Mill Town Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer Pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#65, #29 and #5), out of a total sample of five residents reviewed for immunizations. Findings include: Review of facility policy titled, Immunizations and Vaccines- Residents, dated as revised 02/2022, indicated the following: -It is the policy of the facility that all residents receive immunizations and vaccinations that assist in preventing infectious diseases, unless medically contraindicated, or otherwise ordered by the resident's attending physician, or refused by the resident or resident's activated HCP (health care proxy). -Procedure: 1. Vaccine information statements and consent for pneumococcal, influenza and covid-19 will be a part of the residents' admission packed. Consent for these vaccinations will be obtained from the resident or resident representative at the time of admission. -2. Orders for 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 Based on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#7) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated as last revised 6/2022, indicated the following: -Any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is thoroughly investigated and reported to the Massachusetts Department of Public Health, Division of Health Care Quality and any other appropriate agency has deemed appropriate in accordance with state and federal law. -One abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is observed, suspected, or reported to any facility employee, the employee will immediately notify the unit manager/supervisor, and they will immediately report the issue to 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 Based on record review and interviews, the facility failed to fully investigate a potential allegation of neglect for one Resident (#7) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated as last revised 6/2022, indicated the following: -any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is thoroughly investigated and reported to the Massachusetts Department of Public Health, Division of Health Care Quality and any other appropriate agency has deemed appropriate in accordance with state and federal law. -One abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is observed, suspected, or reported to any facility employee, the employee will immediately notify the unit manager/supervisor, and they will immediately report the issue 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.

Based on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Living was provided for two Residents (#27 and #11) out of a total sample of 22 residents. Specifically: 1. For Resident #27 the facility failed to ensure supervision and cueing with meals was provided. 2. For Resident #11 the facility failed to ensure supervision with meals was provided. Findings include: The facility policy titled Activities of Daily Living (ADL) Support, dated 6/2022, indicated the following: 1. Residents will perform self-care with ADLs at the level on the CNA care plan of care card or assigned tasks. If the resident shows a change in the ADL function the nurse will be notified. 5. Assure adequate intake at each meal by encouraging, cueing, prompting and or feeding as needed. Notify nurses of changes in resident's normal intake. 1. Resident #27 was admitted to the facility in September 2018 and has diagnoses that include dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/25, indicated…

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 to implement safe smoking for one Resident (#70), out of two sampled residents who smoked cigarettes. Specifically for Resident #70, the facility failed to ensure a smoking assessment was completed and a plan of care was developed prior to the Resident smoking at the facility. Findings include: Review of the facility policy titled Smoking, dated 11/22, indicated: -Smoking assessments are performed with residents who state their desire to smoke in order to monitor their ability to perform safe smoking function. This assessment is a rudimentary review of the resident's abilities both cognitive and physical functioning. These assessments are conducted on admission/readmission, with a change in the resident's status, and at least quarterly thereafter. The interdisciplinary team will review all completed smoking assessments to determine the safest smoking plan with the resident. Selected safety precautions will be reviewed with the resident and/or the resident's agent. Resident #70 was admitted to the facility 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 Based on observations, record review and interviews, the facility failed to ensure that services were provided in accordance with professional standards for two Residents (#17 and #2) with a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition) out of two applicable residents, out of a total sample of 22 residents. Specifically, 1) For Resident #17 the facility failed to ensure tube feeding water flushes (intermittent boluses of water, stored in a separate bag, automatically dispensed during regular intervals in conjunction with enteral nutrition formula for purpose of hydration and maintenance of tube patency) was running at the correct setting as indicated in the physician's orders. 2) For Resident #2 the facility failed to properly label, date and store enteral feeding formula as well as change the enteral feeding formula and water flush bags every 24 hours. Findings Include: Review of the facility policy titled Enteral…

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, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Residents (#71), out of one Resident with a PICC Line. Specifically, for Resident #71, the facility failed to ensure that when the PICC line dressing was lifting (compromised), it was changed, and that the insertion site was able to be visualized. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line assessment: Assess the catheter insertion site daily by inspection and palpation through the transparent semipermeable dressing to discern tenderness. Look at the catheter and cannula pathway, and check for bleeding, redness, drainage, and swelling. Review of the facility titled Peripheral and Midline IV Maintenance,…

