Ignite Medical Resort Dyer LLC

Based on observation, record review and interview, the facility failed to ensure residents who were left to complete nebulizer treatments independently had been assessed for safe self-administration for 1 of 4 residents reviewed for respiratory services. (Resident 29) Finding includes: During a random observation on 4/21/25 at 11:40 a.m., Resident 29 was observed sitting alone in his room. A nebulizer treatment was in progress via a face mask. He removed the face mask and put it in the drawer of his nightstand. At that time, the resident indicated the staff did not stay in the room while he received the nebulizer treatments. They would initiate the treatment, and when he thought it was done, he would remove the mask and put it in his drawer. The resident's record was reviewed on 4/23/25 at 2:57 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (low oxygen levels), and dementia. The 4/10/25 Quarterly MDS (Minimum Data Set) assessment, indicated the resident had moderate cognitive impairment, and…

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 the physician was notified of elevated blood sugars, blood pressure medications and insulin being held, and medication refusals for 3 of 3 residents reviewed for notification of change. (Residents 52, 154, and 264) Findings include: 1. The record for Resident 52 was reviewed on 4/24/25 at 3:03 p.m. Diagnoses included, but were not limited to, type 2 diabetes and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 3/2/25, indicated the resident was cognitively intact. A Physician's Order, dated 3/20/25, indicated the resident was to receive Lantus insulin, 25 units subcutaneously (injecting a medication into the fatty tissue layer beneath the skin) at bedtime. The Physician was to be notified if the resident's blood sugar level was less than 60 or greater than 400. The March 2025 Medication Administration Record (MAR) indicated the resident's blood sugar was 425 on 3/20/25 at 9:00 p.m. On 3/21/25 at 9:00 p.m., the resident's blood sugar was 433. There was no documentation indicating 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 ensure the Minimum Data Set (MDS) assessment was accurately completed related to terminal prognosis and hospice care for 1 of 27 MDS assessments reviewed. (Resident 44) Finding includes: Resident 44's record was reviewed on 4/28/25 at 10:05 a.m. Diagnoses included, but were not limited to, hypertension, atrial fibrillation, and Alzheimer's disease. The Quarterly MDS assessment, dated 4/9/25, indicated the resident had not received hospice care and did not have a condition or chronic disease that may result in a life expectancy of less than six months. A Physician's Order, dated 10/4/24, indicated the resident was admitted to hospice services. A Care Plan, dated 2/21/25, indicated the resident had a terminal end stage prognosis and was receiving hospice services. The Hospice Certification, dated 2/26/25, indicated the resident was terminally ill with a life expectancy of six months or less. During an interview on 4/28/25 at 3:14 p.m., MDS Nurse 1 and MDS Nurse 2 indicated the resident was receiving hospice care and 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.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for edema, compression glove use, and oxygen for 1 of 27 resident care plans reviewed. (Resident 60) Finding includes: On 4/22/25 at 9:18 a.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. Her right hand was slightly swollen and there was a compression glove on her bedside table. The resident indicated she used oxygen and it was usually at 2 liters. She wore the compression glove on her right hand, but only at night. Record review for Resident 60 was completed on 4/23/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 2/23/25, indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. A Care Plan, dated 3/10/25, indicated the resident had renal insufficiency. The interventions included to elevate feet to help prevent dependent…

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 professional standards of quality were maintained related to a CNA placing a tube feeding pump on hold for 1 of 2 residents reviewed for tube feeding. (Resident 73) Finding includes: During a random observation on 4/23/25 at 3:34 p.m., Resident 73 was observed in her room in bed. The head of the bed was elevated and the resident's tube feeding was infusing at 50 cubic centimeters (cc's). CNA 1 proceeded to enter the resident's room to perform incontinence care. Prior to lowering the head of the bed, the CNA placed the tube feeding pump on hold. After incontinence care was completed, the CNA had a nurse resume the tube feeding. The record for Resident 73 was reviewed on 4/25/25 at 2:10 p.m. Diagnoses included, but were not limited to, gastrostomy (a feeding tube placed through the abdomen and into the stomach to deliver nutrition, fluids, or medications), adult failure to thrive, and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment, dated 2/24/25, indicated 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 record review and interview, the facility failed to assist a resident to see an eye doctor for 1 of 1 resident reviewed for vision. (Resident 29) Finding includes: During an interview on 4/21/25 at 11:33 a.m., Resident 29 indicated he could not see with the glasses he had and he had not been evaluated by an eye doctor since before his admission to the facility on 7/8/24. During an interview on 4/23/25 at 2:00 p.m., the resident's daughter indicated she had asked Social Worker 1 about setting up an eye doctor appointment for the resident, and he indicated seeing the eye doctor was not part of his care at the facility and they could not make arrangements for him. The resident's record was reviewed on 4/23/25 at 2:57 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (low oxygen levels), and dementia. The 4/10/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and required partial/moderate assistance with activities of daily living and…

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 G-tube (gastrostomy tube, a tube inserted directly into the stomach) flushes were instilled via gravity for 1 of 6 residents observed for medication administration. (Resident 202) Finding includes: On 4/24/25 at 1:04 p.m., LPN 2 was observed preparing Resident 202's medications. She crushed each pill and placed it in a separate cup. She entered the resident's room, put the tube feeding on hold, and poured 30 cubic centimeters (cc) of water into a medication cup. She inserted the G-tube syringe into the medication cup and drew up the 30 cc of water. She opened the G-tube and placed the syringe directly into the tube and pushed the 30 cc of water down the tube using the plunger. She diluted each of the medications in 5 cc of water and administered the medications and remaining flushes by gravity. During an interview on 4/24/25 at 1:30 p.m., LPN 2 indicated she should have administered the G-tube flush by gravity. During an interview on 4/24/25 at 1:53 p.m., the Director of Nursing was made aware 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 received the necessary care and treatment related to oxygen administration for 1 of 4 residents reviewed for respiratory care. (Resident 60) Finding includes: On 4/22/25 at 9:18 a.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. The resident indicated she used oxygen and it was usually set at 2 liters. On 4/22/25 at 2:26 p.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. Record review for Resident 60 was completed on 4/23/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 2/23/25, indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. There was no current care plan related to oxygen use. The Physician's Order Summary, dated 4/2025, lacked any orders for oxygen. During an interview on 4/24/25 at 11:58 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 a medication error rate of less than 5% for 1 of 6 residents observed during medication administration. Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a medication error rate of 7.69%. (Resident 66) Finding includes: On 4/24/25 at 9:30 a.m., LPN 1 was observed preparing Resident 66's medications, which included Lantus (insulin glargine, long-acting insulin). LPN 1 removed the resident's insulin pen from the medication cart and donned a gown and gloves. She entered the room, cleaned the top of the insulin pen with an alcohol swab, and put the needle on the pen. She dialed the Lantus insulin pen to 20 units and administered the injection to the resident's left abdomen. She had not primed the insulin pen prior to administering the injection. She then removed her gown and gloves, washed her hands, and disposed of the needle in the sharps container. The record for Resident 66 was reviewed on 4/23/25 at 2:33 p.m. Diagnoses included, but…

