New Orange Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure necessary care and services related to GT feeding were provided for two of two final sampled residents (Residents 2 and 144) and one nonsampled resident (Resident 30) reviewed for tube feedings. * The facility failed to ensure Resident 2 was administered the water flush via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 30 was administered the enteral feeding via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 144's HOB was elevated at least 30 degrees or greater during the enteral feeding to reduce the risk of aspiration. In addition, the failed to failed to ensure the GT residual monitoring was accurately documented. These failures posed the risk for complications related to use of the GT.Findings: 1. On 2/11/26 at 0930 hours, during the initial tour of the facility, Resident 2's GT feeding…

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 facility document review, the facility failed to ensure the facility staff (CNAs 7 and 8) were competent in providing the necessary care and services to the residents who needed to be shaved. * The facility failed to ensure CNAs 7 and 8 had completed the skills competencies on how to shave the residents with episodes of spasms. This failure resulted in residents' to have cuts to their chins and posed the risk of further injury to the residents. Findings: 1. On 2/13/26 at 1013 hours, an observation was conducted for Resident 4. Resident 4 was observed with multiple surficial cuts to his chin. On 2/13/26 at 1030 hours, an observation and concurrent interview was conducted with LVN 14. When asked about the cuts to Resident 4's chin, LVN 14 verbalized the cuts occurred while the resident was being shaved. Medical record for Resident 4 was initiated on 2/13/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 12/13/25, showed…

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, medical record, facility record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of six nonsampled residents (Resident 56) observed for medication administration. * The facility failed to ensure Resident 56's baclofen (a muscle relaxant) was administered as per the physician's order. This failure posed a risk for the resident to experience muscle spasms and could negatively affect the resident's well-being.Findings: Review of facility's P&P titled Guidelines for Medication Administration (undated) showed routinely scheduled medications will be administered at the times specified in the Standard Times for Medication Doses. Review of facility's document titled Medication Administration Times showed twice a day schedule was to begiven at 0900 and 1700 hours. Review of the facility's P&P titled Obtaining and Refilling Medications Policy dated 2/2017 showed: - it is the policy of the facility to obtain medications from new…

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, medical record review, and facility P&P review, the facility failed to follow-up on the consultant pharmacist's recommendations for one of five final sampled residents (Resident 118) investigated for unnecessary medications.* The consultant pharmacist's report for December 2025 showed a recommendation to update Resident 118's behaviors for PRN Ativan (a medication for anxiety) to include specific and quantifiable behaviors targeted. This failure resulted in the continued deficient practice of inappropriate behavior being targeted by Resident 118's psychotropic medication use. Findings: Review of the facility's P&P titled Medication Regimen Review (MRR) revised 8/2027 showed the consultant pharmacist will review residents' medical records monthly, irregularities will be documented and provided to the facility within seven working days. The report will be acted upon, and nursing personnel will provide a written response. Review of the Consultant Pharmacist's Medication Regimen Review for…

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 facility P&P review, the facility failed to ensure proper storage and disposal of medications for one of two medication storage rooms and three of five medication and treatment carts inspected for medication storage and labeling. * The facility failed to ensure medication storage room and carts were in a clean and sanitary condition. * The facility failed to ensure orally administered medications were stored separate from externally used medications. * The facility failed to ensure all medications and biologicals were not expired. These failures had the potential to negatively impact the residents well- being, the potential for the medications to lose stability and effectiveness, and unsafe administration of the medications and treatment. Findings: Review of the facility's P&P titled Medication Storage and Labeling (undated) showed the following:- all drugs will be labeled and stored in a manner consistent with manufacturer's published specifications, federal and state…

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 facility document review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 88 of 88 residents who received food prepared in the kitchen. * The cole slaw for residents on regular and puree diets was observed with ice in it. This failure had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 88 residents who received food prepared in the kitchen. Findings: Review of the facility's Order Listing Report for February 2026 showed a total of 88 residents received meals prepared in the facility's kitchen. On 2/12/26 at 1028 hours, a resident council meeting was conducted with multiple residents. During this meeting, Residents 1 and 2 verbalized the food was served cold and did not taste good. On 2/12/26 at 1135 hours, an observation of the meal tray service was conducted with the Dietary Supervisor. The kitchen staff were preparing beef stew and corn cole slaw. On 2/12/26 at 1244…

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 facility document review, the facility failed to maintain an effective pest control program to prevent the presence of an insect in Resident 132's room. * An insect was found crawling near Resident 132's bed. This failure had the potential for pests to multiply, and the presence of pest associated germs.Findings: Medical record review for Resident 132 was initiated on 2/11/26. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's MDS assessment dated [DATE], showed Resident 132 was severely impaired and never/rarely made decisions. On 2/11/26 at 1107 hours, during the initial tour of the facility, an observation was conducted with LVN 15 and Consultant 3 inside Resident 132's room. An insect was observed crawling near Resident 132's bed. The insect crawled under Resident 132's bed and LVN 15 and Consultant 1 were able to secure the insect and remove it from Resident 132's room. On 2/11/26 at 1233 hours, an interview was conducted with the Maintenance…

