Life Care Center Of Port Saint Lucie

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review and interview, the facility failed to provide care and services to address the nutritional status for 1 of 3 sampled residents, as evidenced by not weighing according to policy and addressing Resident #4's weight loss, in a timely manner.The finding included:Review of the facility policy titled, Weight monitoring, long term care revised 09/15/25, documented in part Weighing a resident in a long term care facility is an important part of assessing a resident's health. Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, record residents' weight at the time of admission, weekly for 4 weeks, and then monthly. Keep in mind that many residents' have comorbidities that can cause unplanned weight changes and some residents require more frequent weight assessments. Implementation: compare the resident's weight with previous measurements to assess trends in weight gain or loss. If you have a weight change, assess the resident using 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 interview and administrative and clinical record review, the facility failed to provide evidence of a thorough investigation, assessment of the resident, and internal and federal reporting of an incident of a resident with reported new bruises of suspected origin. This failure affects 1 of 3 sampled residents reviewed (Resident # 1).The findings included: Review of the he facility's policy regarding Incident and Reportable Event Management, reviewed 09/25/2024, documented regarding Alleged Violations - Investigate/Prevent/Correct: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.Procedure:The Five I's to Event Management, To help reduce the risk of an event, all residents receive assistance and supervisions as addressed in their care plan. If an event occurs, the facility will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review the facility failed to timely report to the State Agency allegations of abuse for 4 of 4 sampled residents (Resident #1 and Resident #4), and (Resident #5 and Resident #6) involved in an incident. The findings included: Review of the Policy titled Abuse-Reporting and Response - No Crime Suspected, issued on 10/04/22 and revised on 06/17/24 documented, in part . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services…

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 clinical and administrative record review, the facility failed to provide evidence of providing the necessary care and services to ensure that adequate monitoring of temperatures of hot beverages were consistently completed after an incident of a resident experiencing a burn from a hot beverage; failed to ensure hot liquid temperatures above the stated range, according to the facility's Food Temperature Log, Temperature Standards for hot foods should be at 140-170 degrees Fahrenheit were adjusted prior to serving; and failed to ensure the physician prescribed wound care orders were performed as prescribed, affecting 1 of 6 sampled residents ( Resident #1). The findings included: Review of the facility's policy regarding Hot Liquids, revised 01/21/2025 documented, the food provided by the facility should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction, while minimizing the risk for scalding and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review and interview, the facility failed to ensure 1 of 3 sampled residents (Resident #1) grievance was acknowledged and an effort was made to promptly resolve the grievance. The findings included: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with a diagnosis which included Radiculopathy, lumbar region and she left the facility AMA (Against Medical Advice) on 10/15/24. The resident is alert and oriented in all spheres and is able to make needs known. The progress note dated 10/15/24 at 6:42 PM documented that the resident stated, I cannot be here anymore. During the administrative record review, a review of the facility's grievance log from October 2024 to December 2024, revealed no evidence of a grievance filed for Resident #1. An interview was conducted on 12/04/24 at approximately 11:25 AM with the Social Services Director (SSD). The SSD stated that she did not recall Resident #1 and acknowledged that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interview, and record review, the facility failed to ensure care and services were provided in a dignified manner for 6 of 9 sampled residents reviewed with dignity concerns (Residents #26, #49, #54, #74, #3, #372). The findings included: Review of the policy Dignity reviewed 09/25/23 documented, Policy: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. Review of the Grievance Log for the month of July 2024 revealed six customer service concerns. These concerns were related to inappropriate comments toward a family member, in front of residents, by a Certified Nursing Assistant (CNA) on 07/08/24; staff failing to introduce themselves at the beginning…

