Future Care Northpoint

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists and agreed upon by the medical director in a timely manner. This was evident for 1 (Resident #87) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the residents' medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Lorazepam, also known by the brand name Ativan, is a psychotropic medication and classified as a Schedule IV controlled substance. It is commonly used to treat anxiety disorders and is also used for short-term relief of the symptoms 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 interviews with residents, review of the medical record, and interviews with facility staff, it was determined that the facility staff failed to ensure a resident received routine dental services in a timely manner. This was evident for 1 (#20) out of 47 residents reviewed during the facility's recertification survey. The findings include: On 6/16/25 at 9:25 AM in an interview with Resident #20 s/he stated s/he had bad teeth and needed to see the dentist. On 6/18/25 at 8:06 AM review of Resident #20's medical record revealed s/he was admitted to the facility on [DATE]. Further review of the medical record revealed 3 HealthDrive (facility's dental provider) notes from the Registered Dental Hygienist (RDH #37) dated 5/3/24, 11/5/24, and 5/7/25. The 5/3/24 dental note from RDH #37 stated, Periodic oral exam 10/16/24 and Annual exam 4/16/25; however, there was no documentation that the resident had been seen by a dentist for his/her periodic oral exam or annual exam. The 11/5/24 dental note from RDH #37…

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 of the facility's kitchen, review of kitchen records, and interview of staff, it was determined that the facility failed to prevent ice from building up in the walk-in freezer and in the refrigerator. This was evident for two refrigerators/freezers observed during the survey. The findings include: On 06/16/25 at 07:39 AM, Surveyor's initial observation of the cold storage/Freezer room in the kitchen, accompanied by the dietary staff, # 41 revealed that Ice was built on the floor and Ice particles were covering almost 75% of the freezer room Ceiling. Staff #41 was not aware of the preventive maintenance schedule for the freezer room. On 06/16/25 at 12:40 PM, the Surveyor observed the refrigerator/freezer in the second-floor nourishment room, to store residents' food, brought from outside. More than an inch of ice was built around the freezer. The surveyor also noted that the residents' snacks were placed in the refrigerator. On 06/25/25 at 11:45 AM, findings were reviewed with Dietary staff # 41 and with the Nursing home administrator. On 06/25/25 at 2:15 pm,…

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 complaints, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #344, #340) of 15 complaints reviewed during the survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) A review of Resident #344's closed medical record on 06/24/25 at 1 PM revealed 2 physician certifications of incapacity. The first physician certification of incapacity was regarding Resident #344. It was dated and signed on 09/06/2022 at 12 PM by Resident #344's physician due to dementia. The second certificate of incapacity was regarding a totally different Resident. It was dated 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 observations and interviews with staff, it was determined the facility failed to ensure: 1.) Staff wore the appropriate personal protective equipment (PPE) when administering medications to residents on droplet precautions and 2.) Residents' medical equipment was maintained in a sanitary manner. This was found to be evident for 6 of 32 residents observed during the facility's annual Medicare/Medicaid survey (Residents #169, #170, #171, and #53). The findings include: 1. A medication administration observation was done on 7/1/22 at 9:40 AM and the following concerns were identified: a. At 9:40 AM of Staff #16, a Registered Nurse (RN) administered medications to Resident #169. There was a sign posted on the door that read Droplet and Contact Precautions with instructions on PPE ( eye protection) is to be worn before entering the room. Staff #16 wore glasses and did not put on goggles or a face shield before entering the resident's room carrying the resident's medications inside small medication cups. Staff #16 placed the medication onto the resident bedside table which…

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 medical record review and staff interviews, the facility failed to accommodate the needs of residents by failing to ensure residents received preferred incontinent brief sizes (Residents #45 and #66). The findings include: 1. On 6/27/22 at 9:00 am, during initial observation rounds, the surveyor interviewed Resident #45 regarding the resident's preferences. Resident #45 stated that the facility runs out of his/her preferred incontinent brief size regularly. Facility staff will use a smaller incontinent brief and Resident #45 stated that the smaller incontinent brief size causes excessive chafing. On 6/29/22 at 8:26 am, an interview with Clinical Care Coordinator #8 revealed the facility's supply order process. Clinical Care Coordinator #8 stated that when facility staff observes a low number of needed supplies, facility staff will tell the unit manager. The unit manager will check the main unit supply closet for the item. If the item isn't available for restocking, the unit manager will contact Supply…