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 kept in a locked medication cart at all times for 1 of 6 residents observed during medication administration. (Resident 66) Finding includes: On 4/24/25 at 9:30 a.m., LPN 1 was observed preparing medications for Resident 66. She placed a pill card of multivitamin medication and a pill card of ferrous sulfate medication on top of the medication cart. She placed the medication cup containing the resident's morning medications on top of the medication cart. At 9:37 a.m. she indicated she needed to go get something from the Nurse's Station and walked down the hallway away from the medication cart. The two pill cards of medications and the medication cup with the resident's morning medications remained on top of the medication cart, out of her sight. On 4/24/25 at 9:40 a.m., LPN 1 returned to the medication cart. During an interview, at that time, LPN 1 indicated she should not have left the medications unattended. During an interview on 4/24/25 at 10:44 a.m., the Director of Nursing was made aware 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 assist a resident to obtain dental care for 1 of 1 resident reviewed for dental services. (Resident 29) Finding includes: During an interview on 4/21/25 at 11:33 a.m., Resident 29 indicated his dentures did not fit well, making it difficult to chew, and he had not been evaluated by a dentist since before his admission to the facility on 7/8/24. During an interview on 4/23/25 at 2:00 p.m., the resident's daughter indicated she asked Social Worker 1 about setting up a dentist appointment for the resident, and he indicated dental care was not part of his care at the facility and they could not make arrangements for him. The resident's record was reviewed on 4/23/25 at 2:57 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (low oxygen levels), and dementia. The 4/10/25 Quarterly MDS (Minimum Data Set) assessment indicated the resident had moderate cognitive impairment, and required partial/moderate assistance with activities of daily living…

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 the medical record was complete and accurately documented related to medication administration documentation and medication orders for 1 of 27 records reviewed. (Resident 42) Finding includes: Resident 42's record was reviewed on 4/24/25 at 8:26 a.m. Diagnoses included, but were not limited to, diabetes and heart failure. A Physician's Order, dated 2/25/25, indicated Droxidopa (a medication to treat the symptoms of low blood pressure) every 8 hours. The boxes for documenting administration of the medication on the April 2025 Medication Administration Record (MAR) were blank for the following doses: 4/6/25 at 10:00 p.m., 4/7/25 at 6:00 a.m., and 4/12/25 at 6:00 a.m. A Physician's Order, dated 4/13/25, indicated Midodrine (a medication to treat low blood pressure)every 8 hours as needed for hypotension (low blood pressure). There were no orders for blood pressure parameters for administration. During an interview on 4/24/25 at 3:45 p.m., the Assistant Director of Nursing indicated the nurse administered the Droxidopa…

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 the physician was notified in a timely manner of a medication that was unavailable for 1 of 3 residents reviewed for notification of change. (Resident E) Finding includes: Resident E's record was reviewed on 3/3/25 at 11:23 a.m. Diagnoses included, but were not limited to, heart failure, gout (increase level of uric acid), muscle weakness, and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 2/12/25, indicated the resident was to receive Vericiguat (chronic heart failure medication) 10 milligram (MG) oral tablet once a day for heart failure. A Nurse's Note, dated 2/14/25 at 12:29 p.m., indicated Vericiguat oral tablet was not available and pharmacy was aware. A Nurse's Note, dated 2/15/25 at 9:50 a.m., indicated Vericiguat oral tablet was pending delivery from pharmacy. A Nurses Note, dated 2/16/25 at 6:24 p.m., indicated the nurse and the physician notified…

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 staff member (CNA 1) when providing care to a resident (Resident G) who was in Enhanced Barrier Precautions (EBP) for 1 of 4 residents reviewed for EBP. Finding includes: During an observation on 3/3/25 at 9:04 a.m., there was a container on Resident G's outside door that contained PPE of gowns, gloves, and masks. There was a sign on the door frame that indicated the resident required EBP. Resident G was lying in bed, was uncovered and wore a clean incontinent brief. A family member was assisting the resident to lie on his right side and CNA 1 was on the left side of the bed and placed a clean and rolled incontinent pad under the resident. The resident was then rolled to the left side and the incontinent pad was pulled through to be placed under the resident. CNA 1 was not wearing a gown. She then started to leave the room to find assistance to position the resident in the bed. At that time, she indicated a gown should have been worn during care.…

