Sandpiper Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 84 residents with one resident reviewed for therapeutic diet. Based on observation, interview, and record review, the facility failed to follow the menu for Resident (R)3 to provide the physician ordered gluten free diet. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for R3 included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and R3 did not receive a therapeutic diet. The MDS did not trigger the Nutritional Status Care Area Assessment. The Quarterly MDS dated 01/11/24 assessed R3 with a BIMS score of nine, indicating moderate cognitive impairment and did not receive a therapeutic diet. The Care Plan dated 01/10/24 for R3 instructed the staff to serve the diet as ordered. The dashboard of the EMR for R3 revealed an allergy to gluten. 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 99 residents with four residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform proper hand hygiene between resident contacts while delivering meal trays and failure to don appropriate personal protective equipment (PPE - equipment worn by personnel to minimize exposure hazards that can lead to injuries or illnesses) when delivering meals to a resident under isolation precautions (a combination of appropriate PPE and hand hygiene practices to prevent the spread of infectious agents between individuals). This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. Findings include: - Review of the Electronic Health Record (EHR) for Resident (R)1 revealed the following pertinent medical diagnoses: sepsis (a systemic reaction that develops when the chemicals in the immune system…

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 100 residents. Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week by not having a registered nurse scheduled as required. Findings included: - Review of the nursing schedule and day sheets from 12/01/2021 to 12/01/2022 revealed no RN coverage for 12/05/21, 12/19/21, 01/01/22, 01/02/22, 01/15/22, 01/16/22, 01/29/22, 01/30/22, 02/12/22, 02/13/22, 02/26/22, 02/27/22, 12/10/22, and 12/11/22. On 01/05/23 at 01:56 PM, Administrative Staff S reported that that the nurse managers (some of whom are LPNs) cover weekend call time and was unaware that RN coverage must include an eight consecutive hour tour of duty in the building every 24 hours. Review of the facility's undated policy Nursing Staffing Posting Information lacked information about staffing number requirements for RN coverage. The facility failed to ensure the use of a RN for at least eight consecutive hours per day, seven days a week by not having a RN scheduled to work on 14 days…

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 100 residents. The facility reported all residents received meals prepared in the kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and in sanitary conditions due to the staff's failure to date and cover cooked food items, failure to perform hand hygiene, and the failure to handle ready-to-eat sandwich foods including ham, turkey cheese and bread. under sanitary conditions, to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An initial tour of the kitchen on 01/03/22 at 10:00 AM, revealed the following concerns: 1.) A walk-in refrigerator revealed six uncovered, undated pumpkin pies on a tray. On 01/04/23 at 11:00 AM observed dietary staff DD as she made ham and cheese sandwiches and turkey and cheese sandwiches for the noon meal. With gloved hands, staff removed the bread of the bread bag and placed the bread directly on the counter. She then opened the wrapping on the cheese. Dietary staff DD then went to another counter to get the meat that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 100 residents with 20 residents selected for review that included three residents sampled for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, interview, and record review, the facility failed to provide sanitary placement of Resident (R)15 and R47's urinary catheter collection bags. This had the potential to cause urinary tract infections (UTI) and injury from accidental removal of the catheter. Findings included: - Review of R15's diagnoses from the 06/08/22 Physicians Orders in the Electronic Health Record (EHR), revealed the following diagnoses: neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (damage to brain cells due to a lack of oxygen and/or blood flow). The quarterly Minimum Data Set…

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 100 residents, with 20 included in the sample, including one resident sampled for respiratory services. Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services on one Resident (R) 41's, who required physician ordered oxygen. Findings included: - Resident (R) 41's signed physician orders, dated 12/27/22 revealed the following diagnoses: acute respiratory failure (difficulty to breathe) and end stage renal failure dependent on dialysis (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision with his daily cares. The resident would get short of air when lying flat or exertion and required oxygen (O2). The Quarterly MDS dated 12/12/22,revealed no changes in the resident's daily cares. The resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 100 residents with 20 residents sampled. Based on observations, interview and record review, the facility failed to follow physicians' orders for one Resident (R)81, of the six residents reviewed for unnecessary medications. Findings included: - The Physician Orders dated 10/31/22, for R81, indicated the following diagnoses included chronic atrial fibrillation (rapid, irregular heartbeat) and lymphoma (cancer of the lymphatic system that helps to fight infection). The significant change Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, that revealed intact cognition. The resident Th received four days of diuretics (medication to promote the formation and excretion of urine). The significant (MDS) dated [DATE], revealed the resident had no changes on the (BIMS) score. The resident received seven days of a diuretic. R81 was on hospice care. The Care Plan, dated 11/11/22, revealed a black box warning for Lasix…

