Holton Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to secure the facility's electrical panel, a razor, and cleaning chemicals in a safe, locked area, and out of reach of eight cognitively impaired, independently mobile residents. The facility also failed to assess R5 for smoking safety. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included:- During the initial tour of the facility on 08/24/25 at 07:10 AM revealed an unsecured closet with open, unlocked electrical panels. Licensed Nurse (LN) G stated he was not sure if the closet should be locked and would let the director of nursing know. On 08/24/25 at 07:09 AM, the 100-hall shower room door was swung open. Inside the shower room, there was a cabinet that had a padlock hanging open on the lock, with the key in it. Inside the cabinet was shampoo, skin barrier…

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 The facility identified a census of 34 residents. The sample included 12 residents, with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure that the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for a gradual dose reduction (GDR) for Resident (R) 6's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and R14's psychotropic (alters mood or thought) medication indication. The facility also failed to ensure the CP identified and reported as needed diuretic (a medication to promote the formation and excretion of urine) medication lacked administration parameters. The facility further failed to ensure the CP identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R19. The facility failed to follow the CP's recommendation for R24's recommendation 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 The facility identified a census of 34 residents. The sample included 12 residents, two medication carts, one Licensed Nurse (LN) medication cart, and one medication room. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for the residents in the medication cart and the medication room that were labeled with opened on dates for the liquid vials and not expired oral medications. This deficient practice placed the residents at risk for an ineffective medication regimen.Findings included:- On [DATE] at 08:55 AM, during the review of the LN medication cart an Insulin Lispro ( fast-acting insulin that lowers blood sugar in people with diabetes) lacked a date for when it was opened, and an Insulin Glargine (long-acting insulin for type 1 and type 2 diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)) vial was dated [DATE]. LN G verified that there was no open date for the Insulin Lispro vial…

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.

The facility identified a census of 34 residents. The facility had one main kitchen and a dining kitchenette. Based on observation, record review, and interview, the facility failed to ensure that the facility had sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. This deficient practice resulted in poor sanitary conditions in the kitchen and placed the residents at risk of potentially impaired nutrition.Findings included:- On 08/25/25 at 11:40 AM, Dietary Staff BB was the only dietary staff in the kitchen. Dietary Staff BB stated that he had two other staff members, but they both needed Mondays and Tuesdays off. Dietary Staff BB stated he did not have enough kitchen staff to keep the kitchen clean, cook food, and do dishes. He stated the facility had some applications, but the facility had not hired anyone yet.On 08/25/25 at 08:15 AM, Administrative Staff A stated she was aware there was not enough staff in the kitchen. She stated they did have applicants. Administrative Staff A stated that the dietary…

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.

The facility identified a census of 34 residents. The sample included 12 residents, with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 6 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections) and the Influenza vaccine as consented. The facility further failed to offer the PCV20, and Influenza vaccines for R24 and R14. This placed the residents at increased risk for complications related to pneumococcal (a type of bacterial infection).Findings included:- R6's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. Review of Resident Consent for Immunization Form for R6 dated 01/23/25 provided by the facility revealed a signed consent to receive the pneumococcal vaccination and Influenza Immunization. The form indicated R6 was provided educational information related to the PCV20 vaccination and Influenza Immunization. R6's clinical record lacked evidence that R6 received 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 The facility identified a census of 34 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations for Resident (R) 2, R14, and R24. This deficient practice placed these residents at increased risk for COVID-19.Findings included:- Review of R2's clinical record revealed he was admitted on [DATE]. Review of R2's EMR under the Immunization tab lacked documentation of the COVID-19 vaccination offered or declined, and lacked documentation of a historical administration or physician-documented contraindication.Review of R14's clinical record revealed he was admitted on [DATE]. Review of R14's EMR under the Immunization tab lacked documentation of the COVID-19 vaccination offered or declined, 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.

The facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure effective pest control. This deficient practice placed the residents of the facility at risk for decreased health and wellness. Findings included: - On 08/24/25 at 08:05 AM, several flies were in the dining area, flying around the nutrition kitchenette. Two unidentified residents were swatting flies before getting their plate of breakfast. On 08/25/25 at 10:05 AM, more than ten flies were flying around the nurse's station. On 08/25/25 at 11:44 AM, in the kitchen, there were 10-15 flies on the plates and bowls. On 08/25/25 at 12:10 PM, Resident (R) 16 stated her partner at the table brings his fly swatter and kills flies. She stated there were always flies in the dining room. The facility's last pest control inspection reported that on 04/23/25, the provider sprayed for general pests. On 08/26/25 at 12:42 PM, Certified Medication Aide (CMA) R stated the facility did have more flies. CMA R stated the flies come in through the patio. CMA R stated it takes a long…

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 The facility identified a census of 34 residents. The sample included 12 residents, with two residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's call light was within her reach and further failed to ensure R6 was not pushed by staff without foot pedals. This deficient practice left R22 vulnerable for unmet care needs due to the inability to call for staff assistance and the possibility of falls and placed R6 at risk for preventable injury and avoidable accidents.Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), 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.

The facility identified a census of 34 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on the record review and interview, the facility failed to provide the cost for continued services information on the Advanced Beneficiary Notice (ABN Centers for Medicare and Medicaid Services (CMS) form 10055) for skilled services for Resident (R) 9. This placed the resident at risk for uninformed care decisions.Findings included:- Review of R9's ABN lacked documentation regarding the cost for continued skilled services ending on 7/24/25.On 08/26/25 at 01:27 PM, Administrative Nurse D stated that the beneficiary notice should have the cost on it to notify the residents.The facility's Advance Beneficiary Notices policy dated 11/05/24 documented the facility was to ensure timely notices regarding Medicare eligibility and coverage provided. The policy documented the facility would inform Medicare beneficiaries of his or her potential liability for payment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents, with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 33 for chronic pain, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), activities of daily living (ADL), vision, bowel and bladder, activities, falls, psychosocial, dehydration, risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). This deficient practice placed R33 at risk for impaired care due to uncommunicated care needs. Findings…

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 The facility identified a census of 34 residents. The sample included 12 residents, and 12 residents were reviewed for care plan revision. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 19's care plan to include the dialysis (a procedure where impurities or wastes are removed from the blood) provider, frequency of visits, and chair time at dialysis. These deficient practices placed R19 at risk for impaired care due to uncommunicated care needs related to dialysis. Findings included:- R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dependent on dialysis, and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 02/02/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated…

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 The facility identified a census of 34 residents. The sample included 12 residents, with two residents sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 9's plan of care reflected assistance and monitoring while eating. This defiant practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity.Findings Included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of insomnia (inability to sleep), sleep apnea (a disorder of sleep characterized by periods without respirations), hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hyperlipidemia (condition of elevated blood lipid levels), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), metabolic encephalopathy (a condition in which brain function is…

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 The facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 22's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary container. This placed R22 at an increased risk for respiratory infection and complications.Findings Included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and emphysema (long-term, progressive disease of the lungs characterized by shortness of breath).The Quarterly Minimum Data Set (MDS) dated [DATE]…

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 The facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 19's access site for complications at least daily and document arteriovenous (AV- a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day. This deficient practice placed R19 at risk of adverse outcomes and physical complications related to dialysis. Findings included:- R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD- a terminal disease 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 The facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 4's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R4 at risk for decreased psychosocial well-being and ineffective treatment. Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD, panic disorder, impulse, major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by…

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 The facility identified a census of 34 residents. The sample included 12 residents, with four residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 24 and R2. This placed the resident at risk for inappropriate end-of-life care. Findings included:- R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), dementia (a progressive mental disorder characterized by failing memory and confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces,…

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.

