Nspire Healthcare Plantation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the medication error rate was 8 percent. Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #119. The findings included:Review of Resident #119's clinical record documented her admission was on 01/30/26. The resident's Minimum Data Set (MDS) admission assessment dated [DATE] documented the Resident's diagnoses included Deep Venous Thrombosis, Hypertension, and Anxiety Disorder. Her Brief Interview for Mental Status (BIMS) was 15 which indicated she was cognitively intact. On 03/02/26 at 9:01 AM, medication administration observation for Resident #119 with Staff M, Licensed Practical Nurse (LPN), was performed. Medications ordered and due were:Klonopin 0.5mg(milligrams) 1 by mouth twice a dayBuspirone 150mg give 300mg by mouth one time a dayMetoprolol Tartrate 25 MG Oral Tablet 1 tab twice a dayEscitalopram 20 MG Oral Tablet once a dayApixaban 5 MG Oral Tablet 1 twice a day Staff M took the…

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

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI) failed to demonstrate that effective plans of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficiencies in F812 food procurement, store, prepare and serve. These repeated deficient practices have the potential to affect all 110 residents residing in the facility at the time of this survey. The findings included:Review of the facility's survey history revealed the facility was cited at F812 during the Recertification surveys with exit dates of 12/2020, 02/2022, 06/2023, and 08/22/2024. During an interview with the facility's Administrator on 03/04/26 at 1:20 PM, the Administrator was apprised that this deficiency will be cited again on this current survey. The Administrator was asked if he had a Performance Improvement Plan (PIP) as part of the QAPI program for this deficiency and he stated he did not. He was asked if education was being done and/or audits were being done regarding…

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 perform appropriate hand hygiene during medication administrations for 2 of 6 residents, for Residents #79 and 18, and failed to properly disinfect blood pressure (BP) cuff during medication administration for 3 of 6 residents for medication administration observations, for Residents # 119, 110 and 37. The findings included: Review of facility's policy titled, Medication Administration, implemented on 06/01/25, and revised on 11/07/25, documented under policy that medications are administered by licenses nurses, and other staff who are legally authorized to do so in this state, as ordered by physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy and explanation guidelines documented the following: Wash hands prior to administering medications per facility protocol and product (4). Wash hands after observation of a resident consumption of medications (19).…

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

Based on observations, interviews and record review, the facility failed to prepare and serve food in a sanitary manner in accordance with professional standards for food safety. The findings included: 1. On 08/19/24 at 8:48 AM, during the initial kitchen tour accompanied by Staff A, Cook, the Dietary Manager and the Registered Dietitian (RD), the following were noted: a. the handles of a spoodle and three spatulas were damaged to a point that they were no longer easily cleanable. b. there was an accumulation of food residues on the blade and the mounting bracket of the table mounted manual can opener. c. there was an accumulation of dust on the air conditioning vent over the food assembly area. d. the wall over and around the door to the walk-in cooler was damaged and tiles were missing. 2. The facility's policy, titled, Handwashing / Hand Hygiene, with a reference date of August 2019, documented, in part: this facility considers hand hygiene the primary means to prevent the spread of infections. The policy did not specifically address hand hygiene in the kitchen and for food…

