Waters Of Syracuse Skilled Nursing Facility, The

Based on interview and record review, the facility failed to ensure a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form was provided following the end of Medicare skilled services for 2 of 3 residents who discharged from Medicare services and remained in the facility. (Resident 9 & 14) Finding includes: On 1/8/2025 at 9:07 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. 1. The form indicated Resident 9 was not issued an SNF-ABN form. Resident 9 was provided with a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident 9's Medicare coverage would end on 8/28/2024. An Advanced Beneficiary Notice (ABN) was not provided to Resident 9. During an interview, on 1/9/2025 at 9:52 A.M., the Business Office Manager (BOM) indicated Resident 9 had 34 Medicare A days remaining to use and was provided with a NOMNC which indicated Resident 9 would be discharged from Medicare A services on 8/28/2024. 2. The form indicated Resident G was not issued an SNF-ABN form. Resident G was provided with a Notice 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 record review and interview, the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) was completed timely for 1 of 1 residents reviewed. (Resident B) Finding includes: The record for Resident B was reviewed on 1/7/2025 at 11:34 A.M. Diagnoses included, but were not limited to fractured ribs, cancer, end stage renal disease, bipolar, and malnutrition. A PASARR Level 1 for Resident B was completed on 6/16/2024. The Level 1 determined Resident B had a serious mental illness and/or intellectual disability and was placed in the Convalescence category - 60 Day Convalescence Care Approval. A 60 day or less stay in the NF (nursing facility) was authorized. The form indicated Re-screening must occur by or before the 60th day if the individual is expected to remain in the NF beyond the authorization timeframe On 1/8/2025 at 1:13 P.M., the Social Service consultant provided a Notice of Level 1 screen outcome. The level 1 screening form indicated it was valid for 60 days with an end date of September 14, 2024. The record for Resident B lacked 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 record review, observation and interview, the facility failed to ensure base line care plans were initiated for a resident with falls and receiving dialysis, and a resident at high risk for falls for 2 of 5 residents reviewed for base line care plans. (Resident B & 247) Findings include: 1. The record for Resident B was reviewed on 1/7/2025 at 11:34 A.M. Diagnoses included but were not limited to: fractured ribs, cancer, end stage renal disease, bipolar, repeated falls and malnutrition. An admission Minimum Data Set (MDS) assessment, dated 7/30/2024 indicated Resident B was receiving dialysis. A Base Line Care Plan form, dated 7/30/2024, indicated the resident required dialysis and had previous falls with injury. The form lacked goals, interventions and any special needs to properly care for the resident. During an interview, on 1/8/2025 at 10:59 A.M., the MDS coordinator indicated the care plan summary should have had goals and interventions. 2. The record for Resident 247 was reviewed on 1/8/2025 at…

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

Based on observation, record review and interview, the facility failed to complete a comprehensive care plan for 3 of 13 residents reviewed for comprehensive care plans. (Residents 18, 20 and 32) Findings include: 1. During an observation on 1/6/2024 at 9:53 A.M., Resident 18 had facial hair stubble. He indicated this was the longest his facial hair had been in a while and the CNA (Certified Nursing Assistant) was to assist him to shave. A record review for Resident 18 was completed on 1/8/2025 at 1:20 P.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), spinal stenosis and chronic obstructive pulmonary disease (COPD). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/2024, indicated Resident 18 was cognitively intact, required partial/moderate assistance for bed mobility and substantial/maximal assistance for transfers and personal hygiene. A Care Plan for activities of daily living (ADLs) could not be located in the medical record. During an interview, on 1/9/2024 at 10:05 A.M., the MDS (Minimum Data Set) Coordinator indicated a care plan for…

