Aviata At Colonial Lakes

Based on observation and interview, the facility failed to store raw foods (e.g., produce) in a manner to reduce the risk of contamination of ready-to-eat foods and failed to store other food items by sealing, labeling and dating when opened. The facility also failed to ensure dishes and flatware were cleaned and stored under sanitary conditions and equipment was clean and in safe working order. These issues had the potential to negatively affect the health of 154 of the 166 residents in the facility. Findings: On 07/15/24 at 9:55 AM, surveyors entered the kitchen for the initial tour accompanied by the Certified Dietary Manager (CDM). In the walk-in refrigerator, liquid was dripping from the refrigerator condenser onto raw produce including tomatoes, 6 vented plastic containers of strawberries, and other boxes of fresh produce. An approximately 18 inch by 18-inch puddle as well as most of the floor was wet. The CDM stated it was not sanitary to have liquid from a piece of equipment dripping onto food items, but she didn't have anywhere else to put the produce. The surveyors pointed…

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

Based on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in safe operating condition for all mechanical and electrical equipment. This issue had the potential to negatively affect the health of 154 of the 166 residents in the facility who received food and nutrition by mouth. Findings: On 07/15/24 at 9:55 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), it was noted the walk-in refrigerator's condenser was leaking liquid onto food products including raw produce. Most of the floor was wet along with a puddle measured approximately 18 inches by 18 inches. The CDM stated they dry mopped the walk-in floor regularly to remove liquid from it. She stated the condenser had been dripping liquid for more than 6 months. The CDM demonstrated the floor underneath the condenser was soft and boggy from the moisture when it dipped down as she jumped on it. She stated she had informed the Maintenance Department and Administration about the leak. The facility's food service equipment policy with revision date of September…

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

Based on observation and interview the facility failed to maintain clean and soiled utility rooms to ensure proper storage of contaminated and clean linens, and failed to maintain adequate handwashing supplies on 2 of 2 units, out of a total of 3 units, to prevent cross contamination, and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. Findings: The Infection Prevention and Control Program policy revised 10/18 read, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Coordination and Oversight .The infection prevention and control program is coordinated and overseen by an infection prevention specialist [infection preventionist] .Important facets of infection prevention include .educating staff and ensuring that they adhere to proper techniques and procedures . On 7/16/24 at 10:51 AM, interview and observations were conducted with the Infection Preventionist…

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 conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 59 residents, (#321). Findings: Resident #321 was admitted to the facility on [DATE] with diagnoses including a nondisplaced zone 1 fracture of the sacrum, subsequent encounter for fracture with routine healing, type 2 diabetes, chronic kidney disease, and depression. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 7/11/24 revealed the resident's mental cognitive status as alert, oriented, and followed instructions. On 7/15/24 at 03:19 PM, resident #321 was observed lying in bed with her son standing beside her. A 1.5-ounce Major Deep-sea Saline nasal moisturizing spray, Tylenol PM, Magnesium 400 milligrams (mg), and Cranberry extract 500 mg were on the resident's nightstand. Resident #321 stated she used the nasal…

