Hellenic Nursing & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#57), out of a total sample of 27 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her dominant language of Albanian and failed to ensure staff provided person-centered care and services to determine and support the Resident's communication needs. Findings include: Resident #57 was admitted to the facility in May 2019 and had diagnoses including Alzheimer's disease, major depressive disorder, and adjustment disorder. Review of the Minimum Data Set assessment, dated 7/9/24, indicated Resident #57's preferred language was Greek and requires an interpreter to communicate with his/her physician and health care staff. Review of the care plan for communication problems, initiated 5/12/19, indicated Resident #57 has a language barrier and prefers to speak in Albanian, but can understand some Greek…

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

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental and psychosocial well-being for one Resident (#251), out of 27 sampled residents. Specifically, for Resident #251, the facility failed to consistently provide activities based on the comprehensive assessment and care plan. Findings include: Resident #251 was admitted to the facility in August 2024 with the following diagnoses: dementia and behavioral disorders. Review of the medical record indicated Resident #251 was alert and confused at baseline. Review of the Brief Interview for Mental Status (BIMS) Evaluation, dated 8/18/24, indicated the Resident scored 0 out of 15 indicating he/she was severely cognitively impaired. Review of Resident #251's care plans included but were not limited to: -Focus: Resident admitted for long term care. Resident in need of 24 hour care and supervision, dated 8/16/24. Interventions: Encourage/involve in daily activities, dated 8/16/24 -Focus: Resident #251 is…

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

Based on observation, record review, and interview, the facility failed to ensure residents were free from accident hazards for two Residents (#32 and #62), out of a total sample of 27 residents. Specifically, the facility failed to complete his/her quarterly smoking evaluations. Findings include: Review of the facility's policy titled Smoking Policy and Procedure, dated as revised 11/1/2018, indicated but was not limited to: -All residents expressing the desire to smoke tobacco products or use E-cigarettes will be assessed upon admission to the center, when there is a change in status and quarterly. On 8/26/24 at 1:30 P.M. and 8/29/24 at 9:07 A.M., the surveyor observed Residents #32 and #62 smoking in the facility's designated smoking area with staff supervision. a. Resident #32 was admitted to the facility in June 2020 and had diagnoses including bipolar disorder and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/19/24, indicated Resident #32 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15 and…

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

Based on record review, policy review, and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting; a blood thinner) for one Resident (#41), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Anticoagulation-Clinical Protocol, last revised November 2018, indicated but was not limited to: - Monitor and Follow-Up 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. Resident #41 was admitted to the facility in January 2024 with diagnoses of atrial fibrillation and hypertension. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 7/25/24, indicated Resident #41 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated that Resident #41 received anticoagulant medication. Review of Resident #41's current Physician's Orders indicated but was 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.

Based on record review and interview, the facility failed to ensure one Resident's (#56) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 27 residents. Specifically, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised July 2022, indicated but was not limited to: - Policy Statement: - Residents will not receive medications that are not clinically indicated to treat a specific condition. - Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. - Policy Interpretation and Implementation: 1. Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 16. PRN (as needed) orders for antipsychotic medications will not be renewed beyond 14 days…

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

Based on record review, policy review, and interview, the facility failed to ensure that concerns addressed by the Resident Council Group have sufficient follow-up to address and prevent recurrence. Findings include: Review of the facility's policy titled Complaint/Grievance Policy and Procedure, undated, indicated the following: *Voiced grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. During the Resident Group interview on 6/28/23 at 11:08 A.M., nine residents were in attendance, and 8 of 9 residents reported: * Despite repeatedly voicing concerns, month after month, the staff speak Creole on the units, it continues. * Snacks are not passed at nighttime and if they ask the staff for a snack the staff say that they are too busy. The Resident Group suggested the surveyor look back at past year's monthly resident council minutes and said that these concerns are documented. Review of the past year's Resident Council…

