Highlands Lake Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to outside provider appointments for 2 residents (#87 and #135) out of 2 sampled residents. Findings included: 1. Review of Resident #87's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease and vascular dementia. An interview was conducted on 03/04/24 at 11:11 AM with Resident #87 (Resident Council President) she said she has concerns related to appointments. She said her throat is sore and she is supposed to go see an Ear Nose Throat (ENT) Physician. She said the doctor thought she might've had a small airway and when she was sick and got intubated it might've caused some damage so the doctor wanted me to see an ENT and it's been two months. She said she still does not have an ENT…

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 treatment and care to meet the needs of residents by 1.) failing to ensure alterations in skin were identified and treated for one resident (#316) of two residents sampled for skin conditions, and 2.) failed to ensure residents were assessed for a change in condition for one (#366) of five residents sampled for discharges. Findings included: A review of Resident #316's medical record revealed Resident #316 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnosis of sepsis, urinary tract infection, and Diabetes Mellitus. An observation was conducted on 3/5/2024 at 9:09 AM of Resident #316 in the resident's room. Resident #316 was observed resting in bed and dressed in a hospital gown. Resident #316 was observed to have several red colored abrasions on the upper right side of his chest. The skin surrounding the abrasions was observed slightly red in color. A review of Resident #316's physician's 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 observations, record review, and interviews, the facility failed to ensure physician orders were obtained related to care and services for catheters, and catheters were appropriately covered for 1 (#218) of 3 residents sampled for catheters. Findings included: Review of Resident #218's record revealed he was admitted to the facility on [DATE], with diagnosis that included stage 5 chronic kidney disease, polycystic kidney, and malignant neoplasm of prostate. Observations of Resident #218 on 03/04/24 at 10:48 AM from the hallway revealed a catheter bag hanging on the side of the bed, with urine visible and no privacy bag noted. Review of the residents record revealed there were no current orders for a catheter or for catheter care. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of March 2024 revealed there was no documentation indicating monitoring or provision of care to the residents catheter. Review of the resident care plan revealed…

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 related to Intravenous (IV) fluids were provided for a one resident (#68) out of 1 of four residents with IV access in the facility. Findings included: Observations on 03/04/24 at 10:20 AM of Resident #68 revealed the resident sitting up in his bed. An empty Intravenous (IV) bag was noted hanging at his bed side, but not connected to the peripheral line. During an attempt to interview the resident at this time, the resident was unable to verbalize why or how long he has had the peripheral line. Observations on 03/04/24 at 03:48 PM of Resident #68 revealed the resident seated in his wheelchair next to his bed. The empty IV bag was noted to be hanging at the bed side, but not connected to the peripheral line. Continued observations of Resident #68 at this time revealed the peripheral line inserted into the residents right hand and the dressing noted to be soiled, lifting and with no date. Review of Resident #68'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 observations, interviews, and record reviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice by failing to ensure respiratory equipment was stored in a sanitary manner for two (#218 and #103) of two residents sampled for respiratory care. Findings included: Observations of Resident #218 on 03/04/24 at 10:48 AM revealed a CPAP (continuous positive air pressure) machine on the resident's nightstand. Closer observations at this time revealed the CPAP mask laying unbagged face down on the nightstand. Observations on 03/05/24 at 11:45 AM revealed the resident's CPAP mask laying unbagged, face down on the residents nightstand. Review of Resident #218's record revealed he was admitted to the facility on [DATE]. The record revealed there was no current order for the use of the CPAP, no current order for the care of the CPAP and no care plan in place for the use, monitoring and care of the CPAP. Review of the history and physical dated 3/1/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to ensure physician ordered pain medication was prescribed for one resident (#72) out of three residents sampled. Findings Included: During an observation on 03/05/24 at 11:59 AM., Resident # 72 was observed in the hallway, fully dressed, propelling in her wheelchair towards Staff M, Licensed Practical Nurse (LPN). Resident #72 said she was in a lot of pain since last night and she has not received any of her pain medicine. She said that she has been waiting for her pain medication all night and the nurse told her that they did not have her medication. Resident # 72 was presented with signs of distress on her face. During an observation on 03/06/2024 at 2:00 PM., Resident was observed laying down in her bed with her feet placed on her wheelchair. She said she finally received her pain medication yesterday after having to ask for it multiple times. She said the nurses told her she was not able to receive her pain medication because they did…

