Eagle Lake Nursing And Rehab Care Center

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and twelve errors were identified for two residents (#35, #25) out of three residents observed. These errors constituted a 48.00% medication error rate. Findings included: 1) On 08/28/2024 at 9:41 AM a medication administration observation was conducted with Staff M, LPN for Resident #35. Staff M, LPN dispensed the following medications: -Ativan (lorazepam) 1 mg (Milligram) 1 tablet -Famotidine 20 mg 1 tablet -Lactulose 20 gram/30 mL (milliliter) solution 25 mL -Sodium chloride 1 gram 1 tablet -Valproic Acid 250 mg 1 tablet Staff M, LPN stated she did not have the other ordered medications in her cart, and she would have to find them or order them. The missing medications included: -B complex vitamin C-folic acid 400 mcg (Microgram) 1 tablet -Potassium citrate 10 mEq (milliequivalent) extended release 1 tablet Staff M, LPN was observed administering the medications to Resident #35. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure bed rails were secure for 1 resident (#9) of 5 sampled. Findings included: On 8/26/24 at 2:39PM bilateral enabler rails were observed installed on Resident #9's bed. An interview and observation were conducted on 08/26/24 at 2:43p.m. with Resident #9. He stated his bed rail is loose as he physically shook the rail laterally. The right enabler rail was observed to be loose and could be moved out from the side of the bed and back easily. The resident stated he notified the NHA and maintenance multiple times, and nothing has been done to fix it. He stated he used the rail all the time to aid in his mobility but was fearful to use due to the rail not being secure. Review of electronic medical record (EMR) for Resident #9 showed an admission to facility on 12/04/23 with diagnoses including lymphedema, unspecified convulsions, restless agitation, and cellulitis of right lower limb. Review of the Minimum Data Set (MDS) dated [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 ensure call lights were functioning properly in resident rooms and bathrooms for one resident (# 24) out of six residents sampled Findings include: On 08/26/2024 at 2:00 p.m., an observation was conducted in room [ROOM NUMBER] with Resident # 24. She was observed in her bathroom turning on the call light which did not turn on to alert staff to come to her room. During the observation Resident # 24 stated her call light has not worked for a long time. Every time she turns on her call light in her room or in her bathroom it turns on in the resident room next door. She stated sometimes she has to wait for an hour to get assistance due to her call light not working properly. Review of an admission Record dated 8/29/2024 showed Resident # 24 was admitted to the facility on [DATE]. On 08/26/2024 at 2:30 p.m., an interview was conducted with Staff S, the Receptionist. Staff S was observed knocking on Resident # 24's door. She stated she is a…

