Wheat State Manor

The facility identified a census of 32 residents. The sample included 12 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to monitor bowel movements for Resident (R) 2 and follow the physician orders to administer medications for constipation after a 13 day interval with no bowel movements documented. Findings included:- R2's Electronic Medical Records (EMR) documented diagnoses, which included constipation (difficulty passing stools) and pain due to acute trauma. R2's 12/17/25 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS noted R2 was frequently incontinent of bladder and bowels. R2 was dependent on the staff for care. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 was admitted from the hospital following a motor vehicle incident with multiple fractures. R2 had functional limited range of motion to her right arm and both legs. She needed maximum…

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, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 2, R4, and R6, who did not receive medications as ordered. Findings included:1. R2's Electronic Medical Records (EMR) documented diagnoses which included constipation (difficulty passing stools), pain due to acute trauma, and multiple fractures, including to the face, both legs, right arm, and spine.R2's 12/17025 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R2 was dependent on the staff for care. R2 took an anticoagulant (a class of medications used to prevent the blood from clotting) medication,The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R2 was admitted from the hospital following a motor vehicle incident with multiple fractures and injuries. R2 had limited range of motion to her right arm and both legs. She needed maximum assistance with toileting,…

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 38 residents with three residents reviewed for Medicare Advance Beneficiary and Medicare Non-Coverage Notices. Based on interview and record review, the facility failed to ensure three Resident (R) 40, R95 and R 96 received the Center for Medicare/Medicaid Services (CMS) form 10123 (for the right of expedited review of discontinuation of services) as required when skilled services ended. In addition, the facility failed to issue CMS 10055 (the right to continue skilled services and cost of the services) to R40 as required. Findings included: - Review of Resident (R) 40's medical record revealed skilled therapy discharged the resident on 12/21/23. The facility contacted the responsible party by phone but did not issue the required CMS 10123 or CMS 10055. The resident remained in the facility and was placed on hospice services 01/02/24. Review of R95's medical record, revealed skilled services ended 10/18/23, and the facility issued CMS 10055 to the resident's responsible party by email on 10/23/23. The facility did not issue CMS 10123 as required.…

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 38 residents with five residents reviewed for Covid-19 vaccinations. Based on interview and record review, the facility failed to ensure the residents of the facility received up to date Covid vaccinations, if desired, and failed to ensure residents were given the opportunity to rescind previous year declination. Findings included: - Review of Resident (R)32's medical record immunization tab, revealed the resident received a Covid vaccination on 11/17/22 and no Covid vaccine offered in 2023. Review of R 20's medical record immunization tab revealed the resident refused the covid booster on 11/13/21 , with no opportunity to change declination in 2022 and 2023. Review of R5's medical record Immunization tab, revealed the resident received a Covid booster 11/17/22 and no Covid vaccine offered in 2023. Review of R3's medical record Immunization tab, revealed the resident received a Covid vaccination 11/17/22 , and no Covid vaccine offered in 2023. Review of R2's medical record Immunization tab, revealed the resident declined Covid vaccination 01/26/21…

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 reported a census of 38 residents with 13 residents selected for review, which included one Resident (R)20, reviewed for Pre-admission Screening and Resident Review (PASRR) Level two. Based on observation, interview, and record review, the facility failed to obtain a reassessment for R20 to determine mental health needs as required. Findings included: - Review of Resident (R)20's medical record, revealed diagnoses that included schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) with psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), and osteomyelitis (local or generalized infection of the bone and bone marrow). The Annual Minimum Data Set (MDS), 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 reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)19 regarding the use of eyeglasses. Findings included: - Review of Resident (R)19's electronic medical record (EMR) included a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required glasses for her vision. The Visual Function Care Area Assessment (CAA), dated 10/27/23, did not trigger. The Quarterly MDS, dated 01/26/24, did not assess cognition or vision. The care plan, revised 02/01/24, lacked staff instruction on the resident's use of eyeglasses. On 03/06/24 at 10:39 AM, the resident stated her glasses…

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 reported a census of 38 residents with 13 residents sampled, including one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)19 received adequate assistive devices to maintain proper vision, by failing to have her glasses repaired in a timely manner. Findings included: - Review of Resident (R)19's electronic medical record (EMR) included a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required glasses for her vision. The Visual Function Care Area Assessment (CAA), dated 10/27/23, did not trigger. The Quarterly MDS, dated 01/26/24, did not assess cognition or vision. The care plan, revised 02/01/24, lacked 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 reported a census of 38 residents with 13 residents selected for review, which included five residents selected for review for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)13 received reevaluation for continued use of as needed (PRN) psychotropic (medication that alters mood or thought) , and R11 related to lack of an abnormal involuntary movement scale (AIMS) to monitor for adverse effects of antipsychotic medications. Findings included: - Review of Resident (R)13's medical record, revealed diagnoses that included cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia(condition with disordered or absent language function), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory,…

