Crestwood Manor - 104

Based on interview and record review, the facility failed to ensure services provided met professional standards when facility did not provide drug information resources as reference for nursing staff. This failure could contribute to unsafe use of medication and nursing ability to provide quality care to the residents. Findings: During an interview and concurrent record review on 4/24/25, at 1:54 p.m., Licensed Nurse (LN) 2 stated they did not have drug information resources (a drug book or in computer) to look up how to administer Linzess medication (a prescription medication used to treat complicated constipation). LN 2 further stated she was not aware of manufacturer specification to give Linzess on empty stomach 30 minutes before meals. LN 2 stated she was not aware of a drug information book or online drug information via internet that was used in the facility. During an interview on 4/24/25, at 2:03 p.m., Licensed Psychiatric Technician (LPT) 1 stated it would have been nice if MAR (Medication Administration Record, a record that listed drugs to be administered) had…

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

Based on interview and record review, the facility failed to ensure one resident (Resident 39), in a sample of 39 residents, received accurate post fall and comprehensive fall assessments. This failure potentially resulted in Resident 39's subsequent fall 14 days later, negatively impacting Resident 39's health and well-being. Findings: A review of Resident 39's clinical record titled, admission RECORD, indicated Resident 39 was admitted to the facility with diagnoses which included convulsions (a sudden, involuntary contraction or series of contractions of the muscles, often involving shaking or jerking movements). During a concurrent interview and record review of Resident 39's clinical record, with Licensed Nurse (LN) 3, on 4/25/25, at 9:30 AM, LN 3 confirmed the following clinical documents were filled out incorrectly for Resident 39: Fall Risk Assessment, dated 11/8/24, indicted, in Section H, . PREDISPOSING FACTORS . Seizures . NONE PRESENT . contrary to Resident 39's admission RECORD, which indicated Resident 39 did have a history of seizures. Fall Risk Assessment, 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.

Based on observation, interview, and record review, the facility failed to provide adequate pain management, and develop and implement a resident centered care plan (tool that outlines the plan of action that will be implemented during a resident's care) for 1 of 39 sampled residents (Resident 22) when: 1. The pain management services was not adequately provided to Resident 22; and, 2. The facility did not develop and implement a comprehensive person-centered care plan for pain for resident 22. These failures led to Resident 22 experiencing unnecessary pain that potentially affected his physical and psychosocial well-being. Findings: 1. A review of Resident 22's clinical record, admission RECORD, indicated Resident was admitted to the facility with diagnoses including, but not limited to, chronic embolism and thrombosis (long-standing blood clots in the deep veins of the legs, often causing leg pain and swelling) of unspecified deep veins of lower extremity, bilateral. During an interview in Resident 22's room, on 4/22/25 11:37 a.m., and again on 04/23/25 09:16 a.m., Resident 22…

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 safe medication use practices in three out of 39 sampled residents (Resident 134, Resident 19 and Resident 160) when: 1. Resident 134's long term use of a medication called Protonix (or pantoprazole, belongs to a class of drugs called Proton Pump Inhibitor [PPI], a type of medication that reduces the amount of acid stomach produces) was not re-assessed or evaluated for continued use based on standards of practice and Food and Drug Administration's (FDA, a federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of drugs) risk warnings on long term use of PPI's. 2. Resident 19's and 160's diabetic (a disease of unregulated blood sugar) medication including insulin (medication given as injection under skin to control high blood sugar) use did not have safe monitoring parameters for blood sugar levels changes. These failed practices had potential to contribute to unsafe medication use and affect…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 176. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 32 opportunities which resulted in a facility wide medication error rate of 9.37% in 3 out of 13 residents (Resident 111, Resident 21 and Resident 163) observed for medication administration as follow: 1. Resident 111's eye drop administration did not follow standards of practice on ophthalmic (eye) drug medication administration. 2. Resident 21's Linzess (a medication used to treat bowl motility and promotion of bowel movement) was given after morning breakfast against manufacturer specification to be given before meal and on an empty stomach. 3. Resident 163's Blood Pressure (BP, the force of blood pushing against the walls of arteries 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 safe medication storage and labeling practices in three out of three medication rooms and one out of 4 medication carts when: 1. Unlabeled and discontinued medications were stored in active storage areas in the medication rooms at Station 2 and Station 3. 2. Hazardous (drugs known to pose a health risk to healthcare workers due to their toxic properties upon skin contact) liquid medication with spills on the outer body of the medication bottle was stored in medication cart A at Station 3. 3. The pre-pour medication bins were observed to have sticky looking brownish spills in the top drawer of medication cart B at Station 1. 4. Supplies and discontinued medications were stored under the sink in medication rooms at station 1 and Station 2. 5. The refrigerator temperature upon inspection was above the temperature range listed on the temperature log for Station 2. These failed practices could contribute to unsafe medication use,…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted to return to the facility after Resident 1 was transferred from the facility to an acute care facility (hospital) for stabilization. This failure resulted in Resident 1 being held in a temporary facility (acute care) for five days and not returning to the facility she had been at for nearly nine months, which could have resulted in emotional distress. Findings: A review of Resident 1 ' s clinical record titled, admission Record (a document that contained the resident ' s demographic information), indicated Resident 1 ' s diagnoses included Schizophrenia (a serious mental health condition that affected how people think, feel, and behave) and an anxiety (worried) disorder. A review of Resident 1 ' s clinical record titled, Progress Notes, dated 8/17/24, at 1:00 p.m., by the Psychiatric Technician (PT), indicated Resident 1 showed signs of aggression toward staff and lorazepam (anti-anxiety medication) was administered to Resident 1 via an intramuscular (IM - 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.

