Serenity Hill Nursing Center

Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#22 and #34), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Following an interview with the facility's Maintenance Director, it was determined that 38 of 38 beds in use in the facility were affected. Findings include: Review of the facility's policy titled Proper Use of Siderails, revised 2/1/2018, indicated but was not limited to the following: - Manufacturer instructions for the operation of side rails will be adhered to. - When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional 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 a resident group meeting, interviews, and record reviews, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group. Findings include: Review of the facility's policy titled Resident Council, dated 1/2025, indicated but was not limited to the following: - [Facility name] supports a resident council. - Resident council meets on a monthly basis. Those residents who cannot or do not want to attend a council meeting may submit their concerns to a council member for discussion at the meeting. - The Activities Director is there to take the meeting minutes. Review of the facility's policy titled Grievance, revised 12/2021, indicated but was not limited to: - It is the policy of [Facility name] to provide a communication system whereby residents and/or their significant others or representative, can voice concerns about the quality of care received at the facility. - Residents have the right to voice complaints and make suggestions 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 interviews and observations, the facility failed to ensure grievance forms were available in resident care and public areas, so residents and/or visitors were able to access forms without requesting staff assistance. Findings include: Review of the facility's policy titled Grievance, revised 12/2021, indicated but was not limited to: - It is the policy of [Facility Name] to provide a communication system whereby residents and/or their significant others or representative, can voice concerns about the quality of care received at the facility. - Residents have the right to voice complaints and make suggestions for change without the fear of reprisal, discrimination, coercion or unreasonable interruption of care, treatment and services. - All grievances are to be submitted to the Administrator, whose office is located in the Business Office. - Upon notification of a resident grievance, information sufficient to identify the individual registering the concern, the name of the resident (if not the individual submitting the information), date of receipt, nature of the concern,…

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

Based on observations, interviews, and records reviewed, for six Residents (#10, #15, #8, #29, #12, and #37), of 13 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed, consistently implemented, and revised as needed. Specifically, the facility failed: 1. For Resident #10, a. to develop and implement a care plan intervention after he/she sustained a fall, and b. to implement the Resident's falls care plan for a floor mat while in bed at all times; 2. For Resident #15, a. to identify non-pharmacological interventions for the use of an antipsychotic medication; and, b. to develop a comprehensive care plan related to hospice services; 3. For Resident #8, to develop a comprehensive care plan related to anticoagulation use; 4. For Resident #29, to develop a comprehensive care plan related to bladder preferences; 5. For Resident #12, to develop a comprehensive care plan to address the Resident's diagnosis of epilepsy (a brain disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the…

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

Based on observation, record review, and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for four Residents (#12, #22, #37, and #15), out of a total sample of 13 residents . Specifically, the facility failed to review and revise the care plan after comprehensive, significant change, and quarterly assessments were completed to reflect the current status of the Residents. Findings include: Review of the facility's policy titled Comprehensive Care Plan, last revised 1/1/20, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The Interdisciplinary Team (IDT) must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, 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, interviews, and records reviewed, for three Residents (#10, #22, and #34), of 13 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #10, to ensure a physician's order was obtained prior to sending him/her to the hospital; 2. For Resident #22, to ensure a physician's order for the use of an air mattress, including settings, was obtained prior to its use; and 3. For Resident #34, to ensure a physician's order for the use of an air mattress, including settings, was obtained prior to its use. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated…

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

Based on record review and interview, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for two Residents (#29 and #22), out of a total sample of 13 residents. Specifically, the facility failed to assess and implement care plan interventions for: 1. Resident #29 with a history of a traumatic and violent event; and 2. Resident #22 with a history of traumatic events. Findings include: Review of the facility's policy titled PTSD (Trauma), revised 7/2020, indicated but was not limited to the following: - This policy is designed to ensure that residents with actual or suspected Post-Traumatic Stress Disorder (PTSD) received appropriate screening, diagnosis, care planning and treatment in accordance with CMS regulations and clinical best practices. - PTSD is a recognized mental health condition that may affect residents' quality of life, safety, and functional abilities. - All new residents shall be screened for history of trauma or PTSD as part of the admission assessment by nursing and/or social…

