Keswick Multi-Care Center

Based on medical record review and staff interviews, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. As evidenced by not evaluating the effectiveness of treatment orders or timely and accurately assessing wounds. This was evident for 1 (Resident #109) of 4 residents reviewed for pressure ulcers during the annual survey. The findings include: According to the Centers for Disease Control (CDC), pressure ulcers (bed sores, pressure sores, or decubitus ulcers) are wounds from unrelieved pressure on the skin. They are staged by severity: Stage 1 is persistent skin redness; Stage 2 is partial thickness loss (abrasion, blister, or shallow crater); Stage 3 is full thickness loss exposing subcutaneous tissue (deep crater); and Stage 4 is full thickness loss exposing muscle or bone. An unstageable ulcer involves full-thickness skin and tissue loss where the extent of damage is obscured by slough or eschar.The standard of practice for the care of pressure ulcers is for the facility staff 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 surveyor record reviews it was determined that the facility failed to provide safe, appropriate respiratory care and services. This finding was found to be evident at the nursing station on [NAME] Ground Nursing Unit and in 2 (Resident #113 and #173) out of 2 Residents reviewed for usage of oxygen and storage of oxygen.The findings include: On 2/24/2026 at 9:57 AM the surveyor observed an emergency tank of oxygen (etank) at the nursing station on [NAME] Ground Nursing Unit. The etank was in an upright position and not secured in a stand or bracket.In an interview with Registered Nurse (RN) #14 at 10:05 AM on 2/24/2026 the surveyor asked what the expectation was for storage of oxygen and showed RN #14 the etank that was standing upright, not secured, not in a stand at the nursing station. RN #14 stated who put that there and removed the etank to the oxygen storage room.On 2/24/2026 at 11:20 AM the surveyor observed Resident #113 in no distress sitting in the chair in Resident room with oxygen cannula (tubing) in his/her nostrils. Observed 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.

Number of residents sampled: Number of residents cited: Based on medical record review and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was true for (Resident #13) reviewed during the annual re-certification survey.The findings include:On 02/27/2026 at 1:15 PM: The Director of Nursing (DON) was interviewed about the Medication Regime Review (MRR) process. The DON stated that monthly MRRs are emailed by the pharmacist, printed, and followed up on by the nursing team or physician. New orders are then updated, placed in Point Click Care (PCC), and the recommendation is uploaded to PCC. Once the physician updates the recommendations, the changes are sent back to the pharmacist via medical records.03/02/2026 at 1:00 PM: Resident #13's MRR, dated 6/28/2025, was reviewed. The review indicated that the recommendations to increase Allopurinol and decrease Tiotropium were not addressed in a timely manner. Staff #15, a Registered Nurse and Unit Manager, signed the 6/28/2025 MRR…

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 facility staff interviews and surveyor record reviews it was determined that the facility failed to follow a physician medication order for a Resident, failed to provide adequate side effects monitoring for Residents on psychotropic medications, and failed to ensure a Resident's medication regimen was free from unnecessary psychotropic medication as evidenced by medical records lacking physician documentation of rationale for continued as needed psychotropic use, no documented monitoring of side effects, and no documented non-pharmacological interventions prior to medication administration. This finding was found to be evident in 4 (Resident #26, #33, #92 and #7 ) out of 5 Residents reviewed for unnecessary medications during the annual recertification survey. The findings include: Medication Administration Record (MAR) is a legal and essential document used by healthcare professionals to track, verify, and record all administered, missed or refused doses of medication, ensuring patient safety and regulatory compliance. The MAR includes patient information, 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 interviews and clinical record review, it was determined that the facility failed to assist a resident to obtain routine dental care. This was evident for 1 (Resident #2) of 2 residents reviewed for dental services.The findings include:During an interview on 02/25/2026 at 7:26 AM Resident #2 stated that his/her teeth needed cleaning and that he/she had been waiting for 6 months for the facility to make an appointment. On 02/27/2026 at 8:00 AM a review of Resident #2's clinical record revealed the following:A progress note by the physician dated 10/01/2025 stated . The patient also request to follow-up with a dentist at the dental school. Patient requests appointment.A Physician's Order dated 10/01/2025 stated Refer to (Name) dental school for dental cleaning per resident request.A progress note by the physician dated 01/14/2026 stated . The patient also is pending follow-up with a dentist. The patient is not aware of an appointment yet.A progress note by the psychotherapist dated 02/06/2026 stated . client is just wanting to get into his dental appointment. client said I've…

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.