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, policy review, and interview, the facility failed to ensure four Residents (#75, #46, #31, and #21) were free from restraints, out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #75, to assess the use of a rolled-up Hoyer pad and pillows under the fitted sheet on both sides of the Resident as a potential restraint; 2. For Resident #46, to assess the use of multiple blankets under the sheets on both sides of the bed as a potential restraint; 3. For Resident #31, to assess the use of blankets under the fitted sheet on one side of the Resident as a potential restraint; and 4. For Resident #21, to assess the Resident's bed up against the wall as a potential restraint. Findings include: Review of the facility's policy titled Use of Restraints, dated 11/2020, included the following: - Restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. - Restraints should only be used to treat the resident's medical symptoms and never 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 Activity of Daily Living (ADL) assistance was provided to four dependent Residents (#87, #40, #54, and #12), out of a total sample of 26 residents. Specifically, 1. Resident #87's facial hair was not removed timely; and 2. Residents #40, #54, and #12 were not supervised with eating. Findings include: 1. Resident #87 was admitted to the facility in December 2021 and had diagnoses that included dementia, anxiety disorder, and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/6/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #87 scored a 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #87 required 1 person physical assistance with personal hygiene. During an observation and interview on 6/27/23 at 8:02 A.M., the surveyor observed Resident #87. He/she had long chin hair. Resident #87 said he/she would like it removed but the girls never do (it). During a record review on…

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 to store food in sanitary conditions, specifically, label and date leftover food items and dispose of food items after their use by date. Findings include: Review of the facility's policy titled 'Food Handling' indicated the following: *Foods that are prepared and not placed into service are considered unused portions. *Unused portions that have been properly handled, refrigerated, covered, labeled, and dated with use by dates or frozen and reheated and served according to the HACCP Food Flow Charts can be served by the use by date. *Foods that are marked with the manufacturer's use by date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any including portioning. Once a product has been prepared or portioned, a new use by date is established. Follow the use by dating guidelines (Appendix) to establish a new date. On 6/27/2023 at 7:19 A.M., the surveyor observed the following undated food items in the kitchen's refrigerator:…

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 provide a dignified existence for one Resident (#16), out of a total sample of 26 residents. Findings include: Resident #16 was admitted to the facility in May 2023 and had diagnoses that included Alzheimer's disease and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/24/23, indicated that on the Brief Interview for Mental Status exam Resident #16 scored a 6 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #16 requires one person physical assistance with Activities of Daily Living (ADLs). During an interview on 6/27/23 at 7:50 A.M., Resident #16 said that he/she had been wearing the same underwear for four days and that his/her butt is itchy and sticky. Resident #16 said he/she had complained to all the Certified Nursing Assistants (CNAs) each day for four days and that the CNAS have told Resident #16 that he/she has no underwear with his/her name on them. On 6/27/23 at 7:56…

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 ensure two Residents (#16 and #54) consented to the administration of an antipsychotic medication, prior to administration, out of a total sample of 26 residents. Findings include: 1. Resident #16 was admitted to the facility in May 2023 and had diagnoses that included Alzheimer's disease and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/24/23, indicated Resident #16 had received antipsychotic medication for five of the past seven days. Review of the current Physician's Orders indicated: * Resident #16 had an order, started 5/20/23, for Quetiapine Fumarate (an antipsychotic medication) Oral Tablet 25 milligrams (mg). * Resident #16 did not have an order to have his/her Health Care Proxy (HCP) activated. Review of the paper and electronic medical records failed to indicate the Physician had activated Resident #16's HCP, therefore Resident #16 is deemed to be his/her own person. Further review failed to indicate Resident #16 deferred to family to sign consents on his/her behalf.…

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, policy review, and record review, the facility failed to provide meal choices and preferences for one Resident (#27), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Dining and Food Preferences, dated as revised September 2017, indicated the following: *The individual tray assemble ticket will identify all food items appropriate for the Resident/patient based on diet order, allergies & intolerances, and preferences. Resident #27 was admitted to the facility in February 2023 with diagnoses including type 2 diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/28/23, indicated a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating intact cognition. During an observation and interview on 6/27/23 at 8:47 A.M., the surveyor observed Resident #27 eating breakfast in his/her room. Resident #27 told the surveyor that he/she does not always get all the food items on his/her meal ticket. Resident #27 said that he/she reviews the meal tickets at 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.

