Savoy At Fort Lauderdale Rehabilitation And Nursin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to obtain orders for bed rails, failed to develop and implement a care plan for bed rails, and failed to regularly inspect rails for fit and function for 2 of 2 sampled residents reviewed for bed rails, Residents #197 and #199 The findings included: Review of the facility policy, titled, Bed Safety and Bed Rails, with a revision date of August, 2022, documented, in part: Facility Statement: The use of bed rails is prohibited unless the criteria for use of bd rails have been met. Policy Interpretation and Implementation 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping havits and bed environment 6. Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. 7. the maintenance department provides a copy of inspections to the administrator…

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 accurately reconcile controlled medications and failed to ensure discontinued controlled medications were removed from the medication cart for 2 of 5 sampled residents reviewed for controlled medications reconciliation, Resident #33 and Resident #41. The findings included: Review of the facility's policy, titled, Controlled Substances, dated November 2022, included the following: The facility complies with all laws, regulations, and other requirements 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…

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 adequately monitor for side effects and behaviors for resident receiving antipsychotic medication and the consultant pharmacist failed to recommend the monitoring for side effects and behaviors for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #70). The findings included: Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, PTSD, and anxiety disorder.…

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, interview and record review, the facility failed to ensure medications were stored securely for 1 of 4 sampled residents observed for medication administration, Resident #246, and 1 of 25 sampled residents, Resident #8. The findings included: Review of the facility's policy, titled, Medication labeling and Storage, with a published date of 08/06/24, included, in part, the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. Record review for Resident #246 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. 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.

Based on observations, interviews and record review, the facility failed to provide portions of pureed food according to the approved menu, with the potential to affect 14 residents with orders for puree diets, including Residents #4, #40, #48, #199 and #201. The findings included: Review of the approved menu for the lunch being served on 10/02/24 was for 4-ounces of Beef Stew for residents with 'Regular' diet orders and 6-ounces of the beef stew for residents with 'Puree' diet orders. During the kitchen tour, on 10/02/24 at 11:32 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, while plating the lunch meal, Staff F, Cook, placed a scoop of the beef stew that accounted for a serving and plated the remainder of the lunch and passed it off to staff to cover and placed on a tray and in a cart. At the request of the surveyor, Staff F placed a portion of the beef stew in the same manner on the facility's calibrated kitchen scale. The portion of beef stew weighed 4-ounces. At this same time, when a meal of pureed food was called for, Staff F…

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 prepare pureed vegetables in a manner to preserve their nutritive value, with the potential to affect 14 residents with orders for pureed diets, including sampled Residents #4, #40, #48, #199 and #201. The facility failed to follow the recipe for carrots, with the potential to affect all residents that eat from the approved menu. The findings included: Review of the facility's recipe for Carrots, Diced, (no reference date), documented the following instructions: Procedures: 1. Peel and cut carrots into 1/8 inch slices. Steam about 4 minutes. 2. Add broccoli florets and steam another 7-8 minutes or until vegetables are tender. 3. Add butter. Mix. Add salt and pepper to taste just before serving. Notes: 1. For pureed: Measure desired # of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening. 2. Puree Level 4: [NAME] texture, no lumps, liquid must not…

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 prepare pureed vegetables in a form to accomodate the residents' needs, with the potential to affect 14 residents with orders for pureed diets, including Residents #4, #40, #48, #199 and #201. The findings included: Review of the facility's recipe for, Carrots, Diced, (no reference date), documented the following instructions: Puree Level 4: [NAME] texture, no lumps, liquid must not separate from solid, may not be sticky, cannot be drunk from a cup or sucked through a straw. Shows some very slow movement under gravity, but cannot be poured, hold shape of spoon and fall off spoon in a single spoonful. During the kitchen tour, on 10/02/24 at 11:32 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, the pureed carrots that were in a 1/3 sized 6-inch deep hotel pan hot holding unit appeared to be soupy and sloshed about the pan when Staff B, Cook, stirred the carrots. While Staff B, was placing a…

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

Based on observation, interview and record review, the facility failed to prepare, store, and served meals in a safe and sanitary manner and in accordance with standards for food safety. The findings included: During the initial kitchen tour, on 09/30/24 at 9:03 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, the following was observed: 1. Upon entering the kitchen and making an introduction to the staff, the surveyor proceeded to perform hand hygiene at the designated hand washing sink. The surveyor turned on the hot water and waited for the water to get hot. After several minutes, the water did not get to the appropriate temperature for hand hygiene. 2. In the walk in cooler, there was a full sized 6-inch deep hotel pan of par-cooked chicken stored over packages of ready to eat deli meats. The Dietetic Tech and Staff B, Cook, confirmed that the chicken was partially raw. 3. There was a damp towel kept on the handles of the convection oven. When asked about the purpose for having the towels kept in that manner, Staff B stated that it 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.

