Riverbend Nursing And Rehabilitation Center, INC

Based on interviews and record review, the facility failed to maintain a system to periodically reconcile controlled drugs for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a and Medication Cart b) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's undated policy titled, Controlled Substances, revealed, in part, the nursing staff must count controlled medication at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Review of the facility's August 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty: -08/05/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/07/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/09/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/10/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/10/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/12/2024 on the 6:00…

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.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Opened insulin (a medication that lowers blood glucose) pens were dated when opened and discarded as required for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a, Medication Cart b) medication carts observed; and, 2. Heparin (a medication used to prevent blood clots) was stored in a locked compartment and only accessible to authorized personnel. Findings: Review of the facility's undated policy titled, Storage/Handling of Medications, revealed, in part, the facility's nursing staff shall be responsible for maintaining medication storage in a safe manner. Further review revealed, the facility shall not use outdated drugs. 1. Review of the facility's undated policy/procedure titled, Beyond Use Dates of Selected Insulin Products, revealed, in part, Humalog ([Insulin lispro] a type of insulin) pen's beyond use date was after 28 days of the insulin pen being in use. Further review revealed Novolog ([Insulin aspart] a type of insulin) pen's should be discarded after 28 days of use.…

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 Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet the residents needs for 1 (Resident #25) of 1 (Resident #25) sampled residents reviewed for dining services. Findings: Review of facility's Resident Nutrition Services Policy revealed, in part, nursing personnel will inspect food trays delivered to ensure that the correct meal has been delivered. Further review revealed if an incorrect meal is delivered, nursing staff will report it to dietary services so a new tray can be issued. Review of Resident #25's record revealed, Resident#25 was admitted to the facility on [DATE] with diagnoses of, in part, moderate protein-calorie malnutrition, nutritional deficiency, and abnormal weight loss. Review of Resident #25's October 2024 Physician Orders revealed, in part, a diet order for No Added Salt (NAS), mechanical soft with chopped meat. Review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to: 1. Ensure opened food products stored in the walk-in cooler were sealed and labeled with the date the product was opened; 2. Ensure prepared food was stored, cooked, and maintained at the correct temperatures; and, 3. Ensure dishes were cleaned at the correct temperatures with the correct sanitizer levels to prevent foodborne illnesses. Findings: 1. Review of the facility's policy and procedure titled Food Label/Dating/Storage Policy dated 08/15/2018 revealed, in part, luncheon meat can be kept for 3-5 days after opening. Further review revealed salad dressing may be kept up to 30 days in the refrigerator or use best by date. Observation on 10/07/2024 at 12:16 p.m. revealed an opened package of [NAME]-O sliced turkey breast in an unsealed bag with no opening date written on the package or bag. Further observation revealed an opened jar of Culinary Secrets Creamy [NAME] Slaw Dressing without an open date written on it. In an interview…

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

Based on record reviews and interviews, the facility failed to ensure accurate documentation was completed in a resident's record for 1 (Resident #42) of 23 (Resident #25, Resident #28, Resident #31, Resident #35, Resident #39, Resident #42, Resident #26, Resident #48, Resident #51, Resident #52, Resident #57, Resident #60, Resident #92, Resident #93, Resident #94, Resident #95, Resident #100, Resident #107, Resident #109, Resident #110, Resident #111, Resident #262, and Resident #262) sampled residents reviewed for accurate records. Findings: Review of Resident #42's admission orders dated 09/13/2024 and signed by S21Medical Director revealed, in part, flush port of midline every shift with 10 milliliters (mL) of normal saline followed by 3 cubic centimeters (cc) of Heparin. Review of the facility's standing orders dated 07/2024 revealed, in part, central lines and Peripherally Inserted Central Catheter (PICC) lines will be flushed every shift with 10 mL of normal saline followed by 3 cc of Heparin. Review of Resident # 42's Electronic Medical Record (EMR) revealed, in part, no…

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 Based on observation, record review, and interviews, the facility failed to ensure wound care treatments were administered to residents as ordered for 2 (Resident #1 and Resident #3) of 2 (Resident #1 and Resident #3) sampled residents investigated for pressure injuries. Findings: Review of the facility's wound care/dressing change policy revised 12/2022 revealed, in part, in preparation to performing wound care, a review of the resident's medical record and/or care plan, current orders, and diagnoses to determine any special resident needs should be completed. Further review revealed, in part, the date and time the dressing was changed, and the name and title of the individual changing the dressing should be recorded in the resident's medical record. Resident #1 Review of Resident #1's electronic medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, Pressure Ulcer of Sacral Region, Stage 4, Muscle Wasting and Atrophy, and Fusion of Spine, Cervical…