Based on observation, interview, and record review, the facility failed to ensure residents received dental services for 2 of 35 sampled residents (Resident 166 and Resident 75), when: 1. Dental services were not provided for Resident 166; and, 2. Dental recommendations were not followed up on for Resident 75. These failures resulted in Resident 166 and Resident 75 not obtaining dental services and had the potential to cause health complications for Resident 166 and Resident 75. Findings: 1. A Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September of 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated he had not been seen by a dentist since being in the facility. Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have…

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

Based on observation, interview, and record review, the facility failed to ensure one unsampled resident (Resident 19) was treated with dignity and respect when Certified Nursing Assistant (CNA) 2 stood over Resident 19 while assisting her with her lunch meal on 5/20/24. This failure had the potential for CNA 2 to miss a choking event and result in a loss of dignity for Resident 19. Findings: During a concurrent observation and interview on 5/20/23, at 12:31 p.m., in the large dining room located in Station one, CNA 2 was standing next to Resident 19 while assisting her with her meal. CNA 2 stated Resident 19 needed assistance and supervison with her meals. CNA 2 confirmed she should have been sitting next to Resident 19 while assisting her with her meal, not standing. CNA 2 stated, I forgot. A review of Resident 19's care plan, revised 3/4/24, indicated, .[Resident 19] has .self-care performance deficit r/t [related to] Dementia [impaired ability to remember, think, or make decisions], left hand contracture [inability to straighten fingers and wrist], and Schizophrenia [affects a…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 35 sampled residents (Resident 141)'s needs were met when his call light was found on the floor and not within reach. This failure could have resulted in a fall, injury, and/or immediate needs not being met for Resident 141. Findings: A review of Resident 141's clinical record titled, admission Record, indicated Resident 141's diagnoses included ataxia (loss of coordination and muscle control in arms and legs - leading to a lack of balance and trouble walking). A review of Resident 141's clinical record titled, Fall Risk Assessment, dated 5/13/24, indicated Resident 141 received a score of 10 (high fall risk), due to factors that included low blood pressure (can cause dizziness), unstable gait (a person's manner of walking), being chair bound, balance problems, required use of wheelchair, and was on medications that increased the risk for falls. During a concurrent observation and interview on 5/20/24, at 10:48 a.m., with the Certified Nursing Assistant (CNA) 1, Resident 141's call light 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 an evaluation or assessment was documented in the medical record for 1 of 35 sampled residents (Resident 75) when the use of a lap buddy (a device used to secure a resident in a seated position in a wheelchair) was initiated on 10/13/21, after multiple falls, without a documented initial evaluation for its use, or documented assessments for continued use of the lap buddy for Resident 75. These failures resulted in Resident 75 never being assessesed for a device that could potentially be a restraint. Findings: During an observation on 5/21/24, at 7:40 a.m., Resident 75 was observed sitting in Station one's large dining room in a wheelchair with a lap buddy secured across her lap. During an observation on 5/22/24, at 4:26 p.m., Resident 75 was observed sitting in Station one's activity room in a wheelchair with a lap buddy secured across her lap. During an interview with Certified Nursing Assistant (CNA) 4 on 5/22/24, at 4:40 p.m., CNA 4 stated Resident 75's lap buddy was used every time she was in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's assessment was completed accurately for one of 35 sampled residents (Resident 166) when Resident 166's comprehensive assessment did not accurately reflect his dental condition. This failure increased the potential for a delay in dental care services. Findings: Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated he had not been seen by a dentist while in the facility. Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have two missing teeth on his left upper jaw, and the first upper tooth (molar) on…

