Woburn Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to address documented significant weight losses for two Residents (#30 and #12) out of a total of 29 sampled residents. Findings include: Review of the facility policy titled Weight Monitoring, dated as revised 11/26/23, indicated: Policy: Each resident's weight will be monitored to ensure interventions are offered and implemented ensuring the resident's needs are met. Procedure: Monthly weights are to be obtained by the 10th of the month. Residents who have had a five pound weight difference since the previous weight obtained regardless as to when that was should be re-weighed within 24 hours of this most recent weight. If a significant weight change (suggested parameters for evaluating significance of unplanned and undesired weight loss are 5% in 30 days and 10% in 180 days) the physician, Registered Dietitian resident and/or resident representative are to be notified. The care plan will be reviewed and revised to reflect the current…

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 behavioral health services for one Resident (#16) out of a total sample of 29 residents. Specifically, Resident #16 verbalized he/she was not happy and had an increased Patient Health Questionnaire (PHQ-9) score, indicating worsening mood. Findings include: Review of the Behavioral Health Services policy, dated 10/2024, indicated the following: - Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. - Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. - Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmalogical interventions. Resident #16 was admitted 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 observation, interviews, and record review, the facility failed to ensure one Resident (#72) was free from significant medication errors, out of a total sample of 29 residents. Specifically, Nurse #2 attempted to administer medications to the incorrect Resident (#72), including medications that the Resident was allergic to and medications that could jeopardize his or her health and safety. Findings include: According to the U.S. Food and Drug Administration prescribing information for amoxicillin/clavulanate potassium (a penicillin-based antibiotic), dated December 2006, indicated: - Amoxicillin/clavulanate potassium should be used by prescription only. - Amoxicillin/clavulanate potassium is contraindicated in patients with a history of allergic reactions to any penicillin. - Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin-hypersensitivity. Before initiating therapy with amoxicillin/clavulanate potassium, careful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide dental services for one Resident (#8) out of a total sample of 29 residents. Findings include: Review of the facility policy titled, Dental Services, indicated the following: -It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. -Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. -The dental needs of each resident are identified through the physical assessment and MDS assessment processes, and are addressed in each resident's plan of care. -The facility will, if necessary or requested, assist the resident with making dental…

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 the appropriate diet texture for one Resident (#91) out of a total sample of 29 residents. Findings include: Resident #91 was admitted in April 2024 with diagnoses including adult failure to thrive and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #91 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the MDS and certified nursing aide documentation, indicates Resident #91 varies from independence to dependence with eating. Review of the physician's orders for Resident #91 indicated Resident #91 was to receive a pureed diet texture with nectar thickened liquids. During an observation on 1/9/25 at 8:45 A.M., Resident #91 had a tray at his/her bedside table. The Resident had scrambled eggs on his/her tray that were not pureed. During an interview on 1/9/25 at 8:46 A.M., Nurse #7 said that he checks the trays, but Resident #91 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for five of ten sampled residents' (Resident #1, #2, #3, #4, and #5) who were all assessed as being a high risk for developing a pressure injury or had an existing pressure injury upon admission, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice related to timely follow up on recommendations, regarding preventative skin care, and obtaining medication and/or treatment orders. Findings include: Review of the Facility Policy titled, Pressure Injury Prevention and Management, dated as last revised 02/2023, indicated that the facility is committed to the prevention of avoidable pressure injuries and to provide treatment and services to heal the pressure injury, prevent infection, and the development of additional pressure injuries. The Policy also indicated the following; -Basic or routine care interventions could include, but not limited to redistribute pressure (repositioning, protecting and/or offloading heels…