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 Based on interviews and record reviews, the facility failed to assess and/or measure a resident's wound weekly for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for wound management. Findings: Resident #1 Review of Resident #1's hospital discharge record dated 12/29/2023 revealed, in part, Resident #1 had a wound dehiscence (total or partial separation of a wound the was previously closed). Review of Resident #1's nurse's note dated 12/30/2023, revealed, in part, Resident #1 returned back to the facility with sutures to the left side of his head. Review of Resident #1's clinical record revealed no documented evidence, and the facility did not present any documented evidence, Resident #1's left scalp incision was assessed and/or measured upon Resident #1's return from the hospital and/or weekly. In an interview on 04/09/2024 at 1:30 p.m., S2Assistant Director of Nursing (ADON) confirmed there was no evidence of a wound assessment for Resident #1'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 Based on interviews and record reviews, the facility failed to respect a resident or a resident's responsible party's right to choose a health care services for (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for resident rights. Findings: Review of Resident #1's Physician's Communication dated 03/04/2024 revealed, in part, documentation that Resident #1's representative had concerns regarding Resident #1's continued itching and requested that Resident #1 see a dermatologist. In a telephone interview on 04/11/2024 at 4:17 p.m., Resident #1's responsible party indicated Resident #1's skin rash had kept getting worse despite treatment, and Resident #1's responsible party had requested that Resident #1 be sent to a dermatologist. Resident #1's responsible party further stated no appointment with a dermatologist was made, and no staff from the facility had gotten back to her regarding the above mentioned request. Resident #1's representative indicated Resident #1 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 Based on interview and record review, the facility failed to have quarterly care plan meetings with the interdisciplinary team for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for care plans. Findings: Resident #1 In an interview on 04/11/2024 at 4:17 p.m., Resident #1's responsible party indicated she had only been invited to two of Resident #1's plan of care meetings since Resident #1 was admitted to the facility on [DATE]. Resident #1's responsible party further indicated she had not been to a plan of care meeting at the facility during his last 3 months as a resident. Review of a letter presented by S4Social Services Director, revealed, in part, Resident #1 was scheduled to have a plan of care meeting on 01/11/2024. Review of Resident #1's record revealed, in part, no evidence, and the facility did not present any documented evidence, a plan of care meeting was held for Resident #1 between 01/01/2024 and his discharge on [DATE]. In an…

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.

Based on observation, record review, and interview, the facility failed to follow the menu for 1 (Resident #3) of 2 (Resident #2 and Resident #3) sampled residents investigated for dietary services in a total sample of three. Findings: Review of the facility's regular diet menu for 04/11/2024 revealed, in part, residents were to be served roasted pork, au gratin potatoes, sliced zucchini, a dinner roll, a brownie, margarine, salt packet, pepper packet, a choice of a beverage, and water. Observation of the facility's posted lunch menu on 04/11/2024 at 11:22 a.m. revealed, in part, residents were to be served roasted pork loin, mashed potatoes, California blend vegetables, dinner rolls, brownies, salt packet, pepper packet, juice, and water. Observation on 04/11/2024 at 2:30 p.m., revealed Resident #3's lunch tray did contain a piece of battered and/or fried meat. In an interview on 04/11/2024 at 2:30 p.m., Resident #3 indicated she did not like the meat she was given today for lunch, as it was either fried chicken or fried pork. Resident #3 further stated she saw the menu for…

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

Based on observation and interview, the facility failed to provide housekeeping and maintenance services by failing to: 1. Ensure walls in the dirty linen room were repaired; 2. Ensure the clean linen room was kept clean and sanitary; 3. Ensure resident's bathrooms were cleaned for 3 (Resident #30, Resident #60, and Resident #88) of 3 resident's bathrooms observed; and 4. Ensure nursing units were cleaned for 2 (POD B and POD C) of 2 nursing units observed. Findings: Observation on 11/13/2023 at 10:00 a.m. of the dirty linen room, revealed exposed pipe through a hole in the wall measuring approximately 1 foot (ft.) by 1 ft. directly behind the washing machines. Further observation revealed a second exposed pipe through a hole in the wall measuring approximately 1 ft. by 3 ft. on the right side of the washing machines. Observation on 11/13/2023 at 10:05 a.m. of the clean linen room, revealed 5 pairs of shoes with dust and lint on them on top of the air conditioner unit. Further observation revealed a folded blanket on the floor on the floor lying directly under a drain pipe coming…

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.