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 review or revise the individualized fall plan of care to include a new intervention after every fall for 1 out of 3 residents reviewed for care plans, from a total sample of 59 residents, (#62). Findings: Review of the medical record revealed resident #62 was admitted to the facility from an acute care hospital on [DATE] and had diagnoses that included history of falls, difficulty walking, paranoid schizophrenia, anxiety disorder, and dementia. The Quarterly Minimum Data Set with Assessment Reference Date 6/29/24 noted the resident scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively impaired. The assessment noted the resident required significant/maximum staff assistance to complete Activities of Daily Living. The comprehensive fall care plan included focus items for an actual fall with a goal that resident #62 would resume usual activities and minimize the risk of further incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident had a timely appointment for vision care and services for 1 out of 2 residents reviewed for vision and hearing, of a total sample of 59 residents, (#156). Findings: Resident #156 was admitted to the facility on [DATE] from the hospital with diagnoses including hypoglycemia, adjustment disorder, anxiety disorder, and symbolic dysfunctions. Resident #156's Annual Minimum Data Set (MDS) assessment with a reference date of 3/27/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status exam which indicated he was not cognitively impaired. The MDS assessment indicated resident #156 had adequate vision and did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Resident #156's Order Summary Report showed the resident had an order on 4/19/24 for Optometry/Ophthalmology as needed and an Ophthalmology Appointment order was placed 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 interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for Pneumococcal vaccine for 2 of 5 residents reviewed for immunizations, (#5, and #129). Findings: 1. Resident #105, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, dysphagia, malignant neoplasm of prostate, anemia and chronic obstructive pulmonary disease. Review of resident #105's medical record on 7/17/24 revealed no documentation of consents, refusal, or medical contraindication for the Pneumococcal vaccine. 2. Resident #129, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of muscle weakness, type 2 diabetes, dysphagia, hypertension, cerebrovascular disease, syncope and collapse. Review of resident #129's medical record on 7/17/24 revealed no documentation of consent, refusal, or medical contraindication for the Pneumococcal vaccine. On 7/17/24 at 4:42 PM, the Regional Registered Nurse (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 interview and record review, the facility failed to ensure resident funds were accessible on weekends for 1 of 3 residents reviewed for personal funds of a total sample of 68 residents, (#32). Findings: Review of resident #32's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included stroke with left side weakness and paralysis, contracture of the left knee and hip, and anxiety. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 6/9/22 revealed resident #32 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. On 8/15/22 at 1:32 PM, resident #32 stated he requested a withdrawal of $50.00 from his account on the previous weekend but had not received it. He indicated he requested access to his funds from staff members but no one got back to him. On 8/17/22 at 3:49 PM, the Business Office Manager (BOM) explained residents could request money from their personal funds account for up to $50.00 in cash…

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 obtain physician orders upon admission to address wound care for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 68 residents, (#343). Findings: Review of resident #343's medical record revealed she was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, diabetes, adult failure to thrive, and metabolic encephalopathy. Review of the Nursing admission Assessment form dated 8/10/22 revealed the resident was was alert, her memory was okay, and she was oriented to person, place, and time. The form noted the resident had wounds to left buttock and left heel. Review of the physician progress note dated 8/11/22 at 11:53 AM, showed the resident had sacral and left heel ulcers. A care plan dated 8/10/22 and revised 8/17/22 for risk of skin breakdown, related to decreased mobility included interventions for staff to follow facility protocols and treatment as ordered by the physician and Wound Doctor…

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

Based on observation and interview, the facility failed to ensure potentially hazardous foods were at a cold holding temperature of 41 degrees Fahrenheit, or below, to prevent foodborne illness. Findings: Review of the facility lunch menu on 8/17/22, revealed residents had a choice between egg salad sandwich or ham sandwich, creamy dill macaroni salad or potato chips, mandarin oranges, country tomato salad or marinated cucumber and onion salad. On 8/17/22 at 11:35 AM, the lunch tray line was observed and noted one cook, one dietary aide and the Certified Dietary Manager (CDM) in the vicinity of the tray line. [NAME] B checked the temperatures of the cold food items on the holding table with the facility's digital, bayonet style thermometer. She reported the egg salad had a holding temperature of 43.6 degrees Fahrenheit, the macaroni salad had a hold temperature of 43.7 degrees Fahrenheit, the pureed macaroni salad had a holding temperature of 42.3 degrees Fahrenheit, the pureed egg salad had a temperature of 41.6 degrees Fahrenheit and the pureed green bean salad had a holding…