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 pressure ulcer received the necessary treatment and services to promote healing, related to interventions not in place and a treatment was not completed as ordered and care planned for 1 of 3 residents reviewed for pressure ulcers. (Resident G) Finding includes: During an observation on 1/8/25 at 10:00 a.m., Resident G was lying in bed with the head of the bed elevated. There were heel protectors observed lying on top of the dresser and the resident's heels were lying directly on a regular mattress. There was a low air mattress lying on the floor in the entryway of the room. During an observation on 1/8/25 at 10:18 a.m., LPN 1 and LPN 2 entered the room and provided incontinent care to the resident. After washing the resident, a new brief was applied. The skin barrier cream had not been applied. Upon completion of the incontinent care, the heels remained resting on the mattress of the bed. The low air mattress remained on the floor in the entryway of the room. During an interview on…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (LPN 1 and LPN 2) when providing care to a resident (Resident G) who was in Enhanced Barrier Precautions (EBP) for one random observation for infection control. Finding includes: During an observation on 1/8/25 at 10:18 a.m., LPN 1 and LPN 2 entered Resident G's room to provide incontinent care. The LPN's applied gloves, stood on each side of the bed and assisted the resident in turning from side to side. LPN 2 provided washing of the skin and a clean brief was applied. LPN 1 and LPN 2 had not donned a gown prior to providing the care. During an observation and interview on 1/8/25 at 10:32 a.m., there was a sign on the door that indicated the resident required PPE due to EBP and a cart was located inside the door to the room with the PPE. LPN 1 acknowledged the sign on the door and indicated PPE should have been used. LPN 1 was unsure why the resident required EBP. LPN 2 indicated PPE for the EBP should have been utilized. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's responsible party was promptly notified after a significant change in status related to an intravenous (IV) site placement, changes in medications and medication times for 1 of 3 residents reviewed for notification of change. (Resident D) Finding includes: During a phone interview on 11/12/24 at 2:30 p.m., Resident D's responsible party indicated her husband had dementia and she was his primary caretaker. During his stay at the facility, she was never notified of medication changes, times of medications, or the need for IV fluids and the placement of an IV site. The closed record for Resident D was reviewed on 11/12/24 at 1:30 p.m. The resident was admitted to the facility on [DATE] and discharged home on 9/24/24. Diagnoses included, but were not limited to, acute kidney failure, type 2 diabetes mellitus, dementia, pain in the left foot, high blood pressure, atrial fibrillation, chronic kidney failure, anemia, and anxiety. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for residents who needed assistance related to long fingernails for 1 of 5 residents reviewed for ADLs. (Resident F) Finding includes: On 11/12/24 at 11:30 a.m., Resident F was observed in their room. The resident had long fingernails. During an interview with the resident at that time, Resident F indicated they did not have any nail clippers or they would have taken care of the nails themselves. The resident also indicated staff had not asked them if they would like their fingernails cut. On 11/13/24 at 1:30 p.m., the resident was observed in their bed watching television. The resident's fingernails remained long and the resident asked if there was anyone who could cut their nails. On 11/14/24 at 9:00 a.m., the resident's fingernails were observed to have been cut. The record for Resident F was reviewed on 11/12/24 at 11:43 a.m. Diagnoses included, but were not limited to, fracture…

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 areas of bruising were assessed and monitored for 1 of 3 residents reviewed for skin conditions non-pressure related. (Resident K) Finding includes: On 11/12/24 at 11:05 a.m., Resident K was observed in their room watching television. Scattered areas of reddish/purple discolorations were observed to the right and left forearms and hands. The record for Resident K was reviewed on 11/13/24 at 9:17 a.m. Diagnoses included, but were not limited to, orthopedic aftercare following surgical amputation, cellulitis of the left lower limb, type 2 diabetes, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident was cognitively intact and they had received an anticoagulant (blood thinner) during the last seven days. There was no care plan related to the bruising and/or the anticoagulant use. A Physician's Order, dated 8/23/24, indicated the resident was to receive Rivaroxaban (a blood thinner) 2.5 milligrams (mg) daily for deep vein thrombosis…

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 ensure a peripheral intravenous (IV) catheter was maintained, monitored and assessed for patency for 2 of 3 residents reviewed for IV catheters. (Residents G and D) Findings include: 1. On 11/14/24 at 9:46 a.m., Resident G was observed in their room in bed. A peripheral intravenous (IV) catheter was observed in the resident's right upper arm. The record for Resident G was reviewed on 11/12/24 at 2:34 p.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and extended spectrum beta lactamase (ESBL) resistance. The admission Minimum Data Set (MDS) assessment, dated 8/23/24, indicated the resident was cognitively impaired for daily decision making. Physician's Orders, dated 11/6/24, indicated the resident was to receive Meropenem (an antibiotic) one gram IV every eight hours for ESBL in the urine for 10 days. The IV was to be flushed with one unit of normal saline every 24 hours as needed for midline flush…

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 clinical records were complete and accurately documented related to falls for 1 of 3 residents reviewed for falls. (Resident E) The facility also failed to document that treatments were completed as ordered for 1 of 3 residents reviewed for pressure ulcers and 1 of 3 residents reviewed for skin conditions non-pressure related. (Resident K) Findings include: 1. The record for Resident K was reviewed on 11/13/24 at 9:17 a.m. Diagnoses included, but were not limited to, orthopedic aftercare following surgical amputation, cellulitis of the left lower limb, type 2 diabetes, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident was cognitively intact. The resident had a surgical wound and a Stage 3 (a deep wound that involves full thickness tissue loss, but does not expose bone, tendon, or muscle) pressure ulcer. The current Care Plan, indicated the resident had a pressure injury 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 record review and interview, the facility failed to provide and document sufficient information for a resident who was being transferred to the hospital emergency room (ER), related to the circumstances of a resident being transferred to the ER not documented in the resident's record and transfer information was not provided to the Emergency Medical Services (EMS) and hospital, for 1 of 3 residents reviewed for transfers and discharges. (Resident E) Finding includes: Resident E's record was reviewed on 8/6/24 at 10:25 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy. The Census Form indicated the resident was discharged from the facility on 7/19/24. The discharge status was not listed on the Discharge, return not anticipated Minimum Data Set assessment, dated 7/19/24. There was no documentation in the Nurses' Progress Notes, dated 7/19/24, the resident had a change of condition, was transferred to the ER, and/or discharged from the facility. There was no Transfer Form or Discharge Form that indicated the resident had been transferred 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.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed related to falls, medications, and behaviors for 2 of 8 MDS assessments reviewed. (Residents G and J) Findings include: 1. Resident G's record was reviewed on 8/8/24 at 9:21 a.m. The diagnoses included, but were not limited to, dementia. An admission MDS assessment was completed on 6/26/24. The MDS indicated there had been no behaviors, no falls, and the resident had not received an antipsychotic medication. The Nurses's Progress Notes indicated the resident had fallen on 6/22/24 at 11:06 a.m., 6/23/24 at 9:45 a.m., and 6/24/24 at 10:33 p.m. The Physician's Orders, dated 6/23/24, indicated olanzapine (antipsychotic) 10 milligrams daily was ordered for bipolar disorder with behaviors. The Medication Administration Record, dated 6/2024, indicated the resident had 4 episodes of behaviors on 6/24/24 on the evening shift. A Nurse's Progress Note, dated 6/24/24 at 11:33 p.m., indicated Resident G was in the Unit Dining Room with magazines and a cup of water in…