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

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to 1 of 35 sampled residents (Resident 166), when Resident 166 did not have oral hygiene supplies and did not receive oral hygiene from staff. This failure resulted in poor oral hygiene and had the potential to cause health complications for Resident 166. Findings: Review of Resident 166's admission Record indicated Resident 166 was admitted to the facility in September of 2023 with multiple diagnoses including disturbances of salivary secretions (a combination of signs and symptoms associated with a decrease in the secretion of saliva). During a concurrent observation and interview on 5/20/24, at 3:30 PM, Resident 166 stated, while pointing to his upper gum, that two of his teeth were gone and one tooth had something stuck in it. Resident 166's mouth was observed to have two missing teeth on his left upper jaw, and the first upper tooth (molar) on the right side was black and broken. Resident 166 stated it was hard to chew his food and took longer to chew his…

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 2 of 35 sampled residents (Resident 75 and Resident 141) were free from potential accidents and injury when: 1. A fall mat (a soft mat laid on the floor to cushion a fall) was not laid on the floor while Resident 75 was in bed on 5/21/24 per Resident 75's care plan; and, 2. Resident 141's bed side rails (metal rail attached to the sides of the bed that could be used for assistance with repositioning) was left in an unsafe position (sticking out from the bed at the floor level). Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 4 on 5/21/24, at 8:52 a.m., Resident 75 was observed lying in bed asleep with her fall mat folded up and positioned upright next to Resident 75's nightstand. LN 4 confirmed Resident 75's fall mat was not laid out on the floor next to Resident 75's bed and stated the risks for not implementing the fall mat included a fall with injury that could lead to death. During a concurrent interview and record review with LN 1 on 5/23/24, at 10:47 a.m.,…

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 protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on [DATE], which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury. Findings: A review of Resident 1's face sheet (include's the patient's name, address, date of birth , insurance information, diagnoses, and emergency contact information) revealed a diagnosis of schizoaffective disorder, bipolar type (seeing and hearing things that are not reality, depression, and episodes of hyper activity). A review of Resident 1's nurse's progress note, dated [DATE], indicated [Resident 1] attempting to go to the bathroom, demanded roommate to get off the toilet so he could go. [Resident 2] upset and punched [Resident 1] in the face in bathroom both residents share. [Resident 1] had slight bleeding from nose, ice pack applied at nurses station and kept at…

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

Based on observation, interview, and record review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 177 of 177 residents who received food from the facility kitchen, when: 1. One jug of lemonade, one jug of cranberry juice and one jug of tea in the kitchen refrigerator were available for use after the labeled use by date, and one expired bread bag with five whole wheat breads was available to use on the bread rack in the kitchen; 2. Four bags with 12 burger buns in each bag on the bread rack were not dated when taken out of the freezer and 13 boxes with 24 ice cream cups per box in the kitchen freezer were not labeled with a received date and use by date; 3. The kitchen thermometer was not calibrated weekly; 4. Expired test strips were used to test dishwasher solution; 5. Wet dishes were stacked together; 6. The ice machine filter was not changed annually; 7. One sherbet ice cream in the freezer at nurses' station 1, six vanilla ice creams in the freezer at nurses' station 2 and three sherbet…

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 kitchen equipment in a clean and safe manner, when four ovens had baked-on grease and food. This failure had the potential to cause a fire, food contamination and health hazards. Findings: During the initial kitchen tour with Assistant Dietary Services Supervisor (ADSS) 1 on 5/2/23, at 8:51 a.m., double wall ovens and two under range ovens were not clean, had baked-on dark brown grease and food on the racks, oven doors and on the bottom of the ovens. During a continued initial kitchen tour with the Dietary Services Supervisor (DSS) on 5/2/23, at 10:17 a.m., the DSS confirmed all four ovens were not clean and had baked-on grease and food. The DSS stated, That's dirty. The DSS stated ovens were cleaned weekly on Tuesdays. The DSS verified the oven cleaning task was not on the daily cleaning schedule for today (Tuesday). The DSS stated he could not find a cleaning log for the ovens. The DSS stated he did not know when the ovens were last cleaned. During an interview on 5/5/23, at 10:53 a.m., the DSS…

