Brickyard Healthcare - Woodbridge Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 2 residents reviewed for unnecessary medications and bladder.(Resident 4) Findings include: On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and flaccid neuropathic bladder, not elsewhere specified. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. The Bowel and Bladder section indicated Resident 4 had an indwelling, suprapubic and external catheters with a colostomy. A Significant Change MDS dated [DATE] indicated that Resident 4 had an indwelling, suprapubic catheter and no external catheter or colostomy. Physician orders included but were not limited to: Change suprapubic catheter drainage bag weekly and PRN ( As Needed) dated 3/27/2024. Change catheter as needed (occlusion,…

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 implement physician orders or develop care plans for 3 of 5 resident's reviewed for unnecessary medications. (Resident 4, Resident 9, Resident 15) Findings include: 1. On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder, anxiety state, unspecified, chronic pain, essential primary hypertension and osteoarthritis. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. During the 7 days look back period the resident was noted to be on the following types of medications: Antidepressant, Antianxiety, Antipsychotc, Opioid, and Diuretic. Current physician orders included: Norco Oral Tablet 7.5-325 MG (Milligrams) (Hydrocodone-Acetaminophen)(pain medication).Give 1 tablet by mouth every 6 hours as needed for Pain related to PRIMARY GENERALIZED…

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 medication was being properly administered for 1 of 1 random observations of insulin administration. (Resident 25) Finding includes: On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed preparing a Humalog Insulin Kwikpen for insulin administration for Resident 25. An AccuCheck (blood glucose test) indicated the resident had a blood sugar of 200. RN 3 indicated the resident received sliding scale insulin and was to receive 4 units of insulin lispro (a fast acting insulin) for a blood glucose reading of 200. RN 3 set the insulin pen to 6 units and indicated the resident got 4 units of insulin plus 2 units of insulin to prime the pen. She cleaned the tip of the pen, attached the needle, and administered 6 units of insulin to Resident 25 in her left arm. On 7/12/24 at 11:51 A.M., Licensed Practical Nurse (LPN) 6 indicated insulin pens do not have to be primed and she had never primed an insulin pen before. On 7/12/24 at 1:46 P.M., the Humalog Kwikpen user manual was reviewed. It indicated Prime…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents who required restorative services received services in their plan of care for 3 of 4 residents reviewed for restorative nursing. (Resident 2, Resident 7, Resident 13) Findings include: 1. On 7/12/24 at 8:52 A.M., Resident 2's clinical record was reviewed. Resident 2's diagnoses included, but were not limited to, dementia, weakness, and intellectual disabilities. The most recent Quarterly MDS (Minimum Data Set Assessment), dated 6/3/24, indicated resident 2 was severely cognitively impaired, required substantial assistance of staff with toileting and transfers, and was dependent on staff for bathing. Care plans included, but were not limited to: Nursing rehab/restorative AROM (active range of motion) program: AROM to BLE (bilateral lower extremities), hips, knees, and ankles, 20 reps 1-2 sets daily; date initiated 9/13/22. On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record…

