Columbia Healthcare Center

Based on interview and record review, the facility failed to notify the physician of blood glucose levels outside of parameters for 1 of 2 residents reviewed for insulin administration. (Resident 59) Finding includes: On 10/29/24 at 12:59 P.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 7 days during the 7-day lookback period. Physician orders included, but were not limited to: Accu-check (a blood glucose monitoring system) once a day - Notify physician if Accu-check is below 60 milligram per deciliter (mg/dL) or greater than 400 mg/dL, dated 4/22/20 A risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus care plan, dated 4/7/20 and reviewed 9/25/24, included an intervention to document abnormal findings 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 a resident had a care plan implemented related to frequent urinary tract infections (UTI) with multidrug resistant organisms for 1 of 1 residents reviewed for UTI. (Resident 85) Finding includes: On 10/25/24 at 10:58 A.M. Resident 85 indicated that they got frequent urinary tract infections because staff did not clean her properly. The clinical record was reviewed on 10/28/24 at 2:49 P.M. Resident 85 had diagnoses that included but was not limited to urinary tract infection. A Quarterly MDS (Minimum Data Set) Assessment, dated 9/24/24, indicated the resident was cognitively intact, used a wheel chair, required substantial to maximum assistance with bathing and personal hygiene, was incontinent of bowel and bladder, had a primary diagnosis of COPD (chronic obstructive pulmonary disease), had a urinary tract infection within the last 30 days, had an intravenous catheter, had been on intravenous medications, required isolation precautions, and was on antibiotics. Current physician orders included but was 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 ensure a resident did not develop an avoidable pressure ulcer by monitoring skin for 1 of 3 residents reviewed for facility acquired pressure ulcers. (Resident 89) Finding includes: During an interview on 10/24/24 at 2:22 P.M., Resident 89 indicated she had pressure injuries on her right leg from her knee immobilizer not being monitored. On 10/28/24 at 2:40 P.M., Resident 89's clinical record was reviewed. Diagnoses included, but were not limited to congestive heart failure and diabetes mellitus. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 8/7/24, indicated resident 89 was cognitively intact, was fully dependent on staff for transfers, required substantial assistance from staff (staff do more than half the work) for toileting and bathing, and did not have any unhealed pressure ulcers. Current physician orders included, but were not limited to: Right calf: cleanse wound with wound cleanser, pat dry; wound to be packed by wound NP (nurse practitioner) with skin sub, cover with silicone…

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, observation, and record review, the facility failed to administer non-pharmalogical or pharmalogical interventions for pain prior to performing wound care for 1 of 2 residents observed for wound care. (Resident 104) Finding includes: On 10/29/24 at 9:46 A.M., Resident 104's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of lymph nodes of head, face, and neck and squamous cell carcinoma of skin of scalp and neck. A Significant Change MDS (Minimum Data Set) Assessment, dated 9/3/24, indicated Resident 104 was cognitively intact, was completely dependent on staff for transfers required substantial assistance from staff (staff does more than half the work) for toileting and bathing, received as needed pain medication in the last five days and had not received non-medication intervention for pain in the past five days. Current physician orders included, but were not limited to: hydrocodone-acetaminophen schedule II tablet 5-325 mg; oral every four hours as needed, start date 9/10/24. Betadine (povidone-iodine) solution;…

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 medications were administered according to manufacture and professional standard for 1 of 5 residents observed during medication pass. (Resident 89) Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a 7.69% error rate. (Resident 89) Findings include: During a medication administration on 10/25/24 at 7:55 A.M., LPN (Licensed Practical Nurse) 13 prepared Glargine Insulin 30 Units SQ (Subcutaneous) bid (two times a day) and Lispro 10 units SQ tid (three times a day) and did not prime the two insulin injection pens with two units prior to administering. On 10/25/24 at 1:45 P.M., Resident 89's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and Systemic Lupus erythematosus. Physician orders included, but were not limited to, Insulin Glargine-insulin pen; 100 unit/mL (Milliliters) (3 mL); amt (amount): 30 units; subcutaneous. Special Instructions: Give half dose of insulin if BS (Blood Sugar) <…

