Day Brook Village Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to provide treatment and services adhering to professional standards of practice related to Hospice services for one Resident (#62) out of a total sample of 18 residents. Specifically, for Resident #62, the facility failed to ensure that Hospice recommendations for comfort medication orders were implemented in a timely manner leading to a delay in medication administration for the Resident. Findings Include: Review of the facility policy titled Hospice Program, last revised 3/28/22, indicated: -when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other comfort measures. -a member of the interdisciplinary clinical team from each facility and the hospice organization will be designated to ensure the coordination of care delivery. Resident #62 was admitted to the facility in January 2022 with…

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 the safety of one Resident (88) out of a total sample of 18 residents, who was at risk for elopement. Specifically, for Resident #88, the facility failed to assess on admission the Resident with a history of substance use disorder (SUD) for risk of elopement and initiate the elopement response when the Resident left the facility without staff being aware. Findings include: Review of the facility policy titled Elopement Prevention and Response, revised 2/24/25, indicated: -It is the policy of the facility to identify residents at risk for elopement through the completion of the Wandering/Elopement risk assessment and to provide a secure environment through the implementation of individualized care interventions. -It is the policy of the facility to ensure that residents who are at risk of elopement are escorted to and supervised during activities off unit such as rehab and outdoor activities. -Upon admission nursing will complete a wandering/elopement risk assessment. -If residents are determined to be at risk 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 provide adequate nutritional care and services for two Residents (#54 and #35) out of a total sample of 18 residents, identified as being at risk for nutritional decline. Specifically: 1. For Resident #54, the facility failed to address significant weight loss and implement effective nutritional interventions when the Resident was identified as having greater than a 5 percent (%) weight loss in one month. 2. For Resident #35, the facility failed to provide the Resident with a diagnosis of Diabetes Mellitus (DM) the ordered glucose control nutritional supplement, when the nursing staff provided original nutritional supplements during meal times that were not ordered and MAR documentation indicated the Resident was receiving the glucose control supplement increasing the Resident's risk for inaccurate nutritional assessment and inappropriate management of blood sugar levels. Findings include: Review of the facility policy for Nutrition Management last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to accurately monitor the fluid intake for one Resident (#36) out of a total sample of 18 residents. Specifically, for Resident #36, the facility staff failed to accurately allot the daily fluid intake as ordered by the Physician and monitor the total daily fluid intake for the Resident dependent on renal dialysis, placing him/her at risk for complications related to fluid overload. Findings include: Review of the facility policy titled Dialysis Residents-Coordination of Care, revised 11/19/18, included: -The nursing facility is responsible for the overall quality of care and services the resident receives and provides the services, consistent with professional standards of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care. >A comprehensive person-centered plan of care . will include: -monitoring of .fluid needs and restrictions. >The facility remains responsible for the overall quality of care…

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 records reviewed, the facility failed to ensure all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure the Infection Preventionist (IP) attended and participated in one of four consecutive quarterly QAPI meetings reviewed. Findings include: Review of the facility's four most recent quarterly QAPI meeting attendance sheets provided by the facility indicated the following: -All required members were present for the meeting held on 1/28/25. -All required members were present for the meeting held on 10/17/24. -All required members were present for the meeting held on 7/17/24. -The Administrator, Director of Nursing (DON), and Medical Director were present for the meeting held on 2/8/24. -The IP was not present for the meeting held on 2/8/24. During an interview on 4/3/25 at 1:45 P.M., the Administrator said that the facility did not have an IP when the quarterly QAPI meeting was held on 2/8/24.

Based on record review, observation, and interview the facility failed to adhere to infection control standards of practice for one Resident (#44) out of a total sample of 18 residents, and maintain sanitary medication storage for a medication administration cart on one unit (Unit Two) out of two units. Specifically, 1. For Resident #44, the facility staff failed to follow Physician orders for Enhanced Barrier Precautions (EBP's-the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact wound care for the Resident. 2. the facility failed to maintain a clean medication administration cart during a medication administration observation on Unit Two putting the unit residents at risk for medication contamination. Findings include: 1. Review of the facility policy titled Enhanced Barrier Precautions, dated 1/10/23 included but was not limited to: -EBP's will be used in these conditions . <All residents on the unit with any…

