Tower Road Post Acute, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Rights, the facility failed to maintain the dignity and privacy for one of five residents (R) (R50) with a Foley catheter. Specifically, the urinary catheter bag was left uncovered and visible while R50 was out in the hallway. Additionally, R50 was wearing a shirt on with her full name visible across her chest in thick black marker. Findings include: Review of facility's policy titled Resident Rights dated 2/1/2024 revealed under Preparation in section 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including . b. Resident dignity and respect. Review of the electronic medical record (EMR) revealed R50 was admitted to the facility with pertinent diagnoses including but was not limited to dementia, depressive disorder, and anxiety. Review of R50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed 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, record review, resident and staff interviews, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 59 sampled residents (R) (R13) was assessed for self-administration of medication prior to leaving medications at the bedside. The deficient practice had the potential to allow unauthorized access to unsecured medications to residents and visitors at the facility. Findings include: A review of the facility's policy titled Self-Administration of Medications by Patients/Residents revised on 2/1/2024 revealed under Policy Statement: Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Procedure: 1. 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, staff interviews, and review of the facility policy titled, Residents Rights Accommodation of Needs and Preference and Homelike Environment, the facility failed to accommodate the needs of one of 14 residents (R) (R112) reviewed for environmental concerns. Specifically, the facility did not ensure call light was within reach. This failure had the potential to prevent R112 from receiving care or service when needed. Findings include: Review of the facility policy titled Residents Rights Accommodation of Needs and Preference and Homelike Environment effective date 2/1/2024 states under 1. The facility will assess and interview residents for the need to make reasonable accommodations. Call light in reach for room and bathroom and the correct type for resident use to meet the resident need. Review of R112's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident…

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

Based on observations, staff interviews, and review of the facility policy, Visitation, the facility failed to have a system in place which allows visitors into the facility after hours. Findings include: The policy titled, Visitation revealed in the Policy Statement: The facility permits residents to receive visitors whom he or she designates, and the resident has the right to withdraw or deny such consent at any time. Under Guideline . 3. The facility will provide immediate access for residents receiving visits from the following: a. Any representative of CMS or State representatives such as Surveyors. g. The resident's legal representative, immediate family or relatives, and any other person visiting with the resident's consent, subject to limitations outlined in this policy. Observation on 9/18/2024 at 6:00 am from the outside of the front of the facility revealed a very dark entrance. Lights were all off with the exception of security lights in the front. There was a small posting on the front door which read, call 770 422 8913 for after hours. When the number was called, three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy titled, Review of the Beneficiary Notice, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123) to two of two residents (R) (R29 and R36) who remained in the facility and were discharged from Medicare Part A services. Findings include: Review of the facility policy titled Review of the Beneficiary Notice revealed under Procedure, 3. If the resident is unable to sign, and the SNF (skilled nursing facility) is working with a legally authorized representative who is unable to be present at the facility that day, the SNF may issue the NOMNC by telephone. g. The facility must confirm the telephone contact by sending written notice to the authorized representative on the same day the call was made. 4. Copies of the completed NOMNC are: a. Given to the resident or the authorized representative who signed the NOMNC. Review of the Beneficiary Notice for R21 revealed no evidence that a NOMNC form was provided.…

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 record review, the facility failed to accurately document the dental status in the annual Minimal Data Set (MDS) assessment for one of 59 sampled residents (R) (R72). This failure had the potential to prevent R72 from receiving necessary dental care. Findings include: Review of the clinical record for R72 revealed they were admitted to the facility with diagnoses to include but not limited to cognitive communication deficit, unspecified dementia, unspecified neurocognitive disorder with Lewy bodies, depression, and Parkinson's disease. Review of the annual MDS assessment dated [DATE], Section L (Oral and Dental Status Issues) 0200 listed options for the dental assessment to include no natural teeth or tooth fragments (edentulous), obvious or likely cavity or broken natural teeth, and none of the above were present. The assessment documented none of the above indicating no dental concerns. Observation on 9/16/2024 at 2:58 pm of R72 revealed she was missing all but one of her upper teeth.…

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 review of the facility policy titled, PASRR, the facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level II was completed for one of 59 sampled residents (R) (R92). The deficient practice had the potential for R92 to not receive specialized care to treat mental illness. Findings include: Review of the facility policy titled PASRR with an effective date of 2/1/2024, revealed that it is the policy of the facility to screen all potential admissions on an individualized basis. As a part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level 1) for all new and readmissions to determine if the individual meets the criterion for mental disorder, intellectual disability or related condition. Based on the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been…

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 resident, resident family, and staff interviews, record review, and review of the facility policy titled, Minimum Data Set (MDS) / Care Plans, the facility failed to develop and implement a baseline care plan within 48 hours of admission for five of 59 sampled residents (R) (R49, R22, R113, R15 and R70). The deficient practice had the potential to affect the appropriate level of care and services provided for R49, R22, R113, R15 and R70. Findings include: Review of the facility policy titled Minimum Data Set (MDS) / Care Plans revised 2/1/2024 revealed in the Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The baseline care plan will be completed within 48 hours of admission. The Interdisciplinary Team will continue to develop the care plan in conjunction with the Resident Assessment Instrument (RAI), Minimum Data Set (MDS 3.0), and Care Area Assessment (CAAS), completing and conducting Certified Compliance Professional (CCP) meeting by Day 21 post…