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, records review, and interviews, the facility failed to ensure it timely answered call lights in response to residents' needs for 3 of 24 sampled resident, Residents #13, #38, and #55. The findings included: 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. On the most recent Minimum Date Set (MDS) assessment, the Brief Interview for Mental Status (BIMS) was documented as a score of 15 of 15, indicating the resident was alert and oriented to person, time, and place (cognitively intact). On 08/20/24 at 1:25 PM, an interview was conducted with Resident #38 who stated she had voiced multiple complaints regarding the call light response to staff. Resident #38 said at times when the call lights is activated, the Certified Nursing Assistant (CNAs) could be observed passing by the room, but they do not bother to come in the room to check. Resident #38 complained that this situation is usually worse on the weekend. In a followup interview with Resident #38 on 08/21/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the physicians' orders for wound treatment and failed to provide wound care in a timely manner for 1 of 2 sampled residents, reviewed for wound care, Resident #18. The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as a deep tissue injury (DTI), surgical wound. Review of the Physician's orders showed Resident #18 had an order for left dorsal foot and left lateral foot wound, Cleanse with Normal Saline (N/S) apply skin prep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, record review, observation and interview, the facility failed to administer the correct type of Aspirin medication, as per physician's order for 1 of 5 sampled residents observed during a Medication Administration Observation, Resident #94. The findings included: Review of the facility policy and procedure on 08/19/24 at 2:30 PM, titled, Specific Medication Administration Procedures, provided by the facility's Regional Nurse, reviewed May 2022 documented, in part, in the Policy Statement: Administration Procedures for all Medications - To administer medications in a safe and effective manner. Procedures: .C. Review five (5) rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer: a. Check Medication Administration Record (MAR)/Treatment Administration Record (TAR) for order e. Prepare resident for medication administration. 2) Prior to removing the medication from the container. a. Check the label against the order on the [DATE]: After…

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 accurate records related to dressing change for 1 of 2 sampled residents reviewed for wound care, Resident #18; and failed to ensure complete and adequate documentation for 1 of 1 sampled resident reviewed as deceased in the facility, Resident #99. The findings included: Review of the facility's policy titled, Documentation of Progress, dated [DATE], included the following: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. 1. Record review for Resident #18 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) 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 observations, interviews, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during medication administration for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to ensure Personal Protective Equipment (PPE) gowns were available on the 2nd floor for 8 of 11 residents who were on EBP; failed to have appropriate signage posted to indicate precautions for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to properly utilize hand hygiene and discard a used lancet after Blood Glucose check during medication administration observation for 1 of 1 sampled resident, Resident #3; and failed to ensure a sanitary environment during perineal care for 1 of 1 sampled resident reviewed for Urinary Tract Infection (UTI), Resident #56. The census at the time of the survey was 90 residents. The findings included: Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 09/01/22, included in part the following: EBP [Enhanced Barrier…

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-up on monitoring residents with a change in condition for 1 of 2 sampled residents reviewed for death in the facility, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses to include Syncope (fainting), Heart Attack, Chronic Pulmonary Edema (fluid in lungs), Diabetes, Heart Disease, and Alcohol Use. Review of the admission progress note dated [DATE] at 7:08 AM documented the resident was admitted to the facility and was receiving oxygen at 2 liters a minute via nasal canula. The progress note further documented the resident's vital signs were within normal limits, and the resident was very drowsy and lethargic, hard to arouse, and appeared confused. Review of Resident #1's physician orders revealed orders dated [DATE] revealed an order for vital signs every shift. Further review of Resident #1's records revealed the last documentation of the resident's condition / vital signs was on [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare, store and serve food in a sanitary manner and in accordance with professional standards. The findings included: 1). During the initial kitchen tour on, 06/19/23 at 9:24 AM, accompanied by the Dietary Manager, the following were noted: a. the surface of the top of the counter mounted toaster was showing signs of wear and peeling b. there was an accumulation of food residue on the blade of the counter mounted manual can opener. At the conclusion of the initial kitchen tour, the Dietary Manager acknowledged understanding of the concerns. 2). On 06/20/23 at 9:10 AM, Resident #85 was provided lunch to take to dialysis that consisted of a sandwich that was made up of sliced deli meat and cheese, 2 containers of apple juice and graham crackers. It was noted that there was no cooling medium in the soft-sided cooler that was provided to the resident to maintain foods at safe temperatures. During an interview with Staff A, Dietary Aide,…

