Future Care Irvington

Number of residents sampled: Number of residents cited: Based on observation and facility staff interview, it was determined that the facility failed to properly label bulk medications with the date that included month, day and year and to properly date multi-dose insulin injectable pens when they are opened. This was evident for 3 of 6 medication carts that were reviewed.The findings include:1. While conducting the Medication Storage and Labelling facility task, it was observed that in 3 of the 6 medication carts that the bulk medication had either an incomplete date indicating when the medication was opened or no date at all. It was also noted that an open insulin pen was not labelled with the date the medication was opened.2. On September 2, 2025, at 9:30 PM spoke with the Director of Nursing (DON), The Regional Clinical Services Manager (#3) and the Administrator and asked them what their expectations for the labelling of bulk medication and other medications when they are opened. The DON stated that they expected the nurse to date any medication with the date it was opened.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, it was determined that the facility failed to provide sugar substitute as specified by the ordered diet. This was found to be evident for 1 (#86) out of 3 residents investigated for food preferences. The findings include:The primary purpose of a Consistent Carbohydrate diet is to manage blood sugar levels in individuals with diabetes or prediabetes. By maintaining a steady intake of carbohydrates, the body can better regulate insulin production and prevent blood sugar spikes or crashes.On 08/29/2025 at 12:29 PM, the surveyor observed Resident #86's lunch tray. Resident #86 stated that the facility served regular sugar instead of sugar substitute on the tray. He/She further stated, I am a diabetic and should not be served regular sugar. The surveyor observed the tray card provided with the meal. It read CCHO (Consistent Carbohydrate), Dysphagia 3, Thin 1350 fluid restriction/day and specified sugar substitute under condiments. At 12:37 PM on 8/29/2025, LPN #18 confirmed that…

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 of dry goods in the kitchen on 5/30/23 at 9:15 AM, and foods stored in the freezer, the facility failed to label four food items in the freezer with the date. This was evident for 8 items in the freezer, pasta, and can goods in the dry storage areas. The findings include: On 5/30/23 at 9:15 AM a tour of the kitchen was conducted with Staff # 1 (kitchen supervisor). The freezer had a bag of cooked chicken that was not dated, opened and unopened french fries not dated, unopened hot dogs not dated and 4 large boxes of cheese cakes not dated. The items were pulled out of freezer and thrown away. In addition the dry storage area had pasta that was not dated and 1 large can of green beens that was dented and other cans of vegatables not dated. These items were pulled from the dry storage area, as well. The refrigerator had a case of strawberries that was delivered 3 days ago that had mold growing on them. The Director of Dietary Services was made aware of these concerns on 6/2/23 at 10:30 AM.

Based on interviews and review of medical records, and resident interviews, it was determined that the facility failed to: 1) update a care plan to reflect the current needs of the resident, and 2) involve the resident in the care planning process. This was evident of 4 (Residents #80, #97, #142 and #148) of 7 residents reviewed for care planning during an annual and complaint survey. The findings include: 1a) On 6/7/23 at 7:51 AM, the surveyor reviewed Resident #80's medical record. The review revealed that Resident #80 had a past medical history of, muscle weakness, unspecified fall, and anemia (low amount of red blood cells). On 6/13/23 at 7:19 AM, the surveyor reviewed the change in condition notes for Resident #80. The review revealed that Resident #80 had documented change of condition related to falls on 5/27/23, 5/30/23 and 6/5/23. Further review of the change of condition note written on 5/27/23 recommended re-educating the Resident regarding unassisted ambulation. On 6/13/23 at 8:16 AM, the surveyor reviewed Resident #80's care plan. An actual fall care plan was initiated…