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 review of the facility policy titled, Minimum Data Set (MDS) / Care Plans, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for three of 59 sampled residents (R) (R49, R111 and R92). The deficient practice had the potential to affect the care and services provided to R49, R111, and R92. Findings include: Review of the facility policy titled Minimum Data Set (MDS) / Care Plans revised 2/1/2024 revealed in the Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The baseline care plan will be completed within 48 hours of admission. The Interdisciplinary Team will continue to develop the care plan in conjunction with the Resident Assessment Instrument (RAI), Minimum Data Set (MDS 3.0), and Care Area Assessment (CAAS), completing and conducting Certified Compliance…

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 staff interviews, record review, and review of the facility policy titled, Minimum Data Set (MDS/Care Plans, the facility failed to include the resident (R), family, or family representative attended baseline care plan meetings and care plan meetings for one of 59 sampled residents (R) (R15). Findings include: A review of the facility policy titled Minimum Data Set (MDS)/Care Plans revealed under Policy Statement: The Interdisciplinary Team (IDT) will continue to develop the care plan in conjunction with the RAI (Resident Assessment Instrument) (MDS 3.0) and CAAS (care area assessments) completing and conducting CCP (Comprehensive Care Plan) meeting by Day 21 post admission.The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. Resident and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Car Plan. Under procedure number 5. The resident and/or representative will be offered a Care Plan Summary during the Admission, Annual, and/or Significant Change…

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 responsible party and staff interviews, record review, and review of the facility policy titled, Discharge Planning, the facility failed to provide discharge instructions to the responsible party (RP) of one of 59 sampled residents (R) (R366) at discharge. The deficient practice had the potential for the RP of the discharging resident to not have the knowledge of the medications and therapy needs to properly care for the resident at home. Findings include: Review of the facility policy titled Discharge Planning with a revision date of 7/19/2024 revealed that guideline 5 states: The discharge plan will include at least the following: location resident plans to discharge, anticipated referrals, and anticipated durable medical equipment (DME). Guideline 7 states: The stakeholder will give a copy of the discharge plan to the resident and/or representative. A copy will be retained in the resident medical record. Review of the electronic medical record (EMR) for R366 revealed that she was admitted with…

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, record review, and review of the facility's policy titled, AM Care, the facility failed to provide fingernail care for one dependent Resident (R) (R80). The sample size was 59. Findings include: Review of the facility's policy titled, AM Care, dated 2/1/2024, states under the section titled Policy, Morning Activity of Daily Living (ADL) care will be provided to all residents. In subsection titled Procedure, number 12 states to Provide nail care. R80 was admitted to the facility with diagnoses that included but not limited to type 2 diabetes, cerebral infarction (stroke). Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented that R80 had a Brief Interview for Mental Status (BIMS) score of 2, indicating R80 had severely impaired cognition. Section GG (Functional Status) documented that R80 is dependent on a helper for personal hygiene. Review of R80's care plan dated 4/18/2024 documented focus related to ADLs requiring full staff assistance with…

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 responsible party (RP) and staff interviews, and record review, the facility failed to make follow up appointments with physicians and transportation to physicians' appointments after discharge from the hospital for one of 59 sampled residents (R) (R366). The deficient practice had the potential to cause the resident to become unstable and possibly have to return to the hospital. Findings include: Review of the electronic medical record (EMR) for R366 revealed that she was admitted to the facility with diagnoses that included but were not limited to cerebral infarction, atrial fibrillation, cognitive communication deficit, type 2 diabetes, and hypertension. A review of the admission Minimum Data Set (MDS) for R366 from 5/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. R366 was dependent on staff for activities of daily living (ADLs). Review of the discharge instructions from the hospital dated 12/15/2023 from the resident's admission on to the facility revealed that the resident was to follow up with 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, resident and staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to follow physician orders for oxygen therapy for one of 15 residents (R) (R111) on oxygen therapy. The deficient practice posed significant risks, including potential medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Oxygen (O2) Administration with an effective date of 2/1/2024 revealed under section titled Policy Statement, the purpose of this procedure is to provide guidelines for safe oxygen administration. Under section titled Preparation, the facility stated to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Furthermore, the Policy stated: adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. A 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, staff interviews, and a review of the facility's policy titled Medication Storage, the facility failed to ensure medications and biologicals were discarded on or after the expiration date in two of three medication rooms. This deficient practice placed residents at risk of receiving medications or biologicals with altered effectiveness. The facility census was 118 residents. Findings include: A review of the facility's policy titled Medication Storage, dated 1/2023, revealed the Policy included Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe, effective drug administration . The Procedures section included . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Observation on [DATE] at 3:34 pm…

