Complete Care at Sheriden Commons

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to properly assess and manage oral fluid intake, urinary output and bowel output in a resident (R4) who was at risk for dehydration. This deficient practice resulted in harm for one resident (R4) requiring hospitalization for acute kidney disease and fecal impaction. Finding include: R4's diagnosis includes but are not limited to Major depressive disorder, Chronic respiratory failure, Chronic obstructive pulmonary disease, Morbid obesity, Venous insufficiency, Sleep Apnea. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 13 which indicates R4's cognition is intact. R4's nursing progress note dated 07/29/24 documents in part, V22 Medical Doctor (MD) requests for resident (R4) to be sent out to hospital due to critical BUN (blood urea nitrogen) 150 mg/dL (milligrams per deciliter). R4's nursing progress note dated 07/30/24 documents in part, Staff called the hospital and spoke with the nurse who stated that R4…

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

Based on observations, interviews, and records review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to unload clean dishes from the dishwasher in a sanitary manner. (d) dishwasher temperatures not consistently documented. These deficiencies have the potential to affect 76 residents who are on an oral diet and receiving meals from the kitchen. Findings include: On 02/06/2024 at 9:30am, during tour of the kitchen with V3(Dietary Manager), in the dry food pantry was observed three types of cereals: frosted flakes, rice krispies, and honey nut cheerios in open bags in a box with no open by date or expiration dates. V3 said all foods including the opened ones should have a open by date and expiration date so that kitchen staff know when the food needs to be thrown out and staff need to follow the first in first out rule. V3 said residents should be given fresh food that is not expired and stale, to prevent residents getting sick…

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

Based on observation, interview, and record review, the facility failed to a.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 4 out of 22 shifts and b.) keep an accurate count of all narcotic medications for two (R11, R22) residents reviewed for medications. These failures have the potential to affect 42 residents residing in the facility. Findings include: On 02/06/2024 at 10:03AM, V5 (LPN/Licensed Practical Nurse) states that she did not perform a narcotic drug count. V5 was responsible for the 3rd floor Team 2 medication cart for rooms 301 and rooms 309-320. On 02/06/2024 at 10:03AM, review of the Shift Change Accountability Record Sheet for Control Substances for the month of February 2024 for cart identified as Team 2 medication cart located on the 3rd floor of the facility indicated for 2 shifts in February 2024, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 02/05/24, 1st shift oncoming and off-going (7am-7pm) On 02/06/24, 1st shift oncoming (7am-7pm) 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.