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

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program to prevent flying insects in resident rooms and resident common areas for four of four days. Findings included: An observation was conducted on 08/26/24 at 10:05 AM, Resident #22 was observed to be sitting on the side of his bed, dressed in day clothes. There were four flying insects observed flying around the resident and landing on his jacket. Resident #22 said the flying insects come and go and they have been that way for months. He said he does not see anyone coming to spray for pests. (Photographic evidence obtained) An observation was conducted on 08/26/24 at 11:56 AM of a bedframe in the resident hallway with 2 fly insects flying around and landing on the bedframe. An observation was conducted on 08/27/24 at 9:13 AM of Resident #22 in bed, eyes closed with two flying insects flying around the resident and landing on his arm and shirt. An observation and interview were conducted on 08/28/24 at 11:00 AM. A bedframe was outside Resident #11's room in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess with an Interdisciplinary Team approach, obtain physician orders and develop a Comprehensive Person-Centered Care Plan for two of two sampled residents (#50 and #51) related to administering their own medications. Findings included: 1. Resident #51 was admitted on [DATE]. Review of the Resident Face Sheet showed diagnoses including acute bronchitis, shortness of breath, and anxiety disorder. An observation was conducted on 10/30/2024 at 9:08 a.m. with Staff A, Licensed Practical Nurse (LPN) for Resident #51's medication administration. Resident #51 was sitting in his bed. A bottle of Normal Saline Nasal Spray was sitting on the bedside table as well as lotion. A second observation occurred on 10/30/2024 at 1:40 p.m. with the Director of Nursing (DON). The DON asked the resident where the nasal spray came from. He stated his family brought it in for him. She informed him they would need to get an order for the spray and place it in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure medications were stored in a secure and safe manner for one resident (Resident #2) of one resident allowed to self-administer medications, and leaving medication unattended on one (North) of two medication carts . Findings included: 1. On 12/26/24 at 9:13 a.m., Resident #2 was observed lying in bed with an over-bed table hovering over the bed and a table next to the bed with a nebulizer machine sitting on it. A nebulizer pipe was connected to the machine. The observation revealed a foil container labeled Anoro Ellipta on top of a pharmacy bag and a vial of clear liquid under the bag sitting on the over-bed table. A vial of clear liquid was observed lying on top of the nebulizer machine. The resident stated the vial on the nebulizer machine was the 6:00 a.m. dose of Albuterol and they were able to self-administer medications, but hadn't woken up to take the 6 a.m. dose, and the vial on the over-bed table was the noon dose (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 interviews and record review the facility failed to monitor one diabetic resident (#5) out of three residents sampled for blood glucose levels as ordered. Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnoses to include but not limited to osteomyelitis of vertebra, sacral, and sacrococcygeal region, adult failure to thrive, weakness, Pressure Ulcer Stage IV of the left hip, dysphagia, hypoglycemia, history of Bacteremia, Diabetes Mellitus, vascular dementia with other behavioral disturbance, and gastrostomy tube. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment; in Section G: Functional Status, resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, and totally dependent regarding eating; in Section K: Nutritional Status, resident had a feeding tube, and had a mechanically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pain management for one resident (#6) of three residents sampled. Findings included: On 10/17/23 at 09:15 a.m. an observation and interview was conducted with Resident #6 who reported experiencing increased pain when the facility Ran out of his pain medicine. Resident #6 stated he was Always in pain pain intensity increases and decreases; currently his pain level is okay. Review of the resident face sheet showed Resident #6 latest return to the facility on 6/29/22, with diagnoses including Stage 4 sacral pressure ulcer, osteomyelitis (inflammation of the bone), paraplegia, chronic nephritis (inflammation of the kidney) and chronic pain. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed his Brief Interview for Mental Status (BIMS) score was 15, indicating he was cognitively intact. Review of Resident #6's Care Plan initiated on 6/21/2017, showed the following: Problem: Resident #6…

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 a interviews and record reviews the facility failed to ensure a Registered Nurse (RN) was available for 8 consecutive hours every day, seven days a week, for a two-week period from 10/01/23 to 10/14/23. Findings included: A review was conducted of the form entitled, Calculating State Minimum Nursing Staff for Long Term Care Facilities, for the two-week period from 10/01/2023 to 10/14/2023. The instructions read, Enter the number of RN and LPN (Licensed Practical Nurse) hours actually worked per day for the dates above. The document revealed on Sunday 10/01/23, Saturday 10/07/23, Sunday 10/08/23, and Saturday 10/14/23, there were no Registered Nurse (RN) hours recorded. An interview was conducted on 10/17/2023 at 11:50 a.m. with the Nursing Home Administrator. The Administrator confirmed there had not been an RN in the building on 10/01/23, 10/07/23, 10/08/23, and 10/14/23. The Administrator stated the facility was advertising for an RN but did not have a consistent ability to have an RN present on the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to 1) establish a system of receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation; and 2) determine that drug records are in order and an account of all controlled drugs is maintained and periodically reconciled for two residents (#4 and #6) of three residents sampled. Findings included: On 10/17/23 at 09:15 a.m. an observation and interview was conducted with Resident #6 who reported experiencing increased pain when the facility Ran out of his pain medicine. Resident #6 stated he was Always in pain pain intensity increases and decreases; currently his pain level is okay. Review of the face sheet showed Resident #6 latest return to the facility on 6/29/22, with diagnoses including Stage 4 sacral pressure ulcer, osteomyelitis (inflammation of the bone), paraplegia, chronic nephritis (inflammation of the kidney) and chronic pain. Review of Resident #6's Minimum Data Set (MDS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the medical record had complete and accurate documentation related to meals and wounds for two residents (#2 and #5) out of nine residents sampled. Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnoses to include but not limited to osteomyelitis of vertebra, sacral, and sacrococcygeal region, adult failure to thrive, weakness, Pressure Ulcer Stage IV of the left hip, dysphagia, hypoglycemia, history of Bacteremia, Diabetes Mellitus, vascular dementia with other behavioral disturbance, and gastrostomy tube. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment; in Section G: Functional Status, resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, and totally dependent regarding eating; in Section K: Nutritional Status,…