The facility had a census of 18 residents. The sample included 16 residents. Based on record review and interview the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours seven days a week. This placed all residents who resided in the facility at risk for lack of assessment and inappropriate care. Findings included: - A review of the facility's Working Schedule and Additional Information revealed the facility lacked RN coverage for eight consecutive hours on the following days: 10/10/23, 10/14/23, 10/16/23, 10/21/23, 11/4/23, 11/6/23, 11/7/23, 11/11/23, 11/12/23, 11/13/23,11/14/23, 01/10/24, 01/11/24, 01/12/24, 01/13/24, 01/14/24, 01/15/24, 01/16/24, and 01/17/24. The Facility Assessment, dated 01/2023, documented the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care 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.

The facility reported a census of 18 residents. Based on observation, record review and interviews, the facility failed to provide administration services in a manner that enabled effective and efficient use of resources to attain/maintain each resident's highest practicable physical, mental and psychosocial well-being, as evidenced by the deficiencies cited on the health resurvey. This had the potential to affect all 18 residents. Findings included: - Based on observation, record review, and interview, the facility failed to provide trauma-informed care for Resident (R) 17 who had an extensive history of trauma. On 05/11/23, the facility performed a social services assessment on R17 which revealed an extensive history of traumatic relationships, experience with disaster, profound feelings of helplessness, history of serious accidents and/or injuries and a history of abuse and sexual harassment. Despite this information, the facility did not develop a plan of care which identified and addressed triggers in order to prevent recurring traumatization. On 11/01/23 R17 told Activity…

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.

The facility had a census of 18 residents. The sample included 16 residents. Based on interview and record review the facility failed to identify how the facility's Medical Director would fulfill his/her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility The facility lacked a medical director's job description or separate facility policy. This placed all 18 residents at risk for inadequate care and decreased quality of life. Findings included: - Upon request during the annual recertification and extended survey, the facility was unable to provide a contract for a Medical Director or any documentation that indicated the role and responsibility of the facility's Medical Director for 2023. The facility provided a Medical Director Agreement signed by both the physician and the facility corporate representative effective 01/03/2024. The facility provided a typed statement from Administrative Staff A which stated that Administrative Staff A notified the facility's Medical Director on or about December 18,2023 by phone…

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.

The facility had a census of 18 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 1 and 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple dates. Review of the facility's licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. Facility had licensed nurse coverage on 08/27/23, 09/10/23, 09/16/23, and 09/17/23. On 01/24/24 at 02:00PM, observation revealed a registered nurse on duty in the facility. On 01/23/24 at 04:35 PM, Administrative Staff A reported the business office manager sent nursing hour information to the facility's corporate office to be submitted.…

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.

The facility identified a census of 18 residents. Based on observation, interview, and record review the facility failed to ensure procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program. The current QAPI program failed to gather and analyze data, implement, and re-evaluate to address adverse events and potential deficient practices specific to the facility. This had the potential to affect all 18 residents residing in the facility. Findings Included: - The facility failed to promote care in a manner to maintain and enhance dignity and respect placing the affected residents at risk for impaired psychosocial well-being (Refer to F550) The facility failed to provide notification to and include the resident and/or DPOA of the quarterly care plan meetings for Resident (R)13. This placed the R13 at risk for impaired care and decreased autonomy. (Refer to F553) The facility failed to provide CMS form 10055, Advanced Beneficiary Notice, (ABN) which included the estimated cost to continue skilled services to 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.

The facility identified a census of 18 residents. Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required members in attendance. This deficient practice placed all the residents at risk for ineffective care. Findings Included: - A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet for 2023 indicated a QAPI meetings were held each month. The sign in sheets revealed the facility Medical Director did not attend any of the QAPI meetings in 2023. The review also revealed that the Director of Nursing and Infection Preventionist did not attend any of the meetings for the last quarter of 2023. On 01/29/24 at 04:14 PM Administrative Staff A stated the QAA committee met monthly. Administrative Staff A stated facility nurses, medical records, Administrative Nurse D if available, the consultant pharmacist, dietary, maintenance, laundry and housekeeping staff participated in the QAA meetings. Administrative Staff A stated 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.