Based on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect 35 residents residing in the facility. Findings Include: On 02/07/2024 at 8:09AM, surveyor located on the second floor of the facility. During medication administration pass with V11 (LPN), V11 observed preparing liquid antibiotic medication for R57. V11 observed leaving liquid antibiotic medication on top of his medication cart (identified as Team 2 medication cart) and walks away leaving the liquid medication unattended and out of V11's view. On 02/07/2024 at 8:09AM, V11 returns to the medication cart and states to surveyor, I knew you were standing here so that's why I left the medication on top of the cart. Surveyor states to V11 that surveyor is not responsible for monitoring V11's medication cart. V11 states a resident could have gotten the medication and self-administered it and possibly caused harm to the resident since the liquid medication was left unattended. On 02/07/2024 at 8:56AM during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one (R74) out of three residents reviewed for discharge. Findings include: R74's medical record (Face Sheet, MDS/Minimum Data Set, dated [DATE]) documents that R74 is a [AGE] year-old male who is cognitively intact with a BIMS/ Brief Interview for Mental Status score of 15/15. R74 has diagnoses not limited to: Malignant neoplasm of cerebral meninges, chronic obstructive pulmonary disease, malignant neoplasm of right lung, malignant neoplasm of left lung, stage 3 chronic kidney disease, and essential hypertension. On 02/08/2024 at 12:39PM V16 (Clinical Director of Admissions) states whenever a resident is discharged to the hospital, she does not provide written bed hold notification to the resident or resident's representative. V16 states she only sends out an internal email to the facility staff and the liaison at the hospital to let them know that the resident is able to return back to 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 interview and record reviews the facility failed to refer three (R5, R24, R30) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review. Findings include: On 02/08/24 at 1:39 PM, V16 (Clinical Director of Admissions) stated that she is responsible for making sure Level 1 Pre-admission Screening and Resident Review (PASARR) are in the residents' records. V16 said that sometimes the residents are admitted to the facility from the hospital before a level 1 PASARR is completed. V16 said that she then makes the level 1 PASARR request, and the assigned state agency will come into the facility and complete the screening. V16 stated that if a resident requires a level 2 PASARR screening then the state agency sends her an email requesting for updated resident information. V16 stated that this is a situation she has not delt with before. V16 stated that she was informed by the state agency that social services need to notify V16 of the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two low air loss mattresses were set according to manufacturer recommendation for residents (R29, R33) who are identified as high risk for pressure injury. Findings include: On 02/06/2024 at 10:15am, Surveyor observed R29 lying on a low air loss mattress with the weight control/knob set at 350lbs. On 02/06/2024 at 12:45pm, Surveyor observed R33 lying on a low air loss mattress control with the weight control/knob set at 180lbs. On 02/06/2024 at 12:25pm, V11 (Licensed Practical Nurse) states, Air mattress settings should be the same as the resident weights. If the settings are not correlated with residents weight it can cause a pressure wound. On 02/08/2024 at 9:30am, V14 (wound care nurse) states, Low air mattress should be set at residents' current weight according to the manufacturer's recommendations. I have a wound tech that check settings daily. I also check settings daily when doing wound rounds to make sure bed is 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 interviews and records review, the facility failed to obtain consent for psychotropic medication administration for two (R24, R34) residents reviewed for psychotropic medications in a sample of 18 residents. Findings include: R24's current face sheet documents R24 is a [AGE] year-old individual admitted to the facility on [DATE], with current medical diagnosis that include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified. R24's Minimum Data Set (MDS) section C dated 1/24/2024 documents R24 has a Brief Interview for Mental Status (BIMS) score of 11/15 indicating R24 has moderately impaired cognation. On 02/08/2024 at 2:20pm, V2(Director of Nursing) stated psychotropic consents needs to be signed by the resident or their representatives before the resident starts to take the medications so that the resident can be aware of what he/she is taking the medications for. V2…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R23, R57) out of four residents reviewed for medication administration resulting in an 11.11% error rate. Findings Include: R57's medication administration record (MAR) dated 02/01/2024- 02/07/2024 documents: Nebivolol HCL 5mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 02/07/2024 at 8:24AM, surveyor observed that this medication was not given during the 9:00AM medication administration pass with V11 (Licensed Practical Nurse/LPN). R23's medication administration record (eMAR) dated 02/01/2024 - 02/07/2024 documents: Protonix 40mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. Valsartan 80mg- Give 2 tablets by mouth two times a day scheduled at 9:00AM. On 02/07/2024 at 8:42AM during medication administration pass, V11 (Licensed Practical Nurse/LPN) observed administering three tablets of Valsartan 80mg to R23. On 02/07/2024 at 8:42AM, V11 (LPN) states that R23's scheduled Protonix medication is not available 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 interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination with its education for 3 residents (R15, R229 and R49) out of 5 in a sample of 18. Findings include: On 02/07/2024 at 11:40 AM, surveyor sat down with V12 (Infection Preventionist/Clinical Consultant) to go over immunization status for residents. V12 stated all the immunization records, consent and education provided are documented in the resident's electronic health record. V12 stated that R15 refused their influenza immunization. Surveyor asked V12 if R15 had received education for the influenza vaccine. V12 stated yes but the education provided check box was not checked. Surveyor observed V12 click the check box at that moment. V12 also stated that R229 refused pneumococcal immunization. Surveyor asked V12 if R229 had received education for the pneumococcal vaccine. V12 replied yes but the education provided check box was not checked. Surveyor observed V12 click the check box for education provided for R229 at that moment as well. On 02/07/2024 at 11:50…

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.