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 provide the appropriate treatment and services for one Resident (#29), with a history of a traumatic and violent life event, out of a total sample of 13 residents. Specifically, the facility failed to make a referral to Behavioral Health Services upon admission resulting in a 46-day delay of services. Findings include: Review of the facility's policy titled PTSD (Trauma), revised 7/2020, indicated but was not limited to the following: - This policy is designed to ensure that residents with actual or suspected Post-Traumatic Stress Disorder (PTSD) received appropriate screening, diagnosis, care planning and treatment in accordance with CMS regulations and clinical best practices. - PTSD is a recognized mental health condition that may affect residents' quality of life, safety, and functional abilities. - All new residents shall be screened for history of trauma or PTSD as part of the admission assessment by nursing and/or social services. - Veterans and individuals with a known psychiatric history shall receive further…

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 document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections while the facility was experiencing a Group A streptococcal (GAS - bacteria that can cause various infections, ranging from mild sore throat to severe invasive diseases) outbreak. Specifically, the facility failed to: 1. Ensure staff utilized appropriate personal protective equipment (PPE) when entering in and out of resident rooms who were on transmission-based precautions for GAS; 2. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility; and 3. Ensure staff performed proper hand hygiene with glove use during a dressing change for a Resident (#10). Findings include: 1. During an interview on 4/25/25 at 7:27 A.M., the Director of Nursing (DON) said she was also the Infection Preventionist (IP). She said she was contacted 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.

Based on document review and interview, the facility failed to provide education and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Staff members out of a total sample of five staff reviewed for immunizations. Findings include: Review of the facility's policy titled COVID-19 Personnel vaccination requirement, dated as revised 4/1/25, indicated but was not limited to the following: - it is the policy of [Facility name] that all staff members are up to date with vaccine doses of COVID-19 as recommended by the CDC. Review of the CDC guidance titled Stay Up to Date with COVID-19 Vaccines, revised 1/7/25, indicated but was not limited to the following: - Getting the 2024-2025 COVID-19 vaccine is important because: protection from the COVID-19 vaccine decreases with time; immunity after COVID-19 infection decreases with time; COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. - Everyone ages 6 months and older should get the 2024-2025 COVID-19 vaccine. This includes people who…

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 three Residents (#8, #2, #10), out of a total sample of 13 residents, were treated with respect and dignity. Specifically, the facility failed to ensure: 1. Resident #8's Foley catheter (tube inserted into the bladder to drain urine) drainage bag was covered with a privacy shield and/or positioned away from the doorway; 2. Resident #2's catheter drainage bag was consistently placed in a privacy bag; and 3. Resident #10 was provided a dignified dining experience. Findings include: Review of the facility's policy titled Dignity, revised 9/2020, indicated but was not limited to: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. - Residents shall be treated with dignity and respect at all times. - Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. - Demeaning practices and standards of care that compromise dignity are…

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 document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#15 and #37), out of a total sample of 13 residents. Specifically, the facility failed: 1. For Resident #15, to ensure October 2024 consultant pharmacist recommendations for nursing to perform an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) were acted upon timely; and 2. For Resident #37, to ensure October 2024 consultant pharmacist recommendation for nursing to perform an AIMS assessment was acted upon timely. Findings include: Review of the facility's policy titled Drug Regimen Review, effective date 1/1/2001, indicated but was not limited to: - Drug Regimen Review consists of a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of 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 record review and interview, the facility failed to ensure for two Residents (#37 and #15), out of a total sample of 13 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure: 1. For Resident #37, that targeted behaviors and signs and symptoms of potential adverse consequences were monitored for the use of the antipsychotic medication Seroquel; and 2. For Resident #15, to ensure a rationale for use of Seroquel was documented and a gradual dose reduction (GDR) was attempted, unless documented by the prescriber as clinically contraindicated in the medical record. Findings include: Review of the facility's policy titled Antipsychotic Medication, last revised 9/17/20, indicated but was not limited to: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. -The attending physician will identify, evaluate…

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

Based on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment, in one of one kitchenette. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the Unit Kitchen Procedure provided by the facility indicated but was not limited to: -Expired, undated, and uncovered items should be discarded. Shelves should 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.

