Russell Regional Hospital Ltcu

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 19 residents. The sample included eight residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 1's blood sugar was out of the physician-ordered parameters and failed to hold R1's hypertension (high blood pressure) medication when her diastolic blood pressure was out of parameters. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the boy cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension, and heart failure.R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had intact cognition. The MDS documented R1 required substantial staff assistance with showers, dressing, mobility, and transfers. The MDS further documented R1 received hypoglycemic (low blood sugar) and diuretic (a medication to promote the formation and excretion of urine)…

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 19 residents. The sample included eight residents and one medication cart. Based on observation, interview, and record review, the facility failed to label Resident (R) 1's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. Findings included: - On [DATE] at 10:15AM, observation of the facility's treatment cart revealed R1's Novolog (fast-acting insulin) flex pen was labeled with an opened date of [DATE]. The insulin is good for 28 days and expired on [DATE].On [DATE] at 10:20 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened and discard the expired insulin flex pens.Medlineplus.gov directs open, unrefrigerated Novolog can be used within 28 days; after that time, they must be discarded.The facility's Labeling of Medications policy, dated [DATE], documented inspection of medication was done to determine that medications are stored under proper conditions,…

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 19 residents. The sample included eight residents. Based on record review and interview, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) a Minimum Data Set (MDS) assessment within 92 days of the previous assessment for all 19 residents of the facility and one discharged resident. This placed the residents at risk for lack of oversight to ensure their needs were met. Findings included: A review of the facility's MDS documentation revealed transmittal of the comprehensive MDS was past due for the following residents: Resident (R) 119, due 10/4/23 R3 due 10/11/23 R4 due 10/18/23 R14 due 11/08/23 R10 due 11/08/23 R116 due 12/5/23 R13 due 12/20/23 R17 was admitted on [DATE] and the admission MDS was due on 11/14/23. R 15 was admitted [DATE], and no MDS were completed for R15 A review of the facility's MDS documentation revealed transmittal of the Quarterly MDS was past due for the following residents: R118 due 10/12/23 R11 due 10/28/23 R2 due 11/02/23…

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

The facility had a census of 19 residents. Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, for the 19 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and leadership. Findings included: - The Payroll-Based Journal (PBJ) report indicated no RN hours on 08/20/23, 09/01/23, 09/16/23 and 09/30/23. A review of the facility's payroll data revealed the facility lacked a registered nurse eight consecutive hours a day on 08/20/23 and 09/30/23. On 01/17/24 at 01:39 PM, Administrative Nurse D verified on 08/20/23 and 09/30/23 the facility lacked RN coverage. She stated on those days the RN from the hospital assessed and guided the licensed nurse on duty. The facility's RN Coverage on Main Street Manor (long term care) policy, dated 05/18/23, stated MSM would have at least eight hours of RN coverage seven days per week. The facility failed to provide the services of an RN for at least eight consecutive…

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 19 residents. Based on observation, record review, and interview the facility failed to provide the services of a full-time certified dietary manager for the 19 residents who resided in the facility and received their meals from the kitchen, placing the residents at risk for inadequate nutrition. Findings included: - On 01/10/24 at 09:12 AM, observation revealed Dietary Staff (DS) BB in the facility kitchen overseeing the preparation for the noon meal. On 01/10/24 at 09:12 AM, DS BB stated she was the Food Services Manager for the facility and verified she did not have dietary manager certification and was currently taking classes for that. The facility's Dietary Services policy, dated 05/18/23, stated if a qualified dietician does not serve as director of food services, the director of food services would be subject to the state requirements for the position. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 19 residents of 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 19 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (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 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on the following days: 05/20/23, 05/27/23, 06/04/23, 06/09/23, and 06/16/23. The PBJ report for Quarter 4 indicated no licensed nurse coverage on 07/31/23, 08/29/23, 0/09/23, and 09/16/23. The PBJ report also indicated no Registered Nurse (RN) hours on 08/20/23, 09/01/23, 09/16/23 and 09/30/23. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 01/17/24 at 09:20 AM, Administrative Nurse D verified the facility failed to submit complete…

