Riverwood Health Care

Based on observation, and interview, and record review, the facility failed to ensure that staff treated residents with dignity and respect for 1 of 24 sampled residents (Resident 40) when staff referred to Resident 40 as a feeder during care, rather than addressing the resident by name or in a manner that upheld his dignity. This failure had the potential to demean Resident 40, negatively impact his self-esteem, and compromise Resident 40's right to be treated with dignity and respect. Findings:During a review of Resident 40's admission RECORD, indicated Resident 40 was admitted to the facility with multiple diagnoses including dysphagia (difficulty swallowing) and anxiety disorder (a condition in which a person has excessive worry, feelings of fear, dread, and uneasiness).During an observation on 9/9/25, at 11:59 a.m., in Resident 40's room, Certified Nursing Assistant (CNA) 3 was observed helping CNA 2 to provide care to Resident 40. CNA 3 stated to CNA 2, He [Resident 40] is a feeder now? During an interview on 9/9/25, at 12 p.m. with CNA 3, CNA 3 stated that staff should not…

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 safe storage and use of a resident's personal medication for 1 of 14 residents observed during a medication pass (Resident 102) when over the counter medications (OTC, a medication that can be obtained without prescription) and supplements (pills that provide nutrients like vitamins, minerals and herbs that may be missing from a person's daily food intake) were found at Resident 102's bedside without a physician's order.This failure had the potential to result in unsafe and/or unauthorized use of OTC medications and/or supplements that could have resulted in illness or injury to Resident 102 and/or other residents in the facility. Findings:During a concurrent observation and interview on 9/9/25, at 12:15 p.m., with Licensed Nurse (LN) 1, the following OTC medications and supplements were found at Resident 102's bedside:Two yellow capped bottles of a product labeled as Sualin, Natural cough and Cold Remedy, contained three…

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 the protection of residents' personal information for a census of 81 when licensed nurse (LN) 8 left residents personal medical information unattended on the computer screen visible to anyone who walked by in the facility's dining room.This failure had the potential for misuse of residents personal information including identity theft. Findings:During a concurrent observation and interview in the facility's dining room on 9/9/25 at 12:15 PM, a computer was observed unattended with a residents medical information visible. Once LN 8 returned, they closed the computer and stated prior to stepping away from the computer the lock screen button should have been pressed to protect the residents privacy. LN 8 stated the purpose of locking the screen was to protect the resident's information from anyone accessing it who was not authorized. LN 8 stated that not protecting the residents health information places them at risk for identity theft.During an interview with the Director of Nursing (DON) on 9/12/25 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 ensure safe medication storage practices in two of four Medication carts (a mobile cart that holds patient medications and supplies), in one out one treatment carts (a mobile cart that holds medical and wound treatment supplies) and in one out of one medication rooms (a locked room used to store medications and supplies) with a resident census of 87 when:1.Medication cart in hallway #2 stored an undated Humalog insulin pen (drug used for blood sugar disease in a pen shape product) 2.Main medication room stored two opened vials of Aplisol (same as Tuberculin Purified Protein, use to test for TB, or tuberculosis, a serious lung infection) which was not dated when it was first opened. The medication room stored an opened and undated eye drop bottle called Timolol (or Timoptic, used to treat eye disease). 3.Treatment cart in hallway #2 stored opened sterile (free from germs) wound care supplies and/or products without any expiration date (the date that product was no longer should be used).These failures had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and secure communication among staff when resident personal health information (PHI) was communicated via a facility approved group messaging platform (GMP, a smart phone (a mobile phone that performs many of the functions of a computer) free messaging application that lets users call and exchange texts, photos audio, and video messages with others across) on facility staff's personal smart phones based on regulatory requirements (HIPAA-Health Insurance Portability and Accountability Act, a set of federal rules requiring appropriate safeguards to protect the privacy of protected health information from disclosure without patient's consent) for a census of 88 residents. This unsafe practice could compromise residents' private medical information and violate residents' health information privacy and confidentiality. Findings: During an interview on 5/13/25, at 2:10 p.m., Licensed Nurse (LN) 1 stated she was told at change 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 ensure professional standards for safe injection practices were followed when: 1. The Infection Preventionist (IP) stored pre-drawn, unlabeled, and undated flu (influenza, a respiratory disease) vaccine syringes in the staff food refrigerator. 2. Pneumonia vaccines (a vaccine that helps prevent an elderly resident get pneumonia, a serious lung infection) for three residents (Resident 1, Resident 2, and Resident 3) were documented as given, when the actual products were found among medication stored for destruction in the staffs ' food refrigerator. These failures could contribute to unsafe and ineffective use of vaccines and subsequent adverse outcomes for residents and staff. Findings: A concurrent interview with the facility ' s Director of Staff Development (DSD), in her office, and inspection of a dorm-style refrigerator next to her desk, on 10/10/24, at 3:45 PM, revealed stored food items/drinks in addition to a drawer full of injectable (shot into skin or vein) medications and 14 unlabeled pre-drawn…