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 policy titled Hospice Program, the facility failed to ensure one of two residents (R) (R45) reviewed for hospice had a physician's order for hospice services. Findings include: A review of the facility policy titled Hospice Program, last reviewed 9/15/2023, revealed the Policy Statement of Facility contracts for hospice services for residents who wish to participate in such programs. The Guidelines section included . 4. The Interdisciplinary Team (IDT) will coordinate care by the facility staff and the hospice staff. The IDT will be responsible for the following: d.Hospice physician and applicable attending physician orders for the resident. A review of R45's clinical record revealed diagnoses included but was not limited to peripheral vascular disease and Alzheimer's disease with late onset. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments and Programs) documented that R45 received hospice care. A 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, staff interviews, record review, and review of facility policy titled Infection Prevention and Control, the facility failed to ensure proper infection control practices were followed during medication administration via a gastrostomy tube (G-tube) for one of one resident (R) (R39) reviewed with a G-tube, during perineal care for one of 59 sampled R (R50), and during tracheostomy care for one of one R (R39) reviewed with a tracheostomy. In addition, the facility failed to properly clean or disinfect shared medical equipment between residents and failed to ensure hand sanitizer dispensers were filled for staff use. These failures had the potential of exposing residents to infections due to cross-contamination. Findings include: A review of the facility's policy titled Infection Prevention and Control, dated 2/1/2024, revealed the Policy Statement included The facility strives to prevent transmission of infections and communicable diseases, development of nosocomial infections, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure the resident call light system was maintained in working order for one of two hallways (West Hall). This deficient practice had the potential to cause delays in response to resident needs. Findings include: 1. Observation on 9/17/2024 at 1:16 pm revealed four call lights on the [NAME] Hall nursing unit call light board were flashing and there was no sound from the system. In an interview on 9/17/2024 at 1:27 pm, Certified Nursing Assistant (CNA) KK stated she was unsure which rooms the activated call lights were for and notified the Maintenance Director. She stated when a call light was activated, it should make a sound and light up. She further stated if the call light was flashing, it indicated a high alert. In an interview on 9/17/2024 at 1:32 pm, the Maintenance Director stated the call lights had been repaired. 2. Observation on 9/16/2024 at 11:34 am revealed the call device in resident room [ROOM NUMBER]A failed to activate the light…

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 a written notice of transfer for one of two residents (R) (R#20) reviewed for hospitalization out of a total sample of 31 residents. The failure to provide a written notice of transfer increased the risk that the residents and/or representatives would not know the specifics of the transfer or the right to appeal. Findings include: Review of the electronic medical record (EMR) Face Sheet, revealed R#20 was admitted to the facility on [DATE] with congestive heart failure (CHF-the weakened muscles of the heart leading to the inability to properly circulate blood) and Atrial fibrillation (A. fib-irregular heartbeat). Review of the EMR Resident Assessment Instrument (RAI) tab revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/22 with a Brief Interview for Mental Status (BIMS) score of one out of 15 indicating R#20 was severely impaired cognitively. Review of the EMR Progress Notes revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to provide a written bed hold notice for one of two residents (R) (R#20) reviewed for hospitalization out of a total sample of 31 residents. The failure to provide a written bed hold notice increased the risk that the residents and/or representatives would not know to request a bed hold and/or the cost of the bed hold. Findings include: A policy for bed hold notices was requested. The Business Office Manager (BOM) provided a copy of the admission packet, revised 8/1/21, that included the following concerning bed holds: If you go to the hospital or out for an overnight leave you must tell ask [sic] Facility in writing to hold or not assign your bed to another resident. When you are ready to leave, we will give you a copy of our policy with instructions and the bed hold election form for you to complete. Note! There is a fee to hold your bed, and your insurance may or may not cover it: Private Pay . you will be charged and must pay 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 record review, interviews, and policy review, the facility failed to respond to pharmacy recommendations for a written rationale for continuing a PRN (as needed) order for Ativan (antianxiety medication) beyond 14 days and to include a duration date in one of four residents (R) (R#88) reviewed for psychotropic medications in a total sample of 31 residents. This failure increased the risk of R#88 receiving an excessive amount of antianxiety medication. Findings include: Review of the policy titled, Psychotropic Medications Policy, revised 6/22/22, revealed Psychotropic medications will be used appropriately for residents with mental illness and/or related disorders . These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic . PRN orders for psychotropic drugs are limited to 14 days. With the exception of, the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended…

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, observations, interviews, and policy review, the facility failed to: 1. Identify and implement resident specific nonpharmacological interventions for yelling out prior to prescribing Seroquel (an antipsychotic medication) and administered Seroquel without documented behaviors for one resident (R) (R#99); and 2. Prescribe PRN (as needed) Ativan (an antianxiety medication) for a limited time of 14 days and failed to provide a written rationale for extending the medication beyond 14 days for one of four residents (R#88) reviewed for unnecessary psychotropic medications out of a total sample of 31 residents. This failure increased the risk of adverse side effects from the use of psychotropic medications. Findings include: Review of the policy titled, Psychotropic Medications Policy, revised 6/22/22, revealed Psychotropic medications will be used appropriately for residents with mental illness and/or related disorders . These drugs include, but are not limited to, drugs in the following…

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.