Palm Beach Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure right to privacy for Resident's person and records affecting Resident #9, #116, and #77, related to privacy curtains, loudly speaking residents's diagnosis, walking into resident rooms without permission and leaving residents naked. The findings included: 1) Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including: cancer, and bipolar disorder. The quarterly minimum data (MDS) assessment, reference date 03/27/24, recorded a Brief Interview for Mental Status score (BIMS) of 15, indicated the resident was cognitively intact. On 06/24/24 at 11:13 AM, an interview process was started with Resident #9.Tthe resident was observed to be alert and oriented. He explained that privacy is huge for him; sometimes when staff are providing activity of daily living care, to included bed bath, the staff don't close the curtain all the way, while his body was exposed while lying in the bed; sometimes people…

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 staffing calculations, the facility failed to ensure sufficient staffing as evidenced by identified care issues during this survey, voiced concerns from Residents #73, #31, #74, #63, #45, #221, and #104, documented low-weekend staffing, and concerns voiced in Resident Council. The findings included: 1) During this recertification survey, the following issues, potentially related to the lack of staff, were identified and noted: a) Failure to ensure timely and proper incontinence care for Residents #47 and #66, failed to ensure shower and shampooing hair for Resident #74, and failed to ensure nail care for Resident #8. (Refer to F677 and F690). b) Failure to ensure timely and appropriate respiratory care for Residents #78, #51, #31, and #82. (Refer to F695). c) Failure to ensure palatable and hot food as voiced by Residents #82, #89, #93, and #77. (Refer to F804). d) On 06/24/24 at 11:57 AM it was noted the Second Floor Unit Manager was working as the direct care nurse for…

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 interviews, the facility failed to ensure a clean, comfortable and homelike environment for residents on 3 of 4 units. The findings included: During the initial tour of the facility which began on 06/24/24 at 9:30 AM, the following concerns were observed by the survey team: 1) room [ROOM NUMBER] - The foot of Bed A has a chunk of wood missing from the right side of the footboard, leaving jagged edges. Photographic Evidence Obtained. 2) room [ROOM NUMBER] - The top border of the vertical blinds covering the resident's window was off and positioned upright on the floor in the corner of the room. Photographic Evidence Obtained. 3) room [ROOM NUMBER] - The privacy curtain separating Bed A from Bed B had a large, brown stain on bottom, right section of the curtain; and the pole holding tube feeding bottle had residue smeared on the display screen. Photographic Evidence Obtained. 4) room [ROOM NUMBER] - The air-conditioning vent had dust build up in the top and side vents. A small roach 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 policy review, observation, record review, and interview, the facility failed to respond to a voiced complaint for 1 of 1 sampled resident. Resident #38 voiced a concern about her roommate to staff with no further action or response taken. The findings included: Review of the policy Social Services - Grievance Process revised 02/21/23 documented in part, Purpose: It is the policy of this facility to support the resident's right to voice grievances without discrimination or reprisal. Definitions: 1. Grievance is defined as a concern that cannot be resolved to the satisfaction of the person making the objection at the bedside or immediately. Grievances are formal written or verbal complaints . General Guidelines: 1. the Facility Grievance Coordinator is the Director of Social Services . 4. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Coordinator. Procedure: 1. The facility shall implement a process whereby when there is a grievance, it should be: 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 record review and interviews, the facility failed to ensure timely, accurate, and complete Preadmission Screening and Resident Record Review (PASSARs) for 3 of 4 sampled residents reviewed for PASARR's (Residents #64, #78, and #94). The findings included: 1) Resident #64 was admitted to the facility on [DATE] with diagnoses including Psychosis and Dementia. No completed Level 1 PASSAR was found in Resident 64's electronic record. On 06/26/24 at 1:54 PM, a request was made to the Social Services Director for a copy of the PASSAR for Resident #64, since one could not be located in the Resident's electronic record. On 06/27/24 at 11:30 AM, the Social Services Director brought a copy of the PASSAR that had been completed by her on 06/27/24. No previous copy of Resident #64's PASSAR was provided. 2) Resident #78 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including Parkinsonism and Psychosis. A review of Resident #78's Level I PASSAR, completed on 06/22/23, was not completed in its…