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 care plan meetings were held timely for 3 of 25 residents whose care plans were reviewed. (Residents 27, 30 and 38) Findings include: 1. The record for Resident 27 was reviewed on 01/07/2025 at 2:48 P.M. Diagnosis included, but were not limited to arthritis, hypertension, obstructive and reflux uropathy and glaucoma. A Care Plan meeting progress note, dated 4/4/2024, indicated Resident 27's POA (Power of Attorney) was present at the meeting. The record lacked documentation of any care plan meetings having been held after 4/4/2024. During an interview, on 1/8/2025 at 1:23 P.M., the Corporate Social Service Director (SSD) indicated a meeting was held in April and Resident 27 should have had two additional meetings since then, but no meetings have been held since April. 2. During an interview, on 1/6/2025 at 11:02 A.M., Resident 38's Power of Attorney (POA) indicated he had not had any care plan meetings since the initial admission meeting but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an incontinent resident remained free from an indwelling urinary catheter for 1 of 1 residents reviewed for urinary catheters. Finding includes: During an observation, on 1/7/2025 at 1:46 P.M., Resident 34 was lying in her recliner. The urinary drainage tubing was observed over her left thigh and the urinary drainage bag was hung on the wheelchair next to the recliner. A record review for Resident 34 was completed on 1/8/2025 at 10:04 A.M. Diagnoses included, but were not limited to: neuromuscular dysfunction of the bladder, kidney failure and history of urinary tract infections. Resident 34 was admitted to the facility on [DATE]. She was discharged on 10/19/2024 and readmitted on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 10/1/2024, indicated Resident 34 was cognitively intact and was frequently incontinent of bladder. An admission Minimum Data Set (MDS) assessment, dated 12/9/2025, indicated Resident 34 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 record review, observation and interview, the facility failed to ensure nutritional supplements % (percentage) were documented for a resident with weight loss; failed to initiate RD recommendations for supplements for a resident with weight loss and failed to serve the appropriate diet to a resident receiving dialysis for 3 of 4 residents reviewed for nutrition. (Residents 1, 27 and E) Findings include: 1. During an interview, on 1/6/2025 at 10:17 A.M., Resident 1 indicated she had lost maybe another 25 pounds. The record for Resident 1 was reviewed on 1/9/2025 at 8:59 A.M. Diagnoses included, but were not limited to: diabetes, anxiety, kidney failure, and polyneuropathy. Current Physician Order, dated 12/23/2024, included the following: House shake with meals for Supplement- give 1 container/serving by mouth. Record % consumed. A Care Plan, initiated on 9/16/2024, indicated Resident 1 was at risk for nutritional deficit related to diagnoses of heart disease, diabetes, hypertension and gastro esophageal reflux disease. Weight loss. Interventions included but were not…

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

Based on observation, record review and interview, the facility failed to properly store oxygen therapy equipment and C-PAP (continuous positive airway pressure) equipment for 2 of 2 residents reviewed for oxygen therapy. (Resident 18 and 20) Findings include: 1. During an observation, on 1/6/2025 at 9:53 P.M. and 1/7/2025 at 10:37 A.M., Resident 18's C-Pap mask was observed on top of his personal refrigerator, unbagged. During an observation, on 1/8/2025 at 1:14 P.M., Resident 18's C-Pap mask was observed on the floor. During an observation, on 1/9/2025 at 11:27 A.M., a CNA came out of the Resident 18's room. The C-Pap mask was observed on top of the personal refrigerator, unbagged. At 1:30 P.M., the C-Pap mask was still on top of the resident's personal refrigerator. A record review for Resident 18 was completed on 1/8/2025 at 1:20 P.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), congestive heart failure, obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/2024,…

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 pain medications were being monitored for effectiveness for 1 of 2 residents reviewed for pain management. (Resident 1) Finding includes: During an interview, on 1/06/2025 at 10:18 A.M., Resident 1 indicated If I move, I get pain, I get Tramadol. The record for Resident 1 was reviewed on 1/9/2025 at 8:59 A.M. Diagnoses included, but were not limited to diabetes, anxiety, kidney failure and polyneuropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 12/15/2024, indicated Resident 1 had pain occasionally at a score of 6 (moderate) level and received routine and PRN (as needed) pain medications. A current Care Plan, initiated on 4/19/2023, indicated Resident 1 had the potential for pain/discomfort related to their diagnosis, reduced mobility, diabetes and right shoulder pain. Interventions included, but were not limited to: monitor the effectiveness of pain medications and administer pain medication as per MD orders and note the effectiveness. Current physician orders included, but were not limited to:…

