Care One At Brookline

Based on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of three nurses observed made seven errors out of 30 opportunities, resulting in a medication error rate of 23.33%. Those errors impacted three Residents (#15, 22 and #48), out of three residents observed. Findings include: Review of the facility policy titled Administering Oral Medications dated revised October 2010 indicated that; #6: Check the label on the medication and confirm the medication name and dose with the MAR (medication administration record). #8 Check the medication dose. Re-check to confirm the proper dose. 1. Resident #15 was admitted to the facility in July 2022 with diagnoses including cancer, muscle weakness and anxiety disorder. On 11/20/24 at 8:48 A.M., the surveyor observed Nurse #6 give Resident # 15 the following medications: Omeprazole 20 mg (milligrams) 1 tablet Amlodipine 5 mg 2 tablets Refresh eye drops 1 drop each eye. Fluticasone nasal spray one spray each nostril Dairy aid 1 tablet Metoprolol…

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 and interview, the facility failed to ensure medications were properly secured. Specifically: 1. The facility failed to ensure medications were not left unattended on medication carts, at nurses' stations and in resident rooms. 2. The facility failed to ensure a medication cart was locked when unattended on the 3rd floor. 3. The facility failed to ensure medications were not left unattended at the bedside for Resident #4. 4. The failed to ensure medications were labeled with date opened. 5. The failed to ensure medications were not left unattended on top if the medication cart. 6. For Resident #201, the facility failed to ensure medication was not stored at bedside. Findings include: Review of the facility's Medication Labeling and Storage policy, dated February 2023, indicated: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including but not limited…

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 accurately document in the clinical records for 4 residents (#30, #67, #77 and #1) of 24 sampled residents. Specifically: 1. For Resident #30, the facility failed to document diabetic foot care. 2. For Resident #67, the facility inaccurately documented O2 (oxygen) tubing changed when it was not. 3. For Resident #77, the facility inaccurately documented a hand splint/brace was on when it was not. 4. For Resident #1, the facility failed to ensure staff documented the administration of medications. Review of the Documentation of Medication Administration policy dated November 2022 indicated: A medication administration record is used to document all medications administered. Documentation of medication administration includes . date and time of administration, reason(s) why a medication was withheld, not administered, or refused (as applicable); initials, signature and title of the person administering the medication. Review of the facility policy titled…

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 that one Resident (#201) did not self-administer medications out of a total sample of 24 residents. Specifically, Resident #201 was not assessed to be able to safely self-administer medication. Findings include: Review of the facility policy titled, Self Administration of Medications, dated as reviewed February 2021, indicated that as part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate. Resident #201 was admitted to the facility in November 2024 with diagnoses including post-traumatic stress disorder, anxiety disorder and depression. On 11/19/24 at 8:08 A.M., and 12:30 P.M. the surveyor observed a bottle of Motrin B on Resident #201's over the bed table. During an interview on 11/20/24 11:15 A.M., Resident #201 said that he/she put the bottle of Motrin in his/her backpack. Review of the medical record failed to indicate Resident #201 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.

Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan for one Resident (#201) out of a total sample of 24 residents. Specifically, the facility failed to develop a care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care. Findings include: Review of the facility policy titled Care Plans - Baseline, dated revised March 2022 indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. Resident #201 was admitted to the facility in November 2024 with diagnoses including osteomyelitis (infection of the bone), spinal abscess with drains in the back and intravenous antibiotic use. Review of the medical record failed to indicate a baseline care plan was developed within 48 hours of admission to the facility. Further review indicated that as of 5 days post…

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 interview the facility failed to implement resident-centered care plans for one Resident (#77) out of a total sample of 24 residents. Specifically, for Resident #77 the facility failed to implement the use of a hand brace and failed to assist with trimming fingernails. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016 indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #77 was admitted to the facility in June 2023 with diagnoses including stroke with left sided hemiplegia/hemiparesis, diabetes and depression. Review of the Minimum Data Set assessment dated [DATE], indicated a score of 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Further review indicated that Resident #77 is totally…

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 staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one Resident (#14) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated as revised December 2016 indicated the Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. Resident #14 was admitted to the facility in July 2024 with diagnoses including schizophrenia, anxiety disorder and depression. Review of Resident #14's clinical record indicated an MDS was completed on 10/22/24. Review of Resident #4's most recent care plan indicated a target date of 10/16/24. Further review indicated the care plan was not reviewed and had not been reviewed since 7/30/24, and target dates for all goals had not been updated . During an interview on 11/20/24 at 8:14 A.M., the Director of Nursing said that care plans are to be reviewed each…

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 assistance with activities of daily living (ADLs) for 3 dependent Residents (#14, #77 and #15) out of a total sample of 24 Residents. Specifically, the facility failed to: 1. For Resident #14, cut fingernails and remove unwanted chin hair. 2. For Resident #77, cut fingernails. 3. For Resident #15, remove unwanted chin hair. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting and dated revised March 2018 indicated that residents that are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Resident #14 was admitted to the facility in July 2024 with diagnoses including schizophrenia, anxiety disorder and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 scored an 8 out of 15 on the Brief Interview for Mental Status exam,…

