Garden City Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - clinical assessment tool used in nursing homes) diagnostic assessments were accurately documented for 2 out of 5 residents reviewed for unnecessary medications, when Resident 2 and Resident 105 received medications for physician-documented conditions that were not coded on the MDS.This failure had the potential to compromise safe and accurate resident assessment and nursing plans of care. Findings:Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with multiple diagnoses, including dementia (cognitive decline where the specific type and severity are not clearly defined or documented) and atrial fibrillation (type of irregular and fast heart rhythm that occurs in sudden and temporary episodes).Review of Resident 2's History and Physical (H&P), dated 6/9/25, indicated the resident was admitted to the facility with diagnoses including hypothyroidism (low thyroid hormone) and…

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

Based on interview and record review the facility failed to ensure residents received pain management interventions in accordance with assessed pain levels for 1 out of 5 residents reviewed for unnecessary medications, when staff administered PRN (as needed) pain medication for Resident 86 despite documented pain assessments indicating a pain level of 0 (a 0-10 pain scale with 0 being no pain, to 10 being the worst pain). This failure had the potential to result in unnecessary medication administration, increased risk for adverse medication effects, and inaccurate pain assessment.Findings:Review of Resident 86's admission RECORD indicated Resident 86 was admitted to the facility with multiple diagnoses, including muscle weakness, chronic low back pain, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident 86's Medication Administration Record (MAR - a legal record of medications administered to a resident) for January 2026 through February 2026 indicated the resident had a physician order for Morphine…

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 maintain one of four sampled residents' privacy (Resident 1) when licensed nurse (LN) 3 used her personal phone to take a photograph of Resident 1. This failure resulted in a violation of Resident 1's privacy, potentially negatively affecting his psychosocial well-being. Findings:Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 had been admitted to the facility with diagnoses which included dementia (a general term for a loss of brain function that is not a normal part of aging, causing significant problems with memory, thinking, and social abilities).A review of Resident 1's clinical document titled, Progress Note, dated 9/2/25, by LN 3, indicated LN 3 was informed by a NOC shift (6:30 a.m. through 7 p.m.) nurse that Resident 1's arm was tied to the bed during the Intravenous (IV - plastic tube placed in the vein to deliver medication) line placement. LN 3 informed the NOC nurse that she needed to untie Resident 1's arm from the bed…

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 of four sampled residents (Resident 1) environment was free of accident hazards when Resident 1's right wrist remained in an arm positioning device (a medical tool that holds a patient's arm in a specific, stable, and extended position during the procedure and does not allow for movement) following a mid-line insertion (medical procedure of placing a thin, flexible tube (catheter) into a large vein in the upper arm, with the tip terminating just below the armpit).This failure had the potential for injury related to the arm positioning device being secured to Resident 1's bedframe, potentially negatively affecting Resident 1's health, safety, and emotional well-being.A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 had been admitted to the facility with diagnoses which included a fall, abnormal gait, and impaired mobility (any unusual walking pattern that deviates from a normal, smooth, and coordinated stride).A review of 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.

Based on observation, interview, and record review the facility failed to ensure self-administration of medication was clinically safe and appropriate for one of three residents (Resident 1), when Resident 1 was not assessed for self- administration of his medications prior to being provided his medications to self-administer while out on pass. This failure had the potential to contribute to unsafe medication use by Resident 1 and could have led to Resident 1 experiencing adverse health consequences. Findings: Review of Resident 1 ' s admission RECORD, indicated Resident 1 was initially admitted to the facility with diagnoses of osteomyelitis (an infection of the bone that causes inflammation and destruction of bone tissue), paraplegia (inability to voluntarily move the lower parts of the body), and chronic pain (persistent pain that lasts for over three months) among other diagnoses. Review of Resident 1 ' s Medication Administration Note, dated 10/17/24, at 3:30 p.m., written by Licensed Nurse (LN) 4, indicated, .Norco [medication used to treat moderate to severe pain, classified…

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 develop a comprehensive care plan (a plan to address initial goals on admission and physician orders to ensure safety and well-being of a resident) for self-administration of medication for one of three sampled residents (Resident 1) when, Resident 1 was self-administering his multiple medications given to him by facility staff while out on pass from the facility. This failure resulted in a person-centered care plan with individualized interventions not being developed for Resident 1 and had the potential for Resident 1 to not properly self-administer his medications which could have led to subsequent adverse health events. Findings: Review of Resident 1 ' s admission RECORD, indicated Resident 1 was initially admitted to the facility with diagnoses of osteomyelitis (an infection of the bone that causes inflammation and destruction of bone tissue), paraplegia (inability to voluntarily move the lower parts of the body), and chronic pain (persistent pain that lasts for over three months) among other diagnoses. Review 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 and record review, the facility failed to provide care and services after an unwitnessed fall for one of three sampled residents (Resident 1) when: 1. Resident 1 was found on the floor next to his bed on 12/5/24 at 1:25 a.m., with signs of delirium (a sudden, severe change in mental state which can include confusion, disorientation, and an inability to think clearly) and Licensed Nurse (LN) 1 delayed notifying the physician until 7:00 a.m. on 12/5/24; and, 2. LN 1 documented Resident 1 was experiencing signs of delirium after an unwitnessed fall but did not document a neurological (to evaluate level of alertness, orientation, mood), pain, or skin evaluation (to evaluate for trauma, scratches, bruising) was completed. These failures had the potential for Resident 1 to experience pain, suffering, and an increased length of recovery and rehabilitation. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including but not limited to dehiscence of an amputation stump (surgical site of an amputated limb…