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 records reviewed, the facility failed to administer Pneumococcal Vaccinations for two Residents (#36 and #81) of five applicable residents, out of a total sample of 18 residents, increasing the Residents' risk for acquiring Pneumococcal illnesses. Specifically, the facility failed to administer Pneumococcal Vaccines for Residents #36 and #81, when the Residents were eligible to receive, and consented to, the Pneumococcal immunization. Findings include: Review of the facility's policy titled Resident Pneumococcal Immunization, dated September 2011 and revised 9/1/23, indicated the following: -Residents will be offered immunizations to protect them against Pneumococcal disease unless the vaccine is medically contraindicated, or the resident has already been immunized. -Pneumococcal immunizations will be provided as recommended by the CDC (Centers for Disease Control and Prevention) Advisory Committee for Immunization Practices (APIC) recommendations. -Standing orders signed by the 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.

Based on record review and interviews, for one of three sampled residents (Resident #1) who was exhibiting signs and symptoms of Influenza, the facility failed to ensure he/she was provided with quality care and services that meet professional standards of practice, when after an Influenza test had been conducted on 03/06/25, with positive test results on 03/07/25, the test results were not obtained by nursing until 03/12/25, six days after the test was obtained, as a result Resident #1 was unable to receive antiviral medication used to treat Influenza putting him/her at risk for complications from influenza. Findings include: Review of the Facility's policy titled Laboratory and Radiology Services, dated as revised 11/17/16, indicated laboratory and testing will be performed as per medical provider orders and be communicated to the provider and recorded in the patient record in a timely and effective manner. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside 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 and interviews, for one of three sampled residents (Resident #1), who was exhibiting signs and symtoms of Influenza, and for whom nursing received a new order on 3/06/25 for an Influenza test, the Facility failed to ensure Nursing promptly notified the ordering physician, physician assistant, or nurse practitioner of the laboratory results, when he/she tested positive for Influenza on 03/07/25, but the provider was not made aware until 03/12/25, six days later. Findings Include: Review of the policy titled Laboratory and Radiology Services, dated as revised 11/17/16, indicated laboratory and testing will be performed as per medical provider orders and be communicated to the provider and recorded in the patient record in a timely and effective manner. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies 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 records reviewed and interviews, for three of three sampled residents, (Resident #1, Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when 1) for Residents #1, #2 and #3, who all tested positive for Influenza, there were no Physician's orders obtained and therefore no documentation related to the need for Droplet precautions to be initiated and 2) for Resident #1, his/her Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were incomplete. Findings include: Review of the Facility's Policy, titled Documentation-Clinical, dated revised 10/31/23 indicated the following: -This Facility meets DPH requirements for weekly summary of resident condition by ensuring documentation of medication and treatment administration every shift, interdisciplinary progress notes as needed, skin evaluations weekly and Functional Performance point of care documentation every shift. Resident status, including change in condition, nursing or other services provided and resident response or progress will be…

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 ensure treatment and assistive devices for hearing were provided to ensure one Resident (#35) out of a total sample of 18 residents, maintained his/her highest level of hearing abilities. Specifically, for Resident #35 the facility failed to ensure the Audiologist's (health care professional who diagnose, manage, and treat hearing, balance, or ear problems) recommendations to facilitate further medical follow-up related to the Resident's hearing loss was provided timely, so the Resident's request for hearing aids could be addressed. Findings include: Review of the facility policy titled Consulting services, Podiatry/Dental/Optometry/Audiology, approved date 12/22/16, indicated the following: -Appointment is arranged by facility staff. -Consultant brings forward to a licensed professional any urgent care needs based on their consultation. Resident #35 was admitted to the facility in September 2022 with a diagnosis of asymmetric hearing loss bilaterally…

