A Grace Sub Acute & Skilled Care

Based on observation, interview, and record review, the facility had a medication error rate of 5.56% when two medication errors occurred out of 36 opportunities during the medication administration for 2 out of 6 residents (Residents 67 and 93). The failures resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the residents not receiving full therapeutic effects or complications of medications. Findings: 1. During the medication administration observation on 10/14/24 at 9:15 a.m., Licensed Vocational Nurse (LVN) A was observed preparing and administering 15 medications to Resident 67. Included in the medications was an oral inhaler called Alvesco (medication for asthma). After shaking the Alvesco inhaler, LVN A gave it to the resident and asked her to press on the inhaler and inhale deeply. After she finished, LVN A asked Resident 67 to repeat by giving herself another puff without allowing some time in between the inhalations. There was about 4 or 5-second time lapse between the 2 puffs. During an interview shortly after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meals with food items according to preferences and dislikes for two of 44 residents (55 and 67). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents. Findings: Review of Resident 55's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 67's admission Record indicated she was admitted to the facility on [DATE]. During a tray line observation with the dietary supervisor (DS) on 10/15/24, at 12:35 p.m., Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served for him. Resident 67's lunch ticket indicated she disliked rice, but rice was served for her. During a concurrent interview with the DS, she confirmed that Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served 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.

Based on observation, interview, and record review, the facility failed to ensure one of 27 initial pool residents (Resident 1) had access to a staff call device (call button), in case of needing help or for an emergency. This failure had the potential of Resident 1 becoming seriously harmed or even lead to death. Findings: During an observation in Room R3 on 10/14/24 at 8:40 a.m., the call button for bed A was observed hanging on the wall above the head of the bed, not within reach of Resident 1. Resident 1 stated she can not reach the call button, and would want to call. During an observation in Room R3 on 10/14/24 at 12:28 p.m., the call button was still hanging on the wall. During an observation in Room R3 on 10/14/24 3:17 p.m., the call button was still on the wall, out of reach of Resident 1. During an observation and subsequent interview with registered B (RN B) on 10/14/24 at 3:19 p.m., RN B took the call button off of the wall and handed it to Resident 1. RN B stated Resident 1 should have had the call button within reach. During a review of the facility's policy &…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment for one of 22 sampled residents (Resident 28) due to cracked walls near Resident 28's bathroom door and at the bottom left side of the toilet in the bathroom. This deficient practice had the potential to adversely affect the health and safety of residents in the facility. Findings: During an observation and interview with Resident 28 on 10/14/24 at 3:30 p.m., in Resident 28's room, Resident 28 stated about the cracked walls near her bathroom door and at the bottom, left side of the toilet in the bathroom. Resident 28 also stated that the walls were damaged and needed to be repaired. Resident 28 further stated that the facility was aware of the cracked walls near the bathroom door and the bottom left side of the toilet since last year. During a concurrent interview and record review with the maintenance director (MD) on 10/16/24 at 2:00 p.m., upon review of the maintenance log with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Morse Fall Scale (an assessment used to determine a resident's risk for falls) after a fall for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify fall risk factors and implement interventions accordingly. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hemiplegia (one side of the body is paralyzed), disorientation (confusion), and muscle weakness. Review of Resident 1's Morse Fall Scale, dated 4/30/24, indicated Resident 1 was at moderate risk for falling. The instructions printed on the top of the Morse Fall Scale indicated, Complete on admission, quarterly, at change of condition, and after a fall. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/10/24 and written by licensed nurse A (LN A), indicated Resident 1 was seen scooting out of bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Fall Morse Scale was completed accurately for one of two sampled residents (Resident 1). The failure to accurately assess residents ' fall risk has the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions for falls. Findings: Review of Resident 1 ' s medical record indicated he was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that may lead to personality changes). Review of Resident 1 ' s Interdisciplinary Team Progress Notes (IDT), dated 9/14/23 , indicated Resident 1 had an unwitnessed fall on 9/13/23. Resident 1 ' s Minimum Data Set (MDS, a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. A physician order for the wearing of a hand splint was not followed; 2. A physician order for the wearing of a knee brace was not followed; 3. RNA (Restorative Nursing Assistant) services were not provided as ordered; These failures resulted in Resident 1 not receiving proper treatment and had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including subarachnoid hemorrhage (bleeding into the fluid space surrounding the brain), aneurysm of carotid artery (bulging in one of the arteries supplying blood to the brain, head, face, and neck), and obstructive hydrocephalus (fluid build-up in the brain). Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 8/21/23, indicated…

