Haines City Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement an effective infection control program related to 1. the use of Personal Protective Equipment (PPE) for one (#88) of one sampled resident for transmission-based precautions, 2. failed to ensure fingernails of staff were kept in a manner that prohibited the growth of microorganisms and allowed for sufficient hand hygiene, and 3. failed to ensure the storage of personal hygiene equipment for one resident (#91) out of ten sampled residents related to oral hygiene. Findings included: 1. On 11/18/24 at 9:14 a.m. an observation was made of a Contact precaution sign posted outside of Resident #88's room. The sign showed STOP - CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves 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.

Based on observation and interview, the facility failed to ensure a clean and comfortable environment by not maintaining and cleaning one (B Hall) of two community shower rooms. Findings included: On 11/18/2024 at 9:40 a.m., an observation was made of the B Hall community shower room. Upon entering the shower room, it was observed to be cluttered and disorganized. Located on the left-hand side just after entry was a restroom with a toilet and sink. Next to the room with the toilet, there was a shower with a curtain. On the other side of the room there were two sinks. The clutter of the room made it hard to get to the other two sinks. The clutter observed included a privacy curtain, various wheelchair parts, Hoyer lift, bedside commode and a walker. (Photographic evidence obtained). The observation of the shower room also included: 1. The foam mat laying on the top of the shower bed had a dried brown substance on the top. 2. On the shower bed underneath the foam mat and on the mesh part of the bed, there were dried brown and black objects as well as hair. 3. In a corner of the room…

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 ensure one (#61) of forty-eight sampled residents, was provided with personal hygiene fingernail care during at least three of four days observed (11/18/2024, 11/19/2024, 11/20/2024). It was observed all ten of the fingernails were found with dark debris and were long, cracked/chipped and leaving sharp edges. Findings included: On 11/18/2024 at 2:10 p.m., Resident #61 was visited while in her room. She was observed residing in a private room and was noted in her bed lying flat with the Head of Bed (HOB) approximately 30 degrees. Resident #61 was further observed with her hands placed on her lap, over the bed linen. All ten fingernails were observed elongated approximately ½ inch to ¾ inches, cracked and chipped with sharp edges. Further, the under nails were observed with build up of dark debris/matter. An interview with Resident #61 revealed she had impaired cognition, but was able to speak with regards to her daily routines and she was able to speak related to her personal hygiene and nail care. 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 observation, record review and interview the facility failed to ensure a hazarded free room environment, with (brand name) Air Freshener Spray found in one resident room, Resident (#99) out of eight residents sampled. Findings include: During an observation on 11/18/2024 at 10:00 a.m., and 12:41p.m., Resident #99's room was observed with the door open, where other residents were able to enter the room. Her dresser was observed with two air freshener sprays. The bathroom was observed with one additional air freshener spray on the bathroom rail over the toilet. During an interview on 11/19/2024 at 10:00 a.m., with Resident #99. She stated the staff took away her air fresheners today. She stated she has had her sprays on her dresser for about a month but was told by staff today they had to take it away because she is not allowed to have air freshener sprays in her room. Review of an admission Record dated 11/21/2024 showed Resident #99 was admitted to the facility originally on 6/4/2024 and readmitted 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 observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not maintaining the kitchen ceiling in one of one kitchen, repairing of holes in the walls of three resident rooms (#140, #145 and #181), and a stained floor, walls and privacy curtain and broken furniture in one resident room (room [ROOM NUMBER]) out of a total of 64 resident rooms. Findings included: 1. On 01/09/23 at 10:02 a.m., an initial tour of the kitchen was conducted. Three ceiling tiles were observed cracked and chipped in the area near the dish washing machine. In addition, multiple ceiling tiles above the food prep area were observed with an excessive amount of black buildup (Photographic Evidence Obtained). On 01/10/23 at 9:30 a.m., the Nursing Home Administrator reported they have had a Quality Assurance and Performance Improvement (QAPI) in place for building repairs since August 2022 and the kitchen ceiling was 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 observation, record review, and interview, the facility, 1. failed to ensure blood pressures were monitored adequately for a period of three months for one resident (#40) of five sampled residents, and 2. failed to ensure one resident (#98) receiving antibiotic treatment had a diagnosis listed, to indicate the purpose of the treatment of four residents reviewed for a UTI (urinary tract infection) diagnosis. Findings included: 1. A review of the admission Record revealed Resident #40 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. A review of the Order Summary Report with active orders as of 11/01/22 indicated the following order: Hydralazine HCL Tablet 25 MG (milligram)- Give 25 mg by mouth four times a day for hypertension, start date 9/25/22. Hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. A review of the Medication Administration Record (MAR) for November 2022, December 2022, 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, interview, and record review, the facility failed to ensure comprehensive assessments were accurately documented for one resident (#84) of 50 sampled residents. Findings included: A review of Resident #84's admission Record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and mixed receptive-expressive language disorder. A review of the facility's Minimum Data Set (MDS) Resident Matrix revealed physical restraints were used for Resident #84. A review of Resident #84's active physician's orders as of 1/12/2023, revealed an order, dated 8/25/2022 for an electronic monitoring device to the left ankle. A review of Resident #84's physician's orders did not reveal an order for use of physical restraints. A review of Resident #84's Quarterly MDS assessment, dated 10/6/2022, revealed under Section P: Physical Restraints, a physical restraint, categorized as other was used while in bed on a less than daily basis for Resident #84. The assessment also…

