Aviata At Central Park

Based on observation, interview, record review and policy and procedure review the facility failed to provide care for peripherally inserted central catheters in accordance with professional standards of practice for 1 out of 2 residents, Resident #88, out of a total sample of 39 residents. Findings include: During an observation on 1/25/2024 at 12:45 PM of medication administration for Resident #88 Staff E, Registered Nurse (RN) did not perform hand hygiene, donned gloves, locked the medication cart with one of her gloved hands, knocked on Resident #88's room door with one of her gloved hands and entered Resident #88's room. Resident #88 was observed in bed with a right upper arm double lumen PICC line (peripherally inserted central catheter). Staff E touched items on Resident #88's overbed table and placed supplies on the resident's dresser with her gloved hands. Staff E did not remove the gloves, did not perform hand hygiene, and opened an intravenous (IV) tubing package and connected the IV tubing to an IV bag of antibiotics. Staff E removed the end cap from the tubing 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, interviews, and record reviews the facility failed to administer oxygen per physician's orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care (Resident #5 and #27) out of a total sample of 39 residents. Findings include: During an observation on 1/22/2024 at 10:26 AM, Resident #5 was observed resting in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 4 liters. During an observation on 1/23/2024 at 7:27 AM, Resident #5 was sitting in bed with the head of bed elevated receiving oxygen via nasal cannula. The oxygen concentrator was running at 4 liters per minute. The oxygen concentrator was on her right side of the bed pushed against the wall out of the resident's reach. During an interview on 1/23/2024 at 7:27 AM Resident #5 stated, I can't reach the oxygen machine to change it. I don't have the strength to reach that far. During an observation on 1/24/24 at 7:15 AM, Resident #5 was resting in bed with the head of the bed elevated, receiving oxygen via nasal cannula. The oxygen…

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 prevent the possible spread of infection during medication administration for 2 of 6 observations. Findings include: 1. During an observation on 1/22/2024 at approximately 2:02 PM of medication cart #3, Staff, C, Registered Nurse (RN) did not perform hand hygiene and began preparing medications for Resident #84. Staff C opened the medication cart drawer, pulled the medication blister packs up but did not remove the medication blister packs out of the drawer and began to pop the medications into her bare hand, then placed them into the medication cup for a total of six medications. Staff C went to Resident #84's room and without performing hand hygiene administered the medications and returned to the medication cart. Staff C did not perform hand hygiene and began to prepare medications for another resident. During an interview on 1/22/2024 at 2:05 PM Staff C, RN stated, Oh, I didn't realize that I did that. I should not have put the medicine into my hand, they need [the medications] to go directly into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to respond and resolve a grievance through to a conclusion for one resident (#1) out of three residents sampled for grievances. Finding included: Review of a grievance, filed on 8/31/23, revealed the following: Family was upset regarding actions taken after the resident expressed that he had chest pains. He stated the response time for 911 was too long. Also stated they were not informed of transport. The grievance investigation revealed Called family discussed constant refusal of care, family aware stated 'He's Bipolar.' Told family nurse followed MD [Medical Doctor] orders. The grievance plan revealed, Spoke with family about nursing procedures. The expected results of actions taken revealed Reassure family that appropriate steps were taken to provide care. A review of the medical record revealed Resident #1 was admitted on [DATE] and re-admitted on [DATE], with diagnoses including but not limited to, fracture of shaft of left femur, severe sepsis,…

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 record review, the facility failed to provide adequate supervision to mitigate the risk of a fall with major injury for one resident (#1) out of three residents sampled for falls. Findings included: On 10/9/23 at 1:50 p.m., Resident #1 was observed lying in bed. During an interview, Resident #1 did not remember falling out of bed and did not want to talk further. Review of a facility document titled, Incident by Incident type, dated 10/09/23, showed on 7/22/23 at 8:45 p.m. Resident #1 had a fall incident. Review of the admission Record showed Resident #1 was originally admitted on [DATE], with diagnoses including gout, difficulty walking, idiopathic peripheral neuropathy, psychotic disorder with delusions, and lack of coordination. A diagnosis of left femur shaft fracture was added on 7/31/23. Review of Resident #1's Medicare 5-day Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed his Brief Interview for Mental Status (BIMS) score was 14,…

