Greenup Rehab and Nursing

Based on observation, interview, and record review the facility failed to provide residents breakfast meal in a timely manner. This failure affected all 36 residents residing in the facility. Findings include: On 9/24/24 at 8:05 am the main dining room of the facility was full of residents waiting for their breakfast meal to be served. Each resident had beverages, but none of the residents had been served food. R30 stated The facility has not served anybody. We have no idea what is going on. We have been out here for over an hour waiting. Breakfast is supposed to be served at 7:15 am. It is often late, but today its extremely late. On 9/24/24 at 8:10 am V23, [NAME] stated she overslept so the food is just being cooked. On 9/24/24 at 8:16 am V1, Administrator stated V1 realizes the meal is late this morning. V1 stated the expectation is that breakfast is to be served between 7:15 am and 7:30 am. On 9/24/24 at 8:50 am V9, Dietary Manager stated I (V9) came in at 5:00 am this morning but did not cook resident meals. V9 stated she had a food delivery coming in and cleaned until they…

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 prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitization of a commercial table top can opener, free of grease-like substance, metal fragments, rust and exposed metal, failed to maintain food surface areas in a clean sanitary manner, failed to clean grease build-up on kitchen and food storage room floors, failed to adequately clean grease build- up off the flat top grill, failed to clean commercial ovens and failed to air dry dishware. These failures have the potential to affect all 36 residents residing in the facility. Findings include: 1.) On 9/22/24 at 8:15 am on initial tour of the facility kitchen the floors had a build-up of sticky, dark black and brown grease-like debris throughout the kitchen, dishwashing station, dry storage, and cooks' food service line. This surveyors' feet stuck to the floor with every step throughout the heavily soiled areas of the kitchen. There was an accumulation of dust and debris under all the shelving and next to the walls.…

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 establish a water management program, failed to develop a risk assessment ensuring that interventions to monitor control limits are met, develop a method to audit the program to prevent the growth of Legionella and other water borne pathogens in the building's water systems. This failure has the potential to affect all 36 residents that reside in the facility. Findings Include: The facility Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents that there are 36 residents who reside in the facility. The facility Legionella Policy and Procedure dated 4/20/20 documents that each facility will complete a risk assessment to identify if the entire building or parts of the building are at risk for Legionella growth and spread. Additionally, the facility will implement control measures to reduce spread, ensure that the program remains operational, and monitor the program's effectiveness. The facility could not provide documentation of a Legionella risk assessment to identify if the building is at…

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, interview, and record review the facility failed to maintain kitchen equipment in a safe operable and functional manner. This failure affected all 36 residents in the facility. Findings include: 1.) R30's Minimum Data Set, dated [DATE] documents R30's Brief Interview of Mental Status score as 15 out of a possible 15 indicating no cognitive impairment. On 9/24/24 at 8:05 am the facility foyer, resident lounge, and resident shared dining room had a distinct, foul gas-like odor. The resident dining room was filled with residents. R30 stated There is a strong odor of gas coming from the kitchen. I am not sure what that is all about, either. On 9/24/24 at 8:10 am V23, [NAME] and V16, Maintenance Director were in the facility kitchen. V23, [NAME] stated the gas was turned off to the stove and flat-top grill the night before and V23 is not sure why it was turned off. V16, Maintenance Director was present in the kitchen and had already assessed the kitchen for a gas leak. V16 stated there was no…

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 honor residents' right to a clean and comfortable homelike environment by failing to repair and maintain the cleanliness of the only two resident-shared shower rooms in the facility. These failures affect all 36 residents residing in the facility. Findings include: On 09/22/24 at 10:10 am R30 stated Both shower rooms have black areas, maybe mold that they (the facility) can't seem to clean off. R30 also stated The housekeeper are great, so I think it (black mold-like substance) is coming from inside the wall. On 9/22/23 at 1:55 am during a tour with V1, Administrator, the resident shared shower room, closest to the nursing station, and adjacent to the resident common lounge was a dark shower room with one shower stall and one toilet. The shower had a strong, musty odor. There was a small, sole ceiling vent above the toilet alcove that measured approximately six inches by eight inches. The ceiling vent was corroded with a thick gray dust-like substance and had no air movement when tested with one, four by…