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 and interviews it was determined the facility failed to provide a homelike environment as evidenced by residents having scrapped paint and drywall and broken equipment in residents' rooms. This was evident for 3 of 5 residents assessed for a clean and comfortable homelike environment (#26, #34 & #87). The finding includes: On 6/28/2022 at 10:59 a.m. while performing observation rounds on the second floor, the surveyor observed: an exposed wire on the floor at the foot of Resident #26's bed, scraped drywall, and paint on the wall behind the bed, and a pillow stuck under the resident's bed. On 6/28/2022 at 11:44 a.m. the surveyor observed scraped paint on the wall behind Resident #87 bed. On 6/28/2022 at 11:55 a.m. the surveyor observed a missing dresser drawer on the left side of Resident #34's dresser. On 7/5/2022 at 12:05 p.m. during an interview with the Director of Maintenance #13 regarding the regular maintenance in the facility. He/she stated the facility utilize the TELS electronic system for maintenance request and they have daily and monthly logs.…

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 initiate a care plan for a resident who had a significant weight loss. This was evident in 1(#107) of 3 resident records reviewed for care plan timing. The findings include: A review of Resident # 107 electronic medical record on 06/29/22 at 11:53 am revealed on 05/09/22 the resident's weight was documented as 199 pounds. On 06/22/22 the resident's weight was documented as 188 pounds which was a 5.53% weight loss. On 07/05/22 at 12:05 pm during an interview with Staff #11, he/she was asked what type of interventions were put in place for the resident's weight loss? He/she made the surveyor aware the resident's notes were reviewed and made aware of the resident's weight loss. He/she reported not putting any interventions in place or reducing food from his/her end. Staff#11 was unable to provide documentation that a care plan was initiated to address the resident's weight loss.

Based on record review and interview it was determined the facility staff failed to carry out physician's orders for treatment administration. This was evident in 1 in 3 resident records reviewed for timely treatment administration (Resident #26). The findings include: On 07/01/22 at 9:30 am a review of Resident #26's treatment administration record (TAR) revealed multiple orders were not initialed as completed in the electronic medical record: On 01/14/21 at 7:00 am Resident #26 was ordered to have the sacral (lower back and tailbone) wound cleaned with an antimicrobial solution every day and evening shift. The treatment was not initialed as provided on the day shift on 04/02/22. On 02/11/21 at 3:00 pm Resident #26 received orders to have an antimicrobial solution and skin prep the area surrounding the sacral wound and water-insoluble dressing to the wound bed and to cover the wound with a foam dressing. The treatment was not signed off as completed on 04/02/22 on the day shift and 06/23/22 on the evening shift. On 03/25/22 at 7:00 am Resident #26 was ordered a topical antibiotic…

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, a medical record review, and an interview with the staff, the facility's staff failed to consistently apply interventions to prevent fall-related injury for a resident that is a known fall risk (Resident #54). This was evident for 1 out of 1 resident reviewed for accidents during an annual survey. The findings include: On 6/27/22 at 9:30 am Resident #54 was observed unattended and in bed. There were no fall mats on the floor near the resident's bed. On 6/28/22 at 7:13 am, a review of Resident #54's medical record revealed that the resident had a fall incident on 6/6/22. A review of the facility's fall investigation dated, 6/12/22, revealed that the resident was recommended to have fall mats on the right side of the bed. Resident #54's care plan was changed to include fall mats on the right side of the resident's bed to assist in preventing injury from falls. On 6/28/22 at 10:00 am, Resident #54 was observed in bed. Staff was not present in the resident's room. There were no fall mats on the floor near the resident's bed. An interview with the Director 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.

Based on record review and interviews with staff, the facility failed to address the nutritional needs of a resident who had a significant weight loss. This was evident in 1 of 2 resident records reviewed for nutritional assessments (Resident #107). The findings include: A review of Resident #107 ' s electronic medical record on 06/29/22 at 11:53 am revealed on 05/09/22 the resident's weight was documented as 199 pounds. On 06/22/22 the resident's weight was documented as 188 pounds. This is a 5.53% decrease in the resident ' s weight. On 07/05/22 at 12:03 pm, a review of Resident #107 ' s electronic medical record revealed a weight change note dated, 06/24/22. The note read, Value: 188.0 pounds Vital Date: 2022-06-22 change from the last weight of 5.5%. The resident will have a re-weight. Snack daily at bedtime. Referral to a dietician for the addition of supplements if warranted. Further review of the resident ' s record did not reveal evidence of the facility completing a nutritional assessment on Resident #107 after they documented a decline in the resident ' s weight.…

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, medical record review, and interviews with facility staff it was determined the facility failed to ensure a medication rate of less than 5% as evidenced by 2 observed errors out of 27 opportunities for error resulting in an error rate of 7.41 %. This was found to be evident for 1 of 4 residents observed during medication administration observation conducted during the facility's annual Medicare/Medicaid survey. The findings include: A medication administration observation was conducted on 7/5/22 at 9:40 AM with Staff #16, a Registered Nurse (RN). Staff #16 prepared and administered medications for Resident #169. While preparing the resident's medications, Staff #16 observed that the following medications were not in the medication cart: 1. Incruse Ellipta Aerosol Powder Breath Activated 62.5 mcg/inhalation (umeclidinium Bromide- a class of medication called anticholinergics 1 puff inhale orally one time a day for COPD (a type of lung disease that makes it hard to breathe). 2. Advair Diskus Aerosol (Powder Breath Activated 500-50 MCG/Act) 1 puff inhale orally…