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 evaluate a resident by an Interdisciplinary team (IDT), including the physician, for self-administering of medications via a gastrostomy tube for one of two sampled residents (#1). Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking the following medications: antianxiety,…

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 thoroughly investigate an allegation of neglect related to administration of medications inappropriately for 1 of 3 sampled residents (#1). Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking the following medications: antianxiety, antidepressants, diuretics, and opioids.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide pharmaceutical services including administration of all drugs accurately for 1 of 3 sampled residents (#1) related to crushing of Cymbalta before administering via gastrostomy tube and /or administering it whole. Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking 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 observations, interviews, and record review the facility failed to follow infection control protocols related to medication administration and transmission based isolation protocol on one (08/07/2023) of one survey days. Findings included: Medication observation on 08/07/2023 at 9:25 a.m. with Staff C, Licensed Practical Nurse (LPN) for Resident #1. She was located at the end of the hallway. She pushed her medication cart down the hallway to Resident #1's room. She removed Clonazepam (Klonopin) 1 mg (milligrams) via g-tube three times a day for anxiety; Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures; and Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures. The resident refused all other medications. She handed the resident the crushed medications in the same cup and he administered them himself via his g-tube in the hallway. She was then seen pouring up Resident #10's medications at 9:40 a.m., Amlodipine 10 mg daily and Duloxetine 60 mg daily and handing them to 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 interviews and record review the facility failed to ensure implementation of an effective performance improvement action plan ongoing for 15 months related to care plans. Failures included not ensuring consistent audit process and not analyzing and tracking data from audits that were conducted to implement correction. This resulted in five residents (#144, #147, #39, #145, and #146) out of five residents sampled not having comprehensive care plans developed by the interdisciplinary team and within required timeframes. Findings included: 1. A review of the medical record conducted on 09/06/22 for Resident #144 revealed she was admitted to the facility on [DATE] at 2:27 p.m. There was no baseline care plan in her record. 2. Review of the medical record for Resident #147 revealed he was admitted to the facility on [DATE] at 5:00 p.m. There was no baseline care plan in his record. 3. A record review for Resident #39 indicated he was originally admitted on [DATE] and re-admitted [DATE] from the hospital,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure code status (type of emergent treatment a person would or would not want to receive if their heart or breathing were to stop) was identified and confirmed upon admission for two residents (#146, #144) out of four sampled residents. Findings included: Review of the medical record for Resident #144 was conducted on 09/06/22. The Resident Face Sheet revealed she was admitted to the facility on [DATE] at 2:27 p.m. There were no orders entered in the medical record for code status and no advance directive documentation was found identifying code status. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 09/06/22 at 3:35 p.m. She confirmed she was the assigned nurse for Resident #144. She reviewed the resident's electronic medical record (EMR) and confirmed no code status had been identified and no orders for code status had been entered in the record. She confirmed there should be a physician order entered for code status when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure baseline care plans with the instructions needed to provide effective and person-centered care according to professional standards of quality care were developed for two newly admitted residents (#147 and #144) out of four sampled residents. Findings included: A review of the medical record conducted on 09/06/22 for Resident #144 revealed she was admitted to the facility on [DATE] at 2:27 p.m. There was no baseline care plan in her record. Review of the medical record for Resident #147 revealed he was admitted to the facility on [DATE] at 5:00 p.m. There was no baseline care plan in his record. An interview was conducted with the Director of Nursing (DON) on 09/06/22 at 3:50 p.m. She reviewed the medical record for Resident #144 and confirmed there was no baseline care plan. She said, What is supposed to happen there, is I do the observations and I do the 48-hour care plan .this one I am negligent on that, I'll admit that I did not get to it. 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 observations, interview, facility policy and record review the facility failed to ensure a resident centered care plan was developed and implemented related to behavior monitoring for use of a psychotropic medication for one (Resident #39) of five residents sampled. Findings included: On 09/6/2022 at 9:41a.m., an observation was conducted of Resident #39 lying in bed, with Staff E, Certified Nursing Assistant (CNA) sitting in a chair next to Resident #39's bed performing a one on one (1:1). Staff E, CNA was interviewed and she revealed Resident #39 did not have any behaviors at the time. A review of Resident #39's Face Sheet indicated he was originally admitted on [DATE] and re-admitted [DATE] with multiple diagnoses to include vascular dementia with behavioral disturbance, alcohol abuse, anxiety disorder and Wernicke's Encephalopathy (degenerative brain disorder). A review of the Physician Order Report, dated 7/01/2022 - 09/08/2022, indicated Seroquel (Quetiapine) Tablet 50 Milligram (MG), One tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure comprehensive care plans were developed by the interdisciplinary team within required timeframes for two newly admitted residents (#145, #146) out of four residents sampled. Findings included: 1. Review of the medical record for Resident #145 revealed she was admitted to the facility on [DATE]. The resident face sheet revealed diagnoses upon admission included pneumonia due to SARS-associated coronavirus, COVID-19 acute respiratory disease, vascular dementia with behavioral disturbance, type 2 diabetes mellitus with diabetic chronic kidney disease, need for assistance with personal care, dysphagia following cerebral infarction, urinary tract infection, congestive heart failure, atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Active physician orders for September 2022 revealed the resident was receiving the following treatments: physical, occupational, and speech therapy; a mechanical…

