Sandy Springs Center For Nursing And Healing LLC

Based on observations, interviews, and record review, the facility failed to ensure medications were secured, one of three medication carts on the East wing was left unlocked and unattended. The deficient practice had the potential to cause harm to residents located on the East Wing Unit by allowing unauthorized access to medications.Findings include:Per the Facility's Medication Storage Policy, dated October 1, 2025, all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, and medication rooms). Only authorized personnel will have access to the keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation on 12/18/2025 at 8:38 am, during a tour of the East Wing Unit, a medication cart (Middle Cart) positioned to the left of the East Wing Nursing Station was left unlocked. There were no licensed nurses or other authorized staff present in the hallway. The cart contained multiple…

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, policy reviews and staff interviews, the facility failed to ensure that the kitchen was maintained in a sanitary manner. Specifically, the facility failed to maintain hot food items on the steam table above 135 degrees to prevent food borne illness, failed to ensure staff entering the kitchen wore a hairnet properly, and failed to ensure the dish machine had a final rinse temperature at or above 180 degrees for proper sanitization. The deficient practices had the potential to adversely affect 146 of 146 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 3/10/2025 at 9:49 am, it was observed that the kitchen did not have a foot-pedal trash can. During a subsequent visit on 3/27/2025 at 9:48 am the kitchen did not have a foot-pedal trash can. When staff washed and dried their hands with paper towels, staff was observed adjusting the lid of the trash container to place paper in the trash can. During an interview on 3/27/2025 at 10:21 am with Dietary Aide (DA) WW who stated that the staff in the kitchen did not have…

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 5. R4 was admitted into the facility on 6/14/2022 with diagnoses of, but not limited to immunodeficiency conditions, end stage renal disease, dementia, and unilateral primary osteoarthritis of right knee. Review of R4's care plan revealed R4 was incontinent of bowel and bladder and required extensive to total assistance with Activities of Daily Living (ADLs). The care plan also stated R4 would receive peri-care with each incontinent episode. R4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment. The MDS also revealed R4 required extensive to total assistance with ADLs. Observation of incontinent care on 4/8/2025 at 11:45 am for R4 performed by Certified Nursing Assistants (CNAs) JJ and assisted by CNA BB revealed the infection control protocol for incontinent care had not been followed. CNA JJ used a disposable wipe and cleansed the R4's perineal area from back to front four times. CNA JJ also used a one clean washcloth…

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 staff interviews, the facility failed to complete Preadmission Screening/Resident Review Assessment I and II (PASARR) for two of three sampled residents; Resident (R) 74 and R31 for serious mental disorders or intellectual disabilities and related conditions. Findings include: A facility policy titled, Resident Assessment - Coordination with PASARR Program date reviewed/revised 12/2022, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission . ii. Positive Level I Screen…

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 staff interview, record review, a review of the facility policy titled Comprehensive Care Plans, the facility identifies weight loss for two residents (R) (R20 and R59) of four residents reviewed for nutrition out of 36 sampled residents. Findings include: In a review of the facility's policy titled, Comprehensive Care Plans, revised on 9/12/2022, revealed that, 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preference in developing goals of care. The policy also stated that All care assessment areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will be address in the plan of care. 1. In a review of R20's Electronic Medical Record (EMR) revealed an original admission date of 12/16/2024, with multiple diagnosis of but not limited to periprosthetic fracture around…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medications within 60 minutes before or after the scheduled medication time for one Resident (R) 151 of nine sampled residents reviewed for medication administration. Findings include: Review of the facility's policy titled Medication Administration date reviewed/revised January 2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The facility's policy explanation and guidelines revealed .17. Sign MAR (Medication Administration Record) after administered . Review of the Electronic Medical Record (EMR) revealed R151 was admitted into the facility with multiple diagnoses that included but not limited to sepsis cystitis without hematuria, urinary tract…

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 provide Activities of Daily Living (ADL) care for two of 17 sampled residents (R) (R4 and R A). Findings include: 1. R4 was admitted into the facility on 6/14/2022 with diagnoses of, but not limited to immunodeficiency conditions, end stage renal disease, dementia, and unilateral primary osteoarthritis of right knee. Record review of R4's care plan revealed R4 was incontinent of bowel and bladder and required extensive to total assistance with Activities of Daily Living (ADLs). The care plan also stated R4 would receive peri-care with each incontinent episode. R4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS also revealed R4 required extensive to total assistance with ADLs. A record review of R4's Point of Care (POC) which was completed by the Certified Nursing Assistants (CNAs) revealed: R4's POC documentation for January 2025 revealed…

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 staff interviews, the facility failed to ensure Vancomycin (antibiotic medication) was administered as ordered for one of six sampled residents. Resident (R) 399 missed three daily doses of intervenous (IV) Vancomycin prescribed for surgically closed wound infection of front left trochanter (left hip). Findings include: Review of the admission Record revealed R399 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Alzheimer's disease, dementia, contracture of right and left knees, adult failure to thrive, muscle weakness, gastrostomy (PEG-tube), PICC-line, surgically closed wound infection of front left trochanter (left hip). Review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed R399 had a brief interview for mental status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with most activities of daily living (ADLs). Review of Physician Order revealed,…

