North Capitol Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely identify and obtain physician's orders for a surgical wound that was present upon admission to the facility for 1 of 4 residents reviewed for wounds (Resident B). Findings include: The clinical record for resident B was reviewed on 2/6/25 at 11:30 a.m. The diagnoses included, but were not limited to, anal abscess (swollen area within body tissue, containing an accumulation of pus) and colostomy (colon was diverted to an artificial opening in the abdominal wall). She was admitted to the facility on [DATE]. An admission assessment, dated 1/13/25 at 8:04 p.m., indicated she had a wound on her right buttock which was 28 centimeters (cm) in length and 13 cm in width. The depth of the wound was eight cm. There were no other wounds identified on the admission assessment. A Nursing Progress Note, dated 1/13/25 at 9:54 p.m., indicated .This writer notified [name of hospital that discharged resident] . regarding treatment orders for resident .unable 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 and record review, the facility failed to ensure a resident who required follow-up care with an Ears, Nose, and Throat (ENT) physician was provided transportation to those appointments 1 of 3 residents reviewed for quality of care. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/24/24 at 1:23 p.m. The diagnoses included, but were not limited to, malignant neoplasm of oropharynx (a type of head and neck cancer that starts in the middle part of the throat), tongue cancer, laryngectomy (removal of part or all the voice box), glossectomy (removal of part or all the tongue) and hydrocephalus (a buildup of extra fluid within the brain). A list of Resident C's appointments for the last six months was provided by Executive Director (ED) on 9/24/24 at 11:09 a.m. The list indicated in the last six months the resident had appointments on 4/5/24, 4/16/24, and 6/27/24. The resident required transportation to appointments and to be accompanied by a Respiratory Therapist…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's safety when using a mechanical sling lift by a staff member not securing the sling clip to the peg on the mechanical lift and causing a resident to fall to the floor for 1 of 3 residents reviewed for falls. (Resident K) Findings include: The clinical record for Resident K was reviewed on 9/26/24 at 10:21 a.m. His diagnoses included, but were not limited to, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), and contractures (a permanent or temporary shortening of muscles, tendons, skin, and other soft tissues that causes joints to stiffen and limit movement). A Physical Therapy Evaluation, dated 5/20/24, indicated Resident K required a mechanical lift for transfers. A nursing note, dated 9/23/24 at 9:49 a.m., indicated the nurse was alerted by a certified nursing assistant (CNA) that Resident K fell. The resident was lying on the floor in the entry to his room…

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

Based on observation, interview, and record review, the facility failed to properly store foods in the kitchen. This affected of 60 residents in the facility who eat food from the kitchen. Findings include: An initial tour of the kitchen was conducted on 5/28/24 at 10:11 a.m. with Registered Dietician (RD). During the initial tour the following was observed: In the walk-in fridge: - On a shelf in the fridge was a metal pan which contained a package of meat. RD indicated, at the time of the observation, the meat in the pan was thawing and should have been labeled with the kind of meat it was and a date indicating when it was taken out of the freezer to ensure its use within 72 hours of thawing. - Two unopened half gallons of lactose free milk where found to be expired. The expiration dates on the containers of lactose free milk were May 12, 2024 and May 11, 2024 respectively. - Sitting on the floor of the fridge in a milk crate were two unopened gallon jugs of milk. According to the RD at the time of the observation, no food items should be stored on the floor of the fridge. - On a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment related to splintered chair rails behind beds; scrapped walls with exposed drywall; phone [NAME] with exposed wires; not ensuring wheel chairs were clean; not assuring feeding pump poles were clean; bed linens, towels, and washcloths with stains; bedroom furniture on the vent unit with missing and scratched veneer; and floors with loose and missing tiles for 10 of 15 residents reviewed for environment (Resident D, 21, 24, 27, 28, 30, 36, 44, 53 and 55). Findings include: 1. On 5/28/24 at 10:28 a.m., Resident 44's room was observed. The chair rail behind his bed was splintered and broken. 2. On 5/28/24 at 10:21 a.m., Resident 36's room was observed. The wall by the sink was chipped and drywall was exposed. The chair rail behind his bed was broken and splintered. The telephone jack was pulled from the wall with wires exposed. 3. On 5/28/24 at 10:36 a.m., Resident 27's room was observed. 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 have the Interdisciplinary team (IDT) determine and document a self medication assessment was clinically appropriate for 1 of 1 residents randomly observed with medications by their side in a common area. (Resident 18) Findings include: A random observation of Resident 18 was made on 5/28/24 at 11:12 a.m. Resident 18 was sitting in the common area/lounge on the second floor and on a table beside her was a medication cup with pills in it. The cup had several unidentified medication tablets in it. Resident 18 indicated, she questioned the number of medications in the cup and did not want to take medications without knowing what she was given. An interview with Licensed Practical Nurse (LPN 22) conducted on 5/28/24 at 11:17 a.m. indicated, she had given Resident 22 her morning medications and believed she had placed them in her mouth prior to leaving the resident. LPN 22 indicated, Resident 18 must have spit them out back into the cup after…

