Lantern Park Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1) The facility identified a census of 85 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 indicated a Brief Interview for Mental Status (BIMS) score of 15 which indicates no cognitive impairment. It further indicated diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure and anxiety. The MDS indicated Resident #1 required moderate assist from staff for transfers, bathing, dressing and personal hygiene. The care plan with a date initiated of 8/12/24 revealed Resident #1 needed assistance with activities of daily living. The care plan interventions directed staff to provide assistance of one with baths on Monday and Thursday. The facility provided documentation of Resident #1 baths for August 2024 and he only received one bath on 8/29/24. The facility failed to provide documentation of baths in September. During an…

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 clinical record review, staff and resident interviews and observations the facility failed to update residents care plans to reflect their current level of functioning for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 85. Findings include: According to the quarterly Minimum Data Set (MDS) dated [DATE] the resident had diagnoses which included metabolic encephalopathy, legal blindness, lack of coordination and muscle weakness. The resident required substantial assistance of staff for transfers from the bed to chair, ambulation and had total dependence on staff for toileting needs. The resident utilized a wheelchair to move about the facility. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he gave reliable information. Review of the Care Plan dated 1/4/2024, last revised on 3/25/24, indicated the resident will continue to participate in his activities of daily living as his condition allows. The care plan informed the staff 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 clinical record review, observation, staff interview and facility policy, the facility failed to transfer a resident who required a mechanical lift in a safe manner for one of three residents reviewed. (Resident #2). The facility reported a census of 85 residents. Findings include: The MDS (Minimum Data Set) dated 8/15/2024 indicated Resident #2 had no cognitive impairment, had diagnoses including Cerebrovascular Accident (stroke), hypertension and hemiplegia (paralysis of one side of the body). The non-ambulatory resident required total assistance of staff to use the toilet and transfer from one surface to another. The Care Plan revealed the resident had hemiplegia following a cerebral infarct affecting the left, non-dominant side dated 7/31/2024. The resident did not ambulate and required the assistance of one staff to transfer and use the toilet with the use of a sit to stand (E-Z stand) mechanical lift. Communication from therapy to nursing dated 7/30/2024 recommended staff use the E-Z Stand for all transfers, wheel chair for mobility and assistance of one staff for…

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, clinical record review, resident and staff interviews, and facility policy review the facility staff failed to treat residents with respect and dignity for 4 out of 4 residents reviewed (Residents #4, #13, #78, and #86). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #78 dated 5/2/24, included diagnoses of cancer, hepatitis, and malnutrition. The Brief Interview for Mental Status (BIMS) reflected a score of 15 (intact cognition). On 07/29/24 at 11:49 AM, Resident #78 reported as he walked around in his room. One nurse just got fired for her mistreatment of him. Resident #78 stated when he went to Staff A and asked for his pain medication, Staff A, Licensed Practical Nurse (LPN) told him he had cancer that metastasized and he's going to die and there's nothing to do about that. Resident #78 revealed that made him upset and angry. On 7/29/24 at 5:50 PM Staff E, LPN reported Resident #78 walked up to the nurses station…

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

Based on resident interview, record review, staff interview, and policy review the facility failed to ensure residents were informed of new medications and participated in their own treatment plan for 1 of 3 residents reviewed (Resident #41). The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS) for Resident #41 revealed diagnoses of cancer, anxiety, and heart failure. The resident scored 15/15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. The resident's Care Plan documented a focus area dated 6/18/24 for poor impulse control related to getting medications or cares at an exact time frame. Interventions included analyze key times, places, circumstances, triggers, that help de-escalate behavior; administer medications as ordered; and document and give as many choices as possible about cares and activities. On 7/30/24 at 9:50 AM during an interview with Resident #41 she stated nurses were messing with her medications and did not tell her what they were for or why they were doing it. She stated it was tough,…