Based on interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain an environment free of accident hazards. The findings included: Review of the Job Description: Administrator, with no date, included in part the following: Purpose of the Position The primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities: Administrative Functions 1. Plan, develop, organize, implement, evaluate and direct the facility's programs and activities. 2. Review policies and procedures that govern the operation of the facility. Safety…

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 bathrooms located in residents' rooms were adequately equipped with an emergency call system pull cord to allow residents to call for staff assistance, for 6 of 60 rooms reviewed for the residents' call light system on the 2nd (second) and 3rd (third) floors, room [ROOM NUMBER], 222, 232, 304, 307 and 314). The findings included: During the initial tour conducted on 09/30/24 at 10:44 AM of the facility's 3rd floor rooms, it was observed that room [ROOM NUMBER]'s bathroom was missing the pull cord for the emergency call light system. Photographic Evidence Obtained. Further observation at this time of the 3rd floor rooms revealed rooms [ROOM NUMBERS] were also missing the pull cord for the call light system in the residents' bathrooms. During the 2nd floor tour, two resident bathrooms, rooms [ROOM NUMBERS], were observed to be missing the pull cords of the call light system, and in room [ROOM NUMBER], the emergency pull cord 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.

Based on interview, record review, and observation, the facility failed to file an abuse report within 2 hours of being made aware of abuse, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3, reviewed for abuse. The findings included: The facility's policy, titled, Identifying Types of Abuse (revised September 2020) documented a section with the heading Policy Interpretation and Implementation, included the following: Under the heading Physical Abuse, the following was documented: 1. Physical Abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. Under the heading Mental and Verbal Abuse, the following was documented: 1. Mental Abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal Abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communications, or sounds, to residents within hearing distance, regardless of age, ability to…

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 and interviews, the facility failed to provide eating assistance in a dignified manner for 2 of 2 sampled residents observed for in-room dining, Resident #3 and Resident #11. The findings included: 1. Review of Resident #3's clinical record documented an admission on [DATE], with diagnoses that included Parkinson's, Psychosis and Depression. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #3's care plan, titled, Self-care performance deficit initiated on 08/22/22 documented an intervention that read .requires extensive assist with .meals . On 07/17/23 at 12:38 PM, in-room dining observation was conducted at the facility's 300 rooms unit. Observation…

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, observations and record reviews, the facility failed to appropriately respond to and resolve grievances in a timely manner, for 7 of 7 sampled residents in attendance during a meteting with members of the Resident Council. The findings included: The facility's policy, titled, Grievances/Complaints Filing dated 03/13/23, documented, in part, the following: Policy Statement Residents and their representatives have the right to file grievance, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint regarding care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide fingernail grooming for 2 of 2 sampled residents, Residents #16 and #38. The findings included: Review of the facility's policy, titled, Fingernails/Toenails, Care of published on 05/19/23, documented, in part, the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .proper nail care can aid in the prevention of skin problems around the nail bed .trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .documentation: the following information should be recorded in the resident's medical record: the date and time that nail care was given . 1. Review of Resident #16's clinical record documented an admission on [DATE] and diagnoses that included Sepsis, Cellulitis, Depression, and Chronic Conjunctivitis of Right Eye. Review of Resident #16's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental…

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 obtain a physician order for the follow-up care and removal of nasal sutures for 1 of 5 sampled residents observed, Resident #42; failed to follow physician's orders for application of bilateral [NAME] sleeves for 2 of 5 sampled residents observed, Resident #16 and Resident #42; failed to ensure that staff changed dressings in accordance with professional standards and per physician's orders for 4 of 5 sampled residents observed, Resident #16, Resident #21 Resident #66 and Resident #205; and failed to identify, document, and follow-up with the status of a resident's visible skin condition on the anterior chest for 1 of 5 sampled residents observed, Resident #205. The findings included: Review of the facility policy and procedure, provided by Director of Nurse (DON) on 07/20/23 at 3:54 PM, titled, Wound Care, published 05/19/23, documented, in part, in the Policy Statement: The purpose of this procedure is to…

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 obtain physicians' orders for oxygen therapy administration for 1 of 1 sampled resident observed for Oxygen use, Resident #42. The findings included: Review of the facility policy and procedure on 07/20/23 at 1:30 PM, titled, Oxygen Administration provided by the Director of Nursing (DON), documented in part, in the Policy Statement: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency…

