Rehabilitation Center At Hartsfield Village

Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside, for 4 of 4 random observations. (Residents 6, 73, 88, and 82) Findings include: 1. During random observations on 5/28/24 at 3:50 p.m., 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., and on 5/30/24 at 9:32 a.m., Resident 6 was observed in her room. At those times there was a Breo hand held inhaler, antibiotic ointment cream, and healing ointment cream observed on the window sill. The record for Resident 6 was reviewed on 5/29/24 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes, COPD, heart disease, high blood pressure, anxiety and depression. The 4/26/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no self-administration of medication assessment located in the clinical record. The Physician Order Summary for the month of 5/2024 indicated there were no orders for the Breo inhaler or the…

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

Based on observation, record review, and interview, the facility failed to ensure areas of bruising and skin tears were assessed and monitored for 4 of 6 residents reviewed for skin conditions non-pressure related. (Residents 26, 60, 168, and 6) Findings include: 1. On 5/29/24 at 9:45 a.m., Resident 26 was observed in her room in bed. An area of reddish purple discoloration was observed on top of the resident's right hand and in between her ring and middle finger. During an interview at that time, the resident indicated she hit her hand on the door frame. The record for Resident 26 was reviewed on 5/29/24 at 3:56 p.m. Diagnoses included, but were not limited to, Guillain-Barre syndrome and history of falling. The admission Minimum Data Set (MDS) assessment, dated 5/8/24, indicated the resident had short and long term memory problems and was dependent on staff for transfers. The 5/2024 Physician's Order Summary (POS) indicated there was no order to monitor the bruising. The resident was to have weekly skin assessments on Wednesday. There was no documentation in the nursing progress…

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 each resident's dignity was maintained related to uncovered foley (urinary) catheter bags with urine being seen from the hallway for 1 of 1 residents reviewed for dignity. (Resident 73) Finding includes: During random observations on 5/28/24 at 2:52 p.m. and 4:10 p.m., Resident 73 was observed in bed. At those times, his indwelling foley catheter bag was uncovered and hanging on the side of the bed. The urine in the bag could be seen from the hallway. On 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway. On 5/30/24 at 9:34 a.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, 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 thoroughly investigate and resolve grievances in writing from a resident's family member for 1 of 1 resident reviewed for grievances. (Resident B) Finding includes: During an interview with Resident B and her husband on 5/28/24 at 2:57 p.m., they indicated he had a care plan meeting with staff to ensure the staff got his wife dressed and out of bed daily. He indicated the staff left the resident in her room and in the bed several times. Resident B's husband had filed a grievance with the administrator and had not received anything from the staff regarding his complaint. The husband indicated he had requested grievance information and had requested meeting several times to talk about his concerns. The resident's husband also indicated he felt the administrator had avoided responding to him regarding his concerns for his wife's care. The record for Resident B was reviewed on 5/28/24 at 10:00 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant…

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 foley (urinary) catheter bags and tubing were kept off the floor, for 2 of 2 residents reviewed for catheters. (Residents 73 and 93) Findings include: 1. During random observations on 5/28/24 at 10:30 a.m. and 11:47 a.m., Resident 73 was observed sitting in a wheelchair. At those times, his indwelling foley catheter bag was observed on the floor under the wheelchair. The catheter tubing was above his waist. On 5/29/24 at 3:00 p.m., and on 5/30/24 at 3:00 p.m., the resident was observed in bed. At those times, the foley catheter bag was touching the floor. On 6/3/24 8:50 a.m., the resident was observed sitting in the wheelchair in his room eating breakfast. At that time, the foley catheter bag was in a dignity bag under the wheelchair, however, the tubing was dragging on the floor. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 60) Finding includes: On 5/28/24 at 1:58 p.m. and 4:05 p.m., Resident 60 was observed in her room. She had oxygen per nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters. On 5/29/24 at 9:42 a.m. and 1:21 p.m., the resident was again observed in her room with oxygen by the way of a nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters. On 5/30/24 at 9:40 a.m., the resident was observed in her room. Oxygen per nasal cannula was in use and the oxygen concentrator was set at 3 1/2 liters. The record for Resident 60 was reviewed on 5/29/24 at 1:34 p.m. Diagnoses included, but were not limited to, pneumonia, emphysema, and congestive heart failure. The admission Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact and received oxygen therapy. A Care Plan, dated 5/3/24, indicated the resident required the use of oxygen therapy…