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 record review, the facility failed to ensure that one Resident (#37) out of a total sample of 18 residents, received dialysis (a procedure to remove waste products and fluid from the body when the kidneys stop working) care consistent with professional standards of practice. Specifically, the facility failed to: 1. demonstrate ongoing communication and collaboration with the contracted dialysis facility, as required on dialysis treatment days. 2. failed to ensure Resident #37's prescribed medication was scheduled in such a way to be administered prior to dialysis treatment. Findings include: Review of the facility's policy titled; Coordination of Care of Dialysis Residents dated 11/19/18, indicated but was not limited to: -It is the policy of this facility that there is ongoing communication and coordination between the nursing facility and dialysis center to ensure the provision of continuity of care as outlined in the Resident's comprehensive person-centered care plan. -A comprehensive person-centered plan of care is developed and implemented based 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 and interview, the facility failed to ensure adequate psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication monitoring per Physician orders to promote and maintain the highest practicable mental, physical, and psychosocial well-being for two Residents (#56 and #1), out of a total sample of 18 residents. Specifically, the facility failed to: 1. obtain an EKG (Electrocardiogram - records the electrical signal from the heart to check for different heart conditions) per Physician orders for Resident #56. 2. obtain pertinent lab work per Physician's orders for Resident #1. Findings include: 1. Resident #56 was admitted to the facility in April 2023 with the following diagnoses: Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) with severe agitation, Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities),…

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 policy review, the facility failed to ensure the safe storage of medications. Specifically, the facility staff failed to ensure that one medication cart, out of five medication carts remained locked while unattended, allowing access to medications and risk of harm for other residents, visitors and staff. Findings include: Review of the facility policy titled Storage of Medications revised 6/10/22 indicated but was not limited to: - Only Licensed Nurses and Pharmacy personnel are allowed access to medications. -Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 2/1/24 from 8:35 A.M. - 9:00 A.M., the surveyor conducted a medication administration pass with Nurse #1. The surveyor observed that Nurse #1 parked the medication cart outside the resident's room, with the cart facing outward towards the hallway. Nurse #1 said she needed to obtain a set of vital signs prior to administering the medications to the resident, left the medication cart unlocked and proceeded down the hallway and around…

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 ensure that infection control protocols was followed during a medication administration pass procedure. Specifically, the facility staff failed to ensure: 1. medical equipment utilized by multiple residents was sanitized appropriately between use. 2. medications were administered in such a way to prevent contamination, and risk of infection. Findings include: Review of the facility policy titled General Cleaning and Maintenance of Equipment revised 6/28/16, indicated but was not limited to: -Equipment is decontaminated with an Environmental Protection Agency (EPA) - facility approved disinfectant. Review of the facility policy titled Administration Procedures for all Medications dated 9/20/13, indicated but was not limited to: -Cleanse hands using an antimicrobial soap and water or facility-approved hand sanitizer before beginning a medication pass, before handling medication, and before contact with resident. During a medication administration pass on 2/1/24 at 8:35 A.M., the surveyor observed Nurse #1 obtain…

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 record review, the facility failed to administer Influenza Vaccination (annual Flu vaccine) and Pneumococcal Vaccination for three Residents (#5, #22, #64) out of a sample of five residents, to minimize the risk of facility acquired infections. Specifically, the facility staff failed to: 1. For Resident #5 and #22, ensure the Residents received the requested Prevnar 20 vaccine (PCV20 - a type of Pneumococcal Vaccination) as consented to by the Resident and/or the Resident's Representative. 2. For Resident #64, ensure the Resident received the requested PCV20 and annual Flu vaccine as consented to by the Resident and/or the Resident's Representative. Findings include: Review of the facility policy titled Resident Pneumococcal Immunization, last revised 9/1/23, indicated the following: -Residents of the facility will be offered immunization to protect them from Pneumococcal disease . -The Pneumococcal Vaccine/s will be documented within the Immunization Record inside the electronic health record (EHR). Review of the facility policy titled Resident Influenza…