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 and observation, the facility failed to accurately reconcile controlled medications for 3 of 6 sampled residents reviewed for controlled medication administration, Residents #94, #71, and #11. The findings included: 1. On 07/20/23 at 11:57 AM, a side-by-side random review of controlled substance administration was conducted with Staff K, Registered Nurse (RN). The review was done for the medication cart for 3W (3rd floor west) and Resident #11. The medication reviewed was for Tramadol 50 mg tablets, give 1 tablet by mouth twice daily for non-acute pain. A printed copy of the Medication Administration Record (MAR) for July 2023 was provided for Resident #11. The medication was scheduled for 8:00 AM and 8:00 PM. On the Medication Monitoring / Control Record, there were entries from 07/01/23 to 07/19/23 for both the morning and nighttime doses. For 07/20/23, there was an entry for the morning dose. The MAR from 07/01/23 to 07/04/23 and again on 07/19/23, had no entries 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 observation, interview and record review, the facility failed to ensure residents' medications were properly supervised and stored, for 2of 6 sampled residents (Resident #21 and #66), as evidenced by medications being left unattended on the residents' bedside table and on top of the 300 west wing medication cart during a Medication Administration Observation. The findings included: Review of the facility's policy, titled, Storage of Medications, published on 03/13/23, documented, the facility stores all drugs .in a safe, secure .manner . 1. Review of Resident #21's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Osteomyelitis of Sacral and Sacrococcygeal Area, Dementia, Sepsis, Dysphagia (difficulty swallowing), Epilepsy, Neuropathy and Closed fracture of Right Lower Leg. Review of Resident #21's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 of 15, indicating…

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 provide a safe, and clean environment for 6 of 6 sampled residents (Resident #52, #17, #49, #55, #23, and #30). The findings include: During an interview with the Administrator on 03/16/22 at 2:30 PM, she was asked for a maintenance policy that provides the process of how maintenance issues are identified, the process of submission of issues to the maintenance department, and how the issues are resolved. She stated, they do not have a policy. She provided a blank copy of maintenance/custodial work request sheet and a blank copy of facility safety committee meeting. 1. On 03/13/22 at 9:55 AM, an observation was made in Resident #52's room. The area around the air conditioning vent had a dark mold like substance and peeling paint; there was dust like debris in the bathtub; the exhaust fan in the bathroom above the bathtub was caked with dust like debris (Photographic evidence obtained). 2. On 03/13/22 at 10:04 AM, an observation was made in Resident #17's room. The area around the air conditioning vent had 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 provide nutritional interventions in a timely manner for 3 of 7 sampled residents reviewed for nutrition (Resident #32, #35, and Resident #37). The findings included: 1. Review of the facility's policy titled Weight Assessment/Height and Weight Record maintenance and Reporting dated 11/15/21, showed that the Nursing assigned Restorative team shall be responsible to record heights and weights for our residents to prevent, monitor, and intervene in undesirable weight loss. It further showed that any weight loss of 5 pounds or more should be reported to the Dietary Department. In an observation conducted on 03/13/22 at 12:30 PM, Resident #32 received her lunch tray at 12:40 PM, and staff left the room to assist with other residents. At 1:00 PM, Resident #32 was observed with a tray 100% untouched and no assistance from staff. At 1:15 PM, the tray was still 100% untouched by Resident #32, the room. In an interview conducted on 03/14/22 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 interviews, record review, and observations, the facility failed to follow infection control practices during the initiation of in-house Hemodialysis using a Central Venous Catheter (CVC) site for 1 of 1 sampled residents reviewed for dialysis (Resident #36). The findings included: A review of the Agreement for Dialysis Services between the facility and the dialysis company showed the following. When a resident is in the skilled nursing facility, their care will be provided according to acceptable standards of medical practice and by the facility policy and procedures. A review of the facility policy titled Handwashing/Hand hygiene revised in April 2020, showed the use of an alcohol-based hand rub for the following situation: before and after handling an invasive device (catheter), before donning sterile gloves, before handling clean or soiled dressing, before moving from contaminated body site to clean body site, after contact with resident's intact skin, after handling used dressing and contaminating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 5 sampled residents reviewed for Unnecessary Medications, Resident #25, as evidenced by the medication frequency was not being followed as ordered by the physician; and failed to ensure controlled substance medications were reconciled appropriately for 6 of 8 sampled residents reviewed during Medication Storage observation involving Resident #6, Resident #32, Resident #35, Resident #37, Resident #43 and Resident #374. The findings included: 1) Review of the facility Oral Medication Administration policy dated April 2018 documents in part, 'Purpose: To administer oral medications in a safe, accurate and effective manner. Procedures: Review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident.' Review of the clinical record for Resident #25 revealed an admission date of 03/15/21 with diagnoses to…

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 with a frequency of as needed, did not exceed the 14 days requirement for 2 of 2 sampled residents (Residents #6 and #37) reviewed during the controlled substance record review at the facility's second and third floor wings. The findings included: Review of the facility's policy titled Medication Orders: Stop Orders dated [DATE] documented the following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated numbers of days .PRN psychotropic medication orders 14 days . 1). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia and Pulmonary Embolism. Resident's quarterly minimum data set (MDS)…

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.