Sandgate Gardens Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate and timely administration of antibiotics for 1 of 1 sampled resident, Resident #86, who had a Urinary Tract Infection (UTI). The resident was subsequently admitted to the hospital and returned to the facility with the diagnosis of sepsis secondary to the UTI, with additional orders for intravenous (IV) antibiotics. The findings included: Review of the record revealed Resident #86 was admitted to the facility on [DATE]. Urine for a urinalysis was collected by staff at the facility on 03/24/25 and the results were reported to the facility on [DATE] as positive for a Urinary Tract Infection (UTI). The culture was attached to this report and indicated, in part, that the bacteria was resistant to Cipro, an antibiotic often used to treat a UTI. This urinalysis report was not signed off as having been reviewed. Review of the orders revealed Cipro was ordered to be administered twice daily for the UTI as of 03/31/25, five days after the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify and treat pain appropriately for 4 of 4 sampled residents, as evidenced by failure to identify and treat pain for Resident #60; failure to ensure pain medication availability for Resident #84; failure to ensure appropriate indication of use of medication for Resident #86; and failure to ensure pre and post assessment for PRN (as needed) pain medication for Resident #151. The findings included: Review of the policy titled, Standards and Guidelines: Pain Evaluation and Management, issued 7/2020 and revised 2/2024, documented, Guideline: Pain Management is defined as a process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process acute pain (or significant worsening of chronic pain) should be evaluated upon onset and re-evaluated as indicated until relief is obtained. For stable chronic pain the resident's pain and consequences 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 record review and interview, the facility failed to ensure appropriate drug regimen reviews for 2 of 5 sampled residents as evidenced by the failure to follow pharmacy recommendations for Resident #151, and failure to provide rationale for physician disagreement in a pharmacy recommendation for Resident #70. The findings included: 1. Review of the record revealed Resident #151 was admitted to the facility on [DATE]. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], documented the resident was cognitively intact with a score of 15. Review of the pharmacy recommendation dated 04/03/25 documented the resident was recently started on a Nicotine patch 14 mg for smoking cessation without a stop date. This pharmacy review recommended to taper to 7 mg after 6 weeks, and to evaluate and add order to discontinue the order in 6 weeks, then start 7 mg for 2 weeks, then discontinue. The physician agreed with the recommendation. Review of the current orders documented the resident 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 observation, interviews and record review, the facility failed to ensure indication of use, rationale, or behavior for antipsychotic use for 1 of 5 sampled residents, Resident #70, related to anti-psychotic medication. The findings included: Review of record revealed Resident #70 was admitted on [DATE] with diagnosis in part which included Encephalopathy, unspecified, cognitive communication deficit and unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of record revealed Resident #70 was prescribed an anti-psychotic medication on 01/30/25. During observations on 04/14/25 at 9:43 AM, and 1:05 PM, on 04/15/25 at 8:25 AM, and 9:25 AM, Resident #70 was either sitting up in bed or in a wheelchair in her room willing to answer a few basic questions about her meal and how she was feeling. On 04/16/25 at 11:20 AM, Resident #70 was observed sitting in her wheelchair outside with other residents and staff from the Activities…

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 and interview, the facility failed to secure medications in 1 of 5 medication carts B unit, and ensure medication was not found at the bedside for Resident#11. The findings included: On 04/14/25, at 11:05 AM, the surveyor observed a cup of pills on the bedside of Resident #11. One pill was yellow and oval, while the other was round and white. During an interview at 11:10 AM the same day, the surveyor asked Staff K, Licensed Practical Nurse (LPN), to check the room. She acknowledged the presence of the pills on the table. She explained that the yellow pill was Protonix, used for gastroesophageal reflux disease, and the white pill was Amlodipine, prescribed for hypertension. On 04/17/2025, at 9:07 AM, the medication cart in Unit B was found in front of room [ROOM NUMBER], with the drawers facing the room. The cart was left unlocked and unattended. The surveyor stood by the cart for about 3-5 minutes to monitor it. During this time, a nurse was observed exiting from another room across the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices for 1 of 5 sampled residents on Enhance Barrier Precaution (EBP) and 3 of 3 sampled residents with Contact Precautions as evidenced by failure to implement Personal Protective Equipment (PPE) and EBP orders for Resident #21 who had a wound; failure to have orders and implement Contact precautions for Residents #2, #86, and #84. The findings included: Review of the policy, titled, Standards and Guidelines: Enhanced Barrier Precautions. issued 03/2024 and revised 05/28/24 documents, Definitions: Enhanced Barrier Precautions (EBP) refers ton infection control intervention designated to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities .Procedure .1.Enhanced Barrier Precautions are used for resident's with any of the following: .b. Wounds and/or indwelling medical devices even if the resident is no known to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer intravenous (IV) antibiotics timely for 1 of 1 sampled resident, Resident #151. The findings included: Review of the policy, titled, Medication Administration revised 01/2024 documented, in part, 6. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime). Review of the record revealed Resident #151 was admitted to the facility on [DATE] with diagnosis to include Endocarditis (infection of the heart) and multiple fractures. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], documented the resident was cognitively intact with a score of 15. Review of the current orders documented Resident #151 was to be administered 'ceftriaxone 2 grams intravenously (IV) every 12 hours for Endocarditis for 38 Days'. During an interview on 04/14/25 at 10:44 AM, Resident #151 explained he was on an IV antibiotic for his…