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

Based on observation, record review, and interview, the facility failed to ensure individualized Care Plans were developed and implemented related to a knee immobilizer and behaviors for 2 of 8 residents reviewed for care plans. (Resident J and G) See F744 for additional information regarding Resident G. Findings include: 1. During an observation on 8/5/24 at 10:53 a.m., Resident J was in the bathroom sitting in a wheelchair. There was a knee immobilizer on the left lower extremity. The resident indicated she had a pressure sore from the immobilizer that started out as a blister. During an observation on 8/6/24 at 11:04 a.m. with LPN Wound Nurse 3 and LPN Wound Nurse 4, LPN Wound Nurse 3 completed a treatment on the left heel wound and left posterior ankle wound. Both areas were dried. LPN Wound Nurse 3 indicated the immobilizer slid down and the staff continued to pull the immobilizer back up. There was a pad that went under the immobilizer to prevent pressure issues. The treatments were applied and the immobilizer was reapplied with the padding underneath to assist with 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 record review and interview, the facility failed to ensure a resident received the necessary care and services related to antibiotics not administered, a blood sugar level not obtained, and physician notification of elevated blood sugar levels not completed as ordered for 1 of 8 residents reviewed for quality of care. (Resident B) Finding includes: Resident B's record was reviewed on 8/5/24 at 11:10 a.m. The diagnoses included, but were not limited to, diabetes mellitus and an abscess of the abdominal wall. An admission Minimum Data Set assessment, dated 6/14/24, indicated the resident received insulin, an antibiotic, and a hypoglycemic medication. A Care Plan, dated 6/17/24, indicated insulin was received. The interventions included the blood glucose would be monitored as ordered and hyperglycemia protocol would be followed as ordered by the physician. (a) A Physician's Order, dated 6/17/24, indicated ceftriaxone sodium (antibiotic), 1 gram was to be administered once a day for seven days for an abdominal wall abscess. The Medication Administration Record (MAR), 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 record review and interview, the facility failed to ensure a thorough investigation of a fall was completed which included the root cause of the fall and failed to initiate an intervention related to the circumstances of the fall, for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: Resident D's record was reviewed on 8/6/24 at 9:11 a.m. The diagnoses included, but were not limited to, dementia. An admission Cognitive Assessment, completed on 7/18/24 by Social Service, indicated a severe cognitive impairment. An admission Fall Risk Assessment, completed by nursing staff on 7/18/24, indicated a high risk for falls. A Care Plan, dated 7/18/24, indicated a risk for falls. The interventions included a possible root cause of the fall would be determined and the potential cause of the fall would be altered and/or removed. A Nurse's Progress Note, dated 7/22/24 at 10:38 p.m., indicated there resident was observed on the floor. The resident had indicated he just wanted to see what the world looked like from the bottom up. He denied falling. He was assisted off…

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 record review and interview, the facility failed to ensure a resident with dementia received appropriate treatment and services to meet his needs, related to ongoing behaviors without input from the Interdisciplinary Team (IDT) and Social Service, no identification of behavior type, no Care Plan with interventions for the behaviors, no updated nursing interventions for the behaviors, no interventions attempted, and no interventions attempted for the behaviors before medication was administered, for 1 of 1 resident reviewed for dementia/behaviors. (Resident G) Finding includes: Resident G's record was reviewed on 8/8/24 at 9:21 a.m. The diagnoses included, but were not limited to, dementia. An admission Minimum Data Set assessment, dated 6/26/24, indicated a severely impaired cognitive status, no behaviors, no impairment of the bilateral upper extremities, impairment of the bilateral lower extremities, moderate assistance required with chair to bed transfers, supervision with wheelchair mobility, moderate assistance with ambulation of 10 feet, no falls, and received an…

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 staff members (LPN Wound Nurse 3 and LPN Wound Nurse 4) when providing pressure ulcer treatments for 1 of 1 random observation (Resident J). This had the potential to affect 13 residents who required wound treatments. Finding includes: During an observation on 8/5/24 at 11:04 a.m., Resident J's room was entered with LPN Wound Nurse 3 and LPN Wound Nurse 4. There was no sign on the resident's door that indicated Enhanced Barrier Precautions (EBP) were to be used. The dressing had already been taken off the pressure sores on the left heel and the left posterior ankle. The Wound Nurses had applied gloves. LPN Wound Nurse 3 indicated Enhanced Barrier Precautions only had to be implemented if the wounds had drainage. LPN Wound Nurse 3 continued to complete the wound treatments on the left heel and left posterior ankle. A facility enhanced barrier precaution policy, dated 3/2024 and received as current from the Director of Nursing, indicated EBP was 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 record review and interview, the facility failed to provide residents' medical records to the resident/Power of Attorney (POA) in a timely manner after a request was made for 2 of 3 residents reviewed for medical record requests. (Residents G and H) Finding includes: 1. Resident G's closed record was reviewed on 6/18/24 at 8:51 a.m. The diagnoses included, but were not limited to, congested heart failure. An admission Minimum Data Set assessment, dated 3/12/24, indicated no cognitive problems. A Request and Authorization for Release of Health Information form, indicated the complete medical record was requested by the resident and the POA on Friday 5/31/24. The record was not received by the resident and POA until 6/7/24. During an interview on 6/17/24 at 3:24 p.m., the Business Office Manager indicated once the request form for the medical record was filled out, it was scanned and sent to the Corporate Office. The Legal Department reviewed the request and would then contact the facility when the records could be released. The facility also had to wait for therapy and other…

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 1) when emptying out a urinary catheter drainage bag for a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 1 random observation. (Resident J) Finding includes: During an random observation on 6/17/24 at 11:54 a.m., CNA 1 was in Resident J's room and was emptying the resident's urinary catheter drainage bag. There was no EBP sign on the door and no PPE in a cart next to the door. CNA 1 was wearing gloves and no gown. CNA 1 indicated she thought she had education on EBP and stated if the resident was on EBP there would be a sign on the door and a PPE cart in the hallway next to the door. She indicated if the resident had an urinary tract infection, an ostomy, or a urinary catheter, the residents were to supposed to be in EBP. CNA 1 acknowledged she had not donned a gown prior to emptying the urinary catheter drainage bag. During an interview on 6/17/24 at 11:59 a.m., LPN 2 indicated residents with clostridium…

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 to administer their own medications, orders were present for the medications, and a self-administration of medication assessment was completed, for 5 of 5 residents reviewed for self-administration of medication. (Residents J, L, H, M, and K) Findings include: 1. During a random observation on 3/4/24 at 2:45 p.m., a bottle of Nasal Relief nasal spray was observed on the window ledge in Resident J's room. During random observations on 3/5/24 at 9:09 a.m. and 11:15 a.m., the nasal spray remained on the resident's window ledge. The record for Resident J was reviewed on 3/5/24 at 2:44 p.m. Diagnoses included, but were not limited to, type 1 diabetes and acute respiratory failure with hypoxia (low levels of oxygen in the body tissue). The admission Minimum Data Set (MDS) assessment, dated 2/15/24, indicated the resident was cognitively intact. The March 2024 Physician's Order Summary (POS), indicated the resident had no order for the Nasal Relief nasal spray and they did not…

