Parkville Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to report an allegation of abuse to the State Agency when the incident was reported to the facility pending the investigation. The findings include: Resident #1's diagnoses included Cerebral palsy, anxiety, depression, and disruptive mood disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with ambulating, transferring, and required set up for dressing and eating. The Resident Care Plan dated 10/31/24 identified observe for signs of anxiety. Interventions directed at identifying triggers, approach calmly, encourage diversional activities. The nurse's note dated 10/24/24 at 8:59 PM identified Resident #1 was transferred to the hospital after he/she became very verbally…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to provide evidence that three (3) allegations of abuse were investigated. The findings include: Resident #1's diagnoses included traumatic subarachnoid hemorrhage (a head injury that causes bleeding in the space between the brain and the thin tissues that cover it), traumatic brain injury, muscle contractures, urinary incontinence, need for assistance with personal care, muscle weakness, cognitive communication deficit, gastrostomy (a surgical procedure that creates an opening in the abdomen into the stomach providing a route for nutritional support/feeding tube), insomnia (difficulty sleeping), depression and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to be assessed for the Brief Mental Interview for Mental Status (BIMS) however, exhibited both…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to ensure that two (2) allegations of abuse/neglect were reported immediately to the State Agency as required. The findings include: Resident #1's diagnoses included traumatic subarachnoid hemorrhage (a head injury that causes bleeding in the space between the brain and the thin tissues that cover it), traumatic brain injury, muscle contractures, urinary incontinence, need for assistance with personal care, muscle weakness, cognitive communication deficit, gastrostomy (a surgical procedure that creates an opening in the abdomen into the stomach providing a route for nutritional support/feeding tube), insomnia (difficulty sleeping), depression and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to be assessed for the Brief Mental Interview for Mental Status…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #12) reviewed for accidents, the facility failed to ensure the responsible party was notified timely of a change in condition. The findings include: Review of the admission assessment dated [DATE], identified Resident #12 was admitted to the facility during 2/2024 with an admission diagnosis of a fall with a subdural hematoma and had intermittent confusion. The note further identified Resident #1 had an intact head laceration with seven (7) staples, a laceration to the right forearm, and multiple bruising noted over his/her body. The nursing note dated 3/4/2024 at 5:54 AM identified Resident #12 had a fall at 3:31 AM. The note indicated that while staff were providing care to Resident #12's roommate the NA heard a sound, turned, and saw Resident #12 lying on the floor. An RN assessment was completed with no injury identified. Neurological checks and vital signs (temperature,…

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 clinical record review, facility documentation review, facility policy review, for one of three residents reviewed for accidents (Resident #13) the facility failed to ensure the resident was not moved after a fall without direction by the RN, and for one of three residents (Resident #13) the facility failed to ensure the resident was transferred timely after a fall with injury, and for one of three residents (Resident #14) the facility failed to ensure neurological checks were monitored timely after an unwitnessed fall. The findings include: 1. Resident #13's diagnoses included syncope, vascular dementia, history of traumatic injury and history of falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had severe cognitive impairment and required substantial/moderate assistance for ADLs. The Resident Care Plan (RCP) dated 1/3/2024 identified a risk for falls. Interventions directed to observe for decreased balance, leaning, dizziness or fatigue, and to keep call bell 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and interview, the facility failed to develop policies and procedures that encourage the residents to exercise their rights regarding leave of absences and smoking without interference, coercion, discrimination, or reprisal from the facility. According to Appendix PP §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Review of the Travel Pass for Leave of Absence policy, dated 11/13/2014, provided to the survey team upon request, identified…