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 and interviews the facility failed to provide a safe, clean, comfortable homelike environment 3 of 3 units (Unit 100, 200 and 400). The findings included: During observations on 08/05/24, 08/06/24 and 08/07/24, the following environmental concerns were noted in the facility: Rooms: 103-Observations made on 08/05/24 at 9:05 AM, the ceiling vent showed rust and dust. 104-Observations made on 08/06/24 at 10:43 AM, there was a stain on the wall under the window that appeared to be liquid splashed that was dripping down on the wall. 105-Observations made on 08/05/24 at 9:45 AM, the ceiling vent showed rust and dust; The floor was scuffed and paint peeling behind the bed. 106-Observations made on 08/05/24 at 9:23 AM, there was paint peeling from the wall behind bed. 110-B Observations made on 08/06/24 at 10:55 AM, there was a hole in the wall by the window and by the dresser across from bed-B. 111-Observations made on 08/06/24 at 11:15 AM, there was paint peeling from the wall across from bed-A and at the entrance of the room; The ceiling vent was rusted. 112-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 record review and interview, the facility failed to ensure adequate staffing to provide nursing and related services to meet the resident's needs and in a manner that promotes each resident's rights, physical, mental and psychosocial well being for 13 of 24 sampled residents. This failure was evidenced by verbal complaints of a lack of staff by Residents #57, #54, #12, #74, #18, #26, #29, #3, #49, #40, #34, #372, #366, or their family members. This was also evidence by the lack of dignified care for Residents #3, #26, #49, #54, #74, and #372. The findings included: 1) During interviews by the survey team on 08/05/24 and 08/06/24, the following concerns were voiced by residents and families. a) On 08/05/24 at 10:17 AM, Resident #57, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact, stated that the Certified Nursing Assistants (CNAs) rush during care to get done and go to the next resident. The resident stated they don't have enough time to get their work done, providing the example that it took them a week of 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 and interview, the facility failed to respond to and honor request for insulin sensor use for 1 of 6 sampled residents reviewed for choices (Resident #54). The findings included: Review of the record revealed Resident #54 was admitted from the facility's associated Independent Living (IL) facility, to the skilled nursing facility, on 07/18/24 with a diagnosis of Diabetes. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scaled, indicating she was cognitively intact. Review of the current orders revealed as of 07/18/24 staff were to complete an accucheck twice daily for diabetes. This process is completed by obtaining blood via a finger stick to obtain a blood sugar level. Review of a progress note written on 07/27/24 by the Nurse Practitioner documented, The patient is unsure about the facility's protocol for glucose monitoring and would like to have her sensor replaced and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and interview, the facility failed to ensure of proper nail care for 1 of 3 sampled residents reviewed for Activities of Daily Living (ADL's) (Resident #74). The findings included: Review of the policy Nail Care reviewed 08/23/23 documented, Policy: The resident will receive assistance as needed to complete activities of daily living (ADLs). Procedure: For general fingernail care for most residents, the following procedure will be followed: 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Review of the record revealed Resident #74 was admitted to the facility on [DATE] with a diagnosis to include hemiparesis secondary to a stroke. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS documented Resident #74 needed substantial to maximum…

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, and interview, the facility failed to ensure care and services for 3 of 7 sampled residents reviewed for medication use, as evidenced by the failure to follow physician ordered parameters for Resident #26, the failure to ensure timely antibiotics and timely central vascular access device (CVAD) dressing change for Resident #164, and the failure to ensure timely medication administration for Resident #76. The findings included: 1) Review of the record revealed Resident #26 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating some cognitive impairment. Review of the current orders revealed staff were to hold the midodrine tablet used for low blood pressure if the systolic blood pressure (SBP/upper number) was greater than 120, as of the order date of 07/20/24. This medication was ordered three times daily.…

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 implement nutritional supplements for 1 of 3 sampled residents reviewed for nutrition (Resident #3). The findings included: Review of Resident #3's medical records revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis to include Adult Failure to Thrive, Dementia Without Behavioral Disturbances, Mood Disturbance, and Anxiety. A review of Resident #3's quarterly MDS (Minimum Data Set) assessment dated [DATE] documented her BIMS (Brief Interview for Mental Status) score of 8, which indicates she has moderate cognitive impairment. Further review revealed under section K that the resident had a weight loss of 5% or more in the last month or 10% in 6 months and was not on prescribed weight-loss regimen. A review of the resident's weights documented on 03/23/2024, the resident weighed 119.1 lbs. On 07/08/2024, the resident weighed 108.2 pounds which is a -9.15 % weight loss. A progress note from the dietician documented a weight change…

