Goldwater Pontiac Nursing Home

2. R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has severe cognitive impairment. On 5/13/24 at 12:35 PM, R43 was sitting in the lounge area eating lunch, by R43's self, away from all other residents who were in the dining area. At this time, V3 ADON (Assistant Director of Nursing) / Licensed Practical Nurse stated V3 is unsure why R43 is in the lounge area by R43's self other than the fact that R43 likes to tool around and take food off of other resident trays. R43's Care Plan dated 4/23/24 does not document that R43 takes food from other residents and is to sit by R43's self. Based on observation, interview and record review the facility failed to ensure that residents are treated with respect and dignity. This failure affects three (R76, R43, & R66) of twenty four residents reviewed for dignity on the sample list of 30. Findings include: The facility's Dignity policy dated 11/28/12 documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her…

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, record reviews, resident and staff interviews, the facility failed to complete a self-administration of medication assessment for one of one resident (R29), reviewed for self-administration of medication. Findings Include: 05/15/24 09:15 AM R29 was observed with a medication cup on the bedside table with several unidentified medications still inside. R29 was observed with eyes closed resting in a recliner at this time. 05/15/24 09:20 AM R29 room door under constant observation from 09:15 AM until V12 (Registered Nurse) returned to nurses station at 09:20 AM. V12 then accompanied this surveyor to R29's room. V12 looked at the medication cup located on bedside table and picked it up from the bedside table concealing it in her left hand. V12 then aroused R29 by shaking R29's right hand/speaking loudly over the television and asked R29 why R29 did not take his medication. V12 was asked if V12 left the medication cup containing the medications at the bedside, V12 stated V12 left a calcium tablet at the bedside but did not leave this medication cup with medications…

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 staff failed to report allegations of abuse to the Abuse Coordinator for one of three residents (R44) reviewed for abuse on the sample list of 30. Findings Include: R44's MDS (Minimum Data Set) dated 3/14/24 documents R44 has severe cognitive impairments. R44's Nursing Progress Notes document the following: 5/11/24 at 3:34 am by V27 RN (Registered Nurse) - R44 expresses frustration toward staff members, refusing care, and accusing CNAs (Certified Nursing Assistant's) of punching R44 in the gut. Upon inspection, R44 had no bruising or redness to indicate a punch to the gut. 4/27/24 by V28 LPN (Licensed Practical Nurse) - R44 was sitting out in the living room on the wing. There was another resident (unidentified) talking to a stuffed animal. R44 started yelling at that resident, Shut up .you need to comb your hair .When staff told resident that we don't talk like that, R44 said F* you b. When staff educated R44 that if R44 was going to talk like that, R44 could go to R44's room because that isn't nice to talk to people 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 Based on interview and record review, the facility failed to accurately code the Minimum Data Set for three of 24 residents (R29, R43, R53) reviewed for Assessments on the sample list of 30. Findings Include: 1) R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has limited ROM (Range of Motion) to both bilateral upper and lower extremities. R43's Care Plan dated 4/23/24 does not document any limited ROM. On 5/13/24 at 1:57 PM, V3 ADON (Assistant Director of Nursing) / LPN (Licensed Practical Nurse) stated R43 does not have any limited ROM. On 5/14/24 at 3:05 PM, V5 LPN stated R43 has full ROM to all extremities but does have some weakness in the legs. On 5/15/24 at 10:45 AM, V29 MDS Coordinator stated R43's MDS was completed prior to V29 starting at the facility so V29 is not sure why it is coded the way it is but verified that it is coded incorrectly as R43 does not have any limited ROM. 2) R53's May 2024 Physician Orders documents an order dated 3/25/24 to admit into hospice care for comfort measures…

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 assist with shaving and nail care for two (R12, R69) of twenty four residents reviewed for activities of daily living on the sample list of 30. Findings include: 1. R12's care plan dated 12/18/23 documents that R12 has a self care performance deficit. This documents that R12 needs supervision with touch assistance for personal hygiene. This care plan also documents an intervention for staff to check nail length and to clean nails as needed. On 5/14/24 at 10:30 AM, R12 was sitting in the hallway in a wheel chair. R12's face was partially shaved. R12's neck and cheeks had an over growth and sides of face. R12 stated that he shaved himself and that he did the best he could. R12's fingernails were jagged and had an accumulation of a black substance underneath them. On 5/15/24 at 11:36 AM, R12 was sitting in the hallway. The sides of his face and neck continued to have an overgrowth of facial hair. R12 stated he did the best he could to shave his face. R12 stated he likes to be clean shaven but needs help and can't…