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 maintain a medication error rate of less than 5%. A total of 25 medication administration opportunities were observed with 3 medication errors for two (#84 and #61) of three residents sampled for medication administration, which resulted in a medication administration error rate of 12%. Findings included: A review of Resident #84's medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus and hypertension. A review of Resident #84's physician's orders revealed the following orders: - An order, dated 2/9/2023 for Aspirin 325 milligrams (mg) by mouth (PO) one time a day. - An order, dated 2/9/2023 for Citalopram Hydrobromide 20 mg PO one time a day. - An order, dated 6/22/2023 for Divalproex Sodium 125 mg PO every morning and at bedtime. - An order, dated 2/13/2023 for Cholecalciferol 1000 units PO one time a day. - An order, dated 1/18/2024 for Insulin Glargine 100 units/milliliter…

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

Based on observations, interviews, and review of facility policy, the facility failed to ensure proper storage, labeling, and security of medications and biologicals in one of four treatment carts in the facility, three of seven medication carts in the facility, and two of three medication rooms in the facility. Findings included: An observation was conducted on 3/6/2024 at 8:22 AM in the 100 unit of the facility. A medication cart was observed in the unit hallway with a medication cup containing crushed medications on top of it. A resident was observed in a wheelchair next to the medication cart. No staff were observed at the medication cart at the time of the observation. Staff D, Registered Nurse (RN) was observed approaching a treatment cart down the hallway from the medication cart and gathering treatment supplies. Staff D, RN approached the medication cart and an interview was conducted. Staff D, RN stated the crushed medications in the medication cup were for the resident observed near the medication cart. Staff D, RN also stated while preparing the medications, she noticed…

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 maintain an accurate medical record by documenting treatments, which were not completed, for one (#103) of fifty two sampled residents. Findings included: A review of Resident #103's medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and chronic obstructive pulmonary disease. A review of Resident #103's physician's orders revealed an order, dated 10/25/2023, for oxygen at 2 liters per minute (LPM) via nasal cannula, as needed for shortness of breath per resident preference. Resident #103's physician's orders also revealed an order to change oxygen tubing/mask/bag weekly and as needed. An observation was conducted on 3/5/2024 at 10:00 AM in Resident #103's room. Resident #103 was observed resting in bed with an oxygen nasal cannula in place. Resident #103 stated she would usually wear her oxygen at night, but not during the daytime. An observation of Resident #103'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.

Based on observations, interviews, and review of facility policy, the facility failed to maintain an effective infection control and prevention program by 1.) failing to ensure hand hygiene was performed during medication administration and 2.) failing to ensure medications were dispensed in a sanitary manner for one (#84) of three residents observed during medication administration. Findings included: An observation of medication administration was conducted on 3/6/2024 at 8:30 AM with Staff D, Registered Nurse (RN) on the 100 unit of the facility. Prior to the observation, Staff D, RN was observed at a treatment cart near the end of the hallway after assisting a resident. Staff D, RN was not observed performing hand hygiene after handling items in the treatment cart or prior to the observation of medication administration. Staff D, RN reached into her pocket, removed the medication cart keys, and opened the medication cart before preparing the following medications for administration to Resident #84: - Aspirin 325 mg PO, one tablet. - Citalopram Hydrobromide 20 mg PO, one tablet.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to provide a safe and home like environment for one resident (#154) out of 19 residents sampled. Finding Include During an observation on 03/04/2024 at 10:00 AM., Resident #154 was observed laying down in bed with an extension cord in her bed. She said that she uses the cord so that all her electronics can be plugged in to a location that she can reach. She said she has had her extension cord for a while, and she always places it in her bed. She said no one has told her that she the cord is a safety hazard and that she cannot have the cord in her room. During an observation on 03/05/2024 at 2:00 PM., Resident was observed laying down in bed with her call light in reach. Resident extension cord was observed on top of her dresser. She said staff moved her cord so that she can have a bed bath, but staff will put it back in her bed later today. During an interview on 03/06/24 at 04:01 PM with the Maintenance Supervisor. He said residents are not supposed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain an effective pest control program, so the facility was free of pests when one resident (#90) was observed with black ants crawling on him while in bed out of 52 residents sampled. Findings included: Review of Resident #90's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Alzheimer's Disease, muscle weakness, lack of coordination, Type 2 diabetes with foot ulcer, and acquired absence of left great toe. An observation was conducted on 03/05/24 at 2:05 PM. Resident #90 was observed to be lying in bed. Resident #90 was observed to have one small black ant crawling on his sheet over his lap. Staff O, Human Resources (HR) came into the room and pinched the small black ant located on the resident's bedsheet which was laying over his lap. She also confirmed there was another small black ant crawling on his bed next to his shoulder. She stated she was going to get…