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 repeatedly failed to provide dignity while dining for four of four residents (R15, R17, R27, and R87) reviewed for dignity on the sample list of 28. Findings include: 1.) R15's Minimum Data Set (MDS) dated [DATE] documents R15 has a Brief Interview of Mental Status (BIMS) score of five out of a possible 15, indicating R15 has severe cognitive impairment. R15's same MDS documents R15 requires substantial/maximum assistance for eating. R17's MDS dated [DATE] documents R17 has severe cognitive impairment and requires supervision/touching/and or verbal assistance for eating. R27's MDS dated [DATE] documents R27 has severe cognitive impairment and requires substantial/maximum assistance for eating. R87's MDS dated [DATE] documents R87 has a BIMS score of five out of a possible 15, indicating R87 has severe cognitive impairment. R87's same MDS documents R87 is totally dependent on staff assistance for eating. On 9/23/24 at 7:35 am R27 was seated in 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 observation, interview, and record review the facility failed repeatedly to change oxygen tubing and nasal cannula, store oxygen tubing off the floor, and maintain nebulizer breathing treatment equipment and Continuous Positive Airway Pressure (CPAP) equipment in a sanitary fashion. These failures affected two of two residents (R24, R30) reviewed for oxygen in the sample list of 36. Findings Include: 1.) R24's Medical Diagnoses Sheet dated September 2024 document R24 is diagnosed with Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. R24's Physician Order Sheet (POS) dated September 2024 documents R24 is prescribed oxygen at three liters per nasal cannula. The nasal cannula is ordered to be changed every Thursday night. R24's Treatment Administration Record (TAR) dated September 2024 documents staff are to change R24's oxygen tubing every Thursday on night shift. On 9/12/24 the TAR documents the tubing was not changed because R24 was asleep. On 9/19/24 R24's TAR documents R24's tubing…

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 serve palatable resident preferred temperature, and pleasant looking food. This failure affected four of four residents (R9, R19, R30, and R32) reviewed for palatability of food on the sample list of 28. Findings include: 1.) R30's Minimum Data Set, dated [DATE] documents R30's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. On 09/22/24 at 10:15 am R30 stated last night the facility served beef and noodles that had an inch thick layer of grease on top. 2.) On 9/23/24 at 8:11 am R30 was eating biscuits and gravy. R30 stated The meal was served hot, except the oatmeal. R30 had a full bowl of oatmeal, that floated in water. R30 stated the oatmeal was soupy and she will not eat soupy oatmeal.3. On 9/22/24 at 8:30 AM, R9 stated the food at the facility is terrible, it's cold. R9 also stated when they had beef and noodles, there was so much grease on the top of it, you could spoon it off. 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 interview and record review, the facility failed to provide a resident with an Advance Beneficiary Notice (ABN), at the termination of a Medicare Part A covered stay, thereby nullifying the resident's right to continue therapy services at their own expense or decline therapy services. This failure affects one resident (R187) out of a sample of three reviewed for Beneficiary Notices on the sample of 28. Findings include: R187's Beneficiary Protection Notification Review (undated) documents R187 began a Medicare Part A covered stay at the facility on 11/14/23, with a last covered date of 3/17/24. There was no evidence that R187 had received and Advance Beneficiary Notice of her options to decline to receive further therapy, or to continue therapy services at R187's own expense. On 9/25/24 at 11:06 AM, V1, Administrator stated, We did not give (R187) an ABN notice but I'm not sure why because we gave them to other residents. The form entitled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (2018), documents the SNFABN provides…