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 Payroll Based Journal (PBJ) Data, schedule review, staff interview, and policy review the facility failed to submit payroll data for agency staff during the second quarter of the current fiscal year. The facility reported a census of 84 residents. Findings include: A document titled PBJ Staffing Data Report for Fiscal Year 2024 Quarter 2 (January 1 - March 31) documented the facility triggered for one star staff rating and excessively low weekend staffing. On 7/30/24 at 1:00 PM the Administrator provided staff schedules for the month of March. These documented hours worked by nurses, certified medication aides, and certified nursing aides for three shifts each day and included the name of the on-call staff. The documentation also included both facility and agency staff. During an interview with the Administrator on 7/31/24 at 3:22 PM she stated the PBJ data submitted by the facility did not include agency staff. She acknowledged this impacted the data the Centers for Medicare and Medicaid Services had for the facility and stated the facility would have to look into it. 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 clinical record review, policy review and staff interview the facility failed to complete an accurate assessment and provide intervention based on that assessment after a fall for 1 of 4 residents (Resident #4) reviewed. The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented the resident admitted to the facility on [DATE]. The MDS list diagnoses including hypertension, non-Alzheimer's dementia and orthostatic hypotension. The Care Plan included a focus area of being at risk for falls dated 1/31/24. Interventions included encouraging proper footwear and monitor for unsteady gait. The Care Plan also included interventions for Activities of Daily Living (ADL) bathing, personal hygiene, toileting, transfers, upper and lower body dressing all requiring assistance of 1 person. The Progress Note written on 4/21/24 documented the resident fell in the shower room, was complaining of pain 8/10 in her right hip and pelvis. Range of Motion (ROM) 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, and policy review the facility failed to provide resident meals under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 84 residents. Findings include: 1. A dining room observation on 3/18/24 revealed the following: a. At 12:16 PM Staff I, Dietary Aide, accepted a glass from a resident with her right thumb curling over the top of the rim. While she held a cup with her right hand, the dietary aide added a powder substance to the cup from a container in her left hand. Staff I then scratched her left cheek and her nose with the container still in her left hand bringing the container to her face. She did not practice hand hygiene or clean the outside of the container. b. At 12:18 PM Staff I prepared tea for another resident. She touched both sides of the exposed tea bag and held her left thumb inside the cup. She set the cup down and then picked it up with her right palm touching the rim. She handed it to the resident. She did not practice hand hygiene. c. At 12:20 PM Staff I cut a resident's food with his knife…

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, clinical record review, narcotic book records, and policy review the facility failed to identify situations as an alleged drug diversion and to report allegations within the required regulatory timeframe for 1 of 3 residents reviewed (Resident #18). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #18 dated 2/15/24 documented diagnoses of chronic kidney disease, epilepsy, and morbid obesity with alveolar hypoventilation (insufficient breaths per minute). A Care Plan focus area initiated 2/9/23 documented the resident used opioid medications related to chronic pain. A medication card labeled Tramadol HCl 50 milligrams (mg) for Resident #18 observed on 3/20/24 at 2:40 PM revealed 60 tablets were dispensed 6/28/23 and the resident received 1 tablet every 8 hours PRN, (pro re nata, as needed). The first column of 10 medication spaces were empty and the bottom space in the last column was empty. There were 49 tablets left in the medication card. The Medication Administration Record…

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, clinical record review, narcotic book records, and policy review the facility failed to complete a thorough investigation of alleged violations, maintain documentation, and prevent further incidents for 1 of 3 residents reviewed (Resident #18). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #18 dated 2/15/24 documented diagnoses of chronic kidney disease, epilepsy, and morbid obesity with alveolar hypoventilation (insufficient breaths per minute). A Care Plan focus area initiated 2/9/23 documented the resident used opioid medications related to chronic pain. A medication card labeled Tramadol HCl 50 milligrams (mg) for Resident #18 observed on 3/20/24 at 2:40 PM revealed 60 tablets were dispensed 6/28/23 and the resident received 1 tablet every 8 hours PRN (pro re nata, as needed). The first column of 10 medication spaces were empty and the bottom space in the last column was empty. There were 49 tablets left in the medication card. The Medication Administration Record (MAR) for…

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 clinical record review, policy review, staff interviews, and resident interviews, the facility failed to provide an adequate amount of bathing assistance for 2 of 8 residents reviewed for bathing assistance (Residents #1 and #2). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/5/24, listed diagnoses for Resident #1 which included quadriplegia (paralysis in all 4 limbs), neurogenic bladder (a condition which made emptying the bladder difficult), and encounter for surgical aftercare following surgery on the skin. The MDS stated the resident required partial/moderate assistance with eating and oral hygiene, and was dependent on staff for toilet use, showering, and dressing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 1/31/24 Care Plan entry stated the resident required the assistance of 1-2 staff with bathing on Tuesday and Friday. The Documentation Survey Report V2 for February 2024 documented the following: Resident #1…

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 clinical record review, policy review, and staff interview, the facility failed to carry out wound treatment orders for 1 of 4 residents reviewed for wounds (Resident #1). The facility reported a census of 84 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle.…