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

Based on interview and record review, the facility failed to reduce the risk of falling for 1 of 3 residents reviewed for falls. Falls were not accurately documented, and the care plan was not updated with new interventions for a resident with multiple falls. (Resident 6) Finding includes: On 7/9/24 at 9:49 A.M., Resident 6 indicated she had recently fallen and broken her nose because she could not reach her call light. On 7/9/24 at 2:58 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and history of falling. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 6 was cognitively intact, was dependent on staff for transfers, and had 1 fall with major injury since the previous assessment. A Fall Risk Assessment, dated 6/11/24, indicated the resident was at risk for falls. A falls care plan, dated 12/20/22, indicated the resident was at risk for falls due to deconditioning, gait/balance problems,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician orders and implement plan of care relating to dialysis services for 1 of 1 resident's reviewed for hemodialysis. (Resident 13) Finding includes: On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Resident 13 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact, required moderate assistance from staff for toileting and bathing, and was receiving hemodialysis. Current physician orders included, but were not limited to: Obtain weight after dialysis treatments one time a day every Monday, Wednesday, Friday; start date 6/21/24. Monitor left upper extremity for (signs and symptoms) of infection. Every day and night shift for fistula; start date 6/5/24. Dialysis diet, Regular texture; start date 5/27/24. Current care plans 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, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 meal tray tested for food temperature. Findings include: On 7/10/24 at 12:09 P.M., a meal test tray was obtained on the 200 Unit Hall the following temperatures were obtained: chicken thigh- 126.5 degrees F (Fahrenheit) potato -125.5 degrees F cottage cheese 48.2 degrees F desert chocolate eclair pudding- 67.5 degrees F salad 53.6-degrees F During an interview on 7/8/24 at 11:21 A.M., Resident 15 indicated the food is cold. During an interview on 7/9/24 9:43 A.M., Resident 6 indicated the food is not always hot. The CNA's (Certified Nurse Aide) won't serve food right away. During an interview on 7/9/24 at 11:35 A.M., the Dietary Manager indicated the temperature for meats and vegetables should be greater than 165 degrees Fahrenheit and cold items should be less than 41 degrees Fahrenheit. On 7/15/24 at 8:55 A.M., the Administrator provided a current, nondated policy Record of Food Temperatures. The policy indicated .hot foods will be held at 135…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe storage of foods brought in externally for 1 of 1 residents reviewed for resident refrigerators. (Resident 8) Findings include: During an observation on 7/9/24 at 9:39 A.M., Resident 8's refridgerator had two blank temperature logs, dated June 2024 and July 2024, taped to the outside door of the refrigerator; no temperatures were recorded. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. During an interview on 7/12/24 at 11:04 A.M., LPN 14 indicated each morning when staff do rounds to check on resident's, they record the temperature of resident room refrigerators on the paper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that documentation was completed entirely or accurately for 2 of 3 residents reviewed for wounds and 1 of 5 residents reviewed for unnecessary medications. Duplicate medication order was entered, therapeutic leaves were not tracked, and documented skin assessments were not completed accurately. (Resident 15, Resident 8, and Resident 26) Findings include: 1. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, major depressive disorder. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/3/24, indicated Resident 15 was cognitively intact, required supervision for eating, and received an antidepressant medication during the 7-day look back period. Current physician orders included, but were not limited to: Sertraline (an antidepressant medication) Oral Capsule 150 mg (milligrams) - Give 1 capsule by mouth at bedtime related major depressive disorder, 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, interview, and record review, the facility failed to ensure multi-resident use glucometers were cleaned according to manufacture instructions for 1 of 1 random observations. (100 unit) Finding includes: On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed cleaning a glucometer after acquiring a blood sugar from a resident. She wiped the machine with a Micro-kill Bleach wipe for 2 seconds and placed it in the medicine cart. On 7/11/24 at 12:58 P.M., Qualified Medication Aide (QMA) 4 indicated that to clean a glucometer you wipe the machine for 30 seconds using a bleach wipe and then let it air dry. On 7/15/24 at 9:53 A.M., the Infection Preventionist indicated that to clean a glucometer you wrap it in a bleach wipe for 3 minutes and place it in a water cup or on a paper towel so it became clean. On 7/11/24 at 10:15 A.M., the Administrator provided an EvenCare blood glucose monitoring system user's guide, dated 2022, that indicated Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for 1 of 2 residents reviewed for baseline care plans. (Resident B) Finding includes: On 8/23/23 at 8:52 a.m., Resident B's clinical record was reviewed. A progress note titled Clinical admission Evaluation dated 5/20/23 at 1:53 p.m. Late Entry: indicated that Resident B was admitted to the facility on [DATE]. Resident B had diagnoses that included, but were not limited to: Chronic obstructive pulmonary disease, Alzheimer's disease, psychotic disturbance, paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, chronic pain syndrome, essential hypertension, peripheral vascular disease, unspecified asthma, systemic Lupus erytheematosus, emphysema. Care plans were reviewed and included, but were not limited to: Resident is on a regular diet, date initiated 5/22/24. (48 hours after admission) Other care plans reviewed started with a date of 5/24/23 or later. (96 hours after admission) On 8/23/23 at 1:10…

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

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The dietary manager lacked appropriate certification for 1 of 1 kitchen. Finding includes: On 8/31/22 at 10:00 A.M., employee records were reviewed. The current dietary manager lacked a state approved dietary certification. During an interview on 9/2/22 at 9:08 A.M., the Director of Nursing (DON) indicated the current dietary manager obtained that position on 2/2/18, and was currently working on becoming certified. On 9/2/22 at 10:21 A.M., a current manager of dining services job description, dated 9/27/15, was provided and indicated qualifications must include State approved dietary manager certificate or become certified within one year from hire date. 3.1-20(h)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety in 1 of 2 observations of the kitchen. The dishwasher was not tested with chemical strips, and the rinse solution container was empty. (Kitchen) Finding includes: During an initial kitchen observation on 8/29/22 at 7:27 A.M., a strip was placed in the dishwasher after a load was ran, and did not change color. At that time, the Kitchen Manager indicated she was unaware until recently that chemical strips were needed to test the dishwasher, and have had that dishwasher for about a year. At that time, the sanitizer container under the dishwasher was observed to be empty. On 8/29/22 at 7:56 A.M., the Kitchen Manager indicated the sanitizer, rinse, and detergent containers for the dishwasher were supposed to be changed when the solutions get to the bottom of the containers, and could be done by whoever was doing the dishes at that time. She indicated all staff were aware of when and how to change 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 interview and record review, the facility failed to designate a qualified individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a current certified Infection Preventionist for 1 of 1 employee file reviewed. Finding includes: During an interview on 8/29/22 at 10:21 A.M., the Director of Nursing (DON) indicated she was the Infection Preventionist, but was not yet certified. At that time, the DON indicated no other staff was acting as Infection Preventionist . The DON's hire date was 5/3/22. On 9/2/22 at 12:48 P.M., a current, undated Infection Preventionist policy was provided and indicated The facility will ensure the Infection Preventionist is qualified by education, training, experience or certification