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 staff provided written notice of transfer for three Residents (#13, #73, and #77) out of 19 sampled residents. Findings include: 1. Resident #13 was admitted to the facility in September 2020. Review of the Minimum Data Set (MDS) Assessment, dated 5/11/22, indicated that Resident #13 had Dementia (a disorder which manifests as progressive impairment in memory, thinking and behavior) and severe cognitive impairment as evidenced by a score of three out of 15 on the Brief Interview of Mental Status (BIMS). Review of Resident #13's medical record indicated the Resident was transferred to the hospital for evaluation and treatment on 7/6/22. Further review of the record indicated there was no documented evidence that a written transfer notice was provided to the resident representative for the 7/6/22 transfer. During an interview on 08/04/22 at 10:59 A.M., the Social Worker (SW) said there was no record of a written transfer notice for Resident #13's hospitalization on 7/6/22 as required. 2. Resident #73 was admitted 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 to ensure staff provided the Bed Hold Policy before/upon transfer for five Residents (#13, #26, #73, #77, and #80) out of 19 sampled residents. Findings include: 1. Resident #13 was admitted to the facility in September 2020. Review of Resident #13's medical record indicated the Resident was transferred to the hospital for evaluation and treatment on 7/6/22, 7/11/22 and 7/19/22. Further review of the record indicated no documented evidence that written bed-hold notices were provided to the Resident or resident representative prior to the transfers. During an interview on 08/04/22 at 10:59 A.M., the Social Worker (SW) said that no bed-hold notices were completed for Resident #13's hospitalizations as required. 2. Resident #26 was admitted to the facility in March 2022. Review of Resident #26's medical record indicated the Resident had been transferred to the hospital on 3/2/22, 3/11/22 and 4/16/22. Further review of the record indicated no documented evidence that written bed-hold notices were provided to 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, interview and policy review the facility failed to maintain appropriate kitchen sanitation methods, and failed to implement their policy, to prevent foodborne illness and food contamination related to hair restraints, food temperatures and hand hygiene. Findings include: Review of the facility policy titled Dietary Department Guidelines, revised 5/2018, indicated the following: -Employees should have access to proper hand washing facilities with available soap, hot water and disposable towels. Antimicrobial alcohol based hand sanitizer gels/foams or hand hygiene agents that do not require water, cannot be used in place of proper hand washing techniques in a food service setting. -Employees will wear hair restraints to prevent food contamination. Hair nets will be made available at the entrance of the kitchen. A clean hat, for example a chef's hat that restrains hair is also acceptable. -Refrigerated foods and cold foods will be held at refrigerator temps of 40 degrees Fahrenheit or below. On 8/2/22 at 8:06 A.M. the surveyor entered the facility kitchen 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 policy review and interview, the facility failed to maintain an Infection Prevention and Control Program (IPCP), specifically by not completing the SBAR (Situation, Background, Assessment and Recommendation form), or the McGeer criteria (criteria used to substantiate a true infection), per their own program. Also, the facility failed to conduct an annual review of the IPCP. Findings include: Review of the facility policy for Infection Prevention and Control, dated September 2011, indicated the following, when a resident exhibits signs/symptoms of a suspected infection, based on McGeer criteria, the unit nurse will: - Record the resident's name on the Infection Prevention and Control Surveillance form (the Infection Preventionist (IP) said the facility used the SBAR), and - Call Physician and begin to closely monitor. During an interview on 8/3/22 at 7:30 A.M., the IP said that the nurses did not fill out the SBAR as the policy indicated. She also said before the nurse called the physician they needed to complete the McGeer criteria, to assess if a resident had signs 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 observation, record review and interview, the facility failed to ensure the facility was free of pests, specifically insects. Findings include: 1. On 8/02/22 the team of surveyors observed multiple small flies in the main dining area (the area was not in use by residents) throughout the day. On 8/03/22 at 10:08 A.M., the surveyor observed multiple flies in the lounge room, on the first floor unit. During an interview on 8/03/22 at 10:38 A.M., Resident #122 said the flies were driving him/her crazy. The Resident said the flies join me for my meals and I really hate them. The Resident said he/she had told the facility staff but the situation was not getting any better. During the conversation a fly flew between the Resident and the surveyor. During an interview on 8/03/22 at 10:42 A.M., the Director of Maintenance said pest control services were in a couple of weeks ago. He said he was unaware of any active issues in the facility regarding pests. Review of the pest control report indicated they were at the facility on 7/21/22, the report did not indicate if there were any…

