Rockledge Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement its smoking policy and procedures to provide adequate oversight of 16 smokers and ensure the safety of all residents in the facility. Findings: Cross reference F689. On 7/13/23 at 12:11 PM, the facility's Executive Director and Director of Nursing (DON) discussed the facility's protocols for safe smoking. The Executive Director explained residents who were identified as smokers on admission were evaluated by the nursing department to determine if they were physically and cognitively able to smoke safely. He stated the facility maintained an open smoking porch from 7:00 AM to 8:00 PM daily. The Executive Director stated a staff member was always assigned to the designated smoking area to attend to and monitor the smokers. He explained the assigned staff member was responsible for retrieving smoking materials when residents finished smoking and he/she would place the items in 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, and record review, the facility failed to demonstrate the effectiveness of the performance improvement plan for education of nursing staff and implementation of following physician orders for oxygen for 1 of 3 residents reviewed for oxygen therapy out of a total sample of 44 residents. Findings: Cross reference to F695 On 7/13/23 at 7:40 PM, during an interview with the Executive Director, and Director of Nursing (DON), the Executive Director stated that on 6/26/23, they implemented a Performance Improvement Plan (PIP) to ensure proper oxygen use. He stated education was started on 6/26/23 with nursing staff and had been ongoing along with conducting random audits. A request was made to review the in-service training along with subject matter covered and signature records of nursing staff from 6/26/23. The DON stated education was provided to nursing staff verbally on 6/26/23 and 6/27/23. The DON added that education was provided on a one to one basis with each nurse on all shifts for a total of 8 nurses. She reported there were no sign in sheet, and education…

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 a safe and sanitary environment in the laundry department to prevent cross-contamination of facility equipment and facility linens. Findings: An observation of the laundry department was conducted with the Housekeeping/Laundry Manager, Regional Housekeeping/Laundry Manager and Administrator In Training. The laundry's soiled linen sorting area had 6 covered bins containing soiled linen, an outdoor leaf blower, a floor cleaning/buffer machine which was plugged into the electrical socket, and battery and battery charger. The Laundry Manager explained it was a soiled room used for sorting the facility's soiled linens prior to washing. The Laundry Manager and Administrator in Training stated the leaf blower, the floor machine and battery charger should not be in the soiled room to prevent cross contamination. On 07/11/23 at approximately 12:50 PM, the laundry area containing the facility's 3 washing machines revealed all 3 washing machines were currently in process of washing soiled laundry. Approximately 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote dignity and positive interactions through courteous behavior and respectful attitude by direct care staff for 1 of 4 residents reviewed for Dignity of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and history of falls. Review of the Minimum Data Set admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. Review of the medical record revealed resident #252 had a care plan for self-care deficit initiated on 6/30/23. Interventions included instructions to staff to anticipate the resident's needs, use a calm approach, and explain actions during care. On 7/10/23 at 5:18 PM, resident #252…