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 provide comprehensive and effective pain management, for one out of three sampled residents (Resident 1) when Resident 1's pain assessment scale (a tool used to assess the level of pain) indicated moderate pain, and Resident 1 was administered a pain medication intended for mild pain. This failure had the potential for Resident 1's pain not being effectively managed. Findings: Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including but not limited to dehiscence of an amputation stump (surgical site of an amputated limb reopens), cirrhosis of the liver (chronic liver disease which can cause a buildup of toxins in the brain), end-stage renal disease(kidney disease which leads to an ability to remove waste from the blood), and ascites (excess fluid accumulates in the belly). A review of Resident 1's NURSING-ADMISSION/readmission EVALUATION/ASSESSMENT, dated 12/3/24, indicated, .Level of Consciousness .Alert [marked] .Mood and behavior patterns .Calm/Cooperative…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen's commercial can opener blade was clean and free from metal shavings. This failure could have resulted in food borne illness (vomiting, diarrhea, nausea) for 98 residents who ate food from the kitchen. Findings: During a concurrent observation and interview on 10/21/24, at 11:40 a.m., with the Dietary Director (DD), the commercial can opener was observed to have old metal shavings on the blade of the can opener. DD acknowledged the commercial can opener was not clean and it appeared to have curled up metal shavings on the blade that occurred after a can of food was opened. DD stated the can opener was supposed to be cleaned after each use and deep cleaned (ran through the dishwasher) once a week, although there was not a log in place to track the cleanings. DD stated the dirty can opener was a risk for infection and could have led to food borne illnesses for the residents. During an interview on 10/21/24, at 1:00 p.m., the COOK stated the commercial can opener should have been cleaned after…

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 a resident's right to a dignified existence when one resident (Resident 49) in a sample of 21 was exposed to hearing her roommate and another resident engage in sexual activity in their shared room at the facility. The facility was aware of the situation, yet failed to address the issue. This failure led to Resident 49 feeling humiliated and embarrassed and had the potential to negatively impact her psychosocial well-being. Findings: A review of Resident 49's admission Record indicated that Resident 49 was admitted to the facility in 2023. The admission Record further indicated that Resident 49 had diagnoses which included but were not limited to arthritis (painful inflammation and stiffness of the joints), and depression (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living). A review of Resident 49's Minimum Data Set (MDS, a comprehensive care assessment tool), indicated that Resident 49 required maximum assistance with transfers from her bed to a wheelchair,…

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 allegations of abuse were investigated and safeguards were implemented to prevent further abuse for two of 21 sampled residents (Resident 25, and Resident 311) after the facility was made aware of an allegation of verbal abuse and the threat of physical violence involving Resident 311 and Resident 25. These failures placed Resident 311 and Resident 25 at risk for unidentified and ongoing abuse. Findings: A review of Resident 311's admission Record indicated Resident 311 was admitted to the facility with diagnoses which included, but were not limited to, cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), anxiety, and depression (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living). During an interview with the Ombudsman (Omb) on 10/22/24 at 11:40 a.m. at the facility, the Omb stated that Resident 311 reported to her that she was harassed and called a (racial slur) by her roommate. The Omb stated that…

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

Based on observation, interview, and record review, the facility failed to ensure safe use and storage of Emergency kits (or Ekit, a collection of emergency medications) for a census of 98 residents when: 1. Three Emergency kits (Ekit) for IV (Intravenous, Into the Vein) medications at facility's North Station were open and/or unsealed with no documentation on when it was opened, what was removed, or the medications used for specific residents. 2. Two Emergency kits (Ekit) for refrigerated medications containing a controlled drug called lorazepam (or Ativan, a restricted medication in injectable form used for anxiety or seizure- uncontrolled brain activity) were opened, used, and unsealed with no documentation on when or who it was used for. These failures could contribute to unsafe medication use, lack of accountability and risk of drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: 1. During a concurrent observation and interview, at facility's North station, accompanied by Licensed Nurse (LN)…