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 dependent residents with oral care, complete bed bath, hair care, and emptying of a bedside commode for 3 of 6 residents reviewed for activities of daily living (ADLs). (Resident D, Resident E, and Resident F) Findings include: 1. The clinical record for Resident D was reviewed on 5/31/24 at 3:05 p.m. The diagnoses included, but were not limited to, hypertension, congestive heart failure, diabetes mellitus, and muscle weakness. A care plan for skin integrity, dated 5/21/24, indicated Resident D had impaired skin integrity. He was on bedrest, limited in his ability to change positions, and a problem for shear and friction related to required maximum assistance with bed mobility. A physician order, dated 5/17/24, indicated to perform oral care three times a day. An observation conducted of Resident D, on 5/29/24 at 9:56 a.m., of a white coated substance to his tongue. An observation conducted of Resident D, on 5/29/24 at 10:43 a.m., of a white coated substance to his tongue. An observation conducted of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a low air loss mattress was functioning for 2 of 2 residents reviewed for pressure ulcers. (Resident D and Resident 45) Findings include: 1. The clinical record for Resident D was reviewed on 5/31/24 at 3:05 p.m. The diagnoses included, but were not limited to, hypertension, congestive heart failure, diabetes mellitus, and muscle weakness. A care plan for skin integrity, dated 5/21/24, indicated Resident D had impaired skin integrity. He was on bedrest, limited in his ability to change positions, and a problem for shear and friction related to required maximum assistance with bed mobility. An approach was listed to utilize a pressure reducing/redistribution mattress on the bed/low air loss (LAL) mattress. An observation conducted of Resident D, on 5/29/24 at 9:56 a.m., laying on a mattress with a pump to the foot board. There were no lights on the pump to indicate it was on and functioning. An observation conducted of Resident D,…

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 flooring was in good condition to prevent accident hazards for a resident that had tripped on loose flooring and had fallen for 1 of 2 residents reviewed for accidents. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/31/24 at 10:31 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, dependence on ventilator, muscle weakness, morbid obesity, and diabetes mellitus. An ADL care plan, dated 8/4/22, indicated Resident E required assistance with ADLs including bed mobility, transfers, and toileting related to chronic respiratory failure, anxiety disorder, depression, and debility. An approach was listed to assist with toileting and/or incontinence care as needed. A quarterly minimum data set (MDS) assessment, dated 4/4/24, indicated Resident E was cognitively intact, needed substantial/maximal assistance with toileting hygiene and personal hygiene, and supervision/touching assistance with toilet transfer. An interview…

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 infection control practices were maintained during incontinence care and ensure follow-up regarding changes in urinary output from an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheter. (Resident F) Findings include: The clinical record for Resident F was reviewed on 5/31/24 at 10:03 a.m. The diagnoses included, but were not limited to, respiratory failure, diabetes mellitus, obesity, tracheostomy status, gastrostomy status, dependence on ventilator, and neuromuscular dysfunction of bladder. An admission MDS assessment, dated 4/1/24, indicated Resident F was dependent for ADLs, totally incontinent of bowel, and had an indwelling catheter. An ADL care plan, dated 3/28/24, indicated Resident F required assistance with ADLs including bed mobility, transfers, eating, and toileting related to mobility deficits, respiratory failure, obesity, ventilator status, and muscle weakness. The approach listed to assist with bathing as needed, assist with bed mobility as needed, and assist…