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, nail care, removing facial hair, hair washing, and oral care, for 5 of 6 residents reviewed for ADL care. (Residents P, Q, M, C, and N) Findings include: 1. During an interview on 3/4/24 at 2:41 p.m., Resident P indicated they had not been taken to the shower room for at least a month and a half. The record for Resident P was reviewed on 3/6/24 at 10:51 a.m. Diagnoses included, but were not limited to, type 2 diabetes and need for assistance with personal care. The Quarterly Minimum Data Set (MDS) assessment, dated 1/8/24, indicated the resident was moderately impaired for daily decision making and the resident was not able to bathe themselves. A Care Plan, dated 1/5/24, indicated the resident had an ADL self-care performance deficit and limitation in physical mobility. Interventions included, but were not limited 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 record review and interview, the facility failed to ensure clinical records were complete, related to meal consumption intake, for 4 of 6 residents reviewed for food. (Residents Q, M, E, and N) Findings include: 1. The record for Resident Q was reviewed on 3/6/24 at 12:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, peripheral vascular disease, pulmonary embolism, osteomyelitis, high blood pressure, absence of the left toes, and adult failure to thrive. The 2/18/24 admission Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. Physician's Order, dated 2/15/24, indicated a no salt packet, regular texture and consistency diet. The Meal Consumption Logs for February & March 2024, indicated all three meals were blank and not documented on 2/13, 2/15, 2/19, 2/22, 2/24, 2/29, and 3/5/24. There was no breakfast meal documented on 2/14/24 and no lunch meal documented on 2/17/24. The dinner meal was not documented on 2/14,…

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 infection control guidelines for vaccinations were in place and implemented, related to offering and providing the COVID vaccine, for 4 of 5 residents reviewed for vaccinations. (Residents 41, 77, 198, and 247) Findings include: The COVID vaccine records were reviewed on 3/8/24 at 9:40 a.m. a. Resident 41 was admitted on [DATE]. There was no documentation of a signed consent or refusal of the COVID vaccine or of education being provided. b. Resident 77 was admitted on [DATE]. There was no documentation of a signed consent or refusal of the COVID vaccine or of education being provided. c. Resident 198 was admitted on [DATE]. There was no documentation of a signed consent or refusal of the COVID vaccine or of education being provided. d. Resident 247 was admitted on [DATE]. There was no documentation of a signed consent or refusal of the COVID vaccine or of education being provided. During an interview on 3/8/24 at 10:46 a.m., the Infection…

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 implement a system to prevent misappropriation of resident property, related to no documentation of narcotics being signed out of the facility's emergency medication machine, for 1 of 1 residents reviewed for pain management. (Resident Q) Finding includes: During an interview on 3/4/24 at 11:28 a.m., Resident Q indicated nursing staff have told him more than once they have run out of his Norco (a narcotic medication) (Hydrocodone) medication and he was in a lot of pain. He indicated one day, the nurse told him there would be no Norco available until the next day, and that was at 3:00 p.m. The record for Resident Q was reviewed on 3/6/24 at 12:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, peripheral vascular disease, pulmonary embolism, osteomyelitis, high blood pressure, absence of the left toes, and adult failure to thrive. The 2/18/24 admission Minimum Data Set (MDS) assessment, 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 observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for cognitively impaired dependent residents, for 1 of 2 residents reviewed for activities. (Resident 26) Finding includes: During random observations on 3/4/24 at 10:15 a.m. and 1:56 p.m., Resident 26 was seated in a broda chair and positioned next to a table in the Northwest Lounge area. His eyes were closed and the television was turned on. During a random observation on 3/5/24 at 9:30 a.m., the resident was again seated in a broda chair and positioned at the table in the Northwest Lounge area. His eyes were closed and the television was turned on. During random observations on 3/7/24 at 9:04 a.m., 11:26 a.m., and 12:18 p.m., the resident was again seated in a broda chair and positioned at the table in the Northwest Lounge area. His eyes were closed and the television was turned on. At 2:00 p.m., the resident was in his room in bed sleeping. A music activity was taking place in the main dining room. The record was reviewed on 3/5/24 at 3:09 p.m. Diagnoses…

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 ensure areas of bruising were assessed and monitored for 1 of 2 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure treatment orders were obtained for excessive diarrhea for 1 of 1 residents reviewed for constipation and transportation was arranged for surgical appointments for 1 of 1 residents reviewed for change in condition. (Residents 13, Q, and 5) Findings include: 1. On 3/4/23 at 3:15 p.m., Resident 13 was observed with areas of scattered purple bruising to his left forearm and right arm. During an interview at that time, the resident indicated the bruises were from lab draws. The record for Resident 13 was reviewed on 3/6/24 at 2:13 p.m. Diagnoses included, but were not limited to, Parkinson's disease and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 2/10/24, indicated the resident was cognitively intact for daily decision making. A Care Plan, 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 oxygen was set at the correct flow rate for 3 of 4 residents reviewed for respiratory care (Residents M, 5 and 45) Findings include: 1. During random observations on 3/4/24 at 1:50 p.m., on 3/5/24 at 8:43 a.m. and 2:34 p.m., and on 3/6/24 at 9:38 a.m., Resident M was observed wearing oxygen via nasal cannula. The oxygen flow rate was above 3.5 liters per minute. The record for Resident M was reviewed on 3/6/24 at 10:34 a.m. Diagnoses included, but were not limited to, brain and lung cancer, COPD, respiratory failure, and high blood pressure. The 1/22/24 admission Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. The resident used oxygen while a resident. The Care Plan, dated 1/16/24, indicated the resident required oxygen therapy related to lung cancer and COPD. The approaches were to administer oxygen per Physician's Orders. Physician's Orders, dated 1/15/24, indicated provide continuous oxygen at 2 liters per minute. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer pain relief medication as ordered by the Physician, related to the administration of narcotic medication, for 1 of 1 residents reviewed for pain management. (Resident Q) Finding includes: During an interview, on 3/4/24 at 11:28 a.m., Resident Q indicated nursing staff had told him more than once they have run out of his Norco (Hydrocodone) medication, and he was in a lot of pain. He indicated one day, the nurse told him there would be no Norco available until the next day, and that was at 3:00 p.m. The record for Resident Q was reviewed on 3/6/24 at 12:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, peripheral vascular disease, pulmonary embolism, osteomyelitis, high blood pressure, absence of the left toes, and adult failure to thrive. The 2/18/24 admission Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact, and received scheduled and as needed (prn)…