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, medical record review, and facility P&P review, the facility failed to ensure quality care and services were provided for two of ten sampled residents (Residents 4 and 6). * The facility failed to ensure Resident 4 was monitored for the side effects and the effectiveness of the diabetic medication, and for signs and symptoms of hyperglycemia (high blood glucose). * The facility failed to ensure Resident 6's glucose monitoring was performed as ordered by the physician. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being.Findings: Review of the facility's P&P titled Guidelines for Medication Administration (undated) showed to observe the resident/patient for immediate reaction and any reactions that occur during the hours following administration. Record relevant and required information on the appropriate documentation record. Review of the facility's P&P titled Comprehensive 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 medical record review, the facility failed to ensure the necessary care and services were provided when monitoring the blood pressure for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2's blood pressure was monitored as per the physician's order. In addition, the facility failed to ensure the staff had used an approved device to monitor Resident 2's blood pressure. This failure posed the risk for the resident to have inaccurate blood pressure readings.Findings: On 9/18/25 at 1430 hours, an interview was conducted with Resident 2. Resident 2 verbalized his concern about the facility nurses using a wrist blood pressure machine to obtain his blood pressure readings. Resident 2 stated he did not want his blood pressure obtained with a wrist blood pressure machine because it was inaccurate and often gave a systolic blood pressure (SBP) reading of 99 mmHg. Resident 2 stated the nurses would have to retake his blood pressure five times before getting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections for one of three sampled residents (Resident 3). * The facility failed to ensure the EBP was implemented for Resident 3. This failure had the potential risk for transmission of communicable diseases or organisms to residents in the facility.Findings: Review of the facility's P&P titled Infection Prevention and Control Program: Standard and Transmission Based Precautions dated 3/2024 showed EBP are used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves in during high contact resident care that provide opportunities for indirectly transfer of the MDROs to staff hands and clothing then indirectly transferred to the resident to resident; resident with wounds and indwelling medical devices re at especially high…

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, medical record review, and facility P&P review, the facility failed to ensure the licensed nurses had competencies and skill sets needed to care for one of five sampled resident (Resident 1). * LVN 1 reported the abnormal laboratory values to Resident 1's physician without clarifying the physician's orders, which only addressed the resident's fluid status but not the severely low Hgb and Hct, and elevated WBC count. This failure created the potential risk of not providing qualified staff for the resident's care. Findings:Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed the results of the laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending physician promptly or as specified in the order. 1. Closed medical record review for Resident 1 was initiated on 6/24/25. Resident 1 was admitted to the facility on [DATE], and discharged on 5/21/25. Review of Resident 1's H&P…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 was seen for the outpatient physician's follow-up appointments. * The facility failed to ensure Resident 2's wound care was followed as ordered by the physician. These failures had the potential to negatively affect the residents' well-being as the necessary care and services were not provided. Findings: 1. Review of Resident 1's medical record was initiated on 4/25/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of acute and chronic respiratory failure, tracheostomy, and congenital malformation of skull and facial bones. Review of Resident 1's Order Summary Report showed the following physician's orders for the following: -dated 4/3/25, showed appointment speech evaluation MD on 4/7/25 -dated 4/2/25,…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for one of eight sampled residents (Resident 7). * The facility failed to apply barrier cream to Resident 7's sacrum during the wound care as ordered by the physician. * Resident 7's wound care assessment failed to reflect Resident 7 had underminingto the sacrococcyx pressure injury. * The facility failed to ensure the low air loss mattress settings for Resident 7 were set correctly. These failures had the potential for Resident 7 to not receive the appropriate care and services to promote healing of the pressure injury. Findings: Review of the facility P&P titled Skin and Wound Monitoring and Management revised 1/2023 showed the following: 1. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope…

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, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were followed for one of eight sampled residents (Resident 1). * The facility failed to ensure the isolation gown found in the clean linen's drawer outside Resident 1's room was free from the soiled gloves. * The facility failed to change the soiled tracheostomy tie after performing the neck wound care for Resident 1. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2022 showed the following: a. Facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. b. Facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection. c. The facility personnel will use effective methods for safe storage, transport, and disposal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary wound care and services were provided for three of five sampled residents (Residents 2, 3, and 5). * The facility failed to ensure Resident 2's wound care treatment orders were clarified and communicated when there were two physiciansproviding two different wound care orders. * The facility failed to ensure Resident 3 was provided with the appropriate bed mattress to promote healing of the pressure injury. * The facility failed to ensure the physician's order for the correct sequence of Resident 5's wound care treatment was followed. These failures had the potential for Residents 2, 3, and 5 to not receive the appropriate care and services to promote wound healing. Findings: 1. Medical record review for Resident 2 was initiated on 2/25/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Physician Order Summary…

