Good Samaritan Rehab And Care Center

Based on observation, interview, and record review, the facility failed to provide accurate administration of medication for 1 out of 16 residents (Resident 62) observed during medication administration when, Resident 62's medication was given when her vital signs were outside of prescribed parameters. This failure had the potential for Resident 62 to experience an adverse reaction to her prescribed medication. Findings: A review of Resident 62's admission RECORD indicated that Resident 62 was admitted to the facility with diagnoses which included cerebral infarction ( a result of disrupted blood flow of the brain due to problems with the blood vessels that supply it, also known as stroke) and hypertension (a condition in which the force of blood pushing against the blood vessel walls is consistently too high which causes the heart to work harder to pump blood). During an interview and concurrent medication administration observation with Licensed Nurse (LN) 7 on 2/19/25, at 4:15 p.m., LN 7 checked Resident 62's blood pressure and obtained a reading of 102/57. LN 7 then administered…

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 and medical supplies storage in the medication cart, treatment cart, medication refrigerator, and the medication storge room for a census of 81 when: 1. Staff beverages, and staff belongings were stored in the medication storage rooms; 2. The medication refrigerator in the medication storge room which contained narcotics was not locked; 3. Expired medications and opened unlabeled medications were stored in the medication cart; 4. Multi-use wound care irrigation solutions in the treatment cart were opened but not dated; 5. Expired single use wound care ointment and cream, expired multi-use wound care ointments, and expired wound dressing material were stored in the treatment cart; and, 6. A single use sterile dressing in the treatment cart was opened but not discarded. These failures could contribute to unsafe medication use, storage, and medication errors that could affect the well-being of the facility's vulnerable elderly residents. Findings: During a concurrent 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.

Based on interview and record review, the facility failed to provide Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as message, heat treatment, and exercise) and Occupational Therapy (OT- treatment that helps improve the ability to perform daily tasks) services to one of twenty one sampled residents (Resident 81), when Resident 81 did not receive a PT/OT evaluation and treatment as ordered. This failure had the potential for Resident 81 not to attain, maintain, or restore his highest practicable level of physical, mental, functional, and psycho-social well-being. Findings: A review of Resident 81's admission RECORD indicated Resident 81 was admitted to the facility with diagnoses which included generalized muscle weakness, repeated falls, and other symptoms and signs involving cognitive functions and awareness. A review of Resident 81's physician orders dated 1/10/25, indicated Resident 81 had orders for OT Evaluation and Treatment as indicated and PT Evaluation & Treatment as indicated. Further review of Resident 81's record failed to…

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

Based on observation, interview, and record review, the facility failed to maintain and obtain complete medical records for 1 out of 21 sampled residents (Resident 72), when Resident 72's medical record did not contain progress notes from the primary care provider. This failure resulted in an incomplete reflection of Resident 72's progress toward achieving her person-centered plan of care and potentially resulted in insufficient information for the staff to facilitate communication among the interdisciplinary team that provided care for Resident 72. Findings: During an observation on 2/18/25 at 11:23 AM, Resident 72 was observed scratching her chest and upper extremities. During an interview on 2/19/25 at 10:45 AM, License Nurse (LN) 5 stated that Resident 72 was under the care of an outside primary care provider who was treating her and prescribing her medications. A review of Resident 72's medical record failed to show progress notes from her outside primary care provider. During a concurrent interview and record review, on 2/20/25 at 4:04 PM, Resident 72's medical records 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 interview, and record review, the facility failed to provide evidence of the ongoing efforts of a Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach used to continuously identify opportunities for improving the overall quality of life and quality of care and services to nursing home residents) program/plan for a resident census of 81. This deficient practice had the potential for the facility to miss efforts to identify, report, investigate, analyze, and prioritize identified concerns in the facility. Findings: During an interview with the Administrator (ADM) on 2/18/25 at 1:15 PM, the ADM stated she would provide the QAPI documents as requested that morning during the Entrance Conference held at 9:17 AM. During a concurrent interview and record review on 2/18/25 at 5 PM, with the ADM, the Entrance Conference Worksheet, dated 10/23 was reviewed.The Entrance Conference Worksheet indicated, QAPI plan was listed on the worksheet under the heading INFORMATION NEEDED FROM FACILITY WITHIN FOUR HOURS OF ENTRANCE and the worksheet was provided…