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 reported a census of 39 residents with 16 residents sampled, which included three residents for pressure ulcer/injury. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to change gloves and perform proper hand hygiene between phases of wound care for Resident (R)2 and R3. This deficient practice has the potential to lead to cross contamination between residents and negatively affect the residents that resided in the facility. Findings include: - Review of the Electronic Health Record (EHR) for Resident (R)2 revealed the following pertinent medical diagnoses that included anemia (a condition without enough healthy red blood cells to carry adequate oxygen to body tissues) and pressure ulcer (a 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) of the right buttock. The admission Minimum Data…

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 39 residents, with three residents sampled. Based on interview and record review, the facility failed to ensure the resident/resident's representative for Resident (R) 8, the right to be fully informed, in advance, of the risks and benefits of proposed care (initiation of antipsychotic [class of medications used to treat psychosis and other mental emotional conditions] and of treatment and treatment alternatives, as well as the right to choose options/treatments. On 11/14/23, R8's provider ordered Rexulti (atypical antipsychotic medicine for depression and agitation that may happen with dementia due to Alzheimer's disease) and failed to notify the resident's representative of the new order for the Rexulti. Findings included: - The signed Physician Order Sheet (POS), for Resident (R) 8, dated 11/07/23, revealed the following diagnoses; major depressive disorder (major mood disorder), vascular dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain)…

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 reported a census of 39 residents, with one resident reviewed for unnecessary medication. Based on interview and record review, the facility failed to ensure Resident (R)1, received the physician's ordered medication of Fentanyl patch (a controlled medication patch used for severe pain), when staff applied Fentanyl 200 micrograms (mcg), when the physician ordered 112 mcg. The facility failed to notify the physician, perform any necessary clinical interventions, record the medication as given in the clinical record, observe, assess outcome of the elder and document in the clinical record, record any actions, clinical interventions necessary, report the error on the incident report and record notification of family in clinical record with any stated response, education and questions. Facility staff also failed to notify the facility administrative staff. Findings included: - The signed Physician Order Sheet (POS), for Resident (R) 1, dated 10/05/23, revealed the following diagnoses; quadriplegia…

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 reported a census of 46 residents with seven selected for review and one resident reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents from verbal abuse from Licensed Nurse (LN) G. On the morning of 08/26/23, Certified Nurse Aide (CNA) M heard LN G threaten to hit Resident (R) 2 and CNA N heard LN G threaten R2 if she hit her again, she would be sorry. CNA N failed to report the verbal abuse and CNA M reported the verbal abuse to LN H. LN H failed to notify Administrative Nurse D. LN G worked three shifts after the verbal abuse on 08/26/23, 08/27/23, and 08/28/23 until Administrative Nurse D was made aware of the occurrence on 08/31/23. Findings included: - The Medical Diagnosis tab for R2 included a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder). The admission Minimum Data Set (MDS) dated [DATE] for R2 lacked 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.

The facility reported a census of 47 residents. Based on interview and record review, the facility failed to ensure nursing staff proactively followed the principles of antibiotic stewardship to ensure antibiotics were used in a safe and effective manner to prevent adverse effects of antibiotics to the residents of the facility. Findings included: - Review of the February 2022 Infection and Antibiotic Start Log revealed an entry for resident (R)33 whom received treatment of Nitrofurantoin on 02/14/22 for urinary tract infection. The log indicated a urinalysis and culture and sensitivity was sent on 02/14/22 and staff followed up with the culture results at 48 and 72 hours. The staff documented the bacteria as klebsiella pneumoniea with date of final results documented as 04/16/22. A comment indicated the resident was put on Cipro due to culture results. The log lacked documentation that the resident received 10 doses of an ineffective antibiotic. Review of R 33's medical record revealed the following Physician Orders: A Physician's Order, dated 02/14/22, instructed staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents with 15 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide privacy to enhance two dependent Residents (R)36 and R 42, dignity while performing perineal hygiene cares. Findings included: - Review of Resident (R)42 electronic medical record (EMR), under the Med Diag tab, included: dementia (progressive mental disorder characterized by failing memory, confusion) and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. The resident required extensive assistance of two staff for toilet use. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), 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.

The facility reported a census of 47 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for one of the 15 residents (R12) when the resisdent slept in and staff failed to administer morning medications as ordered by the physician. Findings included: - R12's Physician Orders, dated 03/10/221 instructed staff to administer the following medications to the resident: Aspirin 81 milligrams (mg) daily original order dated 08/03/21. Carvedilol 6.25 mg twice a day for hypertension, original order date 08/03/21. Claritin 10 mg daily in morning for allergies, original order date 01/14/22. Famotidine 20 mg two times a day for gastric reflux, original order date 12/03/21. Haloperidol 0.5 mg two times a day for agitation original order dated 12/02/21. Simvastatin 20 mg, daily for hyperlipidemia, original order date 08/03/21. The Care Plan, reviewed 02/10/22, Instructed staff the resident required assistance of one to two persons for activities of daily living. Staff used a mechanical lift for 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 reported a census of 47 residents with 15 selected for review, with three reviewed for activities of daily living. Based on observation, interview and record review, the facility failed to provide bathing, grooming and oral care for one resident (R)12, of the three residents reviewed for activities of daily living. Findings included: - Review of resident (R)12's Physician Order Sheet, dated 03/10/22, revealed diagnoses included hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following cerebra vascular disease (stroke), aphasia (condition with disordered or absent language function) , dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and delirium (sudden severe confusion, disorientation and restlessness). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, with physical behavior directed toward others on one to three days, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents with 15 residents included in the sample, including two residents reviewed for pressure ulcers (PU). Based on interview, record review and observation, the facility failed to reposition one Resident (R)42 timely to prevent the development of PUs and failed to appropriately change the dressing for R 10's pressure ulcer. Findings included: - Review of Resident (R)42 electronic medical record (EMR), under the Med Diag tab, included: dementia (progressive mental disorder characterized by failing memory, confusion) and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He required extensive assistance of two staff for bed mobility and transfers and had no impairment in…