Based on interview, record review, and document review, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols in accordance with the facility's antibiotic stewardship program for two Residents (#1 and #2), out of a total sample of 13 residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, revised 9/17/20, indicated but was not limited to the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. -As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. -The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations…

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 document review and interview, the facility failed to ensure two Residents (#34 and #27), out of a total sample of five residents reviewed for immunizations, was screened for eligibility to receive the recommended pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and was offered and administered (if applicable) the vaccine in a timely manner. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, dated as revised 9/17/20, indicated but was not limited to the following: - all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections - prior to admission residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the series within 30 days of admission to the facility unless medically contraindicated or the resident had already been vaccinated - assessments of pneumococcal vaccination status…

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 review of the facility's licensed nurse staff schedules, employee punch cards, and interviews, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to provide at least eight consecutive hours of RN services in the facility over a 24-hour period for 13 days between 3/30/24 and 5/12/24, when no nurse staffing waivers were in place. Findings include: During an interview on 5/8/24 at 8:54 A.M., the Administrator said the facility had no Nurse staffing waivers. Review of the as worked Nursing Staff Schedule provided by the facility, dated 3/29/24 through 5/14/24, included no evidence an RN worked at least eight consecutive hours at the facility on: -3/30/24 -4/6/24 -4/13/24 -4/14/24 -4/20/24 -4/27/24 -4/28/24 -5/3/24 -5/4/24 -5/5/24 -5/10/24 -5/11/24 -5/12/24 During interviews on 5/14/24 at 8:55 A.M., 2:20 P.M., and 2:34 P.M., the Director of Nursing (DON) and surveyor reviewed the as worked nursing schedules, and staff and agency nurse punch cards from 3/29/24 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 observations, interviews, and records reviewed, for three Residents (#24, #1, and #23), of 12 sampled residents, the facility failed to maintain professional standards of practice. Specifically, the facility failed to: 1. For Resident #24, ensure weekly skin risk assessments were conducted per facility policy and physician's orders; 2. For Resident #26, implement Wound Consultant recommendations; and 3. For Resident #23, to initiate an order for Remeron (antidepressant). Findings include: 1. Review of the facility's policy titled Prevention of Pressure Ulcers/ Injuries and Skin Check / Integrity, dated as revised 9/17/20, indicated but was not limited to: -The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. -Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon and changes in condition. Review of the facility's policy titled Pressure Ulcers/Injury Risk Assessment, dated as…

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, for four Residents (#20, #26, #31, and #1), of 12 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities): 1. For Resident #20, who has an indwelling suprapubic urinary catheter, putting him/her at increased risk for infection; 2. For Resident #26, who has a chronic wound and indwelling urinary catheter, putting him/her at increased risk for infection; 3. For Resident #31, who has a chronic wound, putting him/her at increased risk for infection; and 4. For Resident #1, who has a chronic wound, putting him/her at increased risk for infection. Findings include:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, for five Residents (#15, #18, #20, #26, and #33), of six residents reviewed, the facility failed to provide the pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy. Specifically, for Residents #15, #18, #20, #26, and #33, the facility failed to ensure that pneumococcal vaccinations were administered after consent was obtained. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, last revised 9/17/20, indicated but was not limited to: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series -Administration of the pneumococcal vaccines or revaccinations are made in accordance with current Centers for Disease…