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician orders were followed and care plans were implemented for 6 of 6 residents reviewed for medications and treatments. Residents did not receive medications, side effects were not monitored, skin treatments not performed, labs not obtained, oxygen not applied/worn, care plan interventions not implemented. (Resident B, Resident M, Resident L, Resident K, Resident O, Resident P) Findings include: 1. On 8/29/22 at 8:22 a.m., Resident B indicated they did not always receive their insulin shot. On 8/31/22 at 1:58 p.m., Resident B's clinical record was reviewed. Diagnoses included, not limited to, Diabetes Mellitus with stable proliferative diabetic retinopathy, hyphema, left eye, atelectasis unspecified. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was moderately impaired. Care plans were reviewed and included, not limited to: Alteration in blood glucose due to: hyperglycemic…

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

Based on observation, interview, and record review, the facility failed to ensure the temperature of food items were taken before food was served to residents for 1 of 1 meal observations. Findings include: On 8/31/22 at 7:16 A.M., [NAME] 49 was observed placing food items on trays to be delivered to residents. On 8/31/22 at 7:27 A.M., [NAME] 49 pushed the meal cart out of the kitchen to be delivered to the 200 hall residents. At that time, [NAME] 49 indicated temperatures were not taken for any of the following food items: oatmeal, waffles, sausage links, puree sausage, puree waffles, scrambled eggs, and gravy. During an interview on 9/1/22 at 10:17 A.M., the Dietician indicated all food items should have the temperature taken when the food items are on the steam table and right before being put on the plate from the steam table. On 9/2/22 at 12:48 P.M., a current undated Food Safety Requirements policy was provided and indicated .Cooking--foods shall be prepared as directed until recommended temperatures for the specific foods are reached . 3.1-21(a)(2)

Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) before the proposed end of services for 1 of 3 beneficiary notices reviewed. (Resident 15) Finding includes: On 8/30/22 at 1:45 P.M., during review of three randomly chosen resident Medicare Part A discharge notices, Resident 15's notice stated, The facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted, and a SNF ABN notification form was not provided, and a written note was provided from the facility that stated employee turnover new employee inserviced on process. On 9/1/22 at 1:16 P.M., the Business Office Manager (BOM) indicated an ABN should have been completed. On 9/2/22 at 12:48 P.M., a current, undated Advance Beneficiary Notices policy was provided and indicated .The current CMS-approved [Centers for Medicare and Medicaid Services] version of the forms shall be used at the time of issuance to the beneficiary…

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

Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization. (Resident K, Resident C) Findings include: 1. On 8/30/22 at 10:23 A.M., Resident K's clinical record was reviewed. Resident K had been sent to the hospital on the following dates: From 5/6/22 through 5/12/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative. On 9/1/22 at 10:52 A.M., a notice of transfer or discharge form was provided for Resident K's hospital visit on 5/6/22, but the form was not filled out or dated. From 6/11/22 through 6/13/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative. During an interview on 9/1/22 at 10:52 A.M., the Regional Consultant…

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

Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization. (Resident K, Resident C) Findings include: 1. On 8/30/22 at 10:23 A.M., Resident K's clinical record was reviewed. Resident K had been sent to the hospital on the following dates: From 5/6/22 through 5/12/22 - Resident K's clinical record lacked documentation of a bed hold policy being given to the resident or resident's representative. From 6/11/22 through 6/13/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative. During an interview on 9/1/22 at 10:52 A.M., the Regional Consultant indicated the transfer forms, including the bed hold policy, was not found for that hospitalization, and should have been provided. 2. On 9/1/22 at 1:26 P.M., Resident C's clinical record was reviewed. Resident C…