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 blood pressure medication was not administered outside of the physician-ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 88) Finding includes: The record for Resident 88 was reviewed on 5/30/24 at 9:40 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, and anxiety disorder. The 3/24/24 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. Physician's Orders, dated 4/1/24, indicated Verapamil (a medication used to treat chest pain and lower the blood pressure) 120 milligrams (mg) give 60 mg twice a day and hold if the systolic blood pressure (top number) was under 140. The 4/2024 Medication Administration Record (MAR) indicated the Verapamil 60 mg was administered on the following dates with a blood pressure outside of the ordered parameters: 4/4 at 9:00 p.m. blood pressure of 139/79 4/6 at 9:00 p.m. blood pressure of 122/73 4/7 at 9:00 a.m. blood pressure of 133/74 4/8 at 9:00…

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 maintain clinical records that were complete and accurately documented related to dialysis day, dialysis chair time, and dialysis pick up time, for 1 of 1 resident reviewed for dialysis. (Resident 268) Finding include: 1. The record for Resident 268 was reviewed on 5/28/24 at 1:15 p.m. Diagnoses included, but were not limited to, fracture of nasal bones, subsequent encounter for fracture with routine healing, end stage renal disease, retention of urine, unspecified, dependence on renal dialysis, benign prostatic hyperplasia with lower urinary tract symptoms. The admission Minimum Data Set (MDS) assessment, dated 5/22/24, was incomplete and in process. The resident was admitted on [DATE]. A Physician's Order, dated 5/22/24, indicated the resident was to receive hemodialysis at [name of] Dialysis Center, on Monday, Wednesday, and Friday. The resident's dialysis pick up time was ordered for 3:00 p.m. The resident's dialysis chair time was ordered for 4:00…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to staff failing to sanitize hands in between glove changes for 1 of 1 glucometer use observed and staff failing to donn personal protective equipment (PPE) for a resident in contact precautions during a random infection control observation. (Residents 53 and 73) Findings include: 1. On 5/29/24 at 4:34 p.m., LPN 1 was preparing to complete a blood sugar check via glucometer for Resident 53. The LPN donned gloves and did not hand sanitize nor wash her hands prior. After obtaining the resident's blood sugar result, the LPN removed her gloves and donned a new pair of gloves, she did not hand sanitize in between glove changes. She proceeded to cleanse the glucometer with a germicidal wipe and she removed her gloves. Again, she did not use hand sanitizer. The LPN prepared the resident's medications and administered them. She sanitized her hands prior to leaving the resident's room. During an interview on 6/3/24 at 9:47 a.m., Assistant 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.

Based on record review and interview, the facility failed to ensure the resident's family was notified of a change in condition, for 1 of 3 residents reviewed for notification of change. (Resident H) Finding includes: The record for Resident H was reviewed on 3/19/24 at 4:25 p.m. Diagnoses included, but were not limited to, sepsis, chronic respiratory failure, atrial fibrillation, anemia, heart failure, cirrhosis of the liver, alcohol abuse, and chronic kidney disease. A Nurse's Note, dated 2/26/24 at 9:31 a.m., indicated the Nurse Practitioner (NP) was notified due to the resident not being easily aroused, and only able to verbalize some words but was very lethargic. The NP indicated she would be in to assess the patient. A Nurse Practitioner (NP) Progress Note, dated 2/16/24 at 11:03 a.m., indicated the patient was being evaluated for increased lethargy and dyspnea (shortness of breath). Nursing staff indicated the patient refused oral intake this morning, and his breathing appeared labored. Labs were repeated this morning and results were pending. The patient was noted to awaken…

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

Based on record review and interview, the facility failed to provide appropriate social services follow up, related to an outside allegation of exploitation and misappropriation for a resident by family and facility staff, for 1 of 3 residents reviewed for change of condition. (Resident B) Finding Includes: During a phone interview, on 3/20/24 at 11:13 a.m., the Adult Protective Services (APS) representative indicated she had contacted the assigned facility Social Worker (SW) regarding Resident B and left voice messages. Detailed voicemails were left for the SW on 1/24/24 at 12:16 p.m. and on 1/25 at 1:52 p.m. The SW called the APS representative back on 1/25/24 at 2:10 p.m. During that call, the APS representative discussed the reports of allegations, which included neglect and financial exploitation of Resident B. A psychiatric evaluation was recommended, APS jurisdiction was explained, and documentation for the current healthcare POA was requested. The facility's fax number was provided by the SW, and on 1/29/24 at 12:33 p.m., APS faxed a blank physician report to be completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the admission Minimum Data Set (MDS) assessment was completed within 14 days of admission for 6 of 24 MDS assessments reviewed. (Residents 148, 206, 37, 198, 195, & 12) Findings include: 1. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process. Sections B, E, G, GG, H, I, L, N, O, and P had not been completed. Interview with the MDS Coordinator on 3/8/23 at 3:20 p.m., indicated she was aware the MDS assessments were late. 2. The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to fracture of the right humerus, Alzheimer's disease, and…

