Cedar Crest Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for two of five sampled residents (Residents 29 and 34) when:1. Facility staff did not post an Oxygen in use/No smoking sign on Resident 29's room entrance door;2. Resident 34's nasal cannula (NC, flexible tubing inserted into the nostrils and connected to an oxygen source) was not dated.These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 29's clinical record titled, admission Record, dated 8/8/2025, indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of skin (an abnormal growth of cells that divide uncontrollably), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone) and anxiety disorder (a condition or excessive worry, feelings of fear, dread, and uneasiness). Review of Resident…

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 one of 6 residents (6) was free from unnecessary medications when Resident 6 received morphine sulfate (used to treat pain) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for the residents to experience unrecognized adverse effects.Findings:Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE].Review of Resident 6's physician orders, dated 7/17/25, indicated she had orders for morphine sulfate 20 milligrams (mg, a metric unit of mass)/milliliter (ml, a metric unit of volume) give 0.125 ml every 4 hours as needed for moderate pain and give 0.25 ml every 2 or 4 hours as needed for severe pain. However, the review of Resident 6's clinical record did not indicate that Resident 6 was monitored for the side effects and care-planned on the use of the medication.During an interview with the director of nursing (DON) on 8/11/25, at 2:36…

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

Based on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during medication administrations for two out of seven residents (60 and 98). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the therapeutic effects of the medications and the residents' medications not accounted for.Findings: 1. During a medication pass observation on 8/7/25, at 4:53 p.m. with licensed vocational nurse G (LVN G), LVN G stated he did not have Artificial Tears Solution (eye drops used to lubricate dry eyes) on hand to give to Resident 60. Review of Resident 60's physician order, dated 8/8/21, indicated Resident 60 was to receive Artificial Tears Solution one drop in both eyes four times a day at 9 a.m., 1 p.m., 5 p.m., and 9 p.m.2. During a medication pass observation on 8/8/25, at 9:06 a.m. with LVN L, LVN L was to administer tramadol (used to relieve moderate to severe pain) 50 milligrams (mg, a metric unit of mass) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure supplies were stored appropriately when expired incontinent wash bottle was found in the central supply room. This failure had the potential for the expired incontinent wash being used on the residents.Findings:On [DATE], at 3:54 p.m., during an observation in central supply room with central supply coordinator (CSC), one Ca-Rezz incontinent wash bottle was expired on 3/2025.During a concurrent observation and interview with the CSC, he observed the Ca-Rezz incontinent wash bottle and confirmed that it was expired, and he would put it away.Review of the facility's 2001 policy, Medication Labeling and Storage, indicated . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure to accommodate liquid consistency for one of five sampled residents (Resident 45). This failure had the potential for decreased meal intake, negative effect on health and well-being of Resident 45.Findings: During an observation of lunch meal in dining room on 8/5/2025 at 12:15 p.m., noted Resident 45 lunch meal tray was served with thick consistency white liquid in a plastic cup, not able to come out of the cup when tilted to the sides. Also noted flowing consistency apple juice in a plastic cup was in lunch tray. Resident 45 refused to drink thick white consistency liquid from lunch tray. Resident 45 consumed 3/4th cup of flowing consistency apple juice when fed by staff.Review of Resident 45's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 45 was admitted to facility on 10/3/2023. Review of Resident 45 diagnoses included cerebral infarction (occurs when blood vessel supplying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of twenty-two sampled residents (Residents 37, 1, 53, 71, 41, and 2), when the activity care plans of Residents 37, 1, 53, 71, 41, and 2 were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 37's face sheet (a document that gives the resident's information at a quick glance) indicated, Resident 37 was admitted to the facility on [DATE] with diagnoses including unspecified nondisplaced fracture (the bone typically stays aligned in an acceptable position for healing) of surgical neck of left humerus (a bony constriction at the proximal end of shaft of the upper arm bone), subsequent encounter for fracture (broken bone) with routine healing, history of falling, and other abnormalities of gait (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 kitchen utensils and equipment were maintained in good condition and stored in accordance with professional standards for safety when baking pans and magnetic knife holder were not kept in good working conditions. These failures had the potential to cause the growth of microorganisms, which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites, or toxins) and cross contamination of food that could affect the 81 residents residing and consuming food at the facility. Findings: During the initial kitchen tour observation on 3/25/2024 at 9:21 a.m. with the dietary supervisor (DS), observed ten baking pans with brownish to dark colored spots that looked dirty and rusty and one magnetic knife holder with kitchen knives attached to it with brownish discolorations that looked dirty and rusty as well. During an interview with the DS on 3/25/24 at 9:30 a.m., the DS verified the ten baking pans that looked dirty and rusty and removed them right away. The DS…