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 clinical record review, policy review, and resident and staff interviews, the facility failed to ensure staff emptied a urinary catheter (a drainage system which emptied urine from the bladder into a drainage bag via a tube) in a timely manner for 1 of 3 residents reviewed with catheter (Resident #1). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set Assessment (MDS) assessment tool, dated 2/5/24, listed diagnoses for Resident #1 which included quadriplegia (paralysis in all 4 limbs), neurogenic bladder (a disorder which made urination difficult), and encounter for surgical aftercare following surgery on the skin. The MDS stated the resident required partial/moderate assistance with eating and oral hygiene, and was dependent of staff for toilet use, showering, and dressing. The MDS stated the resident had an indwelling catheter and listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 2/2/24 Care Plan entry stated the resident had a suprapubic catheter (a catheter in 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.

Based on observation, staff interview, record review, and policy review the facility failed to have safeguards in place to protect and account for pro re nata (PRN, as needed) medications for 2 of 4 residents reviewed (Resident #5 and Resident #18). The facility reported a census of 84. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #18 dated 2/15/24 documented diagnoses of chronic kidney disease, epilepsy, and morbid obesity with alveolar hypoventilation (insufficient breaths per minute). A Care Plan focus area initiated 2/9/23 documented the resident used opioid medications related to chronic pain. A medication card labeled Tramadol HCl 50 milligrams (mg) for Resident #18 observed on 3/20/24 at 2:40 PM revealed 60 tablets were dispensed 6/28/23 and the resident received 1 tablet every 8 hours as needed (PRN). The first column of 10 medication spaces were empty and the bottom space in the last column was empty. There were 49 tablets left in the medication card. The Medication Administration Record (MAR) for Resident #18 revealed he received Tramadol HCl 50…

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, staff interviews, and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 82 out of 82 residents. Specifically, food items in the kitchen and storage areas were unlabeled or expired, dietary equipment had a white residue and Dietary Staff were seen in the kitchen not wearing appropriate hair coverings. The facility reoprted a census of 82 residents. Findings Include: 1. The initial kitchen inspection was conducted on 05/15/23 at 09:13 AM through 10:00 AM with the Dietary Manager (DM). The following concerns were noted: a. In the Dry Storage area, an opened bag of corn flakes, removed from the manufacturer's packaging was observed to be dated 04/22/23, which the DM stated was the opened date. There was no use by date. The DM stated that They [staff] know when to discard the food item by the manufacturer's expiration date. Further interview with the DM confirmed there was no longer any packaging on the item to show an expiration date. b. 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 clinical record review, staff interview and review of facility policy, the facility failed to act on a Pharmacy recommendation for one of five residents reviewed for unnecessary medications (Resident #44). The facility failed to act on the Consultant Pharmacist's recommendation that Resident #44, who was prescribed an antianxiety medication (Lorazepam), received a gradual dose reduction. The failure to act on this recommendation had the potential for the resident to experience adverse medication effects such as impaired memory, judgement, and an increased risk of falls. The facility reported a census of 82 residents. Findings Include: Review of Resident #44's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and difficulty walking. Review of Resident #44's EMR Physician Orders located under the Orders tab dated 06/08/22 indicated the medical provider order…

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 interview and review of facility documentation, the facility failed to ensure the facility's Quality Assurance Performance Improvement (QAPI) policy and procedure addressed feedback; data collection systems; the development, monitoring, and evaluation of performance indicators; or corrective actions. This failure had the potential to affect all 82 residents who currently lived in the facility. Findings Include: A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, dated 03/2020, indicated the facility's QAPI policy and procedure failed to: a. Describe how it obtained and used feedback from residents, representatives, and staff to identify high-risk, high-volume, or problem prone issues. b. Describe how the committee would ensure data was collected, used, and monitored. c. Describe procedures for the development, monitoring, and evaluation of performance indicators. d. Describe how corrective measures and preventative actions would be implemented. On 05/18/23 at 1:24 PM, the Administrator and Interim Director of Nursing (IDON) were…

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, staff interview, record review, and facility policy review, the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. As part of this failure, the facility did not have an effective Antibiotic Stewardship Program, which had the potential to affect all residents of the facility (Cross Reference F881). In addition, the facility failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for the 76 facility…