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 safe medication storage practices in medications carts for a census of 98 when: 1. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in the medication cart at North station with no warning label on how to be handled by nursing staff and without being in a protective bag. 2. A cart designed as an extra IV medication cart (IV is Intravenous, Into the Vein) stored a large supply of prescription IV medications bags with no patient specific label in the facility's North station and without a way to track each IV medication bag and what it was used for. 3. The IV medication cart at North station stored resident specific IV medications that were outdated, undated, or for residents no longer in the facility or no longer receiving IV medications, with medication and supplies co-mingled in a cluttered way. 4. The medication Cart and refrigerator at South station stored undated, unlabeled, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide infection prevention and control measures to prevent the possible spread infection for a census of 98 when: 1. Appropriate Enhanced Barrier Precautions (EBP-infection control interventions to reduce the spread of germs through gown and glove use during high contact resident care activities) were not followed for Resident 300 and Resident 60 when accessing Peripherally Inserted Central Catheter (PICC-a tube inserted into a vein and guided into a large vein above the heart, used to administer intravenous medication ) lines for intravenous (IV- an apparatus used to administer a fluid such as medication) antibiotics (medication used to treat bacterial infections); and, 2. Aseptic (free from contamination) technique was not used when reconstituting (adding a liquid diluent to a dry ingredient to make a specific concentration of liquid) IV antibiotics for Resident 300 and Resident 60; and, 3. Dirty cups were placed on the coffee cart…

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 one of 21 sampled residents (Resident 37) had her call light (a handheld device that allowed Resident 37 to communicate with nurses and caregivers in the facility setting) within reach. This failure resulted in Resident 37 not being able to reach staff when she needed assistance on 10/21/24 and could have resulted in injury due to her needs not being met in a timely manner. Findings: During a review of Resident 37's clinical record titled, admission Record (a document that contained Resident 37's demographic information), indicated Resident 37's diagnosis included epilepsy (a brain disorder that can cause seizures/uncontrolled body movements), osteoporosis (a bone disease that caused bones to become weak and more likely to break), and dementia (a chronic condition that caused a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). During an observation on 10/21/24, at 9:20 a.m., Resident 37 was in her bed and her right hand was contracted (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 interview and record review, the facility failed to ensure allegations of abuse were reported to the state survey agency after the allegations of abuse were witnessed by staff and reported to facility administration involving four of twenty-one sampled residents (Resident 32, Resident 38, Resident 25, and Resident 311) when; 1. Resident 32 and Resident 38 engaged in sexual activity, but neither Resident 32 or Resident 38 had the decision-making capacity (the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention) to consent to the sexual activity; and, 2. Resident 311 was involved in a verbal altercation, which included threats of physical violence and racial derogatory remarks, with her roommate, Resident 25, in their room, on 10/6/24. These failures resulted in a delay of the state survey agency investigating the allegations of abuse, which had the potential to put residents' psychosocial and physical health and safety at risk.…

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 of 21 sampled resident's (Resident 20) Preadmission Screening and Resident Review (PASARR - an assessment tool that evaluated Resident 20 for serious mental illness (SMI) and/or intellectual disability (ID), prior to admission to the facility) was completed accurately. This failure could have resulted in Resident 20 not receiving additional psychological services that could have assisted her in living her highest quality of life. Findings: During a review of Resident 20's clinical record titled, admission Record (a document that contained Resident 20's demographic information), indicated Resident 20's diagnoses included schizoaffective disorder (a mental health condition that is marked by hallucinations (seeing things that are not there) and mood disorders) and Bipolar Disorder (a mental illness that caused extreme shifts in mood, energy, and activity levels). A review of Resident 20's clinical record titled, Progress Note, dated 10/2/24, at 11:13 p.m., by the Licensed Nurse (LN) 9, indicated, Resident refused…

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 21 sampled residents (Resident 96), received neurological (brain) assessments (assessment of mental status, strength, and sensation) following a fall, per the implemented care plan (a list of Resident 96's problems, goals, and interventions), and the facility policy. This failure could have resulted in a delay in identification of neurological changes prior to Resident 96's death. Findings: During a review of Resident 96's clinical record titled, admission Record (a document that contained Resident 96's demographic information), indicated Resident 96's diagnoses included muscle wasting and weakness, cognitive (mental) impairment, and Parkinson's disease (a degenerative brain condition that caused tremors (shaking), stiffness, slowed movement, and memory and thinking problems). A review of Resident 96's clinical record titled, EMERGENCY DEPARTMENT NOTE, dated [DATE], at 10:04 p.m., by the Medical Doctor (MD) 3, indicated Resident 96 had…