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

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 2 of residents reviewed for self-administration of medication. (Residents 148 and 5) Findings include: 1. On 3/6/23 at 3:10 p.m., Resident 148 was observed in his room in bed. An Albuterol Sulfate inhaler was observed on his over bed table. Interview with the resident at that time, indicated it was his emergency inhaler and he must keep it at his bedside. There was also a jar of Vicks Vapo Rub on the table. The resident also indicated he had Melatonin (an herbal sleep aid) that he was taking and the facility didn't know he had it. On 3/8/23 at 9:58 a.m., the resident was in his room in bed. The Albuterol inhaler remained on the over bed table, as well as the Vicks Vapo Rub. There was also a bottle of Fluticasone nasal spray on the table. The resident indicated his wife brought it from home. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2…

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 complete a Quarterly Minimum Data Set (MDS) assessment timely for 1 of 24 residents whose MDS assessments were reviewed. (Resident 17) Finding includes: The record for Resident 17 was reviewed on 3/8/23 at 10:34 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 2/2/23, was in process. The Quarterly assessment was not signed as completed by the MDS Coordinator until 3/9/23. The previous Quarterly MDS assessment, was dated 11/2/22. Interview with the MDS Coordinator on 3/8/23 at 3:18 p.m., indicated she was aware the Quarterly assessments were late. 3.1-31(d)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents were provided assistance with activities of daily living (ADLs) related to shaving for 1 of 6 residents reviewed for ADLs. (Resident 247) Finding includes: On 3/6/23 at 2:39 p.m., Resident 247 was observed sitting in her wheelchair in her room. There was facial hair noted along her chin. On 3/8/23 at 11:08 a.m., Resident 247 was observed sitting in her wheelchair in her room. There was facial hair noted along her chin. Resident 247's record was reviewed on 3/8/23 at 2:52 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, fracture of nasal bones, syncope and collapse, and hypothyroidism. The admission Minimum Data Set (MDS) assessment indicated it was still in progress. A Nurses' Note, dated 3/3/23 at 1:07 p.m., indicated the resident was able to make needs known and required extensive assistance with ADL care. The Shower Day Skin Audit, dated 3/7/23, indicated the resident…

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

Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 5 residents reviewed for skin conditions (non-pressure related). (Resident 148) Finding includes: On 3/6/23 at 3:10 p.m., Resident 148 was observed in his room in bed. The resident had a reddish/purple discoloration to both of his hands. On 3/8/23 at 9:58 a.m., the resident was observed in his room in bed. The resident had a pink foam dressing to his left forearm as well as a large area of reddish/purple discoloration to the forearm. The discoloration to the resident's hands also remained. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation. The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process. A Care Plan, dated 2/20/23, indicated the resident was at risk for complications associated with Xarelto (an anticoagulant) therapy. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure preventative measures were in place related to offloading a resident's foot to prevent further pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident 195) Finding includes: Interview with Resident 195 and a previous caregiver for the resident on 3/6/23 at 3:03 p.m., indicated she had an open sore on her heel. The caregiver indicated her foot was never offloaded and was always laying directly on the bed. The resident was currently observed sitting in a wheelchair and her right leg/foot was propped up on the leg rest with a pillow underneath. On 3/7/23 at 9:40 a.m. the resident was observed lying in bed and her right foot was laying directly on the mattress. It was not offloaded. On 3/9/23 at 8:02 a.m., until 10:05 a.m., the resident was observed lying in bed and her right foot was laying directly on the mattress. It was not offloaded. At 10:35 a.m., both Wound Nurses were observed during the pressure ulcer…