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 five of ten sampled residents (Resident #1,#2, #3, #4, and #5), who all required physical assistance of one to two staff members with Activities of Daily Living (ADL) and positioning, and (Resident #3, who also required new treatment orders for newly diagnosed pressure injury) the facility failed to ensure they maintained complete and accurate medical records, related to Certified Nurse Aide (CNA) ADL Flow Sheets and Positioning Sheets and when daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets often left blank and for Resident #3, although nursing noted treatments were in place for his/her buttock/coccyx wound, there were no physician's orders on his/her Treatment Administration Record (TAR) in place, or nursing documenation specifically related to wound care for these areas. Findings include: Based on the Facility Policy titled, Documentation in Medical Record, dated as last revised 02/2023, indicated that the resident's medical record shall contain an accurate representation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of ten sampled residents (Resident #3), who had experienced a significant change with a decline in medical status, the Facility failed to ensure Resident #3's physician was notified of the change which included the development of a new pressure injury and need for change in treatment. Findings include: Review of the Facility Policy titled, Notification of Changes, dated as last revised 02/2023, indicated that the facility will promptly notify the resident, consult the resident's physician, and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification. Resident #3 was admitted to the Facility in February 2024, diagnoses included Alzheimer's type dementia, peripheral vascular disease (PVD), congestive heart failure (CHF), chronic kidney disease, and amyloidosis (ATTR, a rare disease that occurs when a protein called amyloid builds up in organs and can make organs not work properly). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#1) out of a sample of 27 residents. Findings include: A review of the facility's policy titled Use of Psychotropic Medication dated May of 2022 and revised in February 2023, indicated the following: *Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medications. * Resident and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. * The attending physician will assume leadership in medication management by developing monitoring and modifying 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 observation, policy review and interview, the facility failed to ensure that the kitchen was maintained in a clean, sanitary manner. Findings include: Review of the facility's policy, entitled Food Safety Requirements, dated May 2022, included the following: -Food will be stored, prepared, distributed, and served in accordance with professional standards for food service delivery. -Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. -Food service safety, refers to handling, preparing, and storing food in ways that prevent foodborne illness. -Cleaning and sanitizing the internal components of the ice machine according to manufacturer's guidelines. Review of the facility's policy, entitled Cleaning Instructions: Ice Machine and Equipment, dated May 2022, included the following: -Ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. -Wash the interior thoroughly using a detergent solution.…

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 notify the physician of a significant weight loss for one Residents (#1) out of a total of 27 sampled Residents. Findings include: Review of the facility's Weights policy, dated May 2022 and revised February 2023 indicated: *Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. *Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as, 5% change in weight in 1 month (30 days), 7.5% change in weight in 3 month (90 days), or 10% change in weight in 6 months (180 days). *The physician should be informed of a significant change in weight and may order nutritional interventions. *The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to weight loss. Resident #1 was admitted to the facility in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, policy reviews and interviews, the facility failed to investigate an injury of unknown origin for 1 Resident (#30) out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation. Policy dated 02/2023, indicated the following: *Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 5. Focusing the investigation on determining if abuse neglect, exploitation, and/or mistreatment has occurred, the extent and cause; and 6. Providing complete and thorough documentation of the investigation. *Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility staff failed to provide the necessary services to ensure one Resident (#33) out of a total sample of 27 Residents, was able to effectively communicate his/her needs. Finding include: Resident #33 was admitted to the facility in May 2020 with diagnoses including Alzheimer's, major depressive disorder, and hearing loss. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #33 has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #33 is dependent on staff for all functional tasks. On 1/10/24 at 7:52 A.M., Resident #33 was observed sitting up in his/her bed, awake, television on. Resident #33 said I can't hear you I am deaf to the surveyor when attempting to communicate. Resident #33 said I have hearing aids, but no one here knows what happened to them. There was no communication board, writing pad, signs, or pictures 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 observation, record review and interview, the facility failed to provide adequate supervision for one Resident (#105) out of a total of 27 sampled Residents. Subsequently, Resident #105, who was displaying increased symptoms of agitation, wandering and exit seeking, exited the building and was found outside at approximately 10:00 P.M., on 12/4/23 by CNA #1. Findings include: Review of the facility's Elopements and Wandering Residents policy, dated May 2022 indicated: *This facility ensures that Residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. *The facility is equipped with door locks/alarms to help avoid elopements. *Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. *Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interview the facility failed to identify and address a significant weight loss in a timely manner for one Resident (#1) out of a total sample of 27 residents. Findings include: Review of the facility's Weights policy, dated May 2022 and revised February 2023 indicated: *Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. *The facility will utilize a systemic approach to optimize a residence nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors, evaluating, and analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. *Interventions will be identified implemented and monitored and modified as appropriate consistent with the residents assessed needs choices preferences goals…

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, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#205), out of a total sample of 27 residents. Specifically, for Resident #205 the facility failed to obtain arm circumference and PICC line measurements upon admission and weekly as ordered. Findings include: Resident #205 was admitted to the facility in January 2024 with diagnoses including infection and inflammatory reaction due to internal joint prosthesis, displaced fracture of base of neck of right femur, and acute kidney failure. Review of Resident #205's most Minimum Data Set assessment dated , 1/3/24, indicated he/she scored a 14 out of a possible score of 15 on the Brief Interview for Mental Status Exam (BIMS indicating the Resident is cognitively intact. Review of Resident #205's active physician orders indicated Change PICC/midline catheter dressing once weekly. Measure circumference of upper arm of affected arm with each dressing change. Measure…

