orders for Life-Sustaining Treatment (POSLT- end of life medical care decisions) was consistent with other physician orders, and updated after a change of condition. This failure had the potential to cause confusion amongst the healthcare providers and may have resulted in end-of-life treatments that were against Resident 13's wishes. Findings: Resident 13 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm (cancer) of the left breast and secondary malignant neoplasm of bone, per the facility's admission Record. A review of Resident 13's POLST, dated [DATE], the resident's end-of-life wishes included do not attempt resuscitation (DNR), selective treatment, and a trial period of artificial nutrition, including feeding tubes. A review of Resident 13's progress notes dated 2/1, 3/1, and [DATE], .Code Status: The patient states that in the event of experiencing…

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 written care plans were revised for two of 19 residents (Resident 18 and 26). This failure had the potential for residents' current care needs to not be accurately reflected in the written plan of care. Findings: 1. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 18's written plan of care for risk of transmitting an infection dated 4/16/21, indicated, .Approaches droplet precautions [required masking, gown and gloves to enter the room] . On 4/12/22 at 10:51 A.M., an observation was conducted with Resident 18 inside the resident's room. Resident 18's room was not observed to be on any isolation precautions (requiring interventions to contain infectious organisms such as wearing personal protective equipment inside the room). A review of Resident 18's written plan of care for smoking dated 5/3/21 and revised on 1/6/22, indicated, . Approaches . The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 110) Peripheral Intravenous Catheter (PIVC- a catheter placed into a peripheral vein for venous access to administer intravenous therapy such as medication fluids) was dated in accordance to the facility's policy. As a result, Resident 110 was put at risk for infection. Findings: Resident 110 was admitted on [DATE] with diagnoses including, dysphasia (deficiency in the generation of speech and comprehension due to brain disease or damage) following cerebral infarction (occurs as a result of disrupted blood flow to the brain). On 4/14/22 at 9:15 A.M., a concurrent observation of Resident 110's PIVC and interview with LN 11 was conducted. The saline lock (the part of the PIVC inserted through the skin and into a vein) was observed to have a transparent dressing over it. The transparent dressing appeared loosened where the saline lock exited from beneath the occlusive dressing. The dressing did not have…

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 implement safe and/or effective pharmaceutical services procedures to meet the needs of a universe of 75 residents. This occurred when three of three expired medications were available for use. This failure had the potential for residents to receive ineffective or expired medications. Findings: During a concurrent observation and interview on 4/12/22 at 10:15 A.M. of medication storage room located at the [NAME] Wing with licensed nurse (LN) 11, an opened Northera (medication used for dizziness and/or lightheadedness) bottle with manufacturer expiration date of 2/2022, vitamin d3 (a vitamin that helps the body with absorption of nutrients from food) bottle with manufacturer expiration date of 2/2022, and nicotine patches (a medication used to help people stop smoking cigarettes) manufacturer expiration date 1/2022. LN 11 acknowledged the medications and read the expiration dates. LN 11 stated all medications should be properly disposed of when they were expired. LN 11 explained that giving expired medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) was free from significant medication errors, when Resident 27's olanzapine (an antipsychotic medication used for psychosis; a condition that affects the way the brain processes the environment) was not administered in accordance with physician's orders for eight doses. This failure had the potential for Resident 27 to experience serious adverse health outcomes. Findings: Review of Resident 27 clinical record indicated that he was [AGE] years old and admitted to the facility on [DATE]. Resident 27 had multiple diagnosis, such as but not limited to, dementia (a disease which cause loss of memory, language, problem solving and other thinking abilities), psychotic disorder (a condition that affects the way the brain processes the environment), and chronic kidney disease (a disease that affects the ability of kidneys to filter blood). During a concurrent observation and interview on 4/13/22 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 improperly labeled medications/biologicals were not available for use. This occurred when four of four medications were observed without open dates in accordance with current standards of practice, expiration dates when applicable, and/or resident identification tags in accordance with facility policy for a universe of 75 residents. These failures placed residents at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination. Findings: During a concurrent observation and interview on 04/12/22 at 9:53 A.M. of medication storage room located at the East Wing with licensed nurse (LN) 11, an opened tuberculin (a medication that is used for diagnosis of tuberculosis - a highly contagious bacterial infection that primarily affects the lungs) vial without labeled beyond use date or date opened information in the medication refrigerator. LN 11 acknowledged the presence of the vial without any label to indicate when the vial should…

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 one of 19 resident's (Resident 161) meal preferences (food likes/dislikes) were honored. This failure had the potential for Resident 161 to not eat food that she disliked which could contribute to inadequate food intake and possible weight loss. Findings: A review of Resident 161's admission Record indicated the resident was admitted to the facility on [DATE]. On 4/12/22 at 4:34 P.M., an interview was conducted with Resident 161. Resident 161 stated the facility frequently did not honor her food preferences. Resident 161 stated she did not like eggs, but would eat an egg if it was hard boiled. Resident 161 stated several times a week she was served scrambled eggs for breakfast. Resident 161 stated she made her dislike food known and had it recorded on her meal ticket for no eggs except a hard boiled egg. On 4/13/22 at 8:43 A.M., a joint observation, interview, and record review was conducted with Resident 161 inside the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of three sampled residents on hospice (Resident 13). This failure had the potential to affect the coordination and continuity of care for Resident 13. Findings: Resident 13 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm (cancer) of the left breast and secondary malignant neoplasm of bone, per the facility's admission Record. A review of Resident 13's medical record, the resident was referred to hospice on 3/18/22 and began hospice services on 3/30/22. During an interview with licensed nurse (LN 25) on 4/15/22 at 9: 02 A.M., LN 25 stated that when a resident received a hospice referral, a resident interdisciplinary team met for a care conference, which included the development of a new plan of care. During a concurrent interview and record review with LN 25 on 4/15/22 at 9:09 A.M., LN 25 stated Resident 13's record did not have a note regarding a care conference…

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.