Blue Palms Health And Rehabilitation Center At Fle

Based on observations, record review and interviews, the facility failed to provide care consistent with professional standards of practice related to oxygen therapy for one resident (#21) of two residents reviewed for oxygen therapy. Findings included: An observation on 04/08/24 at 9:55 a.m. revealed Resident #21 was receiving oxygen via a nasal cannula, the oxygen concentrator was set at two liters per minute. The oxygen tubing was touching the floor and the storage bag was dated 04/01/2024. An observation on 04/08/2024 at 2:00 p.m. revealed Resident #21 in bed and oxygen was in place. An observation on 04/09/2024 at 8:00 a.m. revealed Resident #21 in bed, oral care had been provided and oxygen tubing was removed off the floor, the bag and tubing had been changed and dated 04/08/2024. An observation on 04/10/2024 8:00 a.m. revealed Resident #21 resting in bed receiving oxygen via a nasal cannula at two liters per minute. Review of admission Record for Resident #21 revealed a date of admission as 9/4/2020. The diagnoses included cerebral infarction, shortness of breath, anxiety,…

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 and interview the facility failed to appropriately store and secure medications related to one (1st floor) of two units for medication at the bedside and one (200 hall, cart 1) of four medication carts left unlocked. Findings included: 1. Observation of Resident #120's room on 04/08/24 at 10:28 a.m. revealed there was a white cream in a medicine cup in a tissue box on the resident's over bed table which was located to the right side of the resident's bed. The cup was not labeled with the name of the substance and there was no indication for the direction of the use of the substance. Interview with the resident at this time revealed the resident indicated that is icy hot from last night. Also noted in the tissue box was a bottle of eye drops and a container of Icy Hot. There was no direction for use of the eyedrops or the Icy Hot. Resident #120 said, Those are mine that I paid for because my eyes get dry. Continued observation of Resident #120's room revealed a green substance in a disposable 4 oz (ounce) juice cup with a vinyl glove covered over…

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 (#6, #120, and #122) of three residents sampled. Findings included: 1. Review of the admission Record for Resident #6 revealed an admission date of 03/21/2024. Resident #6 was noted as her own responsible party. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 04/10/2024 at 10:45 a.m. an interview was conducted with Resident #6. Resident #6 stated she signed so many forms when she was admitted that she does not remember each one. Upon review of the Arbitration Agreement she signed on 04/05/2024, she stated she remembered signing the Arbitration Agreement. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated…

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 facility policy, the facility failed to maintain an effective pest control program related to small flying insects observed in three resident rooms (212, 216, and 218) on one of two floors. Findings included: During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:16 a.m. an observation was made of small flying insects on the resident's water cup. The resident in the window bed stated the cleaning could be better. She stated she had seen a cockroach in the bathroom. The resident stated she had observed the insects in her room before. On 04/09/24 at 11:10 a.m. an interview was conducted with Staff P, Housekeeping. She stated she cleaned all the rooms. She stated if there were bugs anywhere, she would notify her supervisor. During a tour of Resident room [ROOM NUMBER] on 04/09/24 at 11:17 a.m., two urinals were observed on the resident's head of bed, hooked to the bedside rail. They were observed with urine, stained and with a foul order. An observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure, six residents (#25, #34, #69, #75, #87 and #99) and a representative for one resident (#40) were invited and/or participated in their plan of care meetings out a total of 43 sampled residents. Findings included: The policy, Resident/Family Participation in Goal Planning, revised 11/2016, indicated, To assure the residents and resident representative's right to participate in planning the resident's care in making informed decisions regarding medical treatment. The procedure identified the following: - 1. A resident has the right to participate in the development and implementation of his or her person-centered plan of care, including requirements that affect both the initial planning process and changes to the plan of care. - 3. Residents and their families or other resident representatives will be given the opportunity to attend an interdisciplinary goal planning conference to participate in resident care planning and medical…

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 safe and homelike environment related to wall baseboard bumpers, handrails, and a resident wall being in disrepair were reported to maintenance staff within a timely manner for repair on one floor (first floor) of two floors . Findings included: An initial tour of the facility on 11/02/2021 at 12:15 p.m. revealed various locations throughout the facility's first-floor hallways with the wall baseboard bumpers, located approximately one foot from the ground, detaching and sticking out from the wall. During these observations handrails were observed throughout the first-floor hallways in disrepair with the internal metal exposed. (Photographic Evidence Obtained) These locations and observations included: 1. The wall bottom bumper located on the right side of room [ROOM NUMBER]. 2. The wall bottom bumper located on the right side of room [ROOM NUMBER] next to room [ROOM NUMBER]. 3. The handrail on the left side of room [ROOM NUMBER].…

