Countryside Meadows

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure information reported on the Minimum Date Set (MDS) was accurate for 1 of 2 residents reviewed for MDS accuracy (Resident 61). Findings include: On 10/7/24 at 9:56 a.m., Resident 61's record was reviewed. She was admitted on [DATE]. Her diagnoses included, but were not limited to, paroxysmal atrial fibrillation (irregular heartbeat), long term use of antithrombotic (to prevent blood clots) / antiplatelets (prevent blood cells from sticking together), and dementia (brain disorder). Resident 61's medication order included, but was not limited to, aspirin (antiplatelet) 81 mg (milligram), chewable, once a day for paroxysmal atrial fibrillation. No physician order for an anticoagulant (blood thinner) was observed. Resident 61's care plan, dated 9/10/24, indicated she was at risk for bleeding and bruising related to use of antiplatelet medication. The goal was for her to remain free of adverse effects of antiplatelet medication. Resident 61's MDS,…

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 implement a care plan for the use of Seroquel (an antipsychotic) medication for 1 of 3 residents reviewed for care plans (Resident 43). Findings include: On 10/4/24 at 10:52 a.m., a record review was completed for Resident 43. She had the following diagnoses which included but were not limited to dementia, anxiety, major depressive disorder, and bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). Resident 43's medical record lacked a care plan addressing the use of Seroquel for bi-polar disorder. On 10/4/23 at 1:30 p.m., during an interview with the Director of Nursing (DON), she indicated she had nothing to add for the resident not having a care plan. A policy titled, Comprehensive Care Plans was provided by the DON on 10/3/24 at 12:55 p.m., It indicated, .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan .Physician's orders are considered part of the comprehensive plan of care . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident 102), who had diagnoses of dementia and an intellectual disability was adequately assessed for breakthrough pain and change of condition after a fall resulting in a delay of treatment for 1 of 2 residents reviewed for change of condition, and failed to ensure a resident with pain after a fall was sent to the hospital without delay after x-ray results confirmed a fracture for 1 of 2 residents reviewed for change of condition (Resident 40). Findings include: 1. On 10/1/24 at 11:47 a.m., Resident 102 was observed. He was seated in a specialty wheelchair (WC) and was positioned slouched/slid down in his seat. He had a visitor who sat with him and waited for lunch. On 10/1/24 at 11:51 a.m., an unidentified nursing staff member and the visitor repositioned Resident 102 in his WC. They pulled him to an upright seated position. As they pulled him up, Resident 102 called out nonsensical words and grimaced his face. During an interview on 10/1/24 at 11:55 a.m., Resident 102's visitor…

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, record review, and interview, the facility failed to ensure that medications were not left unsupervised in a resident's room for 1 of 1 random observation (Resident 49) and failed to implement fall prevention interventions for a resident (Resident 37) for 1 of 3 residents reviewed for falls. Findings include: 1. On 10/2/24 at 10:32 a.m., a record review was completed for Resident 49. He had the following diagnoses which included but were not limited to type 2 diabetes mellitus (DM), hypertension (HTN), obstructive sleep apnea (OSA), hyperlipidemia (HLD), and generalized anxiety disorder (GAD). During an observation on 10/1/24 at 11:42 a.m., Resident 49 was in transmission-based precautions (TBP). Upon entering his room, it was noted he had a clear, plastic cup with approximately 8 pills inside the cup. Resident 49 indicated those were his morning medications. Resident 49's record lacked a self-medication administration assessment. During an interview with the Director of Nursing (DON) on 10/4/24 at 1:30 p.m., she indicated Resident 49 should not have had his…

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 initiate a pharmacy recommendation for 1 of 5 residents reviewed for pharmacy requests (Resident 13). Findings include: On 10/3/24 at 11:56 a.m., a record review was completed for Resident 13. She had the following diagnoses which included dementia, insomnia, major depression, and gastroesophageal reflux disease (GERD). A pharmacy recommendation was made on 6/21/24 to reevaluate the continued need for omeprazole (a medication for GERD) discontinue and initiate famotidine (a medication for GERD) 20 mg once daily with the end goal of discontinuation. The physician accepted the recommendation and left instructions to implement the recommendation as written. The facility failed to implement the new order for famotidine 20 mg daily. On 10/4/24 at 2:10 p.m., the Director of Nursing (DON) was interviewed. She indicated she could not find where famotidine was ever initiated but did find where Tums as needed (PRN) was initiated instead. A policy titled; General Dose Preparation and Medication Administration was provided by the DON…