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 assess a resident with a tracheostomy (trach) after providing trach care for 1 of 1 residents reviewed for death; ensure infection control practices were maintained during tracheostomy care (Resident D), and oxygen tubing/tracheostomy mask were changed as ordered (Resident E) for 2 of 3 residents reviewed for respiratory care. (Resident 60) Findings include: 1. An observation was conducted of tracheostomy (trach) care for Resident D, on 5/30/24 at 11:45 a.m., by Respiratory Therapist (RT) 4 and RT 5. The bedside table was noted with a tracheostomy kit that was unopened. RT 4 and RT 5 donned personal protective equipment (PPE) that included clean gloves, gown, and a facemask. RT 5 removed the inner cannula with his clean gloves and discarded of such in the trash can. RT 4 prepared to suction Resident D. RT 4 connected the suction catheter to the suction machine and proceeded to suction Resident D. Resident D started to cough and coughed up large amounts of mucous after being suctioned. Mucous was noted within…

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 timely obtain laboratory tests, as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include: The clinical record for Resident 5 was reviewed on 5/29/24 at 11:10 a.m. The Resident's diagnosis included, but were not limited to, diabetes, hypertension, and epilepsy. A care plan, initiated 10/29/18, indicated Resident 5 had ineffective tissue perfusion related to his diagnosis of hypertension, hyperlipidemia (high cholesterol), and history of stroke. The goal was for him to maintain adequate tissue perfusion as evidenced by blood pressure within normal limits for resident, no change in mental status, no complaints of dizziness/lightheadedness/syncope, and no edema. The interventions included, but were not limited to, obtain labs as ordered, initiated 10/29/18, and administer medications as ordered by the physician, initiated 10/29/18. A physician's order, dated 3/28/24, indicated he was to have a CBC (complete blood count) with differential, CMP (complete 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.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during medication administration, while providing a bed bath (Resident F), and ensure personal protective equipment (PPE) was available to utilize prior to entering a room on transmission-based precautions (TBP) (Residents' 6, 21, 22, 41 and 56). Findings include: 1. The clinical record for Resident F was reviewed on 5/31/24 at 10:03 a.m. The diagnoses included, but were not limited to, respiratory failure, diabetes mellitus, obesity, tracheostomy status, gastrostomy status, and dependence on ventilator. An admission MDS assessment, dated 4/1/24, indicated Resident F was dependent for ADLs, totally incontinent of bowel, and an indwelling catheter. An ADL care plan, dated 3/28/24, indicated Resident F required assistance with ADLs including bed mobility, transfers, eating, and toileting related to mobility deficits, respiratory failure, obesity, ventilator status, and muscle weakness. The approach listed to assist with bathing as needed, assist with 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 observation, interview, and record review, the facility failed to ensure privacy curtains were present rooms shared by two resident for 4 of 15 residents reviewed for environment (Resident 14, 36, 43, and 53). Findings include: 1a. The clinical record for Resident 14 was reviewed on 5/31/24 at 11:30 a.m. The Resident's diagnosis included, but was not limited to, hypertension. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/4/24, indicated he was cognitively intact. 1b. The clinical record for Resident 36 was reviewed on 5/28/24 at 10:21 a.m. On 6/3/24 at 11:20 a.m., Resident 14 and Resident 36's room was observed with the ED (Executive Director). There was no privacy curtain present between the residents' beds. During an interview on 6/3/24 at 11:20 a.m., Resident 14 indicated the privacy curtain had been missing for quite a while. 2a. The clinical record for Resident 43 was reviewed on 5/29/24 at 11:32 a.m. The Resident's diagnosis included, but was not limited to, anoxic brain injury. 2b. The clinical record for Resident 53 was reviewed on 5/29/24 at 10:04 a.m.…

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

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program that included the elimination of clutter and debris for an area with a history of pest activity. This had the potential to affect 55 of 68 residents that reside in the facility. (Memory Care Unit and 200 Hallway) Findings include: An interview was conducted on 8/15/23 at 11:00 a.m., with Manager 2, who worked with the pest control company. He indicated there had been ongoing treatment for American cockroaches in the facility. The goal had been to conduct preventative measures and treat for such pests. There had been a concern with residents hoarding items to create clutter within their rooms. That can cause a barrier with treatment and not allow proper treatment to such area due to the clutter. An interview conducted with Resident B, on 8/15/23 at 12:00 p.m., indicated he had noticed cockroaches in his room and the 200-hallway on occasion. An interview conducted with Resident C, on 8/15/23 at 12:20 p.m., indicated she will see cockroaches, on occasion, in the common…