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 provide the pneumococcal immunization for a resident with signed consent for 1 of 5 sampled residents, Resident #24. The findings included: Review of the policy, titled, Standards and Guidelines: Immunizations-Pneumonia, issued 07/2020 and revised 02/2024, documented: 1. Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated 2.Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission .4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) in accordance with Centers for Disease Control (CDC) guidelines .6 Residents who decline the vaccine will be educated on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review and staff interview, the facility failed to ensure that 3 of 3 sampled residents, Residents #1, #2 and #3, reviewed for pressure ulcers, received the necessary treatment and services in a timely manner, consistent with professional standards of practice to promote healing, as evidenced by the staff failed to ensure that a resident who is admitted with a Stage III pressure ulcer received the necessary care and services for 10 days; failed to provide evidence that weekly skin assessments were completed; and failed to provide evidence that the prescribed treatments were performed as prescribed and documented accordingly. The findings included: 1. Review of the clinical record for Resident # 1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Sepsis, and Traumatic Brain Injury. Review of the 11/06/24 second skin assessment documented the resident had a 1 x 0.4 x 0.9 cm open area on the right lower…

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 the right to smoke during designated times for 1 of 1 sampled resident who voiced concerns, Resident #152, and affecting 16 current residents who smoke, including an additional 5 of 6 sampled residents, Residents #32, #34, #63, #151, and #325. The findings included: During an interview on 12/18/23 at 10:14 AM, Resident #152 voiced concerns about the ability to smoke while residing at the facility. Resident #152 voiced they had designated smoking times of 9 AM, 1 PM, 4 PM, and 7 PM, but they have trouble getting it opened. When asked what she meant by that, Resident #152 stated when it's the scheduled smoking times, the area will be locked and staff won't know who is assigned to man the area. Review of the record revealed Resident #152 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed it was still in progress but the section for cognitive status had been complete…

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 housekeeping and maintenance services to provide a clean, comfortable and homelike environment on 2 of 2 units, the outside smoking patio and the common areas of the facility. The findings included: During a tour of the facility conducted on 12/21/23 at 10:09 AM, accompannied by the Maintenance Director and the Maintenance Assistant, the following was observed: a. On the patio outside of the Activity Room on the 100 Unit, which is the designated smoking area, there was an accumulation of cigarette butts in the planters, the ground around the planters, and the area just outside of the door that leads from the Activity Room to the patio. b. In the Main Dining Room, the metal frames around the air conditioning vents were noted to be rusted and damaged and there were several ceiling tiles that showed signs of water damage. c. In room [ROOM NUMBER], the baseboard was not secured under the air conditioning unit, the privacy curtain…