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 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to ensure the consultant pharmacist identified the use of a as needed (PRN) Ativan (antianxiety) medication with a stop date for Resident (R) 8, one of the six residents reviewed. Finding included: - Review of R8's Physician's Orders dated 09/12/22, revealed a diagnosis of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (progressive mental disorder characterized by failing memory, confusion), and paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbance of language and communication and fragmentation of thought). Review of the modification of the annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. 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 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to obtain an end date for the use of as needed (PRN) Ativan (antianxiety) medication for one Resident (R) 8, of the six residents reviewed. Finding included: - Review of R8's Physician's Orders dated 09/12/22, revealed a diagnoses of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (progressive mental disorder characterized by failing memory, confusion), and paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbance of language and communication and fragmentation of thought). Review of the modification of the annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The resident had delusion, but no behaviors…

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 census totaled 100 residents with 20 residents included in the sample, that included one resident sampled for therapeutic diets. Based on observation, interview and record review, the facility failed to ensure Resident (R) 41 received the therapeutic diet of a limited concentrated sweets (LCS)/Consistent Carbohydrate diet, as ordered by the physician. Findings included: - Resident (R) 41's signed physician orders dated 12/27/22, revealed the following diagnoses: acute respiratory failure (difficulty to breathe) and end stage renal failure dependent on dialysis (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision with his daily care. The resident was on a therapeutic diet. The Quarterly MDS dated 12/12/22 revealed the resident required a therapeutic diet. The Nutrition 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.

The facility had a census of 87 residents. Based on observation, interview, and record review the facility failed to ensure facility staff utilized appropriate infection control principles when Dietary Staff failed to perform hand hygiene between meal tray deliveries to multiple resident rooms, and failed to ensure residents followed social distancing protocols while eating in the dining room during a time of COVID-19 (highly contagious respiratory illness that caused the recent pandemic). Findings included: - A dining observation on 02/01/21 at 11:24 AM, revealed four (unidentified) residents sat together at a small square table and only one resident wore a facemask. The table did not allow for adequate social distancing with meals. During an interview on 02/01/21 at 11:45 AM, when asked about the social distancing concern in the dining room, Certified Dietary Manager (CDM) R reported they allowed residents to sit where they wanted to in the dining room. Review of the undated Novel Coronavirus Prevention and Response Policy revealed, Interventions to prevent the spread 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.

The facility census totaled 87 residents, with four residents with orders to receive a fortified diet (added fats and protein to increase calories and nutrients) for additional nutrition. Based on observation, interview, and record review the facility failed to serve fortified diets to four residents with fortified diet orders. Findings included: - Per electronic communication (email) dated 02/08/21 from Administrative Staff A revealed the facility had four unidentified residents with physician orders to receive a fortified diet. Observation on 02/03/21 at 11:20 AM of the noon meal service consisting of fried chicken, mashed potatoes and gravy, and corn, with a jello salad for dessert. The staff served all meal trays with the same diet. During an interview on 02/03/21 at 11:25 AM Dietary Staff (DS) Q when asked about special diets and what a fortified diet was DS Q said he did not know and referred this surveyor to the dietary manager. When the surveyor asked her to explain how she made the mashed potatoes and she replied with whole milk and butter. She did not add any other…

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 census totaled 87 residents with 13 residents the facility identified as on a physician's prescribed therapeutic diet. Based on observation, interview, and record review the facility failed to serve therapeutic diets (diet to treat a medical condition, such as diabetes) to 13 residents as ordered by the physician. Findings included: - Per email dated 02/08/21 from Administrative Staff A revealed there were 13 unidentified residents in the facility on a physician's prescribed, therapeutic diet. Observation on 02/03/21 at 11:20 AM of the noon meal service, revealed Dietary Staff (DS) S served the noon meal consisting of fried chicken, mashed potatoes and gravy, whole kernel corn, and a jello salad for dessert. All trays served contained the same diet. During an interview on 02/03/21 at 11:25 AM when asked about special therapeutic diets such as diabetic diets and what was different in the foods served, DS S reported she served the same food to everyone and referred the surveyor to the dietary manager. During an interview on 02/03/21 at 11:50 AM when asked about special…

