Pearl At Fort Lauderdale Rehabilitation And Nursin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to follow physicians' orders for fluid restrictions for 2 of 2 sampled residents reviewed for dialysis, Resident #123 and Resident #89. The findings included: 1. Record review revealed Resident #123 was readmitted to the facility on [DATE] with a diagnosis of End-Stage Renal Disease and is dependent on dialysis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 has a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Review of the physician's orders showed an order dated 12/09/24 for fluid restrictions of 1500 milliliters (ml) a day, with 420 ml allocated for nursing and 1080 ml allocated for dietary. Further orders showed that Resident #123 was receiving dialysis three times a week in-house. In an observation conducted on 12/09/24 at 12:55 PM, Resident #123 was not in the room, and her lunch tray was noted at the bedside. The lunch tray was noted with a meal ticket that showed…

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 ensure controlled substance medication reconciliations were accurate for 4 of 12 sampled residents reviewed during the controlled substance record review, Residents #14, #168, #186, and #201. The findings included: Review of the facility's policy, titled, Controlled Substances, dated 11/2022, included the following: The facility complies with all laws, regulations, and other requirement related to handling, storage, disposal, and documentation of controlled medications. Dispensing and Reconciling Controlled Substances: 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d.…

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 ensure residents' medication regimen (psychotropic's, antipsychotic, antiplatelet and hypoglycemic medications) were monitored appropriately as evidenced of the lack of written documentation of medication side effects, medication efficacy and behavior that were being monitored for 5 of 5 sampled residents, Resident #77, #86, #167, and #145, for unnecessary medications, and for 1 of 1 sampled resident, Resident #73, reviewed for Mood / Behavior. The findings included: Review of the facility policy, titled, Pharmacy Services-Role of the Consultant Pharmacist, with a revision date of 04/2019, documented in part, .the facility shall have the services of a consultant pharmacist .collaborates on other aspects of pharmacy services, including .recommending current resources to help staff identify .medications side effects and/or adverse effects .the consultant pharmacist will provide specific activities related to medication regimen review…

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 store residents glucometers in a sanitary manner; failed to securely lock the North wing medication storage door, and failed to secure medications at the bedsides for 1 resident, Resident #407. The resident census at the time of survey was 196. The findings included: Review of the facility's policy and procedure, titled, Medication Labeling and Storage, provided by the Director of Nursing (DON) published 11/08/24, documented in the Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Statement #2 revealed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Statement # 3 of the same policy revealed if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted…

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 follow their menu for the regular diet during 1 of 2 observations in the main kitchen. This has the potential to affect 117 residents on a regular diet. The census at the time of survey was 196. The findings included: Review of the fall/winter 2024 diet guide sheet provided to the surveyors included the following menu for the regular diet consistency: 4-ounces (oz) of seasoned cauliflower, 4-oz of spanish rice and 3-oz of apple butter pork loin. In an observation conducted in the main kitchen on 12/11/24 at 11:25AM, the surveyor observed that a lunch tray consisted of pieces of Apple Butter Pork Loin that were pre-sliced. The surveyor asked to put a piece of the Pork Loin on a facility's scale which showed the slice of Pork had a weight of 2.25 ounces. The piece of the Pork was not the correct weight according to the facility's menu that should have been for 3 ounces. An interview was conducted on 12/12/24 at 2:00 PM with the Food Service Director IFSD) who stated that the cook is supposed to pre-cut 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, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet consistency for 2 of 2 sampled residents observed during dining, Resident #22 and Resident #48. This has the potential to affect 17 residents on a Pureed diet. The findings included: Review of the facility's policy, titled, Modified Solid/Liquid Diet Consistency Policy and Procedure, not dated, showed the following: the purpose of this policy is to promote safe swallowing and minimize the risk of aspiration of solids/liquids for patients with impaired swallowing abilities. When prepared appropriately, it allows patients to exert less effort with mastication and allows the ability to control the solids and Liquids in the mouth. This yields a more efficient and safer swallow with less risk of aspiration or choking. It further showed that for the Pureed consistency diet, the food that is allowed on this plan must be pureed, cohesive, pudding-like food in a form without…

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 3. Review of the facility policy and procedure, titled, Resident Food Preferences, provided by the Director of Nursing (DON) published 03/13/23, documented in the Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent Policy Interpretation and Implementation: 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The dietician and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food…