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 review of facility policy, facility document review and staff interview, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included a functional Antibiotic Stewardship Program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols has the potential to affect all 82 residents of the facility. Findings Include: Review of a policy provided by the facility titled Antibiotic Stewardship dated 04/2018 revealed, This protocol will meet the CDC [Centers for Disease Control and Prevention] elements of Antibiotic Stewardship and will be followed by all Care Initiatives Employee. Review infections criteria based off the McGeer's criteria to determine actual infection or not actual .Review days of antibiotic therapy use .Monitor for patterns in facility .UTI [urinary tract infection] in resident WITHOUT catheter .MUST HAVE BOTH CRITERIA 1 and 2 .Criteria 1. MUST HAVE at least 1 of the following.Acute dysuria or acute pain, swelling.AND at least 1 of the following .Acute costovertebral angle pain…

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 clinical record review, staff interview and review of facility documents, the facility failed to ensure six residents (Residents #12, #21, #27, #30, #53, and #124) were afforded privacy out of a sample of 35 residents. The facility failed to protect these six residents' medical diagnoses from non-clinical facility staff, and potential public consumers, by placing the residents' names and mental health diagnoses in the Facility Assessment. The facility reported a census of 82 residents. Findings Include: During review of the admission Records for residents, the following concerns noted: a. Review of Resident #12's admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. b. Review of Resident #21's admission Record, located under the Profile tab in the EMR, indicated the resident was admitted to the facility on [DATE]. c. Review of Resident #27's admission Record, located under the Profile tab in the EMR,…

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, and facility policy review, the facility failed to maintain permanently affixed compartments for storage of controlled drugs for three of three narcotic storage lock boxes observed. The facility reported a census of 82 residents. Findings Include: On 05/18/23 at 10:52 AM, the small medication refrigerator in the medication room was observed with the Interim Director of Nursing (IDON). Three small lock boxes, which were not permanently affixed to the refrigerator, were noted in the refrigerator. The IDON confirmed the boxes were for storage of narcotic medications and that the boxes were not permanently affixed to the refrigerator. Upon further review of the narcotic medication storage boxes the following noted: a. On 05/18/23 at 10:55 AM, Licensed Practical Nurse (LPN) 2 unlocked the lock box for halls 100 and 200. LPN 2 confirmed the unaffixed box contained a bottle holding 24 milliliters (ml) of 2 milligram (mg)/ml lorazepam, a Schedule IV controlled medication. b. On 05/18/23 at 10:56 AM, LPN 1 unlocked the lock box for halls 300 and 400.…

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 personnel record review and staff interview, the facility failed to ensure five Certified Nursing Assistants (CNA) of five random CNA's reviewed for staffing were trained in the facility's Quality Assurance Performance Improvement (QAPI) Program (CNA 2, CNA 5, CNA 6, CNA 7, and CNA 8). The facility reported a census of 82 residents. Findings Include: Review of documents provided by the facility titled Relias [an on-line training program] revealed the following: 1. CNA 2's date of hire was 11/03/06 and his training failed to address the facility's QAPI program. 2. CNA 5's date of hire was 07/20/18 and her training failed to address the facility's QAPI program. 3. CNA 6's date of hire was 01/03/17 and her training failed to address the facility's QAPI program. 4. CNA 7's date of hire was 05/25/12 and her training failed to address the facility's QAPI program. 5. CNA 8's date of hire was 03/26/07 and her training failed to address the facility's QAPI program. During an interview on 05/18/23 at 10:35 AM, the Administrator confirmed the staff were not yet trained on 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 clinical record review, staff interviews and facility policy review, the facility failed to ensure that residents and/or their representatives received written information about and assistance with formulating Advance Directives for three of three sampled residents reviewed for Advance Directives (Resident #14, #51, and #52). The facility reported a census of 82 residents. Findings include: 1. Review of Resident #14's Clinical Census, located under the Census tab of the Electronic Medical Record (EMR), revealed the resident admitted to the facility on [DATE] with diagnoses that included debility, hypertension, and chronic obstructive pulmonary disease. Review of Resident #14's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/23 and located under the MDS tab of the EMR, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of Resident #14's Evaluation…

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 clinical record review, staff interview and facility policy review, the facility failed to ensure written notice was sent to the resident and/or the resident's representatives after emergent transfers from the facility to the hospital for two residents who were reviewed for hospitalizations (Residents #69 and #67). The failure to provide the required written notices, containing all required information, places the residents at risk of involuntary transfer, and/or not being informed of their rights, including how to appeal, their transfer. The facility reported a census of 82 residents. Findings Include: 1. Review of Resident #69's Electronic Medical Record (EMR) revealed an admission Record, which indicated the resident was admitted to the facility on [DATE]. Review of Resident #69's Nursing Progress Notes, located under the Prog (Progress) Notes tab in the EMR and dated 03/27/23, indicated the resident sustained a change in his condition and was sent to a local hospital. Review of the Progress Notes…