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 of facility staff it was determined the facility failed to ensure that tube feedings were managed appropriately according to professional standards. This was evident for 4 residents (#142, #156, #12 and #123) out of 4 residents who were observed to have tube feedings in place. The findings include: On [DATE] at 12:36 PM the surveyor observed Resident # 142's tube feed and line to be disconnected from the resident. Upon further observation, the tube feed container hanging in the room next to the resident was found to have a label which included a date of [DATE], and a time of 7:30 PM. The tubing line that was connected to the feed container was observed to have a label dated [DATE] and failed to include an expiration time for the line. During an interview with Staff #37, Charge Nurse, Licensed Practical Nurse, on [DATE] at 12:50 PM, they reported that staff is not expected to fill out everything on the tube feed labels and the facility's policy is that tube…

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, medical record review and interview it was determined that the facility failed to ensure the accuracy of medical orders/records and bathing documentation. This was evident for 1 (Resident #142) out of 2 residents that were reviewed for bowel and bladder, 1 (Resident #24) out of 9 residents reviewed for pressure ulcer/injury, and 1 (Resident #41) out of 1 resident that was reviewed for neglect. The findings include: 1) Upon review of Resident #142's medical orders on 6/5/23 at 9:17 AM, no order was present directing the insertion/placement of a foley catheter (tube that drains urine from the bladder). On 6/5/23 at 9:17 AM a nursing note dated 5/25/23 at 4:12 PM was reviewed which stated the following information: MD (medical doctor) ordered to place foley catheter for wound healing however, the medical order stated the following information: Patient has Foley catheter ,size French 16, for wound healing. Provide catheter care every shift. On 6/5/23 at 11:11 AM the surveyor requested documentation of the order for insertion/placement of Resident #142's foley…

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 review of medical records it was determined that the facility failed to obtain a resident's advanced directives. This was found evident for 1 of 3 residents (Resident #367) reviewed for advanced directives during an annual and complaint survey. Advanced Directive: A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The findings include: On 6/9/23 at 9:03 AM, the surveyor reviewed Resident #367's medical record. The review revealed that Resident #367 was admitted to the facility in late May 2023. The Brief Interview for Mental Status (BIMS) evaluation was done on 5/25/23, and indicated Resident #367 was cognitively intact, with a score of 15. Further review of Resident #367's medical record revealed a progress note written…

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, staff, and resident interviews it was determined that the facility failed to ensure that a resident was free from verbal abuse. This was found to be evident for 1 (Resident # 115) out of 2 residents reviewed for verbal abuse. The findings include: On 6/1/23 at 10:30 AM, the surveyors reviewed the Facility Reported Incident dated 11/7/22, the facility investigation alleged that Geriatric Nursing Assistant (GNA) # 3 had verbally abused Resident # 115. The surveyors reviewed the facility's Abuse and Neglect of Residents Policy on 6/1/23 at 10:44 AM. The definition of verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. On 6/2/23 at 9 AM, the surveyors conducted an interview with the Administrator, Regional Clinical Services Manager (RCSM) and the Director of Nursing (DON) about the verbal abuse investigation. During the interview the RCSM confirmed that GNA # 3 spoke…

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 reviews of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 (Resident # 115 and # 21) out of 4 residents reviewed for abuse. The findings include: On 6/1/23 at 10:44 AM, the surveyors reviewed Facility Reported Incident (FRI) Facility Reported Incident dated 11/7/2022. The report revealed an allegation of verbal abuse. Geriatric Nursing Assistant (GNA) # 3 allegedly verbally abused Resident # 115 when she referred to the resident as a baby when he took off his/her shirt during care. During the interview conducted on 6/2/23 at 9:00 AM, with the Administrator, Regional Clinical Services Manager (RCSM) and the Director of Nursing (DON) about the allegation of Resident/Patient/Client Verbal Abuse for Resident # 115, the surveyors asked why the resident interview question asked, Has any staff member said to you that you act like a baby. The RCSM responded that she was unsure and would defer to Night Supervisor # 5, who had conducted that…