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 documentation was complete and accurate for 1 of 2 residents reviewed for insulin use. (Resident 59) Finding includes: On 10/29/24 at 12:59 P.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 7 days during the 7-day lookback period. The July 2024 Physician's recapitulation orders dated 7/7/24 at 9:39 A.M., indicated the following order was received: Humalog (insulin lispro) KwikPen - insulin lispro (a short-acting insulin) - Give per Sliding Scale subcutaneous, three times a day, If Blood Sugar is less than 60 mg/dL, call physician. If Blood Sugar is 0 to 199, give 0 Units. If Blood Sugar is 200 to 249, give 1 Units. If Blood Sugar is 250 to 299, give 2 Units. If Blood Sugar is 300 to 349, give 3 Units. If Blood Sugar is 350 to 399,…

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 infection control practices were in place for 2 of 2 residents during incontinence care and 1 of 1 resident during wound care. Staff failed to sanitize hands and change gloves between soiled to clean tasks, as well as failed to use enhanced barrier precautions during wound care. (Resident 64, Resident 85, and Resident 86) Findings included: 1. On 10/24/24 at 10:43 A.M., CNA (Certified Nurses Aide) 3 went into Resident 64's room. CNA 3 donned gloves, checked the resident's brief to see if they were incontinent, started to act upon changing the soiled brief but then indicated they would go get another staff member to assist. CNA 3 touched the resident's remote to their bed, and bedside table with soiled gloves before removing them then did not sanitize or wash hands. On 10/29/24, at 11:44 A.M., Resident 64's clinical record was reviewed. The Annual MDS (Minimum Data Set) Assessment on 8/5/24 indicated the resident was not cognitively intact, required substantial or maximum assistance with toileting and personal hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a the facility implemented the resident's discharge process for 1 of 3 residents reviewed for transfer/discharge rights. A resident who lacked the ability to care for herself discharged home from the facility prior to the arrangement of a home health service and without documentation being completed according to the facility's discharge policy. (Resident B) Finding includes: During record review on 5/8/24 at 11:00 A.M., Resident B's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety, chronic pain, history of falls, weakness, and unsteadiness on feet. Resident B's hospital notes from a hospital admission on [DATE], prior to admitting to the facility on 4/11/24, included, but was not limited to the following physician note; .I have a great deal of concern with the overall safety and stability of this patient, both socially and mentally. As her own outpatient PCP (Primary…

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 dignity for 3 of 3 residents reviewed for quality of care and treatment. Residents were not assisted with care in a timely manner, not treated with respect and dignity. (Resident B, Resident C, Resident D) Findings includes: 1. On 3/25/24 at 9:24 a.m., Resident B indicated they have turned on their call light and waited two hours for care, staff come in and turned off the call light and leave without providing care. On 3/25/24 at 10:23 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unsteadiness on feet, muscle weakness (generalized). An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, toileting extensive assist x 1. Care plans were reviewed and included but were not limited to: Problem start date: 1/25/24: Resident requires assistance with toileting due to: dx…

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 notify the physician of medications not available or given as ordered. A resident's non availability of ordered medications was not reported to the physician. (Resident B) Findings include: On 11/27/23 at 10:20 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of pancreas, unspecified (history of), exocrine pancreatic insufficiency. An admission MDS (Minimum Data Set) assessment, dated 11/13/23, indicated Resident B's cognition was intact. Resident B admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Care plans were reviewed and included, but were not limited to, Resident is a new admission to the facility and requires implementation of services to promote physical, emotional, and psychosocial well-being including assistance with activities of daily living r/t dx of pancreatic cancer, aspiration pneumonia, umbilical hernia, atherosclerotic heart disease,…

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 provide ADL's (activities of daily living), care to 1 of 3 resident's reviewed for bathing. Bathing was not provided to a resident. ( Resident D) Finding includes: On 11/27/23 at 1:56 p.m., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, unsteadiness on feet, muscle weakness (generalized), other abnormalities of gait and mobility. An admission MDS (Minimum Data Set), assessment dated [DATE], indicated Resident D's cognition was intact, shower/bathe self/admission performance was partial/moderate assistance. Resident D admitted to the facility on [DATE] and discharged on 11/21/23. Care plans were reviewed and included, but were not limited to, resident requires assistance with ADL's including bed mobility, transfers, eating, and toileting, related to: weakness, decreased mobility, incontinence, fall risk, HX of falls, cellulitis of lower left limb, d/t chronic ulcer of other part of left lower leg with fat layer…