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

Based on record review and interview, the facility failed to ensure pre/post dialysis assessments were completed for 1 of 1 resident reviewed for dialysis services. (Resident 20) Finding includes: During an interview, on 1/6/2025 at 2:02 P.M., Resident 20 indicated he had just returned from dialysis. A record review was completed for Resident 20, on 1/7/2025 at 1:05 P.M. Diagnoses included, but were not limited to: chronic kidney disease stage 4, anemia in chronic kidney disease and acute kidney failure. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/2024, indicated Resident 20 had moderate cognitive impairment and received dialysis services. A Physician's Order, dated 12/19/2024, indicated Resident 20 to go to the [company name] dialysis unit on Mondays, Wednesdays and Fridays. A Care Plan indicated Resident 20 was at risk for fluid volume deficit related to rapid fluid removal following dialysis treatment. Interventions included, but were not limited to: observation for hypotension (low blood pressure), hypovolemia (low extracellular fluid in the blood),…

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 adjust medication related to laboratory results to ensure the dose was not excessive for 1 of 5 residents reviewed for unnecessary medications. (Resident 32) Finding includes: A record review for Resident 32 was completed on 1/7/2025 at 11:18 A.M. Diagnoses included, but were not limited to: underweight, disorientation, muscle weakness and osteoarthritis. A Quarterly Minimum Data Set (MDS) assessment, dated 11/18/2024, indicated Resident 32 had moderate cognitive impairment. A Physician's Order, dated 4/19/2024, indicated cholecalciferol 10,000 units daily for vitamin D deficiency. A 25-hydroxyvitamin D laboratory test was obtained on 8/13/2024. The test indicated a vitamin D level greater than 120 ng/mL (nanograms per milliliter). The normal range specified on the test result was 30-100 ng/mL. Nurse Practitioner Progress Notes, dated 8/16/2024, 8/26/24 and 8/30/24, indicated Resident 32 was seen by the nurse practitioner. The notes did not address the elevated 25-hydroxyvitamin D laboratory test results. 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 record review and interview, the facility failed to limit the use of an as needed psychotropic medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 20) Finding includes: A record review was completed for Resident 20 on 1/7/2025 at 1:05 P.M. Diagnoses included, but were not limited to: major depressive disorder and adjustment disorder with depressed mood. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/2024, indicated Resident 20 had moderate cognitive impairment and took an antidepressant. A Physician's Order, dated 12/14/2024, indicated Xanax (antianxiety medication) 0.5 milligrams every 12 hours as needed for anxiety. The Medication Administration Record, dated 12/2024, indicated Resident 20 received Xanax beyond the 14-days on 12/28/2024, 12/29/2024 and 12/31/2024. The Medication Administration Record, dated 1/2025, indicated Resident 20 received Xanax beyond the 14-days on 1/7/2025. A Care Plan, dated 1/3/2025, indicated Resident 20 was at risk for increased anxiousness with the need for anxiolytic medication.…