Based on record review and interview, the facility failed to employ a full time Social Service Director. This has the potential to affect all 78 residents residing in the facility whom require medical social services. Findings include: On 11/02/2023 at 3:29PM, V1 (Administrator) states the facility is licensed for 143 beds and does not have a full-time social worker working at the facility. V1 states that the facility should have a full-time social worker at the facility and is looking to hire a full-time social worker as soon as possible. The facility assessment, dated 02/27/2023, documents in part, Indicate the number of residents you are licensed to care for: (enter number of beds) 143. The facility assessment documents that the facility provides services to residents that include skilled care, therapy services, wound care, restorative care, respiratory care, mental health and behavioral care, as well as a variety of other medical needs. The assessment also lists Social Services as a type of staff needed to care for residents in the facility. Facility assessment documents 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.

Based on interview and record review, the facility failed to ensure six residents (R5, R6, R13, R17, R21, R29) were given the right to participate in the development and implementation of their person-centered plan of care. Findings include: On 11/2/23 at 10:15 AM, R17 stated R17 hasn't had a care plan meeting. I don't know if we are having meetings or not. There has been no social worker for two to three months. On 11/2/23 at 12:28 PM, R21 stated we have care plan meetings when we have a social worker. We don't have a social worker now. On 11/2/23 at 1:00 PM, R5 said I have never been to a care plan meeting. I have not received my care plan. I've been here two years. They may come a few days before to tell me about a meeting but then don't come get me for the meeting. They may tell me, rarely, if something has changed in the care plan. On 11/3/22 at 2:00 PM, R6 said I have only had one care plan meeting since I've been here in 5/21. They have not given me a care plan. On 11/7/23 at 9:30 AM, R13 said I have been here for over two years. I haven't had a care plan meeting. Because…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three residents (R12, R26, R30) have a safe, clean, comfortable, and homelike environment. Findings include: On 11/2/23 while touring facility with V16 (Building Manager), surveyor observed: Call light fixture/plate not fully attached to the wall in room [ROOM NUMBER]. Call light functioning. Cracks, chipping/peeling paint, rust color along the baseboards in R30's bathroom; on the ceiling in the dining room on the 3rd floor; on the third-floor shower room floor. R12's television not working and does not have a remote control. On 11/3/23 while touring facility with V16, surveyor observed: Cracks, chipping/peeling paint, rust color on the second-floor shower room floor. On 11/3/22, Surveyor observed cracks, chipping/peeling paint, rust color on the ceiling over R26 bed. On 11/2/23 at 10:15 AM, R17 stated there are televisions that are not working or not working properly. There is a problem with the system according to maintenance. 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.

Based on observation, interview, and record review, the facility failed to a.) provide supervision and monitoring for residents during the designated smoking time to ensure residents practice safe smoking in the designated area and b.) failed to complete a quarterly smoking safety evaluation as required. These failures affected three (R30, R31, R32) residents reviewed for smoking safety. Findings include: On 11/03/2023 at 2:15PM, surveyor observed R30, R31, and R32 outside on the 1st floor patio smoking and not being supervised by staff members. V12 (Activity Aide) observed inside of the facility with the door closed and her back facing the door of the smoking patio. On 11/03/2023 at 2:19PM, V11 (Dietary Manager) observed outside smoking with R30, R31, and R32. On 11/03/2023 at 2:20PM, V11 now located back inside of the facility and states that she is not responsible for monitoring the residents who are smoking and went out on the patio to smoke herself. V11 stated R30 informed her that he did not have any more cigarettes, V11 stated she gave R30 one of her own personal cigarettes.…