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 interviews, the facility failed to assess and provide treatment for pain for one Resident (#7) with a diagnosis of acute pain due to trauma out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Pain Assessment and Management, last revised 3/26/2009, indicated the following: -each resident has the right to expect a prompt, effective response to reports of pain. Therefore, it is the policy of this facility to: -To identify, assess and manage pain effectively and collaboratively with the interdisciplinary team. -To design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with the resident directed goals. Resident #7 was admitted to the facility in June 2021 with diagnoses including acute pain due to trauma, osteoporosis with pathological fracture of vertebra(e) (back bone) and muscle weakness. Review of Resident #7's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident…

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 provide medically related social services to one Resident (#70) who had an active diagnosis of Substance Use Disorder (SUD) (out of a total sample of 22 residents. Specifically, the facility failed to ensure the Social Worker implemented SUD interventions prior to Resident #70's hospitalization for his/her drug use and failed to re-assess after the Resident was re-admitted and confirmed to have actively use an illicit substance (cocaine). Findings include: Review of the facility policy titled, Treatment Options for Residents with Substance Use Disorder, dated 11/4/24, indicated The facility will offer appropriate and individualized treatment for all residents living with the disease of addiction or with a history of substance use disorder. Any resident admitted to the facility who is diagnosed with a substance use disorder, or is diagnosed with such while a resident, will be offered and supported with enrolling and attending appropriate, evidence…

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, record review and interviews, the facility failed to provide follow-up dental services and obtain dentures for one Resident (#21), out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Eye, Podiatry and Dental Care, dated 6/2022, indicated the following: -It is the policy of the facility to implement an eye, podiatry, and dental health program, which assures that each resident receives the necessary care on an as needed basis. -Following the initial assessment each resident is routinely assessed by nursing specific to these areas for changes in baseline or additional needs. Resident #21 was admitted to the facility in July 2017 with diagnoses including Alzheimer's Disease, diabetes, heart failure and muscle weakness. Review of Resident #21's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident is cognitively intact. During…

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 review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #14, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, colostomy, and IR drain (a drainage procedure performed by Interventional Radiology). Findings Include: Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Resident #14 was admitted to 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.

Based on observations, records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure they developed and implemented an individualized comprehensive plans of care that included interventions, treatment goals, and measurable outcomes, when 1) for Resident #2, his/her Plan of Care did not include his/her transfer status for the need of two staff member assistance with a mechanical Lift, and did not include interventions for him/her to be transferred out of bed daily, and 2) for Resident #3, his/her plan of care did not include his/her preference to be barefoot. Findings include: The Facility Policy, titled Resident Assessment, dated 09/04/24, indicated the Facility would develop and maintain an individualized interdisciplinary plan of care, treatment, and services with appropriate education and training about each resident's illnesses and care needs, and an individualized plan of care would be established. A Hoyer (mechanical) Lift transfer is performed using a full body sling attached to the boom of a mechanical lift.…

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 records reviewed and interviews, for one of three sampled residents (Resident #2), who had a physician's order for nursing to document every shift on his/her transfers in and out of bed, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation was inconsistent, with many days not even one progress note was written by nursing. Findings include: The Facility policy, titled Charting and Documentation, dated 06/2022, indicated all observations, services performed, assessments, how the resident tolerated the procedure/treatment, and whether the resident refused the procedure/treatment would be documented in the resident's medical record. 1) Resident #2 was admitted to the Facility in March 2024, diagnoses included chronic pain, lymphoma (cancer of the lymphatic system), metabolic encephalopathy (change in how the brain functions due to another underlying condition), lymphedema (swelling of a limb or limbs due to blockage of the lymphatic system), and generalized anxiety disorder. Review of Resident #2's Nursing Progress…