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 accurately assess and complete the Minimum Data Set (MDS) assessment Section F-preferences for customary routine and activities for 1 of 4 residents reviewed for activities of a total sample of 68 residents, (#138). Findings: Clinical record review revealed resident #138 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, metabolic encephalopathy, Alzheimer's disease, transient ischemic attack, dementia, and contracture of the right and left hip, and right knee. The resident's significant change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 8/02/22 revealed the resident was rarely/never understood. Assessment for Section F0500 Interview for Activity Preferences indicated it was very important for the resident to have books, newspaper, magazines to read, to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather is good,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed for 1 of 3 residents reviewed for PASRR of a total sample of 68 residents, (#36). Findings: Review of resident #36's medical record revealed he was admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety, depression, and mood disorder. The resident's PASRR form was dated 7/21/20, which reflected a completion date of four months after the resident was admitted to the facility. On 8/18/22 at 11:10 AM, the Social Services Director said, My process is to review the PASRR for completeness and accuracy. I was not here when the resident was admitted and I cannot speak for the previous person. She explained the PASRR form should have been completed prior to resident #36's admission. On 8/18/22 at 11:21 AM, the Corporate Admissions Director stated PASRR forms should be reviewed by facility staff prior to resident's admission. She stated if a resident was admitted…

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 person-centered baseline care plan, that addressed care and services, and failed to provide a summary to the resident and resident representative within 48 hours for 2 of 4 newly admitted residents reviewed for baseline careplans of a total sample of 68 residents, (#108, #343). Findings: 1. Resident #108 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, hemiplegia and hemiparesis right dominant side, diabetes, and heart failure. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. The assessment noted the resident required extensive assistance from staff with activities of daily living, was occasionally incontinent of bladder and bowel, and was not steady moving from seated to standing position, walking or moving on or off the toilet. Review of the resident's…

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 develop and implement a comprehensive person-centered care plan for activities for 1 of 4 residents reviewed for activities, (#138), and failed to update a care plan to reflect the residents' preferences and choices for 1 of 4 residents reviewed for choices in a total sample of 68 residents, (#121). Findings: 1. Review of the resident #138's medical record noted she was 64-years-old and admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, Alzheimer's disease, transient ischemic attack, dementia, and contractures of the right and left hips, and right knee. The resident's significant change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/02/22 revealed the resident was rarely/never understood. Assessment for Section F0500 Interview for Activity Preferences indicated it was very important for the resident to have books, newspapers, magazines to read, to do things with groups of people, 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 interview and record review, the facility failed to ensure the comprehensive care plan was reviewed, revised, and individualized, for falls for 1 of 4 residents reviewed for falls out of a total sample of 68 residents, (#108). Findings: 1. Resident #108 was admitted to the facility on [DATE] with diagnoses of hemiplegia, hemiparesis, and heart failure. The resident's Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. The assessment identified the resident required extensive assistance of one staff person with activities of daily living, was occasionally incontinent of bladder and bowel, not steady moving from seated to standing position, and walking or moving on or off the toilet. It noted the resident had history of falls since admission, and one fall in the facility with no injury. Review of the medical record showed a care plan initiated 7/18/22 with revision 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, interview, and record review, the facility failed to provide oral care for 1 of 4 residents reviewed for Activities of Daily Living (ADL) of a total sample of 68 residents, (#12). Findings: Review of resident #12's medical record noted he was admitted to the facility on [DATE] with diagnoses that included apraxia, schizophrenia, contracture, dementia, and gastrostomy. Review of the physician orders revealed the resident was to have nothing by mouth and had orders for tube feedings, Glucerna 1.5 at 60 milliliters/hour for 22 hours per day. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/22 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 3/15. The assessment indicated the resident was totally dependent on staff for bed mobility, dressing, eating, and personal hygiene, and had functional limitation in range of motion on one side of his upper extremity, and on both sides of his…