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 maintain an effective pest control program, as evidenced by pest sightings in the room of Resident #25, the main dining room / activities room, the 100 and 200 units' Clean Utility rooms, and documentation of pests in room [ROOM NUMBER]. The findings included: During an interview, on 12/18/23 at 11:22 AM, with Resident #25, with a documented Brief Interview for Mental Status (BIMS) score of 14, indicating 'cognitively intact', when asked of the presence of pests, Resident #25 stated that she had seen roaches on the floor the previous day. During an observation at the conclusion of the interview, live roaches were observed in all stages of life and too numerous to count, behind the resident's nightstand. During an observation in the Main Dining Room / Activities Room, on 12/18/23 at 1:44 PM, two live and mature roaches were observed in a cabinet. During an observation of the 200 unit 'Clean Utility' room, which was used as a unit pantry, 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 observations, interviews and record reviews, the facility failed to implement care plans for the use of bed rails for 2 of 2 sampled residents reviewed for bed rails, Resident #20 and Resident #151. The findings included: The facility's policy, titled, Proper Use of Side Rails, revised December 2016, documented, in part, under the section for General Guidelines: 4. The use of side rails as an assistive device will be addressed in the resident care plan 1. Resident #20 was admitted on [DATE]. Review of the resident's most recent complete Medicare 5-Day Minimum Data Set (MDS) assessment, dated 11/07/23, documented Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. The assessment documented the resident had no impairments to the upper extremity and was frequently incontinent of bowel and bladder with no incontinent devices in use. Resident #20's diagnoses at the time of the assessment included: Acidosis, Hypertension, Malnutrition, Depression, Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure clean and trimmed fingernails for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #13. The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE], and moved to her current room on 08/14/21. Review of the current Minimum Data Set (MDS) assessment, dated 11/12/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of 01, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS documented the resident needed substantial to maximum assistance for personal hygiene. The current care plans, dated 02/03/23, documented Resident #13 had an ADL (Activities of Daily Living) self-care deficit and needed assistance with all ADLs. A second care plan initiated on 02/03/23 documented the resident was resistive to care/refusing care related to dementia. Review of the recent progress notes for the past 30 days lacked…

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 and record review, the facility failed to ensure a safe and secure bedrail which resulted in an injury for 1 of 2 sampled residents reviewed for siderails, Resident #151, which included failure to: a. Identify the hazard and risk; b. Evaluate and analyze the hazard(s) and risk(s) after an incident occurred; and c. Implement interventions after the incident occurred. The findings included: Review of Resident #151's admission readmission Nursing Evaluation, dated 11/17/23, documented the following information related to the resident's Side Rail Evaluation: The resident is cognitively intact. The resident is independent for transfers/bed mobility. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a ¼ side rail. Review of Resident #151's 5-day Minimum Data Set (MDS) assessment completed on 11/24/23, assessed this resident as having a Brief Interview for Mental Status (BIMS) Score of 04 out of 15,…

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 provide tube feedings in accordance with physician's orders, and failed to ensure weights were monitored as ordered for 1 of 2 sampled residents reviewed for tube feeding, Resident #89. The findings included: Record review revealed Resident #89 was admitted to the facility on [DATE] with a diagnosis that included malnutrition. The admission Minimum Data Set (MDS) assessment, reference date 10/31/23, indicated Resident #89 had cognition impairment, and she was rarely / never understood. Review of physician order dated 10/26/23 indicated the facility was to weigh Resident (#89) daily times 3, then weekly times 4, and then monthly. It also documented to enter the weights in the weights and vitals section in the computer system. Additional review of physician order, dated 11/06/23, revealed, an order for enteral feeding two times a day with Jevity 1.2 at 70ml/hour for 20 hours. Review of care plans with revision date 11/01/23 indicated…

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 policy review, the facility failed to timely manage pain for 1 of 3 sampled residents reviewed for pain, as evidence by Nursing staff failed to properly assess for the effectiveness of as needed pain medication, failed to notify the physician of the ineffective pain medication, and failed to timely update the change in frequency of pain medication once received from the physician for Resident #152. The findings included: Review of the policy, titled, Pain Evaluation and Management, revised 2/2023, documented, Guideline: Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: . g. Monitoring for the effectiveness of interventions. Acute pain should be evaluated 30 to 60 minutes after the onset and re-evaluated as indicated until relief is obtained. Monitoring and Modifying Approaches: . Monitor the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure competent nurse staffing related to medication administration for 2 of 6 sampled residents observed, as evidenced by: Staff C, Registered Nurse (RN)/B Wing Unit Manager, failed to ensure the proper dose of insulin for Resident #57; and Staff B, RN, failed to properly administer medications via enteral (tube) for Resident #80. The findings included: 1. A medication pass observation was made on 12/20/23 at 5:39 PM with Staff C, Registered Nurse (RN), for Resident #57. The RN stated she needed to check the resident's blood sugar level and administer some medications. The RN obtained the Lantus insulin pen from the cart, placed the pen on a clean disposable tray, and stated, If his blood sugar is OK, he will get 20 units. The RN obtained the items to check the resident's blood sugar, and took those items and the insulin pen into the resident's room. After obtaining the blood sugar for Resident #57, the RN took the Lantus…