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 develop a care plan related to floor mats for one resident (#15) of fifty sampled residents. Findings included: A review of the admission Record revealed Resident #15 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to dementia, major depressive disorder, and unspecified abnormalities of gait and mobility. Review of Section C Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], indicated the resident was rarely or never understood. On 01/09/23 at 10:50 a.m., Resident #15 was observed sitting on the side of the bed attempting to get out of the bed. The bed frame was observed resting on the floor. A mattress was observed on the floor to the right of the bed and two stacked floor mats were observed on the left side of the bed (Photographic Evidence Obtained). On 01/11/23 at 4:47 p.m., the resident was observed in bed sleeping with the mattress on the right side of the bed 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 observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADLs) related to oral care, were provided for one resident (#91) of five residents sampled. Findings included: During facility tours conducted on 01/09/23 at 12:35 p.m., and 01/10/23 at 12:52 p.m., Resident #91 was observed in her room, laying on her bed. Resident #91's tongue was noted with a white substance all over the surface of her tongue and around her lips. Resident #91's lips were noted dry and chapped on the surface. The resident stated she remains in bed all the time and was dependent on staff for care. On 01/11/23 at 1:43 p.m., an interview was conducted with Resident #91. The resident stated she does not receive oral care every day. Resident #91 said, Some staff will just have me rinse my mouth with water and they do not use a toothbrush or toothpaste. Some of them use a sponge and wipe around the inside of my mouth. Resident #91 stated she did not know if she owned a toothbrush and stated she…

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 supervision for smoking and limited access to smoking materials for three residents (#58, #712, and #715) out of ten smokers as evidence by the observation of the three residents smoking unsupervised and the observation of smoking paraphernalia removed from resident rooms. Findings included: 1. An observation was conducted on 1/10/23 at 9:30 a.m., of Resident #58 with Staff H, Registered Nurse (RN). The resident was sitting in the courtyard against the exterior wall of the facility's D-wing. The resident was holding a lit cigarette which had approximately 1 left. An ashtray was not available to the resident in the immediate area. Staff H was the only staff member in the courtyard at the time of the observation and had arrived and then left the courtyard. Staff H did not address the unsupervised smoking with Resident #58. On 1/10/23 at 2:00 p.m. an observation was conducted in the courtyard of three residents (#58, #712, and #715)…

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 enteral nutrition in accordance with professional standards for one resident (#459) of two residents sampled for enteral nutrition needs. Findings included: A review of Resident #459's admission Record revealed Resident #459 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident #459's active physician's orders revealed an enteral feed order, dated 1/6/2023, for Glucerna 1.5 at 50 milliliters per hour (ml/hr) with water flush at 30 ml/hr for 20 hours, up at 2:00 PM - down at 10 AM. An observation was conducted on 1/10/2023 at 9:35 a.m. of Resident #459 in the resident's room. Resident #459 was observed resting in bed with the head of the bed elevated and enteral feeding running. An observation of Resident #459's enteral feeding pump revealed Glucerna 1.5 was being administered to Resident #459 at a rate of 55 ml/hr with water flush at 40 ml/hr. The same rate…