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 ensure a resident, (Resident E) received treatments and services in accordance with his guardian's wishes. This deficient practice had the potential to effect 1 of 3 residents reviewed for quality of care. Findings include: During an interview on 8/1/24 at 12:11 p.m., Resident E's guardian indicated, she had received a call from Nurse Practitioner, (NP) on 6/14/24 who indicated, Resident E had not eaten or drank anything and had been sleeping more than usual. The guardian asked the NP, did she believe this change in his condition was related to the progression of his dementia, or could there be something else going on. The NP told the guardian, she did believe the decline was related to his dementia. The NP asked the family about changing his code status from a Full Code, too a Do-Not Resuscitate (DNR). Because the guardian lived out of state, she told the NP she wanted her brother to go visit Resident E first, before she made a decision about changing…

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 the family/representative for a resident, (Resident F) was notified of a change in condition related to an acute urinary tract infection (UTI) which resulted in urosepsis-associated acute kidney injury/failure, (SA-AKI) and had a systemic inflammatory response (SIRS) for 1 of 3 residents reviewed for quality of care. Findings include: During a confidential interview, it was indicated, Resident F's family member received a phone call on the day he passed away which was 5/31/24. The facility wanted to confirm Resident F's Do-Not-Resuscitate (DNR) orders because he had an infection and experienced a change in condition. The facility asked if the family member wanted Resident F to be sent to the hospital. The family member did want Resident F to be sent out and had been unaware that Resident F was being treated for an infection and that his condition had worsened so severely. Resident F had a history of infections and they could get bad fast. When the family member arrived to the facility, there was an ambulance at 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 record review and interview, the facility failed to update a skin care plan for a resident with skin breakdown for 1 of 3 residents reviewed for care plans (Resident D). Findings include: On 7/31/24 at 12:13 p.m., a record review was conducted for Resident D. He had the following diagnoses which included, but were not limited to, cerebral infarction (stroke), Parkinson's disease, and diabetes mellitus. Resident D had a skin event, dated 7/17/24, indicating he had skin breakdown to his coccyx measuring 1.0 centimeters (cm) by (x) 1.0 cm x 1.0 cm. Resident D's care plan, dated 6/14/24, indicated resident was at risk for skin breakdown related to decreased mobility, incontinence, friction/shearing, and related to diagnoses of CVA (Cerebral Vascular Accident) with left sided hemiplegia (paralysis), adult failure to thrive, aphasia (loss of ability to understand or express speech, caused by brain damage), and HLD (hyperlipidemia). On 8/1/24 3:20 p.m., during an interview with the Director of Nursing Services (DNS), she indicated an event was a care plan that was good for 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.

Based on interview and record review, the facility failed to ensure a resident's legal guardian participated and agreed to the changes in the resident's plan of care and treatment for 1 of 3 residents reviewed for quality of care (Resident E). Findings include: During an interview on 8/1/24 at 12:11 p.m., Resident E's guardian indicated, she had received a call from Nurse Practitioner, (NP) on 6/14/24 who indicated Resident E had not eaten or drank anything and had been sleeping more than usual. The NP told the guardian, she did believe the decline was related to his dementia. The NP asked the family about changing his code status from a Full Code, too a Do-Not Resuscitate (DNR). The guardian lived out of state and told the NP she wanted her brother to go visit Resident E before the guardian made a decision about changing the resident's code status. The guardian indicated her brother went to visit Resident E on June 16th. Resident E had been awake, alert, and took food and drink when assisted by the family. The guardian indicated the family requested staff to sit with Resident E 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.