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 implement interventions to prevent accidents for 1 of 2 residents reviewed for falls. Resident 62 had 16 falls April through August, care plan interventions were not followed. (Resident 62) Finding includes: During record review on 08/31/22 10:27 A.M., Resident 62's most recent quarterly MDS (Minimal Data Set) Assessment, dated 8/20/22, indicated the Resident was an extensive assist with 2 (two) staff members for transfers. Resident 62's diagnoses include, but were not limited to, Parkinson's disease, repeated falls, traumatic subdural hemorrhage with loss of consciousness of unspecified duration, fracture of unspecified part of right clavicle, with routine healing, unspecified displaced fracture of seventh cervical vertebra, with routine healing, multiple fractures of ribs, right side, with routine healing, unspecified fracture of the first thoracic vertebra, with routine healing, orthostatic hypotension, cerebral infarct, and syncope and collapse. Resident 62's care plan included, but was not limited to, at…

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

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 2 of 26 opportunities observed to administer medications correctly, resulting in an error rate of 7.69%. This affected 2 of 5 residents observed during medication administration. (Resident K, Resident 40) Findings include: 1. On 8/30/22 at 9:55 A.M., Licensed Practical Nurse (LPN 8) was observed to administer 2 (two) 110 mg (milligram) tablets of Zinc sulfate (A total of 220 mg) to Resident 40. The physician's orders included, but were not limited to, Zinc Tablet 50 MG Give 2 tablet by mouth one time a day for supplement. 2. On 8/31/22 at 7:35 A.M., Registered Nurse (RN) 15 removed an oatmeal from the meal cart and RN 15 pushed a liquid substance into Resident K's oatmeal and returned the oatmeal to the meal cart. During an interview at that time, RN 15 indicated the medication pushed into the oatmeal was Haldol. On 8/31/22 at 8:52 A.M., Resident K's clinical record was reviewed. Current physician orders 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.

Based on interview and record review, the facility failed to test symptomatic residents for COVID-19 for 1 of 1 residents with signs and symptoms. A resident was not tested for COVID-19 until 7 days after symptoms started. (Resident 46) Finding includes: On 8/31/22 at 1:04 P.M., Resident 46's clinical record was reviewed. On 8/26/22 Resident 46 was tested for COVID-19 and had a positive result. During an interview on, 8/31/22 at 1:16 P.M., the Director of Nursing (DON) indicated Resident 46 had COVID-19 symptoms starting on 8/19/22. The DON was unable to find a COVID-19 test result from 8/19/22 through 8/25/22. At that time, the DON indicated residents should currently be tested every Tuesday and Thursday of when symptoms start. On 9/2/22 at 12:48 P.M., a current Clinical Guidance for COVID-19 testing, dated 2/8/22, was provided and indicated when a symptomatic resident was identified, they should be tested for COVID-19 regardless of vaccination status. 3.1-18(b)

Based on interview and record review, the facility failed to follow their contingency plan for staff that are not fully vaccinated for 1 of 1 staff not fully vaccinated. (Staff 19) Finding includes: On 8/30/22 at 11:50 P.M., the COVID-19 staff vaccination status was reviewed. Staff 19 was documented as partially vaccinated. On 8/31/22 at 6:33 A.M., Staff 19 was observed wearing a surgical mask entering a room with 3 residents and was within an arms length of one of those residents. During an interview on 8/31/22 at 6:35 A.M., Staff 19 indicated administrative staff had said something about wearing an n95 while in the facility due to being partially vaccinated. During an interview on 9/2/22 at 9:30 A.M., the Director of Nursing (DON) indicated she was unsure why Staff 19 was working due to facility policy that employees without exemption or approved delay are required to have unpaid leave until fully vaccinated. On 8/29/22 at 10:00 A.M., a current COVID-19 Vaccination and Testing policy, revised 4/18/22, indicated .Any employee that has not provided .an approved delay in vaccination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment in resident spaces in 2 of 3 halls observed. Holes in door, broken footboard, SHARPS container full at bedside, personal care items uncovered and unlabeled.(100 Hall, 200 Hall) Findings include: 1. On 8/30/22 at 8:54 A.M., in the shared bathroom of room [ROOM NUMBER], there was a quarter size hole in the bathroom door, an unlabeled, used urinal on the sink, an uncovered plunger on the floor, uncovered wash basin with used rags on the floor, bucket on floor open with paper towels and an empty, unlabeled urinal in it. In the bedroom, there were 4 (four) used gloves and an empty medication cup on the floor. On 9/2/22 at 9:10 A.M., there was still a quarter size hole in the bathroom door and an uncovered plunger on the floor. 2. On 8/29/22 at 9:03 A.M., in room [ROOM NUMBER], the footboard of bed closest to the bathroom was broken and hanging off the bed and there were multiple black…

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.