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 reported a census of 47 residents with 15 selected for review with two residents reviewed for restorative services/range of motion. Based on observation, interview and record review, the facility failed to provide one of the two residents, (R)12 with a finger positioning device to assist in maintaining anatomical alignment of this resident's hand. Findings included: - Review of resident (R)12's Physician Order Sheet, dated 03/10/22, revealed diagnoses included hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following cerebra vascular disease (stroke), aphasia (condition with disordered or absent language function) , dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and delirium (sudden severe confusion, disorientation and restlessness). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, with physical behavior directed toward…

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 reported a census of 47 residents with 15 residents sampled, including four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to keep one dependent Resident (R)14 safe while drinking hot coffee, failed to safely propel one dependent resident R36 in a wheelchair, and failed to initiate interventions following two falls for R 36. Findings included: - Review of Resident (R)14's electronic medical record (EMR), under the Med Diag tab, included: acquired absence of left and right legs below the knee and dementia (progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. She required extensive assistance of two staff for bed mobility and supervision for eating. She had impairment in functional range of motion (ROM) on both sides of her upper extremities. 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 reported a census of 47 residents with 15 residents sampled, including four residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to provide appropriate peri-care for two Residents (R)33 and R 36 to prevent urinary tract infections and failed to provide catheter care appropriately to prevent urinary tract infections for one R 37. Findings included: - Review of Resident (R)37's electronic medical record (EMR), under the Med Diag tab, included: dementia (progressive mental disorder characterized by failing memory, confusion) and benign prostatic hyperplasia/hypertrophy (BPH) non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. He had an indwelling urinary catheter (a tube to drain…

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 47 residents with 15 selected for review and 6 reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to accurately administer physician ordered medications for one of the six sampled residents, (R)12, on at least seven occasions. Findings included: - R12's Physician Orders, dated 03/10/221 instructed staff to administer the following medications to the resident: Aspirin 81 milligrams (mg) daily original order dated 08/03/21. Carvedilol 6.25 mg twice a day for hypertension, original order date 08/03/21. Claritin 10 mg daily in morning for allergies, original order date 01/14/22. Famotidine 20 mg two times a day for gastric reflux, original order date 12/03/21. Haloperidol 0.5 mg two times a day for agitation original order dated 12/02/21. Simvastatin 20 mg, daily for hyperlipidemia, original order date 08/03/21. Observation, on 04/20/22 at 09:35 AM, revealed Certified Medication Aide (CMA) T, administered to the resident the following crushed medications in chocolate syrup: aspirin 81 milligrams…

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 reported a census of 47 residents with six selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure timely and follow up on the pharmacist recommendations for two of the six residents reviewed, including resident (R) 33and 13. Findings included: - Review of resident (R)33's Physician Order Sheet, dated 03/10/22, revealed diagnosis included urinary tract infection (UTI,) dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain, and arteriosclerotic heart disease (ASHD; disease of the arteries of the heart,) hypertension (HTN; elevated blood pressure). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment 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.

The facility reported a census of 47 residents with 15 selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to monitor physician ordered daily weights for one of the six sampled residents (R)28 to determine appropriate administration need for Lasix (a medication used to remove fluid from the body) as needed, per the physician's order. Findings included: - Review of resident (R)28's Physician Order Sheet, dated 03/15/22, revealed diagnoses included cardiac arrhythmia with pacemaker insertion (irregular heartbeat), coronary artery disease, hypertension (elevated blood pressure), and stroke. A Physician's Order, dated 12/08/21, instructed staff to administer Lasix (medication to remove excess fluid) 40 milligrams (mg) every 24 hours as needed for a five-pound weight gain in 24 hours or for a 10-pound weight gain in one week. Administer with 20 mEq (milliequivalents) of potassium chloride. Review of the February 2022 Medication Administration Record and Treatment Administration…

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 reported a census of 47 residents with six residents selected for unnecessary medication use. Based on observation, interview and record review, the facility failed to ensure as needed psychotropic medications did not exceed the 14-day administration without physician reevaluation, specification of target symptoms, and duration, for two of the six residents (R)33 and R13. Findings included: - Review of resident (R)33's Physician Order Sheet, dated 03/10/22, revealed diagnosis included urinary tract infection, dementia(progressive mental disorder characterized by failing memory, confusion), anxiety disorder(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, diabetes(when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain, and arteriosclerotic heart disease (disease of the arteries of the heart). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive…

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.