Based on observations, record review, and interviews, the facility failed to document the results of glucometer (blood sugar) results for 1 of 3 residents reviewed for quality of care (Resident D). Findings include: On 7/31/24 at 12:13 p.m., a record review was conducted for Resident D. He had the following diagnoses which included but were not limited to cerebral infarction (stroke), Parkinson's disease, and diabetes mellitus. He had a physician order, updated on 7/23/24, to obtain blood sugar every 6 hours and to notify the physician if results are below 70 or greater than 400. His Medication Administration Record (MAR) for June and July 2024 had missing documentation of the results for the following dates/times: a.) 7/14/24 at 8:00 a.m. b.) 7/30/24 at 6:00 a.m. c.) 6/20/24 at 8:00 a.m. d.) 6/19/24 at 8:00 a.m. e.) 6/17/24 at 8:00 a.m. During an interview with the Director of Nursing Services (DNS), she indicated they had gotten away from running reports to see what was omitted from the day before. A policy titled;, Blood Glucose Monitoring, dated 2/2015, was provided by 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 ensure nail care was provided to a dependent resident for 1 of 3 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident D). Findings include: On 6/14/24 at 12:01 p.m., Resident D was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 6/17/24 at 11:50 a.m., Resident D was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. During an interview, on 6/18/24 at 9:35 a.m., Resident D's family member indicated when she visited Resident D, she would sometimes trim and often cleaned underneath Resident D's fingernails because there was dark stuff underneath the fingernails that looked disgusting. On 6/18/24 at 11:45 a.m., Resident D was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television.…

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 accurately promote continuity of care and communication within the resident's care plan, to maintain resident safety, and safeguard against adverse events for 1 of 1 resident reviewed for care plans (Resident C). Findings include: During a phone interview on 1/18/24 at 3:20 p.m., the resident's responsible party indicated Resident C was not allowed to eat by mouth unless he was with a speech therapist. He was given a tray of ham and beans and a sandwich on Christmas eve. Resident C ate the meal. He called her and told her he had received a meal tray. She came into the facility and the nurse told her they had pulled food out of his mouth. On 1/18/24 at 3:40 p.m., Resident C was lying in bed with bedside items on the floor on top of a mat within reach. He indicated he was no longer seen by Speech Therapy (ST). He had a sign on the wall that identified he was to have no solid foods or regular liquids unless given by ST. He indicated had 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 to prevent a significant medication error by not following the manufacture administration guidelines for 1 of 2 residents reviewed for medication administration (Resident C). Findings include: On 1/18/24 at 3:20 p.m., phone interview with the resident's responsible party. She indicated the facility was not administering the resident's chemotherapy medication (Rezlidhia), correctly. She indicated she gave the nurse a copy of the special instructions as to how the medication was to be administered and it was on the medication bottle. The medication was an experimental medication and had very specific indications for administration. On 1/18/24 at 4:00 p.m., an interview with Licensed Practical Nurse (LPN) 3 indicated the resident just moved to the hall, and he was not sure what times his medications were to be given. He verified the administration record and indicated the Rezlidia was to be given at 4 p.m. The next bolus feeding was due 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 observations, interview, and record review, the facility failed to implement a nothing by mouth (NPO) order for a resident with dietary restriction to ensure the resident was not given oral intake for 1 of 1 resident reviewed for gastric tube feedings (Resident C). Findings include: During an interview on 1/18/24 at 3:40 p.m., Resident C indicated he did not receive speech therapy services, but he had a sign on the wall that identified he was to have no solid foods or regular liquids unless given by speech therapist. The resident indicated he was given a sandwich a while back on a meal tray. He thought he had graduated and was cleared to eat since he was delivered a tray. He indicated he did not get choked when he ate the solid food, but the nurse removed the food from his mouth, and he had not had any solid foods since that happened. The resident indicated he was administered feedings through his gastric tube four times per day. On 1/19/24 at 11:39 interview with the Executive Director (ED) the ED indicated on 12/24/23 a certified nurse aide (CNA) obtained a tray for 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 and interview, the facility failed to ensure resident's call lights were in reach for 5 of 24 residents reviewed for call lights. (Resident 9, 74, 31, 17, and 54) Findings include: 1. On 8/23/23 at 10:42 a.m., Resident 9 was in bed, her call light was observed on the floor, at the end of the bed. On 8/24/23 at 9:35 a.m., Resident 9 was in her bed, her call light was observed on the floor, at the end of the bed. On 8/28/23 at 12:30 p.m., Resident 9 was in her recliner. Her call light was behind her bed. 2. On 8/23/23 at 10:55 a.m., Resident 74 was in her bed, her call light was clipped on the top, posterior corner of her bed. She was unable to see or reach it. 3. On 8/23/23 at 11:17 a.m., Resident 31 was in her wheelchair. Her call light was on the floor behind her. She indicated she could not reach it. 4. On 8/23/23 at 11:42 a.m., Resident 17's call light was on the floor out of her reach. 5. On 8/23/23 at 11:56 a.m., Resident 54's call light was clipped on the top, posterior corner of her bed. The resident could not see or reach it. On 8/24/23/23 at 10:20 a.m.,…