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 activity of daily living (ADL) care for 3 of 7 sampled residents related to incontinence for Resident #45, hair shampoo and incontinence care for Resident #74, and nail care for Resident #8. The findings included: 1) Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Vascular Accident (CVA), one-sided weakness (Hemiplegia) and depression. The quarterly Minimum Data Set (MDS), assessment, reference date 04/19/24, recorded a brief interview for mental status (BIMS) score of 08, which indicated Resident #45 was moderately cognitively impaired. This MDS recorded the following mood: Feeling down, depressed, or hopeless. Trouble falling or staying asleep or sleeping too much. Feeling tired or having little energy. Poor appetite or overeating. No behavior concern was recorded. The MDS also recorded Resident #45 required supervision or touching assistance with toileting hygiene.…

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 follow physician orders related to blood pressure parameters and failed to obtain blood pressure and heart rate vital signs for 2 of 5 sampled residents reviewed for medication usage (Residents #40 and #73), and failed to ensure the provision of medications for 1 of 1 sampled resident who voiced complaints (Resident #82). The findings included: 1) Review of the record revealed Resident #40 was admitted to the facility on [DATE]. Review of the current orders revealed Midodrine (a medication for low blood pressure) was ordered as of 12/23/23, to be given three times daily. This order documented nursing staff were to hold the medication is the resident's systolic blood pressure (the upper number) was above 130. Review of the current Medication Administration Record (MAR) for June 2024 documented the following: a) On 06/18/24 at 2200 (10 PM) the resident's blood pressure was 131/76, and the medication administered. b) On 06/22/24 at 1400 (2 PM) 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, observation, interview and policy review, the Facility failed to timely provide the prescribed eyeglasses for 1 of 2 residents sampled for vision (Resident #35). The Findings included: Resident # 35 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Chronic Atrial Fibrillation, Shortness of Breath, Type 2 Diabetes. She had undergone Cataract Surgery on 05/10/2023. Record review on 05/07/2024 of the Minimum Data Set (MDS), Section C revealed this resident received a score of 13 indicating good cognitive function on the Brief Interview for Mental Status (BIMS). Section B showed adequate vison. Additional vision assessment showed resident's ability to see adequate light with glasses or other visual appliances. Corrective lenses (contacts, glasses, or magnifying glass) were used in completing this vision assessment. During an interview on 06/25/2024 at 10:00 AM, the resident stated she is unable to read because the facility did not give her the prescribed…

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 policy review, record review, observation, and interview, the facility failed to ensure proper incontinence care for 1 of 4 sampled residents reviewed with a history of Urinary Tract Infections (UTIs) (Resident #66). The findings included: Review of the policy Nursing - Perineal Care (care provided to a resident after an incontinent episode) revised 02/21/23 documented, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure . For a female resident: e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Review of the record revealed Resident #66 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent upon staff for toileting and was always incontinent of bowel and bladder. Review of the physician orders…

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 policy review, record review, observation, and interview, the facility failed to ensure oxygen care and services for 4 of 5 sampled residents (Residents #78, #51, #31, and #82). The findings included: Review of the policy Nursing - Oxygen Administration effective 04/01/22 documented, General Guidelines: . 5. All disposable equipment labeled with the resident's name, the date it was opened or provided, and should be changed a minimum of every 7 days. 1) Review of the record revealed Resident #78 was admitted to the facility on [DATE] and moved to his current room on 05/14/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident was on continuous oxygen. This MDS documented the resident was totally dependent upon staff for all activities of daily living (ADLs) and had functional limitation in range of motion to all extremities. During an observation on 06/24/24 at 11:14 AM, Resident #78 was lying in bed with the oxygen concentrator running at 3 liters per minute.…

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 medication error rate was 7.69 percent. Two medication errors were identified while observing a total of 27 opportunities, affecting 2 of 6 residents observed (Residents #64, and #57). The findings included: 1) A medication administration observation for Resident #64 was made on 06/27/24 beginning at 5:33 PM with Staff U, Licensed Practical Nurse (LPN). The LPN poured two Tylenol 325 milligram (mg) tablets into the medication cup followed by one 500 mg Methocarbamol (a muscle relaxant) tablet. The LPN poured a cup of water and locked the medication cart. When asked if that was all that was due at that time, the LPN's response was yes. When asked how many pills the nurse had poured into the medication cup for administration, the LPN stated three. The LPN provided the three pills to Resident #64 and continued on with her medication pass. During the reconciliation of medications, the record revealed the current order for the Methocarbamol 500 mg was to give two tablets. During an interview on 06/27/24 at 6:19 PM, when asked 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 record review and interview, the facility failed to ensure laboratory services for 2 of 5 sampled residents as evidenced by the failure to obtain a urine sample from Resident #66 three times as per physician order, and failure to obtain the most recent blood work for Resident #73. The findings included: 1) Review of the record revealed Resident #66 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively impaired and always incontinent of urine. Review of the orders, lab results, Treatment Administration Record (TAR), and corresponding progress notes revealed the following: a) An order dated 12/24/23 documented staff were to obtain urine for a urinalysis. A corresponding nursing progress note dated 12/24/23 at 8:23 PM documented the family reported the resident was complaining of pain when urination. This note further documented upon assessment by the nurse, Resident #66 said it was very painful and with a burning…