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 properly monitor the continuous tube feeding for 1 of 2 sampled residents, resulting in the failure to administer the calculated amount of nutrition and fluids (Resident #84). The findings included: Review of the record revealed Resident #84 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident received all of his nutrition and fluids via a feeding tube. Review of the current order dated 07/10/24 instructed staff to provide Resident #84 via his feeding tube Glucerna 1.5 (a specific brand of tube feed used for residents with blood sugar difficulties) at 65 milliliters (ml) per hour, for 20 hours, for a total amount of 1300 ml. This same order instructed staff to provide 30 ml of water every hour, for 20 hours, for a total amount of 600 ml. This order instructed staff to initiate the tube feeding at 1 PM each day and stop it each day at 9 AM. The current care…

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 pain medication was provided as ordered for 1 of 3 sampled residents reviewed for pain ( Resident #76). The findings included: A review of the Policy titled, Medication Administration Times with an issue date of 11/17/19, Revised 05/06/21 and reviewed 08/28/23 that the following times are used for standard medication times: Medication prescribed one time a day-0800 AM or 0900 AM Medication prescribed in the Evening-5:00 PM or 6:00 PM Medication prescribed at Bedtime-8:00 PM or 9:00 PM Medication prescribed Twice a day- 0900 AM and 5:00 PM Medication prescribed Three times a day-0900 AM, 1:00 PM and 5:00 PM On 08/05/24 at 11:31 AM Resident #76 informed the surveyor that he always has pain in his right shoulder and arm from neck surgery that occurred years ago. He further reportedthat he is not getting his pain medications/patches until hours later. Review of Resident #76's medical records revealed he was admitted to the facility on [DATE] with 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 interview, record review and observation, the facility failed to keep medications secured as evidenced by an observation of dispensed and open medications at the bedside for 1 of 1 sampled residents (Resident #55) and failed to ensure medication carts were free of expired medications in 1 of 3 medication carts with the potential to negatively affect 1 resident (Resident #314), who was prescribed Ferrex 150 MG, which was expired. The findings included: The facility's Pharmacy Services and Procedure Manual, last revised 08/07/23, under the Procedure section has requirements listed in numerical sequence. Item #2 is worded as follows: Facility should ensure that medications and biologics are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Item 3.3 is worded as follows: Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that inaccessible by residents and visitors. Item 4 is worded as follows: Facility…

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 menu and recipe review, observation, and interview, the facility failed to ensure an adequate protein portion for all residents eating the regular meal for lunch on 08/07/24. Upon entrance there were 108 residents in the facility with the potential to affect the 70 residents who consume a regular diet, including sampled Residents #77, #164, #49, #34, #54, #57, #53, #74, #76, #3, #12, and #55. The findings included: Review of the menu for Week 2 revealed the lunch for Wednesday 08/07/24 included kielbasa with peppers and onions. The kielbasa was the meat protein for that meal. Review of the diet spread sheet for the meal documented the serving size to be 4 ounces of kielbasa with 2 ounces of the peppers and onions. Review of the production recipe instructed to serve 4 ounces of sausage (kielbasa) with 3 ounces of vegetables. An observation of the lunch line service on 08/07/24 beginning at 11:20 AM revealed a large pan on the steam table containing sliced kielbasa mixed with onions and green peppers. Staff D, the cook for that day, used a 4-ounce ladle to portion out and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to report an adverse event of a fall resulting in fractures, involving 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy titled, Abuse Reporting and Response - No Crime Suspected dated 10/04/22, documented The facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of residents property and report the results of all investigations to the proper authorities within prescribed timeframe. Abuse Identification: Neglect: is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation and was transferred to the hospital on [DATE] after a fall. Record review revealed Physical…