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 meet professional standards and ensure that Hospice documentation was readily available for 1 of 1 sampled resident reviewed for Hospice, Resident #59. The findings included: Review of the facility Agreement provided by the facility with the Hospice company and signed on 07/27/2023 documented, in part: Facility shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this Agreement. The medical records shall consist of progress notes and clinical notes detailing all Inpatient Services and events. At the request of the Hospice, a copy of the patient's medical history, records and discharge summary shall be provided to the Hospice. Additionally, a review of the Integrated Plan of Care between the Skilled Nursing Facility and the [company] Hospice dated 10/16/2024 stated the following: [company] Hospice Nurse and SNF [Skilled Nursing Facility] representative or staff designee will discuss patient…

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 follow the Enhanced Barrier Precautions (EBP) guidelines for 4 of 4 sampled residents reviewed for EBP, Resident #26, Resident #465, Resident #139, and Resident #460; failed to ensure employees kept fingernails trimmed as per facility's policy; and failed to keep a nebulizer mask stored in a sanitary manner. The findings included: Review of the Center for Disease Control and Prevention (CDC) Enhanced-Barrier Precautions guidelines revealed, in part, the following: Everyone must clean their hands including when both entering and leaving the room; Providers and Staff must also; wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering; transferring; changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing. The CDC website included:…

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's staff failed to encourage and ensure that residents practiced hand hygiene before eating meals for 5 of 5 sampled residents observed during mealtimes, Resident #127, Resident #123, Resident #133, Resident #138, and Resident #39. This had the potential to affect 49 residents that are on the 300 unit. The facility also failed to follow proper infection control standards during medication administration observation for 2 of 7 sampled residents, Resident #15 and Resident #9. The findings included: Review of the facility's policy, titled, Handwashing/hand Hygiene, dated 05/18/23, documented that the facility considers hand hygiene the primary means to prevent the spread of infections. It further directs using hand washing or alcohol-based hand rub before and after eating or handling food. In an observation conducted on 08/28/23 at 12:15 PM on the 300 unit, the first meal cart arrived. Staff started passing out the trays to the individual resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to conduct proper admission, readmission, and quarterly smoking assessments for 10 of 10 sampled residents, reviewed for smoking safety, and as identified by the facility as smokers. The findings included: Review of the facility's policy, titled, Smoking Policy-Residents, published 05/19/23, included, in part, the following: Resident smoking status is evaluated upon admission. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change, and as determined by the staff. The facility provided a Smoker List upon request during the Entrance Conference conducted on 08/28/23. Of the residents named on this list, 10 remained as active residents of the facility. The following are the 10 identified residents who smoke who were found to have discrepancies in smoking assessments, either upon admission, readmission, or quarterly: 1. Resident #422 was admitted to the facility on [DATE]. An admission MDS was done on 08/28/23.…

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 policy and procedure, observation, interview and record review, the facility failed to maintain residents' privacy in a dignified manner for 3 of 5 sampled residents observed, Resident #130, Resident #268 and Resident #267. The findings included: Review of the facility policy and procedure, on 08/30/23 at 2:35 PM, titled, Dignity, provided by the Director of Nursing (DON) published 05/19/23 documented, in part, in the 'Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times .11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .' Review of Certified Nursing Assistant (CNA) job description on 08/31/23 at 9:35 AM dated January 2023 provided by the DON…

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 reviews, the facility failed to transmit Resident Assessments in a timely manner for 20 of 24 sampled residents reviewed for Minimum Data Set (MDS) discrepancies, Residents #142, 143, 26, 120, 13, 20, 65, 136, 118, 140, 135, 95, 63, 117, 77, 67, 92, 48, 51 and 146. The findings included: Following the Survey Day 2 Transition Meeting, the surveyors noted the Resident Assessment Facility Task was triggered for review. Twenty-four (24) residents were identified in this task to be reviewed for Minimum Data Set (MDS) Record over 120 days old. On 08/30/23 at 10:23 AM, the 24 triggered residents' records were reviewed with Staff Q, MDS Coordinator and Staff R, MDS Coordinator. During this record review, it was noted that 20 of the 24 triggered residents had MDS's which were not transmitted properly per the Federal Regulations. During this record review, Staff R stated the facility was aware that there was an issue with transmitting MDS's due to the changing of Electronic Health Records…

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 policy and procedure, observation, interview and record review, the facility failed to ensure proper usage and documentation of hand splints for 1 of 2 sampled residents reviewed for hand splints, Resident #265. The findings included: Review of the facility policy and procedure on 08/31/23 at 11:35 AM, titled, Medication and Treatment Orders, provided by the Director of Nursing (DON) published 05/19/23, documented in part, the following: Under Policy Statement: Orders for medications and treatments will be consistent principles of safe and effective order writing. Policy Interpretation and Implementation: 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record 5. The signing of orders shall be by signature or a personal computer key . Review of the facility policy and procedure on 08/31/23 at 11:45 AM, titled, Activities of Daily Living (ADLs), provided by the DON published 12/28/22…