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 issue a written bed hold notice to a resident's family member when the resident was transferred to the hospital. This failure affects one of one resident (R2) reviewed for hospitalization on the sample list of 28. Findings include: 1. R2's Health Status Note 8/1/2024 11:59 pm documents the following: Note Text: Contacted 911 for emergency transfer at 2235 (11:35 pm) D/T (due to) c/o (complaint of) chest pain with SOB (shortness of breath), tachycardia (very fast heart rate) and low BP (blood pressure) noted. Res. (resident R2) left facility at this time via (local) EMS (emergency medical service) for (distant hospital) ER (emergency room), all paperwork sent. On 9/25/24 at 9:10 am V1, Administrator stated V1 was the staff member responsible to send out the written bed hold notice to R2's family representatives. V1, confirmed she did not send a written bed hold notice to R2's family member in regard to R2's 8/1/24 hospital transfer. The facility BED HOLD GUARANTEE POLICY dated 8/1/17 (sic) documents the following: 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 review the facility failed to closely monitor a resident's weight loss, notify the physician of significant weight loss, and implement nutritional supplement recommendations to slow/prevent weight loss. This failure affected one of one resident (R13) reviewed for nutrition on the sample list of 28. Findings Include: R13's Medical Diagnoses sheet dated September 2024 documents R13 is diagnosed with Dementia and Depression. R13's Minimum Data Set, dated [DATE] documents R13 is severely cognitively impaired and requires partial/moderate assistance for eating. R13's Weight charting on 8/23/24 documented a weight of 239 pounds. R13's Dining Manager note dated 8/25/24 documents R13 was a re-admit from the hospital and weighed 237 pounds. R13 requires assistance during meals and typically eats less than 50%. A house supplement two times per day is recommended. This assessment was completed by V25 Registered Dietician Consultant. R13's Dining Manager note dated 9/14/24 documents R13's…

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 label and document expiration dates for medications for two residents (R7, R25) and failed to lock the convenience box after removing medication for one resident (R33) during medication storage and labeling review on the sample list of 28. Findings include: On 9/22/23 at 11:42 AM, V7 Licensed Practical Nurse (LPN) was observed while doing medication storage and labeling review. While observing expired medications, R7 had a box of Lorazepam 2 milligram (ml) suppositories which did not document an expiration date. V7 LPN stated V7 did not know what the expiration date should be. During this same time, R25 had a container in the refrigerator which had no documented name of what the medication was, nor expiration date documented. V7 LPN again stated V7 was not sure what the medication was or what the expiration date should be. During this same review, the facility's convenience box was observed to have no secure lock on it. A form in the convenience box documented a medication had been removed on 9/21/24 at 5:00…

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 appropriately assess, evaluate, and document a resident's behaviors after administering medications for behaviors for one resident (R29) of five resident reviewed for Unnecessary Medications in the sample list of 28. Findings include: R29's undated diagnoses documents R29's diagnoses as Senile Degeneration of Brain, not elsewhere classified; Unspecified Dementia, severe without behavioral disturbances, Psychotic Disturbance, Mood Disorder, and Anxiety; and Anxiety Disorder, unspecified. R29's Care Plan date 9/22/24, documents R29 has Delirium and is not cognitively aware of anything but does respond to name; experiences levels of lethargy as well as yelling out; and most responses are nonsensical. R29's Behavior Monitoring and Interventions Report dated 7/7/24, documents R29 having behaviors which include socially inappropriate behaviors, agitated, and screaming not at others. R29's Progress Notes dated 7/7/24, do not have any documentation regarding any medications administered or any follow up for behaviors. R29's…