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 clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure one out of a survey sample of 35 residents (Resident #20) received services to maintain or improve the resident's activities of daily living related to mobility. Resident #20 was not provided restorative services, as directed by Skilled Therapy for a walk-to-dine program. The facility reported a census of 82 residents. Findings Include: Review of Resident #20's admission Record in the Electronic Medical Record (EMR) indicated the resident was admitted to the facility on [DATE] with muscle weakness. Review of Resident #20's Quarterly Minimum Data Set, with an Assessment Reference Date of 04/07/23, revealed the resident had a Brief Interview for Mental Status score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident required extensive assistance of two staff for bed mobility and transfers. The assessment revealed the resident was to walk in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, family member and staff interviews and policy review, the facility failed to provide activities designed to meet the individualized needs for one of two residents reviewed for activities out of 35 sampled residents (Resident #50). Specifically, the facility failed to provide a resident with dementia with consistent, resident-appropriate Activities Program to enhance her quality of life. The facility reported a census of 82 residents. Findings Include: Review of Resident #50's admission Record, located under the Profile tab of the Electronic Medical Record (EMR) indicated Resident #50 was admitted on [DATE] and had diagnoses that included unspecified dementia, without behavioral disturbance. Review of Resident #50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #50 was unable to complete the interview. The staff assessment…

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 clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure one of three residents reviewed for accident hazards received adequate assistance and supervision to prevent injuries (Resident #37). Resident #37 required assistance from staff to be fed. On 05/09/23 the resident attempted to feed herself, spilled hot food on her right chest, and sustained a first-degree burn on her chest. After this accident, the facility failed to conduct a comprehensive root cause analysis which contained all components per facility policy. The facility also failed to implement measures identified to prevent further accidents, including an Occupational Therapy assessment and the need for total dependence on staff for feeding to reduce the chance of another potential injury. The facility reported a census of 82 residents. Findings include: Review of Resident #37's admission Record, located under the Profile tab in the Electronic Medical Record (EMR), indicated 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 facility document review, staff interview and policy review, the facility failed to ensure three Certified Nursing Assistants (CNA's) of five reviewed were provided Annual Performance Reviews (CNA #2, CNA #8, and CNA #5). This failure has the potential for decreased quality of life or quality of care for the residents. The facility reported a census of 82 residents. Findings Include: 1. Review of a document provided by the facility titled Annual Review, signed as dated 11/22/21, indicated CNA #2 completed an Annual Review at that time. 2. Review of a document provided by the facility titled Annual Review, signed as dated 03/28/22, indicated CNA #8 completed an Annual Review at that time. 3. Review of a document provided by the facility titled Annual Review, signed as dated 11/07/21, indicated CNA #5 completed an Annual Review at that time. During an interview on 05/18/23 at 9:04 AM, the Administrator and Interim Director of Nursing (IDON) confirmed there were no more recent Annual Performance Reviews completed for CNA #2, CNA #8, and CNA #5. The Administrator stated 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 clinical record review, staff interview and review of facility policy, the facility failed to act on a Pharmacy Recommendation for one of five residents reviewed for unnecessary medications (Resident #44). The facility failed to act on the Consultant Pharmacist's recommendation that Resident #44, who was prescribed an antianxiety medication (Lorazepam), received a gradual dose reduction. The failure to act on this recommendation had the potential for the resident to experience adverse medication effects such as impaired memory, judgement, and an increased risk of falls. The facility reported a census of 82 residents. Findings Include: Review of Resident #44's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and difficulty walking. Review of Resident #44's EMR Physician Orders located under the Orders tab dated 06/08/22 indicated the medical provider order…

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 clinical record review, observation, and staff interview, the facility failed to ensure a medication error rate of less than 5% for one of five sampled residents observed receiving medications (Resident #170. There were two errors in 30 opportunities, resulting in a medication error rate of 6.67%. The facility reported a census of 82 residents. Findings Include: Review of Resident #170's Clinical Census, located under the Census tab of the Electronic Medical Record (EMR) revealed Resident #170 was admitted to the facility on [DATE] with diagnoses that included seizure like activity and dermatosis. On 05/16/23 at 9:22 AM, Licensed Practical Nurse (LPN)2 was observed preparing medications for Resident #170. LPN 2 stated Resident #170 did not have two medications available that he was supposed to receive. Review of Resident #170's Physician Orders for medications, listed under the Orders tab of the EMR, revealed Resident #170 was to receive medications including: a. Lacosamide (an anti-seizure medication)…

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.