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 use and destruction practices in the facility with a census of 86 when: 1. Prescription medication destruction and disposition logs (Refers to paperwork that outlines the process for permanently getting rid of medications, including when and how they were destroyed) were not dated, witnessed and/or cosigned by licensed staff. 2. A discontinued medication called semaglutide (injectable drug used to treat blood sugar disease and for weight loss) prescribed to Resident 4 was stored in an active storage area in the main medication room after Resident 4 was discharged and included two boxes (prescriptions) of semaglutide. (One prescription was brought in by the family, and the second was delivered by the facility ' s pharmacy (Pharmacy A). 3. Three Pneumonia vaccines (an injectable vaccine that helps prevent an elderly resident from getting pneumonia, a serious lung infection) belonging to three different residents (Resident 1, Resident 2, and Resident 3), were found among other medications…

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 in the facility with a census of 86 when: A dorm style refrigerator in an office shared by the Director of Staff Development (DSD), Infection Preventionist (IP) and the staffing coordinator, contained personal food items and a drawer full of prescription injectable (shot into skin or veins) medications including vaccines and unlabeled pre-drawn syringes of a flu (or influenza, a respiratory infection) vaccine. There was no temperature monitoring performed for this refrigerator. The refrigerator in the main medication room stored: 1. Opened vials of flu vaccine and Tuberculosis testing agent (or TB, a serious lung infection) without any marking for a beyond use date (the date after which the drug should not be used). 2. Discontinued medications belonging to a discharged resident (Resident 4) were stored in an active storage area in the refrigerator. These failures could contribute to unsafe medication storage, the risk of drug diversion (unauthorize use of drugs) 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 written notice of a facility-initiated discharge (notice given to resident to find another place to live in 30 days ' time) for one of one sampled residents (Resident 2) when, Resident 2 ' s Responsible Party (RP, a designated person to make decisions for another person) was verbally notified of Resident 2 ' s discharge from the facility on 9/5/24, however a written notice of discharge document was not sent/given to Resident 2's RP. This failure resulted in Resident 2's RP being uninformed of how to appeal the decision of a facility-initiated discharge and removed the opportunity for Resident 2's RP and/or the ombudsman (advocate for residents) to advocate on Resident 2's behalf. Findings: During an interview by phone with Resident 2 ' s RP on 9/23/24 at 12:40 p.m., the RP stated that the facility staff called her and verbally informed her that Resident 2 was sent to the hospital by ambulance on 9/5/24. The RP stated that the facility also told her that Resident 2 was discharged from the facility at that time. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to determine if one of one sampled resident (Resident 2) could return to the facility following a transfer to an acute care hospital from the facility when, Resident 2 was sent to an acute care hospital on 9/5/24 from the facility and not allowed to return; 1. There was no documented evidence that the facility communicated with the hospital (communication with the hospital and nursing home staff and/or via visits to the acute care hospital to assess the resident ' s condition) to determine an accurate status of Resident 2 ' s condition at the time the acute care hospital attempted to discharge Resident 2 back to the facility; and 2. There was no documented evidence that the facility attempted to communicate with the acute care hospital the needs of Resident 2 to return to the facility (treatments, medications, and/or services) to determine if the facility could meet those needs or not. These failures had the potential to negatively impact Resident 2 ' 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5%. There were two errors out of 26 opportunities, which resulted in a 7.69% medication error rate for 2 (Resident #23 and Resident #82) of 5 residents observed for medication administration. Findings included: A facility policy titled, Medication Administration (General), dated 08/18/2022, indicated, 4. Medications shall be administered in accordance with the orders, including any required time frame. An admission Record revealed the facility admitted Resident #23 on 02/23/2024. According to the admission Record, the resident had a medical history that included a diagnosis of multiple sclerosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/05/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #23's Order Summary Report, revealed an order dated 02/23/2024, for multivitamin with minerals oral tablet, give one…