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

Based on observation, interview and record review, the facility failed to ensure nutritive value and flavor was maintained for puree diets for 2 of 2 residents who received a puree diet. Finding includes: During an observation of food preparation for pureed foods, on 1/6/2025 from 11:14 A.M. to 11:36 A.M., the following was observed: The Dietary Manager obtained a bowl of cooked carrots, indicating he was preparing 2 servings. He placed the carrots in the blender and started the blender. He added 1/2 cup of water and resumed blending the carrots and water. He then placed the pureed carrots in a small metal pan and placed it on the steamer table for service. The Dietary Manager indicated he followed the (instruction) sheet that was taped to the inside of a cabinet door. The untitled paper listed the number of servings under the heading portion:#12 scoop for pureed vegetables. The left side of the paper indicated cooked vegetables, 4 oz. spoodle ( green beans, wax beans, carrots, etc.); Chicken Base: teaspoon; Hot water, cups; Thick and Easy Thickener, Tablespoons. For 2 servings 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 observation, record review and interview, the facility failed to ensure infection control practices were carried out appropriately for residents on enhanced barrier precautions (EBP) for 3 of 3 residents reviewed for infection control (Residents 30, 247 & 27). Findings include: 1. During an observation of medication administration on 1/9/2025 at 9:41 A.M., Resident 30 had an Enhanced Barrier Precautions sign on their room door and an isolation cart inside their room. RN 6 entered Resident 30's room wearing a pair of gloves. The RN did not have on a gown. RN 6 proceeded to administer medications to the resident via their feeding tube. On 1/7/2025 at 11:23 A.M., a record review was completed for Resident 30. Diagnoses included, but were not limited to: dysphagia, malnutrition and cerebral infarction. A review of Resident 30's Physician's Orders indicated Enhanced Barrier Precautions due to internal peg tube device. A Care Plan, initiated on 1/16/2024 indicated Resident 30 was on Enhanced Barrier Precautions due to a newly inserted PEG tube. Interventions included, but 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 record review and interview, the facility failed to ensure a change in Notice of Medicare Non-Coverage form (NOMNC) was provided timely, for 1 of 3 residents reviewed for beneficiary notices. (Resident 90) Finding includes: The record for Resident 90 was reviewed on 2/8/2024 at 8:55 A.M. Diagnoses included, but were not limited to: acute congestive heart failure, atrial fibrillation and weakness. The resident was admitted under Medicare part A for rehabilitation. A Social Service Progress Note, dated 11/27/2023, indicated the resident's daughter planned for the resident to discharge back to her previous, unlicensed assisted living facility once she was discharged from therapy services. A Social Service Progress Note, dated 12/6/2023, verified the details for the resident's discharge to her previous residence. Social Services indicated they had sent a referral to a home health agency. A Notice of Medicare Non-Coverage form for Resident 90 indicated the resident's last covered date of therapy services was 12/10/2023. The form was not signed and she went home w [with] HH [home…

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

Based on observation, interview, and record review, the facility failed to implement and revise a care plan for 2 out of 15 resident care plans reviewed. (Residents 11 & 17) Findings include: 1. During an observation on 2/7/2024 at 9:45 A.M., Resident 17's continuous positive airway pressure (CPAP) mask and tubing was on the floor next to the nightstand. The resident indicated that he used the machine at night when he sleeps. A record review was completed for Resident 17 on 2/5/2024 at 1:45 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, obstructive sleep apnea and cerebrovascular disease. There was no Physician's Order for the CPAP machine. There was no Care Plan initiated for the use of the CPAP machine. During an interview on 2/8/2024 at 9:53 A.M. the Director of Nursing indicated Resident 17 should have had a care plan for the CPAP. 2. The record for Resident 11 was reviewed on 2/6/2024 at 1:30 P.M. Diagnoses included, but were not limited to: fracture of the fourth metacarpal bone in the left hand and contracture of the left hand.…

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

Based on observation, record review and interview, the facility failed to ensure an individualized activity program was provided, for 2 of 3 residents reviewed for activities. (Residents 21 and 33) Findings include: 1. The record for Resident 21 was reviewed on 2/5/2024 at 2:30 P.M. Diagnoses included, but were not limited to: major depressive disorder, single episode, dementia with mood disturbance, difficulty walking, glaucoma, and bilateral sensorineural hearing loss. The most recent Annual Minimum Data Set assessment, completed on 8/15/2023, indicated it was somewhat important to do things with groups of people, do her favorite activities, have pet visits, go outside when the weather permitted and listen to music she liked. The care plans regarding activities provided a conflicting description of Resident 21's activity needs. The first activity care plan indicated the resident was independent and able to pursue her own leisure , such as watching television, visiting with her son, and reading. The second activity care plan indicated the resident was cognitively impaired 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 interviews, the facility failed to ensure a splint to prevent contracture progression was applied, for 1 of 1 resident reviewed for limited range of motion. (Resident 11) Finding includes: The record for Resident 11 was reviewed on 2/6/2024 at 1:30 P.M. Diagnoses included, but were not limited to: fracture of the fourth metacarpal bone in the left hand and contracture of the left hand. Resident 11 was observed on 2/5/2024 at 10:37 A.M., seated in her wheelchair. The resident was noted to have contracted hands, especially the left hand. During an interview with Resident 11, on 2/5/2024 at 10:38 A.M., she indicated she had broken a finger in her left hand in the past. The most recent Minimum Data Set (MDS) assessment, completed on 11/16/2023, indicated Resident 11 was cognitively intact. The current care plans for Resident 11 included a plan to address the resident's contracture of her left hand, with interventions to notify the physician if the contracture worsened, and therapy as needed. There was also a care plan for the resident to complete…