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 physician's orders were implemented for compression stockings for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114). Findings: Review of resident #114's medical record revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, heart failure, chronic peripheral venous insufficiency, and generalized edema. Review of the the resident's physician orders revealed an order dated 7/14/22 that read, TED hose: Nursing to assist patient with don/doff of TED hose on BLE [bilateral lower extremities], size 2 XL thigh high at all times for edema. 'TED hose are long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting. [Retrieved from-health. com 8/26/22] On 8/16/22 at 11:02 AM, resident #114 explained he had edema to his thigh, and approximately three weeks ago, the physician ordered thigh high support stockings for him. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide bilateral palm guards and left elbow brace per physician orders to prevent further decrease in range of motion (ROM) for 1 of 5 residents reviewed for limited ROM of a total sample of 68 residents, (#139). Findings: Review of resident #139's clinical record noted she was admitted to the facility initially on 7/22/05, with her most recent readmission on [DATE]. Her diagnoses included, injury of head, quadriplegia, spinal stenosis, dementia, and drug induced subacute dyskinesia. Review of the Functional Maintenance Program document with effective date 4/28/22 indicated the resident should have Bilateral Palm guards for 4-6 hours as tolerated. Progress note on 7/22/22 read, Continues on restorative nursing program for activity tolerance, strengthening, splinting .Resident d/c [discharged ] from restorative to have therapy eval.[evaluation] The resident's physician's order dated 5/16/22 read, bilateral upper extremities palmar…

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 ongoing communication, coordination and collaboration between the nursing home and the dialysis center for 1 of 1 resident reviewed for dialysis of a total sample of 68 residents, (#136). Findings: Resident #136 was admitted to the facility on [DATE], readmitted [DATE] and 8/06/22 with diagnoses including dysphagia, end stage renal disease (ESRD), dependence on renal dialysis, encephalopathy and heart failure. Review of the Minimum Data Set admission assessment with assessment reference date 8/04/22 revealed resident #136 had a Brief Interview for Mental Status score of 4 which indicated he had severe cognitive impairment. He required extensive to total assistance for activities of daily living and did not reject care. Review of resident #136's medical record revealed a physician order dated 8/01/22 for hemodialysis at an outside facility on Mondays, Wednesdays and Fridays at 12:45 PM. Hemodialysis is a procedure where a dialysis…

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 accurate dosage of insulin was administered as per physician's orders, and failed to ensure the medication was administered as scheduled to 1 of 7 residents observed for medication administration observation of a total sample of 68 residents, (#9). Findings: Review of resident #9's clinical record showed he was admitted to the facility on [DATE] with diagnoses of diabetes type II with neuropathy, and long-term use of insulin. On 8/16/22 between 10:00 AM-10:05 AM, during medication administration observation with Registered Nurse (RN) H, resident #9's blood glucose was monitored at 360 milligram/deciliter (mg/dL). On 08/16/22 at approximately 10:19 AM, RN H withdrew 15 units of insulin Lispro from a multi-dose vial and administered the insulin in the resident's upper right arm. In an interview conducted with resident #9 immediately after the administration of the insulin, the resident stated he had already eaten breakfast. RN H…

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 accurately document physician's order for thigh high compression hose for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114). Findings: Review of resident #114's clinical record noted he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, heart failure, chronic peripheral venous insufficiency, and generalized edema. Review of the physician's orders for resident #114 revealed an order dated 7/14/22 read, TED hose: Nursing to assist patient with don/doff of TED hose on BLE [bilateral lower extremities], size 2 XL thigh high at all times for edema. 'TED hose are long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting. [Retrieved from-health. com 8/26/22]. On 8/16/22 at 11:02 AM, resident #114 stated he had edema of his thigh, and approximately three weeks ago, the physician ordered thigh high support stockings for him. He said he has 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 follow appropriate infection control practices to prevent cross contamination during wound care for 1 of 3 residents reviewed for pressure ulcers of a total sample of 68 residents, (#129). Findings: Review of the medical record revealed resident #129 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include vascular dementia, and atrial fibrillation. The physician orders for resident #129 included consult Infectious Disease specialist for left heel wound; obtain an x-ray of the left heel regarding an ulcer related to osteomyelitis or bone infection; and give antibiotics, Augmentin 875-125 milligrams (mg) tablet twice a day and Doxycycline 100 mg twice a day for left heel wound. The physician's wound treatment order directed nurses to apply a non-sting skin protectant and a protective dressing to the left heel daily. On 8/18/22 at 10:15 AM, during resident's wound care observation, Licensed Practical Nurse,…

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.