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, record review, and facility policy review, the facility failed to follow a physician's order to hold carvedilol (a medication used to treat high blood pressure and heart failure) when a resident's systolic blood pressure (SBP, the top number in a blood pressure [BP] reading) was below 130 millimeters of mercury (mmHg) and to not administer midodrine (a medication used to treat low blood pressure) when the SBP was above 120 mmHg for 1 (Resident #21) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Administration (General), dated 08/18/2022, indicated, Policy To be able to safely administer in a timely manner, and as prescribed, in accordance to nursing scope and practices. The policy indicated, 4. Medication shall be administered in accordance with the orders, including any required time frame. An admission Record revealed the facility admitted Resident #21 on 03/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease,…

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, record review, and facility policy review, the facility failed to ensure enhance barrier precautions (EBP) were implemented for 1 (Resident #196) of 18 sampled residents. Findings included: A facility policy titled, Enhanced Barrier Precaution, dated 04/05/2024, indicated, 4. Facility staff shall perform hand hygiene and will don [put on] gown and gloves before performing the following high-contact resident care activities: * Dressing. An admission Record indicated the facility admitted Resident #196 on 07/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of encounter for fitting and adjustment of other gastrointestinal appliance and device, gastrostomy status, and dysphagia. Resident #196's Order Summary Report indicated an order dated 07/18/2024, for enhanced standard precautions related to gastrostomy tube every shift. Resident #196's care plan, included a focus area initiated on 07/18/2024, that indicated the resident was at risk for aspiration and required a feeding tube. 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.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality, when one of three sampled residents (Resident 1) physician order to reduce gabapentin (medication used to treat nerve pain) was not carried out on 4/6/24. This failure resulted in Resident 1 not receiving medication as per her physician's order and had the potential for ineffective treatment and unwanted side effects of the medication. Findings: Review of an admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including but not limited to surgical aftercare following surgery on the nervous system and diabetes mellitus (abnormal blood sugar levels). Review of Resident 1's physician note dated 4/6/24, indicated .Taper off [reduce] gabapentin to 300mg [milligram: unit of measurement] PO [per oral] daily per patient request. Discussed with RN [Registered Nurse] . Review of Resident 1's active physician's orders indicated Resident 1 had an active order for gabapentin 400 mg 1 capsule by mouth every eight hours for neuropathy…

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 promote and facilitate self-determination for five (Resident 1, Resident 76, Resident 331, Resident 335 and Resident 337) of 12 yellow zone (designated area where newly admitted or readmitted residents are kept under observation/quarantine for 14 days for possible COVID-19 infection) residents, when: 1. Resident 1, Resident 76, Resident 331 and Resident 337 were kept in the yellow zone for longer than the required 14-day quarantine period, and, 2. Fully vaccinated residents, Resident 335 and Resident 337 were unnecessarily placed on quarantine in the yellow zone. This failure had the potential to cause psychosocial harm to Resident 1, Resident 76, Resident 331, Resident 335 and Resident 337. Findings: 1. Review of Resident 76's admission record indicated Resident 76 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- an assessment tool used to guide resident care) dated 6/4/21 indicated Resident 76 had intact…