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 an environment free from the risk of infection for a census of 81 when staff refilled an empty soda bottle from the water dispenser at Nurse Station #3 with the water dispenser spout touching the mouth of the soda bottle. These failures resulted in the potential for the spread of infection to residents, visitors, and staff in the facility. Findings: During a concurrent observation and interview, at Nursing Station #3, on 2/18/25, at 3:45 p.m., Medical Records Assistant (MR) 2 filled an empty plastic soda bottle with water from the resident water dispenser with the bottle mouthpiece touching the spout of the resident water dispenser. MR 2 confirmed that she refilled the empty plastic soda bottle with water from the resident water dispenser at the nurses' station with the mouth of the bottle touching the spout of the resident water dispenser. MR 2 stated that it was not acceptable to refill the soda bottle from the resident water dispenser with the mouth of the empty plastic soda bottle touching 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 interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program that includes a set of practices to ensure antibiotics are used appropriately) was followed for one of two sampled residents (Resident 42) on an antibiotic when: 1. Resident 42 developed signs and symptoms of a Urinary Tract Infection (UTI-an infection of the urinary system) and the facility's ANTIBIOTIC STEWARDSHIP GUIDELINE (a set of rules for identifying infections in long-term care facilities) used as part of ASP was not initiated for Resident 42; 2. The Infection Preventionist (IP) was not aware Resident 42 was prescribed antibiotics and did not add Resident 42 to the ANTIBIOTIC STARTS TRACKING log, the MONTHLY SURVEILLANCE REPORT FORM, or the ANTIBIOTIC LOG; and 3. An antibiotic time-out (an active reassessment of an antibiotic prescription 48-72 hours after the medication's first dose) was not done for Resident 42. These failures had the potential to contribute to unsafe antibiotic use and monitoring in the facility for a census of 81 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 that one of three sampled residents (Resident 1) was provided dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) care and services consistent with professional standards of practice when: 1. Resident 1 was unable to attend his scheduled dialysis session and his make-up dialysis session due to transport being unavailable; and, 2. Resident 1's monthly labs from the dialysis center were not available in Resident 1's medical record. The failure of unavailable transportation led to a delay in dialysis care for Resident 1 with a potential to alter Resident 1's health status. The failure to include Resident 1's labs in his medical record had the potential for a lapse in Resident 1's care between the facility and the dialysis center. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2022 with diagnoses that included hypertension, end stage renal disease (chronic…

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 practices in handling hazardous medications (Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) during storage and medication administration with a resident census of 79. The unsafe handling of hazardous medications could pose a health risk to staff and residents. Findings: 1. During a medication administration observation with Licensed Nurse (LN) 5, on 3/4/24, at 8:44 AM, at Hallway 3, LN 5 administered Resident 33's medication, in pill form, called valproic acid (or Depakote, used to treat seizure or used for mental issues) without using any gloves during preparation or administration of the medication. During a review of Resident 33's Medication Administration Record (or MAR, where nursing staff look at doctor's order during medication administration), dated 3/2024, the MAR did not have any instruction on how to handle the medication during pouring and administration related to hazardous drug handling. 2. During a medication administration observation 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.

Based on interview and record review, the facility failed to ensure one of 21 sampled resident's (Resident 28) pain was managed, when the facility did not notify the physician of Resident 28's severe pain, and treated Resident 28 with a medication ordered to manage mild to moderate pain. This failure resulted in Resident 28 experiencing unmanaged pain for long periods of time. Findings: During a review of Resident 28's clinical record titled, admission Record (a document that contains the resident's demographic information), the record indicated Resident 28's diagnoses included paralysis (inability to move the body) affecting the left side of the body following a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts - causing parts of the brain to die). During an interview with Resident 28 on 3/6/24 at 1:38 p.m., Resident 28 stated his left leg was in pain. Resident 28 stated his left leg was crushed during the Vietnam War. Resident 28 stated it made him feel like a little kid when the facility would not give him the…

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

Based on observation, interview, and record review the facility failed to ensure prescribed medication unavailability was communicated to the medical doctor and failed to ensure vital medications were available for administration for two residents (Resident 43 and Resident 80), in a sample of 21, when: 1. Anxiety and narcotic pain medications were not available for administration for Resident 43 with Post Traumatic Stress Disorder (PTSD); 2. Insulin (medication in shot form to treat high blood sugar level) was not available for Resident 80 with a diabetic (blood sugar disease) diagnosis. These failures had the potential to negatively impact Resident 43 and Resident 80's health and well-being. The facility also failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications based on standards of practice for a resident census of 79 when: 3. Pharmaceutical waste (discontinued or no longer needed drugs) including prescription and narcotic (drugs with potential for abuse) medications were not rendered unusable when disposed…