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, policy review and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, and that dented cans of food were not stored with usable cans. Findings include: Review of the facility's policy titled Dietary - Food Storage, dated February 2022, indicated the following: -It is the policy that storage of all food items will be stored in a sanitary environment and all food purchased will be stored in accordance with required temperatures and storage areas. -Any bulging, leaking, or dented cans which indicates food spoilage are not to be used and removed from the storage area. (sic.) -Prepared foods shall be kept covered, labeled with contents and dated. On 6/10/24 at 7:56 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: -A significantly dented can of ready-to-eat peppers on the can-rack in the dry-storage area. -A package of salami, opened, wrapped, but undated in the walk-in refrigerator. -A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to obtain consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#74 and #81) out of a sample of 26 Residents. Findings Include: Review of the facility policy titled Psychoactive Drug Monitoring, revised June 2022, indicated the following: -All psychoactive medication requires consent for use from the resident or legally responsible party prior to administration of medication. 1. Resident #74 was admitted to the facility in March 2024 with a diagnosis of manic depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/24/24, indicated that Resident #74 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating the Resident had moderate cognitive impairment. The MDS further indicated Resident #74 was being administered an antidepressant medication. Review of Resident #74's active physician's orders indicated 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 Based on record review, policy review and interview the facility failed to ensure a plan of care was developed and implemented, with safeguards to prevent further potential abuse, following an allegation of rape was made by one Resident (#70) out of a total sample of 26 residents. Specifically, Resident #70 reported an allegation of rape by a family member, was sent to the hospital for a rape kit assessment and returned to the facility. The investigation into this allegation is ongoing by the District Attorney's office, and since the allegation was made on 4/26/24 the facility failed to develop a plan to protect the resident or other residents of the facility in the event that the alleged perpetrator came to the facility to visit Resident #70. Findings include:: The facility policy titled Resident's Right Program & Abuse Program, revised 6/2022, indicated the following: -It is the policy of Mill Town Health and Rehab is dedicated to maintain an environment free of abuse, neglect and exploitation. The resident…

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 implement the plan of care for two Residents (#15 and #13) out of a total sample of 26 residents. Specifically: 1. For Resident #15 the facility failed to ensure built up utensils and a nosey cup were provided with meals as indicated in the plan of care. 2. For Resident #13 the facility failed to a.) ensure his/her bed was maintained in the low position as indicated in the plan of care and b.) complete weekly skin assessments as ordered by the physician. Findings include: The facility policy titled Adaptive Equipment-Guideline, dated March 2024, indicated the following: 3. When it is determined which adaptive feeding equipment is most appropriate for the resident to utilize, the rehab department will complete an in-service for nursing staff and fill out a diet slip with the types of adaptive feeding equipment to be utilized. 5. Resident care plans will be updated to include the adaptive equipment that will be utilized with each meal. 9. Dietary will ensure the adaptive feeding equipment will be added to 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.

Based on observation, record review and interview the facility failed to ensure supervision and assistance for Activities of Daily Living (ADLs) was provided to three Residents (#15, #13 and #14) out of a total sample of 26 residents. Specifically: 1. For Resident #15 the facility failed to ensure continual supervision, and assist as needed, was provided with meals. 2. For Resident #13 the facility failed to ensure supervision and assistance with meals was provided. 3. For Resident #14 the facility failed to provide assistance with showers. Findings include: The facility policy titled Activities of Daily Living (ADL) support, dated 6/2022, indicated the following: 1. Resident will perform selfcare with ADLs at the level on the CNA care plan or care card or assigned tasks. If the resident shows a decline in ADL function the nurse will be notified. 4. Assist the resident to be clean, neat and well-groomed including nail care and having fingers and toenails to be cut/trimmed per policy. 5. Assure adequate intake at each meal by encouraging, cueing, prompting and or feeding as needed.…

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, interview and observation, the facility failed for 1 (Resident #5) of 26 sampled residents to set the air mattress pressure to the correct, physician-ordered setting. Specifically, the physician order indicated the air mattress should be set to 100 pounds (lbs.) and for three days the pressure was set to 400 lbs. Findings include: Resident #5 was admitted to the facility in April 2021, and had diagnoses which included diabetes and cerebral vascular accident. Resident #5 received hospice services. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she had moderately impaired cognitive skills for daily decision making, dependence on staff for most activities of daily living, and was at-risk for the development of pressure ulcers. The MDS indicated the Resident had a pressure-relieving mattress. Review of Resident #5's current care plan indicated he/she was at risk for the development of pressure ulcers. Interventions included the use of pressure relieving…