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 one of 21 sampled residents (Resident 45) received daily communication in Resident 45's preferred spoken language (Greek). This failure could have resulted in Resident 45's not being able to maintain or improve her ability to communicate with staff. Finding: During a concurrent observation and attempted interview on 10/21/24, at 10:00 a.m., with Resident 45, Resident 45 looked at State Agency and did not respond when asked if Resident 45 had any concerns regarding her care at the facility. Several attempts were made to communicate with Resident 45 in English, without success. During a concurrent observation and interview on 10/21/24, at 10:01 a.m., with the Licensed Nurse (LN) 1, LN 1 asked Resident 45 how she was doing and if she was in any pain. Resident 45 did not respond but looked at LN 1. LN 1 stated Resident 45 was unable to speak fluent English and her preferred spoken language was Greek. LN 1 stated Resident 45 pointed at objects that she wanted and said a few words in English to make her…

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 an environment free of accidents and hazards for one of 21 sampled residents (Resident 84) when Resident 84 left cigarettes and a cigarette lighter accessible to other residents outdoors on a patio. This failure had the potential for an accidental injury to occur to other residents in the facility. Findings: A review of Resident 84's admission Record indicated that Resident 84 was admitted to the facility in 2024. Resident 84's admission Record indicated Resident 84 was admitted with diagnoses which included but were not limited to wedge compression fracture of third lumbar vertebra (the broken bone in the lower back collapses causing the front part of the spine to form a wedge shape), neuropathy (damage to nerves causing pain, numbness, muscle twitching, weakness and swelling), and chronic obstructive pulmonary disease (COPD, a long-term lung disease that cause airflow blockage and breathing related problems, shortness of breath, and cough). A review of Resident 84's Smoking Acknowledgement and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor the use of high-risk medications (medications that pose a health risk if not monitored closely) for two out of 21 sampled residents (Resident 70 and Resident 306) when: 1. Resident 70's hold parameters (a set of numbers that guide the nursing staff to hold and not give medication for safety reasons) for use of blood pressure medication (medication use to lower pressure in arteries) were not followed. 2. Resident 306's blood sugar was not monitored while on two insulin products (insulin an injectable drug used to treat blood sugar disease or diabetes). These failed practices could put Resident 70 and Resident 306 at risk of adverse drug effects. Findings: 1. During a review of Resident 70's medical record, titled Medication Administration Record (or MAR, a document that list medications administered with nursing monitoring parameters), dated 10/2024, the record indicated Resident 70 was receiving a medication to counter low blood pressure as…

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 Antibiotic Stewardship Program (or ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) tracked and assessed antibiotic use based on facility policy for a resident census of 98. This failure could contribute to unsafe antibiotic use, monitoring, and increases the risk of developing resistance to germs that cause infections [when germs are not killed by an antibiotic] in the facility. Findings: During an interview with Infection Prevention nurse (IP), at facility's South station, on 10/24/24, at 9:49 AM, the IP stated when a new antibiotic was ordered, or a resident was admitted to the facility with an antibiotic order he was notified via the computer system or a text from the admitting staff. The IP stated he would then enter the antibiotic order and resident information into a spread sheet for tracking purposes. During a concurrent interview and record review with the IP of an ASP spread sheet, titled Infection Prevention and Control…

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 standards of infection prevention and control for a census of 99 when the freestanding air conditioning (AC) units on each hallway contained air filters that were caked with dust and debris. This failure had the potential to spread infection to the 99 residents residing in the facility. Findings: During an observation on 9/27/24, at 11:19 AM, in the North long hall, the air filter in the freestanding air conditioning unit at the end of the hall was observed to be caked with dust and debris. During an observation on 9/27/24, at 11:21 AM, in the North short hall, the air filter in the freestanding air conditioning unit at the end of the hall was observed to be caked with dust and debris. During an observation on 9/27/24, at 11:27 AM, in the South long hall, the air filter in the freestanding air conditioning unit at the end of the hall was observed to be caked with dust and debris. During an observation on 9/27/24, at 11:30 AM, in the South short hall, the air filters in the freestanding air…

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 professional standards of care were met for three out three sampled residents (Resident 1, Resident 2, and Resident 3) who sustained falls, when post fall charting (documentation of assessments and observations) was not documented for Resident 1, Resident 2 or Resident 3. This failure had the potential for Resident 1, Resident 2, and Resident 3 to have unassessed injuries, untreated pain, and/or underlying illnesses. Findings: 1a. A review of Resident 1's admission RECORD, indicated she was admitted to the facility in mid-2024 with diagnoses which included dementia (a progressive state of decline in mental abilities). A review of Resident 1's Progress Notes, indicated, .09/07/2024 03:35 .Outcomes of Physical Assessment .Nursing observations, evaluation, and recommendations are: CNA went to answer call light in [Resident 1's room number]. Resident was found on the floor between B and C bed .Resident has an injury to back of head and an old scab on her left wrist opened up, some redness on her right cheek noted.…