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 a bathroom shared by residents in 1 of 18 bathrooms on the East Wing (room [ROOM NUMBER]) and 2 of 29 rooms on the [NAME] Wing (rooms #154 & #156) were maintained in a clean and homelike condition. Findings: 1. Observations conducted on 07/10/23 at 3:10 PM, 07/11/23 at 12:17 PM, 7/12/23 at 9:29 AM, 12:52 PM, and 5:44 PM and on 07/13/23 at 10:27 AM and 1:24 PM revealed room [ROOM NUMBER] bathroom (East Wing) with 7 pink plastic wash basins stacked inside each other on the bathroom floor under a white plastic shower/commode chair. The basins were not labeled with resident names and they were not covered. A pink plastic bedpan (not labeled with resident name or covered) was inside the top wash basin. A yellow plastic fracture bedpan (not labeled with resident name or covered) had been placed in the pink bedpan. On 07/13/23 at 10:27 AM and 1:24 PM, there was a small plastic laboratory specimen collection bag with a biohazard symbol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 44 residents, (#71). Findings: Review of the medical record revealed resident #71 was admitted to the facility on [DATE] with diagnoses including left shoulder osteoarthritis, aortic stenosis, generalized weakness, and chronic kidney disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/23/23 revealed resident #71 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. The MDS assessment showed the resident was independent with all activities of daily living, except for supervision with dressing, and he was always continent of bowel and bladder. On 7/10/23 at 1:18 PM, resident #71 explained the main concerns that affected his life in the facility was the bad condition of his bathroom. He said, It's never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedures for prohibition of Abuse for 1 of 4 residents reviewed for Abuse, of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and a history of falls. Review of the Minimum Data Set admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. On 7/11/23 at 1:12 PM, resident #252 expressed concerns regarding a bad experience with staff on her first night in the facility that made her feel afraid. The resident stated in the morning she informed the [NAME] Wing Unit Manager (UM) that she was scared and staff were mean to her. On 7/11/23 at 1:27 PM, the [NAME] Wing UM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARRs of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, epilepsy, recurrent mild depressive disorder, dementia, and traumatic brain injury. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 was admitted to the facility from another nursing home or swing bed. The MDS assessment indicated the resident was not evaluated by a Level 2 PASARR and determined to have a serious mental illness and/or mental retardation or a related condition. PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care and that they receive necessary services in the most appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan that reflected person-centered care related to assistance with toileting for 1 of 3 residents reviewed for activities of daily living (ADLs), of a total sample of 44 residents, (#250). Findings: Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. the document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. The assessment showed resident #250 required assistance from staff for toileting and did not have a urinary catheter. On 7/10/23 at 5:35 PM, resident #250 explained he was continent of urine and on admission to the facility, he informed staff he required assistance with placement of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address dental care and services required by 1 of 2 residents reviewed for dental services, out of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and a history of falls. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed the resident had no obvious or likely cavity or broken natural tooth. On 7/11/23 at 11:18 AM, resident #26 pointed to his left lower jaw and stated he had a broken tooth. The brown, jagged surface of an obviously broken and possibly decayed lower left tooth was clearly visible during conversation with the resident. Review 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 observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care related to shaving, bathing, and nail care to maintain good grooming and personal hygiene for 2 of 3 residents reviewed for ADL care, out of a total sample of 44 residents, (#26 & #250). Findings: 1. Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and a history of falling. Resident #26 had a care plan for self-care deficit with dressing, grooming, and bathing initiated on 5/17/23. The goal was the resident would have a clean, neat appearance. Interventions instructed staff to assist the resident with keeping his nails short, shaped, and clean, and provide hands on assistance with dressing, grooming, and bathing as needed. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview 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 interview, and record review, the facility failed to ensure surgical wound treatments were initiated and provided for 1 of 1 resident reviewed for non-pressure skin out of a total sample of 44 residents, (#298). Findings: Review of resident #298's medical record noted he was admitted to the facility on [DATE] with diagnoses of Open Reduction and Internal Fixation (ORIF) of right lower leg fracture following motor vehicle accident, cardiac and vascular implants and grafts, metabolic encephalopathy, pain, indwelling urinary catheter, and major depressive disorder. Review of the admission Minimum Data Set assessment dated , 02/02/22 noted he was cognitively intact, having mood issues related to feeling down, depressed, hopeless, tired, and trouble concentrating. He required extensive assistance with activities of daily living, was independent with eating, had impairment with lower extremity and used a walker/wheelchair for mobility. He had an indwelling urinary catheter, no scheduled pain medications, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders and follow professional standards of practice related to oxygen use, monitoring oxygen levels, and replacing respiratory supplies for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#27). Findings: Review of the medical record revealed resident #27 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included respiratory failure with low oxygen levels, pneumonitis or inflammation of lung tissue due to inhalation of food or vomit, shortness of breath, and heart disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/06/23 revealed resident #27 had a Brief Interview for Mental Status score of 15/15, which indicated he was cognitively intact. The document showed the resident required extensive assistance from two staff members for bed mobility, dressing, and personal hygiene, and was totally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer pain medication in a timely manner for 1 of 3 residents reviewed for pain management, (#92). Findings: Review of the medical record revealed resident #92 was admitted to the facility on [DATE] with diagnoses including wedge compression fractures of the lumbar and thoracic spine, and muscle spasms. Review of the resident's Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 6/14/23 revealed he received pain medication on schedule and as needed. The resident reported occasional pain in the previous five days, and the worst pain intensity was level 6 on a 0 to 10 scale. The document showed he received opioid pain medication on 6 of 7 days in the look back period. Review of the MDS Discharge-Return Anticipated assessment with ARD of 6/24/23 revealed resident #92 continued to receive pain medication on schedule and as needed. The document showed he received opioid pain medication every day during the 7-day look…

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 pharmaceutical services to maximize the effectiveness and promote optimal therapeutic effect of medication for 1 of 5 residents reviewed for medication administration, of a total sample of 44 residents, (#248). Findings: Review of the medical record revealed resident #248 was admitted to the facility on [DATE] with diagnoses including hypertension, type 2 diabetes, adult failure to thrive, and pancreatic cancer. The resident also suffered from exocrine pancreatic insufficiency, a deficiency of the pancreatic enzymes that results in the inability to digest food properly (retrieved on 7/18/23 from www.webmd.com/digestive-disorders/exocrine-pancreatic-insufficiency). On 7/10/23 at 4:50 PM, resident #248 explained some of her medications had to be given with meals. She stated her physician emphasized the importance of taking her pills at the right time, particularly those that she needed to take with meals. Resident #248 expressed…

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 prevent medication errors for 1 of 5 residents reviewed during the Medication Administration task, of a total sample of 44 residents, (#248). There were 2 errors in 25 opportunities for a medication error rate of 5%. Findings: Review of the medical record revealed resident #248 was admitted to the facility on [DATE] with diagnoses including hypertension, type 2 diabetes, adult failure to thrive, and pancreatic cancer. On 7/10/23 between 4:35 PM and 4:45 PM, Registered Nurse (RN) D was observed during medication administration for resident #248. She removed the resident's pills from blister packs stored in the medication cart and administered medication including one tablet Metformin 500 milligrams (mg), one tablet Metoprolol Tartrate 50 mg, and one tablet Nateglinide 60 mg. On 7/10/23 at 4:50 PM, resident #248 explained some of her medications had to be given with meals. She stated her physician emphasized the importance of taking her…