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, medical record review, and facility P&P review, the facility failed to ensure one of five sample residents (Resident 2) remained free from accident hazards. * The facility failed to provide the bilateral floor mats at Resident 2's bedside as ordered by the physician for safety. This failure had the potential to place Resident 2 at risk for serious injury. Findings: Review of the facility's P&P titled Falls Prevention revised 8/2020 showed the following: - A post fall assessment including recommendations and care plan changes will be completed for all residents who have experienced a fall. - If appropriate, interventions will be initiated by per ID Team member recommendation and when necessary, physician's orders for any fall related incident. - The falls team will generate recommendations which may include but are not limited to nursing interventions. Medical record review for Resident 2 was initiated on 2/25/25. Resident 2 was admitted to the facility on [DATE], and readmitted…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared 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, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of four of 27 final sampled residents (Residents 96, 108, 775, and 78). * The facility failed to ensure Residents 96, 108, 775, and 78's call lights were within the residents' reach. This failure created the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Nursing clinical, Subject Call Lights/Bell Revised May 2020 showed to leave the resident comfortable and place the call device within the resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor. 1. On 11/13/24 at 1554 hours, an observation for Resident 96 and concurrent interview was conducted with LVN 11. Resident 96's call light was observed hanging at the back of the bed which was not within the resident's reach. LVN 11…

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, medical record review, and facility P&P review, the facility failed to notify the physician timely of the resident's changes in status for two of 27 final sampled residents (Residents 51 and 56). * Resident 51's physician was not notified timely for a change in swallow status. * Resident 56's physician was not notified of the resident's recent episodes of emesis and of the resident's tube feeding being placed on hold. These failures resulted in a delay of physician notification, intervention and/or implementation of the physicians' orders with the potential for an adverse resident outcomes. Findings: Review of the facility's P&P titled Change of Condition Reporting dated May 2019 showed all changes in the resident's condition will be communicated to the physician. The staff will document the change of condition in the eInteract Change of Condition UDA and in the nursing progress notes. All attempts to notify the physician will be documented in the nursing progress notes. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide a safe and comfortable environment for one nonsampled residents (Resident 35). * The staff went through the resident's belongings without the resident's consent. This failure resulted in the resident being upset staff went through her personal belongings, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 35 was initiated on 11/12/24. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 9/22/24, showed the resident was legally blind. Review of Resident 35's IDT -BIMS dated 11/6/24, showed the resident was cognitively intact. Medical record review for Resident 325 was initiated on 11/12/24. Resident 325 was readmitted to the facility on [DATE]. Review of Resident 325's IDT -BIMS dated 11/12/24, showed the resident was cognitively intact. On 11/14/24 at 0833 hours, during a medication administration observation…

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 medical record review, the facility failed to ensure the necessary care and services provided to two of 27 final sampled residents (Residents 33 and 73). * Resident 73's skin and wound consult recommendations were not followed up timely by the facility. * Resident 33 was not monitored every shift for at least 72 hours following the weight loss. These failures resulted in a potential delay of identifying changes in the residents' statuses and/or a delay of implementing the interventions to ensure the quality of care was provided. Findings: 1. Medical record review for Resident 73 was initiated on 11/12/24. Resident 73 readmitted to the facility on [DATE]. Review of Resident 73's skin and wound consult dated 10/30/24, showed the resident was seen for dry scattered rashes. The note showed the resident was already being treated with Triamcinolone 0.1% (a topical cream used for skin conditions) for sever itchiness. The dermatologist's recommendations included the following: - Ensure a daily…