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 staff interviews, record review, and a review of the facility policy titled Weight Monitoring, the facility failed to perform weekly weights after significant weight loss and failed to implement a dietician recommendation for one resident (R) 20 of four residents reviewed for nutrition. Findings include: Review of the facility's policy titled, Weight Monitoring, it was revealed that 5. Weight monitoring schedule will be developed upon admission for all residents: . b. newly admitted residents- monitor weight weekly for four weeks C. Resident with weight loss- monitor weight weekly d. if clinically indicated- monitor weight daily e. All others- monitor weight monthly. Review of R20's Electronic Medical Record (EMR) revealed an original admission date of 12/16/2024 and a discharge date of 3/25/2025. R20 was admitted with multiple diagnosis of but not limited to periprosthetic fracture around other internal prosthetic joint, personal history of other mental and behavioral disorders, sequela, dementia,…

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, document review, and facility policy review, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, kitchen staff failed to: - perform hand hygiene between handling soiled and clean dishes, - maintain adequate sanitizer concentration in the low temperature dish machine, - discard expired food items, and - wear sufficient hair restraints while in the food preparation areas. In addition, the facility failed to ensure the microwave in the central supply room, used for residents' food, was clean. These deficient practices had the potential to affect all residents who receive food from the kitchen. Findings included: 1. A review of the undated policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revealed, Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy indicated employees must wash their hands After handling soiled equipment…

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, document review, and interviews, it was determined that the facility failed to ensure residents had a comfortable and homelike environment by consistently providing linens, towels, and washcloths on three of three halls (West Hall, East Hall, and Terrace Hall) reviewed for environmental concerns. This deficient practice affected all residents. Findings included: The facility's policy related to linens including towels and washcloths was requested from the Administrator on 5/4/23 and was not provided by the end of the survey. Observations on 5/2/23 at 8:15 a.m. of the linen carts on [NAME] Hall revealed one cart at the front entry to the hallway that was filled with bed linens but only one towel. Observations on 5/2/23 at 8:24 a.m. of the linen carts on East Hall revealed a cart at the entry of the unit that contained three fitted sheets, three flat sheets, three blankets, a few pillowcases, approximately five gowns, and no towels on the cart. During a group interview on 5/2/23 at 10:34 a.m. with nine residents, including R#117, R#106, R#116, R#26, R#66, R#98,…

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, staff interviews, and facility policy review, it was determined that the facility failed to ensure three of five sampled residents (R) (R#51, R#103, and R#113) reviewed for unnecessary medications were not prescribed psychotropic medications unless necessary to treat a diagnosed, specific condition. Specifically, the facility failed to monitor and document targeted behaviors for R#51, R#103, and R#113 while prescribed psychotropic medications. Findings included: A review of the facility's policy, titled, Unnecessary Drugs-Without Adequate Indication for Use, revised October 2022, indicated, It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drug. The policy further indicated, 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the…

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

Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to ensure the proper labeling of drugs and biologicals and expired medications were removed from three of three medication rooms (West Unit Medication Room, East Unit Medication Room, and the Terrace Unit Medication Room); one of four medication carts (East Unit Medication Cart #1); and one of three central supply rooms (East Hall Supply Room). Findings included: A review of the facility's policy, titled, Medication Storage, revised December 2022 indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. The [NAME] Unit medication room was observed on 5/3/23 at 9:33 a.m. with Unit Manager (UM) LL. Observations revealed an opened undated Trulicity Insulin Pen, an opened undated Ozempic (a noninsulin…

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, interviews, observations, and facility documents and policy review, it was determined the facility failed ensure that one of 57 sampled residents (R) (R#379) was free from physical abuse by another resident. Findings included: A review of a facility policy titled, Abuse, Neglect and Exploitation, dated 10/1/22, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under a definitions section, the facility noted that willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy's Prevention of Abuse, Neglect and Exploitation section indicated the facility would implement policies and procedures to achieve, in part: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined the facility failed to notify the ombudsman in writing when a resident was transferred or discharged from the facility for two of 57 sampled residents (R) (R#94 and R#85). Specifically, the ombudsman was not notified regarding emergency transfers to acute care facilities which were considered facility-initiated discharges. Findings included: An ombudsman notification policy was requested from the facility, but none was provided prior to the end of survey. 1. A review of an admission Record indicated the facility admitted R#94 on [DATE] with diagnoses that included cerebral infarction (stroke) and a tracheostomy. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R#94 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. A review of an eInteract SBAR [situation, background, assessment, recommendation] Summary for Providers, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, it was determined that the facility failed to notify each resident of the facility's bed-hold and reserve bed payment policy before a hospital transfer for two of 57 sampled residents (R) (R#85 and R#94). Findings included: A review of a facility policy titled, Transfer or Discharge, Preparing a Resident for, dated [DATE], indicated 4. The business office is responsible for: a. informing appropriate departments of the resident's transfer or discharge; b. informing the resident, or his or her representative (sponsor) of our facility's readmission appeal rights, bed-holding policies, etc.; and c. others as appropriate or as necessary. A review of an undated facility policy titled, Bed Hold Policy, indicated, There may be times that the Resident is out of the Facility overnight, whether due to a hospital stay or for therapeutic leave of absence. Should this occur, the Resident may request that the Facility hold the Resident's bed during this time ('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.