The facility had a census of 18. The sample included 16 residents. Based on record review, interview, and observation the facility failed to treat residents with respect, dignity, and privacy related to blood glucose testing, insulin (a hormone that lowers the level of glucose in the blood) administration, eye drop administration, and unintentional skin exposure from too-large clothing. This placed the affected residents at risk for impaired psychosocial well-being. Findings included: - On 01/24/24 at 04:40 PM, observation revealed Licensed Nurse (LN) G obtained Resident (R) 1's blood sugar reading using a glucometer (a blood glucose meter monitor device that tests the amount of glucose [sugar] in the blood) from R1's left index finger at the table in the dining room, with 11 other residents seated in the dining room eating supper. Continued observation revealed R1 pulled his shirt up and LN G administered an insulin injection subcutaneously (applied under the skin) into R1's right lower abdomen. On 01/24/24 at 04:50 PM, observation revealed LN G obtained R18's blood sugar reading…

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.

The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accidents and hazards for four cognitively impaired, independently mobile residents who resided in the facility. Findings included: - On 01/22/24 at 09:30 AM, observation during the initial facility tour revealed an unlocked shower room door on the South hall. The shower room contained the following: Two 32-ounce bottles of Virex 11-256 (disinfectant cleaner) spray bottles, with the warning may cause burns, corrosive to nose, throat and respiratory tract, keep out of reach of children One bottle was in the shower room on a shelf and one was on a shelf by the toilet. One 5-ounce (oz) spray can of bedbug and lice spray, with the warning keep out of reach of children, may cause serious eye irritation, if swallowed call a poison control center, in a cabinet by the bathtub. On 01/22/24 at 09:35 AM, Licensed Nurse (LN) G verified the chemicals in the unlocked soiled utility room and stated the shower…

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.

The facility identified a census of 18 residents. The sample included 16 residents with five residents reviewed for immunizations, Resident (R)3, R4, R6, R14, and R16, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and is caused by infection) vaccinations. Based on record review and interviews, the facility failed to provide the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of R3, R4, R6, R14, and R16's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. On 01/2424 at 01:00 PM, Administrative Nurse D and Administrative Nurse E stated the facility was up to date on…

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.

The facility had a census of 18 residents. The sample included 16 residents. Based on interview and record review, the facility failed to inform Resident (R) 13, and/or her Durable Power of Attorney (DPOA) orally or in writing the date and time of R13's quarterly care plan meetings. This placed the resident at risk for impaired care and decreased autonomy. Findings included: - R13's medical record lacked documentation the resident and/or her DPOA was invited to or participated in quarterly care plan meetings in the last year, however, documentation indicated the resident and DPOA had attended one meeting on 08/23/24. R13's medical record had a late note entered on 01/22/24 at 10:30 AM which Administrative Nurse E documented the facility had a care plan meeting with R13, R13's husband, and son but Administrative Nurse E was unable to remember what was discussed and did not have anything documented from the meeting. On 1/22/24 at 12:30 PM, R13 and her DPOA stated staff had not invited them to any care plan meetings in the last year while R13 resided at the facility. On 01/24/24 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.

The facility had a census of 18 residents. The sample included 16 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide CMS form 10055, Advanced Beneficiary Notice, (ABN) which included the estimated cost to continue skilled services to the resident or their representative for Resident (R) 10 and R17. This placed the two residents at risk for unanticipated costs or uninformed decisions. Findings included: - The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. R10's EMR lacked…

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 The facility had a census of 18 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to investigate Resident (R)13's bruises of unknown origin. This placed the resident at risk for unidentified and ongoing abuse and/or neglect. Findings included: - R13's Electronic Medical Record (EMR) recorded diagnoses of heart failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status interview should be conducted but lacked a documented cognition score or staff assessment. The MDS documented R13 was dependent on staff for toileting. The MDS documented…

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 The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to develop an individualized comprehensive person-centered care plan for Resident (R)17 and R4. This placed the residents at risk for unmet mental health care needs related to past trauma. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), need for assistance with personal care, heart failure, pain, disease of the spinal cord, Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented…

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 The facility had a census of 18 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 16's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality) and failed to identify and report the lack of a 14-day stop date or specific duration for R16's as needed (PRN) psychotropic (alters mood or thought) medication. This placed the resident at risk for unnecessary psychotropic medication and related side effects. Findings include: - R16's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, anxiety, or mood disturbance. R16's Annual Minimum Data Set (MDS), dated [DATE],…

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 The facility had a census of 18 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)16's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) and failed to ensure a 14-day stop date or specified duration with rationale for R16 and R17's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R16 and R17 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R16's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) without…

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.