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 physician's orders for a Foley catheter (a flexible tube inserted through the urethra and into the bladder to drain urine) securement device was in place for a resident (Resident 126), failed to honor resident preferences to have a leg bag in place for two residents (Resident 126 and 21), and failed to ensure residents catheter tubing and drainage bags were positioned correctly for 5 residents (Residents 126, 21, 76, 41 and 94) for 5 of 7 residents reviewed for bowel & bladder. Findings include: 1. On 8/28/23 at 9:07 a.m., Resident 126 was observed in the Secured Memory Care (MC) dining room. He was seated in his wheelchair (WC) with a Foley catheter hung beneath the chair. His catheter tubing was observed with cloudy urine in the tube, and the tube was touching the floor. On 8/29/23 at 9:41 a.m., Resident 126 was observed in the MC dining room. He was wearing shorts, so his catheter tubing was visible. The tubing was pulled back against the edge of his WC seat, so the urine drainage port appeared to be…

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 three-compartment sink had sufficient chemicals to disinfection items washed, chef assistant (CA) had his moustache covered, and did not touch his eyeglasses while serving resident lunches and washed his hands correctly before returning to serve on the lunch line again. The facility failed to ensure a Certified Nursing Aide (CNA) while assisting a resident with did not contaminate her hands for 1 of 2 observed. (Resident 15) Findings include: 1a. During the first kitchen tour, on 8/23/23 at 9:55 a.m., the Certified Dietary Manager (CDM) indicated the facility did not have internal thermometers in their 2 milk coolers. On 8/23/23 at 11:05 a.m., Head Chef 24 checked the chemicals in the three-compartment sink. He indicated the chemicals were so low the litmus strip did not read any chemicals. They had been using the three-compartment sink for cleaning stainless steel pans. He indicated the reason the sink had no chemicals was because the dietary aides continued to add water until the chemicals were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident, (Resident 138) had the right for his physician to be notified of an alteration of his medication administration, when a blood pressure medication was withheld due to parameters that were not ordered for his medication, and the facility failed to ensure a resident, (Resident 115) had the right for his physician to be notified of elevated blood sugar levels, as ordered, for 2 of 3 residents reviewed for change of condition. Findings include: 1. On 8/28/23 at 3:27 p.m., Resident 138's medical record was reviewed. Resident 138 admitted to the facility on [DATE] after an acute hospital visit, due to an increase of severe orthostatic hypotension episodes. (OH), (a sudden drop in blood pressure which occurs when a person stands up which can cause lightheadedness, dizziness or even cause a person to faint). Upon his admission, he had diagnoses which included, but were not limited to, OH, syncope and collapse (the medical term for fainting or…

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 person-centered comprehensive care plan was initiated and implemented to prevent the worsening of contractures for 1 of 2 residents reviewed for mobility/range of motion/positioning (Resident 42). Findings include: On 8/29/23 at 11:28 a.m., Resident 42 was observed, lying in bed with a cover over her. Her arms and hands were outside of the cover. Her nails on both hands were long and thickened with brown debris under the nails. The nails were pressed into the residents contracted left hand. A rolled-up wash cloth was in the palm of the residents contracted right hand. On 8/29/23 at 11:28 a.m., Resident 42 was observed. She laid in bed with her eyes closed and her arms at her sides. Her left hand was observed to be contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The nails of her left had begun to press into the palm of her hand. 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.