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 87 residents. The facility had one main kitchen where all food was prepared to serve to residents. The facility failed to prepare and store food in a sanitary manner by failure of dietary staff to wear gloves when handling ready to eat foods and failed to ensure the hairnet covered all hair, the storage of unmarked and outdated foods, failed to cover room trays when they were removed from the delivery cart, failed to perform hand hygiene between tray deliveries to residents, and failed to ensure residents were socially distanced when eating in the dining room. Findings included: - A dining observation on 02/01/21 at 11:24 AM, revealed Dietary Staff X had hair that was not properly contained when wearing a hairnet. During an interview on 02/01/21 at 11:45 AM, Certified Dietary Manager (CDM) R regarding the residents sitting in groups not socially distanced. CDM R reported they have allowed residents to sit where they wanted to. An observation on 02/01/21 at 12:00 PM revealed Dietary Aide (DA) X passed out room trays taken from a heated cart. 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 had a census of 87 residents with 18 sampled, including two regarding grievances. Based on observation, interview, and record review, the facility failed to assist Resident (R) 43 with filling out a grievance form and failed to inform R82 of the grievance policy and procedure. Findings included: - Review of R43's Electronic Health Record (EHR) dated 06/06/19 revealed a diagnosis of cognitive communication deficit (difficulty using spoken language and gestures, inability to initiate and sustain appropriate conversation and use of inappropriate, repetitive language.), anxiety disorder, and diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). Review of the Annual Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of nine, indicating moderately impaired cognition. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/02/20 documented staff were to use simple sentences…

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 census totaled 87 with 18 included in the sample. Based on observations, interview, and record review the facility failed to provide nail care for Resident (R)70. Findings included: - Review of R70's Order Summary Report dated 02/03/21 revealed the diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and schizophrenia (mental disorder that causes disordered thinking and behavior that impairs daily functioning). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. R70 required extensive assistance with personal hygiene. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition and R70 required extensive assistance with personal hygiene. Review of the Activities of Daily Living (ADL) Functional/Rehabilitation…

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 87 residents, with 18 sampled, including two for vision/ hearing. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 82 received proper treatment and assistive devices to maintain vision by not assisting with adequate eyeglasses. Findings included: - Review of Resident (R) 82's Electronic Health Record (EHR) dated 10/09/20 documented the following diagnosis: diabetes mellitus type II (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS noted R82 had eyeglasses. Observation on 02/01/21 at 02:25 PM revealed R82 had eyeglasses in place that were taped with clear tape on the left lens frame covering the entirety of the frame. Interview with R82 on 02/04/21 at 09:40 AM revealed he notified Social Service Designee (SSD) Q multiple…

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 census totaled 87 residents with 18 residents in the sample, and one sampled for Catheter/Urinary Tract Infection (UTI). Based on observation, interview and record review the facility failed to provide appropriate care of Resident (R)81's catheter bag when draining urine to ensure infection control measures where appropriately followed. Findings included: - Review of R81's pertinent diagnoses from the 12/31/20 Physicians Orders Diagnosis in the Electronic Medical Record (EMR) revealed: neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), multiple sclerosis (MS, a progressive disease of the nerve fibers of the brain and spinal cord), and urinary retention (lack of ability to urinate and empty the bladder). Review of the 12/31/20 Annual Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 14, indicating intact cognition. The resident required extensive one-person assistance with personal hygiene, and had an indwelling urinary catheter due to neurogenic bladder and MS. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 87 with 18 residents included in the sample and three residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to provide the care planned supervision at meals to Resident (R) 69, a resident identified by the facility as at risk for significant weight loss, to encourage nutritional intake. Findings include: - Review of the Physician Order Sheet dated 02/01/21 revealed the following diagnoses: nontraumatic intracerebral hemorrhage in hemisphere (a condition in which a blood vessel in the brain ruptures) and cognitive communication deficit (may occur after stroke, tumor or brain injury). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating severely impaired cognition. The resident required set up and supervision with eating meals. R69 weighed 138 pounds and triggered significant weight loss. Review of the Significant Change Minimum Date Set (MDS)…

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 census totaled 87 residents with 18 residents included in the sample, and two reviewed for oxygen use. Based on observation, interview, and record review the facility failed to ensure appropriate physician orders for oxygen use including care and maintenance of oxygen tubing and bubbler for Resident (R)81 and failed to ensure staff practiced appropriate infection control principles regarding oxygen tubing when staff placed oxygen tubing, that had been on the floor, on the resident without changing the oxygen tubing. Findings included: - Review of R81's 12/31/20 Physicians Orders Diagnosis in the Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS, a progressive disease of the nerve fibers of the brain and spinal cord). Review of the 12/31/20 Annual Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 14, indicating intact cognition. He required oxygen therapy while in the facility. Review of the 01/13/21 Quarterly MDS revealed a BIMS score of 13, indicating intact cognition and noted R81required oxygen therapy while 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 87 residents with five reviewed for unnecessary medications. Based on interview and record review the facility failed to adequately monitor the results of blood sugar checks for two residents who received insulin (a hormone that regulates blood sugar) injections, Resident (R) 43 and R82 . Findings included: - Review of R43's diagnoses in the Electronic Health Record (EHR) dated 06/06/19 documented diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). Review of R43's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. R43 had a diagnosis of diabetes mellitus and received insulin injections daily in the seven-day lookback period. Review of R43's Care Plan dated 01/19/21 revealed the resident had a diagnosis of diabetes mellitus with the intervention for staff to obtain blood sugar checks as ordered by 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.