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

During an observation on 5/9/22 at 12:44 p.m., CNAs were seen passing out the lunchtime meal trays to the residents. There were two food carts parked in the hallway of station three and station four which contained the lunch trays of the residents. Two LNs were seen in the hallways of station three and four, standing by their medication carts, and were not participating in the passing of the lunch trays to the residents. During an interview with licensed vocational nurse D (LVN D) on 5/9/22 at 12:44 p.m., he was asked if he checked the contents of the meal trays before the CNAs distributed lunch to the residents on station three and station four. LVN D stated No I did not, I do it if I have time. During an interview with the director of nursing (DON) on 05/12/22 at 8:50 a.m., she stated Our process is to have the licensed nurses check the meal trays and make sure the food matches the diet tray card before the CNAs start passing the trays. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 05/12/22 at 12:17 p.m., lunch trays were being passed…

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

Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Random controlled medication use audit for three of four sampled residents' (Residents 23, 48, and 71) as-needed controlled medications did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. 2. Three of five controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the incoming and outgoing nurse during a shift change) were missing signatures. These failures had the potential for misuse or diversion of controlled medications and inaccurate accountability of controlled medications. Findings: 1. The controlled medication Count Sheets for four random residents receiving as-needed controlled medications were…

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

Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for four of five sampled residents (Residents 42, 53, 64, and 72). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and possible side effects for residents. Findings: 1. During a medication pass observation on 5/9/22, at 09:01 a.m., with licensed vocational nurse D(LVN D), he administered six medications to Resident 53, including a tablet of aspirin enteric coated (a pain reliever with a coating that creates a delayed release of the medication also prevents stroke) 81 milligrams (mg). A review of Resident 53's clinical record indicated a physician's order, dated 12/29/21, for aspirin low strength tablet chewable 81 mg give 1 tablet by mouth one time a day for stroke prevention. During a concurrent interview and…

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

Based on observation, interview, and document review, the facility failed to follow proper sanitation and food handling practices when: 1. There were uncovered food items in the facility's kitchen freezer; 2. There was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator; and 3. Food service equipment was stored wet. These failures had the potential to cause food contamination and food-borne illness to 47 of 47 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD) inside the walk-in-freezer, a large bin containing a plastic bag of dinner rolls was observed. The bag of dinner rolls was open and exposed to the air. Another bin containing a plastic bag of corn dogs was observed to be open and exposed to the air. A third bin containing a plastic bag of bacon was observed to be open and exposed to the air. During a concurrent interview with the RD, he confirmed the plastic bags containing the dinner rolls, corn dogs, and bacon were open and exposed to the air in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Licensed vocational nurse D (LVN D) did not perform hand hygiene in between tasks; 2. Face shield unattended on top of a cart parked in the hallway; 3. Certified nursing assistant K (CNA K) did not tie her isolation gown before entering an isolation room; 4. The restorative nursing assistant (RNA) did not follow the sequence in donning personal protective equipment (PPE). 5. Resident 25 did not have a daily Covid-19 screening monitoring; 6. LVN A did not perform hand hygiene in between changing gloves; 7. Irrigation syringe was hanging on the gastric tube (GT) machine. These failures could result in the spread of infection and cross-contamination that could affect the 87 residents who reside in the facility. Findings: 1. During an observation on 5/9/22 at 9:56 a.m., LVN D went to attend Resident 35, touched the resident's arm, left the room and went to his medication cart and…

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

Based on interview and record review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for an increased dose of an antipsychotic medication (a type of psychotropic medication to manage psychosis including delusions, hallucinations, paranoia, or disordered thought) for one of 23 sampled residents (Resident 48). This failure had the potential to compromise the right of the residents or responsible parties (RPs, persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment to make health care decisions. Findings: A review of Resident 48's clinical record indicated she had been receiving Seroquel (an antipsychotic medication) 50 milligrams (mg, unit of measurement) twice daily for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) M/B (manifested by) angry…