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 adhere to their grievance policy for one resident (#26) of 43 sampled residents. Findings included: An interview with Resident #26 on 11/02/21 at 10:40 a.m. revealed the facility was short staffed to the point where he was left to sit in his own bowel movement for 4 hours. He reported this happened two nights ago (Sunday 10/31/21), when they were short staffed and he used his call light and no one responded on the 3:00 p.m. -11:00 p.m. shift. He reported it wasn't until 1:00 a.m. when a temporary staff person came into his room and assisted him. He reported that he reported this to the nurse, who ended up quitting that same day. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with a diagnosis that included hemiplegia and hemiparesis following cerebral infraction affecting left dominant side. Review of the resident's Brief Interview For Mental Status (BIMS) dated 8/12/21 revealed a score of 15 (cognitively…

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 interview the facility failed to provide for dependent residents appropriate nail care for one resident (#13) of 43 sampled residents. Findings included: Observations on 11/02/21 at 11:54 a.m. of Resident #13 revealed the resident lying in his bed. It was noted that the resident had a contracture to his right hand with his nails elongated approximately half an inch past the top of his finger. Observations on 11/04/21 at 10:48 a.m. revealed the resident lying in bed with his eyes open. The resident was noted with a contracture to his right hand with his nails on the right hand elongated and approximately half an inch past the top of his finger. An interview on 11/04/21 at 10:58 a.m. with Staff H, Licensed Practical Nurse (LPN), revealed that the CNAs do nail care which would include cutting the resident nails whenever necessary. She reported the aides are to check and cut resident nails if needed on the resident's shower days. At this time Staff H checked a white erase…

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 did not ensure that pharmacy recommendations were followed for one resident (#41) out of 5 residents sampled for unnecessary medications, related to the change in dosage for Aspirin from 325 mg (milligrams) to 81 mg recommended by the consultant pharmacist on 08/03/21. Findings included: Review of Resident #41's consultant pharmacist's medication regimen review (MRR) revealed the resident had a recommendation dated 08/03/21 to reduce the resident's aspirin dosage from 325 mg to 81 mg to avoid increased risk of bleeding. In an interview with the Director of Nursing (DON) on 11/04/21 on 8:55 a.m. she said that she had only been in her position since 10/01/21 and was not the DON when the recommendation was made. She said she didn't realize the recommendations hadn't been done before 11/03/21, so she did them at that time. A review of the admission Record revealed Resident #41 was admitted to the facility on [DATE] for diagnoses that included sepsis, presence 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.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and six errors were identified for five (#21, #20, #85, #25, and #37) of five residents observed. These errors constituted a 20.69% medication error rate. Findings included: 1. On 11/3/21 at 4:32 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) and Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #21. Staff A was observed administering the following medications: - Eliquis 5 milligram (mg) oral tablet - Carvedilol 25 mg oral tablet - Gabapentin 300 mg oral capsule - Timolol Maleate 0.5% eye drops - Novolog 100 unit/milliliter (u/mL) FlexPen 2 units injected. During the oral administration of medication Staff A obtained a blood glucose level of 186 from Resident #21. The observation continued as Staff A removed a Novolog 100 unit/milliliter (u/mL) from the medication cart. The staff member dialed the dosage selector to 2 units 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 observations, record reviews, and interviews, the facility failed to store, prepare, and distribute, serve food in accordance with professional standards for food service safety and failed to maintain the kitchen in a sanitary condition. Findings included: On 02/17/2020 starting at 9:15 a.m., an initial tour of the kitchen was conducted with the Operations Manager and the Corporate Food Service Director. An excessive amount of dust was observed on the ceiling vent above the ice machine. Black buildup was observed on the ceiling vent in the area between the stove and walk in cooler. The ceiling tiles near the cooking and food prep area were observed to have an excessive amount of food splatter and dust (photographic evidence obtained). Water damage was observed on the ceiling tile right above the food serving area. The Operations Manager reported that the ceilings were cleaned every couple of months. There was a missing vent above the tilt skillet and the third vent was ajar (photographic evidence obtained). The Operations Manager that they had a work order in for the vents.…