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 honor residents' right to visitation, when unvaccinated or partially vaccinated (individuals not fully protected from COVID-19 infection) residents or families were denied indoor visitation. This failure had the potential to negatively impact physical and emotional well-being of residents. Findings: Review of Resident 331's admission record indicated Resident 331 was admitted to the facility in late May 2021. Review of the Minimum Data Set (MDS- an assessment tool used to guide resident care) dated 6/5/21, indicated Resident 331 had intact cognition. During an interview with Resident 331 on 6/15/21 at 12:16 p.m., Resident 331 stated the facility did not allow his friends to visit him. He said the facility gave him a contact number for his friends to call to schedule the visit. Resident 331 stated when his friends called, the facility told them that they cannot see him. He said his friends come to visit him at the front through a glass barrier. During an interview with the Activities Director (AD) on 6/16/21, at 9:20 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 observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately for six residents from a census of 76 residents (Resident 21, Resident 13, Resident 46, Resident 381, Resident 56, and Resident 27) when: 1. Resident 56's insulin (a medication used to lower blood sugar levels) and Resident 27's inhalers (a medication used to treat lung disease) were stored on medication cart number four after they were discharged from the facility; 2. Resident 21's eye drops were stored in the refrigerator at a temperature not recommended by the manufacturer; 3. Resident 13's insulin pen had been stored in the refrigerator after being opened, contrary to the pharmacy medication label; 4. Resident 46's probiotic was located in the medication cart, not in the refrigerator as recommended by the manufacturer; 5. Resident 381's eye drops were not labeled These failures had the potential for use of discontinued medications, possible medication ineffectiveness, and the…

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

Based on interview, record, and facility policy review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN- a form that provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) notice was issued for one of three sampled residents (Resident 46) when Resident 46's payment status for services received while in the facility had changed. This failure placed Resident 46 and /or responsible party at risk of not understanding the potential liability for payment of services not covered under Medicare (a federal health insurance). Findings: Review of Resident 46's census list indicated, Medicare was the payer of services received while in the facility. On 5/20/21, Resident 46's census list indicated a payer change. It also indicated Resident 46 remained in the facility after a change in payment status. During a concurrent record review and interview with the business officer manager (BOM) and the social service director…

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 complete discharge documentation for one of three sampled residents (Resident 33) when the discharge instructions had multiple blank sections. Without complete discharge instructions Resident 33 could misunderstand needs after being discharged from the facility to home. Findings: A review of Resident 33's admission Record indicated, Resident 33 was admitted to the facility in the spring of 2021 with diagnoses which included difficulty in walking and muscle weakness. Review of Resident 33's clinical record, titled Discharge Instructions, dated 5/27/21, indicated Resident 33's discharge summary only included vital signs, weight, diet, vision and bowel and bladder function. Missing sections included admit date , discharge date , discharge to, speech status, hearing status, physical status, dental condition, cognition status, activity of daily living (ADL) function and skin condition. The form did not indicate that home health would visit him after discharge. During an interview on 6/18/21, at 11:13 a.m., Licensed Nurse (LN) 2…

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 two of 23 sampled residents (Resident 20, Resident 42) received proper treatment to maintain good foot health when: 1. Resident 20's toenails were long, discolored, and curved, and 2. Resident 42 had overlong toenails and had not received podiatry services in over a year. This failure had the potential to negatively affect Resident 20 and Resident 42's mobility and cause complications such as injury, pain, and infection. Findings: 1. Resident 20 was re-admitted to the facility in late 2018. A review of Resident 20's minimum data set (MDS, an assessment tool), dated 3/24/21, indicated a brief interview for mental status (BIMS) score of 3 which indicated severely impaired cognition. During an observation in Resident 20's room on 6/16/21, at 5:06 p.m., Resident 20 was observed with discolored, long curved toenails on the second, third, and fourth digit of her left foot, almost touching the skin on the bottom side of her toes. The nails on the remainder of her digits, on the left and right foot, were…