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 ensure the environment was free from accident hazards for one Resident (#74) out of a total sample of 26 residents. Specifically, the facility failed to implement an intervention intended to prevent further falls after Resident #74 sustained a fall. Findings include: Review of the facility policy titled Falls, revised June 2022, indicated the following: - It is the policy of Mill Town Health and Rehab to make every effort possible to identify any resident at risk for a fall, prevent a fall and if a fall occurs to fully investigate the incident to identify any practices that need to be revised to further support the goal of fall prevention and resident safety. - If a fall occurs, an Incident and Accident Investigation and an Incident/Accident Report is to be completed by the licensed nurse. The licensed nurse or department head will immediately obtain written statements from the CNA's (certified nursing assistants) and other assigned staff, as applicable, on the Post Fall Report. A CQI Falls Assessment Tool 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for three Residents (#70, #24 and #26) who have a history of trauma out of a total sample of 26 residents. Specifically: 1. For Resident #70, the facility failed to develop a trauma care plan, with individualized triggers and interventions, following an allegation of rape made by Resident #70 and failed to complete a PTSD assessment quarterly and following the allegation of rape. 2. For Resident #24, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. 3. For Resident #26, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include:: The facility policy titled Trauma Informed Care Policy and Procedure, dated 9/2022, indicated the following: -Trauma: Individual trauma results from an event, a series of events or set of circumstances that is experienced…

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, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#81) out of a total sample of 26 Residents. Findings Include: Review of facility policy titled Drug Regimen Review, dated as effective 6/2022, indicated: -The consultant Pharmacist reviews the medication regimen of each active resident at least monthly. Findings and recommendations are reported to the Director of Nursing and the Medical Director. -3. The consultant Pharmacist documents potential or actual medication therapy problem and communicate them to the responsible prescriber, unit manager and the Director of Nursing (DON) and the Medical Director. [sic] -4. The consultant Pharmacist documents all potential or actual significant nursing documentation problems found relating to medications and communicates them in writing to the DON and Medical…

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, interview, and record review the facility failed to provide rehabilitation services for one Resident (#53) out of a total sample of 26 residents. Specifically, the facility failed to evaluate a Resident's hand after a hand splint in place for limited range of motion was discontinued due to Resident refusals, and after the Nurse Practitioner documented that she was concerned about Resident #53's nails digging into his/her palm due to a possible hand contracture. Findings include: Review of the facility policy, titled Rehabilitation screen/referral - guideline, dated December 2023, indicated the following: -To screen the resident's functional and clinical status, determine the need for skilled rehabilitation intervention and/or to address problem-specific issues, rehabilitation screening and referrals may be requested, from nursing, therapy, family member and/or caregivers. The rehabilitation screen and referral form will be utilized as a communication tool between nursing and rehab 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 records reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#35) out of a sample of 26 residents. Specifically, for Resident #35 nursing documented they obtained blood pressure from his/her right arm when they did not. Findings include: Resident #35 was admitted to the facility in January 2024 with a diagnosis of end stage renal disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/24, indicated that Resident #35 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating Resident #35 had moderate cognitive impairment. The MDS further indicated Resident #35 received dialysis treatment. Review of Resident #35's active physician orders indicated the Resident had a fistula in his/her right arm. Review of Resident #35's care plans indicated the Resident received Hemodialysis three times a week and had a right arm fistula with the following intervention: -Do not draw blood or take blood pressure in arm with graft. On 6/10/24 at 9:17 A.M., the surveyor observed a sign…

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 interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs. Findings include: During review of five CNA employee records, the Surveyor was unable to locate annual performance reviews for any of the five CNA files reviewed. During an interview on 7/28/23 at 7:25 A.M., the Administrator said annual reviews have not been completed in the past year.

Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to specifically: 1) Develop a care plan for dementia and vision for two Residents (#16 and #30), 2) Failed to implement the plan of care as ordered for three Residents (#69, #63 and #37) out of a total sampled 39 residents. Findings include: 1 A. Resident #16 was admitted in March 2023 with diagnoses including dementia and anxiety. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #16 scored a 12 out of 15 on the Brief Interview for Mental Status, indicating moderately impaired cognition. Review of Resident #16's diagnoses list indicated the Resident #16 has a diagnosis of dementia with behavioral disturbance. Review of the care plan did not indicate that Resident #16 had a care plan developed for dementia care. During an interview on 7/28/23 at 7:32 A.M., Unit Manager #2 said that she would expect a care plan to be developed for someone with dementia. 1 B. Resident #30 was admitted in February 2023 with diagnoses…