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 reviews and interviews it was determined that the facility failed to provide notification in writing of a resident's transfer to the hospital. This was evident for 2 (# 113 and # 51) out of 2 residents reviewed for transfer notifications. The findings include: On 06/06/23 at 07:49 AM, the progress notes revealed hospitalizations for Resident # 113 on 2/8/23 and 3/21/23. The review of the medical records for Resident # 113 did not reveal written notification to the residents Power of Attorney (POA) in writing of the hospital transfers. During an interview on 06/06/23 at 08:43 AM, the Licensed Practical Nurse (LPN) # 6 stated the facility notified the responsible party and completed the bed hold paperwork when a resident is transferred to the hospital. During an interview with the Regional Care Services Manager (RCSM) on 06/06/23 at 11:46 AM, the RCSM confirmed that the facility did not notify Resident # 113's Power of Attorney, in writing of the hospital transfers. On 06/06/23 at 12:10 PM, a review of the progress notes revealed hospitalizations for Resident # 51 on…

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

Based on observations, interviews, and record reviews, it was determined that the facility failed to: 1) develop comprehensive care plans for, 1) oxygen therapy and 2) behaviors related to psychiatric diagnoses. This was found to be evident for 2 (# 125 and # 157) out of 9 residents reviewed for comprehensive care plans. The findings include: 1) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. During an observation conducted on 05/30/23 at 10:27 AM, the surveyors observed Resident # 125 administered through a nasal cannula. On 06/12/23 at 12:25 PM, a review of Resident # 125's care plan did not reveal a care plan for oxygen therapy. During an interview conducted on 06/13/23 at 01:43 PM, the Regional Clinical Services Manager (RCSM) confirmed Resident # 125 did not have a care plan that addressed the continuous Oxygen therapy. The RCSM provided the surveyors with a care plan that included oxygen therapy. 2) On 6/5/23 at 11:01 AM, a medical record review was conducted. 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 interviews with staff and medical record review it was determined that the facility failed to follow-up on a physician's order. This was found evident of 1 of 6 Residents (Resident #97) reviewed for positioning during an annual and complaint survey. The findings include: On 6/9/23 at 5:39 AM, the surveyor reviewed Resident #97's medical records. The review revealed that Resident #97 was admitted to the facility in late 2022 and had a medical history that included, muscle weakness, difficulty in walking, and complications from surgical and medical care. On 6/9/23 at 11:06 AM, the surveyor interviewed Resident #97. During the interview Resident #97 stated the staff had just brought a wheelchair to his/her room. Resident #97 further explained he/she hadn't had one for a month and he/she recently went to his/her podiatry (study, diagnosis, and treatment of disorders of the foot, and ankle) appointment in a stretcher. On 6/9/23 at 11:50 AM, the surveyor reviewed Resident #97's orders. On 5/3/23 an order was placed requesting a clarification of weight bearing status from 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 medical record review and interview it was determined that the facility failed to ensure interventions were implemented to prevent significant weight loss for a resident who was receiving enteral nutrition (receiving feeding through an artificial tube, not by mouth.). This was evident for 1 out of 5 residents reviewed for nutrition. The findings include: Review of the medical record on 6/5/23 at 10:47 AM for Resident #142 revealed they had been admitted to the facility beginning on 12/22/22. The resident's weight was documented as obtained upon admission (198 lbs.), and upon re-weight on 12/23/22 (199.7 lbs.). Additional weights were obtained on 1/4/23 (12 days later, 201 lbs.) and 2/8/23 (35 days later, 173.8 lbs.), at which point Resident #142 had sustained a significant weight loss of 27.2 lbs. On 6/5/23 at 2:02 PM the surveyor reviewed the facility's policy for obtaining resident weights. According to the facility policy, residents are weighed upon admission, then re-weighed within 1-3 days to ensure the accuracy of the admission weight and are to be placed on weekly…