Based on observations, record reviews, and interviews, the facility failed to ensure residents had comprehensive care plans for 2 (Resident #12 and Resident #50) of 22 residents (Resident #12, Resident #21, Resident #22, Resident #24, Resident #30, Resident #31, Resident #37, Resident #50, Resident #58, Resident #60, Resident #62, Resident #65, Resident #67, Resident #69, Resident #71, Resident #72, Resident #75, Resident #79, Resident #81, Resident #93, Resident #97, and Resident #102) included in the final investigation sample. Findings: Resident #12 Review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/2023 revealed, in part, Resident#12 had Urinary Tract Infections that lasted 30 days. Review of Resident #12's Care Plan revealed, in part, no documented evidence of problems, goals, or interventions addressing urinary tract infections. There was no documented evidence and the facility did not present any documented evidence of a Comprehensive Care Plan addressing urinary tract infections for Resident #12. In an interview on 11/16/2023 at…

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

Based on observations, interviews, and record review, the facility failed ensure portable oxygen cylinders were secured in 1 (Resident #58) of 1 resident's room and 1 (Medication Room x) of 2 medication rooms (Medication Room x and Medication Room y) observed for safe storage of portable oxygen cylinders. Findings: Review of the facility's policy regarding Oxygen Administration revealed, in part, portable oxygen cylinders should be secure in a stand. Observation on 11/13/23 at 9:25 a.m., revealed Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way. Observation on 11/14/2023 9:45 a.m., revealed Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way. Observation on 11/14/2023 at 9:46 a.m., revealed 3 one-half portable oxygen cylinders were in Medication Room x and not secured. Observation on 11/15/2023 at 8:50 a.m., Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way. Observation on 11/15/2023 at 3:45 a.m.,…

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.

Based on record review and interviews, the facility failed to ensure: 1. The nurses were signing as verifying an accurate medication count at the beginning and end of each shift for 3 (Medication Cart d, Medication Cart e, and Medication Cart f) of 3 Medication Carts observed and reviewed for accurate dispensation of controlled medications; and 2. The controlled substances count sheet was reconciled with the medication available for 1 (Medication Cart d) of 3 (Medication Cart d, Medication Cart e, Medication Cart f) medication carts observed for controlled substance reconciliation. Findings: Review of the facility's Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Further review revealed the nursing staff must document and report any discrepancies to the Direct or Nursing or designee immediately. 1. Review of Medication Cart e 's controlled substance…

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.

Based on observation, interviews, and record review; the facility failed to provide dinnerware, cups, plates, and utensils to meet resident's preferences and failed to follow the posted lunch menu daily. Findings: Observation on 11/14/2023 at 8:58 a.m. of POD C revealed, in part, breakfast meal was served on disposable plates, eating utensils were plastic, and drinks were served in disposable cups. During Resident Council interview on 11/14/2023 at 10:30 a.m., Resident #32, Resident #10, and Resident #85 stated that they are being served breakfast, lunch, and dinner with disposable plates, disposable cups, and plastic eating utensils during meals and it is hard to eat and cut meat with plastic utensils. Resident #32, Resident #10, and Resident #85 further stated they would prefer to have non disposable plates and silver ware to use. In an interview on 11/14/2023 at 10:58 a.m. S26Dietary Aide and S32Dietary Aide stated meals were served on reusable plates, plastic utensils, along with disposable cups to save time due to being short staffed. SD26Dietary Aide further stated there is…

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

Based on record review, interviews, and observations, the facility failed to ensure: 1. Opened food items were not sealed, labeled, and dated; 2. Scoops were not stored inside the dry goods storage bins; and 3. Proper use and testing of the three compartment sink. Review of the facility's policy entitled Food Label/Dating/Storage dated 08/15/2018 revealed, in part, it is the facility policy to ensure proper food labeling, dating, and storage. Further review revealed staff will ensure all canned items and dry goods must be dated upon receipt, and all opened items that cannot be adequately sealed in a container must be stored in plastic sealable bags or containers and labeled/dated. 1. Observation on 11/14/2023 at 10:40 a.m. of the facility's dry storage area revealed, in part, one bag of dehydrated sliced potatoes, one bag of egg noodles, and one box of brown sugar open to air, not labeled or dated, and were available for resident consumption. Observation on 11/14/2023 at 10:45 a.m. of the facility's walk in cooler revealed, in part, one bag of shredded mild cheddar cheese, one…

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.