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

Based on observation, interview and record review, the facility failed to ensure that the (Facility) Daily Staffing was up to date and posted in a prominent location that is readily accessible to staff and visitors. This failure has the potential to affect all 88 residents residing in the facility. Findings include: On 4/25/2023 at 9:11 AM, a nurse and CNA (Certified Nursing) staffing schedule was observed at the receptionist desk on a clipboard, but it did not include the actual time worked for each category (licensed or non-licensed) and type of nursing staff but rather it listed the shift and units each nurse or CNA was assigned to. On 4/25/23 at 3:05 PM, the surveyor asked V15 (Staffing Coordinator) to show the surveyor where the Daily Staffing is posted. V15 walked the surveyor to the lobby and asked the receptionist where the Daily Staffing is posted. Initially, V16 pointed to the clipboard, but V15 then explained that she (V15) needs the staffing sheet with the hours worked on it. V16 (Receptionist) turned around in her (V16) chair and grabbed a hard, plastic paper cover that…

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

Based on observation, interview, and record review, the facility failed to document temperature readings on the freezer and cooler temperature logs. This has the potential to affect 85 residents in the facility who receive an oral diet. Findings include: On 4/24/2023 at 9:35am upon initial tour of the kitchen, observed the temperature logs for cooler #1, cooler #2, cooler #3, freezer #1 and freezer #2. All temperature logs were missing documentation of a temperature reading for the following dates and times: 1. Cooler #1 missing documentation of a temperature reading for the PM shift on 4/21/2023, 4/22/2023 and 4/23/2023. 2. Cooler #2 missing documentation of a temperature reading for the PM shift on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23 and 4/23/23. 3. Cooler #3 missing documentation of a temperature reading for the PM shift on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23,…

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

Based on observation, interview, and record review, the facility failed to maintain shift change accountability records for controlled substances that enables periodic reconciliation and accounting for residents' controlled medications. This failure has the potential to affect all 42 residents on the second floor of the facility. Findings include: The Facility census shows that there are 42 residents on the second floor of the facility. On 4/6/23 at 10:30am on the second floor with V5(Agency LPN/Licensed Practical Nurse), the Shift change accountability records for controlled substances for the second floor for April 2023 was reviewed. This record shows several missing entries of nurses' signatures, interpreted to mean that there were some shifts that no nurse was accountable or responsible for the narcotics on the floor. Some of the missing entries include 4/4/23, 4/8/23, 4/9/23, 4/15/23, 4/20/23, 4/22/23, and 4/23/23. V5 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V5 responded that she is from 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 observation, interview, and record review, the facility failed to provide a timely response to an activated call light for one resident (R38) and failed to provide a call device for one resident (R60) in the total sample of 40 residents. Findings include: On 4/24/23 at 11:41 AM, R38 stated It's awful. It takes them a long time to answer, regarding call light responsiveness. R38 added that it can take staff up to an hour to respond, and R38 has had to call the receptionist to forward the call to the nurse's station in order to get a hold of someone. On 4/24/23 at 11:50 AM, R38 activated her call light. A red light was observed flashing on the wall behind R38's bed indicating the call light was on. At 11:52 AM, a staff member walked in and introduced himself as V23 (Medical Doctor/Physiatrist). V23 stated that he (V23) is from therapy and will be back to work with R38. V23 left the room without addressing why R38 had her (R38) call light on. At 12:08 PM, 18 minutes after the call light was activated, V8…