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

Based on observations, interviews, and records reviewed, for one Resident (#1), out of 12 sampled residents, the facility failed to notify Resident #1's Responsible Party of a potential need to alter treatment. Specifically, the facility failed to notify Resident #1's Guardian about the start of a new medication and failed to obtain a Guardian Consent. Findings include: Review of the facility's policy titled Psychotropic Medication Use Consent for Psychotropic Medication, last revised 1/1/21, indicated but was not limited to: -Policy -Consent for Psychotropic Medication must be obtained by Healthcare Proxy/Guardian -Procedure -Psychotropic medications include drugs from the following classes: hypnotics, antipyretics, long and short-acting Benzedrine, sedatives/anxiolytics and antidepressants. Resident #1 was admitted to the facility in November 2016 with diagnoses including dementia and unspecified severe protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 3/30/24, indicated Resident #1 had a severe cognitive impairment as evidenced by a Brief…

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 records reviewed, for three Residents (#11, #23, and #139), out of 12 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #11, to develop a care plan for the use of psychotropic medication including antipsychotic and antidepressant medications; and 2. For Resident #23, to develop a care plan for the use of psychotropic medication including antipsychotic, antianxiety, and antidepressant medications; and 3. For Resident #139, to develop a care plan for the use of psychotropic medication including antipsychotic and antidepressant medications. Findings include: Review of the facility's policy titled Comprehensive Careplan [sic], last revised 1/1/20, indicated but was not limited to: - Policy Statement- a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and financial needs is developed and implemented for 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 interviews, record review, and policy review, the facility failed to ensure for one Resident (#1), out of a total sample of 12 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure an antibiotic was administered for the appropriate duration. Findings include: Resident #1 was admitted to the facility in November 2016 with diagnoses including dementia and pressure ulcer of sacral (a bone at the end of the spine) region. Review of the Minimum Data Set (MDS) assessment, dated 3/30/24, indicated Resident #1 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Review of Resident #1's May Physician's Orders indicated but was not limited to: - Erythromycin (antibiotic) Ophthalmic (eye) Ointment 5 milligrams (mg)/gram (gm). Instill 1 ribbon in right eye two times daily for 7 days (4/26/24) Review of Resident #1's April and May 2024 Medication Administration Record (MAR) indicated Resident #1 received the Erythromycin Ophthalmic Ointment for a total of 11 days (4…

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, policy review, and interviews, for two Residents (#139 and #11), of 12 sampled residents, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed: 1. For Resident #139, -to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed, and -to ensure an as needed antipsychotic medication was limited to 14 days as required; and 2. For Resident #11, to ensure an AIMS assessment was completed. Findings include: Review of the National Library of Medicine (NLM) article titled Increasing Abnormal Involuntary Movement Scale (AIMS) Screening for Tardive Dyskinesia in an Outpatient Psychiatry Clinic: A Resident-Led Outpatient Lean Six Sigma Initiative, dated 5/15/23, indicated but was not limited to: - The AIMS is administered every three to six months to monitor the…

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

Based on observation and staff interviews, the facility failed to ensure for one Resident (#26), out of a total sample of 12 residents, that all medications/treatments were properly labeled, stored, and secured to ensure safe administration. Findings include: Review of the facility's policy Storage of Medications, last revised 9/17/20, included but was not limited to: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Resident #26 was admitted to the facility in December 2022 and had a sacral pressure wound. On 5/8/24 at 9:42 A.M., the surveyor observed a bottle of Daikin solution (a strong antiseptic solution that contains bleach used in wound care), with no prescription label affixed to it, on Resident #26's bedside table. On 5/13/24 at 8:13 A.M., the surveyor observed a bottle of Daikin solution with no prescription label affixed to it, on Resident #26's bedside table. On 5/13/24 at 9:40 A.M., the surveyor and Nurse #1 entered Resident #26's room. Nurse #1 said that she is pretty sure the wound physician left the bottle of Daikin 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.

Based on records reviewed, policy review, and interviews, for one Resident (#1), out of 12 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, for Resident #1, the facility failed to ensure his/her skin checks were documented in the medical record as ordered by the physician. Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries & Skin Check/Integrity, last revised 3/17/20, indicated but was not limited to: -Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors/ -Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition.…

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.