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

The facility had a census of 19 residents. The sample included eight residents. Based on observation, record review and interview the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly as required. This placed the 19 residents who resided in the facility at risk for impaired quality of care. Findings included: - The facility provided QAA committee attendance rosters for 01/26/23, 02/23/23, 03/16/23, 04/26/23, 05/31/23, 06/28/23, 07/26/23, 08/30/23, 09/27/23, 10/25/23, 11/29/23, and 12/27/23. The documentation lacked evidence the medical director attended any of the meetings. On 01/17/24 at 09:25 PM, Administrative Nurse E verified the QAA meetings were held monthly and were to include the medical director at least quarterly. Administrative Nurse E verified the dates of the monthly meetings and stated it was hard to get the medical director to come to the meetings due to his busy schedule. Administrative Nurse F verified the facility had meetings on the above-documented dates. The facility's Quality…

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 19 residents. The sample included eight residents with five residents reviewed for immunizations Resident (R)2, R5, R8, R12, and R119, 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 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 R2, R5, R8, R12, and R119'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. The records lacked evidence of a physician-documented contraindication. On 01/18/24 at 11:25 AM, Administrative…

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 19 residents. The sample included eight residents with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to notify the state Long Term Care (LTC) Ombudsman (a person who advocates for residents of nursing homes), as required, of Resident (R) 14's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement. Findings included: - R14 's Electronic Medical Record (EMR) documented diagnoses of psychosis (any major mental disorder characterized by gross impairment in reality perception), dementia (a progressive mental disorder characterized by failing memory, and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R14 was independent…

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 19 residents. The sample included eight residents with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice, as required, to Resident (R) 14 or their representative upon discharge from the facility. This placed the resident at risk for impaired rights. Findings included: - R14 's Electronic Medical Record (EMR) documented diagnoses of psychosis (any major mental disorder characterized by gross impairment in reality perception), dementia (a progressive mental disorder characterized by failing memory, and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R14 was independent with most activities of daily living and had no falls during the lookback…

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 19 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to ensure the stovetop burners in the activity room were disabled when not in use, placing one cognitively impaired, independently mobile resident at risk for injury. Findings included: - On 01/10/24 at 09:40 AM, observation in the facility's activity room revealed an electric stove with four burners which were not disabled. When activated, the burners became hot. At that time, no residents were in the area and the staff was in sight of the stove. On 01/11/24 at 03:15 PM, observation revealed three residents sat in the activity room without staff present. The stove top burner was able to be activated. On 01/11/24 at 03:16 PM, Certified Nurse Aide (CNA) M verified the stove should be locked out, and she notified Administrative Nurse E who verified it should be locked. Continued observation revealed the nurse aides working did not know where the key was or how to lock out the stove. Certified Medication Aide R found the stove key, but…

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 19 residents. The sample included eight 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) 12's use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental-emotional conditions). This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects. Findings include: - R12's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and traumatic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R12'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 19 residents. The sample included eight 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)12's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing). This placed R12 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R12's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and traumatic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R12's Annual…

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 19 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to label Resident (R)3's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen with the name, date opened, and discard date and failed to discard expired stock medication in one medication cart. This placed the affected residents at risk for ineffective medications. Findings included: - On 01/10/24 at 09:20 AM, observation of the medication cart revealed the following: One bottle of loperamide hydrochloride (Imodium-anti diarrhea medication) 2 milligrams (mg), 100 count tablets, expired 11/2023. On 01/10/24 at 09:45 AM, observation of the treatment cart revealed the following: A Tresiba (long-acting insulin) flex pen, that was open but lacked a name, date opened, and a discard date. On 01/10/24 at 09:25 AM, Certified Medication Aide (CMA) R verified the insulin pen belonged to R3 and verified the medication aides and nurses were to look at the medication bottles and verify expiration dates before…