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 record review the facility failed to provide nursing and related services to assure one resident (#1) out of three residents sampled, attained and maintained the highest practicable physical, mental, and psychosocial well-being related to 1) not identifying a change in condition in a timely manner, 2) not notifying provider and resident representative of change in condition, 3) not being prepared for wound care, and 4) not ensuring pain was managed adequately. Findings included: An interview was conducted on 10/9/23 at 2:26 p.m. with Resident #1's family members. The family said on 8/20/23 they were on the phone with Resident #1, and he was complaining of pressure and pain in his chest. They said the resident was yelling ow and nurse, but no one came. One family member said they stayed on the phone with the resident. After about 40 minutes, another family member stated they called the nurses' station and told the person that answered the phone the resident was complaining…

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 interviews, and record review the facility failed to respond to a pharmacist recommendation in a timely manner for one resident (#1) out of three resident sampled. Findings included: Review of a Pharmacy Consultation Report, dated 9/13/23, showed the pharmacist made a recommendation for The initial attempt at a gradual dose reduction (GDR,) please reduce Venlafaxine ER [extended release] to 75 mg (milligrams) daily AND/OR Divalproex DR [delayed release] 125 mg twice daily. The provider was notified, and he told the facility to refer to the psychiatric doctor. On 10/9/23 the psychiatric doctor had still not been notified of the pharmacist recommendation. Review of admission records showed Resident #1 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including mood disorder, major depressive disorder, Type 2 Diabetes Mellitus, chronic pain syndrome, hypertensive heart disease, stage IV pressure ulcer on sacrum, psychotic disorder with delusions and anxiety disorder. Review of Resident #1'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 interviews, medical record review, and facility policy review, the facility failed to provide sufficient preparation and notification of discharge for two residents/resident representatives (#1 and #3) out of three residents reviewed for a safe and orderly discharge. Findings included: A review of Resident #1's medical record showed an admission date of 06/04/23 with diagnoses of Vascular Dementia with unspecified severity, Epilepsy unspecified, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and mood disorder due to known physiological condition. A physician order, dated 06/07/23, showed Resident #1 had an order for an electronic monitoring device placement on the right ankle. The care plan, initiated 06/07/2023, showed Resident #1 was an elopement risk related to dementia. The goals showed Resident #1 will maintain safety though next review date and Will not leave facility unattended. An intervention included the electronic monitoring device and monitoring 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 observations, interviews and policy review, the facility did not ensure a clean and sanitary environment was provided during four of four days (10/10/21 - 10/13/21) related to the ice machine not being clean, nine resident rooms (#50, #51, #52, #53, #55, #56, #57, #59 and #61)) not swept or mopped, ceiling vents were filled with dirt, debris and bio-growth in six resident rooms (#53, #55, #56, #57, #59 and #61), and privacy curtains and linens stained and soiled in six resident rooms (#52, #53, #55, #56, #57 and #65) in one hall (Ground Floor - Hall A) out of six halls. Findings included: During a facility tour on 10/10/21 at 9:54 a.m., resident rooms were observed on Ground Floor - Hall A with dirt, debris, and stains on the floors and the walls. room [ROOM NUMBER] was observed with stains on the walls from feeding tube spills and on the floor. room [ROOM NUMBER] was noted with a dead insect on the floor in front of bed B. In addition, the ceiling vents were observed with dirt, debris, and bio growth…

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 policy review the facility did not ensure that foods were served from clean and sanitary dishware during two of two lunch meal service observations, in two (lower-level dining and main level dining) of two dining rooms. Findings included: On 10/11/21 at 12:31 p.m., a dining service observation was made in the lower-level dining room during the lunch meal. A group of residents were observed in the dining area being assisted by Staff I, Certified Nursing Assistant (CNA). An observation was made of the round plate covers noted with stainless steel tops and bottom inserts. The top covers were in direct contact with the resident's food during transport and service. The stainless-steel parts of the bottom and top covers were noted with brown, greasy, burnt, and built-up oily residue. (Photographic Evidence was Obtained) On 10/11/21 at 12:32 p.m., an interview was conducted with Staff I, CNA. Staff I was observed uncovering residents' trays and distributing lunch. Staff I was asked if the food covers were clean. Staff I said, Does not look clean to me.…