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 nutritional interventions in a timely manner for 2 of 6 sampled residents, reviewed for nutrition, Resident #365 and Resident #340. The findings included: Review of the facility's policy, titled, Nutrition Assessment, dated 05/19/23, documented, in part, the following: the dietitian, in conjunction with the nursing staff, will conduct a nutritional assessment for each resident upon admission (within 14 days). The nutritional assessment will include the current nutritional status and risk factors for impaired nutrition. Review of the facility's policy, titled, Weight Assessment and Intervention, dated 05/19/23, documented, in part, the following: residents' weights are monitored for unintended weight loss. Any weight change of 5 percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. 1. Record review documented…

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 records review, observations and interviews, the facility failed to ensure that residents medications refills were reorder in a timely manner for 3 of 7 sampled residents reviewed for medications and timeliness of administration, Resident #44, # 89, and #434. The findings included: Review of the facility's policy, titled, Medication Ordering and Receiving from Pharmacy, revised dated January 2018, documented, in part, .the facility maintains accurate records of medication order and receipt . Review of the facility's policy, titled, Medication and treatment Orders, published dated 05/19/23, documented, in part, .drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available . 1. Review of Resident #44's clinical record documented an admission on [DATE] with no readmission. The resident's diagnoses included Dry Eye Syndrome, Dementia and Cerebral…

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 ensure that PRN (as needed) physician orders for psychotropic drugs are limited to 14 days for 1 of 5 sampled residents for unnecessary medication (Resident #144). The findings included: Record review documented that Resident #144 was admitted on [DATE] with diagnoses to include Major Depressive Disorder and Unspecific Psychosis. Review of the Physician's orders showed the following order, dated 04/17/23 with no stop date, for Lorazepam 0.5 milligrams to be given every 6 hours as needed for anxiety. Review of the Pharmacy recommendation book showed the following: no recommendations were provided on 04/25/23 regarding the above medication PRN status; no recommendations were provided on 05/09/23 for the above medication PRN status; and no recommendation was provided on 06/29/23 for the above medication PRN status. Further review showed that it was not until 07/29/23 that a recommendation was given regarding the Lorazepam PRN order that…

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 the correct fluid consistency for 1 of 6 sampled residents reviewed for nutrition, Resident #63. The findings included: Record review documented Resident #63 was admitted to the facility on [DATE] with diagnoses that included Lupus, Anemia, and Major Depression. Review of the physician ordered diet included: diet order dated 06/14/23 for no added salt diet with regular texture and nectar-thickened liquids. The annual Minimum Data Set (MDS) dated [DATE] documented Resident #63 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The care plan initiated on 07/10/23 documented Resident #63 is at high nutritional risk for dysphagia and is on thickened liquids by the Speech Language Pathologist (ST). It further showed that Resident #63 is blind in one eye. In an observation conducted on 08/28/23 at 10:34 AM, Resident #63 was in her room with the breakfast tray. The meal ticket…

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 ensure that a nourishing snack was available at bedtime if more than 14 hours passed between the evening and breakfast meals. This was observed for 3 of 3 sampled residents during dining observations, Resident #138, Resident #39 and Resident #92. It had the potential to affect 33 residents who resided on the 300 Unit, of the census of 181 residents. The findings included: A review of the facility's Bulk Snack list provided by the Dietary Manager showed the following: a pitcher of orange juice, a pitcher of cranberry juice, graham crackers or soft cookies, ½ peanut butter and jelly sandwich, fresh fruit, apple sauce, yogurt, tea bags, and sugar. Review of the census list provided by the facility on 08/28/23 showed there were 49 residents in the 300 Unit, 47 in the 100 Unit, 47 in the 200 Unit, and 38 in the 400 Unit. Review of the Diabetic snack list provided by the facility showed that 16 residents had diabetic snacks ordered at night…

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 monitor and follow the care plan for eating assistance for 1 out of 28 sampled Residents (Resident #2). The findings included: Review of the facility's policy titled Activities of Daily Living, supporting revised in March 2018, showed that residents who are unable to carry out activities of daily living independently will receive the necessary to maintain good nutrition, grooming, and personal and oral hygiene. It further showed that total dependence is full staff performance of an activity with no participation by the resident. In an observation conducted on 04/26/22 at 8:35 AM, the breakfast tray was brought into Resident #2's room. Staff went into the room at 8:40 AM to help set up the tray and left the room at 8:42 AM. Continued observation at 9:00 AM, showed that Resident #2's tray was 100% untouched. At 9:10 AM the breakfast tray was taken out of the room by staff untouched. In an observation conducted on 04/27/22 at 8:04 AM, staff…