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 secure 3 of 6 medication carts, failed to secure 1 treatment cart, and failed to secure meds at the bedside for 1 of 19 sampled residents (Resident #143) The findings included: Review of the facility's policy titled, Storage of Medications with a revised date of January 2018 included: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1) Record review for Resident #343 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Displaced Intertrochanteric Fracture of Right Femur, Pain in Right Hip, and Anxiety Disorder. Review of the Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to assist residents during meals in a dignified manner for 2 of 4 residents observed for dignity (Residents #82 and #66) and the facility failed to provide privacy for 1 of 4 residents observed for dignity (Resident #90). The findings included: 1) Record review for Resident #82 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Legal Blindness, Dysphagia, Oropharyngeal Phase, and Moderate Protein-Calorie Malnutrition. Review of the Minimum Data Set (MDS) for Resident #82 dated 03/24/23 revealed the resident had a Brief Interview of Mental Status score of 15 indicating an intact cognitive response. Revealed in Section G for dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of one person assist. Review of the Care Plan for Resident #82 dated 03/27/23 with a focus on the resident has an ADL (Activity of Daily Living) self-care performance…

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 residents with preferences for being out of bed for 1 of 1 residents reviewed for Preferences (Resident #47). The findings included: During tours of the facility conducted on 06/19/23 at 10:51 AM and 12:55 PM, Resident #47 was observed lying in bed. Resident #47's family member was at her bedside during the second observation. Resident #47's family member stated she had a concern about Resident #47 not being out of bed unless the family specifically requested it. When asked how long this has been going on, Resident #47's family member said approximately 6 months. She also stated she has two siblings and they each switch off coming to the facility, so one of them is at the facility with Resident #47 daily. During this interview, the surveyor observed a wheelchair in the far corner of the room. The surveyor asked Resident #47's family member if this was her wheelchair. Resident #47's family memberr confirmed that that 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 record reviews and interviews, the facility failed to act on request for Level II Pre-admission Screening and Resident Review (PASARR) for a resident determined to have 'Serious Mental Illness' for 1 of 3 residents reviewed for PASARR (Resident #11). The facility failed to have a PASARR screening completed upon admission for 2 of 3 residents reviewed for PASARR (Resident #38 and 25). The findings included: 1) Resident #11 was admitted on [DATE]. According to an admission Minimum Data Set (MDS), dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13. Resident #11's diagnoses at the time of the assessment included: Anemia, Hypertension, Hemiplegia, Seizure disorder, Malnutrition, Schizophrenia, Long-term and current drug therapy. Resident #11's care plan initiated on 05/07/23, documented, the resident uses psychotropic medications r/t Schizoaffective Disorder, Schizophrenia, Bipolar. The goals of the care plan included: The resident will be/remain free of psychotropic drug…

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 showers based on shower schedule and resident preferences for Resident 2 of 4 residents reviewed for Activities of Daily Living (ADLs) (Residents #7 and 32). The facility failed to ensure proper nail care for 1 of 4 residents reviewed for ADL Care (Resident #90). The findings included: The facility's policy Bathing/Showering dated 11/30/14 and most recently revised on 04/20/22 did not address residents' refusal to be bathed/showered. 1) Resident #7 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was 'cognitively intact'. The MDS documented that the resident required: 'Limited assistance' and 'one person physical assist' for bed mobility and transfer, and required 'extensive assistance' and 'one person physical assist' for walk in corridor, toilet use, personal hygiene. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide adequate podiatry care for 2 of 2 residents reviewed for Podiatry Care, (Residents #34 and 90). The findings included: 1) During the initial tour of the facility conducted on 06/19/23 at 10:12 AM, Resident #34 stated that he wanted to participate in physical therapy sessions but that his feet bothered him. During this interview, Resident #34 lifted his bedsheets and showed his feet to the surveyor. The surveyor observed that Resident #34's toenails were very long, thick, and overgrown. The surveyor asked Resident #34 if his toenails caused him discomfort. Resident #34 stated not really, but my feet hurt when I stand up. When asked when he was last seen by a podiatrist, Resident #34 stated I'm not sure, but I think about 2 months ago. Resident #34 was admitted to the facility on [DATE]. Resident #34 had a medical history significant for Weakness, Unsteadiness on Feet, and Chronic Pain. A Quarterly Minimum Data Set (MDS) 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 observations, interviews and record reviews, the facility failed to provide appropriate device in the form of a smoking apron to prevent injury and skin damage to 1 of 1 resident reviewed for smoking (Resident #11). The findings included: The facility's policy, 'Smoking - Supervised', dated September 2018 and most recently revised on 02/01/20, documented, The Center will provide a safe, designated smoking area for residents. Residents will be supervised during smoking. Smoking is only allowed in designated areas and oxygen is not permitted. The Center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedures: 1. Residents that smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if additional adaptive or safety equipment is needed. Resident #11 was admitted to the facility on [DATE]. According to an admission Minimum Data Set…