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 20 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to monitor and adhere to the use of facial masks. Placing the residents at risk for infection. Findings included: - On 06/21/22 at 08:00AM, observation revealed a sign posted on the front door of the facility which stated, facial masks are to be worn at all times when in the facility. Further observation revealed facial masks available in a container by the front door. During initial tour on 06/21/22 at 08:10AM, observation revealed Resident 123 (R) with a three-drawer plastic container outside the door of his room. Further observation revealed the container contained personal protective equipment (PPE). On 06/21/22 at 11:28AM, observation revealed a visitor walking out of R123's room. Further observation revealed the visitor standing at the nurse's desk, not wearing a facial mask while talking to facility staff who wore facial masks. On 06/21/22 at 11:30AM, Licensed Nurse (LN) H verified the visitor with no mask on. LN H ambulated 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 20 residents. The sample included 12 residents with five resident reviewed for rehab and restorative services. Based on observation, record review, and interview the facility failed to provide an accurate assessment reflective of restorative needs and services for five of five sampled residents, Resident (R) 1, R10, R13, R18 and R19. This placed the residents at risk not to receive restorative services based on needs and function ability. Findings included: - The Physician Order Sheet, dated 06/01/22, recorded R1 had diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and End-Stage Renal Disease (medical condition in which a person has impaired or no kidney function). The admission Minimum Data Set (MDS), dated [DATE], recorded R1 had Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive impairment) inattention and disorganized…

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 20 residents. The sample included 12 residents with five residents reviewed for rehab and restorative services. Based on observation, record review, and interview the facility failed to provide nursing supervision for the restorative program documentation and services for five of five sampled residents, Resident (R) 1, R10, R13, R18 and R19. This placed the residents at risk not to receive appropriate restorative services and accurate restorative assessments. Findings included: - The Physician Order Sheet, dated 06/01/22, recorded R1 had diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and End-Stage Renal Disease (medical condition in which a person has impaired or no kidney function). The admission Minimum Data Set (MDS), dated [DATE], recorded R1 had Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive 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.

The facility had a census of 20 residents. The sample included 12 residents with one reviewed for transmitting a Quarterly Minimum Data Set (MDS) (an assessment which contains resident specific information for payment and quality measure purposes). The facility failed to transmit the Quarterly MDS for Resident (R) 4 to Centers for Medicare Services (CMS). Findings included: - On 06/23/22 review of the Electronic Medical Record (EMR) documented a completed Quarterly MDS on 04/28/22. Review of the CMS submission validation report revealed no transmission of the 04/28/22 to CMS. The last MDS for R4 transmitted on 01/26/22 (120 days). On 06/23/22 at 08:50AM, Licensed Nurse (LN) G verified the MDS completed on 04/28/22 not transmitted when completed to CMS. Verified the last MDS transmitted to CMS on 01/26/22. On 06/27/22 at 11:00AM, Administrative Nurse (AN) D verified no submission of the completed MDS on 04/28/22. The facility's policy is the Resident Assessment Instrument (RAI) manual. The RAI stated Transmittal requirements. Within 14 days after a facility completed a resident'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 20 residents. The sample included 12 residents with four reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to complete an assessment for a redeveloped pressure ulcer and notify the physician for one of four sampled residents, Resident (R) 18. This placed the resident at risk for a worsened pressure ulcer and development of more skin issues. Findings included: - The Physician Order Sheet, dated 06/03/22, recorded R18 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), depression (mental health disorder characterized by persistent depressed mood, causing impairment of daily life), anxiety (mental health disorder characterized by worry and fear that interferes with daily life) and Chronic Obstructive Pulmonary Disease (COPD) (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum…

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 20 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to date an opened insulin (an injectable medication, a hormone used to move sugar from the blood into other body tissues) vial (small glass bottle) for one of one medication carts. Findings included: - On [DATE] at 08:39AM, observation revealed an opened Lantus (a long-acting insulin) vial in the top drawer of the medication cart. Further observation revealed the vial not dated when opened. On [DATE] at 08:40AM, Licensed Nurse (LN) G verified the undated insulin vial. On [DATE] at 11:00AM, Administrative Nurse (AN) D verified insulin should be dated when opened. The facility lacked a policy for dating opened insulin. The facility failed to date opened insulin for one of one medication carts, placing Resident (R) 15 at risk for use of expired medication.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 20 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use on as needed (PRN) psychotropic medications (medications used to treat mental illness, moods, behaviors) for two sampled residents, Resident (R) 10, and R18. This placed the residents at risk for unnecessary psychotropic medications and adverse side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R10 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), depression (mental health disorder characterized by persistent depressed mood, causing impairment of daily life), delusions (untrue persistent beliefs or perceptions held by a person although…

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 20 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for two sampled residents, Residents (R) 10, and R18. This placed the residents at risk for unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R10 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), depression (mental health disorder characterized by persistent depressed mood, causing impairment of daily life), delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) and anxiety (mental health disorder characterized by worry and fear that interferes…

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.