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

Based on record review and interview, the facility failed to ensure accurate documentation between the medication administration records (MARs) and the medication monitoring control record for 2 of 4 sampled residents, Resident #152 and #23. The findings included: 1. On 12/21/23 at 11:51 AM during the medication storage review process at Unit A2, two residents records were selected for review. Resident #152 had an order of Alprazolam 1 mg 1 tablet by mouth every 8 hours as needed. The medication monitoring control record was compared against the December 2023 MARs. There was a discrepancy in between the records. It was revealed that the Alprazolam was documented for removal in the medication monitoring control record on the following days 12/18 at 5:25, 12/18 1:40, and 12/18 at 9:55, however the removal was not recorded in the December MARs. 2. Resident #23 had an order of Tramadol 50 mg 1 tablet by mouth every 8 hours as needed. The medication monitoring control record was compared against the December 2023 MARs. There was a discrepancy in between the records. It was revealed 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 record review and staff interview, the facility failed to ensure that nursing staff administered insulin as per routine physician's orders and as per physician orders with set parameters for 1 of 5 sampled residents, Resident #45. The findings included: Resident #45 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses that included Bipolar Disorder and Diabetes Mellitus (DM), Type II. Resident #45's initial Minimum Data Set (MDS) assessment completed on 09/18/23 shows the resident having a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating cognition was intact. During the look-back period for the MDS, it was documented that Resident #45 received insulin injections for 6 of the days. Review of the physician medication orders for Resident #45 showed orders as follows: a. Novolog Injection Solution Inject as per sliding scale: if 120 - 140 = 2 units; 141 - 160 = 4 units; 161 - 180 = 6 units; 181 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units greater…