Based on observation and interview the facility failed to: 1. Ensure staff performed hand hygiene during dining for 6 (S20Certified Nursing Assistant (CNA), S21Licensed Practical Nurse (LPN), S22CNA, S23CNA, S24CNA, and S38CNA) of 6 staff observed during dining; and 2. Ensure staff performed hand hygiene during and after incontinence care for 2 (Resident #60 and Resident #69) of 3 (Resident #21, Resident #60, and Resident #69) residents observed for incontinence care. Findings: Review of the facility's Handwashing/Hand Hygiene policy revealed, in part, staff must perform hand hygiene before and after direct resident contact, before and after handling food, before and after assisting a resident with meals, before and after assisting a resident with toileting, and after removing gloves. Review of the facility's Perineal Care policy revealed, in part, after Perineal Care (the washing of the genital and rectal areas of the body) is completed, staff should remove gloves and perform hand hygiene before replacing incontinence items, replacing clothing, repositioning the resident, or making…

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 Based on record review and interview, the facility failed to report an injury of unknown origin to the state agency in a timely manner for 1 (Resident #37) of 2 (Resident #30, Resident #37) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse/Neglect Policy revealed, in part, if the source of injury is unknown and cannot be determined, the incident will be reported by the Administrator to the Department of Health. Review of Resident #37's medical record revealed, in part, Resident #37 was admitted to the facility on [DATE] with a diagnosis of traumatic subdural hemorrhage (an injury to the head that causes bleeding in the skull). Further review revealed Resident #37 had severely impaired cognition and was dependent on staff for functional mobility. Review of Resident #37's Incident Report dated 11/13/2023 at 10:00 a.m. revealed, in part, S41Licensed Practical Nurse (LPN) was called into the shower room by a certified nursing assistant (CNA). Further review revealed S41LPN identified…

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.

Based on observations and interview, facility failed to post nurse staffing data as required. Findings: Observation on 11/13/2023 at 10:20 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 11/14/2023 at 9:50 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 11/15/2023 at 2:50 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. In an interview on 11/15/2023 at 2:50 p.m., S16Licensed Practical Nurse stated she was in charge of ensuring the schedule was posted but did not realize the format of the posting did not meet regulations. In an interview on 11/15/2023 at 2:55 p.m., S4CNA Supervisor stated she was in charge of ensuring the CNA schedule was posted 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.

Based on observation and interviews, the facility failed to ensure a medication cart had medication properly secured for 1 (Medication Cart d) out of 3 medication carts (Medication Cart d, Medication Cart e, and Medication Cart f) had medication properly secured. Findings: Review of the facility's Controlled Substances Policy revealed, in part, controlled substances must be under double lock when the nursing cart is left unattended, therefore, the cart must be locked. Observation on 11/15/2023 at 12:55 p.m. revealed S17Licensed Practical Nurse (LPN) left Medication Cart d unlocked and unattended while she went to transport a resident off of the unit. Further observation revealed S17LPN left the keys to Medication Cart d on top of the cart. Further observation revealed Medication Cart d was left unlocked and unattended until 1:00 p.m. on 11/15/2023. In an interview on 11/15/2023 at 1:01 p.m., S17LPN stated she should have not left Medication Cart d unlocked nor left her keys to Medication Cart d on top of the medication cart. In an interview on 11/15/2023 at 4:30 p.m., S2Director 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.

Based on interviews and record reviews, the facility failed to ensure that medication orders were verified and accurately documented for 2 residents (Resident #1 and Random Resident #4) of 9 sampled residents. Findings: Resident #1 Review of Resident #1's Physician's Consultation report dated 06/28/2023 revealed, in part: Apply Bactroban to prevent infection. Review of Resident #1's June 2023 Physician's order revealed, in part, no order was transcribed for Bactroban. Review of Resident #1's June 2023 electronic Medical Administration Record (eMAR) revealed, in part, no documentation of administration of Bactroban. In an interview on 08/01/2023 at 03:53 p.m., S1DirectorofNursing (DON) stated the order dated 06/28/2023 to apply Bactroban (Mupirocin) to prevent infection was not clear. In an interview on 08/01/2023 at 03:54 p.m., S1DON acknowledged that an order is not clear if dosage, frequency, and administration of the medication or if the medication is a new order or there is a change in an order is not written. Review of Resident #1's June 2023 eMAR revealed documentation 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.