Complete Care At Hillside LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the facility policy, the facility failed to ensure one of three residents (R)85 reviewed for prevention of skin breakdown, received treatment and interventions according to physician orders out of a total sample of 47 residents. This failure placed the resident at an increased risk for a worsening pressure ulcer, pain, and a decrease in quality of life. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, revised 05/26/23, revealed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors;…

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, interviews, record review, and policy review, the facility failed to ensure that a resident with a urinary catheter bag was properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of two residents (R)85 reviewed for urinary catheters and urinary tract infections out of a total sample of 47 residents. Findings include: Review of the facility's policy titled, Indwelling Catheter Care, revised 08/11/24, revealed It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Privacy bags will be available and catheter drainage bags will be covered at all times while in use .Ensure drainage bag is located below the level of the bladder to discourage backflow of urine .Assist resident to a comfortable, appropriate position .Document…

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, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 12) out of 47 sampled residents was provided with the necessary respiratory care and services in accordance with professional standards. This failure had the potential to impact the residents treatment and interventions. Findings include: Review of the facility-provided policy titled Nebulizer Therapy, dated 03/13/23, revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Correctly assemble the tubing, nebulizer cup, and mouthpiece and ensure connections are secured tightly .Observe the resident during the procedure for any change in condition .When medication delivery is complete, turn the machine off .Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry .Air dry on an absorbent towel .Once completely dry, store 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 residents received alternative measures prior to installation of side rails for two residents reviewed for side rails (Resident (R) 83 and R298) of 31 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails. Findings include: 1. Review of R83's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included paraplegia, and complete traumatic amputation of right shoulder and upper arm. Review of R83's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/24 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was not impaired. Review of R83's Care Plan, dated 10/09/23 and located 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 record review and staff interviews, the facility failed to ensure the medical necessity of psychotropic medication administration for one Resident (R)48 of five residents reviewed for Psychotropic Medication Administration and a total of 47 residents reviewed in the sample. Informed consent was not obtained from the resident and/or resident's representative related to administration of psychotropic medication. This failure created the potential for the resident to receive unwanted medications. The findings include: Review of the facility's policy titled Use of Psychotropic Medications, revised in 07/11/24 read, in pertinent part, Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Review of R48's admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included End Stage Renal…

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, observations, record review, and review of facility policy, the facility failed to ensure one Resident (R)201 of seven residents reviewed during medication pass observations was free from a significant medication error. The resident's insulin (a medication used to control blood sugar) was not properly administered, creating the potential for the resident to receive an inaccurate dose. A total of 47 residents were reviewed in the sample. Findings include: Review of the facility's policy titled Insulin Pen Procedure, dated 03/13/23 read, in pertinent part, j. Injecting the insulin: v. While still pressing the plunger, keep the needle in the skin for up to 6 to 10 seconds and then remove the needle from the skin. Review of R201's admission Record, dated 02/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes. Review of R201's admission Minimum Data Set (MDS) assessment, with an Assessment…

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, observations, record review, and review of facility policy, the facility failed to ensure resident medication stored in facility medication carts was appropriately labeled to indicate the open date of the medication for three Residents (R)47, R110, and R298 out of a total resident sample of 47. This failure created the potential for residents to experience negative effects related to the administration of expired and/or out-of-date medication. Findings include: Review of the facility's procedure titled Insulin Pen Procedure, dated [DATE] read, in pertinent part, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date; and Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. The medication cart on the facility's third floor was observed with Licensed Practical Nurse (LPN)8 on [DATE] at 9:20 AM. Open insulin glargine pens were found in the cart 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, record review, facility policy review, the facility failed to ensure that one (Resident (R) 9) of five residents, reviewed for influenza and pneumococcal vaccinations were provided risks verses benefits prior to the administration of the pneumococcal vaccine. Findings include: Review of a facility policy titled Pneumococcal Vaccine, dated 08/02/24, indicated .It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. Review of R9's admission Record, located in the electronic medical records (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of [AGE] years old. Review of the Medication…

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, record review, and facility policy review, the facility failed to ensure that the room for one resident (Resident (R) 54) of 47 sampled residents was equipped with a functioning call light. This failure had the potential to result in a delayed response to the needs of the resident. Findings include: Review of the facility-provided policy titled Call Lights: Accessibility and Timely Response, dated [DATE], revealed The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . Review of the Face Sheet located in the Profile tab of the Electronic Medical Record (EMR) revealed R54 was admitted to the facility on [DATE] with diagnosis of heart…