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 accurate and complete documentation for one of three residents sampled (Resident 2) when Resident 2 was transferred to an acute care hospital and the facility did not document the date and time of her transfer, where she transferred to, how she was transported, or the disposition of her personal effects and her medications. This failure had the potential to negatively impact resident 2's continuity of care and had the potential risk of her receiving inadequate care or services. Findings: A review of Resident 2's admission RECORD, indicated she was re-admitted to the facility in February of 2024 with diagnoses which included chronic obstructive pulmonary disease (COPD-long term lung disease that causes shortness of breath and cough) and urinary tract infection. A review of Resident 2's Progress Notes, indicated, 2/11/2024 19:09 [7:09 PM] .resident receiving acute care outside of facility . on 2/12/24, at 12:51 AM the notes indicated, .Sent out to hospital. A review of Resident 2's SBAR [Situation, Background,…

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 professional standards of practice were followed for one of three sampled Residents (Resident 1) when Resident 1 did not receive her medication as prescribed, and the physician was not informed the medication was unavailable for administration. This failure had the potential to negatively impact the health and well-being of Resident 1. Findings: Resident 1 was admitted to the facility in March of 2024 with diagnoses which included chronic obstructive respiratory disease (COPD, long term lung disease that causes shortness of breath and cough). A review of Resident 1's Order Summary Report, indicated, .Trelegy Ellipta inhalation [medication used to make breathing easier and improve lung function] .1 puff inhale orally [by mouth] one time a day for dyspnea [shortness of breath] .start date 3/14/24 . A review of Resident 1's progress notes indicated the medication was unavailable on 3/16/24, 3/17/24, 3/18/24, 3/19/24, and 3/20/24. 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 interview, and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2) when Resident 2 fell from bed while her fitted sheet was being replaced. This failure resulted in Resident 2 receiving lacerations (deep cut or tear of skin) to her left great toe, right knee, a nosebleed, and a hematoma (pooling of blood from ruptured vessels, causing a bump under the skin) to her forehead. Findings: A review of Resident 2's admission RECORD, indicated she was admitted to the facility in the fall of 2007 with diagnoses which included chronic obstructive pulmonary disease (COPD-long term lung disease that causes shortness of breath and cough) and morbid obesity (being 80 - 100 pounds above an individuals recommended weight). A review of Resident 2's Progress Notes, dated 2/10/24, at 10:21 PM, indicated, .pt [patient] fell out of bed, the CNA [certified nurse assistant] stated that CNA was giving a bed bath and turned pt over to put a fitted sheet on bed, pt was holding on to side rail and let go, pt fell face first with injuries 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, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 1 of 2 sampled residents (Resident 1) when; 1. Resident 1's as needed breathing treatment was not provided in a timely manner; and 2. Resident 1's oxygen concentrator (a machine used to deliver extra oxygen to a person) filter was covered in dust/debris. These failures resulted in delayed breathing treatment being provided to Resident 1 and had the potential for Resident 1's oxygen concentrator to not function as intended. Findings: 1. Review of Resident 1's admission record indicated Resident 1 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD; a disease of the lungs that blocks airflow and makes it difficult to breath), shortness of breath (SOB), pulmonary edema (excess fluid in the lungs), and respiratory failure (a serious condition that makes it difficult to breathe on your own). During an interview on 1/18/24, at 12:16 p.m., Resident 1 stated she had to wait for over 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, and record review, the facility failed to ensure professional standards for food service safety were maintained for 91 of 91 residents who received food from the kitchen, when Dietary Aide (DA) 1 was preparing food for the facility while not wearing a beard net/restraint (used to prevent facial hair from falling into food). This failure had the potential to result in DA 1's facial hair to be introduced to the food being prepared resulting in physical and bacterial contamination. Findings: During a concurrent observation and interview with the Certified Dietary Manager (CDM), in the kitchen on 9/11/23, at 9:31 AM, DA 1 was observed preparing food in individual bowls without wearing a beard net/restraint. The CDM stated he was not certain of the length of facial hair allowed while working in the kitchen. During an interview with the CDM on 9/13/23, at 12:09 PM, the CDM confirmed any facial hair requires a beard net/restraint according to facility policy. A review of the FDA (Food and Drug Administration) Food Code 2017, indicated in section 2-402.11,…