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 complete and accurate controlled medication records. This failure has the potential to affect one resident (R1) of three reviewed for medications. Findings include: On 5/30/2024 at 10:41AM, V2 (Director of Nursing) reported recently auditing R1's pain medication (oxycodone) administration record and controlled medication count sheet and finding discrepancies between the records. V2 reported facility staff failed to accurately document on R1's controlled medication count sheet all doses administered to R1 as documented on R1's medication administration record. V2 reported facility staff also failed to accurately calculate remaining doses of R1's medication on R1's-controlled medication count sheet. R1's controlled medication count sheet (May 2024) documents four count corrections on 5/21/2024, a late entry for medication administered on 5/15/2024, and multiple calculation errors on 5/21/2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive Plan of Care with fall interventions for one (R3) of three residents reviewed for Care Plans in the sample of three. Findings include: R3's Diagnosis Sheet (current and on admission [DATE]) includes the following diagnoses: Displaced Spiral Right Humeral Shaft Fracture, Traumatic Subarachnoid Hemorrhage, Head Laceration, Anxiety, Depression and Urinary Tract Infection. The Facility Incident Fall Log dated for February 2024 documents two falls for R3. The first is documented on 2/14/24 and the second fall is documented on 2/19/24. R3's Fall Risk Evaluation dated 12/26/23 documents the following: Intermittent Confusion, 1-2 falls in past 3 months, Chair bound - requires restraints and assist with elimination, balance problem while standing, balance problem while walking, decreased muscular coordination, jerking or unstable when making turns, requires use of assistive devices (i.e., cane, wheelchair, walker, furniture,…

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 form fall interventions and implementation of safety measures to prevent a resident (R3) from falling. R3 is one of three residents reviewed for falls in the sample of three. Findings include: R3's Diagnosis Sheet (current) includes the following diagnoses: Displaced Spiral Right Humeral Shaft Fracture, Traumatic Subarachnoid Hemorrhage, Head Laceration, Anxiety, Depression and Urinary Tract Infection. R3's Minimum Data Set (MDS) dated [DATE] (5-day initial admit) documents that R3 is frequently incontinent and is dependent upon staff for transfers and toileting. This same MDS documents R3 having impairment to the right side and a history of falls. R3's Physician Order Sheet (POS) dated March 2024 documents and order dated 12/26/23 for Eliquis 5 milligrams twice a day (blood thinner) and Meclizine 25 milligrams three times a day as needed for dizziness. This same POS documents R3 is non-weight bearing in the right upper extremity. R3 is to wear a brace…

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 have RN (Registered Nurse) coverage for 8 hours/day, 7 days/week for one day, 12/3/23 of 15 days reviewed for nursing coverage. This failure has the potential to affect all 36 residents residing in the facility. Findings include: The nursing schedule provided by V1 Administrator dated 11/26/23 through 12/10/23 documents no RN coverage on 12/3/23. On 12/11/23 at 10:29 AM V1 confirmed there was no RN coverage on 12/3/23. On 12/11/23 at 2:43 PM, V2 Director of Nursing stated they do not have a staffing policy. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 12/10/23 documents 36 residents reside in the building.

Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination of disposable plates and failed to maintain sanitary kitchen and pantry floor areas. These failures have the potential to affect all 36 residents in the facility. Findings include: 1. On 12/10/2023 at 9:12AM, kitchen supplies including disposable plates and cups were stored on a shelf below exposed pipes in the kitchen basement. One pipe was actively leaking onto a box of disposable plates located on the shelf. The box was wet and discolored and the water drip had leaked onto the plates stored inside, leaving a leaving a yellow residue on the plates. 2. On 12/10/2023 at 8:55AM, the entire flooring surface throughout the kitchen and pantry areas was discolored with soiling and also had accumulations of debris including onion peels, tree leaves, binder clips, dried pasta, and single serve condiment packets. V6 (Dietary Manager) was present and reported the dietary staff are responsible for routine floor maintenance in the dietary areas, but they have been waiting 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 interview and record review the facility failed to ensure that controlled substances were accounted and reconciled for seven (R2, R3, R4, R10, R15, R16, and R23) of seven residents reviewed for controlled substance accounting and reconciliation from a total sample list of 26 residents. Findings include: The facility provided Controlled Substance Policy revised date 11/16/2018 documents that the Schedule II drugs and those in other schedules which have been restricted and stored in the Controlled Substance cabinet will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. On 12/11/23 at 10:00AM, the long hall medication cart was reviewed with V7 Licensed Practical Nurse. 1. The controlled substance box contained R2's Oxycodone (narcotic) 100 milligrams/5 milliliters with a remaining 20.75milliliters (ml) of medication. Additionally, R2's Lorazepam (controlled sedative) 1mg was in the controlled substance box with 10 remaining tablets. 2. The controlled substance box contained R3's Lorazepam 0.5mg, with a remaining 24 tablets. 3. The…