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

Based on observation, interview and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 74) when Resident 74 was not able to reach for her call light. This failure had the potential for residents' needs not being met. Findings: During a concurrent observation and interview on 5/9/22, at 8:42 a.m., with licensed vocational nurse A (LVN A) in Resident 74's room, Resident 74 was hitting the right siderail of her bed with her right hand. LVN A took the call light hanging on top of a gastric tube feeding machine (a device used for direct feeding to the stomach) situated on the left side of Resident 74. LVN A stated that the call light must be within reach of Resident 74. During an interview on 5/12/22, at 10:27 a.m., with certified nursing assistant H (CNA H), she stated that Resident 74 uses her right hand to use the call light. During an interview on 5/12/22, at 10:32 a.m., with registered nurse C (RN C), she stated that Resident 74 uses the call light for help. During an interview on 5/12/22, at 1:32 p.m., with the director of…

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

Based on observation, interview, and record review, the facility failed to protect a residents' personal health information for one of three computer monitors. This failure had the potential for the public to see or access resident's personal medical and demographic information. Findings: During an observation of nursing staff administering medications to residents on 5/11/2022, at 10:35 a.m., one laptop was open with residents' personal health information on laptop screen unattended. During an interview on 5/11/2022, at 10:45 a.m., with registered nurse B (RN B), she stated that she got busy and forgot to log out before going into a resident room. During an interview on 5/13/22 at 10:05 a.m., with the director of nursing, she stated that after giving medications, the nurse must close the laptop screen. No personal health information should be left unattended. A review of the facility's policy titled, Protected Health Information (PHI), Management and Protection, dated April 2014, indicated that It is the responsibility of all personnel who have access to resident and facility…

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

Based on observation, interview, and record review, the facility failed to provide services to prevent contracture (condition leading to deformity) for two of nine sampled residents (Resident 77 and Resident 28) when: 1. Resident 77's lower extremities (legs and feet) did not have heel protectors (device to prevent deformity) applied on bilateral feet. 2. Resident 28 did not have a splint (device used to protect deformity) applied on his left arm as ordered. These failures had the potential to cause or worsen bone deformities. Findings: 1. During an observation on 5/9/22 at 8:58 a.m., in Resident 77's room, Resident 77's lower extremities did not have heel protectors. During a concurrent observation and interview on 5/9/22 at 3:40 p.m., with licensed vocational nurse A (LVN A) in Resident 77's room. Resident 77's soft heel protectors were inside the cabinet. LVN A stated she would check on the order for soft heel protector application. During a concurrent interview and record review on 5/10/22 at 10:23 a.m. with LVN A, LVN A stated that physician order, dated,11/15/2021, indicated…

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

Based on observation, interview, and record review, the facility failed to provide timely assessment and intervention for pain for one of two sampled residents (Resident 68). This failure had the potential for increased pain and discomfort for Resident 68. Findings: During an observation on 5/9/22, at 10:20 a.m., in Resident 68's room, she was rubbing the left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), she informed the nurse of Resident 68's pain on the left side of her face about two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During an observation on 5/11/22, at 9:52 a.m., in Resident 68's room, registered nurse B (RN B) assessed the resident for pain. During a follow-up interview on 5/11/22 at 9:58 a.m. with RN B, she stated that Resident 68…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of one resident (Resident 23) when Resident 23's dialysis site dressing was not removed as ordered. This deficient practice had the potential for the resident to be inadequately assessed and be at risk for complications. Findings: Review of Resident 23's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys no longer functioning in permanent basis) and thrombosis (blood clot) due to vascular prosthetic devices, implants and grafts, subsequent encounter. Review of Resident 23's physician order dated 1/8/21 indicated Resident 23's dialysis days were Tuesdays and Thursdays from 6:15 a.m. to 9:15 a.m. Review of Resident 23's physician order dated 5/8/22 indicated remove dialysis dressing to left arm AV shunt (a…

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

Based on observation, interview and record review, the consultant pharmacist (CP) failed to identify and report the irregular medication orders for two of seven sampled residents (Residents 64 and 84) in the monthly Medication Regimen Review (MRR). This failure resulted in medications not given in accordance with accepted standards of practice and had the potential for not meeting the residents' therapeutic needs or excessive use of medications for the residents. Findings: 1. During a medication administration observation on 5/10/22, at 08:47 a.m., licensed vocational nurse (LVN) J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During medications reconciliation, Resident 64's vitamin D order was: vitamin D tablet (cholecalciferol) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 48 and 13) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. The facility increased Resident 48's Seroquel (an antipsychotic medication) for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) without adequate indication and documentation, and did not monitor the resident's lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) annually while the resident was on two antipsychotic medications. 2. For Resident 13, there was no specific behavior for the use of Seroquel. These failures had the potential for increased risks associated with psychotropic medication use that include but are not limited to sedation, anxiety, agitation, and memory loss. Findings: 1a. A review of Resident 48's clinical…