The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R)13 and R6's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help)in a sanitary manner, and staff failed to properly store R15's used urinary catheter (tube inserted into the bladder to drain urine) bag when not in use during the day. This placed the residents at increased risk for infection and communicable diseases. Findings include: - On 01/22/24 at 12:30 PM, observation revealed R15's urine collection catheter bag and catheter tubing hung on the towel rack in the bathroom, unbagged. R15 had a roommate who shared the bathroom with the resident. On 01/23/24 at 10:30 AM, observation revealed R13's unbagged oxygen tubing and nasal cannula laid on the nightstand, attached to the oxygen concentrator. On 01/23/24 at 10:40 AM, observation revealed R6's…

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.

The facility had a census of 30 residents. The facility identified 29 residents positive for Covid-19 ( highly contagious, potentially life threatening respiratory virus). The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for the 30 residents who resident in the facility. The facility failed to assess and ensure water temperatures were adequate to ensure the laundry, bedding, and linens were sanitized and disinfected for the 30 residents who resided in the facility. The facility failed to disinfect shared blood glucose glucometer between uses. The facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections one of three halls, when housekeeping staff failed to clean the floor with a disinfectant cleaner, during cleaning of a resident's room on Covid-19 isolation . 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.

The facility had a census of 30 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 08/09/22 at 10:20 AM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. She stated she had not had the training. Administrative Nurse D was going to have another nurse assigned to the Infection Preventionist nurse after that nurse passed her Registered Nurse licensing. The Infection Management policy, dated December 2020 documented the purpose is to identify, monitor, analyze and report infections in the facility. Infection control prevention practices are to be trained routinely with in person education or online training database with staff.…

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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview and record review the facility failed to store, prepare and serve meals in a sanitary manner for the residents at the facility. This deficient practice placed the affected residents who received meals from the kitchen at risk for food borne illness. Findings included: - On 08/04/22 at 08:27 AM, observation in the facility's kitchen revealed the following: The white freezer had an open, undated bag of potato triangles, an open, undated bag of six hamburger patties, and five uncovered cups of a desert. The double refrigerator had an open, undated bag of tortillas. The dry storage room had an open box of 4-pound bags of cheesecake mixes on the floor. On 08/09/22 at 12:17 AM, observation during the meal service revealed Dietary Staff (DS) CC donned a soiled oven glove and while adjusting the steam table pans, she stuck her thumb with soiled oven glove into the spaghetti. DS CC used gloved hands, instead of tongs, to place buttered bread on the plates, at times leaving spaghetti…

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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview and record review the facility failed to provide a safe, clean, sanitary environment. This deficient practice placed the affected residents at risk for impaired well-being. Findings included: - On 08/09/22 at 04:10 PM, observation in the facility kitchen revealed the following: A vent screen on the electric panel wall had black substance in spotty areas. A small ceiling vent, 15 (inches) x 15 was rusty, linty. A large ceiling vent 2'(foot) x 4' by the double refrigerator had lint hanging down ½ inch. An approximately 4 x 4-inch hole in a ceiling tile above the double refrigerator door. The ice machine lacked a two-inch air gap in the drainage system. On 08/10/22 at 09:30 AM, observation in the facility revealed the following: The chapel floor had carpet stains around the outside walls up to three feet inside the room. A two-foot diameter stain in the center of the chapel. The chapel hallway ceiling had soiling or stains on approximately 75% of the tiles. Lullaby hall ceiling…

