Phillips County Retirement Center

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) and other waterborne pathogens. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 05/16/24 at 11:00 AM, Maintenance Staff U verified he was not aware of any routine facility water management checks and verified the 300 hall was presently not in use. Maintenance Sraff U stated staff do not flush water in the unoccupied rooms but did occasionally use the shower room in the 300 hall for one resident at the facility. On 05/16/24 at 11:20 AM, Administrative Staff A verified the city checked the water monthly but stated he did not have any records of the monthly…

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 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards with staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This placed the 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 05/13/24 at 11:44 AM, observation revealed an unlocked cabinet underneath the sink, in a kitchenette, located off the family dining room. The unlocked cabinet contained a plastic gallon bottle of Attack [NAME] Enzyme (a molecule that enhances cleaning performance while decreasing environmental impact) odor digester, drain opener, and maintainer. The label on the bottle reads Keep out of reach of children, avoid contact with eyes, and may cause skin irritation. On 05/13/24 at 11:48 AM, Licensed Nurse (LN) G verified the above finding and stated the cabinet should be locked. LN…

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 31 residents. The sample included 12 residents with three reviewed for abuse. Based on observation, record review, and interview the facility failed to report an incident of neglect for Resident (R) 14 to the State Agency as required. This placed the resident at risk for ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate an incident of neglect for Resident (R)14. This placed R14 at risk for unidentified and ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain),…

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 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 26's Care Plan with interventions for the care of R26's stasis ulcers (open wound caused by problems with blood flow (circulation ) in your leg veins) on her shins. This deficient practice placed the resident at risk for decreased quality of care due to uncommunicated care needs. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had diagnoses of weakness, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented R26 required partial to moderate staff assistance with most…

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 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the physician acknowledged and responded to the Consultant Pharmacist's recommendation for the required stop date for Resident (R)19's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant…

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 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for R19's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant (medication used to treat depression) medication during 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 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store medications appropriately when staff did not label Resident (R)4s' insulin (a hormone that allows cells throughout the body to uptake glucose) flex pens with the date opened and discard date on one treatment cart. These deficient practices placed the affected resident at risk for ineffective medications. Findings included: - On 05/13/24 at 10:30 AM, observation of the treatment cart revealed the following: R4's Basaglar (long-acting insulin) flex pen lacked an open date and discard date. On 05/13/24 at 10:35 AM, Administrative Nurse D verified the nurses were to date the flex pens when opened and discard the expired insulin and expired medications. The facility's Medication Storage and Labeling policy, undated, documented medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within secured (locked) locations, clean and sanitary, and maintained temperatures in accordance with…

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 31 residents. The sample included 12 residents with two 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)12. This placed R12 at risk for inappropriate end-of-life care. Findings included: - R12's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) aphasia (a condition with disordered or absent language function), and dementia (progressive mental disorder characterized by failing memory, and confusion. R12's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R12 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.

The facility identified a census of 31 residents. The sample included 12 residents with five residents reviewed for immunization. Based on record review and interviews the facility failed to obtain the resident or the DPOA signed consent to receive the influenza immunizations for Resident (R) 4, R13, and R18. This placed the residents at risk for influenza infection and related complications. Findings included: - Review of R4, R13, and R18's clinical medical records lacked evidence the facility or the resident's representative received or was offered the current influenza vaccine during the flu season. On 05/16/24 at 11:00 AM, Administrative Nurse D stated residents were offered the influenza vaccinations yearly and the facility sent out the consent forms. Administrative Nurse D said the facility did not receive all the forms back and did not follow up, so some residents did not receive the yearly flu vaccinations. Administrative Nurse D verified some of the residents' representatives were hard to get ahold of and did not return the forms. The facility's Immunization Policy, revised…

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 29 residents. The sample included 12 residents. Based on record review and interview the facility failed to deliver mail to the facility residents on Saturdays. This placed the residents at risk for impaired psychosocial wellbeing. Findings included: - On 06/13/22 at 01:00 PM during the resident council meeting, the residents verbalized there was no mail delivery on Saturdays. On 06/13/22 at 01:45 PM, Administrative Staff A stated the housekeeping staff were supposed to get the mail on the weekend, then deliver the mail to the residents. Administrative Staff A verified the mail should consistently be delivered to the residents on Saturdays; Admisnitrative Staff A verified the facility did not always deliver mail to the residents on Saturdays. The undated facility policy Resident Rights, documented the resident has the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility through any other means than a postal service. The facility failed to deliver mail to the residents in the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent accidents for three sampled residents, Resident (R) 11, R18, R30 and R10, who had falls. This placed the residents at risk for further injury and skin breakdown. Findings included: - The Electronic Medical Record (EMR) documented R11 had diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R11 had severely impaired cognition, required extensive assistance of one staff for bed mobility and was independent with transfers,…

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 29 residents. The sample included 12 residents, with nine reviewed for falls. Based on observation, record review, and interview, the facility failed to provide a safe, accident free environment when the facility failed to prevent a skin tear and loss of a toenail while getting Resident (R)19 into the facility whirlpool, failed to implement meaningful, resident centered interventions for four sampled residents, R11, R18, R30 and R10, who were at risk and had falls. The facility further failed to ensure environment was as free of hazards as possible when the facility stored chemicals in unsecured areas accessible to residents. This placed the residents at risk for falls, and accident related injury . Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting the left non-dominant side, dementia without behavioral disturbance (progressive mental…

