Chesterton Manor

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for 3 of 3 wound care treatments observed. (Residents 3, 6, and 226) Findings include: 1. On 3/5/25 at 11:30 a.m., the Assistant Director of Nursing (ADON) was observed performing the treatment to Resident 3's sacral pressure area. The ADON entered the resident's room and proceeded to wash her hands with soap and water. She donned a pair of gloves, repositioned the resident in bed, and removed the dressing to the resident's sacrum. She was not wearing a gown when she repositioned the resident and removed the dressing. The ADON proceeded to remove her gloves, used hand sanitizer, donned new gloves and a gown and completed the resident's treatment to her sacrum. The record for Resident 3 was reviewed on 3/5/25 at 11:21 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, chronic kidney disease stage 4,…

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 the call light system in a resident's room and the call light system at the nurses' station was properly functioning during random call light observations. (Residents 38 & 18) Findings include: 1. During an observation on 3/2/25 at 12:00 p.m., Resident 38's call light button was pushed. The light inside the room on the wall was observed to be functioning. At 12:27, there was no staff response to the resident's light. The call light in the hallway outside the resident's room was observed and was not activated. At 12:29 p.m., the nurse indicated that the call light was not working, and she would notify the Maintenance Director. 2. On 3/3/25 at 9:24 a.m., Resident 18 indicated her call light lit up outside of her room, but did not work at the nurse's station. She said the staff would only know if her light was going off if they looked down the hall for it. During the environmental tour with the Maintenance Director and the Administrator on 3/6/25 at 2:49 p.m., the Maintenance Director tested the call light in Resident…

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

Based on observation, record review, and interview, the facility failed to ensure dependent residents received timely assistance with ADL's (activities of daily living) related to incontinence care for 2 of 4 residents reviewed for ADL's. (Residents C and F) Findings include: 1. On 11/12/24 at 5:38 a.m., Resident C was observed lying in bed asleep. The room had a strong urine odor that could be smelled from the doorway. CNA 1 checked on the resident and asked if care could be provided. When CNA 1 pulled the sheet up from the resident's body, there was stool and urine that had leaked onto the bed sheet. The resident's brief was soiled through with urine and stool. During an interview at the time, CNA 1 indicated the resident was not soiled when she came in at 11:00 p.m. CNA 1 had not checked the resident for incontinence since 11:00 p.m. on 11/11/24. The Record for Resident C was reviewed on 11/12/24 at 12:33 p.m. Diagnosis included, but were not limited to, Alzheimer's, depression, anxiety, anemia, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/24,…

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 correct Personal Protective Equipment (PPE) was used by a staff member (CNA 3) when providing care to a resident (Resident E) who was in Enhanced Barrier Precautions (EBP) and failed to ensure hand hygiene was completed by a staff member (CNA 2) after the care had been completed, for one random observation for infection control. Finding includes: During an observation on 11/12/24 from 5:37 a.m. through 5:59 a.m., the following was observed: At 5:37 a.m., Resident E was lying in bed. She indicated she had been incontinent of a bowel movement. A urinary catheter drainage bag was observed positioned on the the side of the bed. A sign posted above the bed indicated Enhanced Barrier Precautions were to be used during care. At 5:40 a.m., CNA 3 entered the room and indicated she would need to have another staff member assist her with the incontinence care. CNA 3 donned gloves, retrieved a plastic measuring container from the bathroom, and started to empty out the urinary catheter drainage bag. CNA 3 was…

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

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 67 of 67 residents who resided in the facility. Finding includes: The staffing schedules for 9/1-9/20/23 and 1/1-1/31/24 were reviewed on 2/7/24 at 8:40 a.m. There were currently 2 RN's who worked in the facility as a floor nurse. The other RN's who were employed at the facility, were the Director of Nursing (DON) and the MDS Coordinator. Nursing time cards were reviewed on 2/7/24 at 9:25 a.m., and the following was noted: There was no RN coverage for 7/22/23. There was no RN coverage for 9/2/23. There was no RN coverage for 9/3/23. There was no RN coverage for 9/16/23. There was no RN coverage for 9/17/23. There was no RN coverage on 1/6/24. During an interview on 2/7/24 at 12:10 p.m., the Administrator indicated that they did not have an RN working on the dates above. 3.1-17(b)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, for 3 of 4 residents reviewed for skin conditions (non-pressure related), and signs and symptoms of constipation were monitored, for 1 of 1 residents reviewed for constipation. (Residents 56, 22, 166, and 217) Findings include: 1. During a random observation on 2/7/24 at 9:25 a.m., a circular fading reddish/purple bruise was observed on Resident 56's left forearm. During an interview at that time, the resident indicated he noticed the bruise after staff had helped him put on his shirt. The record for Resident 56 was reviewed on 2/7/24 at 1:35 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), intestinal obstruction, weakness, and surgical aftercare following surgery on the digestive system. The Quarterly Minimum Data Set (MDS) assessment, dated 12/5/23, indicated the resident was cognitively intact. He required extensive assistance with bed mobility…