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

Based on observation, interview and record review, the facility failed to ensure the cleanliness of a personal refrigerator, failed to provide a thermometer and maintain a temperature log for the personal refrigerator, and failed to ensure food stored in the personal refrigerator was dated to prevent foodborne illness for one resident (R21) out of 4 residents reviewed in the total sample of 40 residents. Findings include: On 4/24/23 at 11:30AM, the surveyor observed a personal refrigerator in R21's room with no temperature log or thermometer inside. The inside of the refrigerator appeared dirty with spilled brown rice from a carton of Chinese food. On 4/24/23 at 11:31 AM, this observation was brought to the attention of V4 (LPN/Licensed Practical Nurse). The surveyor inquired about a temperature log. V4 stated, I don't see one. Inside the refrigerator, V4 found a bottle of pop, Chinese food, and pickles. V4 stated, No, I (V4) don't see a date on them. He's (R21) alert and oriented so he (R21) will throw it out himself. V4 added, I see some little crumbs in here. On 4/24/23 at 12:09…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to clip or trim the fingernails of one resident (R54) out of three residents reviewed for fingernail care. Findings include: R54 has the following diagnose which include, but are not limited to cerebral infarction due to embolism of left middle cerebral artery, anemia, unspecified, flaccid hemiplegia affecting right dominant side, benign prostatic hyperplasia with lower urinary tract symptoms, essential (primary) hypertension, neuromuscular dysfunction of bladder, unspecified, obstructive and reflux uropathy, unspecified, major depressive disorder, single episode, unspecified, retention of urine, unspecified, malignant neoplasm of colon, unspecified, unsteadiness on feet, aphasia, other lack of coordination, chronic viral hepatitis c, other psychoactive substance abuse, uncomplicated, other hydronephrosis. R54's Minimum Data Set (MDS) dated [DATE] Section C, documents, in part, BIMS (Brief Interview for Mental Status) Score of 08, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure that a resident's (R84) blood pressure was measured before administering a heart medication as ordered by the Physician and failed to ensure that the resident's (R84) Heart rate was properly measured as ordered by the Physician. This failure has the potential affect all residents that reside in the facility and who relies on a Nurse to follow Doctor's orders pertaining to their care and treatment. Findings include: R84 is [AGE] year old with diagnosis including but not limited to: Hypertension, Cerebral Infarction due to Occlusion or Stenosis of Right Posterior Cerebral Artery, Hemiplegia and Hemiparesis, and Chronic Obstructive Pulmonary Disease. R84's BIMS (Brief Interview of Mental Status) score is 10, which indicates Severe Cognitive Impairment. On 4/23/23 at 10:45 am, V4 (Licensed Practical Nurse) was observed handing R84 a medication cup that contained the following heart medications: Amlodipine 10 MG, Hydralazine HCl 10 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.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for one resident (R63). This failure affected one resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 40. Findings include: R63's admission record includes but not limited to Osteoarthritis, Spinal Stenosis, Pressure Ulcer, Diabetes, Gas Gangrene, Thoracic Aortic, Dementia, Osteoarthritis, Acute Kidney Failure, and Hypertension. R63's (2/14/23) cognitive assessment determined a score of 8 (moderately impaired). On 4/24/23 at 10:56 am, R63 was lying on a low air loss mattress with multiple layers between R63 and the low air loss mattress. The layers observed on R63 consisted of a flat sheet, a flat sheet folded multiple times for a draw sheet that was positioned under R63's lower back and buttock, and an incontinent brief. On 4/24/23 at 11:10 am, V6 LPN (License Practical Nurse) checked the layers of linen between R63 and the low air loss mattress, per surveyor's request, and stated, there is a flat…

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, interviews, and record review the facility failed to follow the medication labeling and storage policy by not documenting an open date on eye drops. This failure affected two residents (R37 and R75). This failure was identified on two medication carts reviewed for medication labeling and storage out of four carts. Findings include: R37 is a [AGE] year old with diagnosis including but not limited to: Idiopathic Peripheral Neuropathy, Type 2 Diabetes Mellitus, Dementia, Hypertension, Anxiety disorder, and Major Depressive Disorder. On [DATE] at 12:25 pm, Carboxymethylcellulose Sodium Solution 1% was observed on the third floor medication cart A for R37. R37's Physician Order Sheet dated [DATE], documents an order for Carboxymethylcellulose Sodium 1%, instill one drop in both eyes every six hours as needed for dry eyes. R75 is a [AGE] year old with diagnosis including but not limited to: Dementia, Disorientation, and Hypertension. On [DATE] at 12:35 pm, the following eye drops were observed…

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.