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, interview and record review the facility failed to ensure the results of the most recent state or federal surveys were readily accessible to residents, or visitors to examine the survey results without having to ask staff to see them. Findings included: During a confidential Resident Council meeting conducted on 10/11/21 at 10:00 a.m. with a group of five alert and oriented residents, the group reported they were not aware of where the survey results were kept. On 10/11/21 following the Resident Council meeting an inspection of the facility revealed a posting in a wood frame sitting on a small desk in the front lobby entrance indicating The Survey Results Are Here. Closer inspection of the desk revealed a box on the desk which contained survey results in sheet protectors (Photographic Evidence Obtained). Observations of the ground floor entrance revealed a wood framed posting that indicated the survey results could be found by the lobby. Additional inspection of the facility revealed the survey results are located in the lobby which was an area not accessible…

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 record reviews, the facility failed to honor resident rights, by not ensuring 1. the facility had a system in place for residents to promptly receive mail on the day that it was delivered by the US Postal Service to include weekends, and 2. the privacy for all residents in a confidential and private manner related to having residents wear a colored wrist band to identify who had or had not been vaccinated for COVID-19. Findings included: 1. A confidential Resident Council meeting was conducted on 10/11/21 at 10:00 a.m. with a group of five alert and oriented residents in attendance. An interview with the Resident Council Group during the meeting revealed the US Postal Service delivered mail to the facility daily from Monday to Saturday. The group reported the mail was received during the week, and delivered to the residents by the Activities Department. The Resident Council Group reported that no one delivered mail to the residents on Saturdays and Sundays. An interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews the facility did not ensure the care plan was implemented for falls related to floor mats for one resident (#55) of four residents sampled for falls, and for not ensuring partial dentures were provided for one resident (#55) of thirty-six sampled residents. Findings included: Resident #55 was admitted to the facility with diagnoses of dementia with behavioral disturbance and acquired absence of right and left above knee, upon review of the admission Record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of the progress notes in the medical record revealed the following: 10/8/21 Resident was found on the floor in front of his bed by CNA (certified nursing assistant) during rounds. It appeared he fell out of his bed. No apparent no injury noted at this time. ROM (range of motion) performed. Resident denies any complaint of pain, stated…

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, observations, and interviews, the facility failed to provide appropriate treatment and services for enternal feeding by not ensuring the physician's order for the tube feeding rate was followed for one resident (#195) of six residents with tube feedings. Findings included: Review of the admission record revealed Resident #195 was admitted to the facility on [DATE] with diagnoses of moderate protein calorie malnutrition and gastrostomy. Review of the 10/4/21 Initial Nutritional Evaluation revealed the following: III. Tube Feeding/Oral Nutrition A. Tube feeding orders: yes B. Tube feeding orders: Jevity 1.5 at 65 ml (milliliters) per hour Z5. Plan/Recommendations: Jevity 1.5 to run at 55 ml per hour times 20 hours/day. Review of the physician's orders in the electronic medical record dated 10/8/21 reflected Enteral feed order every shift 55 ml/ hr (hour) for 20 hours. Further review of the physician's orders dated 10/10/21 showed Jevity 1.5 at 55 ml/hr fro 20 hours. Review of the care plan…

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 did not ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and three errors were identified for two (Resident #41 and #48) of four residents observed. These errors constituted a medication error rate of 12 percent. Findings included: An observation of First Level medication administration on 10/12/21 at 9:09 a.m., resulted in Staff E, Licensed Practical Nurse-Agency (LPN), not giving Resident #48 one capsule of Creon Delayed Release Particles 12000 Unit (Pancrelipase (Lip-Prot-Amyl)) on time and with meals as a digestive aid. During the observation Staff E, LPN confirmed the medication was late, and it was supposed to be administered at 7:30 (a.m.). Staff E, LPN stated, I came in and could not get access to the computer, it's always like this every time I work here. Staff E, LPN, further revealed he did not tell anyone in the facility that medications were late and did not call the physician. Staff E, LPN crushed a medication identified as Potassium Chloride…