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 monitor a resident's urine output after an indwelling foley catheter was removed to prevent reoccurrence for 1 of 3 residents reviewed for bowel and bladder incontinence. (Resident B) Finding includes: The closed record for Resident B was reviewed on 3/9/23 at 3:14 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and hydronephrosis (the swelling of one or both kidneys). The admission Minimum Data Set (MDS) assessment, dated 11/4/22, indicated the resident was moderately impaired for decision making. The resident was an extensive assist with a 2 person physical assist for bed mobility and toilet use. She had an indwelling foley catheter. Nurses' Notes, dated 10/19/22 at 7:34 a.m., indicated the resident arrived to the facility around 6:35 p.m. The resident was admitted to the facility for therapy following hospitalization for a fall at home resulting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the meal consumption logs were completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 37) Finding includes: The record for Resident 37 was reviewed on 3/8/23 at 10:01 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, adult failure to thrive, protein calorie malnutrition, respiratory failure, COPD, heart failure, and dependence on supplemental oxygen. The admission Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was not cognitively intact and needed supervision with set up assistance with eating. The resident had no oral problems, weighed 108 pounds, and was receiving a therapeutic diet. A Care Plan, dated 2/16/23, indicated the resident may need supervision to eat and drink at times. The approaches were to monitor and record intake of food/fluids. A Care Plan, dated 2/9/23, indicated the resident received a regular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed as per Physician's Orders and facility policy for 2 of 3 residents reviewed for oxygen therapy. (Residents 37 and 206) Findings include: 1. On 3/6/23 at 2:25 p.m., 3/7 at 10:11 a.m., and 3/8 at 9:45 a.m., Resident 37 was observed sitting in a wheelchair in her room. At those times, the oxygen tubing and humidification bottle was dated 2/20/23. The resident indicated she wore oxygen at night time. On 3/9/23 at 8:03 a.m., the resident was observed in bed with her eyes closed. At that time she was wearing oxygen at 2 liters per minute via nasal cannula. The record for Resident 37 was reviewed on 3/8/23 at 10:01 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, adult failure to thrive, protein calorie malnutrition, respiratory failure, COPD, heart failure, and dependence on supplemental oxygen. The admission Minimum Data Set (MDS) assessment, dated 2/15/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to manage medications appropriately related to medications not administered as ordered by the physician and the side effects of opioid medication not monitored for 2 of 5 residents reviewed for unnecessary medication. (Residents 191 and 206) Findings include: 1. During an interview with Resident 191 on 3/6/23 at 3:51 p.m., he indicated he goes to dialysis on Tuesdays, Thursdays, and Saturdays. He indicated his chair time was 7:00 a.m. The record for Resident 191 was reviewed on 3/9/23 at 1:55 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, absence of toes, type 2 diabetes, diabetic neuropathy, end stage renal disease, hypertensive chronic kidney disease, anemia, and dependence on renal dialysis. The admission Minimum Data Set (MDS) assessment was still in process. Physician's Orders, dated 2/28/23, indicated Clopidogrel 75 milligrams (mg) daily at 9 a.m. and Carvedilol 25 mg 1 tablet twice a day 9:00 a.m. and 9:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure there was an indication for the use and interventions were attempted prior to administering an as needed (PRN) anti-anxiety medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 148 and 206) Findings include: 1. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation. The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process. A Physician's Order, dated 2/28/23, indicated the resident was to receive Xanax (an anti-anxiety medication) 0.25 milligrams (mg) three times a day as needed (PRN) for anxiety. The March 2023 Medication Administration Record (MAR) indicated the resident received the prn Xanax on 3/2 at 10:01 a.m. and 8:36 p.m., 3/3 at 9:21 p.m., 3/4 at 8:22 p.m., and 3/6/23 at 5:03 a.m. and 8:55 p.m. The PRN reason 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 and interview, the facility failed to ensure medications were labeled for 2 of 4 medication carts observed. (A-100 & D-200 carts) Findings include: 1. On 3/10/23 at 12:24 p.m., the A-100 Cart was reviewed with RN 1. There was a stack of Lidocaine 5% patches in a drawer unlabeled. The nurse was unable to find the original label/box. She indicated the box did not fit in the drawer so they had torn off a section of the box that contained the label which indicated whose patches they were. The label section of the box was not found in the cart. 2. On 3/13/23 at 9:55 a.m., the D-200 Cart was reviewed with Agency LPN 1. A bottle of fleet suppositories and a bottle of Tylenol 650 milligrams were in the cart drawer with no labels on either of the bottles. Agency LPN 1 indicated each bottle should have a label with the patient name and the order on them. Interview with the Director of Nursing on 3/13/23 at 10:19 a.m., indicated she had no further information to provide. 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to ensuring multi-use equipment was disinfected after resident use for random observations for infection control. (Residents 198 and 52) Findings include: 1. During a random observation on 3/6/23 at 2:12 p.m., Agency LPN 1 was observed checking Resident 198's blood pressure with a wrist cuff. After obtaining the blood pressure reading, the LPN put the wrist cuff back into a pouch that was around her waist and left the room. She walked out to her medication cart and proceeded to prepare and pour medications for another resident. She did not sanitize the blood pressure cuff. Interview with Agency LPN 1 at 2:17 p.m., indicated she had forgotten to clean the wrist blood pressure cuff after she used it for the resident. 2. During a random observation on 3/6/23 at 2:37 p.m., CNA 1 was observed checking Resident 52's vital signs with a multi-use blood pressure machine and cuff on wheels. After completing the resident's vital signs check, he…

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.