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

Based on observation, interview and record review the facility failed to store and secure controlled medications behind a separately locked compartment for four (R10, R22, R36 and R193) of four residents reviewed for medication storage from a total sample list of 26 residents. Findings include: The facility provided Procurement and Storage of Medications Policy date reviewed November 2018, documents that Schedule II drugs are to be stored under a double-lock subject to a different key and that medication bottles are to be kept clean and orderly. On 12/11/23 at 9:31AM R10's Lorazepam 2 milligrams (mg) per milliliter (ml) (a schedule 4 controlled, antianxiety medication) bottle and paper packaging was saturated with Lorazepam. Additionally, the refrigerator containing Lorazepam 2mg per ml for R10, R22, R36 and R193 was unlocked. On 12/11/23 at 9:35AM, V7 Licensed Practical Nurse stated that the medication room refrigerator was supposed to be locked and that R10's Lorazepam should be disposed of because the bottle and box were saturated with Lorazepam, subjecting anyone who picked up…

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 notify the Physician of missed medication for one of one resident (R38) reviewed for Physician notification in the sample list of 26. Findings include: The facility's Medication Administration policy with a revised date of 11/18/17 documents, If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason. R38's Order Summary Report dated 12/12/23 documents a diagnosis of Paroxysmal Atrial Fibrillation (A-fib) and an order for Apixaban (anticoagulant) Oral Tablet 2.5 mg (milligrams), give one tablet by mouth two times a day for A-fib with a start date of 9/2/23. R38's Medication Administration Record dated 9/1/23 through 9/30/23 documents the Apixaban 8:00 AM dose was not administered on 9/22/23 and 9/23/23 and the 5:00 PM dose was not administered on 9/23/23 for a total of three doses missed. R38's Nurse Progress Notes dated 9/22/23…

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 complete a restraint/enabler assessment for two residents (R12, R21) and failed to release a restraint during lunch for one resident (R12) of two residents reviewed for restraints in a sample list of 26. Findings include: The facility's policy Physical Restraint/Enabler Policy revised 7/24/18 documents Policy: To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. Definition of Physical Restraint: Physical restraints is any manual method, or physical or mechanical device, equipment, or material attached or adjacent to the resident's body, which the individual cannot remove easily, and which restrict freedom of movement or normal access to his or her body. This definition also states, Also Physical restraint may include a device which prevents the resident from rising, such as placement of a chair or bed so close to a wall 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R27 Order Summary Report dated 12/12/23 documents diagnoses including Unspecified Dementia with Agitation and Depression. This Order Summary documents an order for Citalopram HBR (Hydrobromide) (antidepressant) 20 mg (milligrams) one tablet one time a day related to Depression. R27's Care Plan dated 3/24/23 documents R27 has a history of signs and symptoms of depression and is currently being treated. This Care Plan documents interventions of administering medications as ordered. R27's medical record documents one Psychotropic medication assessment dated [DATE]. R27's medical record does not document any other Psychotropic medication assessments for 2023. On 12/11/23 at 12:22 PM, V3 Minimum Data Set Nurse confirmed V3 is responsible to complete the Psychotropic medication assessments. On 12/11/23 at 2:43 PM, V3 confirmed that R27's quarterly Psychotropic medication assessments were not completed like they should have been. The facility's Psychotropic Medication Policy with a revised date of 11/28/17…