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, record reviews, policy review and interviews, the facility specifically: 1) Failed to prevent an elopement of one Resident (#80) from the facility and ensure a wander guard was in place after the elopement, 2) Failed to provide the correct diet for one Resident (#89) who had a recent choking episode, and 3) Failed to complete investigations and fall assessments after three Residents (#45, #80 and #16) falls, out of a total sample of 39 residents. Findings include: 1. Resident #80 was admitted to the facility in April 2023 with diagnoses including dementia and traumatic brain injury. Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE] indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating the Resident has severe cognitive impairment. The MDS also indicates the Resident requires supervision for all mobility tasks and that the behavior of wandering occurs daily. Throughout survey, Resident #80 was observed…

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, policy review and interview, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: 1. Review of the facility policy titled, Dietary-Personal Hygiene, dated 6/22, indicated the following: *Policy: It is the policy of the facility that all dietary personnel are educated on expected standards of personal hygiene in order to protect the passing of bacteria and disease using food as the vehicle host. *Procedure: 1. All dietary employees are educated on the following as it relates to the prevention of spreading bacteria and personal hygiene practices: a. Hand washing and gloving specific to facility policy: ii. Between all tasks. vi. Before and after handling any food surfaces. On 7/27/23 at 7:36 A.M., the following was observed in the main kitchen of the facility kitchen during the breakfast meal service: *Food Service Employee #1 was observed preparing breakfast and was wearing gloves as the surveyor entered the kitchen. The food service employee…

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, policy review and interviews, the facility failed to provide a dignified dining experience to 1) the residents on the second floor unit and 2) Resident #22, out of a total sample of 39 residents. Findings include: Review of the facility policy titled, Quality of Life - Dignity, dated 12/2022 indicated the following: *Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number. diagnosis or care needs. 1. During the breakfast meal on 7/26/23 at 8:18 A.M., the following was observed: *A Certified Nursing Assistant (CNA) was heard referring to residents who needed assistance with meals as feeds. She used the term in front of several residents. *A nurse was observed assisting a resident with her meal in the dining room. The nurse was standing while assisting and not sitting next to the resident at her eye level. *A CNA was assisting a resident in his/her room…

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 obtain updated informed consent for antipsychotic and psychotropic medications for two Residents (#4 and #16) out of a total sample of 39 residents. Findings include: 1. Resident #4 was admitted in 06/2017 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #4 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the MDS indicated that Resident #4 requires extensive assist to dependence with care. Review of the clinical record indicated that Resident #4 was prescribed the following medications: -Quetiapine Fumarate (an antipsychotic medication used to treat Bipolar) 100 milligrams (mg) at bedtime -Sertraline (a medication used to treat depression) 75 mg one time a day -Ativan ( a medication used to treat anxiety) 0.5 mg every 4 hours Review of the Medication Administration Record indicated that Resident #4 received all of these…

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, record review, policy review and interviews, the facility failed to ensure a call light was within reach for two Residents (#72 and #22) out of a total sample of 39 residents. Findings include: Review of the facility policy titled, Answering the call light, dated 6/2022, indicated the following: *When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. A. Resident #72 was admitted to the facility in March 2021 with diagnoses including dementia. Review of Resident #72's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #72 requires extensive assistance with all activities of daily living. On 7/26/23 at 8:33 A.M. Resident #72 was observed lying in bed. His/her call light was on the ground next to the bed and out of reach of the Resident. When asked how the Resident…

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 file a grievance for one Resident (#40) out of a total sample of 39 residents. Findings include: Review of the facility policy titled Grievance, dated 06/2022, indicated the following: - Grievance is defined as a real or imagined wrong or other cause for a complaint or protest, especially unfair treatment. - Includes those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and any concerns regarding their safety at the facility. Resident #40 was admitted in March 2022 with diagnoses including hypertension and anxiety. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #40 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 7/28/23 at 7:50 A.M., Resident #40 said that he/she told the Administrator that a certified nursing aide was on his…