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 a pressure ulcer wound treatments was completed as ordered, implement pressure relieving interventions and prevent potential cross contamination of the wound for two of five residents (R13, R51) reviewed for pressure ulcers on the sample list of 30. Findings Include: The facility's Pressure Ulcer Prevention Policy dated 1/15/18 documents specialty mattresses such as a low air loss, alternating pressure, etc mattress may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds, and use a pressure reducing pad in chairs of all types to protect bony prominence's for residents. 1) On 5/13/24 at 11:29 AM, V3 LPN (Licensed Practical Nurse)/ADON (Assistant Director of Nursing) stated that R51 has a chronic stage four Pressure Ulcer to the Sacrum. On 5/13/24 at 11:36 AM, R51 was sitting up in a wheelchair with a gel pressure…

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 as needed psychotropic medications were limited to 14 days or less for one of five residents (R53) reviewed for psychotropic medications on the sample list of 30. Findings Include: R53's May 2024 Physician Orders document an order dated 4/5/24 for Lorazepam {benzodiazepine} topical gel 1 mg (milligram) per ml (milliliter) - apply 1 ml to the inner wrist or other hairless area every 4-6 hours PRN (as needed) for anxiety or agitation. The facility's Psychotropic Medication-Gradual Dosage Reduction Policy dated 2/1/18 documents PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. On 5/15/24 at 10:25 am, V2 DON (Director of Nursing) stated PRN psychotropic medications, including Lorazepam, should be limited to 14 days or less.

Based on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two of six residents (R36, R71) reviewed for medication administration on the sample list of 30 . The facility had two errors out of 34 opportunities for a medication error rate of 5.88%. Findings Include: 1. On 5/14/24 at 3:23 pm, V30 RN (Registered Nurse) entered R36's room to check R36's blood glucose level, which was 156. At this time, V30 stated V30 was only checking R36's blood glucose level and would be giving R36 the ordered insulin, which will be 5 units per the sliding scale orders and other ordered medications at 4:00 pm. R36's May 2024 Physician Order Sheet documents orders to check R36's blood glucose levels TID (three times a day) and is set up for 6:00 am, 12:00 pm and 4:00 pm. These orders also document to administer Lispro Insulin Subcutaneous Solution Pen Injector 100 U (Units) per ml (milliliter) per sliding scale: if 0 - 130 = 0 u; 131 - 200 = 5 u; 201 - 250 = 10…

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 residents are free of significant medication errors, by administering a residents intravenous antibiotic medications without consulting the physician due to critical lab values. This failure affects one (R71) resident out of a sample of 30. Findings include: The facility's Infusion Therapy Procedures policy dated 12/2014 documents: Anti-Infective Therapy lists policy to provide for safe and effective administration of anti-infective therapy. Procedures include the patient will be assessed by the nurse and physician prior to medication administration to ensure that the patient is clinically stable and has no previous history with adverse medication including lab work monitoring. R71's physician order summary documents order for Ceftriaxone 2 grams intravenously every 24 hours at 2:00 PM and Vancomycin 1500 milligrams intravenously every 24 hours for a foot infection. This physician order summary documents a lab orders dated 5/8/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure employees with symptoms of COVID-19 were tested for COVID-19 and excluded from resident contact while symptomatic. This failure had the potential to affect eight (R6, R7, R8, R9, R10, R11, R12, and R13) of thirteen residents reviewed for COVID-19 on the sample list of 13. Findings include: On 9/25/23 at 8:45 AM, a sign posted on the facility's front door stated that the facility was experiencing a COVID-19 outbreak. On 9/25/23 at 10:09 AM, V3 Infection Preventionist stated the facility's COVID-19 outbreak began on 9/16/23. V3 stated V6 Certified Nurse's Assistant (CNA) and V10 CNA both tested positive on 9/17/23. On 9/25/23 at 10:57 AM, V6 CNA stated she tested positive for COVID-19 on 9/16/23. V6 stated she was working on the floor and started feeling dizzy and getting a migraine. V6 stated it was about 10 AM when she started feeling this way. V6 stated she continued working until 6:00 PM which was the end of her shift. V6 stated…

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 sanitary food processing equipment, free of grease-like substance, metal fragments, rust and exposed metal. These failures have the potential to affect all 78 residents residing in the facility. Findings include: 1. ) On 7/27/23 at 10:00 am V8, Dietary Manager (DM), V8, DM acknowledged the commercial table-top mounted can opener was rusty, corroded with a brown grease-like buildup in the gears and had metal fragments adhering to the grease- like substance. The same can opener had chipped silver paint off of the tip of the can opener blade, which exposed bare metal. V8, DM stated The can opener is not sanitary and will need to be replaced. 2.) On 7/27/23 at 10:15 am, V8, DM also acknowledged the facility commercial table-top, eight quart mixer had exposed metal and a build-up of brown grease-like substance, and yellow food-like particle on the underside plate overhanging the mixer bowl. The same underside plate had…