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 monitor behaviors related to a psychotropic drug regime for one resident (#39) of five sampled residents. Findings included: On 09/6/2022 at 9:41a.m., an observation was conducted of Resident #39 lying in bed, with Staff E, Certified Nursing Assistant (CNA) sitting in a chair next to Resident #39's bed performing a one on one (1:1). Staff E, CNA was interviewed and asked if the resident is having any behaviors. She revealed he did not have any behaviors, but her assignment is to watch the resident due to his aggressive behaviors in the hospital, and that he tried to elope from the hospital and leave. On 09/07/2022 at 3:17 p.m. Resident #39 was observed to be lying in bed, an unidentified CNA was in the room performing a 1:1. On 09/08/2022 at 9:41a.m. Resident #39 was observed to be walking with a CNA and a nurse by the nursing station. Resident #39 was observed to be dressed appropriately for the time of day, and pleasantly smiled at 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 interviews, observations and record reviews, the facility did not ensure that 1) medications were available for 2 residents, (Resident #3 and Resident #17), and 2) did not ensure eye drops orders were clarified for 1 resident, (Resident # 2) of 21 sampled residents. Findings included: 1. An electronic medical record (EMR) review for Resident #3 on 03/18/21 revealed that Resident #3 missed a scheduled medication (Lorazepam 0.5 mg (milligram) schedule 1 tablet) from 3/1/21 to 3/6/21, missing 12 administration opportunities. A current prescription order revealed that Resident # 3 should receive the medication as follows: Lorazepam 0.5 mg; amount one tablet; oral; frequency twice a day at 06:00 a.m. and 06:00 p.m. Diagnosis: Generalized anxiety disorder. Resident #3 was admitted to the facility on [DATE], with a diagnosis to include; Parkinson's disease, neuroleptic parkinsonism, feeding difficulties, acute respiratory disease, muscle weakness, respiratory TB, Dysphagia, oral phase, insomnia unspecified,…

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 ensure that the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and twenty-four errors were identified for four (#16, #7, #19, and #13) of five residents observed. These errors constituted a 64.86% medication error rate. Findings included: 1. On 3/15/21 at 11:31 a.m., an observation of medication administration with Staff Member H, Licensed Practical Nurse (LPN), was conducted with Resident #16. The staff member reported the residents previous obtained blood glucose level of 347 and stated the resident was to receive 8 units of Novolog. She removed a Novolog Flexpen that was opened on 3/12/21 and dialed it to 8 units. Prior to entering the resident's room, when asked how she primed the Flexpen, she asked, you mean by 2 units?. She reported no I did not when asked if she had primed the Flexpen. The staff member entered Resident 16's room and interjected the Novolog insulin into administered 8 units into the resident's right arm, without priming…

