Palms At Sebring Nursing And Rehabilitation The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor resident rights to formulate advance directives for two residents (#259 and #94) of 22 residents sampled for advance directives. Findings included: 1. During an interview on 2/26/25 at 9:36 a.m., the court appointed guardian for Resident #259 stated contacting the facility on multiple occasions to inform and ascertain information related to Resident #259, including the resident being intellectually disabled since birth and not able to make decisions. The guardian also stated the hospital had the paperwork from the court and the paperwork was sent with Resident #259 upon admission to the facility. The guardian stated they verbally told the nurses and sent the court documents of the guardianship to the facility. The facility not only had him sign to papers of disenrollment of healthcare coverage, but the facility also had Resident #259 sign vaccination consents and discharge paperwork, all being a violation of the court order. Review of 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 observation and interview, the facility did not ensure privacy of residents' personal health information on one unit (East) out of two units in the facility. Findings included: An observation was conducted on 2/22/25 at 10:28 a.m. of a medication cart outside of room [ROOM NUMBER]. The computer screen was unlocked with a resident's medical record displayed. The nurse was in a resident room and people were observed moving through the halls. An observation was conducted on 2/22/25 at 10:44 a.m. of a lab book sitting on the top counter at the nurses' station with a resident's face sheet sticking out of the book. The book was visible to anyone walking past the nurses' station. At the time, four residents were sitting at the nurses' station and no staff were present. An observation was conducted on 2/22/25 at 12:10 p.m. of a second-floor medication cart sitting in a resident hall with the computer screen unlocked and a resident's medical record displayed on the screen. No staff were present and residents…

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 the prevention of the development of pressure wounds for one resident (#28) out of eight residents sampled. Findings included: On 2/22/2025 at 10:15 a.m., an observation and interview were conducted with Resident #28 and his family member in his room. Resident #28 was in bed and stated he was in a car accident and broke both his legs. Resident #28's family member stated the resident has several new open wounds on his right leg and bottom since he has been in the facility. An observation was made when Resident #28 lifted his right leg to reveal a dressing on the lateral lower area. The dressing had dried light to dark brown drainage and was dated 2/20. Resident #28's family member stated the wounds to his legs were from the brace he was wearing after his accident, but added he no longer wears the brace while he is in bed. An observation was made of two soft boots on the resident's wheelchair seat. The family member stated sometimes the staff will place the soft boots on the resident when he is in bed.…

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 the environment was free of possible accident hazards related to smoking materials for one resident (#104) of one resident sampled for smoking and related to razors and scissors in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of thirty-one resident rooms observed. Findings included: 1. On 2/22/2025 at 12:20 p.m., an observation was made of Resident #104 in his room during the initial tour of the facility. In Resident #104's room there were two packs of cigarettes and three cigarette lighters in view. Resident #104 stated he was in the facility for therapy in hopes to discharge home. On 2/23/2025 at 9:25 a.m., an observation was made of Staff T, Certified Nursing Assistant (CNA) in Resident #104's room, cleaning. Resident #104 was not present in the room. The smoking materials observed the day before in Resident #104's room were no longer present. On 2/23/2025 at 12:49 p.m., an observation and interview were…

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

Based on observations, interviews, and record review, the facility did not ensure post-dialysis communication was implemented and documented in the medical records for one resident (#33) of one resident sampled for dialysis. Findings included: A review of Resident #33's admission Record showed an original admit date of 7/6/2022, with a readmission date of 9/21/2024, and a diagnosis of end stage renal disease (ESRD). A review of Resident #33's February 2025 physician orders showed an order dated 2/5/2025 for dialysis weekly on: Monday/Wednesday/Friday at [dialysis center]. A review of Resident #33's dialysis communication records from 1/25/2025 to 2/21/2025 did not show a section for post-dialysis assessment or vital signs upon return to the facility. Upon further record review, no orders to address the resident's central line access for dialysis and/or documentation for post-dialysis assessment or vital signs were revealed. On 2/24/2025 at 12:00 p.m., an interview was conducted with Staff U, Licensed Practical Nurse (LPN) , Staff C, LPN and Staff V, Registered Nurse (RN). All three…