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 operationalize their Infection Prevention and Control Program by failing to track infections, conduct infection surveillance, and review their policy annually. This failure has the potential to affect all 78 residents residing at the facility. Findings Include: The facility policy Infection Prevention and Control Program dated 11/28/17 and last reviewed on 1/7/19 documents the facility is to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. This facility has established an Infection Control Program which addressed all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers. The designated Infection Control employee and Quality Assurance Committee is responsible for monitoring the effectiveness of the program and continually improving outcomes. All…

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 an Infection Preventionist. This failure has the potential to affect all 78 residents residing at the facility. Findings include: On 7/26/23 at 9:38 AM, V1 Administrator in Training stated V3 is the facility IP (Infection Preventionist) however V3 has been off work for a couple of months and is on FMLA (Family Medical Leave Act) but is working some remotely on reporting of infections. On 7/26/23 at 2:41 PM, V1 stated V1 is not able to find V3's IP certificate of training but since V3 is off of work, V2 DON (Director of Nursing) is covering as IP and provided V2's certificate of training, dated 5/21/22. On 7/26/23 at 2:44 PM, V2 confirmed V2 is working as the facility IP and has been completing the Antibiotic Stewardship information but nothing else. V2 stated V2 generally works 8-10 hours a day and only spends an hour or two a day on Infection Control. The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an air mattress is safe operable condition, ensure bed brakes were locked, and follow the facility Fall Prevention Program guidelines, which resulted in R57 falling from bed. The facility also failed to ensure a safe environment according to the plan of care, free from trip hazards for one resident (R17) at risk for falls. These four failures affect two of eight residents (R57 and R17) reviewed for falls/accident hazards on the sample list 28. Findings include: 1.) R57's Minimum Data Set (MDS) dated [DATE] documents the following: R57's Brief Interview of Mental (BIMS) status score of 13, out of a possible 15, which indicates R57 has no cognitive impairment. The same MDS documents R57 requires extensive, physical staff assistance of one person for bed mobility. R57's Care Plan dated as initiated 11/08/2022, and updated 07/19/23, documents the following: (R57) is at risk for falls r/t (related to) Weakness, impaired balance r/t LAKA…

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 obtain a physician's order for oxygen administration and failed to store oxygen tubing in a sanitary manner for one of two residents (R63) reviewed for oxygen in the sample list of 28. Findings Include: The Oxygen and Respiratory Equipment policy dated 1/7/19 documents oxygen nasal cannula tubing should be stored in a clear plastic bag when not in use. R63's Medical Diagnoses List dated July 2023 documents R63 is diagnosed with Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, and Congestive Heart Failure. R63's Physician Order Sheet (POS) dated July 2023 documents R63 is prescribed oxygen at two liters via nasal cannula for mild Dyspnea or oxygen saturation less than 88 percent. This order was not added until 7/28/23. On 7/25/23 at 2:04 PM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor. On 7/27/23 at 11:15 AM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor. On 7/27/23 at 11:27…

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 obtain a physician order for dialysis treatment and failed repeatedly to monitor the dialysis catheter site and dressings for two of two residents (R29, and R58) reviewed for Dialysis on the sample list of 28. Findings Include: The Dialysis Monitoring and Observation policy dated 2/13/18 documents if the resident has a catheter for dialysis the nurse should assess the catheter site for any signs of drainage and assess the condition of the catheter dressing every shift. 1. R29's Medical Diagnoses list dated July 2023 documents R29 is diagnosed with End Stage Renal Disease. R29's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing. On 7/25/23 at 2:16 PM, R29 stated she goes out of the facility for Hemodialysis, three times per week, outside of the facility, and the dialysis staff change her catheter site dressing and flush her dialysis catheter. R29 stated the facility nursing staff do not ever ask to observe her dialysis…

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 the necessary behavioral health care services for one of one residents (R48) reviewed for behavioral health on the sample list of 28. Findings include: On 7/26/23 at 10:05 AM, V12 (R48's family member) stated R48 gets physical with the staff, actually hitting a staff member last week, and has depression due to loosing R48's spouse last year. V12 also stated that back in the day, V12 believes R48 had a diagnosis of Bipolar but it was not really discussed. V12 explained that V12 was called in today by the staff due to R48 refusing care. R48's ongoing Diagnosis Listing documents diagnoses of : Unspecified Dementia without behavioral disturbances, psychotic disturbance, or mood disturbance, and anxiety. R48's MDS (Minimum Data Set) dated 7/5/23 documents R48 exhibits physical behaviors 1-3 times a week, verbal behaviors 4-6 times a week, rejects care and wanders 1-3 times a week and receives antipsychotic and antidepressant medications daily and antianxiety medications 6 out of the last 7 days. R48's July 2023…