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 resident and staff interviews it was determined that the facility did not ensure that twelve (#56, #73, #104, #130, #140, #148, #208, #211, #212, #213, #406, and #407) of 58 residents were treated with respect and dignity related to lack of clothing for two residents (#208 and #213); reused non- skid socks for two residents (# 211 and # 212); identifying information in ID bands for two residents (#148 and #56); timely assistance with meals for one resident (#104); providing care and speaking to residents in a rushed manner for five residents (#130, #140, #407, #406, and #73), and staff talking on phones and to each other in patient care areas in a foreign language and during patient care. Findings included: 1. A review of the Face Sheet indicated that Resident #130 was admitted on [DATE] with a diagnosis of Multiple Sclerosis, Mood Disorder due to Major Depressive like episodes, Major Depressive Disorder. Resident #130's most recent comprehensive minimum date 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 observations, record reviews, and interviews, the facility failed to ensure sufficient staffing was maintained to provide necessary care and services to the residents. Findings included: 1. On 2/18/20 at 9:01 a.m., Resident #315 reported insufficient number of staff at night, during mealtimes, and between shifts. The resident identified the need to be assisted to ambulate to the restroom, and sometimes the need to use the restroom was urgent with a capital U. Resident #315 described staff ignoring the call light or stick head in and being informed of having to wait due to staff being busy, I'm busy. On 2/19/20 at 6:46 a.m., Staff Member X, Certified Nursing Assistant (CNA), stated the facility generally replaces staff call-offs, short-staffing happens, and the facility have implemented more agency staff. Staff Member X reported feeling rushed and not being able to get the work done when staffing was short. At 7:05 a.m. on 2/19/20, Staff Member Y, Licensed Practical Nurse, stated the facility was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medication regimen was free from unnecessary psychotropic medications for five of six sampled residents. Three residents (#118, #130 and #36) lacked behavior monitoring and two residents (#104 and #50) lacked the rationale for the use of as needed psychotropic medications for over 14 days. Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression…

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 failed to ensure medications were stored in an orderly manner in one medication cart (2nd floor #1), and medications with a shortened open life were dated as opened in two medication carts (West 2 and [NAME] 3) out of three medication carts reviewed, and two of two refrigerated narcotic storage boxes were permanently affixed to the refrigerator. Findings included: An observation was conducted, on 2/18/20 at 11:06 a.m., with Staff Member L, Licensed Practical Nurse (LPN) of the 2nd Floor #1 medication cart. The blister packaged medications was divided in the drawers by separators labeled with room numbers and bed letters. In the area designated as 213A were blister packages containing medications prescribed to two different residents, both residing in room [ROOM NUMBER]. The staff member confirmed the area for 213A contained medications for two different residents. On 2/19/20 at 7:20 a.m., an observation of the [NAME] #3 medication cart was conducted with Staff…

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 use appropriate hand hygiene while assisting two residents (Resident #85 and #12) with their meals, left nebulizer tubing unbagged for one resident (Resident #2), a catheter bag was stored inappropriately for one resident (Resident #127), and failed to ensure two glucometers were cleaned and disinfected in between residents appropriately and according to manufacturer's recommendation. Findings included: 1. On 02/18/20 at 11:41 a.m., observations were made in the main dining room on the second floor. Staff W, Certified Nursing Assistant (CNA), was observed sitting in the middle of Resident #85 and #12 at the table and assisting them with their meals. Continued observations revealed Staff W was assisting both residents with their meals by using her right hand only to assist both residents and was not noted to wash or sanitize her hands in between assisting the residents. Staff W was also observed giving the residents juice from a cup with the right hand only and was not noted to wash or sanitize her hands 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 reviews, and interviews, the facility failed to assess two residents (Resident #34 and #73) out of the sampled 58 residents for the self-administration of medications. Findings included: On 02/17/20 at 2:05 p.m., Resident #34 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:08 p.m., Resident #73 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:09 p.m., the Staff C, Licensed Practical Nurse (LPN), confirmed that she was the nurse for both residents. Staff C was down the hall from the residents' room near the nurses' station on the medication cart. Staff C was asked if the residents could self-administer their own medications, and she stated that they were not self-administering their own medication. She stated that she gave them the treatment, and after 10 minutes she goes back to the room to check on them. A record review…

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 the accuracy of the code status for one resident (Resident #26) out of the sampled 58 residents. Findings included: The Face Sheet revealed that Resident #26 was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia and altered mental status. Section C of the Quarterly Minimum Data Set (MDS) with an effective date of 10/01/19 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A record review of the Face Sheet for Resident #26 under the Advance Directives section revealed that the resident's code status was listed as Full Code and Do Not Resuscitate (DNR). The banner at the top of the resident's electronic medical record indicated that she had a code status of DNR (photographic evidence obtained). The Face Sheet revealed that Resident #26 had a family member listed as the Power of Attorney (POA). A review of the February 2020…