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 and interview it was found that the hospital's Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 13% medication error rate (See F759). Findings: On 3/26/24, a review of Resident 19's clinical record revealed a physician's order for Flonase (Fluticasone) 50 micrograms. The instructions were to administer one spray in each nostril once daily for the treatment of allergies. However, during an observation at 8:02 AM on the same day, a Licensed Vocational Nurse A (LVN A) administered Flonase to Resident 19 but did not follow the prescribed instructions. Instead of one spray in each nostril, LVN A sprayed two sprays in each nostril. This discrepancy between the prescribed dosage and the actual administration could potentially result in an excessive dose, leading to adverse effects or reduced treatment efficacy. Later that day, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to treat one of 22 sampled residents (Resident 390) with respect and dignity when Certified Nurse Assistant E (CNA E) was standing while feeding the resident. This failure had the potential to negatively affect residents' emotional and psychosocial well-being. Findings: Review of Resident 390's clinical records indicated he was admitted on [DATE] and had diagnoses including dysphagia (difficulty swallowing). During an observation and interview on 3/26/24 at 8:32 a.m. with CNA E, CNA E was observed standing over Resident 390 while feeding the resident. Licensed Vocational Nurse J (LVN J) was observed in the room for medication administration. CNA E confirmed the observation. CNA E stated she should have sit down while feeding residents but she did not sit down on a chair. During an interview on 3/26/24 at 8:35 a.m. with Licensed Vocational Nurse J, she confirmed the above observation. LVN J stated CNA E should have sit down to 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 document the status of the resident's advance directive (AD, a written set of instructions, such as a living will or durable power of attorney, which is a document that authorizes to act on behalf of the resident for health care when the individual is incapacitated) for one of seven residents investigated (Resident 2). This failure had the potential for the resident's wishes to not be fulfilled, and not address. Findings: Review of Resident 2's face sheet (a document that gives residents' information at a quick glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including angioneurotic edema (which usually presents with episodic and unpredictable swellings of the head and neck, especially of the tongue and oropharynx), subsequent encounter, unspecified heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and unspecified hyperlipidemia (a condition in which there are high levels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 79). Failure to accurately assess had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions for the resident. Findings: Review of Resident 79's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 79 was admitted to the facility on [DATE] with diagnoses including displaced (the ends of the bone have come out of alignment) intertrochanteric (located between the greater and lesser trochanters and is composed of dense trabecular bone) fracture (broken bone) of left femur (thigh bone), subsequent encounter for closed fracture (a break in the continuity of the bone which does not communicate with the outside of the body) with routine healing, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of 22 sampled residents (Resident 390) when staff failed to ensure oxygen was administered as specified in the physician's order. This failure had the potential to compromise the residents' health and safety. Findings: Review of Resident 390's clinical records indicated he was admitted on [DATE] and had diagnoses including chronic respiratory failure (inability to keep oxygen and carbon dioxide at normal levels). Review of Resident 390's physician's order, dated 3/21/24, indicated he was to receive oxygen (O2) at 2 liters per minute (LPM, rate of oxygen administration) via a nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) every shift. Review of Resident 390's care plan for admitted on oxygen therapy indicated, Administer oxygen as ordered by physician. During an observation on 3/27/24 at 8:08 a.m., Resident…

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 consistently complete the dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) communication form after dialysis for one of five residents (Resident 381) who received dialysis services. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis. Findings: Review of Resident 381's clinical record indicated she was admitted on [DATE] and had diagnoses including end stage renal disease (kidneys are no longer able to work as they should to meet the body's needs). The clinical record further indicated Resident 381 received dialysis on Tuesdays, Thursdays, and Saturdays. Review of Resident 381's dialysis communication forms indicated that To be filled up by licensed nurse receiving patient from dialysis on the dialysis communication form was not completed consistently. The dialysis communication form was to be completed by the facility…

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

Based on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, four medication errors were observed out of thirty opportunities for three of seven residents, resulting in an error rate of 13%. Findings: A review on 3/26/24 of Resident 19's clinical record revealed a physician's order for Flonase (Fluticasone) 50 microgram, with the following instructions: *Administration: One spray in each nostril *Frequency: Once daily *Indication: Treatment of allergies During an observation on 03/26/24 at 8:02 AM, a Licensed Vocational Nurse A (LVN A) administered Flonase to Resident 19. LVN A sprayed two sprays in each nostril instead of the prescribed one spray in each nostril as indicated in the physician's orders. This discrepancy between the prescribed dosage and the actual administration could potentially result in an excessive dose, which may lead to adverse effects or reduced treatment efficacy. During an interview conducted on 03/26/24 at 2:45 PM, LVN A confirmed…