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 working systems were in place related to food choice, communicating menu options to residents, and assessing for food preferences for eleven (Residents #5, #65, #35, #63, #30, #117, #234, #103, #45, #23) out of 52 sampled residents. Findings included: 1. An interview was conducted with Resident #117 on 11/15/21 at 10:49 a.m. She said the facility did not offer her food choices for her meals, said there was no option to select preferences from a menu, and said, they just bring what they bring. Resident #117 was observed during lunch meal on 11/16/21 at 12:50 p.m. Her tray and meal ticket revealed an entrée of cheese enchiladas, Spanish rice, vegetable blend, and cornbread. The resident said she did not like rice. The meal ticket did not reveal any listing of likes or dislikes. A review of the resident's medical record revealed she was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] revealed a Brief…

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 that dignity was maintained related to catheter care for one resident (#374), of 10 residents sampled. Findings Included: On 11/15/21 at 10:44 a.m., an interview was conducted with Resident #374. She was observed sitting in her wheelchair with a [urinary] catheter bag containing amber colored urine, attached to the back of the chair. The [urinary] catheter bag was observed without a privacy bag. Photographic evidence obtained. On 11/16/21 at 11:08 a.m., an observation of Resident #374 was made. Resident #374 was in bed with room door open. The [urinary] catheter bag containing amber colored urine, was observed from doorway, without a privacy bag. Photographic evidence obtained. On 11/17/21 at 9:09 a.m., an observation of Resident #374 was made. Resident #374 was sitting in her wheelchair with the room door open. The [urinary] catheter bag containing amber colored urine, was observed hanging from the back of her wheelchair. The [urinary] catheter bag was observed without a privacy bag. Photographic…

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 that the Nursing Home Transfer and Discharge Notice form was provided to the appropriate parties and failed to ensure that the State Long-Term Care Ombudsman received a copy/notification of the Nursing Home Transfer and Discharge Notice for two (#95, #44) of three residents reviewed for admission, transfer, and discharge rights. Findings included: 1. A review of Resident #44's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had an unplanned transfer to an acute care center on 10/15/21. The resident was readmitted to the facility on [DATE]. A review of the facility's Nursing Home Transfer and Discharge Notice revealed a date the notice was given as 10/15/21, the effective date was not decipherable. Page 2 of the Nursing Home Transfer and Discharge Notice under the section that required signatures of the physician was blank. In addition, the section indicating, Notice received by; Resident or…

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 that at the time of transfer of a resident to the hospital or therapeutic leave, the Resident/Representative was provided with a written notice that would indicate the duration of a bed-hold for one (Resident #95) of three residents reviewed for admission, transfer, and discharge rights. Findings included: A review of Resident #95's clinical record revealed she had been discharged from the facility to the hospital on [DATE] and 11/15/21. On 11/18/21 at 1:16 p.m., the Social Service Director, Staff B provided the bed hold notices for 09/21/21 and 11/15/21. Review of the notices revealed no resident or representative signatures indicating receipt of the notices. An interview was conducted with Staff B on 11/18/21 at 1:43 p.m. He confirmed the bed hold notices were not signed by the resident or representative and confirmed that the signatures that were present on the form belonged to facility staff. He said he had not found any evidence in any…

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, interviews, observations, and policy review the facility did no ensure weight loss was identified and addressed in a timely manner for two residents (#47 and #224) of six residents sampled for nutrition. Findings included: 1. Resident #47 was admitted to the facility with a diagnosis of right femur fracture, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating his cognition was intact. A review of Section K, Swallowing/Nutritional Status, reflected a weight of 238 pounds. Review of the physician's orders in the electronic medical record reflected a diet order dated 8/13/21, Regular diet, regular texture. Review of the weight record in the medical record showed the following weights: 8/13/21 238 lbs. (pounds) 9/5/21 237 lbs. 9/16/21 216 lbs. 10/7/21 221 lbs. 10/14/21 225 lbs. A warning indicated a 5% weight loss in 30 days. 11/4/21 201 lbs. A warning…