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2. A review of Resident 58's admission RECORD indicated Resident 58 was admitted to the facility in early 2023. During a concurrent observation and interview with LN 5 on 9/11/23, at 12:13 PM, in Resident 58's room, LN 5 confirmed Resident 58's oxygen, via nasal canula (prongs in the nose to deliver a flow of oxygen), was at 3.5 liters per minute (LPM - measure of oxygen flow rate.) During a record review of Resident 58's care plans, there was no evidence of an oxygen care plan in place for Resident 58. During an interview with the DON on 9/14/23, at 2:12 PM, the DON acknowledged Resident 58 did not have an oxygen care plan in place and confirmed there should have been an oxygen care plan in place for Resident 58. The DON explained the importance of the oxygen care plan was so that staff knew how to care for Resident 58. Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for 3 of 24 sampled residents (Resident 193, Resident 58, and Resident 48), when: 1. An indwelling catheter (a tube which is inserted into 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 ensure care services provided met professional standards of quality for 3 of 24 sampled residents (Resident 191, Resident 12, and Resident 58), when: 1. A PICC line (peripherally inserted central catheter: a long, thin, flexible tube that is put into a vein in the upper arm to access the large veins in the chest to administer long term intravenous (IV) medications or nutrition) dressing was not changed per physician order and the PICC line site (insertion point on the body) was not monitored for Resident 191, 2. A licensed nurse (LN) signed off a PICC line dressing was changed without changing the dressing for Resident 12; and, 3. Resident 58's medical record did not reflect an accurate documentation of the medical diagnosis Bipolar disease (a mental health disease that causes extreme mood swings). These failures placed Resident 191 and Resident 12 at risk of infection, resulted in inaccurate medical records for Resident 12 and Resident 58, and had the potential of care needs being unmet for Resident 191,…

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 provide restorative nursing assistant (RNA) services (interventions to increase or maintain residents' mobility and to prevent decline in mobility) for 3 of 24 sampled residents (Resident 46, Resident 48, and Resident 83) when: 1. Resident 46 had an order for RNA services three times a week beginning on 4/7/23. Resident 46's RNA documentation indicated she received services six times during the period of 8/13/23 through 9/13/23. 2. Resident 48 had an order for RNA services three times per week beginning on 5/9/23. Resident 48's RNA documentation indicated she received services two times during the period of 8/13/23 through 9/13/23. 3. Resident 83 had an order for RNA services three times per week beginning 8/27/23. Resident 83's RNA documentation indicated she received services one time during the period of 8/27/23-9/11/23. These failures had the potential risk for Resident 46, Resident 48, and Resident 83 to not improve or maintain their current level of mobility and the potential to suffer a decline in functional…

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 appropriate care and services on the use of an indwelling catheter (tube which is inserted into the bladder and left in place in order to drain urine) for 1 of 24 sampled residents (Resident 193), when 1. There was no physician order for Resident 193 indicating use of an indwelling catheter, 2. There was no record of catheter care being provided to Resident 193, and 3. Resident 193's urine output was not monitored. This deficient practice had the potential for inaccurate clinical use of an indwelling catheter and had the potential to result in catheter related complications such as urinary tract infection (UTI) for Resident 193. Findings: Review of an admission record indicated Resident 193 was admitted to the facility in late 2023. Review of a physician order, dated 9/5/23, indicated Resident 193 was capable of understanding rights and responsibilities and able to participate in her treatment plan. During an observation 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 ensure respiratory care provided was consistent with professional standards of practice for 2 residents (Resident 58 and 194) who received oxygen and respiratory treatment in a sample of 24 when: 1. Oxygen therapy was provided without a physician order for Resident 58, 2. Resident 194's nebulizer treatment (a small machine that turns liquid medicine into a mist) was not monitored during administration; and, 3. Resident 194's nebulizer mask was not dated and changed weekly. These failures placed Resident 58 and Resident 194 at risk for respiratory distress and inadequate treatment. Findings: 1. During a concurrent observation and interview with licensed nurse (LN) 5 on 9/11/23, at 12:13 PM, in Resident 58's room, LN 5 confirmed Resident 58's oxygen, via nasal canula (prongs in the nose to deliver a flow of oxygen), was being delivered at 3.5 Liters per minute (LPM - measure of flow rate). LN 5 confirmed Resident 58 did not have a physician's order for oxygen and there should be an order in place. 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 interview and record review, the facility failed to ensure accountability of the delivery documents for prescription and narcotic medications (drugs with abuse potential) into the facility with a census of 91 residents. This failure had the potential for drug diversion and could contribute to unsafe medication handling. Findings: During a concurrent interview and inspection of the facility's pharmaceutical services for medication delivery, titled Packing Slip (or delivery document, a paper document with listed medication delivered for residents), accompanied by Licensed Nurse (LN) 9, at the North station, on 9/12/23, at 9:32 AM, LN 9 stated the late shifts often received the medication delivery from the pharmacy. LN 9 stated the delivery slips were saved in a file at the nursing station. LN 9 was not sure why the documents were not signed and dated upon delivery of the medications. LN 9 stated the delivery driver required a signature for the delivery on their paper or electronic device. LN 9 acknowledged the Packing slip pages did not have any signature of receiving 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 interview and record review, the facility failed to ensure that the terms and conditions of a binding arbitration agreement (a contract between two or more parties that requires them to resolve contract disputes before an arbitrator, neutral third party rather than through the court system) were clearly explained to five of five residents (Resident 32, Resident 48, Resident 58, Resident 196 and Resident 197) whose arbitration agreements were reviewed, in a form and manner that they understood, when Resident 32, Resident 48, Resident 58, Resident 196 and Resident 197 were not informed that a binding arbitration agreement was optional and not an admission requirement, by signing it they would be giving up their right to litigation in a court proceeding, and that they had the right to rescind the arbitration agreement within 30 calendar days of signing it. This failure resulted in Resident 32, Resident 48, Resident 58, Resident 196, and Resident 197 signing the binding arbitration agreement without fully…