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

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheet, in May 2022, for one of two medication refrigerators; 2. Two insulin (medication to treat high blood sugar) pens had the pharmacy label on the caps instead of the body of the pens; 3. One opened tuberculin purified protein derivative (PPD, a solution used for tuberculin skin test) multi dose vial, one insulin pen, and an opened insulin vial were without the open date or discard date, to make sure they were not used beyond the discard date; 4. Two residents' expired medications were not removed from stock; 5. One unopened insulin vial was not labeled after removing from the refrigerator; 6. One pharmacy dispensed levetiracetam (medication to treat seizures) bottle was without an expiration date on the pharmacy label; 7. Three diabetisource ac (a tube feeding formula) was unattended on top of a cart in the hallway. The deficient practices had a…

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

Based on observation, interview, and record review, the facility failed to assist and provide emergency dental care for one of two sampled residents (Resident 68). This failure had the potential for Resident 68 to suffer pain. Findings: During an observation on 5/09/22, at 10:20 a.m., in Resident 68's room, she was observed rubbing her left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), CNA F stated that she told the nurse and social services assistant (SSA) of Resident 68's dental pain two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During a concurrent observation and interview on 5/11/22, at 9:52 a.m., with registered nurse B (RN B), in Resident 68's room, she assessed the resident for dental pain using a flashlight. She observed the inside of the…

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

Based on observation, interview, and record review, the facility failed to assure proper infection control practices was followed when: 1. Resident 382's undated used gastrostomy (GT, a surgical opening into the stomach for administration of nutrition and medications) syringe, opened unlabeled one gallon of distilled water were in the resident's room. 2. Resident 90 outdated nebulizer tubing was left on top of the machine. 3. Resident 131's suction machine (a device act or process of sucking) tubing was hanging and touching the floor. Findings: 1. During an observation on 6/4/19 at 9:47 a.m., undated GT syringe was at the bedside of Resident 382. During a concurrent observation and interview with licensed vocational nurse R (LVN R) on 6/4/19 at 9:53 a.m. She confirmed the above observation. LVN R further stated that it should have been dated. During an observation on 6/4/19 at 9:54 a.m., one gallon of opened unlabeled distilled water was in Resident 382's room. During a concurrent observation and interview with the LVN D on 6/4/19 at 9:57 a.m. She confirmed the above 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 observation, interview, and record review, the facility failed to maintain a resident's privacy for two of 25 sampled residents (Residents 382 and 76) when their body was exposed from the waist down and could be viewed outside from the hallway. This failure had the potential to affect Residents 382 and 76's self-esteem and self-worth. Findings: 1. Review of Resident 382's clinical record indicated he had diagnosis of traumatic subarachnoid hemorrhage (bleeding into the space between the surface of the brain) with loss of consciousness, epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), tracheostomy (incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea), gastrostomy (surgery that makes a small opening through the skin into the stomach or intestine) and type 2 diabetes (condition that affects the way the body processes blood sugar (glucose). Resident 382's minimum data set (MDS, an assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an informed consent for psychotropic medication (medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 36). This failure resulted in Resident 36 not being aware of the risks and benefits of taking psychotropic medications. Findings: Review of Resident 36's clinical record indicated she was re-admitted on [DATE] with diagnoses to include major depressive disorder( depression, a persistent feeling of sadness, and loss of interest). Review of Resident 36's physician orders' included Cymbalta (an antidepressant) delayed release 60 milligram (mg., a unit of measure on capsule by mouth one time a day for chronic pain management. Review of Resident 36's clinical record, Resident's Consent for use of Psychotropic Medications, dated 4/15/19, indicated there was no informed consent obtained from the Responsible Party. Resident 36 did not have the capacity to give informed consent. During an interview…

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

Based on observation, interview, and record review the facility failed to notify all pertinent officials, in a timely manner, following an allegation of abuse for one of two residents (Resident 103) when Resident 103 had notified a staff member of her allegation. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse. Findings: During an interview with Resident 103 on 6/3/19 at 9:02 a.m., she stated a certified nursing assistant (CNA) hurt her and put her in a cold shower, because she had a bowel movement and needed to be cleaned up and changed. During an interview with CNA A on 6/3/19 at 9:16 a.m., she stated Resident 103 had told her approximately three months prior about the alleged abuse, but she did not tell anyone. Review of the facility's policy, Abuse Prevention Policy dated 2/23/17, indicated employees and all health practitioners of the facility were mandated reporters. An employee who had knowleged or has been told by an elder or dependent adult that he/sshe experienced behavior…