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, policy review and interview, the facility failed to report and implement corrective actions to minimize reoccurrence of an adverse event, a fall resulting in a fracture, involving 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy titled, Conducting an Investigation, Reviewed 07/18/23 documents If it is determined that alleged abuse and neglect, injury of unknown source, exploitation, or misappropriation of resident property has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state and federal regulations . If the alleged violations is verified appropriate corrective action must be taken. Record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation and was transferred to the hospital on [DATE] after a fall. Review of the Minimum Data Set, admission assessment with reference date 09/19/23, documented the resident was assessed as independent 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, interview and record review, the facility failed to provide mechanically altered food per physician's orders for 17 of 103 residents, including 3 of 3 sampled residents (Resident #12, #13 and #21). The findings included: The facility's policy for 'Mechanically Altered Diet', dated 03/15/22, documented, this diet can be used as a transition from the pureed textures to more solid textures. The Mechanically Altered Diet requires the resident to have the ability to chew and tolerate mixed textures. This diet consists of foods that are mechanically altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow .Foods in large chunks or foods that are too hard to be chewed thoroughly should be avoided. In the section of the policy titled 'Foods Allowed' the policy documented the following as being acceptable: All well-cooked, soft, canned, or frozen, tender vegetables (vegetables should be in small bite size pieces) Broccoli casserole, green bean casserole and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure showers as per resident's choice for 1 of 6 sampled residents, and failed to ensure a right to choose the location to obtain care and services of a suprapubic catheter (urinary drainage device) for 1 of 1 sampled residents (Resident #56). The findings included: 1) During an interview on 06/05/23 at 2:59 PM, Resident #56 stated they used to get showers three times a week, but the schedule was changed to twice weekly. When asked how many showers she would like each week, Resident #56 stated she would like three. When asked if she had requested showers three times weekly, Resident #56 stated she had, and that staff had told her they schedule everyone to have showers twice weekly. Resident #56 stated she had asked why two showers a week and not three, and was not provided with an answer. Review of the record revealed Resident #56 was admitted to the facility on [DATE] and moved into her current room on 10/05/21. Review of the current Minimum Data…

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 wound care per physician's orders and in accordance with professional standards for 1 of 4 sampled residents reviewed for non-pressure-related skin conditions (Resident #21). The findings included: The facility's policy, titled, Treatment Orders, revised on 04/19/22, documented, in part: Procedure 1. After observation / evaluation of the affected skin area, the physician is notified. 2. As appropriate, the physician writes a treatment order that includes at least the following: a. Site of wound b. Name of cleanser c. Name of ointment (medicated or non-medicated) d. Type of dressing e. Number of times to perform the treatment/duration of treatment. 3. The physician order is followed, as are the manufacturer's instructions for use for each product ordered. 4. Treatment order templates in PCC (Point Click Care - the facility's electronic health record system). Record review revealed Resident #21 was admitted to the facility on [DATE]…

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 follow physician orders for water flushes for 1 of 1 sampled residents who is fed via enteral means, to prevent potential dehydration (Resident #74). The findings included: An observation on 06/06/23 at 10:27 AM revealed the tube feeding and water bag for flushes and hydration for Resident #74 were hung to begin on 06/05/23 at 6:00 PM, as per documented label. The tube feeding at this time was nearly finished with about 100 ml (milliliters) left in the bag that could hold 1000 ml. The water flush bag was nearly full with about 850 ml. The feeding pump was set to administer the feeding at 65 ml/hour. The Flush was set to administer 50 ml of water every 0 (zero) hours. The pump readout documented that none of the flushes had been administered. (Photographic Evidence Obtained). An observation at this time revealed the lips of Resident #74 to be dry and chapped. When asked how she was doing, Resident #74 stated, . my mouth . yucky . During an…

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 accommodate food preferences for 2 of 6 sampled residents (Resident #47 and #12). The findings included: On 06/08/23 at 9:30 AM, Resident #47 stated, The kitchen can't seem to get my food preferences right; I don't understand why they are always out of bananas. If they can't get them from the vendor, why can't they go to the store and just buy some for those of us that want them. I ask for a banana ever day with my dinner, and this past week they haven't had any. Resident #47 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of Resident #47's Menu shows she had ordered Frosted Flakes and Banana for dinner on 06/04/23, 06/05/23, 06/06/23, and 06/07/23. On 06/04/23, she received a banana that she reported was bad and could 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.