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 observations, review of the clinical record, facility documentation, facility policy and interview for 5 of 5 residents (Residents #37, 47, 130, 133, and 137) reviewed for medication administration, the facility failed to ensure that blood glucose levels were obtained and Insulin was administered per the physician's order, and for 1 resident (Resident #291) reviewed for bowel regimen, the facility failed to transcribe a physician's order accurately. The findings include: The findings include: 1. Resident #37 was readmitted to the facility on [DATE] with diagnosis that included diabetes type 2, legal blindness, and chronic kidney disease. The readmission MDS dated [DATE] identified Resident #37 had moderately impaired cognition, utilized a walker and wheelchair for mobility, and was Insulin dependent. A care plan dated 5/2/23 with a focus of diabetes had interventions that included to administer Insulin or other diabetic medications as ordered. Physician's order dated 6/1/23 directed to administer 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #15) reviewed for an allegation of abuse, the facility failed to report the allegation of abuse according to their policy. The findings: Resident #15 was admitted to the facility with diagnoses that included congestive heart failure, systolic heart failure, and hypertension. The quarterly MDS dated [DATE] identified Resident #15 had intact cognition and was independent with care. Review NA #5's employee file identified a Corrective Action Record for Job Performance dated 10/4/22. Incident description identified Resident #15 reported he/she went to station 4 to use the scale and get weighed. NA #5 rudely scowled at him/her stating no you can't come over here, go back to where you came from. Interview with the DNS on 6/26/23 at 3:35 PM indicated she did not have a reportable event form for the 10/4/22 report by Resident #15. After review of NA #5's Corrective Action Record for Job…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #15) reviewed for an allegation of abuse, the facility failed to investigate the allegation of abuse according to their policy. The findings: Resident #15 was admitted to the facility with diagnoses that included congestive heart failure, systolic heart failure, and hypertension. The quarterly MDS dated [DATE] identified Resident #15 had intact cognition and was independent with care. Review NA #5's employee file identified a Corrective Action Record for Job Performance dated 10/4/22. Incident description identified Resident #15 reported he/she went to station 4 to use the scale and get weighed. NA #5 rudely scowled at him/her stating no you can't come over here, go back to where you came from. Interview with the DNS on 6/26/23 at 3:35 PM indicated she did not have a reportable event form for the 10/4/22 report by Resident #15. After review of NA #5's Corrective Action Record for Job…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #106) reviewed for PASARR, the facility failed to submit a new application for PASARR when a resident received a new psychiatric diagnosis. The findings: Resident #106 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia, diabetes, hypertension, stroke, pacemaker. The quarterly MDS dated [DATE] identified Resident #106 had severely impaired cognition and required extensive assistance with care. A physician's order dated 10/27/20 directed to add a diagnosis of schizoaffective disorder. The psychiatric APRN note dated 10/27/20 identified that Resident #106 was evaluated for response to medication changes. The APRN indicated she would update diagnosis to reflect schizoaffective disorder and increase the Olanzapine (antipsychotic medication) to 10 mg at 5:00 PM. Interview with SW #1 on 6/26/23 at 9:48 AM identified the social workers are…

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, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #48, 79 and 98) reviewed for range of motion, the facility failed to ensure splints were applied per physician's order. The findings: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia and osteoarthritis. A physician's order dated 5/18/22 directed facility staff to apply bilateral hand orthotics after morning care and remove at evening care. A physician's order dated 3/6/23 directed facility staff to apply BK elbow splints in the evening and removal in the morning. The quarterly MDS dated [DATE] identified Resident #48 had severely impaired cognition and was dependent requiring a 2 person assist with personal hygiene, eating and bed mobility. Resident #48 had bilateral ROM limitations to his/her upper and lower extremities. The care plan dated 5/16/23 identified Resident #48 had contractures to his/her bilateral hands…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #30) reviewed for positioning, the facility failed to ensure the resident was positioned for meals in a safe manner. The findings: Resident #30 was admitted to the facility with diagnoses that included repeated fall, weakness, and dementia. A Physical Therapy Discharge summary dated [DATE] identified Resident #30 needed supervision and touch assistance for lying to sitting on the side of bed, sitting to lying, sitting to standing, and transfers. A Customized Wheelchair 24 Hour Positioning Plan dated 12/2022 identified Resident #30 was to wear a pelvic positioning device, leg rests with an attached calf pad, cushion, headrest in a tilt in space wheelchair. Further, to be out of bed at 9:00 AM, 12:00 PM, upright for meals, and 5:00 PM upright for meals, and 8:00 PM back to bed. Additionally, reposition every 2 hours and provide care. The annual MDS dated [DATE] identified…