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 assess for psychotropic medications to ensure appropriate indications for the use of psychotropic medications, and obtain consent repeatedly for 33 days, for psychotropic medications for one of two residents (R48) reviewed for psychotropic medications on the sample list of 28. Findings Include: R48's ongoing Diagnosis Listing documents the following diagnoses: Unspecified Dementia without behavioral, psychotic, mood disturbances or anxiety, and anxiety. R48's July 2023 Physician Order Sheet documents the following medication orders: Lorazepam {Antianxiety} 0.5 MG (milligrams) - Give 1 tablet by mouth, BID (two times a day) for anxiety. Seroquel {Antipsychotic} 50 MG - Give 50 mg, by mouth BID for Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbance, and Anxiety. Sertraline {Antidepressant} 50 MG - Give 50 mg, by mouth BID for depression R48's Discontinued Medication List dated July 2023 documents the following: Seroquel 50 MG - give 50 mg by mouth in 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 administer immunizations according to resident wishes for two of five residents (R7 and R63) reviewed for immunizations on the sample list of 28. Findings include: The facility Influenza and Pneumococcal Immunizations Policy dated 4/21/22 documents the facility will minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and Pneumococcal pneumonia. Each resident is offered a Pneumococcal immunization per CDC (Centers of Disease Control and Prevention) recommendations. The resident medical record includes documentation that indicates, at a minimum that the resident either received or did not receive the Pneumococcal immunization due to medical contraindications or refusal. R63's medical record documents R63 was born in 1930 and admitted to the facility on [DATE]. R63's Immunization consent dated 5/25/23 documents that R63 would like to receive the Pneumococcal Immunization. R63's ongoing Immunization History…

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, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to dispose of expired refrigerated food, failed to date and label open refrigerated food, failing to maintain a can opener and mixer in a sanitary operable condition. These failures have the potential to affect all 65 residents residing in the facility. Findings include: 1. On 08/09/22 at 9:32 am, during the initial tour of the facility kitchen where residents meals are prepared, V4, Dietary Manager (DM), acknowledged the facility refrigerator had the following: A five pound, half full container of pasta salad with no open date; a five pound, half full container of cottage cheese with crusted edges at the top of the cottage cheese and no open date; a five pound, half full container of cucumbers and onions with no open date and a 24 ounce three-quarter full container of horseradish sauce that expired on 4/26/22. On 08 /09/22 at 9:40 am V4, Dietary Manager stated Those need thrown away. I (V4, DM) am not sure why they (food items above) weren't…

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 document appropriate rationale for extended use of as needed (PRN) psychotropic medication, failed to evaluate the need for continued use of PRN psychotropic medication, and failed to obtain and document consent for psychotropic medication. These failures affect four (R25, R51, R55, R57) of six residents residents reviewed for unnecessary medications on the sample list of 36. Findings include: 1. R55's Face Sheet (undated) documents the following diagnoses: Dementia without Behavioral Disturbance, Psychosis, and Anxiety Disorder. R55's Order Summary Report dated 8/10/22 documents the following anti-psychotic medication order: Seroquel, give 25mg (milligrams) one tablet by mouth as needed (PRN) for behaviors two times a day PRN. The start date for the medication is 5/14/22 and no end date is documented. There is no documentation in R55's electronic medical record of the physician's rationale for exceeding 14 days for the PRN Seroquel and no 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 record review, observation and interview the facility failed to lock bed wheels and provide adequate staff assistance to prevent a fall for R57. The facility also failed to maintain a safe environment, free of tripping hazards in R44 bedroom and bathroom. R44 and R57 are two of six residents reviewed for falls on the sample list of 36. Findings include: 1. R57's Physician Order Summary Report Sheet (POS) dated 08/10/22 documents the following diagnoses: History of Falls, Morbid Obesity Severe, Type II Diabetes with Diabetic Polyneuropathy, Chronic Kidney Disease, Weakness, Anxiety, Low Back Pain and Bilateral Primary Osteoarthritis of Knees. R57's Minimum Data Set (MDS) dated [DATE] (before the fall documented below, 1/30/22) documents the following: R57's Brief Interview of Mental Status score of 15 out of a possible score of 15, which indicates no cognitive impairment. The same MDS documents R57 required extensive physical assistance of two staff for bed mobility and has functional limitations 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.