Plum Tree Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure (P&P) for pre-admission screening and resident review (PASRR- screening for residents with mental disorder and residents with intellectual disability) screening was completed and submitted for one of two sample resident (Resident 24) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior). This failure had the potential for mentally ill sample resident not to receive benefit from specialized health care and services. Findings: Review of Resident 24 face sheet (FS- a document that gives a resident's information at a quick glance) indicated Resident 24 was initially admitted to facility on 5/21/2023 and re-admitted on [DATE]. Resident 24's FS also indicated diagnoses including anxiety disorder (excessive, persistent worry and fear of everyday situations) dated 1/8/2025, and delusional disorders (a serious mental illness that causes resident can not tell…

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 ensure food was stored and/or prepared under sanitary conditions when an opened bag of hamburger buns past their used-by date was found in the kitchen pantry. This failure had the potential to cause food borne illness. Findings: During an initial kitchen observation and interview on 3/24/25 at 9:12 a.m. with the Dietary Director (DD), an opened bag of hamburger buns containing six buns dated 3/6/25 was found in the dry storage room/pantry. The DD stated, bread could have been stored seven days from the labeled date. The DD also stated, the hamburger buns dated 3/6/25 must be discarded. A loaf of bread with a labeled date of 3/23/25 was also found beside the hamburger buns. The DD pointed at the sticker on the shelf underneath the loaf of bread which indicated Item: Bread Date: 3/23/25 Use By: 3/30/25. The DD verified there was no sticker for use by date for the hamburger buns dated 3/6/25. A review of facility's Policy and Procedure (P&P) entitled, Food Receiving and Storage dated 2001, the P&P 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 interview and record review, the facility failed to provide services according to professional standards of practice for 1 of 2 sampled residents (Resident 1). When staff failed to: 1. Document to keep Resident 1's oxygen saturation (a measure of how much hemoglobin: protein responsible for transporting oxygen, is currently bound to oxygen) greater 90% as prescribed by the physician; 2. Notify the physician regarding Resident 1's change of condition and there was no physician order for transfer to the acute care hospital. These failures had the potential to affect his medical condition and address the residents needs during the transfer to the acute care hospital. Findings: 1. During a review of Resident 1's Order Summary Report dated, 4/24/24, Report indicated, Oxygen: At 3 L/min [liters per minute] via NC [nasal cannula] qs [every shift] to keep 0xygen sats [oxygen saturation] >90%. every shift for sob [shortness of breath]. During a concurrent interview and record review on 5/13/24, at 11:51 a.m., with Director of Nursing (DON), Resident 1's Treatment Administration…

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

Based on observation, interview and record review, the facility failed to implement proper infection control practices for 1 of 2 sampled residents (Resident 2) when Resident 2 ' s oxygen tubing and humidifier was not replaced and labeled according to facility policy. This failure had the potential for Resident 2 to develop an infectious disease from old oxygen tubing. Findings: During a concurrent observation and interview on 5/13/24, at 11:22 a.m., with Registered Nurse (RN) A, in Resident 2 ' s room, Resident 2 was receiving oxygen via oxygen tubing through a nasal cannula (tube that provides oxygen directly to the nose). The oxygen tubing did not have a date when it was last replaced. The humidifier container on the oxygen machine did not have a date on it when it was last replaced. RN A confirmed there was no date on the tubing and no date on the humidifier. She stated licensed nurses should have change and label the date every week. I have no way of knowing how old the tubing is. During a review of Resident 2 ' s Order Summary Report May 2024, report indicated, an order 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 record review, the facility failed to ensure services were provided to meet the professional standard of practice for four out of five sampled residents (Resident 24, 34, 4, and 3) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. Resident 24 had no documentation of apical pulse checks and no pacemaker malfunction monitoring, no pacemaker-related information in the medical records, no medical identification card regarding pacemaker, and no care plan regarding the pacemaker management, 2. Resident 34 had no care plan to manage the pacemaker care; 3. Resident 4 had no medical identification card regarding pacemaker; and 4. Resident 3 had no documentation of pacemaker information. These failures had the potential to compromise those residents' health and safety. Findings: 1. A review of Resident 24's clinical record indicated he was admitted to the facility on [DATE] 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 observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. three personal water bottles were kept in the medication room; 2. unlabeled used medication in the refrigerator; 3. discontinued medications were not discarded. These deficient practices had the potential for unsafe, ineffective and risk the misuse of medications. Findings: During the inspection and observation of the facility's Medication Storage room [ROOM NUMBER] on 11/27/23 at 8:00 a.m., the following were identified: 1. three personal water bottles, one opened and two unopened personal water bottles, were kept in the medication storage room, 2. one used medication in the medication refrigerator, Admelog Solostar (insulin lispro, fast-acting insulin, used to control blood sugar spikes), 100 unit (the concentration of insulin)/milliliter (ml, unit of volume), inject 5 units subcutaneously (beneath or under, all layers of the skin), 3 times daily with meals, discard 28…