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 properly store medications during for 1 of 6 sampled residents observed during the medication pass observation, Resident #57; and failed to properly store the extra supply of OTC (over the counter) medications in the Central Supply storage room. The facility had independently ambulatory residents in the facility at the time of the survey. The findings included: 1. A medication pass observation was made on 12/20/23 at 5:39 PM with Staff C, Registered Nurse (RN)/B Wing Unit Manager, for Resident #57. The RN stated she needed to check the resident's blood sugar level and administer some medications. The RN obtained the Lantus insulin pen from the cart, placed the pen on a clean disposable tray, and stated, If his blood sugar is OK, he will get 20 units. The RN obtained the items to check the resident's blood sugar, and took those items and the insulin pen into the resident's room. After administration of the insulin, the RN took the insulin pen and placed it on top of the medication cart. Photographic Evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure laboratory services for 1 of 7 sampled residents, Resident #37. The findings included: Review of the record revealed Resident #37 was admitted to the facility on [DATE], and moved to her current on 02/23/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 0, on a 0 to 15 scaled, indicating the resident was severely cognitively impaired. This MDS also lacked any documented behaviors. Review of the physician orders revealed an HbA1C (blood level to determine the overall blood sugar control) was to be drawn on 09/14/23 and then every three months thereafter. The record lacked any results for 09/14/23 or 12/14/23. Further review of the orders revealed a comprehensive metabolic panel (CMP/a variety of laboratory values) was to be drawn on 09/14/23 and then every six months thereafter. The record lacked the results for the 09/14/23 CMP. During 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 observation and interview, the facility failed to ensure the inspection of bed mattresses and bedrails to identify potential hazards, for 2 of 2 sampled residents reviewed for bedrails, Residents #20 and #151. The findings included: The facility's policy, 'Proper Use of Side Rails, revised December 2016, documented in the section titled 'General Guidance': 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting a potential benefits and risks. 13. when side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount 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 administrative and clinical record review and staff interview, the facility failed to ensure the clinical records accurately documented physicians orders for residents' treatment and services; and failed to accurately document the performance and administration of medications, treatment and services. This failure affected 2 of 3 sampled residents' clinical records reviewed, Residents #1 and #4. The findings included: 1. Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Systolic Congested Heart Failure and Ischemic Cardiomyopathy. Further review of the clinical record revealed that the staff failed to consistently document that they administered the prescribed medication by placing their initials in the appropriate boxes and failed to ensure they had a physician prescription for administered treatments and transfers as follows: a. Review of the physician orders revealed that the physician prescribed for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure required interdisciplinary team (IDT) members participation in care planning process for 12 of 22 sampled residents reviewed for care plan, Residents #73, #94, #47, #41, #36, #5, #27, #78, #54, #35, #45, and #3. The findings included: 1. Record review for Resident #27 revealed the quarterly care plan review was held on 06/10/22 with interdisciplinary team (IDT) participation that included: the minimum data set coordinator (MDS), activity staff, license practical nurse (LPN), therapy and physician. There was no evidence of certified nursing assistance (CNA) and Dietitian participation in this care plan review. 2. Record review for Resident #35 revealed the quarterly care plan review was held on 04/22/22 with IDT participation that included: MDS, LPN, therapy, social services and physician. There was no evidence of CNA and Dietitian participation in this care plan review. 3. Record review for Resident #47 revealed the admission care plan 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, record review and interviews, the facility failed to follow standards of practice for infection control practices related to PPE (Personal Protective Equipment) use and glucometer disinfecting. This has the potential to affect all residents in the facility. The census at the time of the survey was 99 residents. The findings included: Review of the policy COVID-19 (Florida) Guidance and Initiatives, revised 06/21/22, documented in part, Personal Protective Equipment and Hand Hygiene . 3. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door. 5. As per CDC's protocol, for a resident with known or suspected COVID-19: employees providing care wear gloves, isolation gown, eye protection and an N95 or high-level respirator if available. A facemask is an acceptable alternative if an N95 or higher-level respirator is not available. 6. Hand Hygiene should be performed for at least 20 seconds with soap and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure COVID-19 testing was completed as per manufacturer's instructions for 6 of 6 observed staff tests (Staff N, Staff O, Staff P, Staff Q, Staff R, and Staff S); and for 4 of 4 observed sampled residents (Residents #210, #48, #78, and #102). Upon entrance to the facility on [DATE], there were eleven (11) COVID-19 positive residents. After completion of resident testing on 08/22/22, there were eighteen (18) COVID-19 positive residents. After resident testing on 08/24/22, there were an additional six positive residents (25 positive residents). The nursing staff were not following manufacturer's instructions for COVID-19 testing, thus the actual number of COVID-19 positive residents and or staff may have been more. The findings included: Review of the manufacturer's instructions for the [NAME] BinaxNOW COVID-19 Antigen test documented, in part, the following, Sample Test Procedure: 1. Hold Extraction Reagent bottle vertically. Hovering 1/2 inch above the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide enablers per resident request for 1 of 3 sampled resident's reviewed for choices, Resident #78. The findings included: Review of Resident #78's medical records revealed an admission to the facility on [DATE] with diagnoses to include Enterocolitis due to Clostridium Difficile, Hypertension, Atrial Fibrillation, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus, Anxiety, Depression, Abnormalities of Gait and Mobility, Generalized Muscle Weakness, and Pressure Ulcer of Sacral, Left lower Back and Left Heel. Review of the MDS (Minimum Data Set) 5 day, dated 07/20/22, documented thr resident had a BIMS (Brief Interview for Mental Status) score of a 15, indicating intact cognition. Her Functional Status documented total dependence of one person for bed mobility, toileting, and bathing. She required extensive assistance of two person for transfers, dressing and hygiene. She had impairment to her…