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 and observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three (Residents #65, #68 and #176) of 18 sampled residents related to the use and storage of oxygen masks and tubing. Findings included: 1. Review of Resident #176's medical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included acute systolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease with acute exacerbation, moderate persistent Asthma, and solitary pulmonary nodule. Observations of Resident #176 on 11/15/21 at 12:45 p.m., revealed that she was sitting up in her wheelchair next to her bed with oxygen (O2) running via nasal cannula. Closer observations revealed the oxygen tubing lying across the floor. Continued observation of the resident's room at this time revealed that the resident had a night stand next to her bed close to the window. It was noted that the resident had a Continuous Positive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not ensure two (Residents #123 and #225) of five residents reviewed for medication availability, received their physician ordered medications. Findings included: A review of the face sheet in the admission record for Resident #123 revealed an admission diagnosis of respiratory failure with hypercapnia and COPD (chronic obstructive pulmonary disease). An observation was conducted on 11/16/21 at 9:34 a.m. during medication administration with Staff A, LPN (licensed practical nurse) for Resident #123. During the observation an interview was conducted with Staff A, LPN who stated that there was an inhaler, Wixela, being sent for Resident #123 after the insurance approved it. It had not arrived yet. Staff A, LPN said the Wixela inhaler was ordered on the tenth. She said the insurance had to approve it. Staff A, LPN said she was not sure if Resident #123 had it and it ran out. But it was ordered the ninth. This inhaler takes awhile. She did not know the reason. A…

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

Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for one (Resident #123) of four residents with twenty-seven opportunities observed during medication administration, resulting in a medication error rate of 7.41%. Findings included: A review of the face sheet in the admission record for Resident #123 reflected an admission diagnosis of respiratory failure with hypercapnia and COPD (chronic obstructive pulmonary disease). An observation was conducted on 11/16/21 at 9:34 a.m., during medication administration with Staff A, LPN (licensed practical nurse). During the observation, an interview was conducted with Staff A who stated that there was an inhaler, Wixela, being sent for the resident after the insurance approved it. It had not arrived yet. Staff A prepared medications for Resident #123. After knocking on the door and announcing herself, Staff A put on a pair of gloves and gave Resident #123 her pills with water. Next, Staff A removed a small volume nebulizer (SVN) mask from a bag dated 11/15/21 and squeezed…

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 review of the facility policy, the facility did not ensure that refrigerated controlled Schedule II-IV medications were secured in a locked and permanently affixed compartment in 3 (Park Place, [NAME] Point, and [NAME] Court) medication storage rooms of 3 medication storage rooms. Findings included: On 02/27/20 at 11:48 a.m. the Park Place medication storage room was observed with Staff B, Registered Nurse (RN). An unlocked refrigerator was observed to be opened by Staff B, RN. A locked black plastic box, approximately 4 inches x 18 inches, was observed on the second shelf inside the refrigerator and was not permanently affixed. The black box was taken out, placed on the countertop and unlocked by Staff B, RN. Observed inside the box was a labeled plastic bag that contained a small bottle of oral Ativan, a Schedule IV medication. (Photographic Evidence Obtained). The medication and the box were placed back into the refrigerator. On 02/27/20 at 11:55 a.m. the [NAME] Point…

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, interviews, and policy review the facility did not ensure that the medication error rate was less than 5 percent in regards to 6 errors in 27 opportunities for one resident (#278) out of 7 sampled residents, resulting in a 22.2%. medication error rate. Findings included: Resident #278 was admitted to the facility with a diagnosis of congestive heart failure (CHF), according to the face sheet in the admission record. On 2/28/20 at 10:10 a.m. an observation was conducted during medication administration with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN poured medications for Resident #278, including spironolactone 25 mg (milligrams), furosemide 20 mg, sertraline 25 mg, glucosamine chondroitin complex two pills, omeprazole 40 mg, and losartan potassium 25 mg. Resident #278 came into the hallway where Staff E, LPN was pouring her medications, and was heading to therapy. Staff E, LPN told Resident #278 she was preparing her medications. Resident #278 waited next to the medication cart where Staff E, LPN was preparing the medications. 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.