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 sanitary conditions were maintained in the kitchen when: 1. Undated and unrefrigerated bottle of sauce in the dry storage area; 2. Dented can in the dry storage area; 3. Two kitchen staffs did not completely cover their hair while handling food; 4. Ice machine had a black substance inside; and 5. Food prep sink drain was too close to the floor drain. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1.During a concurrent kitchen observation and interview on 11/27/23 at 10:53 a.m. with the Registered Dietician (RD), there was a bottle of opened bottle of sauce without an open date in the dry storage area. The food label on the bottle also indicated, refrigerate after opening. The RD confirmed the above observations and stated the bottle was open with no open date. During a review of the facility's policy and procedure (P &P) titled, Food Storage dated 2017, the P&P indicated, When a food package was…

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

Based on observation, interview and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed Vocational Nurse (LVN) B did not remove gloves, sanitize (to reduce or remove pathogenic agents) hands and put on new gloves, after she fixed the plastic liner of the trash can before handing the inhaler to Resident 115, 2. Registered nurse (RN) C did not change gloves, sanitize hands and put on new gloves, after she picked up the pills of Resident 7 that fell on the floor, then discarded them, and administer the new medication pills, 3. Foley catheter bag (bag that is connected to the foley catheter, where the urine that drains through the catheter is collected) of Resident 265 was touching the floor, and; 4. The maintenance supervisor (MS) did not do hand washing upon entering the kitchen. These failures could result in the spread of infection and cross-contamination that could affect the 58 residents residing in the facility. Findings: 1. During the medication administration observation of Resident 115 with licensed vocational nurse B…

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 inform the resident the items and services included in the nursing facility for one of four sampled residents (Resident 45) when Resident 45's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, notice that transfers potential financial liability) was not provided. This failure had the potential in Resident 45 not being informed of his payment responsibilities to the facility after Medicare Part A services ended. Findings: A review of Resident 45's medical record indicated he was admitted to the facility under Medicare Part A on 4/27/2023. The medical record further indicated Resident 45 came off Medicare Part A services on 6/7/2023 but continued living in the facility. A review of Resident 45's SNF Beneficiary Protection Notification Review, filled out by the facility on 11/29/2023, indicated the facility initiated Resident 45's discharge from Medicare Part A services when benefit days were not exhausted (the resident still had Medicare Part A days remaining). The SNF Beneficiary Protection…

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 services were provided to meet the professional standard of practice for two of 15 sampled residents when: 1. Resident 57 refused her medications and the doctor was not notified and; 2. Resident 111 refused her medication and the doctor was not notified. These failures had the potential to jeopardize the residents' health. 1. During the medication administration observation of Resident 57 with licensed vocational nurse B (LVN B), on 11/29/23 at 8:45 a.m., Resident 57 refused two of his medication the juven packet (therapeutic nutrition drink), to give one packet by mouth, once a day for supplement, mix in four to eight ounce (oz, a unit of weight) fluids, and prostat (ready-to-drink concentrated liquid protein medical food), 30 milliliter (ml, unit used to measure capacity) by mouth two times a day for supplement. Review of Resident 57's physician orders, indicated, Resident 57 had an order of juven packet, one packet by mouth, once time a day for supplement, mix in four to eight oz fluids, ordered 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, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 44) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: Resident 44 received Seroquel (an antipsychotic medication) without adequate indication and evaluation for its use. The failure resulted in unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: Resident 44 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and adjustment disorder with depressed mood (an emotional or behavioral reaction to a stressful event or change in a person'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 observation, interview and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of thirty-one opportunities during the medication administration, for one out of eight residents, (Resident 115). These deficient practices resulted in medications not given in accordance with the prescriber's orders, which resulted in the resident, not receiving the full therapeutic effects of the medications and may cause preventable side effects for the resident. Findings: During the medication pass observation on 11/29/23 at 9:54 a.m., with licensed vocational nurse B (LVN B), LVN B was not able to administer two of Resident 115's medications which was the calcium with vitamin D (essential to building strong, dense bones), 600 milligrams (mg, a unit of measurement of mass)-200 units (mesures the biological effects of a substance), 1 tablet daily at 9 a.m., and the latanoprostene bunod (used to lower the pressure inside the eye) 0.024%, 1 drop to both eyes daily at 9…