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 and interview, the facility failed to keep the resident's environment in good repair, related to marred walls, doors, and door frames, gouged walls, missing baseboards, and non-skid strips peeling off the floor, for 2 of 4 units in the facility. (100 and 200 Hall). Findings include: During the Environmental tour on 2/12/24 at 10:53 a.m., the following was observed: 1. Hall 100 a. room [ROOM NUMBER] - The resident room and bathroom doors were marred as well as the frames. The corner by the closet and bathroom door was gouged and missing the baseboard. There was 1 resident who resided in the room and used the bathroom. b. room [ROOM NUMBER] - The resident room and bathroom doors were marred, as well as the door frames. The walls in the bathroom and in the room were marred. The floor around the toilet was rusty. Two residents resided in the room and used the bathroom. c. room [ROOM NUMBER] - The walls in the room were marred. There was 1 resident who resided in the room. 2. Hall 200 a. room…

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 residents had Physician's Orders for medications, and an assessment to self-administer their own medications, for 3 of 3 residents reviewed for self-administration of medication. (Residents 56, 22, and 54) Findings include: 1. During a random observation on 2/6/24 at 10:24 a.m., two small bottles of Tylenol were observed in a plastic bin containing denture supplies, located on Resident 56's bedside table. During random observations on 2/7/24 at 9:26 a.m., 1:24 p.m., and 3:05 p.m., the bottles of Tylenol remained in the plastic bin. During random observations on 2/8/24 at 9:57 a.m. and 3:04 p.m., the bottles of Tylenol remained in the plastic bin. During a random observation on 2/9/24 at 10:16 a.m., the bottles of Tylenol remained in the plastic bin on the resident's bedside table. The record for Resident 56 was reviewed on 2/7/24 at 1:35 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and intestinal obstruction. The Quarterly Minimum Data Set (MDS) assessment, dated…

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 a resident with a suprapubic foley catheter received foley catheter care, and catheter bags and tubing were kept off the floor, for 2 of 3 residents reviewed for catheters. (Residents B and D) Findings include: 1. During an interview on 2/6/24 a 10:55 a.m., Resident B indicated nursing staff were not cleaning around his suprapubic foley catheter. At that time, the resident lifted up the bed linens, so his catheter site could be observed. The area around the catheter was red with dried blood noted. There was no split gauze sponge around the ostomy. On 2/6/24 at 1:30 p.m., the resident was observed in bed. At that time, the catheter bag and tubing were observed on the floor. At 3:30 p.m., the catheter bag was now hanging on the side of the garbage can and the bottom of the bag was touching the floor. On 2/7/24 at 9:06 a.m., the resident was observed in bed. At that time, he lifted up the bed linens, so the suprapubic catheter stoma could be observed. There was no bandage noted around the ostomy, and 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, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to not flushing the PICC line with the correct amount of saline, and a lack of documentation the saline and heparin flushes were administered as ordered, for 1 of 1 residents observed with a PICC line during medication pass. (Resident 62) Finding includes: On 2/9/24 at 11:55 a.m., RN 1 was observed passing medication to Resident 62. He prepared the intravenous (IV) medication of Ceftriaxone 2 grams (gm) and primed a new IV tubing. The RN cleaned the left upper arm access lumen with an alcohol swab, flushed the PICC line with 4 milliliters (ml) of normal saline, attached the tubing containing the Ceftriaxone, and started the IV infusion. At 1:08 p.m., RN 1 was observed disconnecting the IV tubing after the medication had completed infusing. He flushed the PICC line with 4 ml of normal saline, followed with 5 ml of…

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 oxygen was administered as ordered, and set at the correct flow rate, for 1 of 1 residents reviewed for respiratory care. (Resident 54) Finding includes: On 2/6/24 at 10:40 a.m., Resident 54 was observed in bed and not wearing oxygen. The oxygen concentrator was set at 3 liters. The resident indicated she only wore oxygen at night. On 2/7/24 at 9:08 a.m., the resident was observed in bed not wearing oxygen. The oxygen was set at 4 liters. On 2/8/24 at 9:54 a.m., the resident was observed in bed taking a nap, and was not wearing oxygen. The oxygen concentrator was turned off. On 2/9/24 at 7:37 a.m., the resident was sitting up in bed preparing for breakfast. She was wearing oxygen via nasal cannula and the concentrator was set at 3.5 liters. The record for Resident 54 was reviewed on 2/8/24 at 11:00 a.m. Diagnoses included, but were not limited to, hypertension (high blood pressure), heart failure, cancer, respiratory failure, stroke and chronic obstructive pulmonary disease. The Quarterly Minimum Data…