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 and interviews with facility staff it was determined the facility failed to adhere to the policy for storage of controlled substances by ensuring that the narcotic keys remain with the assigned nurse. This was found to be evident during a medication administration observation during the facility's annual Medicare/Medicaid survey. Findings include: While conducting a medication administration observation for Resident #170 on 7/5/22 with Staff 16, another Staff #17, a Licensed Practical Nurse (LPN) approached Staff #16 and asked her for the medication keys. Staff #16 gave the medication keys to Staff #17. She then went to the medication cart that was approximately 15-20 feet away and diagonally across from where we were standing and opened the lock on the medication cart and then unlocked the narcotic medication box and retrieved medications from the narcotic medication box. After retrieving the medications, Staff #17 brought the keys back to Staff #16. They did not do a medication narcotic count. Staff #16 was asked to explain why she gave the narcotic keys 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 observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, 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 06/27/22 at 12:00 PM a tour of the facility's main kitchen was conducted with the Food Service Manager. The following was observations were made during the tour: 1. The kitchen walls were missing random baseboard tiles and had holes in the baseboard where the tiles used to be. 2. The surveyor observed a full cart of trays with slices of cake in the refrigerator uncovered. 3. In the refrigerator surveyor identified Caesar salad dressing open with a date of 3/9/22 and sweet relish open with a date of 3/9/22. The Dietary Manager confirmed that the date of 3/9/22 was when the product was open. 4. The freezer had a build-up of ice on the fan, ceiling, and shelving units. These deficiencies were confirmed with the food service…

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 failed to maintain medical records in accordance with professional standards. This was evident in 2 of 7 resident records reviewed for documentation (#26 & #107). The finds include: On 07/01/22 at 11:25 am a review of Resident #26's treatment administration record (TAR) revealed on 03/04/21 the resident was ordered Calazime skin protectant paste to be applied topically to the sacrum and perineal areas every shift and as needed (PRN). In May of 2022, 20 of 31 days the nurses who were assigned to care for the resident documented NA (not applicable) on the TAR where the site of the cream was ordered to be applied. The chart Codes/Follow-Up Codes listed at the bottom of the TAR does not include not applicable (NA) in the legend. During an interview with the Director of Nursing (DON) Staff 2, she was unable to tell the surveyor the meaning of NA in the medical record. On 07/01/22 at 1:43 pm during an interview with RN #5, he/she stated the order says where to place the skin protectant. When asked why he/she…

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 urinary catheter care to Resident #13 as ordered. This is evident for 1 of 66 residents selected for review during the annual survey process. The findings include: Medical record review revealed Resident #13 was seen by the urologist on 7/7/17. Urologist are physicians who specialize in the genitourinary tract-the kidneys, urinary bladder, adrenal glands, urethra and male reproductive organs-and male fertility. Urologists are also trained in the surgical and medical treatment of diseases that affect these organs. It was noted at the time Resident #13 had a suprapubic catheter due to chronic urinary retention. A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the tummy, a few inches below the navel (tummy button). Urinary retention is an inability to completely empty the bladder. It was noted on 7/7/17 the urologist made the recommendations: catheter drainage approximately 50 cc (1 ½ ounce)…

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 staff interview it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection. This was evident for 6 of 66 residents (#11; #38; #66; #77; #110 & #428) reviewed during the survey process. The findings include: Review of the medical record of Resident #11 and an interview with the unit Manager Staff #2 failed to reveal documentation regarding the care and cleaning of Resident #11's BiPAP machine. BiPAP and CPAP machines are Bilevel Positive Airway Pressure /Continuous Positive Airway Pressure machines which are non-invasive forms of therapy used to treat patients suffering from sleep apnea. Sleep apnea is a serious sleep disorder that occurs when a person's breathing is interrupted during sleep. In an interview with Unit Manager Staff #2 on 10/19/18 at 8:00 AM surveyor asked who is responsible for cleaning BiPAP and CPAP machines, how often they are cleaned and where this information is documented? Staff #2 stated that she didn't know and would have…