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 safe infection control practices for 3 residents (Resident 39, Resident 15, and Resident 30) during a medication pass observation when the facility failed to clean and disinfect shared glucometers (a device used to measure the amount of sugar in the blood) in-between resident care. This failure could pose health and safety risks and cause the spread of infection in the facility. Findings: 1. During a medication administration observation with Licensed Nurse (LN) 5 and her trainee, LN 11, on 9/11/23, at approximately 11:50 AM, at the South station, LN 5 used a glucometer to measure Resident 39's blood sugar. LN 5 with gloved hands, poked Resident 39's finger with a lancet (small, sharp objects that are used to prick the skin) to get drops of blood, put the drop of blood on the test strip, and then put the blood-soaked test strip in the glucometer to measure the blood sugar. Afterward, LN 5 exited the room and placed the glucometer on top of the mobile medication cart just outside Resident 39's room. LN 5…

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 self-administration of medication was clinically safe and appropriate for one of 13 residents observed for medication administration (Resident 13). This failure had potential to contribute to unsafe medication use by the resident and other residents including Resident 13's roommates. Findings: During a medication administration observation, with Licensed Nurse (LN) 5, on 9/11/23, at 12:40 PM, LN 5 prepared five different medications in the pill form for Resident 13 in a small medication cup and went inside the resident's room. LN 5 then placed the medication cup on Resident 13's food tray and left the room to the medication cart just outside the room. In an interview with Resident 13, in her room, on 9/11/23, at 12:45 PM, Resident 13 stated she preferred to take the medications on her time frame since she took them slowly. Resident 13 further stated, she would take the small pills first and then after her lunch will take the bigger pills. Resident 13 stated the nurse would leave the meds with her and…

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

Based on observation and interview the facility failed to ensure reasonable accommodation of needs were honored for 1 of 24 sampled residents (Resident 83) when Resident 83 was not provided with an appropriate call light to meet her needs. This failure resulted in Resident 83's needs to be unmet with the potential to cause physical and psychosocial harm. Findings: A review of Resident 83's admission RECORD, indicated Resident 83 was admitted to the facility in mid 2023 with diagnoses which included osteoarthritis (disease that causes joint pain and stiffness) and weakness. During a concurrent observation and interview on 9/11/23, at 10:14 AM, in Resident 83's room, Resident 83 was observed lying in bed with a frown on her face. Resident 83 stated staff just leave her, and she had been waiting two hours to be changed. When asked if she called for help, Resident 83 stated she turned on her call light. The call light was not observed to be on. Resident 83 demonstrated how she turned on the call light. Resident 83 reached her left arm out to the left bedrail, put her elbow up in the air…

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 notify the local long-term care (LTC) Ombudsman (an official advocate who represents the interests of the residents residing in a LTC facility) for two of three closed record sampled residents (Resident 82 and Resident 90) who transferred out of the facility. This failure placed Resident 82 and Resident 90 at risk of not receiving the necessary protections and support of the Ombudsman. Findings: 1. A review of Resident 82's clinical record indicated Resident 82 was transferred to an acute care hospital on 8/26/23. There was no documented evidence in resident 82's clinical record to indicate the Ombudsman received notification of the transfer. 2. A review of Resident 90's clinical record indicated Resident 90 was transferred to an acute care hospital on 7/25/23. There was no documented evidence in resident 90's clinical record to indicate the Ombudsman received notification of the transfer. During a concurrent interview and record review on 09/14/23, at 10:24 AM, the Social Services Director (SSD) stated the Ombudsman 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.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) screening was accurate for one resident (Resident 75) in a sample of 24, when Resident 75's intellectual disability was not indicated on the PASARR. This failure had the potential for Resident 75's care and intellectual needs to be unmet due to the facility being unaware of Resident 75's intellectual disability. Findings: A review of Resident 75's admission RECORD, indicated Resident 75 was admitted in early 2023 with diagnoses which included, developmental disorder of scholastic skills (a disturbance in the normal patterns of skill acquisition evident from early stages of development). A review of Resident 75's PASARR, dated 4/25/23, in Section II - Intellectual or Developmental Disability (ID)/(DD), all questions were marked as no regarding diagnosis, age of onset, if Resident 75 had ever received services, and types of services. 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 interview and record review, the facility failed to ensure duration of PRN (as needed medication use) psychotropic (medication used to treat mental health) medications used were clarified with a medical doctor for two out of 24 sampled residents (Resident 22 and Resident 58) when: 1. Resident 22 was prescribed PRN anxiety medication called lorazepam (or Ativan, a nerve pill) with no duration of use or re-assessment. 2. Resident 58 was prescribed PRN anxiety medication called lorazepam with no duration of use or re-assessment. These failures had the potential for unnecessary medication use without assessment resulting in a negative impact on resident's health. Findings: 1. During a review of Resident 22's medical record, titled Medication Administration Record (or MAR, a document that listed medication administration and monitoring), dated 9/2023, the MAR indicated the following order: Lorazepam Oral Tablet 0.5 MG (anxiety pill; MG is a unit of measure); Give 1 tablet by mouth every 4 hours as needed (same as PRN) for Anxiety -Start Date- 8/4/23. Further review of the MAR…