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 acceptable parameters of nutritional and hydration status for 2 of 36 sampled residents (Resident 119 and Resident 174) when: 1. Resident 119's order to be fed by staff and nutritional care plan was not followed; and, 2. Resident 174's fluid intake was not monitored. These failures had the potential to cause further weight loss for Resident 119 and risk for dehydration for Resident 174; with the potential for a decline in each residents' physical health and functional status. Findings: 1. A review of Resident 119's admission Record indicated Resident 119 was admitted to the facility in 2023 with diagnoses which included abnormal weight loss and adult failure to thrive (a decline in adults that involves weight loss, decreased appetite, and poor nutrition). According to the Minimum Data Set (MDS, an assessment tool) dated 4/14/23, Resident 119 required extensive assistance for her activities of daily living including eating. A review of Resident 119's electronic health record, titled, Progress Notes,…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices for a census of 177, when the medication error rate was over 5% (% or percentage was a fraction of a number out of 100) during medication administration. The calculated medication error rate was 10.71%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. 1a. Licensed nurse administered a topical prescription medication to Resident 42 when it belonged to, and was labeled for Resident 70. 1b. Licensed staff pre-poured 10 medications for Resident 54 and: i. documented the administration 40 minutes after it was given, ii. did not follow the doctor's order and manufacturer instruction during medication administration of Zyprexa Zydis (Olanzapine, a mind altering/calming medication) iii. medications names or purpose were not explained to Resident 54. 1c. Licensed staff pre-poured medications for Resident 164 and, i. documented the drug administration 40 minutes after it was given, ii. a sleep…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices when: 1. Expired medications were found in one of three medication rooms (Medication room Unit 2). 2. Multiple unopened injectable medication called Ozempic (diabetic drug in a pen-style injection delivery system) labeled, Refrigerate Until Opened, were stored at room temperature in a storage area in one out of three medication rooms (Medication room Unit 1). 3a. Food items were stored along with medications in three of three medication room refrigerators (located in Unit 1, Unit 2, and Unit 3), where refrigerated ophthalmic (for eyes), oral, and injectable medications were kept in a storage container inside each refrigerator. 3b. Twice daily temperature monitoring was not completed of a refrigerator located in the Director of Nursing (DON) office which contained vaccine products, and the vaccine product temperature was not monitored twice daily. 4. A hazardous liquid medication called valproic acid (a medication used to treat mood and seizure) was stored in two out 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 treat one of thirty six sampled residents (Resident 174) with dignity and respect when his request for drinking fluids was not honored. This failure had the potential to cause emotional distress and dehydration for Resident 174. Findings: Review of the admission Record indicated Resident 174 was admitted to the facility in 2022 with multiple diagnoses including abnormalities of gait and mobility. During a concurrent observation and interview on 5/2/23 at 10:42 a.m., Resident 174 stated one of his concerns was not getting enough fluids to drink. There was no water or fluid available at his bedside. During an interview on 5/3/23 at 8:42 a.m., Licensed Nurse (LN) 12 stated water pitchers were not kept at residents' bedsides due to behaviors and safety risk. LN 12 stated water was available at the nurses' station and was provided to the residents upon request. LN 12 added residents were provided fluids with meals and nourishments each shift. LN 12 further stated fluids were also offered to residents during…

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 daily quality control monitoring was completed for one of three glucometer devices in facility's Station 3. This failure had the potential for a resident to receive an inaccurate blood glucose test result and an incorrect amount of blood glucose medication. Findings: During concurrent observation and interview on 5/4/23, at 11:32 a.m., in Unit 3 hallway, Licensed Psychiatric Technician (LPT) 2 received permission to enter Resident 96's room for a scheduled blood glucose test (a measurement of blood sugar). LPT 2 used a lancet (a small device with a sharp point used to sample blood from a finger) to obtain a blood sample from Resident 96. LPT 2 then used a test strip (a small disposable plastic strip used to collect a drop of blood) to collect the blood sample from Resident 96's finger. LPT 2 inserted the strip into the glucometer (a small handheld device that measures blood sugar levels), and stated the glucometer was not working properly. LPT 2 stated she would return to the Unit 3 medication room and…

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

Based on interview and record review, the facility failed to ensure high-risk blood thinning medication (medications with bleeding risk) monitoring was completed on a daily basis for two of the five sampled residents (Resident 33 and Resident 69). This failure had the potential to result in undetected adverse effects that could occur when blood thinning medications were administered. Findings: 1. During a review of Resident 33's medical record, titled Medication Administration Record (or MAR, a legal document in medical records that listed medications use and monitoring), dated 5/2023, the MAR indicated Resident 33 received apixaban (also known as Eliquis, a blood thinning medication) 2.5mg (mg-a unit of weight) by mouth two times per day for DVT (Deep Vein Thrombosis, or blood clot) since 2/1/23. Further review of the MAR did not show any apixaban side effects (or adverse effect of the blood thinner medication such as bleeding or bruises) to watch for, or documentation of monitoring performed. During a review of Resident 33's care plan (a document containing a record of health…

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 a safe and sanitary environment for a census of 177 when water drainage (the system or process by which water or other liquids are drained from a place) from the washing machines was overflowing into the laundry area. This failure had the potential for clean laundry to be contaminated and increased the risk of infection for residents in the facility. Findings: During a concurrent observation and interview on 5/4/23, at 10:58 a.m., with the Laundry Aide (LA) in the laundry area, the LA confirmed water was overflowing from the drainage area behind the running washing machines. The LA stated water overflowed from the drainage when all three washing machines were running at the same time. The LA further stated water overflow was happening every day and laundry staff was mopping the floor two to three times a day. LA explained the maintenance supervisor was aware of the overflow. During a concurrent observation and interview on 5/4/23, at 1:49 p.m., the Maintenance Supervisor (MS) confirmed water 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.