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 medications were managed appropriately, related to missed doses of an anticoagulant medication, for 1 of 5 residents reviewed for unnecessary medications (Resident Q) Finding includes: During an interview, on 3/4/24 at 11:22 a.m., Resident Q indicated he had missed his Lovenox (anticoagulant) injections many times. Some days he only received 1 shot, and on other days he did not receive any of them. The record for Resident Q was reviewed on 3/6/24 at 12:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, peripheral vascular disease, pulmonary embolism, osteomyelitis, high blood pressure, absence of the left toes, and adult failure to thrive. The 2/18/24 admission Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact and received an anticoagulant and antiplatelet medication while a resident. A Care Plan, dated 2/12/24, indicated the resident received an anticoagulant…

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 medication error rate of less than 5% for 3 of 6 residents observed during medication pass. Three errors were observed during 29 opportunities for errors during medication administration. This resulted in a medication error rate of 10.34%. (Residents 49, 41, and J) Findings include: 1. On 3/6/24 at 9:41 a.m., LPN 1 was observed preparing Resident 49's medications. She crushed different oral medications at one time, including one Isosorbide Mononitrate ER Tablet Extended Release 24 hour 30 milligrams (mg) tablet. A total of 13 crushed pills were observed in the medication cup. The record for Resident 49 was reviewed on 3/6/24 at 9:28 a.m. There was no physician's order to crush medications. LPN 1 contacted the pharmacy to verify if the Isosorbide ER tablet could be crushed. The pharmacy indicated the medication should not be crushed. During an interview, on 3/6/24 at 9:19 a.m., LPN 1 indicated the extended release medications should not be crushed. 2. On 3/6/24 at 10:23 a.m., LPN 2 was observed…

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

Based on observation, record review, and interview, the facility failed to ensure medications were properly stored, related to one unlabeled insulin vial and loose pills inside the medication drawers, for 1 of 4 medication carts observed. (North East Cart 2). Findings include: 1. During a medication storage observation, on 3/6/24 at 11:51 a.m., the North East Hall medication cart was observed with LPN 2. There was one unlabeled and undated insulin vial in the medication cart. During an interview, on 3/6/24 at 11:51 a.m., LPN 2 indicated the insulin vial should have been properly discarded. 2. During a medication storage observation, on 3/7/24 at 5:59 p.m., the North East Hall medication cart was observed with LPN 3. At that time, there were 15 loose pills inside the drawer of the medication cart. The pills ranged in size and color. During an interview, on 3/7/24 at 5:59 p.m., LPN 3 indicated she should have cleaned her cart out and properly disposed of the loose medications. A facility policy, titled, Medication Labeling and Storage, provided by the Director of Nursing as current,…

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 infection control guidelines were in place and implemented, related to improper disposal of a used lancet placed in the garbage can, for 1 of 1 residents observed for glucometer use. (Resident 41) Finding includes: On 3/6/24 at 10:23 a.m., LPN 2 was observed preparing to check Resident 41's blood sugar. She removed the glucometer, lancet, alcohol swabs, and the test strips from the medication cart. She performed hand hygiene and donned gloves to both hands and proceeded to walk into the resident's room. At that time, she checked the resident's blood sugar and threw all of her supplies into the resident's garbage can when she was finished. During and interview on 3/6/24 at 10:26 a.m., LPN 2 indicated she was rushing and accidentally tossed everything in the garbage can. She was aware the lancet was to be disposed of into a sharps container. A Policy, titled, Injection Safety and Sharps Injury Protection Plan, presented by the DON as current on 3/8/24 at 3:00 p.m., indicated, .Used disposable…

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 resident's family was notified of behaviors, medication changes, and transfers to the Emergency Room, for 1 of 5 residents reviewed for family notification. (Resident B) Finding includes: Resident B's record was reviewed on 11/27/23 at 10:40 a.m. The diagnoses included, but were not limited to, dementia. An admission Minimum Data Set assessment, dated 10/26/23, indicated short and long term memory problems, no behaviors, and received an antipsychotic, and anti-anxiety, and an antidepressant medication. An admission Cognitive Evaluation, dated 10/20/23, indicated a severely impaired cognitive status. The Nursing Progress Notes, dated 10/25/23 at 6:57 a.m., 10/31/23 at 10:18 p.m., 11/4/23 at 8:07 p.m., 11/7/23 at 5:23 p.m., 11/10/23 at 5:30 p.m., 11/20/23 at 7:05 p.m., 11/24/23 at 12:53 p.m., and 11/24/23 at 11:47 p.m., indicated the resident had agitated behaviors. The Nursing Progress Notes, dated 11/4/23 at 8:07 p.m. and 11/25/23 at 12:05 a.m., indicated the resident had been transferred to the emergency 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 record review and interview, the facility failed to provide and document sufficient information for a resident who was being transferred to the hospital emergency room related to Transfer Forms/assessments not completed for 1 of 1 resident reviewed for transfer to an Emergency Room. (Resident B) Findings includes: Resident B's record was reviewed on 11/27/23 at 10:40 a.m. The diagnoses included, but were not limited to, dementia. The Nurses' Progress Notes, dated 11/4/23 at 8:07 p.m. and 11/25/23 at 12:05 a.m., indicated the resident was transferred to the emergency room related to behaviors. There was no transfer form with information about the resident's status sent with the resident to the Hospital. During an interview on 11/27/23 at 3:06 p.m., the Director of Nursing indicated there were no transfer forms for the emergency room Transfer completed. This citation relates to Complaint IN00422105. 3.1-12(a)(21)

Based on observation, record review and interview, the facility failed to ensure a resident with dementia received appropriate treatment and services to meet her needs, related to ongoing behaviors without input from the Interdisciplinary Team (IDT) and Social Service, no updated Care Plan with interventions for the behaviors, no interventions attempted and/or no documented effectiveness of the interventions, for 1 of 3 residents reviewed for dementia/behaviors. (Resident B) Finding includes: During an observation on 11/27/23 at 10:48 a.m., Resident B was being assisted to the bathroom by Employee 1. Employee 1 moved slowly and explained each movement prior to assisting her. The resident was calm and cooperative. During an interview, Employee 1 indicated the resident could be resistive and combative. The behaviors usually occurred when she was tired and when she was assisted into the bed and left alone for a short time, she would usually calm down. Resident B's record was reviewed on 11/27/23 at 10:40 a.m. The diagnoses included, but were not limited to, dementia. An admission…