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 maintain a functional and sanitary environment by not assuring the resident rooms were routinely dusted for 3 of 3 residents observed for environment (Resident 54, 56, and 66), and that the kitchen floor was in good repair with the potential to affect 60 of 69 residents who reside at the facility. Findings include: 1 a. The clinical record for Resident 66 was reviewed on 3/1/23 at 10:52 a.m. The Resident's diagnosis included, but were not limited to, acute respiratory failure. On 3/2/23 at 1:22 p.m., Resident 66's room was observed. There was a purple fan on the windowsill. The fan grid had a large amount of dust present on the inside of the grid and there were pieces of dust, attached to the grid, which were moving being blown by the wind from the fan. On 3/3/23 at 1:30 p.m., Resident 66's room was observed. The purple fan was on the windowsill and continued to have a large amount of dust present on the inside of the grid. 1 b. The clinical record for Resident 56 was reviewed on 3/6/23 at 9:45 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 interview and record review, the facility failed to ensure a resident was invited to participate in interdisciplinary care plan meetings for 1 of 1 resident reviewed for care planning (Resident 38). Findings include: The clinical record for Resident 38 was reviewed on 3/1/23 at 2:54 p.m. The Resident's diagnosis included, but were not limited to, chronic respiratory failure and hypertension. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/18/23, indicated she was cognitively intact. During an interview on 3/1/23 at 2:54 p.m., Resident 38 indicated she had not attended an interdisciplinary care plan meeting for over a year. The clinical record did not contain any interdisciplinary care plan notes for the last 6 months. During an interview on 3/7/23 at 12:08 p.m., CS (Corporate Support) 1 indicated there were no care plan meeting notes present for Resident 38 for the last 6 months and that there was not documentation that she had been invited to care plan meeting during that time frame. On 3/7/23 at 12:36 p.m., the Executive Director provided the IDT…

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 activities provided in the memory care unit was engaging to a cognitive impaired resident for 1 of 1 residents reviewed for activities in the memory care unit. (Resident G) Findings include: The clinical record for Resident G was reviewed on 3/1/23 at 11:00 a.m. The diagnosis included, but was not limited to, dementia. A Quarterly 10/24/22 Minimum Data Set (MDS) assessment, indicated Resident G was severely cognitively impaired. An activities care plan for Resident G dated 2/10/23 indicated .Resident enjoys the following activities: watching movies with pop corn (classics), listening to music, playing board and card games, patio time, and socializing, family visit. Goals. Resident will participate in the daily cottage programming .Approach . Encourage resident to participate in activities he enjoys, such as watching TV (classics) listening to music, playing board and card games, patio time, and socializing . An observation was made of activities in the memory care unit dining room on 3/1/23 at 11:13…

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 provide a resident's supplement, as ordered, to 1 of 1 resident reviewed for nutrition (Resident 61) and to administer medications as ordered for 1 of 6 residents reviewed for unnecessary medications. (Resident G) Findings include: 1. The clinical record for Resident 61 was reviewed on 3/1/23 at 11:00 a.m. His diagnoses included, but were not limited to: depression, gastro-esophageal reflux disease, moderate protein-calorie malnutrition, dysphagia, and dementia. He admitted to the facility on [DATE]. The vitals section of the electronic health record indicated the following weights on the following dates: 2/6/23 at 147 pounds; 1/26/23 at 143 pounds; 1/20/23 at 145 pounds; and 1/12/23 at 145 pounds with a BMI (body mass index) of 20.8. The 1/22/23 registered dietician nutrition review indicated he was receiving 237 ml of Ensure Plus twice daily in between meals with good acceptance of the supplements. His estimated nutritional needs were…