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

Based on observation, interview, and record review, the facility failed to provide comprehensive pain management, including assessment, for one out of 23 sampled residents (Resident 380) when, Resident 380 had not been evaluated for the presence of pain using a pain assessment scale (a tool used to assess the level of pain) for a total of 12 days . This failure resulted in Resident 380's pain not being effectively managed, with the possibility of pain not being treated when indicated. Findings: A review of Resident 380's admission Record indicated, Resident 380 was admitted to the facility in mid 2021 with diagnoses which included aftercare following heart surgery. A review of Resident 380's Brief Interview for Mental Status (3.0 BIMS) dated 6/5/21, indicated, Resident 380 scored 15 out of 15 which indicated Resident 380 was cognitively intact (the ability to remember, learn new things, concentrate, and make decisions that affect everyday life). During an interview, on 6/15/21, at 9:10 a.m., Resident 380 stated, she had pain located at the incision site on her chest. Resident 380…

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 pharmacy services were maintained for two of four residents observed during medication pass when: 1. The facility's pharmacist did not recognize a discrepancy between the dosage form (such as a chewable form) of a medication and the order for a medication for Resident 45 and Resident 16 and; 2. The facility's pharmacist did not ensure controlled drugs (medications that may be abused or cause addiction) were destroyed in a manner where they were unrecognizable and irretrievable. Findings: 1. During a medication pass observation on hall four (an area where residents reside) on [DATE], at 8:52 a.m., licensed nurse (LN) 5 administered an 81 mg (a unit of measure) chewable aspirin to Resident 45 in a plastic medication cup, along with other medications, and Resident 45 swallowed all of them whole. During a record review of Resident 45's physicians order for the 81 mg chewable aspirin, dated [DATE], the record revealed, .Aspirin 81…

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 the medication administration error rate was less than five percent (%), when three medication errors occurred out of 27 opportunities during medication administration for 3 out of 4 residents (Resident 45, Resident 16, and Resident 60). As a result of these failures, the facility's medication administration error rate was 11%. Findings: 1. During a medication pass observation on Hall four (an area where residents reside) on 6/17/21, at 8:52 a.m., licensed nurse (LN) 5 administered an 81 mg (a unit of measure) chewable aspirin to Resident 45 in a plastic medication cup, along with other medications, and Resident 45 swallowed all of them whole. During a record review of Resident 45's physicians order for the 81 mg chewable aspirin, dated 5/5/21, the record revealed, .Aspirin 81 Tablet Chewable 81 MG .by mouth .one time a day .everyday . 2. During a medication pass observation on Hall four on 6/17/21, at 9:10 a.m., licensed nurse (LN) 5 administered two 648 mg chewable Calcium Carbonate (antacid) tablets…

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 the facility policy review, the facility failed to properly store and label food in accordance with professional standards for food service safety for residents who received deli meat or drink thickener from the kitchen, when: 1. Two packages of meat stored in the walk-in freezer were not labeled by the specific meat name, and, 2. Three cans of expired food and drink thickener were available for use in dry storage. These failures had the potential to expose residents to a food allergen and/or expired food products. Findings: During the initial kitchen tour observations with [NAME] 1 on 6/15/21 at 8:25 a.m., two packages of meat in a clear plastic bag were stored in the walk-in freezer. The bag was labeled as deli meat, dated 6/10/21, use by date 9/10/21. During a subsequent interview with [NAME] 1, [NAME] 1 identified the meat was bologna and turkey, then stated bologna and pastrami. [NAME] 1 was unable to identify the specific type of meat. [NAME] 1 acknowledged that the label did not specify the type of meat. She stated the label should specify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were in place and adhered to by staff to prevent possible spread of COVID-19 in the facility, when: 1. Two (Resident 331 and Resident 332) of 12 yellow zone residents (designated area for newly admitted residents' quarantine to prevent or contain COVID-19) were not cohorted (people with the same infectious disease or potential exposure to the same infectious disease are roomed together) adequately when Resident 332 was readmitted into the same room with Resident 331 on the last day of Resident 331's quarantine, and, 2. The Laundry Supervisor did not put on proper Personal Protective Equipment (PPE) (special equipment that protects from infection) before entering a yellow zone room. These failures put staff and residents at risk of contracting COVID-19, with the potential of causing serious illness or even death. Findings: 1. During an observation and interview on 6/15/21, at 12:16 p.m., Resident 331…

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.