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 for safe discharge plan to address resident's health and safety needs for one of two sampled residents (Resident 1) when Resident 1's blood glucose monitoring (using a device to automatically estimate blood glucose levels) and insulin (insulin: a hormone controls blood sugars) administration was not address upon discharge to the board and care home (B&C home: a residential house that provides care for a small group of seniors). This failure could potentially affect the Resident 1's health and wellness upon discharge from the facility. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) undated indicated, Resident 1 was admitted to facility on 8/28/2023. Resident 1's FS also indicated, he was admitted with diagnoses including type 1 diabetes mellitus (a disease in which the body does not make enough insulin to control blood sugar levels), hyperglycemia (increased blood sugar levels),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement resident-specific and person-centered care plans for six of 12 sampled residents (Residents 11, 15, 16, 25, 23, and 31). Care plans are the basis for resident care and treatment. Failure to develop and implement resident care plans could contribute to residents' compromised care and complications. Findings: 1. Review of Resident 11's care plans included the following: 1.) Physical mobility needs dated 11/23/21 indicated a goal, The Resident will demo the appropriate use of (SPECIFY adaptive device(s) to increase mobility . 2.) Her ADL (activities of daily living) care plan indicated impaired mobility with transfers related to (SPECIFY), with approaches/tasks that included SIDE RAIL: (SPECIFY) Mobility Bar/Enabler, 1/4 rail(s), 1/2 rail(s), full rail(s) as needed . 3.) The care plan dated 11/30/2021 indicated, The resident has dehydration or potential fluid deficit r/t . 4.) At risk for self-image identification 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 record review, the facility failed to provide pharmaceutical services to meet the needs of residents when: 1. Two of five E kit (emergency kit, a limited supply of medications in the facility for use during emergency or after-hours situations) were opened and were not replaced in a timely manner for a census of 46 residents. This failure had the potential for residents not receiving emergency medications in a timely manner, thereby adversely affecting resident's condition. 2. There were multiple missing entries of licensed nurses' signatures in the change of shift narcotics reconciliation Narcotic Report records for two out of the four medication carts. 3. Staff failed to accurately and timely log in the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications (those with high potential for abuse or addiction) the record for three residents (Resident 6, 19 and 23) in two of four medication carts. These deficient practice resulted in narcotics count discrepancy. Findings: 1. During a tour of Station…

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 properly dispose multiple discontinued medications of discharged residents, opened and expired medications, opened/undated medications in three of four medications carts. This failure had the potential of administering expired medications, and/or incorrectly administering the medications to other residents. Findings: During an inspection of Station 2 medication storage room and concurrent interview with registered nurse B (RN B) on 2/7/2022 at 11:20 a.m., there were discontinued medications for discharged residents found inside the medication refrigerator with the following: 1. Twelve bags of reconstituted (to restore a dried substance to a fluid form that can be used for injection) Cefazolin (antibiotic) 1000 mg (milligrams, unit of measurement) for Resident 144 who was discharged on 12/30/2021. RN B confirmed there were 12 bags and stated the resident was already discharged so this medication should have been disposed right away. 2. One bottle of Lorazepam (antianxiety, controlled medication) 2 mg/ml…

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.

