New Horizons Limestone

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of the facility policy titled Oxygen Administration, Transport and Storage - Patient Care, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for two residents (R) (R9 and R180) of 27 residents reviewed for oxygen use. The deficient practice had the potential to increase the residents' risk of respiratory complications and adverse clinical outcomes. Findings Include: Review of the facility's undated policy titled Oxygen Administration, Transport and Storage – Patient Care, documented in section for oxygen administration A physician or advanced practice professional (APP) order is required prior to administering oxygen. The policy specifies that the order must include: a. The oxygen delivery device b. The liter flow and/or oxygen concentration (percentage). 1. Record review of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] and pertinent diagnoses including but…

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, staff interviews, and review of facility policy titled, Self-Administration of Medications, the facility failed to ensure two residents (R) (R130 and R57) could safely self-administration medications by leaving medications at the bedside unsupervised. This deficient practice had the potential to increase the risk of clinical complications. Findings include: Record review of the facility's policy titled, Self-Administration of Medications, revealed under section titled, III Policy, if a resident requests to self-administer medication (s) it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right. The policy further states that, A resident may only self-administer medications after the IDT has determined medications may be self-administered. The policy requires consideration of the resident's cognitive status, ability to follow directions, understanding of medications, and ability to ensure medications are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Care Plan - LTC - Patient Care, the facility failed to develop and implement comprehensive, person-centered care plan for one resident (R) (R9) of 60 sampled residents. Specifically, the facility failed to develop and implement care plan interventions related to oxygen administration. This deficient practice had the potential to result in inadequate monitoring and improper oxygen administration, which could compromise the resident's health and safety.Findings include:Review of the undated facility policy titled Care Plan - LTC - Patient Care, documented in Section III Policy Do not leave blanks or incomplete sections. Further review revealed that Complete the . Care Plan based on . provider orders and .documents the resident's immediate problems that require nursing care interventions and will guide the delivery of nursing care.Record review of the electronic medical record (EMR) revealed R9 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 observation, staff interview, review of manufacturer package inserts, and facility policy titled Medication Storage, the facility failed to ensure proper medication labeling, expiration dating, discard procedures, and secure storage for one of eight medication carts. This deficient practice had the potential to place residents at risk for administration of expired, improperly labeled, or unsecured medications, which could compromise resident health and safety. Findings Include: Review of the facility's policy titled Medication Storage, dated 8/22/2023, documented All medication storage areas will inspected. to ensure that all medications are being properly and safely stored in accordance with manufacturer's instructions. IN addition, documented in section Procedures III. All expired. medications are segregated until they are removed from the organization. Outdated. medications will be kept in a designated area until they are returned to the supplier. and Item XVI. B. Medications stored throughout the center must be stored in accordance with manufacturer's instructions.to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of facility's policy titled, Nutrition Food and Supply Storage Procedures, Facility A failed to properly discard expired food items, label food items with expiration dates, and properly refrigerate opened food items. This deficient practice had the potential to result in foodborne illness affecting 77 out of 82 residents who receive food orally at Facility A. Findings include: Record review of facilities policy titled, Nutrition Food and Supply Storage Procedures dated 7/1/2023, under section titled, Purpose revealed, All food, non-food items and supplies used in food preparation shall be stored in such manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. (A.) General Storage .2. The use-by date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by date should be…