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, interviews with Resident and staff, review of facility's policy, and of medical records it was determined that the facility failed to follow professional standards for a resident receiving oxygen by: a) administrating oxygen without an order, and b) administrating oxygen at an inaccurate rate. This was found evident of 1 of 7 Residents (Resident #131) reviewed for respiratory care during an annual and complaint survey. The findings include: 1a) On 6/7/23 at 9:49 AM, the surveyor reviewed Resident #131's medical record. The review revealed that Resident #131 was admitted to the facility on [DATE]th 2023 and had a past medical history of chronic respiratory disease, chronic obstructive pulmonary diseases, and heart failure. Further review of the record revealed a nursing admission note dated 4/7/23 stating, Resident #131 was oriented to room and was on 4 Liters of oxygen via Nasal Cannula (a tube that lays outside of nares that delivers oxygen). On 6/7/23 at 10:20 AM, the surveyor reviewed…

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, observations, and interviews it was determined the facility failed to ensure a resident's orders for life sustaining treatment were valid and reviewed by the physician during the facility's admission process. This was evident for 1 out of 3 residents reviewed for advanced directives. The findings include: On 6/1/23 at 1:20 PM the surveyor reviewed the paper chart for Resident #151 and was unable to locate a Maryland Orders for Life Sustaining Treatment (MOLST) form. A Pennsylvania Orders for Life Sustaining Treatment (POLST) form was observed located in the paper chart last dated 3/3/23. Resident #151 was admitted to the facility on [DATE]. The Pennsylvania Life Sustaining Treatment Orders had not been signed by a physician. On 6/1/23 at 1:26 PM the surveyor requested a copy of the POLST form from Staff #43, Unit Manager, Regional Mobile Resource RN, and inquired as to where the MOLST form was located. Surveyor observed the electronic medical admission record which stated See MOLST. 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 interviews with staff and record review it was determined that the facility failed to: 1) comprehensively review behavioral health medications, and 2) contact psychiatric services for a resident who had an order to see a Psychiatrist. This was evident for 2 (Resident # 124 and #157) out of 8 residents reviewed for behavioral health during the annual and complaint survey. The findings include: Gradual Dose Reduction: Is a process of tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or the medication can be discontinued. 1) On 6/8/23 at 10:21 AM, the surveyor reviewed Resident # 124's medical record. The review revealed that Resident #124 had a past medical history of delusional disorders, unspecified dementia, psychotic disturbance, mood disturbance and anxiety. Further review of the medical record revealed Resident #124 had been seen by Certified Registered Nurse Practitioner - Psychiatric Mental Health CRNP-PMH (Staff #41) for a follow-up evaluation on 11/21/22. Staff #41 recommended that 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, interviews, and review of policies and procedures, the facility failed to: 1) ensure that staff performed hand hygiene, and 2) to sanitize equipment between residents. This was evident for 3 (# 28, # 29, and # 38) out of 8 staff observed during the annual and complaint survey. The findings include: Hand Hygiene observations were conducted on 06/13/23 at 08:08 AM during the breakfast service. The surveyors observed Certified Nursing Assistant (CNA) # 28 enter and exit resident room numbers 248, 250, and 242 without performing hand hygiene. 1) During the continued observations, the surveyors interviewed CNA # 28. The CNA confirmed she had not performed hand hygiene. When asked what her understanding of the handwashing policy was, she stated, It is expected that I perform hand hygiene on entry and exit of resident's room. I usually do but I was nervous because you were watching. Hand Hygiene observations were conducted on 06/13/23 at 08:15 AM during the breakfast service. The surveyors…

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 surveyor observation during facility environmental observations it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 2 of 4 resident units. The findings include: On 2/21/2019 during an initial tour of the facility the following observations were made: 1) At 10:28 AM in room [ROOM NUMBER]N 270 a dried, yellow stain was observed on the floor under the bed closest to the window. The bottom panel of the air unit in this room was observed loose and protruding from the unit itself. 2) At 10:47 AM in room [ROOM NUMBER]S 205-1 the bottom panel of the air unit in this room was observed loose and protruding from the unit. The Administrator was made aware of these findings during the exit conference on 2/28/2019.

Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 13 residents (Resident #106 and #113) reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident #106 was conducted on 02/21/19. Review of the physician order written on 8/21/18, revealed that Resident #106 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfer to the resident, resident representative and the ombudsman. 2. A medical record review for Resident #113 was conducted on 02/22/19. Review of the physician order written on 1/4/19, revealed that Resident #113 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation.…

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 medical record and staff interview, it was determined that the facility staff failed to provide the resident or their representative with a written notice of bed-hold policy, at the time of the resident transfer for hospitalization. This was evident for 1 of 13 residents (Resident #106) reviewed for hospitalization during an annual recertification survey. The findings include: Review of the medical record for Resident #106 revealed the resident was transferred to an acute care facility on 8/21/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed-hold policy upon transfer to the hospital. On 02/21/19 01:44 PM, the Administrator confirmed that Resident #106 and the Resident's responsible party did not receive the facility bed-hold policy when Resident #106 was transferred to the hospital.

Based on medical record review it was determined that the facility failed to ensure the Pain Tool 2.1 assessment accurately reflected the resident's status. This was evident for 1 of 5 residents (Resident #144) reviewed for Pain Management. The findings include: The Pain Tool Assessment is used to document a resident's pain within the last 24 hours and includes the location and source of any pain identified. Resident #144's medical record was reviewed on 2/26/19 at 11:25 AM. A review of the resident ' s Pain Tool Assessment form dated 2/1/2019 at 10:50 PM stated that Resident #144 had not experienced pain within the last 24 hours. However, a review of the Pain Level Summary for Resident #144 indicated that on 2/1/19 at 6:21 PM, the resident expressed a pain level value of 8. In addition, the resident ' s Medication Administration Record confirmed the pain level of 8. (Pain Level Values ranging from 7-10 are characterized as severe) The Administrator was made aware of surveyor ' s findings during the exit conference on 2/28/2019.

Based on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident (#45) to reflect accurate and current interventions. This was evident for 1 of 1 residents reviewed for care plans during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and ensures the resident's needs are attended to. The care plan is to be reviewed and revised…

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 review of a closed medical record, it was determined that the facility staff failed to provide a resident with a completed discharge summary before the resident was discharged home. This was evident for 1 of 1 resident (Resident #172) reviewed for discharge during an annual recertification survey. The findings include: Review of Resident #172's closed medical record on 2/26/19 revealed that Resident #172 was discharged home on [DATE]. Resident #172's medical record failed to reveal a completed discharge summary from Resident #172's attending physician that included: A recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. On 02/26/19 09:56 AM, the Administrator confirmed that Resident #172 did not receive a completed discharge summary from Resident #172's attending physician.

Based on observation, medical record review and interview it was determined the facility staff failed to provide grooming and personal hygiene services. This is evident for 1 of 2 residents (Resident #107) selected for review for Activities of Daily Living (ADL) care during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. Observation of Resident #107 on 2/28/19 at 8:45 AM and at 10:30 AM revealed Resident #107 to have elongated fingernails with brown-black matter under them. Interview 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 medical record review and interview, it was determined the facility staff failed to provide care to Residents (#45 and #108) in order to obtain or maintain optimal level of well-being. This was evident for 2 of 61 residents selected for review of quality of care during the annual survey. The findings include: 1. The facility staff failed to administer an antibiotic as ordered by the physician. Medical record review for Resident #45 revealed that on 2/16/19 the physician ordered: Levaquin 500 milligrams via PEG tube 1 time a day for 5 days for urinary tract infection. Levaquin is an antibiotic and is indicated for the treatment of complicated urinary tract infections. Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. This provides nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth PEG tubes are also used for 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 medical record review and interview, it was determined the facility staff failed to ensure a snack was provided to Resident (#151). This was evident for 1 of 8 residents selected for review of nutrition during the annual survey process. The findings include: Review of the medical record review for Resident #151 revealed on 1/25/19 the dietician communicated with the dietary department the following: please send high calorie house snack 2 times a day at 2:00 PM and hour of sleep (ice cream, cookies, magic cup). Review of the medical record on 2/26/19 at 11:00 AM revealed no evidence the facility staff was providing Resident #151 with the high calorie snack as ordered at 2:00 PM and hour of sleep. Although, the amount consumed was not ordered, it is the expectation that dietary supplements and the amount consumed be documented to ensure the resident is taking in the ordered number of calories to increase or maintain caloric intake. Interview with the Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to ensure a snack was provided to Resident #151.

Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and follow the physicians' orders for administration of that pain medication for residents. This was evident for 2 of 4 residents (Resident #68 and #92) selected for review of pain management during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. 1. The facility staff failed to administer pain medication as ordered by the physician. Review of the medical record for Resident #68…

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 employee files and staff interview, it was determined that the facility failed to perform an annual performance review for a Geriatric Nursing Assistant (GNA #8). This was identified for 1 of 2 GNA staff members reviewed during a complaint investigation. The findings include: Review of GNA #8's employee and education records revealed he/she was hired on 8/23/17 and the file did not contain the required performance evaluation for 2018. During an interview with the facility administrator on 2/27/19 at 9:00 AM, the facility administrator confirmed that the facility had not conducted a yearly performance evaluation for GNA #8.

Based on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident (#151). This was evident for 1 of 61 residents selected for review of medication review and 1 of 61 selected for review during the annual survey process. The findings include: Medical record review for Resident #151 revealed the consultant pharmacist was in the facility 8/14/18 and made recommendations about the administration of Lorazepam. Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting. Further record review revealed the physician was in the facility in 8/14/18, 9/7/18, 10/12/18, 11/13/18, 11/27/18, 12/10/18, 1/24/19 and 2/27/19; however, failed to address the consultant pharmacist recommendation at that time. Interview with the Corporate Nurse on 2/28/19 at 1:30 PM confirmed the facility staff failed…

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 interviews of facility staff, it was determined that food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 2/27/2019 at 7:58 AM during a routine tour of the main kitchen, steam table pans were observed wet stacked on the drying rack. Pans and equipment must be thoroughly dried to ensure adequate sanitization. The Food Service Manager was immediately made aware of these findings and removed the wet stacked pans from the drying rack and placed them onto the soiled side of the 3 compartment sink to be washed again.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a resident. This was evident for 1 of 61 residents (Resident #92) selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. 1a. The facility staff failed to document the administration of an antibiotic. Medical record review for Resident #92 revealed on 2/12/19 the physician ordered: Tigecycline 50 milligrams (mgs) intravenously (IV) for pneumonia for 7 days. Must give loading dose of 100 milligrams IV first, then 50 mgs every 12 hours. Tigecycline is an antibiotic for several bacterial infections and is administered intravenously. Intravenously is given directly into the vein for faster absorption of the…

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

Based on observation and interview it was determined that the facility staff failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evident during the initial tour of the nursing units and was found to be evident for 2 out of 2 residents (Resident #46 and #106) reviewed during the investigative portion of the survey. The Findings Include: 1. On 02/21/19 01:30 PM, an observation revealed that outside Resident #46's room was a container that contained items necessary for isolation precautions, gowns, masks, and gloves. Nurse #14 was observed walking into the room and not washing or sanitizing his/her hands and without the proper isolation precautions such as gown and gloves that was required to prevent the transmission of disease and infection. Medical record review on 02/21/19, revealed: Contact Isolation for CRE, which stands for Carbapenem-resistant Enterobacteriaceae, which are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. CRE are an important emerging…

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.