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, staff interviews, and record review, the facility failed to ensure the resident food stored in the refrigerators in the nourishment rooms on 3 of 3 units was stored in a sanitary manner. This involved 3 of 3 units and had the potential to affect 96 of 98 residents residing in the facility. Findings include: 1.On 01/24/24 at 9:28 AM the refrigerator/freezer in the nourishment rooms on the 100 unit was inspected with the assistance of Corporate Dietary Manager 27 (CDM27). The refrigerator contained the following: Oikes yogurt with a use by date of 05/03/24. The container was not labeled with a name. An unlabeled and undated Styrofoam cup half full of a tan colored food substance. An open and half used 16-ounce bottle of Gatorade with no name or open date on it. A [NAME] donut bag with a breakfast sandwich in it with no name or date. A whole pizza in a pizza box with no name or date on it. A 4-ounce Sysco Imperial nutrition supplement with no date on it to indicate when it was thawed out. 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 observations, record review, interviews, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure donning and doffing procedures, hand hygiene, and isolation precautions were followed according to facility processes to prevent the potential spread of infection to facility residents and staff. This had the potential to affect 98 of 98 residents who resided at the facility. Findings include: 1. An observation on 01/29/24 at 10:41 AM revealed R7's COVID-19 positive isolation room with an isolation cart and a doffing bin outside the room. The doffing bin label read, Yellow isolation gowns . Please take to laundry at the end of each shift. The sign on the door read, Stop, Contact and Droplet Precaution. You must perform hand hygiene before entering…

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, interviews, and facility policy review, the facility failed to ensure call lights were within reach for three residents (Residents (R) 45, 55, and 34) out of a sample of 40 residents reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the resident in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible. Findings include: 1. Review of R45's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R45 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, hypertensive heart and chronic kidney disease without heart failure, and epilepsy. Review of R45's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/23, located under the RAI (Resident Assessment Instrument)…

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 record review, review of facility policy, review of the Resident Assessment Instrument (RAI) manual, and staff interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for one of 40 sampled residents (Resident (R) R87) reviewed for care plans. Specifically, R87 did not have a Care Plan to address Post Traumatic Stress Disorder (PTSD). Findings include: Review of R87's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 01/05/24 with admitting diagnoses of post-traumatic stress disorder (PTSD), diabetes, and other disorders of gait and mobility. Review of R87's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/24 and located under the MDS tab of the EMR, revealed R87 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R87 was cognitively intact. Review of R87's Care Plan, located in the EMR under the Care Plan tab, revealed there was not a care plan for PTSD. On 01/29/24 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 record review and staff interview, the facility failed to accurately assess one resident after an unwitnessed fall and failed to put additional interventions in place to prevent future falls for one of three (Resident 10 (R10)) sampled residents reviewed for falls. Findings include: Review of R10's Diagnosis tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, and glaucoma. Review of R10's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/19/23, revealed R10 was identified as moderately cognitively impaired, having functional limitations on one side of her upper and lower extremities, frequently incontinent of urine, and always incontinent of bowel. Review of R10's Plan of Care (POC), located under the POC tab of the EMR and with a revision date of 05/24/23, revealed the resident was dependent 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 observation, interview, record review, and policy review, the facility failed to obtain a physician's order for the use of oxygen for one of four residents (Resident (R) 2) reviewed for oxygen therapy out of a total sample of 40 residents. Findings include: Review of R2's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R2 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, cervical disc disorder with myelopathy, chronic diastolic (congestive) heart failure, and acute and chronic respiratory failure with hypoxia. Review of R2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/23, located under the RAI (Resident Assessment Instrument) tab, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact. R2 was documented to be on oxygen while a resident. Review of R2's EMR under the Orders tab revealed a 06/27/23 physician order…

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 record review of one (R1) out three residents sampled for care plans, the facility failed to implement a care plan for R1's use of oxygen. Findings include: 10/12/23 - R1 was admitted to the facility with diagnoses including acute respiratory failure with hypoxia (not enough oxygen reaching body tissues). R1's physician's orders included oxygen at 2-3 liters continuously every shift via nasal cannula (medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels). 11/17/23 10:30 AM - A review of R1's care plans failed to show evidence of a care plan for the use of oxygen. The facility failed to implement a care plan for R1's continuous use of oxygen. Findings were reviewed with E1 (NHA), E2 (DON) E5 (Staff Educator) and E4 (Regional Clinical Consultant) on 11/17/23 at 5:00 PM.

Based on interview and record review it was determined that for one (R1) out of three residents reviewed for care, the facility failed to ensure that R1 received treatment and care in accordance with professional standards of practice and physician orders. On the evening of 11/14/23 R1 had a change in condition and became unresponsive in the facility and was transported to an acute care hospital without a nursing assesment including vital signs. Findings include: A review of R1's clinical record revealed: 10/12/23 - R1 was admitted to the facility with multiple diagnoses including acute respiratory failure with hypoxia, anemia, high blood pressure, diabetes and congestive heart failure, and R1 took daily medications to address those diagnoses. 10/12/23 - A physician's order was written for low blood sugar protocol: if the resident became symptomatic and was difficult to arouse or unconscious . remain with patient., monitor vital signs, perform blood glucose, if blood glucose is above 70, notify practitioner of symptoms. If blood glucose equal to or below 70 immediately administer…