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 designate a healthcare professional with specialized training as the Infection Control Preventionist (ICP) for the facility. Findings included: During an interview with the Director of Nursing (DON), on 3/18/21 at 2:11 p.m., she stated she does not have Infection Control Preventionist credentials. The DON further stated one of the nurses, Staff Member Q, Registered Nurse (RN) had a certificate, but 'was not technically the ICP.' The DON offered to obtain a copy of the certificate but was unable to provide it. When asked who did staff education related to infection control, she stated that the previous Assistant Director of Nursing (ADON) did but she left in December 2020 and the new ADON started at the facility one week ago. The DON stated she did spot-on education if she observed an issue. She further stated that the Nursing Home Administrator (NHA) was the Department of Health contact. During an interview, on 3/18/21 at 3:00 p.m., the NHA identified the facility's Infection Control Preventionist as the DON, stating I…

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, staff interviews, and record review the facility failed to ensure that one (#20) of 21 sampled residents was provided with linens to cover a mattress. Findings included: On 03/15/21 at 10:58 AM, Resident#20 was observed to have four covers/blankets; however, the mattress was bare and had no sheet over it. The resident was alert but confused and unable to understand the surveyor's questions when asked about his missing linens. A review of Resident #20's clinical record revealed he had resided in the facility since 2018 and had a Brief Interview of Mental Status (BIMS) score of 10 (moderate cognitive impairment) according to the quarterly Minimum Data Set (MDS) assessment dated [DATE]. On 03/15/21 at 11:31 AM, a second observation was conducted. The resident was lying in bed with covers on but again, no linens were on the mattress. On 03/17/21 at 10:10 AM, an interview was conducted with the resident's Certified Nursing Assistant (CNA), Staff C, who was shaving the resident. She stated 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.

Based on interviews, policies and resident council minutes review, the facility failed to act upon resident's concerns and grievances as evidenced by: (1) same grievances reported and documented without resolution for 6 out of 6 resident council meeting minutes. (2) Facility not having social services personnel available. (3) Nursing home administrator (NHA) failure to attend resident council meetings per the request of council participants. (4) NHA failure to respond to grievances and complaints. Findings included: A review of resident council meeting minutes was conducted with the following items marked as unresolved and action needed for the following dates: 2/10/21: 1/13/21: 11/18/20: 12/2/20: 10/4/20: 9/9/20. Grievances are not always being resolved satisfactorily and or resolution is not relayed to residents. Communication from NHA and Director of Nurses (DON) is not satisfactory to the residents. DON sends unit manager, NHA is very difficult to access. Residents concerned with use of agency staff stating that meds are not given correctly at times and treatments are not always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure it developed skin assessments for two residents (#5, and #45) of 21 sampled residents. Findings included: 1. Resident#5 was admitted to the facility on [DATE] with a readmission date of 11/23/2020 and multiple diagnosis that included respiratory failure, pressure ulcers unstageable, Seborrhea capitis and dysphagia. On 03/15/21 at11:44 AM Resident#5 was observed with a skin rash on his right elbow, and a size approximately 3x3inches. In a subsequent interview, Resident#5 stated that it wasn't being treated, and no medication or ointment was applied to his rash on his elbow. He further said it has not been looked at or treated. An interview with staff member B, Licensed Practical Nurse (LPN) was conducted on 03/16/21 at 3:27 PM. She stated the resident's rash that was noted yesterday on his right elbow. She confirmed that she had not documented any skin assessments/notes regarding the rash on his elbow. The medical record revealed 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.

Based on observations, record reviews, and interviews the facility failed to develop and implement a baseline care plan for one (#99) of 21 residents sampled. Findings included: A review of the policy titled Care Plans and Care Plan Meetings, dated 10/5/18, revealed: Baseline Care Plan- A preliminary plan of care that includes the minimum healthcare information necessary and instructions will be started and the facility will enable the resident to be informed of and participate in the development and implementation of the care and treatment regimen which will provide effective and person-centered care to properly care for the resident that meets professional standards of quality of care and meets the resident's immediate needs shall be developed for each resident. The baseline care plan summary must be provided to the resident and/or their representative between the 48th hour and completion of the comprehensive care plan . The policy identified that nursing staff will review the Attending Physician's orders (e.g. dietary needs, medications, and routine treatments, etc.) with 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 interview and record review, the facility did not ensure that the resident and resident representative were involved in care planning for one (Resident #3) of nine residents reviewed for care planning. Findings included: In an interview with Resident #3's Power of Attorney (POA) on 03/15/21 at 4:22 p.m., the POA stated that she had not participated in a care plan meeting in a long time. The POA reported that the facility did not have a social worker and that care planning and care coordination was lacking. The POA stated that before COVID-19, they would send a letter inviting the Resident Representative to the meeting. When asked if during COVID-19 she had participated in a conference call or video conference call care plan meeting, Resident #3's POA answered, No. It's been at least a year. An interview was conducted with the Nursing Home Administrator (NHA) on 03/17/21 at 2:52 p.m. The NHA stated that they started care plan meetings recently. The NHA said that they just got a conference call number probably a week ago. The NHA reported that the social worker had…