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 did not ensure pharmacy recommendations were completed for two residents (#57 and #5) out of five reviewed for unnecessary medications. Findings included: Review of admission Records showed Resident #57 was admitted on [DATE] with diagnoses including atherosclerotic heart disease. Review of Resident #57's February 2025 physician orders showed an order for Peridex mouth/throat solution 0.12%. Give 15 ml (milliliters) by mouth every 12 hours for gum/teeth pain, dated 11/20/24 and a second order for Peridex mouth/throat solution 0.12%. Give 15 ml by mouth every 12 hours as needed for mouth pain for 2 weeks, dated 2/9/25 to 2/23/25. A review of a Consultant Pharmacist Medication Regimen Review dated 12/16/24 revealed: Peridex 0.12% (Chlorhexidine Gluconate) should not be swallowed. Please add to the order: Swish 15ml for 15-20 seconds, the expectorate- do not swallow A review of a Consultant Pharmacist Medication Regimen Review dated 2/16/25 revealed: Perdix should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility did not ensure medications were stored properly on two out of two units in the facility related to unlocked medication carts, unsecured medication, and medication in resident rooms. Findings included: An observation was conducted on 2/22/25 at 10:23 a.m. of a medication cart at the second-floor nurses' station. There were two bottles of medication sitting on top of the cart, one was a stool softener and the other a multivitamin. Both bottles contained medication. No staff were in sight of the medication cart and three residents were sitting within 10 to 15 feet of the cart. An observation was conducted on 2/22/25 at 10:47 a.m. of an unlocked medication cart at the first floor nurses' station. No staff were near the cart. An observation was conducted on 2/22/25 at 11:51 a.m. of an unlocked medication cart on the second floor. No staff were in sight of the medication cart and a resident was sitting approximately 5 feet away from the cart. A nurse walked back up to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to implement protocols from the facility's antibiotic stewardship program for one resident (#3) out of three residents reviewed for antibiotic use. Findings included: An observation and interview on 2/22/25 at 2:32 p.m. showed Resident #3 lying in bed with an Intravenous Therapy (IV) pole at the bedside. The IV pole contained two empty bags of Vancomycin, both dated 2/22/25. Resident #3 stated she was getting IV antibiotics because she recently had a severe Urinary Tract Infection (UTI) that sent her to the hospital. Resident #3 stated she did not know how long she would be on IV antibiotics but stated she was feeling much better. Review of the admission Record showed Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included but not limited to infection and inflammatory reaction due to other urinary tract infection (UTI) unspecified, urinary catheter initial encounter, infection and inflammatory reaction due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice for one resident (#4) out of one resident reviewed for admission, transfer, and discharge. Findings included: On 01/09/2025 at 10:30 a.m., Resident #4 was observed in his room, in bed, working on his laptop. Resident #4 stated the facility was discharging him for non-payment. He stated he did not want to talk about it. On 01/09/2025 at 11:15 a.m., the Nursing Home Administrator (NHA) stated, one resident, Resident #4 had been provided a 30-day discharge notice on 12/05/2024. He stated the reason for the 30-day notice was that the resident was combative. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which meant he was cognitively intact. A review of the medical record showed 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.

Based on observation, staff interview and policy review the facility failed to store food in accordance with professional standards for food service safety as evidenced by failure to discard food items that were expired, unlabeled and undated food items in the kitchen and one of two medication storage rooms, and one dietary staff member not wearing a hair net in the kitchen area. Findings Included: An observation, during the initial kitchen tour on 01/09/23 at 9:25 AM, revealed two (2) low-fat 1% gallons of milk that had an expiration of 12/28/2022. An immediate interview on 01/09/23 at 9:25 AM, Dietary Staff C confirmed the milk was expired and stated, hopefully no one used it. An observation, on 01/09/23 at 9:30 AM, revealed a handful of yellow colored hard tubular food product that was wrapped up with plastic wrap that was not labeled or dated. An immediate interview on 01/09/23 at 9:30 AM, Dietary Staff E stated, what is that and identified the food product as left-over uncooked spaghetti. Dietary Staff stated that should have been labeled and dated. An observation on 01/09/23…