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 resident's record was complete and accurate, related to no documentation of a resident's return from the Emergency room, no documentation of of an appeal of a NOMNC (Notice of Medicare Non-Coverage) letter, and events that occurred during a potential discharge of a resident and reasons for discharge from the facility, for 2 of 5 residents reviewed for medical records. (Residents B and E) Findings include: 1. Resident B's record was reviewed on 11/27/23 at 10:40 a.m. The diagnoses included, but were not limited to, dementia. An admission Minimum Data Set assessment, dated 10/26/23, indicated short and long term memory problems. An admission Cognitive Evaluation, dated 10/20/23, indicated a severely impaired cognitive status. The Nurse's Progress Note, dated 11/4/23 at 8:07 p.m., indicated the resident was transferred to the emergency room related to agitated behaviors. There was no documentation when the resident returned from the emergency room or treatment summary from the Emergency Room. A Social Service…

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 resident was free from unnecessary medications, related to a medication administered when the blood pressure was out of the prescribed parameter, for 1 of 1 resident reviewed for unnecessary medications. (Resident F) Finding includes: Resident F's record was reviewed on 10/11/23 at 8:46 a.m. The diagnoses included, but were not limited to, diabetes mellitus and end stage renal disease with dialysis. A Physician's Order, dated 9/14/23, indicated Midodrine (treatment for low blood pressure) 10 milligrams (mg), was to be administered every eight hours for hypotension. The Midodrine was not to be given if the systolic (upper number) blood pressure was greater than 120. The Medication Administration Record (MAR), dated 9/2023 indicated the following blood pressures and documentation the Midodrine had been administered at 6 a.m. each day: On 9/14/23 the blood pressure was 140/83. On 9/17/23 the blood pressure was 124/75. On 9/19/23 the blood pressure was 126/55. On 9/20/23 the blood pressure was 122/66. On 9/21/23 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 were invited to attend and participate in care planning conferences for 3 of 6 residents reviewed for participation in care planning. The facility also failed to ensure Care Plans were reviewed and revised related to behaviors for 1 of 21 Care Plans reviewed. (Residents E, 16, 31, and 26) Findings include: 1. Interview with Resident E on 1/29/23 at 10:07 a.m., indicated he was not aware of being invited to his care conference. The record for Resident E was reviewed on 1/31/23 at 10:03 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), cellulitis of the left lower limb, and Parkinson's. The resident was his own Responsible Party. The admission Minimum Data Set (MDS) assessment, dated 1/15/23, indicated the resident was cognitively intact. The resident's Care Plan was dated 1/13/23. There was no documentation indicating the resident had been invited and/or participated in his care conference. Interview with the Social Service Director on 2/2/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to dirty fingernails, transfers to the bathroom, shaves, and showers, for 4 of 7 residents reviewed for ADLs. (Residents B, F, H and G) Findings include: 1. On 1/29/23 at 8:43 a.m., and 11:30 a.m., Resident B was observed in bed. At those times, his fingernails were long and dirty. On 1/30/23 at 2:27 p.m., the resident was observed in bed and his fingernails were long and dirty. On 1/31/23 at 9:25 a.m., the resident was observed sitting up in the broda chair. At that time, the resident's fingernails were long and dirty. On 01/31/23 at 1:48 p.m., and 2:59 p.m., the resident was observed in bed. At those times, the resident's fingernails were long and dirty. The record for Resident B was reviewed on 1/31/23 at 3:10 p.m. Diagnoses included, but were not limited to, dependence on renal dialysis, legal blindness, type 2 diabetes, anorexia, metabolic…

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 ensure signs and symptoms of constipation were monitored for 1 of 3 residents reviewed for constipation. The facility also failed to ensure areas of discoloration were assessed and monitored for 1 of 1 residents reviewed for anticoagulant medication side effects and 1 of 2 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure fall follow-up was completed for a resident with a potential injury and documentation for a discharge was completed for 2 of 2 residents reviewed for hospitalization. (Residents E, C, D, and F) Findings include: 1. Interview with Resident E on 1/29/23 at 10:13 a.m., indicated he was having issues with constipation. The resident indicated he took Miralax (a laxative) at home but had not received it since he had been admitted to the facility. During the interview, the resident was observed with reddish/purple discoloration to the top of his left hand and in between the fingers.…

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 2 of 2 residents reviewed for self-administration of medication. (Residents 125 and 19) Findings include: 1. On 1/30/23 at 10:54 a.m., Resident 125 was observed in his room seated in his wheelchair. A tube of Diclofenac (a topical pain reliever) gel was in the resident's room and he was observed applying some of the gel to his left knee. The record for Resident 125 was reviewed on 2/1/23 at 10:21 a.m. Diagnoses included, but were not limited to, fall and arthritis. The 2/1/23 admission Minimum Data Set (MDS) assessment was in progress. A Physician's Order, dated 1/26/23, indicated the resident was to receive Diclofenac Sodium External Gel 1 %, apply 4 grams to the left medial knee topically every 6 hours as needed for pain. There was no Physician's Order indicating the medication could be left at the bedside and the resident could apply the gel himself. There was also no self-administration of medication…

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 the resident was notified of a new medication for 1 of 2 residents reviewed for notification of change. (Resident F) Finding includes: During an interview on 1/29/23 at 10:47 a.m., Resident F indicated she had refused a Vitamin B12 injection yesterday. No one had explained what it was for and why she had to take it. She indicated the nurse on duty last night indicated it was for pain in her shoulder, but the resident stated she had no pain in her shoulder. The resident was adamant she was not taking the B12 injection without an explanation of why she had to receive it. During an interview on 1/30/23 at 2:29 p.m., the resident indicated the Nurse Practitioner (NP) came in earlier and explained why the Vitamin B12 injection was ordered. She indicated she was going to contact her primary Physician and if he said it was okay, then she would take the injection. The record for the resident was reviewed on 1/31/23 at 1:53 p.m. The resident was admitted…