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, record reviews, policy review and interviews, the facility failed to keep one Resident (#69) free from restraints while eating in the dining room, out of a total sample of 39 residents. Finding include: Review of the facility policy titled, Use of Restraints, dated 12/2022, indicated the following: *It is the policy of the facility, following CMS and DPH Regulations, that all residents will be free from any physical or chemical restraint imposed for the purposes of discipline or convenience, and not required to treat a resident's medical condition. All residents are to be treated with respect and dignity. *Items/devices that could be considered a restraint: - Using devices in conjunction with a chair, such as trays, tables, bars or belts that the resident cannot remove easily, that prevents them from rising. Resident #69 was admitted to the facility in August 2022 with diagnoses including dementia. Review of Resident #69's most recent Minimum Data Set (MDS) dated [DATE] indicated 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 Based on observations, record reviews, policy reviews and interviews, the facility failed to investigate bruises of unknown origin for two Residents (#7 and #4) out of a total sample of 39 residents. Findings include: Review of the facility policy titled, Resident Protection During Abuse Investigation Policy and Procedure, dated 06/2022, indicated the following: * All alleged or suspected abuse, neglect, mistreatment, or misappropriation of resident property will be cause for a thorough investigation conducted immediately by the management. * The Unit Manager/Supervisor, and/or Director of Nursing will complete the investigation form with a written, dated, signed statement from all persons involved. * When abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is observed, suspected, or reported to any facility employee, the employee will immediately notify the Unit Manager/Supervisor and they will immediately report the issue to the Administrator or DON in his/her absence. *…

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 staff failed to ensure that services provided meet professional standards of quality, for one Resident (#57) out of a total sample of 39 residents. Findings include: Resident #57 was admitted in March 2023 with diagnoses including malignant neoplasm (abnormal cancerous growth) of the brain. Review of Resident #57's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating severe cognitive impairment. The MDS also indicated Resident #57 requires extensive assistance of two people for all self-care activities. Record review on 7/27/23 at 6:54 A.M., indicated Brookhaven Hospice services were initiated for Resident #57 on 3/15/23. Review of Resident #57's current physician orders failed to indicate an order for hospice services. During an interview on 7/28/23 at 9:26 A.M., Nurse #2 said a doctor's order should be written before the nurse or unit manager initiate…

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 reviews and interviews, the facility failed to specifically; provide needed assistance for activities of daily living for one Residents (#63) out of a total sample of 39 residents. Findings include: Resident #63 was admitted to the facility in November 2019 with diagnoses including non-traumatic subarachnoid hemorrhage (bleeding between the brain and tissue covering the brain), and hemiplegia affecting left non-dominant side. Review of Resident #63's most recent Minimum Data Set (MDS) assessment, dated 5/25/23, indicated Resident #63 has a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #63 requires extensive assistance of 1-2 people with functional daily activities. During an interview on 7/26/23 at 8:51 A.M., Resident #63 said he/she does not get his/her weekly showers all the time because he/she requires too much assistance. Review of the shower schedule for the unit indicated Resident #63 is scheduled to receive a shower on Thursdays and Sundays.…

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 specifically: 1) Failed to obtain a physician order for the use of oxygen for two Residents (#35 and #12), 2) Failed to ensure an oxygen filter was cleaned for one Resident (#4) out of a total sample of 39 Residents. Findings include: Review of the policy titled, Oxygen Weaning, dated 6/2022, indicated the following: *Policy: -Residents who require increased oxygen due to an acute disease process may possibly be weaned from their oxygen as their state improves. The physician must provide an order for continuous oxygen with a liter flow and device, and a low threshold pulse oximetry reading for oxygen adjustments. *Procedure: -Verify physician's order. -Document should include date and time, oxygen setting saturation and heart rate at starting point, oxygen setting oxygen saturation and heart rate at ending point as well as any negative outcome. 1A. Resident #35 was admitted to the facility in March 2023 with diagnoses including chronic obstructive…

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 ensure services consistent with professional standards were provided for one Resident (#64) who required dialysis (a procedure to remove waste products and excess fluids from the body when the kidneys fail to properly work), out of a total sample of 39 residents. The facility failed to ensure that Resident #64's post dialysis weights were documented as ordered. Findings include: Resident #64 was admitted to the facility in December 2021 with diagnoses including end stage renal disease, dependence of renal dialysis. Review of Resident #64's most recent Minimum Data set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of MDS indicated the Resident required limited assistance for care. During an interview on 7/27/23 at 7:58 A.M., Resident #64 was observed in his/her bed, Resident #64 said he/she goes to dialysis on Monday,…

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 obtain appropriate consent for an antipsychotic medication for one Resident (#60), resulting in the Resident receiving the medication for four months without consent, out of a total sample of 39 residents. Findings include: Resident #30 was admitted in February 2023 with diagnoses including heart failure and schizophrenia. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #30 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During an interview on 7/26/23 at 9:39 A.M., Resident #60 said that he/she was receiving too much Risperidone. (an antipsychotic medication used to treat schizophrenia and bipolar). Review of the clinical record indicated that Resident #60 was on a Roger's Guardianship (a court appointed guardianship that gives a guardian authority to consent to medical treatment decisions). Review of the treatment plan for Resident #60 indicated…