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 the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#12, #41, and #24) of three residents sampled. Findings included: 1. Review of Resident #12's Face Sheet revealed Resident #12 was admitted on [DATE]., with diagnoses that included end stage renal disease, insomnia, and depression. Review of the Minimum Data Set (MDS), provided by the facility and dated 1/12/23, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating the resident was cognitively intact. Review of the binding arbitration agreement revealed it was signed by the facility representative (Staff G, admission Coordinator) and Resident #12 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign 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, record review, and review of facility policy, the facility failed to provide Pneumococcal vaccinations for three (Residents #4, #12, and #33) of five residents sampled for Pneumococcal vaccinations, failed to provide influenza vaccinations for three (Residents #12, 33, and 63) of five residents sampled for influenza vaccinations, and failed to provide COVID-19 vaccinations for two (Residents #33 and 63) out of five residents sampled for COVID-19 vaccinations. Findings included: A request was made for pneumococcal, flu, and COVID vaccination consent/refusal and proof of administration for five residents on 1/11/23 to Staff B, Registered Nurse (RN)/Minimum Data Set (MDS Coordinator,) who was covering in the absence of the Director of Nursing (DON.) A record review for Resident #12 indicated he was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines with Resident #12's name on it. The form was not filled out or signed.…

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

Based on observation, record review, interview, and policy review the facility failed to provide care and services related to catheter care for one resident (#25) out of six residents with indwelling catheters. Findings included: A review of admission records revealed Resident #25 had diagnoses to include urinary tract infection, cerebral palsy, and abdominal pain. A review of Resident #25's care plan revealed a care plan for increased risk for urinary tract infection related to presence of indwelling catheter for diagnosis of urinary retention, it noted catheter was changed to suprapubic catheter on 1/25/22. Interventions included change catheter bag monthly and observe/record urine appearance. A review of physician orders revealed the following orders: 1-Cleanse suprapubic site with normal saline, pat dry, apply clotrimazole solution and cover with split 4 x 4 gauze twice daily. Order date 8/28/22. 2-Suprapubic catheter care every shift. Order date 8/28/22. A review of the electronic Treatment Administration Record (eTAR) indicated order 1 was not documented as completed on 23 out…

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

Based on observations, interviews, record review, and policy reviews facility failed to ensure one resident (#25) out of thirty-one sampled residents received trauma-informed care in accordance with professional standards of practice and accounted for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization. Findings included: A review of Resident #25's Minimum Data Set (MDS,) section I, Active Diagnosis, dated 12/3/22, revealed a diagnosis of Post Traumatic Stress Disorder (PTSD.) A review of admission records indicated Resident #25 was admitted in 2019 with diagnoses to include anxiety, personality changes due to known physiological condition, and persistent mood disorder. A review of Resident #25's care plan revealed no care plans for PTSD or trauma-informed care. On 1/12/23 at 8:28 a.m., an interview was conducted with Staff B, Registered Nurse (RN,) MDS Coordinator, who is currently covering for the Director of Nursing (DON.) When asked if they have care plans for PTSD and Trauma-Informed care she stated, not at this…

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 resident-centered plan of care related to Dementia Care for one (#21) of one resident reviewed for dementia care out of 21 facility residents with dementia related diagnosis or Alzheimers' disease. Findings included: A record review for Resident #21 revealed admission to the facility in 2020 with diagnoses that included dementia, communication deficit and mood disorder, according to the Face sheet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section I revealed diagnoses that included Non-Alzheimer's Dementia. Review of a behavioral health note dated 10/18/2022 listed a secondary diagnosis of Dementia. Review of the resident's care plan on 01/11/2023 did not reveal a focus area related to Dementia care. During an interview on 01/11/2023 at 01:38 PM with Staff B, Registered Nurse (RN), MDS Coordinator, she stated the Social Services department was responsible for behavioral and Dementia care planning. On…

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 facility file review, the facility did not ensure a safe, clean, comfortable, and homelike environment during four of four days observed (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) as evidenced by: 1) one of one smoking area observed with cigarette butts on the ground and cigarette butts in a trash can that was not fire rated, 2) seating equipment in disrepair in one (first floor) of two dining rooms, and 3) Twelve (203, 204, 206, 210, 211, 213, 216, 219, 222, 227, 230, 231) of 62 resident rooms with soiled floors, cracked and chipped tiles, unbagged plungers, and walls in disrepair. Findings included: 1. During facility-wide tours on 4/20/2021 at 10:30 a.m., 4/21/2021 at 7:30 a.m., 1:00 p.m., 4/22/2021 at 7:45 a.m. and 2:00 p.m. and 4/23/2021 at 9:00 a.m. the following was observed: The first floor dining room was observed with a door that led from the dining room into a screened in porch. The porch was identified as a smoking area for residents. The porch…