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 and labeling practices were based on standards of practice with census of 79 when: 1. The Emergency Kit (or Ekit- a supply of products for use when urgently needed) for IV (Intravenous, into the vein) medications was not labeled with a list of items or the earliest beyond use date (or expiration date) in medication room at Station 3. 2. Expired hand gel (a liquid gel for hand sanitization) bottles were stored in the active storage area in the medication room at Station 3. 3. Undated and opened medication container was stored in the unlocked refrigerator at Station 3's medication room where staff's personal bags were stored at the same time. 4. Undated, unsecured, and opened medication containers were stored in the medication room at Station 1 including the unlocked refrigerator where food items were stored along side medications. 5. Unlabeled and undated medications were stored in the active storage areas in medication cart 2, medication cart 3 and and treatment cart 2. These…

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 3. During an interview on 3/7/24 at 11:40 a.m., the Administrator stated the facility did not have a policy and procedure for the required water management program. During an interview on 3/7/24 at 12:00 p.m., the Administrator stated she had worked at the facility for more than 10 years and there had never been a water management program at all during that time. During an interview on 3/7/24 at 12:05 p.m., the Infection preventionist stated the facility not having a water management program placed residents at risk for water borne illnesses. According to a memo released by the Centers for Medicare and Medicaid Services (CMS) to all healthcare facilities, dated 7/6/18, and titled, Requirement to Reduce Legionella [bacteria that can cause serious lung infections] Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), the memo indicated, . Legionella can cause a serious type of pneumonia [lung infection] .Those at risk include persons who are at least [AGE] years…

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 Physician's Orders for Life Sustaining Treatment (POLST- a written physician's order that documents the types of medical treatment the resident wants to receive during serious illness, for example, chest compressions if the heart stops beating and/or a tube placed down the throat if breathing stops) was fully completed and/or uploaded to the resident's Electronic Health Record ([EHR]- information stored in the facility's computer system) per facility policy for 1 of 21 sampled residents (Resident 64). This failure had the potential for a delay in treatment for Resident 64 during a medical emergency and/or the incorrect life sustaining treatment administered to Resident 64. Findings: A review of Resident 64's medical record titled, admission Record, indicated Resident 64 was admitted to the facility with diagnoses which included diabetes (problems with blood sugar) and dependence on renal dialysis (a procedure to remove waste products 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 2 of 21 sampled residents (Resident 75 and Resident 81) received care and services safely when Resident 75 and Resident 81 were unable to open bathroom door #7. This failure led to feelings of entrapment (caught, trapped or entangled) and the inability to maintain independence with Activities of Daily Living (ADL - examples: toileting, shaving, brushing teeth). Findings: a. During a review of Resident 75's clinical record titled admission Record, (a document that contains the resident's demographic information), the record indicated Resident 75's diagnosis included muscle weakness. During an interview with Resident 75 on 3/5/24, at 10 a.m., Resident 75 stated she had not been able to open hallway bathroom door #7 by herself because the door was too heavy. A review of Resident 75's clinical record titled Minimum Data Set Section GG Functional Abilities and Goals, (MDS - an assessment tool utilized for facilitating care management 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 interview, and record review, the facility failed to develop and implement psychotropic (mind altering medications often used to treat mood disorder, anxiety, or depression) and high-risk medication (medication known to cause serious harmful effect due to nature of the product) care plans (a component of care that outlines nursing care to provide coordinated and resident specific care to improve overall health and ensure appropriate nursing actions) for 3 out of 21 sampled residents (Resident 80, Resident 57, and Resident 28) when: 1. Resident 80's psychotropic medication use was not care planned for the licensed staff to monitor the progress and use of the two medications called duloxetine (also known as Cymbalta mind altering medication used to treat depression) and cariprazine (also known as Vraylar, a mind-altering drug used to treat mood disorder), 2. Resident 80's blood thinner medication (by thinning the blood , the medicine could cause bleeding and at the same time prevented blood clot formation, heart attack or stroke) use was not care planned for the licensed…