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, observations and interviews, the facility failed to follow the facility's Urinary Catheter Care policy, and failed to ensure the staff followed hand hygiene practices consistent with accepted standards of practice during foley/peri-care provided to 1 of 1 resident sampled for urinary catheter care review (Resident #3). The findings included: Review of the facility policy titled Catheter Care, Urinary revised on 09/05/17 documented .remove catheter securement device .reattach catheter securement device . The policy did not address the use of enhanced barrier precautions when providing urinary catheter care. Review of the Center for Disease Control and Prevention (CDC)-Hand Hygiene Guidance last reviewed on 01/30/20 documented .Healthcare Personnel should use an alcohol based hand rub or wash with soap and water for the following indications: .immediately after glove removal . Review of Resident #3's clinical record documented an admission on [DATE] with no readmissions. The 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 record review, observations and interviews, the facility failed to monitor the resident's weight as evidenced by six (6) pounds weight loss in 12 days for 1 of 1 resident sampled for nutrition review (Resident #143). The findings included: Review of the facility's policy titled Weighing the Resident revised on 05/06/22 documented residents will be weighed unless ordered otherwise by the physician: on admission/readmission, weekly for 4 weeks, monthly thereafter, as needed .weights will be documented .in the clinical record . Review of Resident #143's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Fracture of Right Femur, Rheumatoid Arthritis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Chronic Kidney Disease, Depression, Gastro-Esophageal Reflux Disease (GERD), Irritable Bowel Syndrome and Long Term Use of Systemic Steroids. Review of Resident #143's Minimum Data Set (MDS) admission assessment dated [DATE] documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure tube feeding tubing was changed in a timely manner and failed to ensure tube feeding was administered per physician orders for 4 of 4 residents reviewed for Tube Feeding (Resident #47, 67, 20, and 40). The findings included: Review of the facility policy titled Enteral Feeding-Enteral Nutrition Pump, revision date 11/12/18 revealed the following: Closed System Enteral Feeding Containers and tubing can hang safely for up to 48 hours. Use only 1 feeding set per container. 1) During the tour of the facility conducted on 06/19/23 at 10:51 AM, the surveyor observed that Resident #47 was lying in bed with eyes closed. Upon closer observation, Resident #47 had a bottle of Jevity 1.5 (formulary type) tube feeding that was labeled as started on 06/18/23 but was untimed and was infusing at 50 milliliters/hour (mL/hr). Further observation revealed the water flush bag was dated 06/17/23 at 2:00 PM. The tube feeding was at the 350mL mark out…

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 administer scheduled medications in a timely manner for 1 resident reviewed for pain management (Resident #60) and for 1 resident reviewed for insulin (Resident #3). Medications are administered within (60 minutes) of scheduled time. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. The findings included: Review of the facility's policy titled, Medication Administration - General Guidelines with a revised date of December 2019 included: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Fracture of Sacrum, Fracture of Pubis, Displaced Fracture of Base of Neck of Right…

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.