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 review of clinical records and policies and procedures, the facility failed to develop a care plan for one (#30) of 32 sampled residents related to respiratory care and behaviors and failed to implement care plan interventions related to smoking for one (#59) of 32 sampled residents. Findings included: 1. On 04/21/21 at 9:41 a.m., Resident #30 was observed lying in the bed flat on his back. The head of the bed was not elevated. The resident was sleeping. An oxygen concentrator was noted in the room running. Resident #30 was noted to have the oxygen tubing with a nasal cannula lying in the bed beside him. A review of the medical record for Resident #30 indicated the resident had a diagnosis of congestive heart failure, hypertension, and obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders…

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

Based on record review, observation, interviews, and policy review the facility did not ensure systems and processes for treatment of a pressure ulcer were implemented related to timely treatment of infection, appropriate disinfection of treatment supplies, maintenance of dressings on a pressure ulcer, adequate cleansing of the pressure ulcer, and appropriate application of the ordered treatment in a manner to prevent the worsening of a pressure ulcer for one resident (#40) of two residents sampled for care and services for pressure ulcers. Findings included: Resident #40 was admitted to the facility with a diagnosis of type II diabetes mellitus, according to the face sheet in the admission record. A review of the history and physical from the hospital, dated 11/4/20, reflected a chief complaint of pressure sore on coccyx. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 03/03/21, section H, bladder and bowel, revealed Resident #40 was always incontinent of urine and bowel. Review of Section M, skin conditions, reflected a stage 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 record review, interviews, and policy review the facility failed to ensure a root cause analysis and meaningful interventions were implemented to prevent accidents for one (#8) of three residents reviewed for falls. Findings included: Resident #8 was admitted to the facility with diagnoses of dementia and history of falling, according to the face sheet in the admission record. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 3, indicating Resident #8 had severe cognitive impairment. Review of the 72 hour charting/report reflected Resident #8 was transferring herself from bed to wheelchair and her leg gave out and fell to her bottom on 4/3/21. A review of the facility documentation for Resident #8 reflected she had fallen on the following dates: 12/11/20 1/9/21 1/16/21 2/28/21 3/3/21 4/3/21 Review of the care plan dated 10/28/20 revealed no new interventions following the 4/3/21 fall had been implemented. A 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 observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to proper storage of a nebulizer machine and continuous positive airway pressure (CPAP) treatments, consistent with professional standards of practice for one (Resident #30) of one resident investigated for respiratory care. Findings included: A review of the medical record for Resident #30 indicated the resident had a diagnosis of obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders indicated the following active orders: Atrovent administer one vial via nebulizer every six hours for shortness of breath or wheezing; auto CPAP 5-15 sonometers with heated humidification (dated 4/12/21). A review of the provider progress notes for Resident #30 indicated the following: -a visit dated 4/7/21 noted…

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 did not ensure appropriately stored refrigerated controlled substances in two of two medication refrigerators in two of two medication storage rooms on two of two nursing units (the first and second floors). Findings included: On 4/20/21 at 10:13 AM an observation was conducted on the second floor in the medication storage room with Staff A, LPN. The medication refrigerator contained a locked controlled substance box on the top shelf that was not secured to the refrigerator. Photographic evidence obtained. During the observation an interview was conducted with Staff A, LPN who said she was not aware it needed to be secured to the refrigerator. On 4/22/21 at 8:46 AM an observation was conducted in the medication room on the first floor with Staff K, RN (registered nurse). The locked controlled substance box was sitting on a shelf in the refrigerator, unsecured. Staff K, RN removed the locked box from the refrigerator and placed it on the counter. She unlocked it and opened it and removed a bottle of lorazepam 2 mg/ml. Staff K, RN…

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 two (#282, #17) of two sampled hospice residents had a record of the benefit of election for hospice and a hospice plan of care or indication of hospice personnel involved in hospice care and working in collaboration with the facility. Findings included: During multiple facility tours throughout the survey, Resident #282, a hospice resident was observed laying in bed, appeared to be resting. A review of Resident # 282's clinical record revealed an admission date of 03/30/21 with diagnoses to include: unspecified systolic (heart failure), acute encephalopathy, Gastro-esophageal reflux disease, unspecified dementia, essential hypertension, hypothyroidism, hyperlipidemia, heart disease, unspecified atrial fibrillation, dehydration, history of dementia and hypothyroid. Continued review of the record revealed no hospice physician consult order, no benefit of election, no plan of care for hospice or indication of hospice personnel…

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.