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 reviews, and a review of the grievance logs, the facility failed to ensure that residents were served food at a palatable temperature for 3 of 15 sampled residents with voiced food concerns (Residents #82, #89, and #77), and 4 residents from Resident Council who voiced food concerns also (Residents #88, #84, #14, and #15). The findings included: 1) During an interview on 06/27/24 at 5:48 PM. Resident #82 was asked how the temperature of his dinner was. The resident responded, It's a little warm today. Sometimes it's cold, not every day. When asked how often the food was cold the resident answered, half and half. Review of the Minimum Data Set assessment dated [DATE] showed that Resident #82's Brief Interview for Mental Status (BIMS) score was 15. This indicated that the resident was cognitively intact. 2) An interview with Resident #89 on 06/27/24 at 6:02 PM revealed that when she was asked how the temperature of her dinner was, she responded: Most times it's warm, sometimes it's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to provide foods per preferences for 5 of 15 sampled residents with voiced food concerns (Residents #104, #63, #77, #73, and #107). The findings included: Review of the policy Dining and Food Preferences, revised 9/2017, documented that food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 1) In an interview on 06/27/24 at 10:24 AM Resident #104 was asked if she likes the food here. She said she was served foods that she doesn't like, and orange juice every morning that she will never drink because of her diabetes. 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 policy review, record review, observation, and interview, the facility failed to follow Infection control practices during a blood sugar check for 1 of 2 sampled residents observed as evidenced by the failure to properly disinfection the glucometer (machine used to obtain the blood sugar level from a blood sample) (Resident #4), and failed to properly utilize personal protective equipment (PPE) for 1 of 2 sampled residents observed on Enhanced Barrier Precautions (EBP) (Resident #31). The findings included: 1) The facility's practice was to disinfect the glucometers after each use as per manufacturer's instructions on the disinfectant wipes. Review of the manufacturer's instructions for the MicroKill Bleach wipes used by the facility, indicated a three minute wet time to kill all organisms, including blood born pathogens. An observation of a blood sugar check was made for Resident #4 on 06/27/24 at 5:46 PM with Staff U, Licensed Practical Nurse (LPN). The LPN gathered the needed items, including 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 and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 2 of 2 residential living areas (First and Second Floors) . The findings included: During the environmental tour conducted on 05/09/23 at 1 PM and 05/10/23 at 11 AM, accompanied with the Director of Housekeeping, the following were noted: First Floor: room [ROOM NUMBER]: Bathroom walls require repainting. room [ROOM NUMBER]: Exterior of sitting chair was heavily worn. Room#104: No television remote (D-bed). room [ROOM NUMBER]: Room wall clock was not set at the correct time, and room walls was noted to be in disrepair and peeling paint. room [ROOM NUMBER]: Room furniture (chair and side tables) were worn and in disrepair. room [ROOM NUMBER]: Bathroom door was in disrepair. North Shower Room: No privacy curtain for shower stall. Hallway Linen Cart: The exterior cover had numerous areas of large tears. room [ROOM NUMBER]: Room walls in…

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 physician prescribed fluid restrictions for 3 (Resident #133, #119, and #276) of 3 sampled residents. The findings included: Review of the facility's Nutritional Services and Nursing Services Procedure (October 2019:- Page 15 of 43) noted the following: Policy: Fluid Restitutions shall adhere to a structured and planned allotment of fluids as prescribed by the physician. Policy Interpretation and Implementation: #4: Water pitchers will be removed from the resident's room. Beverage preferences will be obtained and reflected on the resident's meal ticket/tray card. #7: Nursing services will maintain documentation of fluids accepted with meals and medications. #8: Compliance or failure to follow physician orders shall be documented in the medical record as deemed necessary and communicated to the physician in a timely manner. 1) During the observation of the Lunch meal on 05/08/23 at 12:30 PM, it was noted the meal tray was served 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 interview and record review, the facility failed to report an allegation of resident to resident misappropriation of funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11). The findings included: A review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 11/2019, documented: All suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the event must be reported no later than 24 hours after the allegation is made. Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required limited one-person assist with activities 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 interview and record review, the facility failed to take corrective actions addressing misappropriation of a resident's funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11). The findings included: A review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 11/2019, documented: Prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. The center has procedures to identify, correct, and intervene in situations in which abuse, neglect/misappropriation of resident property is most likely to occur. This includes an analysis of features of the physical environment that may make abuse/neglect more likely to occur, such as secluded areas of the center. Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required…