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 interview, the facility failed to provide a meaningful activity program for one Resident (#44) out of a total of 24 sampled residents Findings include: Resident #44 was admitted to the facility in June 2023 with diagnoses including malignant neoplasm of frontal lobe and aphasia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #44 is severely cognitively impaired and requires assistance with bathing, dressing and transfers. During an interview on 11/19/24 at 10:20 A.M., the surveyor observed Resident #44 resting in bed. Family Member #1 said that she visits Resident #44 regularly and that Resident #44 is confused and bedbound. Family Member #1 said that she has not seen staff offer Resident #44 in room activities, turn his/her TV on or play music for him/her. Review of Resident #44's Activities Care Plan, dated 6/13/24, indicated: Focus: Resident experiences barriers to activities, especially communication and language barriers. Due to brain…

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

Based on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#67) out of a total sample of 24 Residents. Specifically, the facility failed to ensure the oxygen filter was clean and the oxygen tubing changed as ordered. Findings include: Review of the facility policy titled Oxygen Administration and dated revised October 2010 failed to indicate how often the oxygen tubing was to be replaced and how often the concentrator filter was to be cleaned. Resident #67 was admitted to the facility in October 2021 with diagnoses including chronic obstructive pulmonary disease, heart disease, and kidney disease. On 11/19/24 at 8:38 A.M., the surveyor observed Resident #67 lying in bed receiving oxygen via nasal cannula, attached to an oxygen concentrator. The surveyor observed the oxygen tubing to be dated 10/11/24. The surveyor also observed the concentrator filter to be covered with a gray fuzzy substance. Review of the doctor's orders indicated an order dated 10/26/22 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 that pain management was provided to residents who require such services, consistent with professional standards of practice for one Resident (#4) out of a total sample of 24 residents. Specifically, for Resident #4 the facility failed to administer the correct dose of a lidocaine patch (topical pain patch that comes in different strengths) and apply the lidocaine patch to the correct location. Findings include: Review of the facility policy, Pain Assessment and Management, dated as revised October 2022, indicated the purpose is to help staff identify pain in the resident, and develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. * Implementing Pain Management Strategies 5. The following are considered when establishing the medication regimen: a. Starting with lower doses and titrating upward as necessary; 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly 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 record review and interview, the facility failed develop a trauma-informed care plan to address the diagnosis of post-traumatic stress disorder (PTSD) for one Resident (#201) of 24 sampled residents. Findings include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care dated revised August 2022 indicated that individualized care plans are developed that address past trauma in collaboration with the resident and family as appropriate. Further review indicated to identify and decrease exposure to triggers that may retraumatize the resident. Resident #201 was admitted to the facility in November 2024 with diagnoses including post-traumatic stress disorder (PTSD), osteomyelitis (infection of the bone), spinal abscesses with drains in the back and intravenous antibiotic use. Review of the medical record failed to indicate a baseline care plan for PTSD was developed within 48 hours of admission to the facility. Further review indicated that as of 5 days post admission, a baseline plan of care for PTSD had not been developed. During 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 review and interview, the facility failed to review the consultant pharmacist's recommendations for the monthly medication regimen reviews (MRR) for one Resident (#4), out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing staff and the physician reviewed the consultant pharmacist's recommendations for Resident #4 from 9/23/24 and 10/25/24. Findings include: Review of the facility policy, Medication Regime Reviews, dated as revised May 2019, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. 8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: a. the resident's name; b. the name of the medication; c. the identified irregularity; and d. the pharmacist's recommendation. 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she…

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 infection control practices to prevent possible spread of infection by failing to follow infection control practices during medication pass. Findings include: Review of the facility policy titled Administering Oral Medications, dated revised October 2010 indicated that for tablets or capsules from a bottle pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medications with your hands. For unit dose tablets or capsules place the packaged medications directly into the medication cup. During medication pass on 11/20/24, at 9:48 A.M., the surveyor observed Nurse #4 pour 5 out of 7 unit dose medications into her hand before transferring each one into a medication cup, potentially contaminating the poured medications. The surveyor also observed Nurse #4 pour 5 out of 5 medications from different bottles into her bare hand, placing some into medication cups, and returning the unused medications to the bottles, potentially contaminating these 5 bottles 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 records reviewed, interviews, and policy review, the facility failed to ensure one Resident (#285) received care in accordance with professional standards of practice, out of a total sample of 19 residents. Specifically, the facility failed to ensure nursing reconciled and transcribed medications from Resident #285's hospital discharge summary accurately. Findings include: Review of the facility policy titled, Medication Reconciliation, dated as revised 12/11/14, indicated the Center will accurately reconcile medications of newly admitted residents to contribute to the creation of an accurate master medication list. The purpose of this policy is to: -Describe the process for creating the most accurate list possible of all medications a newly admitted patient or resident is taking -Provide correct medications to the patient or resident after transitioning to the Center's care. General Information: -Prescribing errors may occur when a patient is admitted to the hospital or transferred across the continuum…