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 medical record review, the facility failed to ensure the staff reported and addressed a new pressure ulcer timely for one of three final sampled residents (Resident 51) reviewed for pressure ulcers. This failure had the potential to result in a delay of treatment and interventions being put in place to prevent further decline. Findings: Medical record review for Resident 51 was initiated on 11/12/24. Resident 51 was admitted to the facility on [DATE]. On 11/14/24 at 1024 hours, an observation of Resident 51's being transferred to the wheelchair after her shower and morning ADL care provided by the CNA and RNA. After CNA 1 and the RNA left the resident's bedside, an observation of Resident 51's right heel showed an open area of approximately 2 cm with a minimal depth. Review of Resident 51's medical record showed no documented evidence of a wound located on the resident's right heel. On 11/14/24 at 1409 hours, an interview and medical record review were conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to implement two staff assistance for ADL care for one of eight final sampled residents (Resident 51) reviewed for accident harzards. This failure resulted in the resident sustaining another fall, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 51 was initiated on 11/12/24. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Fall Committee IDT note dated 8/23/24 at 2023 hours, showed Resident 51 sustained a fall on 8/19/24. The note showed a CNA rolled the resident in bed to place a mechanical lift sling under the resident, and the resident slid off the bed. The IDT note showed they recommended two-person assistance with ADL care. Review of Resident 51's Fall Committee IDT note dated 10/2/24 at 1459 hours, showed Resident 51 sustained a fall on 9/30/24. The note showed a CNA was providing bedside care and the resident began to slide off the bed. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTI for one of two final sampled residents (Resident 30) reviewed for indwelling urinary catheter. * Resident 30's urinary drainage bag and tubing were positioned above the bladder. This failure posed the risk for Resident 30 to develop urinary tract infection and other complications from UTI. Findings: Review of the facility's P&P titled Nursing Clinical, Subject Catheter Drainage Bag Revised November 2019 showed under the Standard Drainage Bag procedures, to position the drainage bag below the level of the resident's bladder and the drainage bag should be kept off the floor. On 11/14/24 at 0839 hours, an observation for Resident 30 and concurrent interview was conducted with CNA 6. Resident 30's indwelling urinary catheter drainage bag was observed inside the dignity bag (a bag used to cover and hold the catheter drainage bag so it is not visible) but its…

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 medical record review, the facility failed to ensure the correct enteral formula was administered to one of two final sampled residents (Resident 56) reviewed for tube feeding * Resident 56 had the incorrect strength of tube feeding administered. This failure resulted for a less than the ordered calories to be administered to the resident, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 56 was initiated on 11/12/24. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's Order Summary Report dated 11/14/25, showed a physician order dated 10/21/24, for Vital 1.5, to provide 1900 ml daily at 95 ml/hr for 20 hours, and to start at 1500 hours, and run until the total volume delivered. On 11/13/24 at 1510 hours, an observation, interview, and medical record review was conducted with LVN 1. LVN 1 stated they held the resident's tube feeding due to vomiting and for approximately two hours…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for four of seven residents (two final sampled residents, Residents 65 and 83; and two nonsampled residents, Residents 725 and 726) reviewed for respiratory care. * The facility failed to ensure Residents 83, 725, and 726's oxygen tubing was dated. * The facility failed to ensure Resident 65 received oxygen as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the inaccurate administration of oxygen and improper care of oxygen equipment. Findings: Review or the facility's P&P titled Oxygen Administration (mask, cannula, catheter, use of humidifier) revised 12/2023 showed it is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as emergency measure until the order can be obtained. Oxygen tubing is to be replaced every seven days. 1. On 11/12/24 at 0826…

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, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 18, 41, and 56) reviewed for side rail use remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the side rails use for Resident 18. * The facility failed to ensure documented evidence of the least restrictive measures attempted prior to the side rail use for Resident 41. * Resident 56's siderail order was for an inappropriate use. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute…

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controlled medications were accounted for and documented for one of three inspected medication carts (Medication Cart A) with controlled medications. * The facility failed to ensure accurate and complete documentation of controlled medication administration for two nonsampled residents (Residents 22 and 94). These failures had the potential for the medications to be administered in errors and opportunities for drug diversion. Findings: Review of the facility's P&P titled Controlled Medications revised 12/2019 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: - Date and time of the administration. - The amount administered. - Signature of the nurse administering the dose (completed after the medication is administered). At each shift change, a physical inventory of all…

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, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure was monitored accurately as ordered by the physician related to the use of an antipsychotic medication for one of five final sampled residents (Resident 42) reviewed for unnecessary medications. This failure had the potential for Resident 42 to have adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dose of the psychotropic medication for Resident 42. Findings: Review of the facility's P&P titled Unnecessary Drugs revised 5/2007 showed it is the policy of the facility that each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); 2. For excessive duration; 3. Without adequate monitoring; 4. Without adequate indications for its use; 5. In the presence of adverse consequences which indicate the dose…