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, record review, and interview the facility failed to ensure the physician order for one resident (#17) out of five residents sampled for unnecessary medications was implemented following the recommendation of the consulting pharmacist. Findings included: The admission Record for Resident #17 indicated an admission date of 1/21/21 and included diagnoses not limited to unspecified sequelae of cerebral infarction, ischemic cardiomyopathy, and moderate recurrent major depressive disorder. An observation of Resident #17 lying in bed was conducted, on 1/9/23 at 12:23 p.m. The Medication Regimen Review (MRR) conducted on 10/29/22, identified a recommendation from the Consultant Pharmacist asking the physician to consider a gradual dose reduction, Alprazolam 0.5 milligram (mg) orally (po) every day (qd) for anxiety (anx). The Physician/Prescriber Response section indicated the physician agreed with the recommendation, was signed, and dated on 11/3/22 or 11/7/22 (date showed as a 3 or 7 written over the other number). The physician's progress note, dated 10/27/22 (2 days…

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 the medication error rate was less than 5.00%. Thirty- eight medication administration opportunities were observed, and twenty-three errors were identified for four (#43, #11, #27 and #3) of six residents observed. These errors constituted a 60.53% error rate. Findings included: 1. On 4/28/21 at 11:32 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #43. The electronic medication profile for Resident #43 was observed to be red-colored, which the staff member stated was due to the medications were late. Staff F was observed dispensing the following medications: - Acetaminophen[[NAME] 325 milligram (mg) - 2 tablets - Vitamin C 500 mg tablet - Clopidogrel 75 mg tablet - Docusate Sodium 100 mg softgel - Fish Oil 1000 mg softgel The staff member searched the medication cart for the Calcium - D3 tablet that was also due at 9:00 a.m. but was unable to locate so he…

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, record reviews, and interviews, the facility failed to ensure one of one kitchen was maintained in a clean and sanitary manner, one (Station #2) of two refrigerators in the pantry stations was maintained in a clean and sanitary manner, and temperatures were documented daily for the refrigerators and freezers in two pantry stations (Station #1 and Station #2) of two pantry stations. Findings included: On 04/27/21 starting at 9:50 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The white flap inside of the ice machine was observed with black buildup. The inside of the drink nozzle was observed with white buildup. An excessive amount of black buildup was observed above the food preparation area. An excessive amount of dust was observed on two ceiling vents above the food serving area (Photographic Evidence Obtained). The CDM stated that she spoke to maintenance on Friday (4/23/21), and he stated that he had to order replacement tiles for the ceiling. She then stated she spoke with maintenance about the whole ceiling…

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 honor the rights to a dignified existence by not ensuring that a resident's environment enhanced the quality of life for one resident (#77) of 43 sampled residents. Findings included: Observations of Resident #77's private room on 4/27/21 at 10:49 a.m. revealed that the resident's room was [NAME], with the closet empty and no dresser in the room. During the observation it was noted that there was a large box sitting on an armchair with personal items in it. While interviewing Resident #77, at this time, the resident reported that she had COVID-19 two weeks ago and that the facility moved her to her current room. She reported that all her belongings are in the cardboard box and that nothing was unpacked. An observation of Resident #77's private room on 4/28/21 at 12:25 p.m. revealed that her belongings were still in a cardboard box, and the room was still [NAME]. An interview with the resident confirmed that her belongings are still in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to implement the care plan for two residents (#49 and #94) out of forty-three residents sampled in regards to ensuring the resident (#49) was not isolated in her room and ensuring the resident (#94) had bilateral floor mats as ordered. Findings included: 1. A review of the admission Record for Resident #49 revealed the resident was admitted to the facility on [DATE] and 9/25/14. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, unspecified hand contracture, and aphasia following unspecified cerebrovascular disease. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident did not have a Brief Interview of Mental Status score, indicative of severe cognitive impairment. The MDS identified that Resident #49 exhibited physical behavioral symptoms directed toward others, (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1 to 3…

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 reviews, and interviews, the facility failed to provide restorative services per physician's orders for two residents (#30 and #49) out of the sampled forty-three residents. Findings included: 1. On 04/27/21 at 12:00 p.m., Resident #30 stated that he wanted to get out of bed to keep his legs strong. He stated that he only had therapy for 30 days and was not doing restorative. Resident #30 stated restorative staff are always doing other duties on the floor. He stated this was not fair to him because he was not ready to give up. On 04/28/21 at 11:03 a.m., Resident #30 reported that he had only seen restorative twice since he had been admitted into the facility. He stated that he wanted to stand to help keep his legs strong. Resident #30 stated he had probably been out of bed four times in the last three weeks, and he use to get up every day. He reported he had a stroke on the left side and does not want to get weaker. A review of the admission Record for Resident #30 revealed that he…