Based on record review, staff interviews, and facility policy review, it was determined that the facility failed to refer a resident with newly evident or possible serious mental disorder for a Level II preadmission screening and resident review (PASARR) for one of 57 sampled residents (R) (R#103). Findings included: A review of the facility policy, titled, Resident Assessment-Coordination with PASARR Program, revised December 2022, indicated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy further indicated a negative Level I screen Permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. The policy indicated, PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to provide activity of daily living (ADL) task for two of 57 sampled residents (R) (R#104 and R#279) related to showers. Findings included: A copy of the facility's policy for ADLs and showering/bathing was requested from the Administrator on 5/4/23 and was not provided by the end of the survey. 1. A review of an admission Record indicated the facility admitted R#104 on 10/28/22 with diagnoses that included heart failure, right femur fracture, and generalized muscle weakness. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/26/23, revealed R#104 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance from staff with transfers, walking, eating, and toilet use; extensive assistance from staff with bed mobility, dressing, and personal hygiene; and 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.

Based on record review and interviews, it was determined that the facility failed to assess and monitor a pressure ulcer for one of three residents (R)(R#279) reviewed for pressure ulcers. Specifically, the facility failed to appropriately assess and monitor R#279's left heel wound, and document wound type, characteristics, measurements, healing, and response to treatment. Findings included: A copy of the facility's policy for pressure ulcer assessment and treatment was requested from the Administrator on 5/4/23 and was not provided by the end of the survey. Review of R#279's admission Record revealed the facility admitted the resident on 12/9/22 with diagnoses that included hidradenitis suppurativa (a long-term skin condition characterized by painful bumps under the skin), diabetes mellitus, end stage renal disease (ESRD), kidney transplant failure, and an acquired absence of right leg above the knee. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/12/23, revealed R#279 had a Brief Interview for Mental Status (BIMS) score of 15, indicating…

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

Based on record review and interviews, it was determined that the facility failed to ensure medications were available from the pharmacy for one of three sampled residents (R#279) reviewed for medication administration. Findings included: The facility's policy on pharmacy services was requested from the Administrator on 5/4/23 and was not provided by the end of the survey. A review of R#279's admission Record revealed the facility admitted the resident on 12/9/22 with diagnoses that included bilateral absolute glaucoma. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/12/23, revealed R#279 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of R#279's Care Plan, dated 12/12/22, indicated the resident was on antibiotic therapy related to a right eye infection. Interventions directed the staff to administer antibiotic medications as per…

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 policy review, the facility failed to ensure an accurate medical record was maintained for one of 57 sampled residents (R) (R#106) related to pre-admission screening and resident review (PASARR) Level II. Specifically, the facility failed to ensure the diagnosis for Depakote (medication used for bipolar disorder, seizures, and migraine headaches) use was correct. Findings included: The facility's undated policy, titled, Unnecessary Drugs-Without Adequate Indication for Use, indicated, 3. Documentation will be provided in the resident's medical record to show adequate indications for the medications' use and the diagnosed condition for which it was prescribed. A review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, revealed the facility admitted R#106 to the facility on [DATE]. The MDS revealed the resident had active diagnoses to include anxiety disorder and bipolar disorder. The MDS revealed the resident had…

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

Based on interviews, document review, and policy review, the facility failed to maintain an effective Quality Assurance Program. Specifically, the facility failed to act on available competency validation data to make improvements in staff competency related utilizing a mechanical lift. This deficient practice affected one of three sampled residents (R) (R#12) reviewed for accidents, with the potential to affect the remaining 36 residents who required the use of a mechanical lift for transfer. Findings included: A review of the Quality Assurance Performance Improvement [QAPI] Plan, dated 1/2/23, revealed objectives of the QAPI plan include, 1. Establish a facility-wide process to identify opportunities of improvement through continuous attention to quality of care, quality of life and resident safety. 2. Address gaps in systems or processes. 3. Ensure adequate provision of staffing, time, equipment, and technical training resources. 4. Establish clear expectations around safety, quality, rights, choice, and respect. The policy indicated, Our purpose is to provide quality care 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.

The facility failed to clean and store continuous positive airway pressure (CPAP) equipment after use for one of two residents (R) (R#14) reviewed for respiratory care; and (2) failed to ensure three of five sampled residents (R) (R#51, R#103, and R#113) reviewed for unnecessary medications were not prescribed psychotropic medications unless necessary to treat a diagnosed, specific condition related to monitoring and documenting targeted behaviors for R#51, R#103, and R#113 while prescribed psychotropic medications. Findings included: 1. A review of a facility policy titled, Noninvasive Ventilation, dated November 2022, specified CPAP, or continuous positive airway pressure, is a respiratory therapy intervention use to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. A review of an admission Record revealed the facility admitted R#14 on 3/25/23 with a diagnosis to include sleep apnea (a condition in which breathing stops and restarts while sleeping). 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.