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 record review and interview, it was determined that for one (R1) out of three residents reviewed for Staffing, the facility failed to provide competent nursing care that included assessments and interventions for a resident who experienced a change in respiratory condition. Findings include: A review of R1's clinical record revealed: 10/12/23 - R1 was admitted to the facility with multiple diagnoses including acute respiratory failure with hypoxia, anemia and congestive heart failure. R1 was hospitalized from [DATE] - 10/12/23 which included the treatment of respiratory wheezing, and R1 was started on oxygen at that time. 10/12/23 - A Physician's order was written for Do Not Resuscitate. 10/16/23 - A Physician's order was written for Oxygen at 2-3 L/min via nasal cannula continuously. 11/9/23 - A Physician's order was written for 02 sats to keep oxygen saturation greater than or equal to 92%. Every Shift. 11/14/23 1:30 PM - A progress note was written by E8 that revealed that R1's blood pressure, 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 observations and interviews, it was determined that the facility failed to ensure that food was stored, prepared, and served in a sanitary manner. Findings include: The following were observed during the kitchen tour on 1/10/22 from 9:35 AM to 10:15 AM: - The paper towel dispenser at the cooking area hand sink had clean paper towels dispensing into the hand washing splash zone. The splash zone is an area around a sink in which contamination could occur. CMS identifies it as 3 feet apart; - The fume hood was greasy; - The hand sink by the dishwashing area was inaccessible. Findings were reviewed and confirmed by E5 (FSD) on 1/10/22 at approximately 10:15 AM. Findings were reviewed on 1/19/22 during the Exit Conference, beginning at 3:20 PM, with E1 (NHA), E6 (NPE/Staff Developer), E10 (Regional Clinical Consultant), and E11 (Complete Care Representative).

Based on record review and interview, it was determined that for one (R28) out of 19 resident in the investigative sample, the facility failed to develop comprehensive care plans for identified resident care areas. Findings include: 1a. Review of R28's clinical records revealed the following: 8/12/18 - R28 was admitted to the facility with an indwelling suprapubic (SP) catheter for a diagnosis of neurogenic bladder. 8/13/18 - The care plan for the SP catheter included a goal that R28 would have no signs or symptoms (s/s) of urinary tract infection. Interventions included to monitor for s/s of infection and report to Physician, catheter care twice a day and prn (as needed), keep catheter off of the floor, and provide privacy and comfort. 3/10/19 through 10/27/20 - The following physician's orders were written and initiated related to the care and maintenance of the SP catheter: - 9/19/19 Cleanse SP site daily with soap and water and to Z-Guard with foam drain sponge every night shift. - 10/27/20 Change supra pubic (sic) catheter with 22 FR (french- the catheter size) and 10 ml…

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 record review and interview, it was determined that the facility failed to ensure that for one (R60) out of two residents reviewed for hospitalizations received medication as ordered by the physician. Findings include: Review of R60's clinical records revealed the following: 10/8/21 - Review of hospital records and nurse progress notes revealed that R60 was diagnosed with a urinary tract infection (UTI) after being sent to the emergency room for an evaluation. R60 returned to the facility with a prescription for the antibiotic medication Keflex. 10/13/21 1:43 PM - Review of nurse progress notes revealed that E9 (RN) received an order from the hospital for R60 to begin a different antibiotic, Bactrim, to be given twice a day for seven days due to the Keflex being an ineffective option for treatment of the UTI. 10/13/21 2:50 PM - E9 (RN) transcribed R60's order for Bactrim. 10/13/21 2:55 PM - E9 (RN) discontinued the Keflex order for R60. 10/13/21 9:00 PM - Review of the facility's electronic Medication Administration Record (eMAR) revealed that R60 did not receive the first…

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 review of the clinical record and the facility's policy and procedure, it was determined that for one (R80) out of two residents sampled for Coumadin medication review, the facility failed to ensure that R80's 1/3/22 lab result was received and reviewed by the physician. Findings include: 5/21 (revised) - The facility's Coumadin Anticoagulant Therapy policy and procedure stated, . Policy: All residents requiring Coumadin administration will have a . INR drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Licensed nurses will monitor the required lab work completion . Procedure: 1. Obtain physician's order for . INR drawing . 2. Post . INR results on flow sheet or EHR (electronic health record), indicating date . 4. Prior to administering the dose of Coumadin nurse will be required to check and document date and results of last INR for current dose of Coumadin . Review of R80's clinical record revealed: 1/3/22 - A physician order documented, . INR one time only until 1/3/2022 . 1/3/22 - The January 2022 electronic…

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, clinical record review and interviews, it was determined that the facility failed to ensure that the physician's order for one resident (R79) was followed during a random dining observation. Findings include: Review of R79's clinical record revealed the following: 11/23/21- R79 was originally admitted to the facility. 11/26/21 - The admission MDS Assessment documented that R79 was independent in daily decision making. 12/17/21 - A physician's order was written for regular, low lactose and low fiber diet and to avoid diary such as milk and ice cream. 1/10/22 12:45 PM - During a random dining observation, R79's lunch tray and comparison of the meal ticket (a form used by the facility in which residents check their meal selection) did not match. R79's meal ticket stated .NO DIARY/lactose intolerance, LOW FIBER .NO ENTREE, GIVE instead meat sandwich (no cheese) .Give bag of chips. The tray did not contain the sandwich with chips and incorrectly contained an entree of fettuccini alfredo (contains butter, heavy cream and parmesan cheese which are all diary…

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.