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 medications were properly stored, related to loose pills inside the medication drawers, for 2 of 4 medication carts observed. (Hall 100 and 200). Finding includes: 1. During a medication storage observation, on 2/9/24 at 1:16 p.m., the 100 Hall medication cart was observed with RN 1. At that time, there were 9 loose pills inside the drawer of the medication cart. The pills ranged in size and color. 2. During a medication storage observation, on 2/9/24 at 1:30 p.m., the 200 hall cart was observed with RN 1. There were 15 loose pills inside the drawer of the medication cart. The pills ranged in size and color. During an interview, on 2/9/24 at 1:20 p.m., RN 1 indicated he had just cleaned the carts a few days ago and loose pills should not be inside the medication cart. A facility policy, titled, Storage of Medication and Biologicals, provided by the Director of Nursing as current, indicated, . Medication storage areas are to be kept clean, well lit, free of clutter, and free of extreme temperatures. 3.1-25(j)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to clarification orders for as needed (PRN) pain medications, and documentation of meal consumption, for 2 of 21 records reviewed. (Residents 13 and 22) Findings include: 1. The record for Resident 13 was reviewed on 2/8/24 at 10:53 a.m. Diagnoses included, but were not limited to, osteoarthritis of the left hip and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 1/2/24, indicated the resident was moderately impaired for daily decision making. The resident received pain medications and she had occasional pain. Her pain scale was a 4. A Physician's Order, dated 2/1/24, indicated the resident was to receive Norco (a narcotic pain medication) 5-325 milligrams (mg), 1 tablet every 8 hours as needed (PRN) for a pain scale of 7-10. The February 2024 Medication Administration Record (MAR), indicated the resident received the PRN Norco on 2/1 at 9:43 a.m., 2/2 at 10:51 p.m., 2/6 at 9:30 a.m., and 2/8/24 at 8:47 a.m. 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, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 3 residents randomly reviewed for self-administration of medication. (Residents 31, 55, and 57) Findings include: 1. On 3/20/23 at 10:25 a.m., Resident 31 was observed in her room in bed. There were two tubes of Preparation H hemorrhoid cream on the resident's bedside stand. On 3/21 at 10:52 a.m. and 3/22/23 at 11:15 a.m., the tubes of Preparation H remained on the bedside stand. The record for Resident 31 was reviewed on 3/23/23 at 11:36 a.m. Diagnoses included, but were not limited to, type 2 diabetes and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 3/10/23, indicated the resident was cognitively intact. The resident had no Care Plan related to self-administering medications. A Physician's Order, dated 3/16/23, indicated the resident was to receive Preparation H rectal ointment 0.25-14-74.9% (Phenylephrine-Mineral Oil-Petrolatum), insert 1 application as needed (prn) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependant residents related to completing scheduled showers and shaving male residents for 3 of 7 residents reviewed for ADL care. (Residents 55, 45, and 15) Findings include: 1. During an interview with Resident 55 on 3/20/23 at 1:32 p.m., she indicated she did not always get a shower twice a week. She could not remember the last time her hair had been washed. At that time, her hair was visibly greasy with dandruff flakes noted. During another interview with the resident on 3/21/23 at 9:02 a.m., she indicated her hair still had not been washed, nor had she had a shower. The record for Resident 55 was reviewed on 3/22/23 at 10:40 a.m. Diagnoses included, but were not limited to, kidney failure, kyphosis, conversion disorder with seizures, high blood pressure, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/23, indicated the resident was…

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

Based on observation, record review, and interview, the facility failed to ensure skin excoriation and bruising was assessed, monitored, and treated for 2 of 7 residents reviewed for skin conditions non-pressure related. (Residents 55 and 32) Findings include: 1. During an interview on 3/20/23 at 1:29 p.m., Resident 55 indicated she had extreme itchiness behind her thighs. She did not feel like she got washed up like she should have been. The record for Resident 55 was reviewed on 3/22/23 at 10:40 a.m. Diagnoses included, but were not limited to, kidney failure, kyphosis, conversion disorder with seizures, high blood pressure, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/23, indicated the resident was cognitively intact. The resident needed extensive assist with a 2 person physical assist with personal hygiene. The resident needed help with bathing with a 2 person physical assist. A Care Plan, revised on 2/1/23, indicated the resident had potential for impairment to her skin. The approaches were to keep her skin clean and dry and to use…