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 policy review the facility failed to ensure one medication was stored and locked up for one day (10/12/2021) of four days of the survey and failed to follow their policy to secure medications appropriately in three (First Floor-B Hall, First Floor - A Hall, Ground Floor - A Hall) of five medication carts. Findings included: On 10/11/2021 at 3:45 p.m., an observation of the medication cart on first floor B Hall medication cart included loose tablets as follows: two round white, one white oval, one round yellow, 1/2 yellow, and four white half pieces with a white ¼ piece. Staff F, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained.) On 10/11/2021 at 4:00 p.m., an observation was made of the First Floor medication cart located on the A Hall, and revealed one loose white tablet. Staff G, Registered Nurse (RN) confirmed the presence of the unsecured tablet. On 10/11/2021 at 4:15 p.m., an observation of the Ground Floor…

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

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 5 (#11, #68, #10, #113, #35) of 33 sampled residents related to Resident #11 by failing to disinfect the glucometer and performing hand hygiene after touching the glucometer; the facility failed to ensure Resident #68 was placed on contact precautions after observation of watery odorous stool started on 1/23/20; the facility failed to ensure eye drops were administered for Resident #10 without contaminating the bottles; the facility failed to ensure staff entering Resident #113's room donned PPE and did not take in reusable equipment, and the facility failed to ensure medical waste for Resident #35 was disposed of according to their policy. Findings Included: 1. During observation of Resident #11's glucose testing, on 1/29/20 at 4:01 p.m., Staff Member I, RN, obtained the lancet and alcohol pad from the medication cart. Staff Member I, RN, knocked and asked Resident #11 if she could check his blood sugar. The resident agreed and the nurse…

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 interviews, record review and observations, the facility failed to offer or arrange for outside activities for 4 (#69, #14, #46, and #100) of the 33 residents sampled, including but not limited to, going out of doors in the fresh air when weather permitted and making periodic shopping trips for those who would enjoy them. Findings included: During a meeting of the Resident council on 01/30/20 at 10:00 AM, Resident #69 stated that the facility did not take residents outside for fresh air; he stated that unless they are able to get themselves out there on their own or have a visitor who takes them outside, then they don´t go outside. Resident #14 stated that the staff told her that they don´t have any way to transport them to a shopping location. Resident #46 stated that she was able to go outside, but that she cannot get to the store on her own. Resident #100 stated that the staff had not offered her any opportunities for any organized outings. Review of the Minimum Data Set (MDS) records for Residents #14, 46, 69 and 100 revealed that each of them specified that when asked…

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 did not ensure assistive services were provided in a timely manner for one (#18) of thirty-three residents related to concerns with hearing. Findings included: Review of Resident #18's clinical record included an admission date of 8/28/2018. Pertinent medical diagnoses revealed dysphagia following cerebral infraction and cognitive communication deficit. Review of Resident #18's care plan dated 8/09/2019 revealed a focus of communication problem related to Hearing deficit with interventions that included but was not limited to: Anticipate and meet needs and refer to Audiology for hearing consult as ordered. Review of the Quarterly Minimum Data Set, dated [DATE], revealed a brief interview for mental status (BIMS) score of 13, indicating a resident with only slight cognitive impairment. The resident was documented as having a moderate hearing difficulty with no use of hearing aid or other hearing appliance. On 01/29/20 at 10:00 am an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide necessary treatment and services to promote wound healing for one (Resident #54) of three sampled residents for wound care. Findings included: Resident #54 was admitted to the facility on [DATE] with a diagnosis of acute hematogenous osteomyelitis right femur and type 2 diabetes mellitus with foot ulcer. A review of the medical record indicated Resident #54 had a treatment order with a start date of 1/30/20 for Dakins (1/4 strength) solution 0.125%. Directions: Apply to right hip, coccyx topically every shift for wound until 02/06/2020 23:59. Cleanse right hip and coccyx with normal saline solution. Apply moistened Dakin's gauze to wound bed. Cover with silver alginate gauze and bordered foam dressing. A review of the comprehensive care plan for Resident #54 revealed a focus area as follows: Focus: Resident #54 has pressure injury and potential for pressure injury development related to immobility. Goal: Pressure injury will…