Based on observation, interview and record review, the facility failed to ensure a nebulizer mask was covered and nasal cannula (NC) tubing was observed disconnected from the oxygen concentrator for 2 for 8 residents observed. (Resident 29 and 69) Findings include: 1. On 8/29/23 at 3:54 p.m., Resident 29's diagnoses included, but were not limited to, dementia and chronic obstructive pulmonary disease (constriction of the airway causing difficulty breathing). Resident 29's care plan indicated she would have adequate respiratory functions. Her physician's order, dated 6/12/23, indicated ipratropium-albuterol solution (dilates airways) was used for nebulizer treatments, three times a day. Another physician order, dated 5/1/23, indicated albuterol sulfate (dilates airways) solution was used for nebulizer treatments as needed. On 8/24/23 at 10:07 a.m., her nebulizer mask was observed uncovered and unbagged. On 8/26/23 at 4:22 p.m., her nebulizer mask was observed uncovered and unbagged. 2. On 8/30/23 at 9:33 a.m., Resident 69's diagnoses included, but were not limited to, chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow up with the pharmacy to ensure a resident (Resident 138) received medications as ordered by his physician for 1 of 6 residents reviewed for unnecessary medications. Findings include: On 8/28/23 at 3:27 p.m., Resident 138's medical record was reviewed. Resident 138 admitted to the facility, on 5/19/23, after an acute hospital visit, due to an increase of severe orthostatic hypotension episodes (OH), a sudden drop in blood pressure that occurs when a person stands up which can cause lightheadedness, dizziness or even cause a person to faint. Upon his admission, he had diagnoses which included, but were not limited to, OH, syncope and collapse (the medical term for fainting or passing out), and end stage renal (kidney) disease. He had a physician's order for midodrine 2.5 mg (milligrams) to be given every 8 hours. (Midodrine is a medication used to treat low blood pressure, [hypotension] which works by stimulating nerve endings in blood vessels,…

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 insulin labels were consistent with the physician's orders (Residents 82 and 241) and to ensure an insulin opened date was legible (Resident 53) for 3 of 3 residents reviewed for insulin storage. Findings include: 1a. On 8/29/23 at 12:04 p.m., Resident 82's order for insulin was reviewed with Registered Nurse (RN) 32. RN 32 indicated her Medication Administration Record (MAR) indicated she had a standing order for 6 units of Lispro insulin per insulin pen. With her current blood sugar, she would receive a total of 10 units per sliding scale. RN 32 indicated she would give one additional unit for every 50 points over the blood sugar of 150. RN 32 removed an insulin vial from the medication cart. The physician's instructions on the pharmacy bottle indicated to give 4 units of insulin scheduled. On 8/20/23 at 12:12 p.m., RN 32 indicated see knew the label on the insulin prescription bottle was different than the instructions on the MAR. She indicated Resident 82's MAR order required her to give 4 units…

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 glucometers (device for measuring blood sugar) were cleaned according to the package instructions on the disinfecting wipe for 2 of 2 residents observed for glucometer cleaning. (Resident 82 and 241) Findings include: On 8/29/23 at 11:56 a.m., Registered Nurse (RN) 32 indicated each medication cart had its own glucometer. She used a bleach germicidal wipe to clean the glucometer in preparation to check Resident 82's blood sugar (BS). She indicated the glucometer should be wiped for 1 minute and let sit for 3 minutes to dry. On 8/29/23 at 11:57 a.m., RN 32 indicate the whole glucometer was not wet. She was just waiting 3 minutes for the other tiny, bubbled areas to dry. On 8/29/23 at 1:45 p.m., the packaging was reviewed for the Clorox Healthcare Bleach Germicidal Wipes: Instructions. It indicated to wipe the surface to be disinfected. Use enough wipes for the treated surface to remain visibly wet for 3 minutes, then let it air dry. On 8/29/23 at 11:59 a.m., RN 32 dropped the glucometer on the floor 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.