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 a prescribed ointment was appropriately labeled, and failed to maintain medication and supplies securely to prevent unauthorized access in 1 of 1 treatment cart and 1 of 2 medication carts on the [NAME] Wing. Findings: 1. On 7/10/23 at 3:06 PM, an unlocked treatment cart was observed to the left of the [NAME] Wing nurses' station. The treatment cart faced the hallway and all drawers were easily opened. Residents and staff were noted in the hallways and common area in front of the nurses' station. A staff member who worked at a computer in the nurses' station confirmed she was the Wound Nurse. On 7/10/23 at 3:09 PM, the Wound Nurse, Licensed Practical Nurse (LPN) C, stated she unlocked and checked the treatment cart at the start of the 3:00 PM shift. She acknowledged the treatment cart was supposed to be locked to prevent unauthorized access. LPN C looked around the area and stated there were four confused residents in the vicinity…

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 routine dental services for 1 of 2 residents reviewed for dental care, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and history of falls. A Nursing admission assessment dated [DATE] showed the admission nurse evaluated resident #26's oral status and noted he wore a dental appliance and had no dental problems. A physician order dated 5/15/ 23 indicated the resident could obtain a dental consult as needed. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed he required extensive assistance from one staff member for personal hygiene such as brushing his teeth, and he did not reject care. The MDS assessment…

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

Based on observation, and interview, the facility failed to ensure food was safely stored to prevent foodborne illness for residents residing in the facility. Findings: On 7/10/23 at 10:30 AM, during the initial tour of the kitchen, the upright double door refrigerator contained three plated salads wrapped in plastic with no date and a potato (maybe baked) on a plate wrapped in plastic with no date. [NAME] E stated she made the salads that morning but did not have time to put a date label on them. She did not have a comment about the potato. On a rack in the dry storage area, an opened bag of cornbread mix was wrapped in plastic and had no open/use-by date and the expiration date could not be seen. On 7/13/23 the Certified Dietary Manager stated her expectation was that any food prepared ahead of time or left over needed to be labeled with the date before it was placed in the refrigerator.If dry food was opened, it should be dated before it is put back on the shelf. She noted that all dietary staff had been educated in the past regarding labeling food with the date. Policy 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.

Based on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition rooms (East & [NAME] Wing). Findings: 1. On 11/03/2021 at 1:07 PM, observation of the East Wing nutrition room with the Central Supply Manager revealed three cups of poured juice unlabeled and undated, and an individual container of cottage cheese past the expiration date inside the refrigerator. Food particles and a yellow substance were seen on the inside door of the refrigerator on the door shelves. No temperature log was found for the refrigerator. Food particles and trash were observed on the cabinet shelf, under the basket of snacks when it was lifted by the Central Supply Manager. She stated the kitchen was responsible for maintaining and cleaning the nutrition room. She was unsure who was responsible for the refrigerator temperature logs, but felt it was someone from the kitchen. She said the kitchen staff were supposed to clean the room and check the refrigerator when they came to replenish the nutrition room. The Central…

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 a resident was assessed to self-administer oral pain/sleep medication and topical pain relief cream medications for 1 of 50 total sampled residents (#88). Findings: Resident #88 was admitted to the facility on [DATE] with diagnoses including-unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, and muscle weakness. The resident's quarterly Minimum Data Set assessment, with reference date of 10/08/21, revealed the resident's cognition was moderately impaired and a brief interview mental status score of 12/15. On 10/31/2021 at 11:09 AM, the medication Tylenol PM 500 milligrams, a 3 ounce tube of Aspercream, and a 3 ounce jar of Biofreeze was in a pink wash basin on the resident's tray table in her room. Resident #88 stated that the creams are for the pain in her right shoulder. She also stated her son brought the Tylenol PM because He knows I have trouble sleeping. On 11/01/2021 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 2. Resident #644 was readmitted to the facility on [DATE] with diagnoses that included stroke, dysphagia, protein calorie malnutrition, type 2 diabetes, and adult failure to thrive. Review of the quarterly MDS assessment dated [DATE] revealed resident #644 is rarely/never understood and needed extensive assistance with eating. On 10/31/2021 at 12:15 PM during lunch trays distribution, CNA B took the untouched tray off of resident #644's overbed table. In the resident's room, CNA B said she was taking the tray back to the food cart to stay warm because the resident is a feeder and we do them last. CNA A, who was also in the room, did not try to correct CNA B for calling resident #644 a feeder. On 10/31/2021 at 12:36 PM, resident #644 was in bed with the head of bed raised for lunch and CNA A was standing on the resident's left side of the bed feeding her a mechanical soft diet of fried chicken, mashed potatoes, broccoli and apple pie. CNA A did not talk to the resident and did not sit next to her during the meal.…

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.