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 administer an anticoagulant medication as ordered for one resident. This failure resulted in a significant medication error for one of one resident (R38) reviewed for medication errors in the sample list of 26. Findings include: The facility's Medication Administration policy with a revised date of 11/18/17 documents, If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. R38's Order Summary Report dated 12/12/23 documents a diagnosis of Paroxysmal Atrial Fibrillation (A-fib) and an order for Apixaban (anticoagulant) Oral Tablet 2.5 mg (milligrams), give one tablet by mouth two times a day for A-fib with a start date of 9/2/23. R38's Medication Administration Record dated 9/1/23 through 9/30/23 documents the Apixaban 8:00 AM dose was not administered on 9/22/23 and 9/23/23 and the 5:00 PM dose was not administered on 9/23/23 for a total of three doses not administered. R38's Nurse's Progress Notes dated 9/22/23 at 7:41 AM documents the…

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

Based on observation, interview, and record review, the facility failed to prevent the potential for chemical cross-contamination in the kitchen dishwashing sinks. This failure has the potential to affect all 37 residents residing in the facility. Findings include: On 10/11/2022 at 10:40AM, the kitchen three-basin sink had a floor cleaner chemical dispenser mounted directly above the center basin of the sink with the outlet tubing coiled into and resting on the bottom of the third basin of the sink. A container of chemical floor cleaner supplied the dispenser and was not labeled for use with food contact surfaces. A chemical dispenser supplying food-grade dish detergent and sanitizer was plumbed in series downstream from the floor cleaner dispenser. On 10/11/2022 at 11:58AM, V6 (Dietary Aide) reported the floor cleaner dispenser is used daily to dispense chemicals into a mop bucket for floor cleaning. On 10/13/2022 at 11:50AM, V6 reported the sink basin the floor cleaner dispenser outlet hose was resting into was used for sanitizing dishes. On 10/13/2022 at 12:10AM, V7 (kitchen…

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 complete the recapitulation of stay, discharge summary and failed to implement a discharge plan of care for one (R37) resident out of one resident reviewed for discharge in a sample list of 22 residents. Findings include: R37's Undated Face Sheet documents an admission date of 6/19/22 and discharge date of 8/1/22. R37's Comprehensive Care Plan does not include a focus area, goal nor interventions for discharge. R37's Medical Record does not include a recapitulation of stay summary nor any copies of information sent with R37 at time of discharge. R37's Interdisciplinary Team meeting and Social Service progress notes do not include discharge summary information. On 10/13/22 at 12:11 PM V3 Social Service Director (SSD) stated I did not know a recapitulation of stay needed to be completed. I have not done one of those for any of the discharges since I have worked here. There is no summary of any kind. (R37) was admitted to facility for a short-term rehabilitation stay and planned to return to home after therapy released (R37).…

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 facility staff failed to prevent cross contamination during urinary catheter care for 1 (R6) of 1 resident reviewed for urinary catheter care in a sample of 22 residents. Findings include: V16, Certified Nurses Assistance (CNA) was observed on 10/13/22 at 1:11 PM doing urinary catheter care for R6. During the procedure, V16 washed her hands, donned on gloves to continue with her procedure of urinary catheter care. V16 then reached over and pulled V16's sweatshirt left sleeve up to the elbow and then bent over to touch the bed control and to raise the bed up to complete care. V16 did not remove the contaminated gloves. V16 continued on performing urinary catheter care with contaminated gloves on. V16 set the plastic bag with dirty wash clothes on the floor and realized what she did and picked the plastic bag up from the floor and put it on the bottom of the bed V16 had the same gloves on while performing the urinary catheter procedure. After completing care for R6's perineum area , V16 removed her gloves used hand sanitizer and donned…

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.