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, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 25% for nine medication errors out of 36 medication administration observations. One nurse (LVN 2) observed administering the medications was found to have errors while administering the medications to one of 27 final sampled residents (Resident 43) and one nonsampled resident (Resident 35). This failure created the risk of the resident developing complications and ineffective therapeutic effects of the medications. Findings: 1. On 11/14/24 at 0800 hours, a medication pass observation was conducted with LVN 2 for Resident 51. LVN 2 was observed administering eight medications to Resident 43. LVN 2 was observed crushing each medication and mixing them with applesauce in the individual cups. After administering the medications to the resident, the LVN went to discard the used medications cups. An observation of all eight medicine cups showed a residual of medication in each cup. LVN 2 verified 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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication and disposal of biologicals. * The facility failed ensure one single-use medication was discarded after use in Medication Cart E. * The facility failed to ensure the sublingual medication was not stored with externally administered medications in Medication Cart D. * The facility failed to ensure the contents of the sharp disposal container remained below the full line for Medication Cart A. In addition, the facility failed to ensure oral medications, topical medications, ophthalmic medications (medication to treat conditions of the eye), nasal medications, inhaled medications, and suppositories (a solid, cone-shaped or round object that contains medication and is inserted into a body cavity) were stored separately in Medication Cart A. *T he facility failed to ensure the subcutaneously administered medications (inserted beneath the skin either by injection or infusion) were not stored with the topical medications, and 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 medical record review, the facility failed to follow-up with the physician for the abnormal laboratory results for one of five final sampled residents (Resident 70) reviewed for unnecessary medication. This failure had the potential for the resident to have undesirable outcomes. Findings: Medical record review for Resident 70 was initiated on 11/12/24. Resident 70 was readmitted to the facility on [DATE]. Review of Resident 70's Skilled Nursing H&P examination dated 9/9/24, showed the resident had intractable epilepsy (a seizure disorder). Review of Resident 70's Order Summary Report dated 11/14/24, showed a physician's order for divalproex sodium (a compound containing valproic acid and sodium valproate) 500 mg daily for seizure activity. Review of the Consultant Pharmacist's Medication Regimen Review for August 2024 showed a recommendation for Resident 70. The recommendation showed to clarify if the valproic acid was for seizures, and if it was, to obtain a valproic acid level. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for four of 27 residents (three final sampled residents, Residents 33, 41, and 105; and one nonsampled resident, Resident 49) reviewed for medical records. * The facility failed to ensure Resident 33's intravenous fluid intake was documented. * The facility failed to ensure the RNA documented Resident 33's refusal to be weighed. * The facility failed to ensure Resident 49's MAR was completed. * The facility failed to ensure Resident 105's hospice visitation log was completed. * The facility failed to ensure Resident 41's updated flu vaccination consent was filed in the appropriate medical records folder. These failures had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: Review of the facility's P&P titled Nutrition Status Management revised 12/2024 showed the following: - Evaluations will include determining…

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, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infection were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for January 2024 through September 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to implement their infection control surveillance program for July 2024 through September 2024. * The facility failed to ensure infection control practices were implemented for one final sampled resident (Resident 775) * The facility failed to ensure tracheostomy supplies in the respiratory carts were stored properly for use. * The facility…

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

Based on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program (ASP) when: * The facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for one nonsampled resident (Resident 525). * The facility failed to use the correct Surveillance Data Collection Form for two final sampled residents (Residents 96 and 108) and four nonsampled residents (Residents 4, 8, 86, and 531). * The facility failed to properly use the Surveillance Data Collection Form criteria to indicate a true infection for one final sampled resident (Resident 83) and three nonsampled residents (Residents 2, 19, and 80). These failures had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving proper treatment and care. Findings: Review of the facility's P&P titled Infection Prevention- Surveillance of Infection and Reporting undated showed the IP/DNS (Director of Nursing Services)/Designee will trend all validated infections using McGeer'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, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of six sampled residents (Resident 1). * The facility failed to implement Resident 1's plan of care to monitor and document output as per the facility's protocol. This failure had potential for not providing appropriate, consistent, and individualized care. Findings: According to the facility's P&P titled Care plan and Care Plan Update last revised 2/2023, it is the policy of the facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. According to the facility's P&P titled Intake and Output Policy revised 10/2020, under the documentation section, licensed nurse will document resident's intake and output at the end of each shift in the Intake and Output…

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, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered Norco oral tablet 10-325 mg (medication to manage pain) when Resident's A pain level was below the parameters to administer the ordered medication. This failure had the potential for Resident 1 to receive unnecessary medication and experience adverse effects from the medication. Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of Norco included sedation, confusion, and constipation. According to the facility's P&P titled Medication Administration-General Guidelines, undated, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Under Procedure – Administration, medications are administered in accordance…