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, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, Facility A failed to adequately assess one out of 60 sampled residents (R) (R71) for self-administration of medication. This had the potential to result in serious health complications, including medication misuse or overdose, and compromise the safety and well-being of the resident. Findings include: A review of the facility's policy titled Resident Self-Administration of Medication, dated 7/1/2023 under section titled Purpose revealed, The purpose of the Self-Administration of Medication Policy is to develop guidelines about facility staff expectations in the nursing home to honor resident's request for Self-Administration of Medications whenever assessed as appropriate to keep resident at their highest level of functioning. Under the section titled Policy revealed, If a resident requests to self-administer medication(s), it is the responsibility 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 staff interview, record review, review of the facility's document titled, [Name] Bed Hold Notice Facility B failed to provide a written bed hold notices for one out of two residents (R) (R179) reviewed for hospitalization. This failure had the potential to place R179 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital. The sample size was 60 residents. Findings include: Review of the facility's document titled, [Name] Bed Hold Notice dated 2/10/2025 under the section titled Please provide to the Resident or Representative revealed, Please review the information provided below to understand the financial obligations related to your decision to hold or release your bed at [Name of facility] Under the section titled Bed Hold Details revealed, Medicaid will provide payment for residents for up to seven nights of bed hold during hospitalization. Medicaid residents are provided up to eight days per year of Therapeutic leave (other than hospitalization). If a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, Facility B failed to ensure that one of 14 residents (R) (R150) receiving respiratory therapy, nebulizer mask was covered or properly stored. This deficient practice had the potential to put R150 at risk for increased respiratory infections. Findings include: Review of the electronic health records (EHR) revealed, R150 was admitted to the facility with diagnoses of chronic obstruction pulmonary disease (COPD), chronic respiratory failure with hypoxia (reduced oxygen in the blood), acid reflex, and chest congestions. Review of R150's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 14 which indicated his cognition was intact; Section O (Special Treatments and Programs) revealed, R64 received oxygen therapy. Review of R150's physicians orders revealed, orders for albuterol (Proventil) 2.5 milligrams (mg)/ 3 milliliters (mL) (0.083 percent) nebulizer solution 2.5 mg;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the facility's policy titled Laboratory Services-12-1022-POC Glucose Testing with [Name] Glucometer, Facility A failed to discard expired Glucometer Control Solution Level 3, that was stored in one of four medication carts (Hall 300 medication cart). This deficiency created a risk of the expired solution being used, potentially compromising the accuracy and functionality of the glucometer, which could lead to unreliable blood glucose readings. Review of the undated facility policy Laboratory Services-12-1022-POC Glucose Testing with [Name] Glucometer under the section titled III. Equipment and Supplies revealed, D. [Name] glucose control solutions: Levels 1 and 3 .2. Unopened reagent bottles are good until the expiration dated printed on the container. 3. When opened, the bottles are good for 90 days or until the manufacturer's expiration date, whichever comes first. MUST BE LABELED WITH NEW EXPIRATION DATE. An observation on [DATE] 8:20 am 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 activities of daily living (ADL) care was provided for two dependent residents (R) (R#482 and R#60) related to baths/showers. R#482 and R#60 resided in Facility B. The sample size was 70. Findings include: 1. Review of the medical record revealed R#482 was admitted to the facility 12/15/21, with the diagnoses to include but not limited to, colonic mass, right tibia/fibula fracture, stage V chronic kidney disease with dialysis, end stage renal disease (ESRD), diabetes (DM), and chronic obstructive pulmonary disease (COPD). Interview on 8/30/22 at 11:24 a.m., R#482 revealed that she had not received a shower in the last two weeks. Review of the shower log and electronic documentation revealed that R#482 received a bath/shower on 5/31/22, 6/9/22, 6/16/22, 6/28/22, 7/5/22, 7/12/22, 7/16/22, 7/26/22, 7/28/22, 8/2/22, 8/9/22 and refusal on 8/30/22. Further review of records revealed that R#482 was admitted to the hospital on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide evidence that restorative nursing services were provided for passive range of motion (PROM) and active range of motion (AROM) as recommended by Physical Therapy (PT) and Occupational Therapy (OT) for bilateral upper extremities (BUE) and for splint or brace for one Resident (R) (R#113) of one reviewed for restorative nursing. R#113 resided in Facility B. The sample size was 70. Findings include: Review of the medical record revealed that R#113 was admitted to the facility on [DATE] with diagnoses of traumatic quadriplegia, swelling of upper extremities, and complex regional pain syndrome of upper extremities. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that R#113 is cognitively intact. The MDS revealed he is totally dependent requiring two person plus assist for bed mobility and transfers and has limited range of motion in bilateral…

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.