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 interview, the facility failed to provide a safe, clean comfortable homelike environment for the residents. The findings included: During tour of the facility, including resident rooms on 08/22/22 and through 08/25/22, and a secondary tour completed on 08/24/22 at 8:21 AM, with the Director of Maintenance & Housekeeping, and the Administrator, the following concerns were noted, observed, and acknowledged during tour: 1. 100 unit: a. room [ROOM NUMBER]A - Floors were dirty with debris. There were clothes piled up in the corner of the room. The resident stated he cannot get anyone to hang his clothes up for him. During the secondary tour on 08/24/22 (Thursday), two dead cockroaches were observed in the room, with one under the bed along with a dirty razor, which has been there since Monday. b. room [ROOM NUMBER]A - There was clothes piled next to bed. A sampled resident complained that staff say they don't have time to put away her clothes. Her closet was observed behind the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 22 sampled residents, as evidenced by Resident #94 was inaccurately coded as having wandering behaviors and an indwelling urinary catheter; and Resident #207 was admitted to the facility and continued to utilize oxygen, while the MDS lacked any documentation of the oxygen use. The findings included: 1. Review of the record revealed Resident #94 was admitted to the facility on [DATE], with a readmission on [DATE]. Review of the order summary report, that included discontinued orders, lacked any evidence of an indwelling urinary catheter (Foley). Review of the current Minimum Data Set (MDS) assessment, dated 08/01/22, documented Resident #94 had an indwelling urinary catheter. Observation of Resident #94 on both 08/23/22 at 2:51 PM and on 08/24/22 at 9:13 AM lacked any noted urinary catheter appliance. During an interview on 08/25/22 at 10:31 AM, the A Hall Unit Manager 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 observation, record review and interview, the facility failed to ensure care and services for Foley catheter for 1 of 2 residents, Resident #206, reviewed for indwelling catheters. The findings included: A review of the Policy and Procedures for 'Urinary Catheter Care', documented under general guidelines 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Review of Resident#206's records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Retention of Urine, Chronic Kidney Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Hemiplegia and Hemiparesis following a Cerebral Infarction. A review of the Physician's Orders revealed that there was no physician order for a Foley catheter. A review of the Nursing admission Assessment on 08/16/22 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 timely nutritional assessment for 2 of 4 sampled residents, Resident #27 who had a facility acquired pressure ulcer of Stage 4, and failed to ensure timely nutritional assessment for a resident who had a significant weight loss and to ensure weights were obtained, Resident #41. The findings included: 1. On 08/24/22, beginning at 12:00 PM, clinical record review started for Resident #27. There was a physician order, dated 07/28/22, for wound care treatment as follows: Stage 4 pressure of the Sacrum / cleanse with normal saline, pat dry, apply acetic acid solution, wet to moist covered with island gauze with border dressing once daily. Additional record review showed documented evidence of a nutritional assessment, dated 03/10/22. Further record review indicated a quarterly minimum date set (MDS) assessment, reference date 06/10/22. There was no documented evidence of a quarterly nutritional assessment with this quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to obtain a physician's order for oxygen and ensure proper maintenance was done for 1 of 1 sampled resident reviewed, Resident #207. The findings included: Review of the Policy & Procedures for Oxygen Administration documented, in part, to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident#207 medical records reveal resident was admitted to the facility on [DATE] with diagnoses to include Pulmonary Hypertension due to lung disease and Hypoxia, Heart Failure, Nonrheumatic Tricuspid Valve Insufficiency, Hypertension, Emphysema, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Review of the Admission/Medicare 5-day MDS (Minimum Data Set) dated 08/17/22 documents resident has a BIMS (Brief Interview for Mental Status) of 8, indicating mildly impaired cognition. Review of the physician orders revealed there was no order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure appropriate coordination of care for 1 of 1 sampled resident, Resident #73, reviewed for dialysis care, as evidenced by the resident was scheduled for a procedure to the dialysis fistula (access) and the facility staff did not ensure NPO (nothing by mouth) status; and failed to ensure pre and post dialysis assessments were completed for Resident #73. The findings included: Review of the policy, Hemodialysis Access Care, revised September 2010, documented, in part, Care of AVFs (arteriovenous fistula for dialysis access) . 4. To prevent infection and/or clotting: . d. Check for signs of infection at the access site when performing routine care and at regular intervals. g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. Review of the record revealed Resident #73 was admitted to the facility on [DATE]. Review of the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure ordered labs were completed for 2 of 6 sampled residents reviewed, Residents #35 and #3. The findings included: 1. Clinical record review for Resident #35 revealed an admission to the facility on [DATE] with diagnoses that included: Hypertension and Anemia. Additional record review evidenced a care plan dated 08/05/22 that indicated Resident #35 had Anemia, and interventions included: obtain and monitor lab / diagnostic work as ordered. Report results to MD [medical doctor] and follow up as indicated. Further record review indicated a physician order, dated 08/02/22, for a laboratory test of glomerular filtration rate (GFR) which is a blood test that measures how much blood your kidneys filter each minute. Resident #35's record lacked evidence of this lab test result. Review of the August 2022 medication and treatment administration records lacked documentation of this ordered lab. The August 2022 lab requisition book lacked evidence of this…

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.