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 residents had respiratory orders, tubing changes and equipment properly stored when not in use, for 2 of 7 reviewed for respiratory care. (Residents 17 & 20) Findings include: 1. During an observation on 2/7/2024 at 9:45 A.M., Resident 17's continuous positive airway pressure (CPAP) mask and tubing was on the floor next to the nightstand. The resident indicated that he used the machine at night when he sleeps. During an observation on 2/7/2024 at 1:37 P.M., the CPAP mask and tubing was lying on floor next to the nightstand. During an observation on 2/8/2023 at 9:33 A.M., the CPAP mask and tubing was lying on top of the machine on the nightstand, uncovered. A record review was completed for Resident 17 on 2/5/2024 at 1:45 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, obstructive sleep apnea and cerebrovascular disease. A review of Physician Order's indicated that Resident 17 did not have an order for CPAP use or cleaning/changing of the equipment. A Care Plan…

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

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors related to not following a Physician's Order for Coumadin (warfarin, a blood thinner) therapy, for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: A record review for Resident 22 was completed on 2/6/2024 at 12:10 P.M. Diagnoses included, but were not limited to: pulmonary embolism and Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/27/2024, indicated Resident 22 received an anticoagulant. A Nurse's Note, dated 1/23/2024 at 3:46 A.M., indicated a lab draw was completed. A PT/INR (prothrombin time/international normalized ratio) blood test, dated 1/23/2024, indicated an INR of 1.8 (therapeutic range 2.0-3.0). The lab report had a handwritten note that indicated to begin warfarin 6 milligrams, and recheck the PT/INR lab on 1/30/2024. A Nurse's Note, dated 1/24/2024 at 4:13 P.M., indicated the Nurse Practitioner was notified of the INR result of 1.8, and an order was received to increase 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, and interview, the facility failed to document the open date of Tubersol (tuberculin skin test serum), and keep lorazepam liquid stored/locked properly in the Pyxis system, for 1 of 1 medication rooms reviewed for storage and labeling. Findings include: 1. On 2/9/2024 at 10:19 A.M., a locked miniature refrigerator was observed, with RN 3, to have a bag of two Tubersol 5 units per 0.1 milliliters vials with one opened and the other vial opened. The open vial did not have an open date written. Another bag of one opened vial of Tubersol received from the pharmacy on 12/6/2023, was not dated with an open date. During an interview on 2/9/2024 at 10:23 A.M., RN 3 indicated Tubersol needed to be used within 28 days of opening, and dated with the date opened. 2. On 2/9/2024 at 10:21 A.M., the unlocked Pyxis system refrigerator was observed with RN 3. Two bottles of lorazepam liquid were observed in an unlocked drawer of the refrigerator. During an interview on 2/9/2024 at 10:27 A.M., RN 3 indicated since the Pyxis system had been installed, the lorazepam had not been…

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 sanitize a community use blood glucose monitor after use, which had the potential to affect 4 residents who receive blood glucose testing. Finding includes: During an observation of the medication pass on 2/6/2024 at 7:53 A.M., RN 3 was observed to obtain a blood sugar for Resident 6. The blood glucose monitor was taken from the right upper medication cart drawer. No prior sanitation of the monitor was observed. After the blood glucose test was completed, RN 3 was observed placing the blood glucose monitor back into the medication cart without sanitizing the monitor. During an interview on 2/6/2024 at 8:23 A.M., RN 3 indicated she should have sanitized the blood glucose monitor prior to placing the monitor into the medication cart. She indicated, Sometimes you don't think about it. A policy was provided on 2/9/2024 at 11:16 A.M., by the Director of Nursing (DON). The policy titled, Cleaning/Disinfecting/Maintaining Glucose Meters, indicated .The Glucose meters will be disinfected between each resident use to prevent 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.