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

Based on interview, and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for four of four residents (Residents 43, 78, 95 and 106). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred. Findings: 1. Review of Resident 43's situation background assessment recommendation (SBAR, a form of communication used in healthcare settings) dated 4/23/19 indicated he was transferred to an acute care hospital. 2. Review of Resident 78's SBAR dated 3/30/19 indicated he was transferred to an acute care hospital. 3. During concurrent interview and record review with licensed vocational nurse F (LVN F) on 6/5/19 at 9:28 a.m., she reviewed respiratory therapist (RT, specialized healthcare practitioner for patients who have trouble in breathing) notes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) for seven of 25 residents (Residents 8, 61, 104,35,45,125 and 108) when their MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Findings: 1. During an initial tour on 6/3/19 at 8:56 a.m., Resident 8 stated she did not have dentures and showed her teeth. Resident 8 had upper and lower broken teeth. Review of Resident 8's MDS section L (Oral/Dental Status) dated 5/22/19 did not indicate a broken teeth assessment. During concurrent observation and interview with minimum data set coordinator M (MDSC M) on 6/4/19 at 3:42 p.m., MDSC M confirmed the above observation and stated the assessment was inaccurate. He stated the assessment should have reflected Resident 8's broken teeth. Review of Centers for Medicare and Medicaid Services (CMS, a federal agency) Resident Assessment Instrument…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an individualized person-centered comprehensive care plan for four of 25 residents (Residents 35, 43, 32 and 94) when: 1. Resident 35's hand roll intervention was not implemented; 2. Resident 43's care plan was not revised; 3. Resident 32's care plan was not developed for enoxaparin sodium (anticoagulant medication); and 4. Resident 94's care plan was not developed for zolpidem tartrate (sedative-hypnotic medication) and enoxaparin sodium. These deficient practices had the potential for the resident's needs not being met. Findings: 1. During an observation on 6/3/19 at 8:49 a.m., Resident 35's both hands had contractures (a deformity that caused of stiffness or constriction of connective tissues). There was a rolled towel on her left hand but nothing on the her right hand. During concurrent interview and record review with nursing supervisor L (NS L) on 6/7/19 at 11:06 a.m., she reviewed Resident 35's care plan and confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided for three of seven residents (Residents 35, 36, 43, and 107) when the restorative nursing assistant (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented. This deficient practice had the potential to result in residents' decline in range of motion. Findings: 1. Review of Resident 43's June 2019 physician orders did not indicate a RNA program order. During a concurrent interview and record review with licensed vocational F (LVN F) on 6/7/19 at 8:31 a.m., LVN F reviewed Resident 43's situation background assessment recommendation (SBAR, a form of communication used in health care settings) dated 4/23/19. LVN F confirmed Resident 43 was transferred to an acute hospital and returned to the facility on 5/16/19. During an interview with minimum data set coordinator N (MDSC N) on 6/6/19 at 12:58 a.m., he…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented for one of four sampled residents with G-tube (Resident 73). The facility failed to ensure a physician order was followed when the gastrostomy tube was not available for replacement when obstructed. This failure had the potential to delay the nutritional needs and compromise the health of the residents. Findings: Review of Resident 73's face sheet indicated he had diagnoses gastrostomy (a surgical operation for making an opening in the stomach), persistent vegetative state (a disorder of consciousness in which patients with severe brain damage), and diabetes (increase in blood sugar). Review of Resident 73's minimum data set (MDS, an assessment tool) dated 4/12/19, indicated persistent vegetative state, required assistance with bed mobility, dressing, toileting, personal hygiene and bathing. During an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five residents (56 and 125) with behavior problems were adequately monitored. For Residents 56 and 125, the facility did not follow-up on psychiatric services (referral). This failure could potentially affect the residents' highest physical, mental and psychosocial well- being. Findings: 1. Review of Resident 56's clinical record on 6/7/19, indicated he was admitted on [DATE], with diagnoses to include anxiety disorders (feelings of intense, excessive and persistent worry and fear about everyday situations). Review of Resident 56's minimum data set (MDS, an assessment tool) dated 3/29/19 indicated he was cognitively intact and he had verbal behavioral symptoms (i.e. angry outbursts) directed at staff. Review of Resident 56's physician orders' indicated he was on Depakote for mood instability manifested by angry outburst; Duloxetine for depression ( persistent feeling of sadness and loss of interest) manifested by multiple…