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 did not ensure that the medication error rate was below 5% for one (#10) of 5 sampled residents who were administered medications. This resulted in 5 errors from 26 medication administration opportunities, for a medication error rate of 19.23%. Findings Included: During medication administration on 1/30/20 at 9:35 a.m. with Staff Member J, RN, she prepared Resident #10's medication: Staff Member J, RN, observed the computer screen and removed one 400 mg tablet of guaifenesin from the over the counter medications and placed it in the medicine cup. One tablet of Depakote delayed release 125 mg's and placed in the medicine cup. One tablet of Amlodipine 10 mg tablet and placed in the medicine cup. Staff Member J, RN, stated she was finished with the pills for Resident #10. During review of the eye drops, she observed aspirin chewable 81 mg tablet was due and removed one from the drawer and placed that in the medicine cup. Staff Member J, RN, confirmed she had 4 pills in the medicine cup and poured them into a bag, crushed…

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 record review, the facility failed to maintain drugs and biologicals used in the facility in a safe and secure manner in one (ground floor) of two medication storage rooms and one (C) of six medication carts. Finding included: On 01/28/2020 at 7:15 a.m., an observation of the ground floor medication storage room was conducted with Staff C, Registered Nurse (RN). Staff C, RN, was asked to open the medication storage room for inspection. Upon entry to the medication storage room, the refrigerator was found to be unlocked. A metal box was observed inside of the refrigerator that was not permanently affixed. The metal box was removed from the refrigerator and Staff C, RN, was asked to open the metal box. Inside of the metal box were six vials of Ativan 2mg/ml (a schedule IV controlled medication) in a plastic bag. An interview was conducted with Staff C, RN, at the time of the observation. Staff C, RN, stated that the refrigerator is never locked and the Ativan is kept in the refrigerator for emergency use. (Photographic evidence was obtained.) On…

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

Based on observation, interview and record review, the facility failed to obtain and ensure timeliness of laboratory results for one (#68) of 3 residents sampled related to stool samples for Clostridium Difficile on 4 different days. Findings Included: During observation of Resident #68's medication administration with Staff Member I, RN, on 1/30/20 at 9:02 a.m. revealed the resident turned to her right side with white bed sheets observed up to her chest. Resident #68 turned back toward Staff Member I, RN, and looked at her as brown, watery, odorous stool oozed through the white sheets. Resident #68 used her left hand to pull the sheet away from her by placing her left hand in the watery stool and lifting the white sheet. Staff Member I, RN, observed the resident moving the sheets, and walked back to the door and asked the CNA in the hall to get the resident changed. Staff Member I, RN, walked back in the room and placed her personal blood pressure cuff on Resident #68's left arm and sat the resident up in bed to finish giving her medications. Resident #68's sheets were observed…

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

Based on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 3 of 6 (top middle, top right, and bottom middle) burners on the stove. Findings included: Observations of the main kitchen during the comprehensive tour of the kitchen on 1/30/20 at 1:45 pm revealed that the main kitchen houses a 6-burner stove. Close observation of the stove revealed the top middle, top right burner and bottom middle burner did not have pilot lights lit. On 01/30/20 at 2:00 pm, an observation was made of Pilot lights for the six-burner stove in the kitchen. At such time the top middle and top right stove burners were not operable, and the bottom middle burner did not light upon turning of stovetop knobs. Kitchen staff obtained a handheld lighter from close by to light burner. Staff stated the burners in the back are not used when cooking. On 01/30/20 at 02:10 pm, an interview with the Dietary Technician and Dietician revealed there was no knowledge of the pilot lights being operable. The Dietary Technician The Assisted…

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.