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 order, receive and administer pain medications for 1 of 2 sampled residents reviewed for pain management (Resident #49). The findings included: The facility's policy for 'Pain Assessment and Management', dated 2001 and most recently revised March 2015, documented: General Guidelines 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Recognizing pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavior signs of pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs. The facility's policy for 'Medication and Treatment Orders' dated 2001 and most recently revised July 2016,…

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, interviews, record review and policy review; the facility failed to remove narcotics from 2 of 8 medication carts for 3 of 3 sampled residents who did not have current orders for the narcotics, Resident #84, #135 and #438. The findings included: The facility's policy titled Storage of Medication revised April 2007 reveals The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On 04/28/22 at 9:30 AM, the Medication Cart for Team 1 in the 100 unit was reviewed with Staff J, a Registered Nurse (RN). Resident #84's medication card for Ativan 0.5 milligrams (mg) was in the narcotic lock box with no current order. The order stopped on 04/22/22. On 04/28/22 at 9:45 AM, the Medication Cart for Team 2 in the 300 unit was reviewed with Staff K, a Licensed Practical Nurse (LPN). Resident #135's medication card for Tramadol 50 mg was in the narcotic lock box. The order stopped on 04/15/22. Additionally, in the Medication Cart for Team 2 in the 300 unit, was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that a psychotropic (drugs that affect a person's mental state) medication ordered by the practitioner were necessary and the resident's representative was aware and involved in the decision for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #110). The findings included: Review of the facility policy titled Administering Medications revised in April 2019 showed that following: if medication and dosage is believed to be excessive for the resident, or has been identified as having potential adverse consequences, the person preparing the medication will contact the prescriber and the resident's attending physician to discuss the concerns. In an interview conducted on 04/25/22 at 12:30 PM, with Resident #110's son, he stated that his mom was placed on psychotropic medication without their knowledge. He further said that the only reason he knew that his mom was placed of the new psychotropic medication was after the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to secure medications for 1 of 1 sampled residents (Resident #190) identified in the north wing. The findings included: Review of the facility's policy titled Storage of Medications revised on 04/2007 documented .drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems . Review of the facility's policy titled Preparation and General Guidelines-Self-Administration of Medications revised on 01/2018 documented .if the residents desires to self-administer medications, an assessment is conducted by the interdisciplinary team .the interdisciplinary team verifies the resident's ability to self-administer medications . Review of Resident #190's clinical record documented an admission to the facility on [DATE]. The resident's diagnoses included Left Hip repaired, Hypertension, Diabetes Mellitus, Depression, Macular Degeneration, Glaucoma and Muscle weakness. The residents baseline care plan included a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow physician's orders for 3 of 3 sampled resident reviewed for nutrition, therapeutic diets (mechanical soft) for Residents #110, #51, and #34. The findings included: A review of the facility's guidelines utilized the the main kitchen titled, Nutritional Education for Mechanical Soft Diet from the Manual of Medical Nutrition Therapy 2019 Edition showed the following: foods allowed in the mechanical soft diet are eggs, ground or chopped moist meats, baked fish, stewed made with tender chopped meat, finely ground chicken and well-cooked vegetables. A review of the facility's Speech Language Pathologist guidance titled Understanding Mechanical Soft Diets, undated, showed the following: Level-2 consist of foods that are moist, soft texture and easily swallowed. Meats are ground or finely cut to equal size no bigger than 1/4 inch. A review of the Nutrition Care Manual under section Dysphagia Level 3: Advanced or Mechanical Soft, showed…

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, record review and interviews; the facility failed to carry out a physician's order for blood testing for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbances, atrial fibrillation, and major depressive disorder. A 5 day Minimum Data Set with an assessment reference date of 11/17/21 revealed in Section C a Brief Interview for Mental Status of 0, which indicates the resident has severe cognitive impairment. A review of the physician's orders dated 04/01/22 reveals an order for Depakote DR (delayed-release) 125 milligrams (mg) sprinkle cap administer two by mouth three times daily. An additional order dated 04/01/22 reads Depakote level in one week, Thyroid profile all in one week along with FBS (fasting blood sugar). Further record review revealed there was no evidence the orders were completed. 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.