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 reviews, and interviews the facility failed to ensure weekly weights were obtained following weight loss for two residents (#94 and #27) out of four residents sampled for nutrition. Findings included: 1. Review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to gastrostomy status, other seizures, and unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], identified that the resident had a nasogastric or abdominal feeding tube (percutaneous endoscopic gastrostomy (PEG)) and received more than 51% of her total calories through a tube feeding. The Malnutrition, At Risk of Malnutrition, Morbid Obesity Screening Assessment, effective 3/31/21, indicated that Resident #94 was at risk for malnutrition. The Malnutrition Assessment identified that the most recent weight was 122.4 pounds (#) as of 3/30/21 and a Body Mass Index (BMI) of 20. The initial…

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, policy reviews, and interviews the facility failed to ensure respiratory equipment for two residents (#40 and #94) out of thirty residents who received respiratory treatments was stored in a sanitary manner for three of four days. Findings included: During an interview on 4/27/21 at 12:07 p.m., Resident #40 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine sitting on her bedside dresser. On top of the machine was a CPAP uncovered mask. The resident confirmed using the machine nightly. (Photographic Evidence Obtained) On 4/28/21 at 10:20 a.m., Resident #40 was observed sitting in a wheelchair in front of her bedside dresser. On top of the dresser was a CPAP machine with its mask and tubing sitting on top of it. The mask was not in a labeled bag. On 4/29/21 at 10:25 a.m., an observation indicated the Resident #40's CPAP mask was lying uncovered on top of the machine. A review of the admission Record revealed that Resident #40 was admitted to the facility 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, record reviews, and interviews, the facility failed to monitor side effects of psychotropic medications for two residents (#30 and #25) and failed to monitor behaviors for one resident (#25) out of the sampled five residents reviewed for unnecessary medications. Findings included: 1. A review of the admission Record for Resident #30 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified sequelae of cerebral infarction. A review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Section N Medications revealed that the resident received antipsychotics five days a week and antidepressants four days a week. The resident had the following active physician orders: Desvenlafaxine Extended-Release Tablet 24 hour 50 mg (milligram)- Give 1 tablet po (by mouth) one time a day for depression,…

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, record reviews, and interviews the facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner related to not ensuring medications were inaccessible to residents, unauthorized personnel and/or visitors during two of six observations of medication administration and failed to permanently affix two of two refrigerated narcotic boxes. Findings included: During the task of medication administration on 4/28/21 at 11:32 a.m., after dispensing medications for Resident #43, Staff F, Registered Nurse (RN), walked away from the medication cart to the nursing station, leaving a bottle of Fish Oil, Docusate Sodium, Tylenol (Acetaminophen), Vitamin C, and the blister card of Clopidogrel on top of the cart while it was unattended. On 4/28/21 at 11:49 a.m., Staff F retrieved Resident #11 from near the nursing station and assisted the resident into his room then administered medication to the resident. Staff F left the bottle of Multi-Vitamin with mineral tablets on the medication cart during the administration. 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 observations, interviews, and record review the facility did not ensure sufficient staff were available to provide meal assistance for five residents (#20, #52, #54, #55, and #66) during dining services, of 102 residents in the facility, on one of four hallways (the B Hall) for two of two days observed. Findings included: Resident #66 was admitted to the facility with a diagnosis of dementia, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #66 was rarely/never understood, and the Brief Interview for Mental Status (BIMS) could not be conducted, indicating severe cognitive impairment. Section G, Functional Status was reviewed and reflected that Resident #66 required extensive assistance of one staff member for eating. Resident #20 was admitted to the facility with a diagnosis of Alzheimer's disease, according to the face sheet in the admission record. Review of the MDS assessment dated 4/18//21, reflected Resident #20 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 interviews, record review, observations, menu review, and policy review the facility did not ensure cultural food choices were available for one resident (#61) of 43 residents sampled. Findings included: Resident #61 was admitted with a diagnosis of sepsis according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment, dated 3/1/21, reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #61 was cognitively intact. On 4/27/21 at 12:27 p.m. an interview was conducted with Resident #61. She said the food is always the same. It's green beans or corn every day, and mashed potatoes or pasta. She prefers Latin American food. No one has ever asked her about her preferences. Resident #61 reported that the alternate is a sandwich. A review of the Resident Profile, Company Name, Dietary Management System, dated 12/22/20 reflected no likes or dislikes were indicated for any of the meals. An observation was conducted on 4/27/21 at 12:37 p.m. during the lunch meal. Resident #61's lunch plate had mixed vegetables,…

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.