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 staff notified a physician of a medication (narcotic) being unavailable for several days, to administer to one Resident (#74), out of 19 sampled residents. Findings include: Review of the facility's policy for Medication Variance, dated 1/10/17, indicated the following: -A medication variance can include omission. -The purpose is to ensure the Resident is free from significant medication variances. -Nursing staff aware of medication variance are responsible to notify the physician. Resident #74 was admitted to the facility in August 2020 with diagnosis of chronic pain. Review of the June 2022 Medication Administration Record (MAR) indicated to administer methadone (narcotic used to treat pain) 10 milligrams (mg) by mouth daily. Further review indicated the medication was not administered to the Resident from 6/4/22 through 6/7/22. The medication was listed as unavailable. Review of the progress notes from 6/4/22 through 6/7/22 failed to indicate a physician or nurse practitioner (NP) was notified of the medication…

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 record review the facility failed to follow the care plan and implement their policy relative to weights, for two Residents (#75 and #67), out of 19 sampled residents. Findings include: Review of the facility policy for Nutrition Management, revised 6/6/22, indicated the following: Monitor resident's weight as ordered, at a minimum monthly, unless contraindicated by advanced directives. 1. Resident #75 was re-admitted to the facility in April 2022. Review of the Resident's care plan for nutrition, initially developed 1/5/22, indicated the Resident was at nutritional risk due to weight loss over time. The Resident was to be weighed monthly. Review of the weight variance report provided, indicated the Resident weighed 132 pounds (lbs) on 4/5/22. His/her most recent weight was 128.6 lbs, done on 6/20/22. No weight had been obtained since then. During an interview on 8/3/22 the Registered Dietician (RD) said the Resident had weight loss, but had not been weighed since 6/20/22, and was supposed to be weighed monthly. 2. Resident #67 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.

Based on record review and interview, the facility failed to ensure its staff responded to irregularities in the medication regimen review by the pharmacist timely, and to ensure the attending physician's documented their review, including actions taken, in the medical record of two Residents (#13, and #74) out of a total sample of 19 residents. Findings include: 1. Resident #13 was admitted to the facility in September 2020. Review of Resident #13's medical record indicated that the pharmacy had conducted Medication Regimen Reviews (MRRs) and made recommendations on 1/3/22, 2/1/22, 3/1/22, 4/4/22 and 5/2/22. Further review of Resident #13's medical record indicated no documented evidence of the written recommendations for the reviews or the attending physician's response to the reviews. The reviews were requested from the facility. Review of the MRRs provided by the facility were as follows: Risperidone: MRRs dated 1/3/22, 2/1/22 and 3/1/22 indicated to reassess the need for as-needed (PRN) risperidone (an antipsychotic medication) every 14 days per Center for Medicare and Medicaid…

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 (#74) was free from a significant medication error, related to an omission of a narcotic, out of 19 sampled residents. Findings include: Resident #74 was admitted to the facility in August 2020 with diagnosis including chronic pain. Review of the June 2022 Medication Administration Record (MAR) indicated to administer methadone (narcotic used to treat pain) 10 milligrams (mg) by mouth daily. Further review indicated the medication was not administered to the Resident from 6/4/22 through 6/7/22. The medication was listed as unavailable. Review of the National Library of Medicine website indicated opioid withdrawal, related to abruptly stopping the use of methadone, has an onset of 12-48 hours after the last dose and symptoms include (but not limited to) anxiety, nausea, vomiting. Review of a nurse practitioner (NP) progress note, dated 6/7/22, indicated the Resident ran out of the methadone after the dose on 6/3/22 and staff did not request a refill until this clinician came in today. 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 record review and interview the facility staff failed to (1.) document the acceptance or refusal of immunizations for one Resident (#26) and (2.) offer the Pneumococcal Immunization for two Residents (#74 and #182) out of a total sample of five applicable residents. Findings include: Review of the facility's Resident Influenza Immunization policy, dated 12/2016, indicated the following: -Influenza Vaccine will be offered annually, -The Influenza Vaccine administration or refusal will be documented, and -The Influenza Vaccine will be offered annually regardless of prior season declination. Review of the facility's Resident Pneumococcal Immunization policy, revised 2/23/2022, indicated the following: -Pneumococcal Immunization will be offered as recommended by the Center for Disease Control, -The Pneumococcal Immunization administration or declination will be documented in the electronic record. 1. For Resident #26, the facility staff failed to administer and/or document the Resident's refusal of the Influenza and Pneumococcal immunization. Resident #26 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.