Based on observations, records reviews, and interviews, the facility failed to implement the plan of care for three Residents (#451, #54 and #82), out of a total of 26 sampled residents. Specifically, the facility failed: 1. For Resident #451, to ensure nursing implemented a physician's ordered bed alarm for a resident with a history of a fall with injury; 2. For Resident #54, to implement the orthotic/splint care plan; and 3. For Resident #82, to develop a communication care plan. Findings include: 1. Resident #451 was admitted to the facility in September 2022 with diagnoses including chronic obstructive pulmonary disease, muscle weakness, and glaucoma. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/8/23, indicated Resident #451 had one fall in the past month. Review of the Physician's Order, dated 6/15/23, indicated: * Alarms: Bed alarm - Check function and placement every shift Review of the plan of care related to falls, dated 6/15/23, indicated: * Resident #451 uses bed electronic alarm. Ensure the device is in place as needed. During observations on…

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 interviews, the facility failed to revise the plan of care related to advanced directives for one Resident (#451), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Advanced Directives, undated, indicated: * The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directives. Resident #451 was admitted to the facility in September 2022 with diagnoses including chronic obstructive pulmonary disease, dysphagia, muscle weakness, and sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/8/23, indicated that Resident #451 was coded: Do Not Resuscitate- NO Review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated 6/8/23 and 6/10/23, indicated: Do Not Resuscitate (DNR) Do Not Intubate and Ventilate (DNI, DNV) Review of the Physician's Order, dated 6/20/23, indicated: Code Status: DNR, DNI, DNV. May transfer to hospital. Review of the plan of care related to advanced directives, 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.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure professional standards of care were followed related to physician's orders for two Residents (#63 and #4) out of 26 sampled residents. Specifically, the facility failed: 1. For Resident #63, to obtain weekly weights, per the physician's order; and 2. For Resident #4, to ensure the physician's orders were implemented for a.) a stop sign outside of his/her room, and b.) the application of compression stockings (TEDs). Findings include: 1. Review of the facility's policy titled Weight Surveillance, undated, included the following: * Resident weights are an important indicator of nutritional and overall health status. * Licensed nurse is to enter the weights into the resident's record. Resident #63 was admitted to the facility in December 2020 with diagnoses including Alzheimer's disease, type 2 diabetes, and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set assessment, dated 5/25/23, indicated Resident #63 was assessed by staff to have severe…

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 ensure quality care was provided to one Resident (#451), out of a total sample of 26 residents. Specifically, on 6/5/23 Resident #451 fell while in the facility and sustained a subdural hematoma and laceration to his/her right forehead and was transferred to the hospital. Resident #451 returned on 6/8/23 with four sutures to his/her right forehead. On 6/27/23, 6/28/23 and 6/29/23 (24 days after the sutures were inserted) the sutures were still in Resident #451's right forehead and nursing failed to obtain a suture removal date. Findings include: Resident #451 was admitted to the facility in September 2022 with diagnoses including chronic obstructive pulmonary disease, dysphagia, muscle weakness, and sleep apnea. Review of the Minimum Data Set (MDS) assessment, dated 6/8/23, indicated Resident #451 could make self understood and he/she could understand others. Review of the Hospital Discharge summary, dated [DATE], indicated on 6/5/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review, and interviews, the facility failed to ensure that routine devices (hearing aids) used to maintain hearing were provided for one Resident (#451), out of 26 sampled residents. Specifically, the facility failed to provide and implement the use of hearing aids for Resident #451 who was hard of hearing. Findings include: Review of the facility's policy titled Care of Hearing Aids, undated, indicated the purpose is to maintain the resident's hearing at the highest attainable level. Review the resident's care plan to assess for any special needs of resident. Documentation: 3. If the Resident refused the procedure, the reason(s) why and the intervention taken. Reporting: 1. Notify the supervisor if hearing aid is damaged or needs to be sent to the dealer for cleaning. 2. Notify the supervisor if the resident complains or problems related to hearing and/or the hearing aid or has a wax build up in the ear. 3. Report other information in accordance with facility policy…