3. During the kitchen tour with dietary supervisor (DS) on 2/9/2022 at 10:13 a.m., the kitchen reach-in refrigerator had the following food items: a. One whipped ricotta cheese and one sour cream in 5 pound plastic containers opened and unlabeled; b. One unlabeled personal drinking bottle; c. One open tomato juice in 1.36 liter carton, prepared date: 1/7/2021. d. One open preserved cherry halves in 4 pound plastic container jar. Prepared date: 4/18/2021. During a concurrent interview with DS, she confirmed the above observation and stated the shelf life for the above food items was thirty days from the time they were opened. She also stated the unlabeled personal drinking bottle belonged to one of her staff. All food items should be labeled to keep track of the expiration date. She acknowledged routine inspection should be done to make sure all food items were current and labeled. The DS also stated that it was everyone's responsibility to ensure the food served to residents were not expired. The facility's 2008 policy and procedure, Refrigerators and Freezers, indicated 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 maintain the dignity for two of 12 residents (Residents 11 and 26) when staff did not close the door and draw the privacy curtains that exposed to public view: 1. Resident 11's bare upper and lower body while lying in bed, and 2. Resident 26's left upper body and chest during rehabilitation treatment. These failures violated the residents' right to dignity and privacy. Findings 1. During the initial tour on 2/7/2022 at 12:45 p.m., Resident 11's door and privacy curtain were open. Resident 11 was lying in bed with no body covering on except her incontinent pad. Resident 11's upper and lower body parts were bare and exposed to staff and visitors who were passing by. This observation was validated by restorative nursing assistant A (RNA A) who came inside Resident 11's room and pulled the curtain to provide privacy. RNA A stated this resident was confused and usually took off her gown and clothes. RNA A also stated the Resident 11's curtain should be pulled to provide privacy to the resident. During an 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 ensure residents received treatment and care in accordance with professional standards for two of 12 sampled residents (Residents 11 and 25) when: 1. Staff did not implement Resident 11's care plan to elevate heels off the bed to help prevent possible skin problems. 2. Staff did not accurately code Resident 25's minimum data set (MDS, an assessment tool) regarding the presence of functional limitation in range of motion on the resident's right lower leg. These failures had the potential for Resident 11 to develop pressure injury and/or skin problems. Accuracy in Resident 25's assessments was important in the development of a care plan with appropriate interventions. Findings: 1. Review of Resident 11's facesheet included diagnosis of pressure ulcer (skin breakdown related to prolonged pressure on a bony area) sacral region (lower back). Her minimum data set (MDS, an assessment tool), dated 11/29/2021 indicated she had short and long term…

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 fall management were implemented for three of 12 sampled residents (Residents 11, 16, and 25) when: 1. Staff did not implement the fall care plan to keep the call light within reach, complete a Fall Risk Review after each fall incident, and ensure Neurological/Vital Signs check were accurately done for Resident 11. 2. Staff did not accurately code the minimum data set (MDS, an assessment tool), implement the post fall care plan for pharmacy consult, and complete a Fall Risk Review after each fall incident for Resident 16. 3. Staff did not ensure the call light was within reach, complete Fall Risk Review after fall incident, develop, update, and implement person-centered and resident-specific fall care plans, and ensure Neurological/Vital sign check was accurately documented for Resident 25. These failures had the could compromise the residents' safety and result in further falls and/or injury. Findings: 1. During an observation on…

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

Based observation, interview, and record review, the facility failed to ensure a resident receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of 12 sampled residents (Resident 17). For Resident 17, a person-centered and resident specific care plan for the access site was not developed and implemented. Also, the licensed nurse did not follow-up and complete the post-hemodialysis assessment and report upon Resident 17's return to the facility and did not report/call the dialysis unit when Resident 17's central catheter (surgically-placed dialysis access inserted in the neck, chest or groin area) was not marked with precautions and had no dressing applied. These failures had the risk of causing Resident 17's health complications. Findings: Review of Resident 17's clinical record indicated Resident 17 had diagnoses including end stage renal disease and dependence on renal dialysis. She had dialysis three times a week on Mondays,…

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 three of 12 sampled residents (Residents 16, 29 and 22) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 16, there were missing informed consents for the use of sertraline (an antidepressant medication) and increased dose of olanzapine (an antipsychotic medication), manifested behaviors were not monitored consistently, and the behaviors monitored by the nurses were not consistent with the resident's behaviors indicated in the care plan. 2. For Resident 29, there was no risks and benefits statement for continued use of Haldol (an antipsychotic medication) and manifested behaviors were not monitored consistently. 3. For Resident 22, there was no gradual dose reduction (GDR) for sertraline and temazepam (a sedative medication used to help a person sleep), manifested behaviors were not monitored consistently, and side effects 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.