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 a safe environment, and adequate supervision for one of four sampled residents (Resident 72) when: 1. Resident 72's fall risk assessment was not completed accurately and fall interventions were not updated after Resident 72 experienced multiple falls in February of 2024; and, 2. Resident 72 eloped (leaving) from the facility on 1/29/24, without staff being aware until they were contacted by the police department. These failures may have contributed to Resident 72's recurrent falls and the potential for serious injury, negatively effecting Resident 72's health and well-being. Findings: 1. During a review of Resident 72's clinical record titled, admission Record, (a document that contains the resident's demographic information) indicated Resident 72's diagnosis included epilepsy (a brain disorder that leads to involuntary movements), Merrf syndrome (a syndrome that results in brief, sudden, jerking muscle movements, impaired ability to coordinate movements), and muscle weakness. During an observation on…

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

Based on observation, interview, and record review, the facility failed to follow the Physician's orders for one of 34 residents receiving supplemental (additional) oxygen (Resident 80). This failure resulted in Resident 80 receiving over twice the ordered amount of supplemental oxygen and could have led to injury due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - long term inflammatory lung disease that causes obstructed airflow from the lungs and too much oxygen could cause a person to lose their drive to breathe). Findings: During a review of Resident 80's clinical record titled, admission Record (a document that contains the resident's demographic information), the record indicated Resident 80's diagnosis included COPD and asthma (chronic lung disease that can cause coughing, wheezing, and shortness of breath). A review of Resident 80's clinical record titled, Physician Orders, dated 1/17/2024, indicated Resident 80 had a physician's order for supplemental oxygen at 2 Liters (L) via nasal canula (device that delivers extra oxygen through a tube and into the…

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

Based on observation, interview, and record review, the facility failed to apply appropriate siderails for 1 of 21 sampled residents (Resident 63), when Resident 63 was ordered half siderails but was found with two full bed siderails in use. This failure had the potential to cause restricted exiting from the bed, increased risk of injury, increased depression, and entrapment. Findings: A review of Resident 63's medical document titled, admission Record, indicated Resident 63 was admitted to the facility with diagnoses which included post-traumatic stress disorder (PTSD - a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), and depression. During an observation in Resident 63's room, on 3/5/24, at 9:51 AM, Resident 63 was lying in bed with her eyes open. Resident 63's bed was equipped with full siderails bilaterally (on both sides of the bed) which were up at the time of the observation. Resident 63 was non-interviewable. During an observation in Resident 63's room, on 3/6/24, at 3:15 PM, Resident 63 was lying in bed…

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

Based on interview and record review, the facility failed to monitor the adverse effects of high-risk medications (medication known to cause serious harmful effect due to nature of the product) in two out of five residents (Resident 80 and Resident 57) sampled for unnecessary drugs when: 1. Resident 80's blood thinner medications (by thinning the blood , the medicine could cause bleeding and at the same time prevent blood clot formation, heart attack or stroke) was not monitored for adverse effects of apixaban (also known as Eliquis, drug used to prevent blood clot by thinning the blood), ticagrelor (also known as Brilinta, drug used to thin the blood to prevent stroke or heart attack) and naproxen (also known as Naprosyn, a pain medication known to have bleeding side effects) with a known adverse bleeding side effects per manufacturer drug information; and, 2. Resident 57's blood thinner medication was not monitored for adverse effect of clopidogrel (also known as Plavix, drug used to thin the blood to prevent stroke or heart attack) and aspirin (a drug often used for prevention of…

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

Based on interview and record review, the facility failed to develop and implement psychotropic (mind altering medications often used to treat mood disorder, anxiety, or depression) medication side effect and behavior monitoring in one out of five sampled residents (Resident 80) when Resident 80's duloxetine (also known as Cymbalta mind altering medication used to treat depression) and cariprazine (also known as Vraylar, a mind-altering drug used to treat mood disorder) were not monitored based on manufacturer instructions and standards of practice. This failure could have contributed to unsafe medication use and contribute to lack of progress in Resident 80's mental health care. Findings: During a review of Resident 80's medical record titled, Order Summary Report dated 3/2024, the record indicated the following mind-altering medication orders: Cariprazine HCl Oral Capsule 1.5 MG [or Vraylar, MG is milligram a unit of measure]; Give 1 capsule by mouth one time a day related to ANXIETY .Start Date: 2/27/24. DULoxetine HCl Oral Capsule . 60 MG [or Cymbalta]; Give 1 capsule by mouth…