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 residents with impaired hearing received the necessary services related to ear wax removal for 1 of 2 residents reviewed for vision and hearing. (Resident 55) Finding includes: During an interview with Resident 55 on 3/20/23 at 1:32 p.m., she indicated she was having trouble hearing and her ears were clogged. The wax needed to be removed from her ears and she had requested to go to an urgent care. The resident indicated the staff were aware of the situation. The record for Resident 55 was reviewed on 3/22/23 at 10:40 a.m. Diagnoses included, but were not limited to, kidney failure, kyphosis, conversion disorder with seizures, high blood pressure, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/23, indicated the resident was cognitively intact and her hearing was adequate. There was no Care Plan indicating the resident had ear wax or trouble hearing. A Nurse's Note, dated 3/13/23 at 7:32 p.m., indicated…

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 ensure acceptable parameters of nutrition were maintained related to documenting food consumption for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 59) Finding includes: The record for Resident 59 was reviewed on 3/21/23 at 2:19 p.m. Diagnoses included, but were not limited to, morbid obesity, dysphagia (difficulty swallowing), and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 2/18/23, indicated the resident was cognitively intact and required extensive assistance with eating. The resident was coded as having a significant unplanned weight loss. A Care Plan, revised on 3/20/23, indicated the resident had a nutritional problem or potential nutritional problem related to morbid obesity and receiving a therapeutic diet. The resident had a significant weight loss in the past 30 days. Interventions included, but were not limited to, provide and serve diet as ordered. Monitor intake and record every meal. On 9/9/22, the resident…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and functioning for 3 of 3 residents reviewed for oxygen. (Residents 59, 58, and 15) Findings include: 1. On 3/20/23 at 3:23 p.m., Resident 59 was observed in her room in bed. The resident had oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 3 1/2 liters. On 3/21/23 at 9:14 a.m., 10:57 a.m., 1:18 p.m., and 3:15 p.m., the resident's oxygen concentrator was set at 3 1/2 liters. The record for Resident 59 was reviewed on 3/21/23 at 2:19 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 2/18/23, indicated the resident was cognitively intact. The resident was coded as receiving oxygen therapy. A Care Plan, dated 3/16/23, indicated the resident had the diagnoses of COPD and obstructive sleep apnea. The resident had shortness of breath while lying flat. Interventions included, but were not limited…

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 manage medications appropriately related to not monitoring the side effects of opioid medication and administering blood pressure medication outside of the parameters for 2 of 5 residents reviewed for unnecessary medication. (Residents 59 and 23) Findings include: 1. The record for Resident 59 was reviewed on 3/21/23 at 2:19 p.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 2/18/23, indicated the resident was cognitively intact and required extensive assistance with bed mobility, transfers, and toileting. The resident was always incontinent of bowel and bladder. The resident was assessed for pain and had received as needed (PRN) opioid pain medication during the assessment reference period. A Physician's Order, dated 1/25/23, indicated the resident was to receive Norco (an opioid pain medication) 5-325 milligrams (mg), 1 tablet every 6 hours PRN for pain. A Physician's Order, dated 2/27/23, indicated the resident was…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet individual needs related to not following a recipe for pureed food. This had the potential to affect 3 residents who received a pureed diet. (Main Kitchen) Finding includes: On 3/22/23 at 9:02 a.m., [NAME] 1 was observed preparing pureed food. There was no recipe present. She indicated three residents received a puree diet but would prepare 5 servings. She added 5 Salisbury steaks to the puree blender and started blending. She then added water and two slices of bread and continued to puree. She then added more water and thickener to the blender and started blending. She then poured it out into a pan. The Salisbury steak was a smooth consistency. Interview with the [NAME] on how much she had to add to the Salisbury steak indicated she eyeballed it. She further indicated they did not have any broth so she added water. Interview with the the Dietary Manager after the Salisbury steak was pureed indicated the [NAME] should have followed the recipe. They had broth and she…

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 promote antibiotic stewardship related to unnecessary antibiotic use for 1 of 1 residents reviewed for antibiotic use. (Resident 4) Finding includes: On 3/20/23 at 2:35 p.m., Resident 4 was observed lying in bed. The resident indicated she had recently taken an antibiotic for a cough and was feeling better. Record review for Resident 4 was completed on 3/23/23 at 1:22 p.m. Diagnoses included, but were not limited to, asthma, anemia, heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 3/7/23, indicated the resident was moderately impaired for daily decision making and she had received an antibiotic. A Physician's Order, dated 3/1/23 and discontinued on 3/8/23, indicated ciprofloxacin (antibiotic) 500 mg (milligrams); give 1 tablet twice a day for cough for 7 days. A fax to the Physician, dated 3/1/23, indicated the resident had a nonproductive cough and the facility wanted to have an order for cough syrup. The Physician responded with orders to start Tessalon (cough medicine) 100 mg three…

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.