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 did not ensure three (#3, #14, #20) of four residents reviewed for Activities of Daily Living (ADL) received assistance with showers and nail care. Findings included: 1. Observation on 3/15/21 at 11:30 a.m., 3/15/21 at 4:22 p.m., and 3/16/21 at 3.39 p.m. revealed Resident #3 was laying in bed with hair that appeared unkept. A review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. Continued review of the MDS revealed Resident #3 required extensive physical assistance with one person physical assistance for personal hygiene and total dependence with bathing with one person physical assistance. An interview was conducted with Resident #3's Power of Attorney (POA) on 03/15/21 at 4.22 p.m. revealed that Resident #3 had not a shower. The POA reported that, they wash her up, and her hair has not been washed in months. 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 interviews, observations, and records review, the facility failed to provide an on-going activities program to support the comprehensive assessment and care planned choices and preferences for one (#3) of three residents sampled for activities. Findings included: Observations of Resident #3 were conducted on 03/15/21 at 11:23 a.m. and 12:21 p.m., 3/16/21 at 10:23 a.m., 11:30 a.m., and 3:31 p.m., and on 3/17/21 at 10:00 a.m. and 4:20 p.m. Resident #3 was observed sleeping or laying in her bed with her eyes closed. There was no evidence of either a radio, Television (TV) or mobile device being used or provided in Resident #3's room. Additionally, there were no observations of any one on one activities provided to Resident #3. Resident #3 was not noted to be assisted out of bed to attend any socially distanced group activities during the course of the survey conducted 03/15/21 to 03/18/21. On 03/16/21, 03/17/21 and 03/18/21, the Activities Director was observed sitting at the front desk screening incoming…

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, interviews and record review, the facility failed to maintain the reach in freezer at appropriate temperatures and ensure staff kept personal items separate from food storage on 2 of 2 days observed (3/15 and 3/17/21). Findings included: On 03/15/2021 at 9:39 AM, an initial kitchen tour was conducted with Staff P, Cook. The reach-in freezer at this time was found to be 2 degrees Fahrenheit. A review of the freezer's temperature log for the month of March revealed that the freezer was consistently above the 0 degree Fahrenheit threshold. Staff P was unaware of the freezers temperature. A review of the facility's temperature log revealed the logged temperature on the morning of 3/15/2021 was 4 degrees. On 03/17/2021 at 11:37 AM, during a tour with the Certified Dietary Manager (CDM), a staff member's personal jacket was found on a dry food storage shelf along with a staff member's N95 mask sealed in a plastic bag. The CDM stated that neither of those items were supposed to be there and that this was something that he had not seen before. In addition, a second…

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 one (#18) of 21 sampled residents had an accurately documented code status in the medical record. Findings included: On [DATE] at 11:16 AM, a review of Resident #18's Electronic Medical Record (EMR) revealed the resident was identified as a full code. Further review revealed the resident had a signed Do Not Resuscitate (DNR) Order. A review of the facility's nurses' stations Full Code and DNR books revealed Resident #18 was identified by the facility as both a full code and Do Not Resuscitate (DNR), despite the documentation of the DNR order. An interview on [DATE] at 11:25 AM with Staff B, Registered Nurse (RN), revealed that to check a resident's code status she would look at the resident's EMR or the Full Code/DNR books. When asked to look for Resident #18's Advance Directive, Staff B referenced the resident's face sheet on the EMR and stated that she would perform CPR. On [DATE] at approximately 11:30 AM the Director of Nursing (DON) 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.