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, staff interview, and document review, the facility failed to store food in a sanitary manner when containers of left over food in the refrigerator were found not fully covered, undated, and unidentified. These failures placed residents at risk of being served spoiled, outdated food and/or contribute to foodborne illness. Findings: During a concurrent observation and interview on 3/5/19, at 8:05 a.m., a walkthrough of the kitchen was conducted with the facility's cook. When the walk-in refrigerator was entered, a container of gravy, soup, and partly covered containers of prepared food were found to be undated and unidentified. When the cook was asked what the food was and how long it had been there, she said it was stewed pork with vegetables from yesterday. In a subsequent interview and review of the week's menu for the past 3 days, the facility's registered dietician (RD) verified, pork with vegetables was not found as a resident food item in the lunch or dinner menus. The cook was then asked further about the left over food; she declared the food had been…

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 their infection prevention program for 5 residents (Resident 38, Resident 71, Resident 46, and 2 unknown residents) out of a census of 89 when: 1. Certified nurse assistant (CNA) 4 did not perform hand hygiene after contact with Resident 5 before she picked up Resident 71's plate and bowl and assisting Resident 38 with her meal; 2. CNA 6 did not perform hand hygiene after picking food up off the floor and before assisting two unknown residents out of the dining room; 3. Licensed nurse (LN) 8 and CNA 9 did not perform hand hygiene after contact with Resident 46. These failures placed Resident 38, Resident 71, Resident 46, and two unknown residents at risk for the spread of infection. Findings: 1. During a dining observation in the activity room on 3/5/19, at 12:20 p.m., CNA 4 assisted Resident 38 with her meal when Resident 5, who was seated at a different table, pounded his fist on the table, and yelled at Resident 71 who was trying to grab his (Resident 5's) dessert. CNA 4 got up, walked to…

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

Based on observation, interview, and policy review, the facility failed to ensure personal privacy for three of 27 sampled residents (Resident 25, Resident 46, and Resident 142) when the privacy curtain or window curtain was not pulled while personal care was being provided. This failure resulted in Resident 25, Residents 42, and Resident 142's privacy not being protected. Findings: a. Resident 142 was a long-term resident of the facility. During a concurrent interview and observation on 3/5/19, at 9:15 a.m., Resident 142 was observed lying in bed, naked, while certified nurse assistant (CNA) 1 provided incontinent care. Resident 142 resided in the B bed, next to the window. The privacy curtain between the A bed and B bed had been pulled, however, neither the privacy curtain on the other side of Resident 142's bed or the window curtain was pulled. While standing at the foot of Resident 142's bed, a car was observed driving past the unblocked window. CNA 1 stated she should have pulled the privacy curtain or pulled the window curtain. b. Resident 46 was admitted to the facility 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 the Minimum Data Set (MDS, an assessment tool) and the Joint Mobility Assessment accurately reflected one of 27 sampled resident's (Resident 33) condition. This failure had the potential for Resident 33 to receive inadequate care. Findings: Resident 33 was admitted to the facility with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movement). On 3/5/19, at 10:40 a.m., Resident 33 was observed in bed. Resident 33 had contractures (deformity and rigidity of joints) on both upper extremities and on her right lower extremity. Three splints were observed on Resident 33's wheelchair at the bedside. A review of an MDS and a joint mobility assessment dated [DATE] were not consistent. The MDS showed Section G (Functional Status assessment) G0400A Upper extremity (shoulder, elbow, wrist, hand) and Section G0400B Lower extremity (hip, knee, ankle, foot) were coded as 0, which 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 develop a comprehensive smoking care plan (CSCP) for one of 27 sampled residents (Resident 53). This failure had the potential to not provide a plan for safe and person centered care for Resident 53. Findings: Resident 53 was admitted with diagnoses which included altered mental status. In an interview on 03/05/19, at 10:21 a.m., Resident 53 stated, he was admitted to the facility as a smoker. When asked how often he smoked a day, Resident 53 stated, I smoke four times a day by myself. During an observation on 3/6/19, at 4:30 p.m., Resident 53 was seen sitting in a wheelchair smoking in the facility designated smoking area. Review of Resident 53's clinical record showed no evidence that a CSCP was developed. In an interview and concurrent record review on 3/7/19, at 7:41 a.m., licensed nurse (LN) 6 confirmed Resident 53 was a smoker and a CSCP was not developed. LN 6 stated she could not find a CSCP in Resident 53's clinical records. LN 6 added the CSCP should have been developed to ensure Resident 53 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 provide measures to prevent further decrease in joint mobility as ordered by the physician for one (Resident 33) of 27 sampled residents when splints were not applied per physician's order. This failure had the potential to place Resident 33 at risk to develop further decrease in range of motion. Findings: Resident 33 was admitted to the facility with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movement). On 3/5/19, at 10:40 a.m., Resident 33 was observed in bed without a splint or a brace on. Resident 33 had contractures (deformity and rigidity of joints) on both upper extremities and on her right lower extremity. Three splints were observed on Resident 33's wheelchair at the bedside. In a subsequent observation on 3/5/19, at 2:34 p.m., Resident 33 remained in bed without a splint on. In a concurrent interview and record review on 3/5/19, at 2:43 p.m., restorative nurse assistant (RNA) 1 explained she applies Resident 33's right knee and bilateral arm…