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 The facility had a census of 30 residents. The sample included 12 residents with two reviewed for urinary catheter (tube inserted into the baldder to drain urine). Based on observation, interview and record review the facility failed to care plan Resident (R) 29's urinary catheter leg bag. This deficient practice placed R29 at risk for unmet care needs. Findings included: - R29's Physician Order Sheet (POS), dated 06/28/22, documented diagnoses of benign prostatic hyperplasia (condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), urinary calculi (hard deposits made of minerals and salts that form inside the kidneys), and neuropathic bladder (bladder that doesn't empty or store urine properly). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R29 required supervision for eating, walking, locomotion, limited assistance of one staff…

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 The facility had a census of 30 residents. The sample included 12 residents with one reviewed for urinary catheter (tube inserted directly into the bladder to drain urine). Based on observation, interview and record review the facility failed to provide adequate care and services for catheters for Resident (R) 29. This deficient practice placed R29 at risk urinary infections. Findings included: - R29's Physician Order Sheet (POS), dated 06/28/22, documented diagnoses of benign prostatic hyperplasia (condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), urinary calculi (hard deposits made of minerals and salts that form inside the kidneys), and neuropathic bladder (bladder that doesn't empty or store urine properly). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R29 required supervision for eating, walking, locomotion, limited…

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 The facility had a census of 30 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to act upon the Consultant Pharmacist (CP) recommendations the facility staff complete an abnormal movement assessment for the continued use of antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication, Risperdal, for Resident (R)19. The facility further failed to ensure the CP identified and reported an inappropriate diagnosis for the use of an antipsychotic medication for R18 and the lack of a stop date for as needed psychotrpoic medications (class of medications which alter mood or thought). These deficient practices placed R19 and R18 at risk for unnecessary medications and adverse side effects related to antipsychotic drug use. Findings include: - R19's Physician Order Sheet (POS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 30 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate side effect monitoring for two of the five sampled residents, Resident (R)19's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication Risperdal and R18's olanzapine ( antipsychotic). The faility further failed to ensure R18's as needed (PRN) Ativan (an antianxiety medication that calm and relax people with excessive restlessness, nervousness and tension) had the required 14 day stop date or a rationale for continued use. This placed R19 and R18 at increased risk for side effects related to medications and unnecessary medication use. Findings include: - R19's Physician Order Sheet (POS), dated 08/05/22 documented diagnoses of paranoid schizophrenia (a thought process believed to be heavily influenced by anxiety or…

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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R)27, reviewed during medication administration pass, remained free of medication errors. This placed the resident at risk for adverse reaction from the medication and resulted in a facility medication error rate of 7.14 percent (%). Findings included: - Resident (R)27 's Physician Order Sheet, dated 07/20/22, recorded diagnoses of dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering and hoarding), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R27's Physician Order, dated 08/01/22 instructed staff to administer potassium chloride (potassium supplement) extended release (ER), 20 milliequivalents (mEq) one tablet a day, and bupropion HCL (mood stabilizer) ER 150 milligrams (mg), one tablet a day. On 08/09/22 at 09:05 AM, observation…

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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)20's expired insulin (hormone which allows cells throughout the body to uptake glucose) flex pen in one medication cart, and failed to discard expired stock medications in one medication room. This placed the affected residents at risk for ineffective medications. Findings included: - On 08/04/22 at 08:20 AM, observation of the medication cart, revealed R20's Lispro (a rapid acting insulin) flex pen, expired 6/28/22. On 08/04/22 at 08:30 AM, observation of the medication room refrigerator revealed one box of bisacodyl suppositories (laxative) 10 milligram (mg), 100 count, expired 4/22, and three boxes of Influenza vaccine Flu zone (vaccine indicated for the prevention of influenza disease) high dose vials, 10 count per box, expired 06/30/22. On 08/04/22 at 08:35 AM, Licensed Nurse (LN) G verified the stock medications in the medication cart, and the medication in the medication room refrigerator was expired. LN G…

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.