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. Specifically, the facility failed to change and clean the oxygen filters for one Resident (#207) out of a total sample 27 residents. Findings include: Review of the facility policy Oxygen Administration, dated 5/2023, indicated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Resident #207 was admitted to the facility in January 2023 with diagnoses including asthma, COPD, acute respiratory failure. Review of Resident #207's most recent Minimum Data Set assessment dated , 1/4/24 indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating the Resident was cognitively intact. On 1/9/24 at 8:16 A.M. and 1:44 P.M., the surveyor observed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews and policy review the facility failed to ensure 1. medication carts were locked on 2 of 4 nursing units and 2. failed to ensure medications were stored appropriately in one Resident room. Findings include: Review of the facility policy Medication Storage, dated 2/2023, indicated All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms.) During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. On 1/9/24 at 7:52 A.M., the surveyor observed both medication carts in the hallway unsupervised and unlocked on the D Unit. No nurse was present at the medication carts. During an interview on 1/9/24 at 7:52 A.M., the Staff Development Coordinator (SDC) said that both medication carts are unlocked and should be locked because the nurses are not present at either of the medication carts. On 1/11/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure medications were stored securely on 3 of 4 units including for 1 Resident (#29) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Medication Storage and dated revised 5/31/22, indicated the following: 1. only authorized personnel will have access to the keys to locked compartments. 2. during medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. 1. On 12/06/22, at 4:00 P.M., the surveyor entered the C unit and observed Staff Developer (SD) #1 and #2 cleaning inside the medication cart, removing medication and placing them in a clear plastic bag. The surveyor then observed SD #2 to take the clear plastic bag of medications down the hall and out of sight During an interview on 12/06/22, at 4:00 P.M., SD #1 said that she and SD #2 were cleaning out the medication cart and she was cleaning up a…

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

Based on observation and interview the facility failed to provide a dignified existence for 1 Resident (#70), during a vomiting episode, out of a total sample of 25 residents. Findings include: Review of the facility policy titled Promoting Resident Dignity and dated 6/1/22, indicated the following: 1. Maintain resident privacy. 2. All staff members who are involved in providing care to residents are to promote and maintain dignity . Resident #70 was admitted to the facility in November 2022 with diagnoses including schizophrenia, fractured vertebra and cognitive communication deficit. On 12/06/22, at 8:45 A.M., the surveyor observed Resident #70 sitting on the side of the bed vomiting into a bucket. Occupational Therapist Assistant (OTA) #1 was with the Resident. The surveyor was able to see the Resident from the hallway, the door and the draw curtain remained open. During an interview on 12/06/22, at 12:24 P.M. Unit Manager #1 said it is the expectation that staff provide privacy by pulling the draw curtain or shutting the door when someone is vomiting. She said that it was OTA #1…

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 professional standards of medication administration were adhered to, for one Resident (#63), out of a total 25 sampled residents. Findings include: Review of the American Association of Poison Control Centers guidelines indicated that isopropyl alcohol is a poisonous substance and is not to be ingested. Resident #63 was admitted to the facility in April 2018 with diagnoses including Alzheimer's disease, depression and heart disease. Review of the facility policy titled Medication Administration and dated 6/1/22, indicated that medications are administered in accordance with professional standards of practice . Review of the medical record indicated a doctor's order for Anbesol maximum strength liquid 20% 1 application dental two times a day for left lower toothache for 7 days. During a medication pass on 12/06/22, at 4:39 P.M., on the A unit, the surveyor observed Nurse #3 remove an alcohol prep pad (impregnated with 70% isopropyl alcohol) from the medication cart, open the pad and pour several drops 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 record review, interview and facility policy review, the facility failed to ensure that oxygen was being administered as ordered by the physician for 1 Resident (#30) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Oxygen Administration, dated 6/1/22, indicated the following: - Oxygen is administered under the orders of a physician. - The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessments and orders, such as, but not limited to: - Equipment setting for the prescribed flow rates. Resident #30 was admitted to the facility in May 2019 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE] revealed that he/she had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, which indicated that Resident #30 had moderate cognitive impairment. The MDS also indicates that Resident #30 was dependent on staff for…

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

Based on observation and interview the facility failed to implement infection prevention and control practices during medication pass on 1 of 3 units observed. Findings include: Review of the facility policy titled Infection Prevention and Control Program, dated 6/1/22, indicated that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility policy titled Cleaning and Disinfection of Resident-Care Equipment and dated 5/24/22, indicated the following: 1. Reusable multi-resident items are items that may be used multiple times for multiple residents. Examples include . blood pressure cuffs 2. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. During medication pass on 12/07/22, at 8:44 A.M., the surveyor observed Nurse #4 obtain a blood pressure/oximeter stand from in front of dining room. Nurse #4 then walked to the end of the hall into a…

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