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 an environment that is free from accident hazards for two of 27 sampled residents (Resident 46 and Resident 53) when: 1. Resident 46's care plan for padded siderails was not implemented. This failure had the potential for Resident 46 to sustain an injury during seizure activity. 2. Resident 53's Smoking Data Collection and Assessment (SDCA-an assessment tool) was not completed. The SDCA was used to determine the resident's ability to smoke safely. This failure had the potential for Resident 53 to receive inadequate supervision to smoke safely. Findings: 1. Resident 46 was admitted to the facility with diagnoses which included seizure disorder. Resident 46 used siderails in bed for bed mobility. On 3/7/19, at 9:15 a.m., Resident 46 was observed in bed with both siderails up and not padded. In a review of Resident 46's clinical record, a care plan for safety during seizure activity, dated 10/7/18, indicated Resident 46's siderails should be padded. In an interview with the director of staff development…

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 aspiration (breathing in food or liquid into the airway) precautions for one (Resident 46) of 27 sampled residents when Resident 46's bed was flat during tube feeding (nutrition administered through a tube inserted through the abdomen). This failure placed Resident 46 at risk for aspiration pneumonia (inflammation or infection of the lungs caused by aspiration). Findings: Resident 46 was admitted to the facility with dysphagia (difficulty swallowing). Resident 46 received tube feeding via a tube feeding pump. On 3/5/19, at 10:05 a.m., Resident 46 was observed in bed with the tube feeding infusing via pump at 75 milliliters (ml, unit of measure) per hour. Resident 46's head of bed (HOB) was flat. Certified nurse assistant (CNA) 4 was at the bedside providing care to Resident 46. In a concurrent interview with CNA 4, CNA 4 stated she just put Resident 46's HOB down to provide care. When asked if Resident 46's tube feeding was on, CNA 4 replied, Yes. I put her [HOB] up right away when I'm done…

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 qualified staff provided oxygen (O2) therapy for one (Resident 55) of 27 sampled residents when certified nurse assistant (CNA) 8 turned on Resident 55's O2 concentrator (device that concentrates the oxygen from the air). This failure placed Resident 55 at potential risk of receiving an incorrect amount of O2 which can lead to respiratory distress. Findings: Resident 55 was admitted with diagnoses which included chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). During a concurrent interview and observation on 3/5/19, at 11:15 a.m., Resident 55 was seen lying in bed wearing a nasal cannula (NC-a tubing or device that is placed in the nostrils to deliver supplemental oxygen). The NC was attached to the O2 concentrator next to Resident 55's bed. The O2 concentrator was noted to be off and the O2 indicator gauge was at a 0. When asked if she could feel the air from the O2 concentrator, Resident 55 stated, No. During a continuous 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.

Based on observation, interview, and medication warning label review, the facility failed to safely store medications for one resident (Resident 68) out of a census of 89 when Calmoseptine ointment (skin ointment used to prevent and heal skin irritation) was found on top of Resident 68's bedside table. This failure had the potential for accidental ingestion of a harmful substance by a resident. Findings: On 3/5/19, at 9:49 a.m., two clear, plastic 30 milliliters (ml, unit of measure) cups with light pinkish ointment in them were observed on top of Resident 68's bedside table. In a concurrent observation and interview on 3/5/19, at 9:51 a.m., licensed nurse (LN) 6 went inside Resident 68's room, picked up the two plastic cups of ointment, and brought them outside the room. LN 6 said, I'm not sure what it is. In a concurrent observation and interview with the director of staff development (DSD) on 3/5/19, at 9:53 a.m., LN 6 showed the DSD the two cups of ointment. The DSD said, I'm not sure if it's ok to be at bedside. In an interview with LN 3 on 3/5/19, at 9:55 a.m., she looked 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.