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 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 29 residents in the facility who received their meals from the facility kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 06/12/22 at 07:45 AM, during initial tour, observation revealed the following: Seven 18 inches by 3 foot fluorescent lights, located above the food preparation area, with plastic light covers, with a brownish speckled discolored material in the light cover with one light cover with approximately eight inch crack. Continued observation revealed the stove hood had a grey fuzzy substance along the edges of the hood with grey fuzzy substance covering the two fire suppression spigots over the stove and on the louvers of the stove hood exhaust. On 06/13/22 at 01:10 PM, Administrative Staff A verified the overhead fluorescent light fixture with brown substance in the covers and one cracked light cover.…

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 29 residents. The sample included 12 residents, with one reviewed for notification of change. Based on observation, record review, and interview, the facility failed to notify the physician in a timely manner when Resident (R) 18 developed a change from her baseline/normal behaviors. This placed the resident at risk for physical decline and delayed treatment. Findings included: - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, mask like faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and intellectual impairment…

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 29 residents. The sample included 12 residents, with one reviewed for restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body). Based on observation, record review, and interview, the facility failed to provide a physician's order and an assessment for Resident (R) 30's a merry-walker (an enclosed framed wheeled walker), placing the resident at risk for complications related to physical restraints. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension,…

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 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to report an injury of unknown origin to administration staff for one sampled resident, Resident (R) 19, who had a skin tear of unknown origin on his right hand. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting the left non-dominant side, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and contracture of the left hand (abnormal permanent fixation of a joint. The Quarterly Minimum Data Set, dated 05/12/22, documented R19 had severely impaired cognition and was dependent upon two staff for transfers, toileting and extensive assistance of two staff for bed mobility and dressing. The MDS further documented R19 did not have any skin…

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 29 residents. The sample included 12 residents with two reviewed for skin issues. Based on observation, interview and record review the facility failed to provide preventative interventions related to skin issues for two sampled residents, Resident (R)25 who developed a non-pressure skin issues and R19, who experienced a skin tear of unknown origin. This deficient practice placed R25 and R19 at increased risk for skin injuries. Findings included: - R25's Physician Order Sheet (POS), dated 05/17/22, documented diagnoses of an open wound to the buttock. The Quarterly MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R25 required supervision for eating and extensive assistance of one staff for bed mobility, transfers, and dressing. The MDS documented R25 had an open lesion on her buttocks. The Pressure Ulcer Care Area Assessment (CAA), dated 02/20/22, documented R25 had a diagnosis 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 had a census of 29 residents. The sample included 12 residents with two reviewed for pain. Based on observation, interview and record review the facility failed to provide interventions during wound care to manage Resident (R) 25's distress and pain. This placed the resident at risk for prolonged and unnecessary pain or distress. Findings included: - R25's Physician Order Sheet (POS), dated 05/17/22, documented diagnoses of open wound of buttock, and dementia (the loss of cognitive functioning). The Quarterly MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R25 required supervision for eating and extensive assistance of one staff for bed mobility, transfers, and dressing. The MDS documented R25 had an open lesion on her buttocks, received scheduled pain medication, had vocal complaints of pain daily, and received opioid medication seven days of the look back period. The Pressure Ulcer Care Area…

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 29 residents. The sample included 12 residents with one reviewed for side rails. Based on observation, interview, and record review the facility failed to assess Resident (R) 17's bed side rails for safety, This deficient practice placed R17 at risk for entrapment or injury. Findings included: - R17 was admitted to the facility 04/28/22 for skilled care related to muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R17 required assistance of two staff for bed mobility, transfers, toileting, and dressing. The MDS documented R17 had a fall prior to admission, no falls since admission, and no restraints were used. The ADL Care Area Assessment (CAA), dated 05/11/22, documented R17 needed staff assistance to get in and out of bed and was independent in rolling left and right once in bed. The Care Plan, dated 04/28/22, lacked side rail information. R17'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to respond to the consultant pharmacist (CP) notification of the inappropriate diagnosis for antipsychotic medications (type of psychiatric medication which are available on prescription to treat psychosis and are licensed to treat certain types of mental illness) for two of five residents reviewed, Resident (R)5 and R10. This deficient practice placed R10 and R5 at risk for continued use of antipsychotic medications without an appropriate diagnosis. Findings included: - R5's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of anxiety disorder (persistent feeling of anxiety or dread), vascular dementia (dementia caused by an impaired supply of blood to the brain), and recurrent major depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).…

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 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review two of five residents reviewed, Resident (R)5 and R10 had an inappropriate diagnosis for antipsychotic medications (type of psychiatric medication which are available on prescription to treat psychosis and are licensed to treat certain types of mental illness). This deficient practice placed R5 and R10 at risk for continued use of antipsychotic medications without an appropriate diagnosis. Findings included: - R5's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of anxiety disorder (persistent feeling of anxiety or dread), vascular dementia (dementia caused by an impaired supply of blood to the brain), and recurrent major depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview…

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

The facility had a census of 29 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure medication was administered per physician orders for Resident (R) 18, who received the wrong dosage of Sinemet (dopamine promoter medication) nine times a day for eight days. This placed R18 at risk for adverse side effects and complications related to medications errors. Findings included: - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, mask like faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin),…

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.