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, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for one of six sampled residents (Resident 1). * Resident 1 had three personal clothing itemshanging in a bathroom shared with another resident. * A food cart containing the lunch trays to be passed to the residents was in the hallway next to a dirty linen bin. These failures had the potential to cause the transmission and development of disease and infection. Findings: 1. According to the CDC, under Environmental Infection Control Guidelines, contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately. Medical record review for Resident 1 was initiated…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to prevent falls for one of four sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with two persons assist during the transfers on 2/28/24, as per the MDS assessment and sustained a fall during this transfer. The fall care plan was not revised to include two persons assist as per the PT's recommendation. In addition, Resident 2 was no not monitored every shift for 72 hours after the fall. * CNA 1's competency for using the gait belt was incomplete and a gait belt was not issued to CNA 1 as per the facility's P&P. These failures had the potential for not providing adequate supervision and assistance to prevent accidents or falls for the resident. Findings: 1. Review of the facility's P&P titled Significant Change in Condition, Monitoring revised 2/2023 showed if any time, it is recognized by any one of the team members that 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, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. * The facility failed to monitor Resident 1 after a change of condition. This failure posed the risk of the resident not receiving the necessary care and services. Findings: Review of the facility's P&P titled Significant Change in Condition, Monitoring- revised 2/2023 showed the following: 1. If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of, and he/she will monitor. Example would be the following (but not limited to): - change in ability to ambulate or propel wheelchair; - change in ability to transfer or position self; - change in ability to feed or drink; - change in ability to groom or dress; - change in behavior or increased…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were administered for one of the three sampled residents (Resident 3) as ordered by the physician. This failure posed the risk to negatively impact Resident 3's medical condition. Findings: Review of the facility's P&P titled Medication Administration - General Guidelines (undated) showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so and administered in accordance with the written orders of the attending physician. Review of the facility's document titled Plan for Medication administration as prescribed by physician and in accordance with the written/prescribed orders showed the acceptable medication pass time is one hour before and one hour after the scheduled time and for most medications. Medical record review for Resident 3 was initiated on 1/22/24. Resident 3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to document the administered medications in the MAR for one of three sampled residents (Resident 1). This failure posed the risk of errors in medical care as the documentation was incomplete. Findings: Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MAR for December 2023 showed a physician's order to administer the following medications at 0600 hours: - famotidine (medication for acid reflux) 20 mg; - glipizide (medication for diabetes) 5 mg; - gabapentin (medication for nerve pain) 300 mg; and - ipratropium-albuterol solution (breathing treatment) 0.5-2.5 mg per 3 ml. Further review of Resident 1's MAR for December 2023 showed a physician's order to administer insulin lispro (medication for diabetes) per the sliding scale (the dose of insulin based on blood sugar levels) at 0630 hours. Review of Resident 1's MAR for December 2023 showed the blank…

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, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 2) remained free from the accidents hazards. * The facility failed to implement the safety interventions as ordered by the physician and care planed for Resident 2 who was at high risk for falls. This failure had the potential to place Resident 2 at risk for serious injury. Findings: Review of the facility ' s P&P titled Fall Management System revised June 2018 showed each resident is assisted in attaining or maintaining their highest level of function through proving the resident adequate supervision, assistive devices, and functional program as appropriate to prevent accidents. It is the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Medical record review for Resident 2 was initiated on 12/13/23. Resident 2 was readmitted to the facility on [DATE].…

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, medical record review, and facility document review, the facility failed to provide the pharmaceutical services to meet the resident ' s needs for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1 ' s oxycodone HCL (narcotic pain medication) was accurately reconciled. The oxycodone HCL tablets taken out of the bubble pack (a packaged used to dispense medications) documented on the Medication Count Sheet did not match the electronic MAR as administered to Resident 1. This failure had the potential for exposing the resident to ineffective treatment, medication errors, and the potential for diversion of controlled medications. Findings: Medical record review for Resident 1 was initiated on 11/30/23. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of the MDS dated [DATE], showed Resident 1 was cognitively intact. Review of the Order Summary Report dated 11/30/23, showed two physician '…

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, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered amiodarone HCl (medication for heart rhythm problems), carvedilol (medication to treat high blood pressure), spironolactone (medication to treat high blood pressure and fluid retention), and sacubitril-valsartan (medication to treat patient with chronic heart failure) when Resident 1's blood pressures were below the parameters to administer these ordered medications. * The facility failed to notify the physician when amiodarone HCl, carvedilol, spironolactone, and sacubitril-valsartan were held for two consecutive times as ordered by the physician. These failures had the potential for Resident 1 to receive unnecessary medication and develop symptoms such as bradycardia (slower than normal heart rate) and hypotension (low blood pressure). Findings: According to Lexicomp, an online reference for clinical drug…

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, medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record whenthe one of two sampled residents (Resident 1) was discharged from the facility. * The facility failed to ensure Resident 1's medical record contained a list of reconciled pre-discharge and post discharge medications when Resident 1 was discharged home in accordance with the facility's P&P. This posed the risk for not identifying discrepancies or differences in Resident 1's pre-discharge and post discharge medication orders, which had the potential to negatively impact the Resident 1's wellbeing. * The facility failed to document information in Resident 1's medical record specific to the release of controlled medications to Resident 1's family. This posed the risk for diversion of controlled medications. * The facility failed to document the amount/number of non-controlled medications provided to Resident 1 when he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for two of four sampled residents (Residents 1 and 2) as evidenced by: * The facility did not interview other residents receiving care by the alleged staff for their abuse investigation. This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 11/17 showed the abuse investigation would include interviews with other residents to whom the accused employee provides care or services. 1. On 8/23/23 at 1324 hours, an interview was conducted with Resident 1's Family Member 1. Resident 1's Family Member 1 stated Resident 1 verbalized she (Resident 1) was raped by a male staff at the facility. Closed medical record review for Resident 1 was initiated on 8/23/23. Resident 1 was admitted to the facility 8/2/23, and left against medical advice…