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, record review, and policy review, the facility failed to follow the Weight Surveillance policy for one Resident (#87), out of a total sample of 26 residents. Specifically, the facility did not obtain monthly weights as ordered for Resident #87 and did not reweigh Resident #87 when a 12.5% weight loss was recorded to ensure accuracy of the weight obtained. Findings include: Review of the facility's policy titled Weight Surveillance, undated, indicated the following: * Reweighs are to be obtained if there is a three (3) pound discrepancy from previous weight. Licensed staff will do re-weigh and notify unit manager if discrepancy is accurate. * Unit manager will report to the Physician, Dietitian, MDS coordinator and Responsible Party, any significant, unplanned weight loss or gain. * Dietitian to reassess and document interventions to address significant weight loss or gain. Resident #87 was admitted to the facility in December 2021 and had diagnoses that included dementia, anxiety disorder, and need for assistance with personal care. Review of 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, record reviews, policy review, and interviews, the facility failed to maintain respiratory equipment according to professional standards of practice for two Residents (#27 and #452), out of a total sample of 26 residents. Specifically, the facility failed: 1. To label the oxygen tubing and clean the filter as ordered; and 2. To implement a physician's order for dating and initialing nebulizer tubing, and to store a nebulizer face mask to prevent possible contamination. Findings include: 1. Review of the facility's policy titled Oxygen Administration via nasal Canula, mask, CPAP, BiPAP, undated, indicated the following: * Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. * Review the Resident's care plan to assess for any special needs of the resident. Resident #27 was admitted to the facility in February 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/28/23, indicated that on…

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 interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for three Residents (#21, #12, and #86), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Pharmacy Recommendations Protocol, undated, included but was not limited to: * Pharmacy Recommendations will be received via email or physical copy given to Unit Manager by pharmacy consultant. A Consultant Pharmacist Medication Regimen Review will be included. The original regimen review will be obtained by the DON [Director of Nurses] and a copy given to the unit manager. Unit Responsibilities 1. Nursing recommendations will be reviewed and addressed. 2. MD/NP [Medical Doctor/Nurse Practitioner] recommendations will be reviewed with MD/NP/PA [Physician's Assistant] and follow-through completed based on direction. 3. Unit will note follow-through action on the original follow through listing and return it to the DON when all recommendations have been addressed. 1. Resident #21 was admitted to the facility…

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 four nurses observed made 3 errors in 36 opportunities on two of three units resulting in a medication error rate of 8.33%. These errors impacted two Residents (#20 and #95), out of seven residents observed. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated the following: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation *2. Medications must be administered in accordance with the orders, including any required timeframe. *3. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders). Nurse must write reason if not given timely. 1. During a medication pass on 6/28/23 at 8:12 A.M., the surveyor observed Nurse #1 prepare and administer the following medication to Resident #20: *…

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 one Resident (#4) was free from a significant medication error, out of a total sample of 26 residents. Specifically, Resident #4 was administered an antibiotic twice daily for 14 days instead of twice daily for 14 doses (7 days) as indicated by the hospital discharge summary and discharge prescription. Findings include: Resident #4 was admitted to the facility in November 2022 with diagnoses including right fibula fracture, diabetes, and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/16/23, indicated Resident #4 can make self understood and he/she can understand others. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #4 was diagnosed with a urinary tract infection. The summary indicated to administer antibiotics as prescribed. The discharge summary indicated for Cefpodoxime (antibiotic) 200 milligrams (mg) by mouth two times a day and to dispense 14 tablets (7 days). Review of 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, policy review, and interviews, the facility failed: 1. To ensure medications were stored securely in 2 out of 4 resident care units, and 2. To ensure medications with shortened expiration dates were labeled and dated after being opened in 2 out of 3 medication carts. Findings include: Review of the facility's policy titled Storage of Medications, undated, indicated the following: Policy statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation. *The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. *Multi-dose vials which have been opened or accessed (e.g., needle- punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. *Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not…

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 they maintained a complete and accurate medical record for one Resident (#4), out of a total sample of 26 residents. Specifically, for Resident #4, the physician's ordered calcium carbonate tablet did not have a dose as required. Findings include: Review of the facility's policy titled Medication Orders, undated, indicated the purpose is to establish uniform guidelines in the receiving and recording of medication orders. -medication orders- when recording orders for medication specify the type, route, dosage, frequency and strength of the medication ordered. Resident #4 was admitted to the facility in November 2022 with diagnoses including right fibula fracture, diabetes, and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/16/23, indicated Resident #4 can make self understood and he/she can understand others. Review of the Physician's Order, dated 8/16/22, indicated: -Tums Tablet Chewable (Calcium Carbonate Antacid) Give 1 tablet by mouth one time a day 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.