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 employ staff with the appropriate competencies and skills sets to carry out the function of preparing pureed diets for 8 resident meals during 1 of 1 food processing reviewed. Findings include: On 8/9/23 at 11:35 A.M., the puree process for the noon meal was observed. The Dietary Manager oversaw the process while Kitchen Staff 17 prepared the pureed food. Kitchen Staff 17 indicated she was preparing 10 servings for 8 residents who required pureed food. When measuring the dry potato pearls, Kitchen Staff 17 misread the amount to measure, and held the measuring cup sideways so both the amount and the measurement were incorrect. They were out of the butter blend listed in the recipe, so Kitchen Staff 17 added regular butter from 7 individual 5-gram packets. Neither Kitchen Staff 17 nor the Dietary Manager knew the conversion from grams to ounces and did not check to make sure they were meeting the nutritional requirements outlined by the Dietician. The recipe for the puree menu that was prepared for lunch on 8/9/23 was…

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

Based on observation, record review and interview, the facility failed to provide food and drink that are palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test trays and resident interviewed for palatable food served at a palatable temperature. Findings include: 1. The following resident interviews were obtained: On 8/8/23 at 9:07 A.M. Resident 5 complained of the food being cold. On 8/8/23 at 10:04 A.M., Resident 26 complained on cold food. On 8/8/23 at 10:56 A.M., Resident 72 complained of lukewarm food. 2. During Resident Council meeting on 8/9/23 at 9:30 A.M., residents complained about food portions, some were not getting the double portions they ordered, the poor quality of food, and the food being cold. Residents complained about getting spoiled milk and watered-down juice. One resident produced multiple pictures of a meal they had recently been served, which was listed on the menu as chicken stir fry over rice with egg roll. On the plate, the rice covered over 3/4 of the plate, the chicken stir fry was about 1/2 cup on the side of the rice, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide a nourishing snack at bed time for 5 of 5 residents interviewed for bedtime snacks, and to provide meals at times comparable to normal mealtimes in the community for 1 of 1 meals observed. Findings include: 1. During Resident Council meeting on 8/9/23 at 9:30 A.M., residents complained about not getting bed time snacks. Resident 10 indicated they all keep their own stash of snacks that they buy when they go to Wal-Mart. They also complained about meals being late. The following interviews were obtained: On 8/10/23 at 10:30 A.M., Resident 24 complained about not getting bed time snacks. On 8/10/23 at 10:35 A.M., Resident 57 complained about not getting bed time snacks. On 8/10/23 at 10:40 A.M., Resident 113 complained about not getting bed time snacks. On 8/10/23 at 10:45 A.M., Resident 112 complained about not getting bed time snacks. He indicated he buys extra snacks at Wal-Mart for himself and other residents. During 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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed. Findings include: On 8/7/23 at 9:54 A.M. the kitchen tour began. 1. The kitchen floor was sticky, with food crumbs and scattered pieces of debris observed throughout. 2. There was a dirty towel on the floor behind the coffee machine. 3. The tops of 4 storage bins were sticky, the flour was not labeled or dated. 4. There was a fist-sized hole in the drywall above the faucet of the 3-sink, all the way through. 5. There were 3 ceiling lights burned out in kitchen, 1 ceiling light burned out in dishwashing room, and 3 ceiling lights were without covers in the kitchen. During an observation of the walk-in refrigerator on 8/7/23 at 10:00 A.M., there was: 6. 1 gallon of milk open not labeled 7. 3 18-qt. containers of yellow-colored drink, 1 of 3 was labeled, all expired on 8/2/23 8. 1 metal container of sliced cheese was open not labeled 9. 1 plastic container of ham was expired 8/5/23 10. 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 1 of 1 locked dementia unit. (The Cottage) Findings include: During observation of the unit on 8/8/23 at 1:00 P.M.: 1. The bathroom between rooms [ROOM NUMBERS], which was shared by 4 residents, was observed to have 2 nail holes and a 13 diameter area on the wall where the toilet paper holder had been replaced. The surface of the drywall was torn off. 2. In room [ROOM NUMBER], there was a fist-sized patch of paint chipped off on the left side of the bathroom door frame about halfway up. 3. In the bathroom between rooms [ROOM NUMBERS], which was shared by 4 residents, there was a 12 x 4 area behind the left side of the toilet that had not been painted and had 2 different colors (red and blue) showing through. 4. On 8/9/23 at 3:39, during an observation and interview with LPN (Licensed Practical Nurse) 14, room [ROOM NUMBER] was found to have a bathtub that was dirty on the bottom, with 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 and interview the facility failed to accommodate each resident with the use of call lights to summon help from staff for 4 of 4 residents reviewed for assistance. (Resident 26, Resident 117, Resident 29, Resident 114) Findings include: 1. On 8/8/23 at 9:43 A.M., Resident 26's call device was observed out of reach at the top of the bed. It was a push button type of device. During an interview at that time, the resident indicated she had to go to the bathroom and could not find the call device. The call device was activated for the resident at 9:44 A.M. On 8/14/23 at 8:55 A.M., the resident's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and COPD. admission MDS 6/20/23 indicated resident has severe cognitive impairment and requires extensive assist of 2 for toileting. The current care plan, dated 6/15/23, included resident is at risk for falls. Interventions included, but were not limited to, touch pad call light in reach. The resident was not provided a touch pad type call light for use. 2. On 8/8/23 during a tour of the 1400…