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, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) received quality of care as evidenced by: - The weekly skin assessments were not completed for Resident 1. This failure posed the risk of the resident not receiving appropriate care. Findings: Review of the facility's P&P titled Skin Care Policy/Procedure revised 2/22 showed in part, the following: * Assessment of wounds identified after admission: - A licensed nurse will assess/evaluate a resident's skin at least weekly. - Areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the nursing notes. * Weekly Skin Check: - The licensed nurse should document skin evaluations in accordance with this policy and document on the skin assessment/evaluation weekly /PRN form. On 8/23/23 at 0938 hours, Resident 2 was observed with red circular discoloration to her right shin. On 8/24/23 at 0951 hours, an interview was conducted…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, and complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for 33 residents who used the side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails…

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, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of psychotropic medications (any drug prescribed to stabilize or improve mood, mental status, or behavior) for one of 25 final sampled residents (Resident 16). * The informed consent was not obtained from Resident 16 prior to administering mirtazapine (antidepressant medication). This failure had the potential for the resident to be unaware of the risks associated with the medications which may have adverse side effects detrimental to the resident's well-being or choice. Findings: Review of the facility's P&P titled Informed Consent - Psychotherapeutic Medications revised 12/14/17, showed the attending physician (healthcare practitioner) will be responsible for obtaining informed consent from the resident/ surrogate decision maker prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident's stay in the facility, providing…

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 medical record review, the facility failed to ensure the call light was kept within reach for two of 25 final sampled residents (Residents 56 and 77) and one nonsampled resident (Resident 664). This failure posed the risk for the residents not being able to call for assistance should they require it. Findings: Review of the facility's P&P titled Call Light, Answering (undated) showed it is the policy of the facility to leave the call light within the reach of the resident, answer calls and respond to the resident's requests and needs as quickly as possible. 1. On 5/10/22 at 1043 and 1502 hours, Resident 77 was observed in bed. The call light was hanging over a mat propped against the wall behind Resident 77's bed. The call light was out of Resident 77's reach. Resident 77 stated he needed his incontinence briefs changed. When asked if he could reach the call light, Resident 77 stated no. On 5/10/22 at 1514 hours, an observation and concurrent interview were conducted with LVN…

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 medical record review, the facility failed to develop a plan of care to reflect the individual care needs related to the deep tissue injury (DTI) for one of 25 final sampled residents (Resident 10). This posed the risk of not providing appropriate, consistent, and individualized care to Resident 10. Findings: The National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 defined DTIs as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Medical record review for Resident 10 was initiated on 5/10/22. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Admission/readmission Screener dated 1/26/22, showed the resident was admitted to the facility with the right heel DTI.…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of the 25 final sampled residents (Residents 8 and 40) and two nonsampled residents (Residents 84 and 93) to maintain their highest physical well-being. * The facility failed to complete the CXR, CBC, BMP, and Mg laboratory tests for Resident 8 as per the physician's order. * Residents 84 and 93's medications were not administered in a timely manner. * Resident 40's wound dressing on both legs and feet were loose, soiled, and touching the floor. In addition, Resident 40's wound dressing were not dated to show when it was last changed. These failures had the potential to negatively impact the resident's' well-being. Findings: 1. Review of the facility's P&P titled Lab and Diagnostic Orders dated 11/2018 showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the tests…

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 medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of 25 final sampled residents (Resident 10). * The facility failed to ensure Resident 10's heels were offloaded which contributed to Resident 10 developing a Stage 2 pressure ulcer on the right lateral (to the side of, or away from the middle of the body) heel. * The facility failed to ensure Resident 10 received wound care for the fluid filled blister (Stage 2 pressure ulcer) on the right medial (toward the middle or center of the body) heel from 5/7 to 5/10/22. * Resident 10 was admitted to the facility with a DTI (deep tissue injury) on the right heel. The facility failed to ensure Resident 10 received the necessary treatment and services for the DTI. These failures had the potential of Resident 10 not receiving the appropriate care and services to promote healing or prevent the development of the pressure…