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 monitor and assess a resident after antibiotic therapy had been started for a urinary tract infection (UTI) for 1 of 2 residents reviewed for UTI. (Resident 35) Finding includes: During an interview on 1/29/23 at 2:20 p.m., Resident 35's spouse indicated the nurse collected a urine sample and told him his wife had a UTI, but he did not know if she was on an antibiotic. The record for Resident 35 was reviewed on 1/31/23 at 10:32 a.m. Diagnoses included, but were not limited to, peg tube, weakness, mild protein malnutrition, UTI, and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 11/11/22, indicated the resident was severely impaired for decision making. The resident was frequently incontinent of urine and bowel. A Care Plan, dated 1/30/23, indicated the resident was on an antibiotic for a UTI. The approaches were to observe for possible side effects every shift. A Urinalysis collected on 1/11/23, indicated the resident had some bacteria. A culture, dated 1/16/23, indicated Escherichia Coli…

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 ensure the intake amounts of nutritional supplements were documented and food consumption logs were completed for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents B and G) Findings include: 1. During an interview on 1/29/23 at 11:30 a.m., Resident B indicated he did not always get his Nepro supplement and he had lost weight. The record for Resident B was reviewed on 1/31/23 at 3:10 p.m. Diagnoses included, but were not limited to, dependence on renal dialysis, legal blindness, type 2 diabetes, anorexia, metabolic encephalopathy, high blood pressure, stroke, and end stage renal disease. The Quarterly minimum Data Set (MDS) assessment, dated 11/28/22, indicated the resident was cognitively intact. The resident needed extensive assist with 1 person physical assist for personal hygiene and eating. The resident had no oral problems, weighed 151 pounds and had a significant weight loss during 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 oxygen was set at the correct flow rate and the nasal cannula was properly placed for 2 of 4 residents reviewed for respiratory services. (Residents 4 and H) Findings include: 1. On 1/29/23 at 1:45 p.m., Resident 4 was observed sitting in a wheelchair in her room. At that time, she was wearing oxygen by the way of a nasal cannula. The flow rate was set above 2.5 but not at 3 liters per minute. On 1/30/23 at 10:48 a.m., and 2:25 p.m., the resident was observed in her wheelchair. At those times, she was wearing oxygen by the way of a nasal cannula. The flow rate was set above 2.5 but not at 3 liters per minute. On 1/31/23 at 9:23 a.m., and 10:45 a.m., and on 2/1/23 at 9:18 a.m., the resident was observed in her wheelchair. At those times, she was wearing oxygen by the way of a nasal cannula. The flow rate was set above 2.5 but not at 3 liters per minute. The record for Resident 4 was reviewed on 1/30/23 at 3:00 p.m. Diagnoses included, but were not limited to, COPD, chronic pulmonary edema, heart…

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 with complaints of pain received the appropriate scheduled medication to relieve the pain based on the resident's pain level for 1 of 3 residents reviewed for pain. (Resident C) Finding includes: The closed record for Resident C was reviewed on 1/30/23 at 11:35 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, fall, fracture of medial orbital wall, high blood pressure, traumatic subdural hemorrhage with loss of consciousness. There was no Minimum Data Set (MDS) available for review. A Care Plan, dated 12/29/22, indicated the resident was at risk for alteration in comfort related to generalized aches and pains. A Nurses' Note, dated 12/29/22 at 4:51 p.m., indicated the resident was alert and oriented times 4 and had a bruised eye from a previous fall. The resident had dizzy spells and was an assist times one. The resident was not to be left alone while on the toilet. The resident was resting in bed…

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 medications were not used for excessive duration and monitored adequately related to medicated wipes and giving medications outside of blood pressure parameters for 2 of 5 residents reviewed for unnecessary medications. (Residents 42 and 4) Findings include: 1. The record for Resident 42 was reviewed on 1/31/23 at 11:16 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and atrial fibrillation (irregular heartbeat). The 12/30/22 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 10/11/22, indicated the resident was to receive a Chlorhexidine Gluconate Cloth External Pad (a topical antiseptic that helps reduce the chances of infection prior to surgery), apply to body topically one time a day for MRSA decolonization. There was no stop date for the order. Interview with the Director of Nursing on 2/2/23 at 2:15 p.m., indicated the Chlorhexidine pads needed to be discontinued. 2. The record for 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 record review, and interview, the facility failed to ensure residents did not receive unnecessary psychotropic medications without adequate indications for use for 1 of 5 residents reviewed for unnecessary medications. (Resident G) Finding includes: The record for Resident G was reviewed on 2/2/23 at 10:05 a.m. Diagnoses included, but were not limited to, acute respiratory failure, insomnia, fibromyalgia, anxiety disorder, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 1/31/23, indicated the resident was cognitively intact for daily decision making. The resident received anti-anxiety medication, antidepressant medication, and opioids in the last seven days. A Care Plan, dated 1/25/23, indicated the resident used anti-anxiety medications related to an anxiety disorder. Interventions included, but were not limited to, administer medications as ordered and monitor for side effects. A Physician's Order, dated 1/25/23, indicated lorazepam 1 milligram tablet every 12 hours as needed (PRN) for anxiety. The lorazepam medication was administered on 1/25/23…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was free from significant medication errors related to administering the wrong insulin for 1 of 6 residents observed during medication pass. (Resident 42) Finding includes: On 2/1/23 at 4:07 p.m., LPN 3 checked Resident 42's blood sugar by the way of a glucometer. The resident's blood sugar was 417 and the LPN indicated she was going to have to notify the Physician to see if additional insulin coverage would be needed. The Physician ordered an additional 5 units of insulin to be given. The LPN indicated the resident would receive a total of 15 units. At 4:22 p.m., the LPN removed a Glargine insulin pen from the medication cart. The pen was primed and the LPN proceeded to dial up 15 units. She then entered the resident's room and administered the insulin in the abdomen. The record for Resident 42 was reviewed on 2/2/23 at 10:00 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and atrial fibrillation (irregular heartbeat). The 12/30/22 Quarterly Minimum Data Set (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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 2 residents reviewed for urinary tract infections (UTI). (Resident 35) Finding includes: During an interview on 1/29/23 at 2:20 p.m., Resident 35's spouse indicated the nurse collected a urine sample and told him his wife had a UTI, but he did not know if she was on an antibiotic. The record for Resident 35 was reviewed on 1/31/23 at 10:32 a.m. Diagnoses included, but were not limited to, peg tube, weakness, mild protein malnutrition, UTI, and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 11/11/22, indicated the resident was severely impaired for decision making. The resident was frequently incontinent of urine and bowel. A Care Plan, dated 1/30/23, indicated the resident was on an antibiotic for a UTI. 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.