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

Based on interview and record review, the facility failed to ensure an accurate accounting of controlled substance (CS) medications (medications with a high risk for abuse and addiction) when random CS medication audits did not reconcile for seven of 19 residents (Residents 36, 37, 41, 59, 60, 88 and 382). This failure had the potential to result in the abuse or the misuse of controlled medications. Findings: 1. During an interview and record review with the director of nursing (DON) on 6/5/19 at 1:50 p.m., she compared the Medication Administration Record (MAR) and the corresponding Controlled Drug Record (CDR) of Residents 36, 37, 41, 59, 60, 88 and 382 for the month of April, May and June 2019. The DON further stated the narcotic medications were not properly accounted for and confirmed the following discrepancies: Resident 36's MAR did not reflect hydrocodone-acetaminophen (pain medication) 5-325 milligram (mg- unit of measure) being administered on 6/3/19 as it was recorded in her CDR. Resident 60's MAR did not reflect lorazepam (anxiety medication) 0.5 mg being administered 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 interview and record review, the facility failed to ensure the residents were free from unnecessary drugs for four of four sampled residents (Residents 128, 59, 36, and 43). Resident 128 who received lorazepam (antianxiety medication) ordered as needed (mg, unit of measurement) had no evidence of documentation the prescribing physician evaluated Resident 128 for the appropriateness of the medication. Resident 59 who received Lurasidone (Latuda) 120 milligram (mg, unit of measurement) daily for paranoid schizophrenia (a mental illness characterized by delusions and hallucinations); Resident 43 who received Risperdone (antipsychotic medication); and Resident 36 who received Cymbalta (antidepressant medication) had no monitoring for side effects every shift as prescribed by the physician. This failure had the potential for the residents to receive unnecessary medication. Findings: 1. Review of Resident 128's face sheet indicated she had diagnoses dementia (memory problem) and hypertension (increase in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were observed during medication administration for one resident (Resident 60). This failure had the potential to compromise the resident's medical health. Findings: Review of Resident 60's physician orders dated 3/5/19, indicated Budesonide Suspension (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) 0.5 milligrams/2milliliters (mg, ml units of measure). 2 ml inhale orally via nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) two times a day for COPD (chronic obstructive pulmonary disease, a lung disease in which airflow is obstructed and interferes with normal breathing). Resident 60's physician order dated 5/27/19 indicated Ipratopium-Albuterol Solution (help control the symptoms of lung diseases) 0.5-2.5(3)mg/3ml. 3 ml inhale orally via nebulizer every 4 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were appropriately stored and labeled during an inspection of two medication rooms and randomly selected medication carts when the following was found: 1. An emergency kit (e-kit, a box containing medication needed for immediate administration) containing injectable (put into the body using a needle and syringe) medications contained expired medications. 2. Medications that required refrigeration were stored inside the medication carts. 3. An injectable medication pen was opened and used with no date. 4. Liquid nutritional supplement was expired. These failures had the potential for the administration of expired or deteriorated medications or biologicals. Findings: 1. During an observation and concurrent interview with licensed vocational nurse B (LVN B) on 6/03/19 at 2:57 p.m., an e-kit containing injectable medications were examined in the medication room shared by Stations 3 and 4. On the outside of…

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

Based on observation, interview, and record review, the facility failed to store and ensure food under sanitary conditions for one of two sampled residents (Resident 94) when resident food brought by a family member (FM) was not properly stored, labeled and dated. This failure had the potential for food borne illness and food contamination. Findings: Review of Resident 94's clinical record indicated, he had diagnoses of morbid (unhealthy state) obesity due to excess calories and tracheostomy (a tube is inserted through a cut in the neck below the vocal cords) status. During an observation on 6/3/19 at 8:33 a.m., Resident 94 was lying on bed with three opened bags of biscuits on the bedside table and an opened bag of a loaf of bread. During an observation and interview with registered nurse J (RN J) on 6/4/19 at 4 p.m., she stated Resident 94 had opened bags of biscuits on the table and an opened bag of loaf bread. RN J stated the food was not properly stored, labeled and dated. During an interview with registered dietitian (RD) on 6/6/19 at 1:19 p.m., he stated the staff should have…

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