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 safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 91 residents. The facility had a total of four errors out of 46 opportunities which resulted in a facility wide medication error rate of 8.7 %. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. These failures had the potential to result in unsafe medications use, not following the doctor's orders, and the potential to cause complications accessing a Gastrostomy tube (or G-tube; a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications). Findings: During a medication administration observation, for Resident 7, in the North Station of the facility, with Licensed Nurse (LN) 7 and a trainee nurse, LN 10, on 9/12/23, from 9:34 AM to 9:58 AM, the following observations were noted with 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.

Based on observation, interview, and record review the facility failed to ensure safe medication storage practices in one out of four medication carts (a mobile cart that contains medications for daily administration) when the medication cart for the South-3 station stored undated (medications with limited potency after opening per manufacturer labeling) and expired medications (medications that should not be used after its beyond use date) and the medication refrigerator at the South Station contained undated medications. These failures had the potential for residents to receive medications that were expired and/or with unsafe or reduced potency. Findings: During inspection of the medication cart for the South-3 station, accompanied by Licensed Nurse (LN) 12, on 9/11/23, from 2:30 PM to 3:10 PM, the following irregularities were noted: 1. An eye drop medication called latanoprost (an eye drop used for an eye disease called glaucoma) for three different residents did not have a date indicating when the eye drops were first opened. Review of the eye drop label on the box indicated…

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 professional standards of practice were followed, when the facility did not notify Resident 1's Primary Care Provider (PCP) of urinalysis (UA-checks urine for urinary tract infection) and culture and sensitivity (C&S - A culture is a test to find germs such as bacteria or a fungus that can cause an infection, and sensitivity indicates which medicine will work best to treat the infection) results received following Resident 1's discharge. This failure resulted in Resident 1 not receiving timely follow up care for a urinary tract infection (UTI). Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included hypothyroidism (a condition where the thyroid does not create and release enough thyroid hormone into your body) and a pelvic fracture. A review of Resident 1's Discharge Summary ., dated 7/31/23, at 12:43 PM, indicated Resident 1 was discharged from the facility on 7/31/23, at 1pm. 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 interview and record review the facility failed to ensure one of five sampled resident's (Resident 1), Discharge Summary contained all the required information for continuity of care when: 1a. Information regarding Resident 1's signs and symptoms of a urinary tract infection (UTI-when bacteria cause infection in the urinary tract), a urinalysis (UA) with culture and sensitivity (C&S) was completed, and pending lab results for the UTI were not included in the Discharge Summary; and, 1b. The medication reconciliation list provided to Resident 1 was not complete. These failures resulted in Resident 1's primary care provider (PCP) and home health agency (HHA) not being aware of the need to follow up on Resident 1's signs and symptoms of a UTI, the results of the UA C&S that was done, and Resident 1 not receiving education on a medication that was prescribed to her. Findings: 1a. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included hypothyroidism (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.

Based on observation, interview, and record review the facility failed to ensure one resident (Resident 1), in a sample of five, was free of significant medications errors when Resident 1's physician order for Liothyronine (a medication used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone), was ordered by an outside orthopedist (bone doctor) (MD) 2 and was sent electronically to and filled by the pharmacy. The facility received the medication but did not follow-up on the medication to ensure the medication was entered into Resident 1's electronic health record (EHR). This failure resulted in Resident 1 not being administered the Liothyronine from the time it was ordered on 7/24/23 until 7/31/23 when Resident 1 was discharged . Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included hypothyroidism (a condition where the thyroid does not create and release enough thyroid hormone into your body) and a pelvic fracture. A review of Resident 1's Visit Notes, dated 7/24/23,…

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.