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 observations, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #125) reviewed for oxygen therapy, the facility failed to ensure that the resident's oxygen tubing was changed per physician's orders. The findings include: Resident #125 was admitted to the facility on [DATE] with diagnoses that included abdominal wall cellulitis, dependence on supplemental oxygen, and failure to thrive. A physician's order dated 5/8/23 directed to administer oxygen at 2 liters per minute via nasal cannula continuously and to change the oxygen tubing weekly on Sunday during the 11:00 PM - 7:00 AM shift, and as needed. The admission MDS dated [DATE] identified Resident #125 had moderately impaired cognition, was occasionally incontinent of bladder, had a colostomy, and required the assistance of 1 staff member with bathing, toileting, and personal hygiene. The care plan dated 6/19/23 identified Resident #125 may need assistance with ADLs related to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #106) reviewed for unnecessary medications, the facility failed to respond to a pharmacy recommendation for an extended time (6 months). The findings: Resident #106 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia, and hypertension. A physician's order dated 12/5/22 directed to give Xarelto (a blood thinner) 20mg once daily scheduled at 9:00 AM. The quarterly MDS dated [DATE] identified Resident #106 had severely impaired cognition and required total assistance with care. Additionally, Resident #106 was on an anticoagulant 7 days a week. The care plan dated 12/19/22 identified anticoagulant use. Interventions included to educate resident and staff to report any bruises or bleeding from his/her gums, nose, or with bowel movements. A Medication Regimen Review dated 1/6/23 identified that Resident #106 was receiving Xarelto once in 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 clinical record reviews, review of facility documentation review, facility policy review and interviews for one resident (Resident # 26) reviewed for dental and (Resident # 93) reviewed for change in condition the facility failed to ensure the responsible party was notified of a change in treatment in accordance to facility policy. The findings included: 1.Resident #26 's diagnoses included hemiplegia following cerebral infraction, dysphagia, seizures, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 99 out of fifteen, indicative of severe cognitive impairment and indicated the resident required total assistance for Activities of Daily Living. The Resident Care Plan (RCP) dated 4/7/21 identified a risk for malnutrition. Interventions directed to monitor for chocking, aspiration, and vomiting. A physician's order dated 4/14/21 at 10:00 A.M. directed a referral to the oral surgeon for extraction…

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 clinical record reviews, observation, review of facility policy and interviews for one of three residents (Resident #46) reviewed for nutrition and for one of five residents observed during medication administration ( Resident # 87), the facility failed to ensure medication orders were transcribed and administered per physician's orders and for one resident who utilized a foley catheter ( Resident # 114) , the facility failed to follow physician's orders. The findings included: 1.Resident #46's diagnoses included dementia, pulmonary fibrosis, adult failure to thrive and severe malnutrition. The quarterly MDS assessment dated [DATE] identified resident was cognitively intact and required total one-person assistance with bathing, dressing, grooming and toilet use, extensive one-person assistance with bed mobility, transfers and ambulation and was independent with eating after setting up. The care plan dated 4/7/21 identified nutritional risk related to potential for weight loss, depression, dementia, 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 review of the clinical record, review of facility documentation, interviews and review of facility policy for one of three residents reviewed for abuse (Resident #43), the facility failed to ensure the resident was treated with dignity and respect. Additionally, for one of three sampled residents (Resident# 112) reviewed for potential abuse, the facility failed to ensure the resident was treated in a dignified manner. The findings include: 1. Resident #43 diagnoses included diabetes mellitus and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment, had no behaviors, the resident was dependent on one staff for bed mobility and toileting, and was occasionally incontinent of urine. The care plan dated 4/12/21 identified a problem with impaired mobility and sitting balance, interventions included to provide me assistance and repositioning. The physician's orders dated 5/22/21 directed to transfer the resident with a mechanical lift…