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, that the facility failed to provide services that included Speech Therapy, Dietary Services, Social Services, and Dental Services to ensure that 1 (Resident #122) of 9 sampled residents reviewed for nutrition maintained their ability to self feed independently. The findings included: During the initial screening of Resident #122 on 05/08/23 at 10 AM, the resident was noted to be alert, oriented, and responding to the surveyors questions. The resident stated to the surveyor that he was admitted to the facility approximately one month ago. The resident further stated that the hospital lost his dentures upon discharge to the facility. He further stated that he has been in gum pain continuously when attempting to eat foods provided by the facility and has informed staff of the denture issue on a couple of occasions. During the observation of the lunch meal on 05/08/23 at 12:15 PM it was noted that the resident was served a No Added Salt diet that was 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 interview and record review, the facility failed to acquire lab results prior to administering an anticoagulant (blood thinner) to 1 of 5 sampled residents reviewed for unnecessary medications (Resident #24). The findings included: Record review revealed Resident #24 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment, and required extensive one-person assist with activities of daily living. A review of Resident #24's physician orders revealed an order dated 04/02/23 for Warfarin 5 milligrams (mg) every evening (6:00 PM) for Atrial Fibrillation. Resident #24 was care planned for anticoagulant therapy. Interventions included to administer as ordered and labs as ordered. Further review of Resident #24's orders revealed an order dated 04/15/23 for PT/INR (blood clotting labs) on 04/16/23. A review of Resident #24's Medication Administration Record (MAR) revealed Warfarin 5 mg was administered on 04/16/23 at 6:00 PM. 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 record review and interview, the facility failed to respond to a urine culture results in a timely manner for 1 of 1 sampled residents reviewed for Urinary Tract Infection (UTI) (Resident #24). The findings included: Record review revealed Resident #24 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment, and required extensive one-person assist with activities of daily living. A further review of Resident #24's records revealed a progress note dated 04/12/23 at 11:58 PM, documented: During round resident was observed using urinal dark brownish urine smell fish like noted. MD made aware order was received for urine analysis and culture. Fluids encouraged no complaint voiced per patient. Will continue to monitor. A review of Resident #24's progress note dated 04/18/23 at 11:12 AM documented: MD made aware of (resident) appearing confused and urine culture results and ordered Augmentin 875-125 mg (antibiotic), 1 tab every…

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, observation and record review, the facility failed to accurately document controlled mediations for 3 of 5 residents (Resident #41, Resident #115, and Resident #132). The findings Included: The facility's policy and procedure titled, 7.0 Best Practices for Medication Dispensing: Scheduled II Narcotics has a subsection H. Dispensing of Controlled Dangerous Substances (CDS). The subsection has a numbered list of entries. Entry #5 states When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the inventory sheet the date of administration, the quantity administered, the amount of medication remaining, and his/her initials. 1. On 05/10/23 at 12:10 PM, a side-by-side review of Controlled Medications, for the first floor Medication Cart #1, was conducted with Staff A, a Registered Nurse (RN). Staff A was instructed to pull a card of controlled medications for two residents, one at a time, to be checked against the Controlled Medication Log. Resident #115's card was the second card…

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 medication error rates were not 5% or greater. The facility had a medication error rate of 13.79%. Four (4) medication errors were identified while observing a total of 29 opportunities, affecting Resident #21. The findings included: A medication administration observation was conducted on 05/09/23 at 9:06 AM with Staff Z, an agency nurse. Staff Z gathered medications for Resident #21. Staff Z admitted to not having a multi-vitamin, a stool softner, and a calcium pill on hand as ordered for Resident #21. Staff Z continued to administer the remainder of the medications due to the resident at that time. Staff Z was observed handing a nasal inhaler to the resident, without any instructions. Resident #21 was observed instilling 2 sprays of the nasal spray in each nostril. An interview was conducted with the Director of Nursing (DON) on 05/09/23 at 12:30 PM. The DON stated Staff Z was an agency nurse who informed her of missing medications for Resident #21. The DON stated the medications were over 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.