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 ensure a PRN (as needed) psychotropic medication was re-evaluated and included a duration of use for one Resident (#67) out of a total sample of 39 residents. Findings include: Resident #67 was admitted to the facility in April 2023 with diagnoses including dementia. Review of Resident #67's most recent Minimum Data Set, dated [DATE] indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicates Resident #67 requires extensive assistance for all functional daily tasks. Review of Resident #67's medical orders indicate the following active physician orders: *Seroquel (an anti-psychotic medication) Oral Tablet (Quetiapine Fumarate). Give 12.5 mg by mouth as needed for Delusions related to DELUSIONAL DISORDERS (F22) Give one tablet daily PRN, written on 7/7/23. Review of the Medication Administration Report for July 2023 indicated Resident…

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, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of three nurses observed made 3 errors in 29 opportunities on two of two units resulting in a medication error rate of 10.34%. These errors impacted two Residents (#24 and #21), out of four residents observed. Findings include: Review of facility policy titled 'Oral Medication Administration Procedure', dated 6/2022 indicated the following but not limited to: Policy: It is the policy of the facility to administer oral medication in an organized and safe manner is needed. During a medication pass on 7/27/23 at 8:25 A.M., the surveyor observed Nurse #2 prepare and administer the following medications to Resident #24: *Miralax 17 GM (grams) mixed in water by mouth half cupful poured. *Lamotrigine 20 mg (milligram) one tablet by mouth. On 7/27/23 at 8:34 A.M., during the medication administration to Resident #24 the surveyor observed a white pill roll down to the floor. Resident #24 told Nurse #2 that he/she felt…

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, policy review and interviews the facility failed: 1, To ensure medications with shortened expiration dates were labeled and dated after being opened in 2 out of 2 medication carts, and in one medication room. 2, To ensure orally administered medications are kept separate from externally used medications. Findings include: Review of facility policy titled 'Medication Storage in The Facility' dated 6/2022 indicated the following but not limited to: Policy: It is the policy of the facility that medications, treatments, and biological are stored safely, securely , and properly following manufacture's recommendations or facility policy. Procedure: *Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, unlabeled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from pharmacy, if current order exists. *Orally administered medications are kept separate from externally used medications, ( i.e., suppositories, liquids and lotions).…

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, record reviews and interviews, the facility failed to maintain accurate medical records for one Resident (#69) out of a total sample of 39 Residents Findings include: Resident #69 was admitted to the facility in August 2022 with diagnoses including dementia. Review of Resident #69's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident was not able to complete the Brief Interview for Mental Status and was assessed by the staff to have severe cognitive impairment. On 7/27/23 at 9:28 A.M., and 11:54 P.M. Resident #69 was observed sitting in wheelchair in the dining room wearing only non-skid socks, and he/she was not wearing compression stockings. Review of Resident #69's physician orders indicated the following order dated 6/20/2023: *Apply compression stocking to RLE in the morning and remove per schedule. Review of Resident #69's Treatment Administration Report (TAR) dated 7/27/23 indicated the nurse had marked the above order as completed. During an interview on 7/27/23…

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

Based on interview and observations, the facility failed to disinfect shared resident medical equipment and adhere to infection control during medication pass. Findings include: On 7/27/23 at 8:25 A.M., Nurse #2 was observed preparing medication for administration, Nurse #2 was observed dropping a medication on the medication cart, she then proceeded to pick up the medication with bare hands and place the medication in the medication cup. Nurse #2 was then observed going to pour another medication in the same cup, the surveyor asked Nurse #2 to stop as the medication in the cup was contaminated. During an interview on 7/27/23 at 2:41 P.M., Nurse #2 said should have not touched the medication with her bare hand, she also said she should not have discarded the medication when it dropped on the medication cart due. On 7/27/23 at 9:00 A.M., Nurse #7 was observed checking a resident's blood pressure and returned the blood pressure machine to the nurse's station without disinfecting it. During an interview on 7/27/23 at 12:46 P.M., Nurse #7 said the expectation is that shared medical…

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.