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 clinical record reviews, review of facility policy and interviews for one of three residents (Resident #46) reviewed for nutrition and for one of five residents (Resident # 87) observed during medication administration , the facility failed to ensure the resident's medication order was transcribed and administered in accordance to professional standards . The findings included: 1.Resident #46's diagnoses included dementia, pulmonary fibrosis, adult failure to thrive and severe malnutrition. The quarterly MDS assessment dated [DATE] identified resident was cognitively intact and required total one-person assistance with bathing, dressing, grooming and toilet use, extensive one-person assistance with bed mobility, transfers and ambulation and was independent with eating after setting up. The care plan dated 4/7/21 identified nutritional risk related to potential for weight loss, depression, dementia, and weight less than ideal body weight (IBW). Interventions included to follow diet as ordered, weights,…

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 clinical record reviews, review of facility policy for one of five residents reviewed for unnecessary medication for ( Residents # 66 and #70), the facility failed to ensure the resident physician's orders were signed in timely. The findings included: 1. Resident # 66's diagnoses included diabetes mellitus, major depression, hypertension and anemia. The admission MDS dated [DATE] identified the resident was cognitively intact, required total dependence with personal hygiene The physician's orders dated 5/1/2021 through 6/22/21 directed to administer Levemir 100 unit/ml to inject 68 units at hour of sleep, rotate sites and to discard 28 days after use. A review of the Resident # 66's physician's orders dated the resident's physician's orders were last signed by physician for 4/1/21 through 5/30/21. Further review of the resident's physician's orders dated 5/1/21 through 6/22/21 lacked evidence the physician had reviewed and signed the resident's physician's orders since 4/1/2021 through 4/30/21.…

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 clinical record reviews, observations,, review of facility policy review and interviews for two of four residents (Resident # 66 and # 87) reviewed for Medication Administration, the facility failed to ensure the medication error rate was not greater than 5%. The findings included: 1. Resident # 66's diagnoses include coronary artery disease, renal insufficiency and anemia. The quarterly MDS assessment dated [DATE] identified no cognitive impairment, the resident required extensive assistance with personal hygiene. Observation of the medication administration on 6/22/21 at 8:00 A.M. identified the charge nurse administering one multivitamin to the resident instead of one multivitamin with mineral per physician's order. Interview with the DNS on 6/22/21 at 11:30 A.M. identified the charge should have administered the multivitamin with mineral per physician orders. The DNS also notified the physician of the resident receiving a multivitamin instead of multivitamin with mineral. 2. Resident #87 's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of facility policy, the facility failed to ensure that sharp medical equipment and medication were secure. The findings include: Observation on 6/21/2021 at 12:15 P.M. on Unit 3 the surveyor observed the medication cart parked in the hallway between resident rooms, 308 and 310. The door was closed to room [ROOM NUMBER]. Further observed on 6/21/21 identified the top right side of the medication cart with eight lancets loosely scattered, and in the center of the cart there was a blister card with the medication( Eliquis (Anti-coagulant) tablets) without the benefit of licensed staff presence and a pharmacy delivery sheet. The surveyor continued to monitor the medication cart for five minutes. No licensed staff was noted near the cart, however two ambulatory residents and three residents using wheelchairs passed by the cart with the lancets and medication on top. Surveyor notified the DNS on 6/21/21 at 12:20 P.M. of the observation at which time LPN #5 came out of one 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one resident (Resident #26) reviewed for dental, the facility failed to ensure the resident had adequate transportation for an appointment in a timely manner. The findings include: Resident #26 's diagnoses included hemiplegia following cerebral infraction, dysphagia, seizures, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 99 out of fifteen, indicative of severe cognitive impairment and indicated the resident required total assistance for Activities of Daily Living. The Resident Care Plan (RCP) dated 4/7/21 identified a risk for malnutrition. Interventions directed to monitor for chocking, aspiration, and vomiting. A physician's order dated 4/14/21 at 10:00 A.M. directed a referral to the oral surgeon for extraction of #10, #11, #24 and #25 teeth secondary being very loose and an…

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.