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 that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal and oral hygiene for 3 of 4 residents reviewed. ( Resident 26, Resident 72, Resident 88) Findings include: 1. During an interview and observation with Resident 26 on 8/8/23 at 9:43 A.M., her hair was observed to be very disheveled. She indicated the facility has staff but some of the people don't bother to work. Resident indicated she had to go to the bathroom now. She called for help at 9:44 A.M. No help arrived, no one was in the hall. At 9:55 A.M., the resident got to her feet and refused to sit back down. She begged to go to the bathroom. A clinical instructor, who indicated she was employed by the facility, came to the door to see what was going on. She left to get help. Resident continued to try and walk to the bathroom and cried out I'm pooping on myself. At 9:58 A.M., QMA (Qualified Medication Aide) 9 and CNA (Certified Nursing Assistant) 6 arrived 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 interview, record review, and observation, the facility failed to provide adequate supervision, assistance devices, or interventions to reduce the risk of fall for 2 of 3 residents reviewed for falls with major injuries. (Resident 94 and Resident 39) Findings include: 1. Resident 94's clinical record was reviewed on 8/9/23 at 9:32 A.M. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dysphagia, and invertebral disc degeneration. Resident 94's most recent Annual Minimum Data Set (MDS) Assessment, dated 7/7/23, indicated the resident was severely cognitively impaired, required extensive assistance of two people for mobility and transfers, and required extensive assistance of one person for toileting and bathing. Resident 94's care plan included, but were not limited to, Assist with toileting and/or incontinent care and Assist of one with transfers, dated 08/24/2021. A fall event report was created on 7/20/23 at 2:43 P.M. The fall event indicated an unwitnessed fall occurred in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment to prevent urinary tract infections (UTIs) for 1 of 1 residents reviewed for catheter use and history of UTIs. A catheter bag was observed on the floor. (Resident 49) Finding includes: On 8/8/23 at 9:08 A.M., Resident 49's catheter bag was observed laying on the floor next to the resident's bed. On 8/9/23 at 8:57 A.M., Resident 49's catheter bag was observed laying on the floor next to the resident's bed. On 8/9/23 at 9:11 A.M., RN (Registered Nurse) 12 changed the dressing around Resident 49's supra pubic catheter. At that time, the catheter bag was on the floor and the tubing touched the floor. RN 12 exited the room and left the catheter bag on the floor. On 8/9/23 at 9:19 A.M., RN 12 indicated that Resident 49 had a history of throwing the catheter bag on the floor. She further indicated that staff should pay attention to where the catheter bag is when they are in the room and pick it up…