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 review, the facility failed to provide Activities of Daily Living (ADLs) for one Resident (#2) out of a sample of 19 Residents. Specifically, the facility failed to provide mouth care resulting in thrush on the Resident's tongue. Findings include: A review of the facility policy titled, 'Mouth Care', with a revision date of February 2018, indicated the following: *The purpose of this procedure is to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. Resident #2 was admitted to the facility in September 2019 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe impairment. A review of the Resident's November physician's orders indicated the following: *NPO (Nothing by Mouth) diet, NPO texture and NPO consistency *Enteral feed every 6 hours 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, record review and interview the facility failed to ensure quality care was provided for 1 Resident (#29) out of a total sample of 19 residents. Specifically, the facility failed to ensure a physician's order was in place for a resident's wound treatment. Findings include: Review of the facility policy titled Skin Tears-Abrasions and Minor Breaks, Care of, dated September 2013, indicated the following: -The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. -Obtain a physician's order as needed. Document physician notification in medical record. -Review the resident's care plan, current orders, and diagnosis to determine resident needs. -Check the treatment record. -Complete in-house investigation of causation. -When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/Accident. Resident #29 was admitted to the facility in May 2023 and had diagnoses that included Type II Diabetes with Diabetic Neuropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to obtain consent to receive vision services resulting in the Resident not receiving vision services since admission for one Resident (#5) out of a total sample of 19 residents. Findings include: Review of the facility policy titled Physician Orders for Consultation, dated and revised 1/5/22, indicated the following: The purpose of this policy is to: *Ensure that consultations for specialty care or ancillary services (including podiatry, dental, optometry, audiology and physiatry services) are ordered by the attending physician to meet the medical or clinical care needs of each patient. Process: *The interdisciplinary team (including the attending physician, nurses, therapists, and social workers) will identify the need for consultative services. *The attending physician or designated practitioner will order consultative services when necessary to meet individualized medical and clinical needs of the resident. *The center will assist…

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 a peripherally inserted central catheter (PICC) was flushed in accordance of professional standards of practice for one Resident (#285) out of a total sample of 19 residents. Specifically, for Resident #285, the facility failed to ensure nursing obtained physician's orders for routine flushes. Findings: Review of the facility policy titled, Central Line Catheter Flushing, dated June 2016, indicated to maintain patency of the central venous access device (CVAD). VII. To maintain the patency of a peripherally inserted central catheter (PICC); the catheter will be flushed every 8 hours or once per shift with 10 milliliters (ml) 0.9% preservative-free sodium chloride flush followed by 5 ml heparin 10 units/mI flush, unless closed ended or valve catheter then only 10 ml 0.9% preservative-free sodium chloride flush every 8 hours or once per shift is required to maintain patency. A. Verify physician's orders. M. Document on IV medication administration record (MAR) and/or resident's medical record. 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 policy review, record review and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident for one Resident (#285) in a total sample of 19 residents. Specifically, for Resident #285 who was admitted to the facility with clostridium difficile (infection that causes diarrhea and inflammation of the colon) and required an antibiotic medication (fidaxomicin), the facility failed to ensure they obtained his/her physician ordered antibiotic medication, as a result Resident #285 was not administered the antibiotic as ordered, and he/she missed 5 doses. Findings include: Review of the facility policy titled, Unavailable Medications, dated February 2019, indicated medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every…

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, record review and policy review, the facility failed to obtain consent to receive dental services resulting in the Resident not receiving dental services since admission for one Resident (#5) out of a total sample of 19 residents. Findings include: Review of the facility policy titled Dental Services, dated and revised December 2016 indicated the following: *Routine and emergency dental services are available to meet the resident's oral health services in accordance with resident's assessment and plan of care. *Routine and 24-hour emergency dental services are provided to our residents through: a. a contract agreement with a licensed dentist that comes to the facility monthly b. Referral to the resident's personal dentist c. Referral to community dentists or d. Referral to other health care organizations that provide dental services *A list of community dentists available to provide dental services to our residents is posted at each nurses' station and the list is also available from Service…

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 review, the facility failed to transcribe a physician's order accurately for one Resident (#2) out of a sample of 19 Residents. Specifically, the facility failed to accurately document the medication route of administration. Findings include: Resident #2 was admitted to the facility in September 2019 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe impairment. A review of the Resident's November physician's orders indicated the following: *NPO (Nothing by Mouth) diet, NPO texture and NPO consistency *Enteral feed every 6 hours for dysphagia *Diflucan (medication used to treat thrush) Oral Tablet 150 milligrams (mg), give 1 tablet by mouth in the evening. During an interview on 11/21/23 at 8:14 A.M., the Director of Nurses said Residents who are NPO should not have medication orders that read, administered by mouth. He expects…

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.