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 perform an Comprehensive Resident Centered Care Plans including a baseline care plan on admission for one of 58 sampled residents (#256). Findings included: 1. Observation on 02/17/20 at 1:10 p.m. Resident #256 was sitting at the dining room table having only eaten a few bites of his lunch. He stated he had eaten a big breakfast and was not very hungry. The resident had multiple discolored areas on both hands and arms. Observation on 02/19/20 at 3:45 p.m. the resident was in the dining room in a wheelchair. He was dressed and groomed for the day in shorts. He was noted to have discolored areas on both hands and arms as well as both knees. Resident #256 was admitted on [DATE]. Record showed diagnoses included but not limited to Cerebral Vascular Accident (CVA) and unsteady gait. A record review showed the chart lacked an admission assessment nor baseline care plan for the 02/15/20 admission. During an interview on 02/19/20 at 9:00 a.m. 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 and resident and staff interview, it was determined the facility did not ensure that a care plan was developed related to communication for 1 of 58 residents reviewed (#139). Findings Included: Review of the record for Resident #139 revealed that she was admitted to the facility on [DATE] from the hospital. Diagnoses on the face sheet revealed Displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, History of falling, Other specialized disorders of muscle, Other abnormalities of gait and mobility, Muscle wasting and atrophy, Dysphasia following cerebral infarction, pain, Hyperlipidemia, Anxiety disorder, Age related osteoporosis, Hypertension, Embolism and thrombosis of unspecified artery, Unspecified dementia without behavioral disturbance, Major depressive disorder. Review of the hospital record from the discharge on [DATE] revealed diagnoses which included Expressive Aphasia and Dysarthria secondary to old stroke. Review 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 observations, record review, and interviews, the facility failed to ensure that one resident (Resident #26) out of the sampled 58 residents who was identified as a risk for elopement was assessed appropriately. Findings included: On 02/17/20 at 1:58 p.m., a wanderguard was observed on Resident #26's right wrist. On 02/18/20 at 10:05 a.m., the resident was observed sitting in the hallway near the nurses' station. The wanderguard was observed on Resident #26's right wrist. On 02/20/20 at 1:48 p.m., Staff V, Certified Nursing Assistant (CNA), reported that Resident #26 had had the wanderguard for a while. When asked had Resident #26 ever tried to elope, Staff V stated that she had found Resident #26 downstairs on the first floor a few times and she had to bring her back up to the second floor. On 02/20/20 at 12:30 p.m., Staff L, Licensed Practical Nurse (LPN), reported that she did not see an order for the wanderguard. Staff L was asked where was the elopement book and she stated that she would have 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.

Based on resident interview, staff interview, resident record review and review of policy and procedure, it was determined that the facility did not ensure that a resident who was admitted as continent of bladder and bowel received services and assistance to maintain continence for one (#210) of 58 residents reviewed. Findings included: Review of the record for Resident # 210 revealed that she was admitted from the hospital on 1/30/20. Review of the admission nursing clinical note, dated 1/31/20 revealed that the resident was continent of bowel and bladder. Review of the the nursing admission evaluation, completed on 1/3/120 revealed that the resident was continent of bladder. Bowel continence status was not documented. A Minimum Data Set ( MDS) admission assessment, with a lock date of 2/12/20, indicated a score of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated cognitively intact. The MDS assessment indicated the resident needed the extensive assist of two persons for bed mobility, transfer, dressing and toilet use. Urinary incontinence and bowel…

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 the pharmacy recommendations were acted upon for three of six sampled residents (#36, #50 and #118). Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). Record review of the physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day started 08/13/19 and discontinued on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day started 01/24/20 for major depression, an order date of 01/23/20. A physician order dated 01/23/20 showed increase…

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%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three (#155, #103, and #130) of seven residents observed. These errors constituted a 14.29% medication error rate. Findings included: On 2/18/20 at 4:20 p.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #155. Staff Member I was observed administering the following medications: - Active Protein 30 milliliters (mL) orally - Novolog 100 unit/mL Flexpen, 10 units subcutaneously Prior to the administration, Staff Member I obtained a blood glucose level, using an Evercare G3 glucometer, of HI. The staff member informed the resident the doctor would need to be notified. A review of Resident #155's February Medication Administration Record (MAR) revealed a sliding scale of units to be administered dependent on the blood glucose level of the resident. The sliding scale…

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 two of 58 sampled residents was free from a significant medication error related to one resident receiving an incorrect dosage of Zoloft (#36) and one resident not receiving all their medications on dialysis days (#151). Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day starting 01/24/20…

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 the medical record was accurate and complete for one (#138) of 58 sampled records related to falls. Findings included: Observation on 02/17/20 at 12:54 p.m. Resident #138 was out of bed sitting in a broda chair. She had enablers in an up position with a mat in place beside of her bed. The medical record showed she had fallen out of bed. She had an egg-shaped swollen area over her right eye. There was a purplish yellow discolored area from her eye down her right cheek. She was dressed and groomed for the day including her hair being combed. She was drinking a soda. On 02/19/20 at 3:50 p.m. it was noted that she had a discolored area on her right hand also. Record review of the facility's policy, Fall Prevention Program, not dated showed to assure proper follow-up is carried out to reduce the amount of resident falls through assessment and staff awareness and implementation of appropriate interventions. The members 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.