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 implement infection control practices when: 1. One laundry staff did not perform hand hygiene before handling clean linens and residents' personal clothings; and 2. For Resident 381, staff did not perform hand hygiene during her treatment. These failures had the potential to spread infections, and compromise resident's health and safety in the facility. Findings: 1. During an observation and concurrent interview with the maintenance director (MD) on 3/28/24, at 11:00 a.m., in the laundry room, the MD stated that the clean area was located on the right side of the room, designated for linens (such as sheets, blankets, and pillows), towels, bibs, and residents' personal clothing. It was noted that laundry staff H (LS H) entered the laundry room and began folding linens in the designated clean area. Subsequently, LS I entered the laundry room and performed hand hygiene before handling clean linens and residents' personal clothing, while LS H…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services for seven of 41 sampled residents (Residents 12, 11, 45, 66, 7 and 8) when: 1. Staff did not develop a personalized and resident-centered care plan, or document any follow-up treatment/skin reassessment when Resident 12 sustained a hematoma (a collection of blood, usually clotted, outside of a blood vessel that may occur because of an injury to the wall of a blood vessel) and cut on her right eyebrow. 2. Staff did not follow the physician's order to place floor/landing pad next to the bed when Resident 11 was in bed. 3. Staff did not follow the physician's order for bilateral heel floaters while in bed for Resident 45. 4. Licensed nurses did not follow the physician's orders for pain medication based on the residents' pain level for Residents 66 and 7. 5. Licensed nurses did not follow ordered parameters for blood pressure medication for Resident 8. These failures had the potential…

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 follow proper infection control procedures when: 1. The nebulizer face mask and tubing for two Residents (24 and 28) were found undated and uncovered. 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene and did not change gloves after touching potentially contaminated surfaces during the medication administration for Resident 42. 3. The two staff did not perform hand hygiene during dining observation. These failures put residents, staff and visitors at risk of possible spread of infection. Findings: 1. Review of Resident 24's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems) and asthma (a long-term disease of the lungs, causing the airways to inflame and narrow, making it hard to breathe). Review of Resident 24's physician order indicated he had an order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and medical record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 41 sampled residents (Residents 12 and 19), to reflect the fall incidents that occurred prior to the scheduled MDS assessment. MDS assessments should be accurate so as to provide the appropriate fall interventions to help prevent residents' further falls. Findings: 1. A review of Resident 12's Quarterly MDS dated [DATE], indicated the fall incident with no injury was not coded in item J 1800. Resident 12's fall incident on 9/13/2020 was not addressed on this assessment. 2. A review of Resident 19's Quarterly MDS dated [DATE], indicated the fall incident with minor injury was not coded in item J 1800. Resident 19's fall incident on 6/24/21 with minor injury was not addressed on this assessment. During the clinical record review and concurrent interview on 11/4/21 at 11:34 a.m., the minimum data set coordinator (MDSC) confirmed that the fall incidents for Residents 12 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 interview and record review, the facility failed to ensure an account of all controlled drugs was maintained and reconciled for 3 out of 4 randomly selected residents (Residents 66, 329 and 330) and, to ensure safe and effective use of medications for one of 18 sampled residents (Resident 32) when: 1. Three out of four randomly selected residents' (Residents 66, 329, and 330) controlled medication (those with high potential for abuse and addiction) records did not reconcile. The nursing staff signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications; and 2. Resident 32 received ferrous sulfate (iron, for prevention/treatment of iron deficiency anemia) and calcium (a medication used to prevent or treat low blood calcium level)…

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 two of 18 sampled residents (Residents 17 and 43) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 17 received quetiapine (brand name: Seroquel, antipsychotic medication) 50 milligrams (mg, unit of measurement) since 5/7/2019 without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. The failure had the potential to result in complications from long term use of Seroquel such as movement disorders, falls with injury, cerebrovascular adverse events [cerebrovascular accidents (CVA), commonly referred to as stroke, and transient ischemic events], and increased risk of death. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had 7.69 percent medication error rate when two medication errors out of 26 opportunities were identified during the medication pass for one of five residents (Resident 42). These failures had the potential to result in an ineffective drug therapy and possible adverse events (such as side effects) for the resident. Findings: 1. During a medication administration observation on 11/01/21 at 9:06 a.m., licensed vocational nurse A (LVN A) crushed one tablet of ferrous sulfate (iron pill, to treat or prevent iron deficiency anemia) 325 milligrams (mg, unit of measurement). She mixed it with about 10 milliliters (ml, volume of measurement) of water and administered to Resident 42 through the gastrostomy tube (G-tube or GT, feeding tube placed through the abdomen into the stomach). During an interview with LVN A on 11/01/21 at 9:58 a.m., LVN A stated the facility had been using the same ferrous sulfate brand from Manufacturer A (MNFTR A), and the nurses…

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 label and store medications and biologicals when: 1. A bottle of lorazepam (anti-anxiety medication) oral liquid solution for Resident 42 was opened but not dated. 2. A vial of Tuberculin Purified Protein Derivative (to test for tuberculosis [TB]) was opened but not dated. 3. Two Systane eyedrops (Artificial Tears) were opened but not dated in medication cart #4. 4. A vial of Heparin (blood thinner to treat or prevent blood clots) injection solution was opened but not dated in medication cart #2. 5. Breo inhaler (medication for breathing problems) was open but not dated in medication cart #2. The deficient practice had the potential for the products to be used beyond the date they were safe and effective for use. Findings: 1. During a concurrent observation and interview with the assistant director of nursing (ADON), on 11/01/21 at 11:01 a.m., in Medication Room Two, an inspection of the medication refrigerator identified a bottle of lorazepam oral liquid solution for Resident 42, which was opened…

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.