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 medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 108) remained free from accident hazards. * The facility failed to ensure Resident 108's side rails were padded as care planned. This failure posed the risk for Resident 108 to become injured by the side rails. Findings: On 5/10/22 at 1433 hours, Resident 108 was observed lying in bed with one side rail elevated by the right side of the head of the bed. The side rail was not padded. Medical record review for Resident 108 was initiated on 5/10/22. Resident 108 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 4/18/22, to implement bilateral upper side rails for comfort and security. Review of Resident 108's History and Physical examination dated 4/18/22, showed Resident 108 had diagnoses, including seizure disorder (the physical manifestations, such as convulsions, sensory disturbances, or loss of consciousness, resulting…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and serviced for one nonsampled resident (Resident 25). * Resident 25's indwelling urinary catheter tubing was observed to dragging on the ground as he self-propelled his wheelchair. This failure posed the risk for the resident to develop complications related to urinary catheter use. Findings: Review of the facility's P&P titled Urinary Catheter Care revised 9/2014, under the section for Infection Control, showed the urinary catheter tubing and drainage bag are kept off the floor. Medical record review for Resident 25 was initiatied on 5/9/22. Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 25 needed extesnive assistance with his ADL care. Resident 25 had an indwelling urinary catheter. Review of the plan of care showed a care plan problem addressing the risk for infection related to Resident 25's use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care for one of 25 final sampled residents (Resident 16). * The facility failed to ensure Resident 16 was administered medications as ordered on the days the resident left the facility for dialysis treatment (a treatment to rid the blood of toxins and waste when the kidneys fail to function). This had the potential for Resident 16 not getting the appropriate doses of medications as ordered, resulting in possible medical complications. Findings: Review of Resident 16's medical record was initiated on 5/9/22. Resident 16 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed the following physician's orders: - dated 2/1/22, for Resident 16 to go to dialysis on Tuesdays, Thursdays, and Saturdays at 1400 hours; - dated 2/1/22, to administer amiodarone (antiarrhythmic medication, used to treat serious irregular heartbeat) 200 mg one tablet by mouth two times a day…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling and disposal of medications. * The facility failed to ensure the discontinued medication for one of 25 final sampled residents (Resident 40), and medications for seven nonsampled residents (Residents 38, 47, 62, 113, 114 115, and 366) who were transferred, discharged home or expired were removed from the medication cart. These failures had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the prepared medications for Resident 463 were labeled when stored in the medication cart as the licensed staff await for the resident to be able to take the medications. This had the potential for the medications to be accidentally administered to another resident and/or diverted. * Medication Carts A and B were left unlocked and unattended. This had 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 facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * Open food containers had no open dates. * Expired food was not discarded. These failures had the potential to cause food borne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Condition of Residents dated 5/9/22, showed 72 of 177 residents received food from the kitchen. Review of the facility's P&P titled Labeling and Dating of Food dated 2020 showed newly opened food items will need to be closed and labeled with an open date and used by date. On 5/9/22 at 0829 hours,during the initial kitchen tour with the Dietary Manager, the following was observed inside the walk in refrigerator: - an open container of mayonnaise with no open date, - an open container of dill pickles with no open date, - an open container of low fat cottage cheese with no open date, and - one head of lettuce which appeared dry, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one of 25 final sampled residents (Resident 6). * Resident 6's medical record had two different physician orders to address his end of life choice. Resident 6 had physician's orders to administer Full code/full treatment and DNR. This failure posed the risk for the resident receiving emergency measures against his wishes. Findings: According to the facility's P&P titled Charting and Documentation revised on [DATE] showed documentation in the medical record would be objective, complete, and accurate. According to the facility's P&P titled Physician Order for Life Sustaining treatment (POLST) revised on [DATE], showed the POLST is an approach to end of life planning based on the conversations between the patients and their healthcare providers. The POLST form is a physician order and emergency medical personnel are required to adhere to its instruction regarding CPR and other…

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 facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * CNA 8 failed to remove her gown and gloves and perform hand hygiene before exiting Resident 31's room which was an isolation room due to exposure to COVID 19. This failure had the potential for the spread of infectious diseases in the facility. Findings: Review of the CDC document titled Use of Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, and How to Safely Remove PPE (undated), showed safe work practices should be used to protect yourself and limit the spread of contamination. Gowns and masks worn in isolation rooms should be removed before exiting a patient room and hand hygiene should be performed immediately after removing all PPE. On 5/10/22 at 0953 hours, CNA 8 wearing an N95 mask, face shield, gown and gloves was observed standing at the doorway of Room 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 observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. The facility failed to ensure four glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control record matched the serial numbers of the glucometer and the lot numbers of the control solutions. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses. Findings: Review of the users guide for EvenCare G2 Blood Glucose Monitoring System 2017, under Control Solution Testing, showed the purpose of the control solution testing is to make sure the EvenCare G2 meter and the EvenCare G2 test strips are working properly. Check the expiration date printed on 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.