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 staff failed to provide resident (#109) with the most dignified existence. This was evident for 1 of 66 residents selected for review during the survey process. The findings include: Based on review of nursing progress notes, resident and staff interviews and it was determined the facility staff failed to provide Resident #109 with the proper equipment to promote a safe, comfortable and dignified environment for his/her shower. In an interview on 10/16/18 at 1:07 PM Resident #109 stated that on Saturday evening when s/he was scheduled to have a shower the available shower chair was too small. S/he told Geriatric Nursing Assistant staff #1 (GNA) that s/he would need a larger chair. GNA Staff #1 stated that she was too busy (listing all the things she had to do) and could not go get another chair at that time. Resident #109 stated that s/he didn't want to be a nuisance, so s/he decided not to push it any further. Resident #109 stated that s/he sat in the smaller chair and when s/he attempted 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 observation, resident and staff interviews it was determined that the facility staff failed to provide a private space to support residents right to privacy while conducting their monthly resident council meeting. The findings include: This surveyor was invited to attend the Resident Council meeting held on 10/17/18 at 2:00 PM in the second-floor dining room. The Activities Director who was also invited assisted the Resident Council President to conduct the meeting. During the meeting a family visitor entered the dining room uninvited, to purchase snacks from the vending machine. In an interview with the Director of Nursing, The Corporate Nurse and the Activities Director on 10/17/18 at 3:25 PM they were made aware of this concern. the Activities Director stated that going forward she will be posting a sign on the dining room doors to ensure that everyone will be aware that there is a private meeting in progress.

Based on resident and staff interview, it was determined the facility failed to have a resident's personal funds consistently available to the residents on the weekends. This was evident for 1 (Resident #90) of 2 residents reviewed for personal funds during an annual recertification survey. The findings include: Resident #90 was interviewed on 10/16/18 at 10:58 AM and was asked Can you get your money when you need it, including weekends? Resident #90 stated I cannot get any money on the weekends because no one is here. In an interview with the facility Business Office Manager (BOM) on 10/19/18 at 8:59 AM, the BOM stated the facility banking services are closed on the weekends and there is no one here to hand out cash to the residents. The facility must make arrangements to allow all residents access to their personal funds including on the weekends.

Based on resident interview, staff interview, and a review of the personal funds accounts for selected residents it was determined that the facility staff failed to provide an interested family member of a resident's (#72) quarterly statement of their personal funds account. This was true for 1 out of the 2 residents reviewed for this survey task. The findings include: An interview with Resident #72 on 10/19/18 at 12:25 PM revealed that the resident has not received a quarterly statement for the resident's personal funds account. The Business Office Manager was interviewed on 10/19/18 at 12:25 PM. She stated she does not have record of the sister being the Responsible party (RP)/Power of Attorney (POA) for the resident. She shared copies of the quarterly statements and showed that the resident did not sign the paperwork. A review of Resident #72's clinical record revealed that the resident's sister signed the Resident's Agent Financial Agreement with Futurecare Northpoint form. The sister signed on the blank entitled Resident's Authorized Representative. The resident's sister is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical records and staff interview, it was determined that the facility staff failed to implement resident-centered care plan related to 1) a resident's pain management and 2) observing a resident for bruising. This was evident for 2 (Residents #8, #231) of 66 residents reviewed during an annual recertification survey. The findings include. 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. 1) Review of Resident #231's closed medical record on 10/18/18, revealed that the nursing staff had created a care plan on 09/20/18 to address Resident #231's pain related to a disease process. Nursing interventions included: administering analgesia as per physician order, monitor for side effects and effectiveness, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor and document for probable cause of each pain episode and remove or limit 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 medical record review, observation and interview revealed the facility staff failed to provide 1:1 supervision for eating as ordered by the physician for Resident #43. This was evident for 1 of 66 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #43 revealed on 10/12/18 the physician ordered: resident needs 1:1 supervision during meals to prevent aspiration. Pulmonary aspiration is food, stomach acid, or saliva is inhaled into the lungs. You can also aspirate food that travels back up from your stomach to your esophagus. Surveyor observation of the resident on 10/19/18 at 8:05 AM revealed the facility staff delivered Resident #43 breakfast tray and left the room. Further surveyor observation of Resident #43 at 8:10 AM and 8:20 AM revealed the resident in the room, eating breakfast; however, there was no noted facility staff noted in the room to supervise the eating of breakfast. The Director of Nursing was made aware of the same on 10/19/18 at 9:00 AM. Interview with the Director of Nursing on 10/19/18…

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 medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for 2 residents (#91 and #100). This was evident for 2 of 66 residents reviewed in the annual survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Resident #91's chart had a request on 8-3-18 for a nephrology consult. The consult was not in the medical record. Interview with the Director of Nursing on 10-18-18 at 1:00 PM confirmed that the nephrologist examines the residents in the on-site dialysis unit but does not document in the facilities medical records. The nephrologist maintains the visit notes in their office chart. The nephrologist information is not accessible to the facility physicians. 2.…

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.