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

Based on observation, interview, and record review, the facility failed to ensure that hand hygiene was performed prior to donning sterile gloves and performing tracheostomy care of 1 of 1 resident reviewed for tracheostomy care (Resident 28). Findings include: The clinical record for Resident 28 was reviewed on 3/1/23 at 11:38 a.m. The Resident's diagnosis included, but were not limited to, chronic respiratory failure and dependence on ventilator. A care plan, dated 9/3/2015, indicated Resident 28 was at risk for respiratory distress related to tracheostomy. The goal was for her to be free of respiratory distress. The approached included, but were not limited to, provide tracheostomy care as ordered, dated 9/3/2015). A physician's order, dated 8/10/22, indicated she was to receive tracheostomy care, per standard of practice, with sterile water, and normal saline every shift. On 3/3/23 at 11:10 a.m., RT (Respiratory Therapist) 7 was observed providing tracheostomy care to Resident 28. RT 7 washed her hands with soap and water and donned non-sterile disposable gloves. She placed 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 assess a resident's pain that included location of the pain, intensity of the pain and effectiveness of an as needed (PRN) pain medication, and provide non-pharmacological interventions to address the resident's pain for 1 of 2 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 3/1/23 at 1:30 p.m. The diagnosis included, but was not limited to, dementia. The Admissions 12/13/22 Minimum Data Set (MDS) assessment, indicated Resident B was cognitively impaired. A pain care plan for Resident B dated 12/5/22 indicated Resident is at risk for pain related to complaints of back pain, debility, PVD [Peripheral Vascular Disease], dx [diagnosis] depression, dx pain, lumbar fracture .Approach .Assist with positioning to comfort. Document effectiveness of prn medications .Offer non- pharmacological interventions such as quiet environment, rest, shower, back rub, reposition . A physician order dated 12/6/22 indicated Resident B was to receive 5-325 milligrams of…

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

Based on interview and record review, the facility failed to ensure a resident had adequate indication for use of an antibiotic, did not receive duplicate antibiotic therapy (Resident 58 and 31), and to monitor a resident's medication by not timely obtaining a VPA (valproic acid) lab, as ordered, (Resident 47) for 3 of 5 residents reviewed for unnecessary medications. Findings include: 1. The clinical record for Resident 58 was reviewed on 3/2/23 at 2:39 p.m. Resident 58's diagnoses included, but not limited to, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic kidney disease, diabetes type II, and syncope. A Nurse Practitioner's (NP) note dated 12/13/2022 at 12:01 p.m. indicated, Patient seen today for acute concern of cough, congestion, wheezing, fatigue, and chest pain. Patient reporting illness on 12/12/22 with STAT [sic, immediate] labs completed, CXR [chest x-ray]. WBC [white blood count] count on 12/12 is 5.1, and CXR was negative as well. Patient reported continued feeling of illness, fatigue, cough, congestion and right sided chest pain when breathing.…

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 implement an antibiotic stewardship program which contains protocols to ensure residents who require antibiotics are prescribed the appropriate antibiotic, monitors/re-evaluates the use of antibiotics, provides appropriate indications for use, and failure to adhere to an algorithm for identification of a true infection for 2 of 5 residents reviewed for unnecessary medications. (Residents 58 and 31) Findings include: 1. The clinical record for Resident 58 was reviewed on 3/2/23 at 2:39 p.m. Resident 58's diagnoses included, but not limited to, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic kidney disease, diabetes type II, and syncope. A Nurse Practitioner's (NP) note dated 12/13/2022 at 12:01 p.m. indicated, Patient seen today for acute concern of cough, congestion, wheezing, fatigue, and chest pain. Patient reporting illness on 12/12/22 with STAT [sic, immediate] labs completed, CXR [chest x-ray]. WBC [white blood count] count on 12/12 is 5.1, and CXR was negative as well. Patient reported…

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 timely administer a resident's influenza vaccination for 1 of 5 residents reviewed for vaccination. (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 3/6/23 at 3:08 p.m. Her diagnoses included, but were not limited to, chronic respiratory failure, anoxic brain damage, dependence on respirator, and Alzheimer's disease. She was admitted to the facility on [DATE]. The physician's orders indicated she may have an annual flu vaccine, starting 3/1/22. Her 4/5/22 admission Agreement included an Influenza Vaccination Consent. The consent indicated she did not have any contraindications to receienving the influenza vaccine and wished to receive the influenza vaccine. It was docusigned by Resident 56 on 4/5/22 at 2:39 p.m. The Preventive Health Care section of the electronic health record indicated she received an influenza vaccine at the facility on 3/3/23. An interview was conducted with the IDNS (Interim Director of Nursing…

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.