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 provide a resident with a urostomy care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 residents with a urostomy. (Resident 72) Finding includes: On 8/10/23 at 9:07 A.M., LPN (Licensed Practical Nurse) 5 was observed changing the urostomy dressing for Resident 72. The resident had been on contact precautions beginning 8/9/23 at 10:30 A.M. due to the presence of an antibiotic-resistant urinary tract infection (UTI). LPN 11, who identified herself as the wound nurse, observed the procedure but did not assist. Approximately 200 cc's of rust-colored urine were observed in the catheter bag. When disconnecting the catheter bag, LPN 5 placed it in the waste basket next to resident's bed. She removed the old urostomy bag and deposited it in a plastic bag on the bed. There were 2 stents, about 8 long, protruding from the stoma. They were filled with a dark red substance that was not draining. When applying the new urostomy bag, LPN 5 discussed with the…

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

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care (Resident 26). Findings include: During an interview with Resident 26 on 8/8/23 at 9:43 A.M., she indicated how she needed her oxygen. During an observation on 8/8/23 at 9:34 A.M., the tubing on Resident 26's oxygen concentrator was not dated. There was a 2-inch strip of brown sticky substance on top of concentrator. The oxygen was on at 1.5 liters per minute (lpm) per nasal cannula (nc). During an observation on 8/9/23 at 11:00 A.M., the resident was observed in the hallway, asleep in her wheelchair, with a portable oxygen tank hanging from the wheelchair. The tubing was not dated, and was connected to the portable oxygen tank which was empty, as indicated by the contents indicator being in the red and the arrow resting at zero (0). The oxygen concentrator in the resident's room was observed to be on at 1.5 lpm. The brown sticky…

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 it was free of a medication error greater than 5 percent for 1 of 4 residents observed during medication pass. Three medication errors were observed during 35 opportunities for error in medication administration. This resulted in an 8.57% error rate. (Resident 1) Findings include: During a random medication administration, on 8/9/23 at 8:51 A.M., QMA (Qualified Medication Aide)10 administered 13 pills and 2 nasal sprays to Resident 1: Clonidine 0.1 mg 1 po (by mouth) bid (twice a day). Amlodipine 5 mg 1 po daily. Baby Asa (aspirin) 81 mg 1 po daily. CertaVite 1 tablet 1 po daily. Docusate 100 mg (milligrams) 2 po bid. Depakote delayed release 125 mg 1 po bid. Epinaster 0.05% 1 qtt (drop) both eyes BID. Azelstaine 137 mcg (microgram) (0.1%) 1 spray each nostril bid. Atrovent 0.06% 2 sprays bid each nostril. Lisinopril 10 mg 1 po bid. Vitamin D3 1000 units 2 tabs po daily. Protonix 40 mg 1 po daily. Propranolol 40 mg 1 po bid. Senokot-S 8.6mg/50 mg (sennosides/docusate) 1 po bid. Optimal D3…

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 provide proper storage of medications in 4 of 6 medication/treatment carts. Loose pills and unlabeled biologicals/medications were found in drawers of treatment cart and medication carts. (1400 Hall medication cart, First floor treatment cart, 2200 Hall medication cart, 2400 Hall medication cart) Findings include: 1. On 8/9/23 at 9:05 A.M., the medication cart on the 2400 Hall was observed to have the following medications laying loose in the cart: 1 large white oblong pill with numbers 1104 30 1 large white pill 2 bottles of multivitamin with the initial [resident initial] 1 bottle of opened Activa (protein supplement) no label or name 1 bottle of Melatonin no label with the [resident initial] 1 large bottle of Tums with Resident 1 name but no label 2. On 8/10/23 at 7:50 A.M., the medication cart on 1400 Hall was observed to have the following medications unlabeled in the cart: 1 Tresiba insulin pen not labeled. 1 Victoza insulin with no name or prescription label 3. On 8/10/23 at 7:54 A.M., the treatment…

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.