Number of residents sampled: Number of residents cited: Based on observation and staff interview, it was determined that the facility failed to ensure the appropriate maintenance of the exterior trash compactor to prevent the harborage and infestation of pests. This was evident for 1 of 1 exterior trash compactor reviewed during the recertification survey. The findings include:On 02/24/2026 at 10:50 AM, the surveyor evaluated the external dumpster area with the Maintenance Director. The trash compactor was situated at the far end of the open loading dock, approximately 24 feet (equivalent to 2 standard loading bays) from the rear doors of the kitchen and about 6 feet from the central storage room doors where the emergency water supplies were stored. The cemented surfaces surrounding the trash compactor and beneath it were found to be unclean, exhibiting waste leaks and debris. In addition, several wooden pallets were propped against the side wall. The surveyor emphasized the importance of maintaining cleanliness in these areas to avoid the attraction of pests and insect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility failed to maintain infection prevention and control practices. This finding was found to be evident in review of a complaint related to linen availability, usage and storage in the facility during the annual recertification/complaint survey.The findings include: On 2/24/2026 at 12:07 PM the surveyor observed the clean linen cart on the [NAME] Ground Nursing Unit in the hall next to Resident room [ROOM NUMBER]. The clean linen cart was sufficiently stocked with wash clothes and linen, but the clean linen cart was observed uncovered. Two staff members were observed obtaining linen from the uncovered clean linen cart.In an interview with Registered Nurse (RN) employee #14 at 12:12 PM on 2/24/2026 the surveyor asked what the expectation was for the clean linen cart. Employee #14 observed the clean linen cart and proceeded to cover the linen cart with the tan-colored plastic cover that was attached to the clean linen cart and stated that 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.

Number of residents sampled: Number of residents cited: Based on observation, and staff interview, it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 3 of 3 pieces of equipment reviewed during the recertification survey.The findings include:All essential kitchen equipment, including but not limited to walk-in coolers, chef base drawer refrigerators, steam tables, dishwashers, convection ovens, stoves, and warming cabinets must be maintained in safe operating conditions in accordance with the manufacturer's specifications and remain accessible throughout kitchen operations. On 02/24/2026 at 8:30 AM, the following kitchen equipment was determined to be nonfunctional according to the manufacturer's specifications:1) The steam table located on the cookline. This unit was being used as a prep table, with steam wells used for storing paper products.2) The Chef Base 4-drawer refrigerator situated on the cookline. Cooking equipment were placed on top of this unit.3) The solid interceptor located beneath 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 interview, record review, facility document, and facility policy review, the facility failed to protect a resident from verbal abuse for 1 (Resident #6) of 8 residents reviewed for abuse. Findings included: A facility policy titled, Prevention and Reporting of Abuse and Neglect, revised 10/2024, indicated, [Facility Name] has a zero tolerance for resident/patient abuse and neglect in any of it's [sic] forms. An admission Record indicated the facility admitted Resident #6 on 03/15/2022. According to the admission Record, the resident had a medical history that included diagnoses of cerebrovascular disease, depression, dementia, and chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #6 felt down, depressed, or hopeless, seven to eleven days during the assessment's lookback period. The MDS revealed the resident felt tired or had little energy for two to six…

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, facility document and policy review, the facility failed to report an injury of unknown source within two hours of being informed that the resident sustained a serious bodily injury for 1 (Resident #1) of 8 residents reviewed for abuse. Findings included: A facility policy titled, Prevention and Reporting of Abuse and Neglect, revised 10/2024, indicated, [Facility Name] has a zero tolerance for resident/patient abuse and neglect in any of it's [sic] forms. The policy revealed, 3. Abuse Reporting a. The facility will report allegations of abuse, neglect, exploitation, or mistreatment, misappropriation of resident property, as well as injury of unknown origin, in accordance with regulatory reporting guidelines: i. abuse and serious bodily injury within 2 hours to state agencies, unless; ii. the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; and does not result in serious bodily injury; which will be reported no later than 24 hours.* iii. The police department (911) will be notified of all…

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 dietary staff it was determined the facility failed to: 1) ensure all dietary staff wore a hair restraint, 2) ensure stored foods were covered and labeled, and 3) ensure the dishwasher was maintaining the minimum wash temperature for sanitization of dishes. These deficient practices have the potential to affect all residents. The findings include: 1) On 10/7/24 at 7:51AM surveyors conducted an initial tour of the facility's kitchen. On 10/7/24 at 7:54AM surveyors observed Dietary Aide #30 at the serving line plating food with no hair restraint covering exposed hair. At this time the surveyor conducted an interview with Dietary Aide #30 who stated the following to the surveyor regarding not wearing a hair restraint for exposed hair: I'm sorry, it must have come off. At this time, Dietary Aide #30 was observed obtaining a hairnet. On 10/7/24 at 8:19AM the surveyor conducted an interview with Certified Dietary Manager (CDM) #31 who confirmed with the surveyor that their expectation was 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 record review and interview it was determined the facility failed to accurately address reporting timeframes for allegations of abuse in their facility policies. This was evident during the surveyor's review of a facility reported incident, MD#00188565 and has the potential to affect all residents. The findings include: On 10/7/24 at 8:45AM surveyors requested the facility's abuse prohibition policy and procedures from the facility's Administrator during the entrance conference, and the policies and procedures were provided shortly thereafter. On 10/8/24 at 11:46AM the surveyor began review of facility reported incident MD#00188565 which involved an allegation of abuse that had not been reported to the Office of Health Care Quality (OHCQ) within the required reporting timeframe. On 10/15/24 at 11:54AM the facility's Administrator was interviewed regarding abuse reporting time frames during the investigation of additional facility reported incidents (MD#00200867 and MD#00181354) which both included an allegation of abuse not reported to OHCQ within the required reporting…

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, facility reports, record reviews, and interviews, it was determined that the facility staff failed to 1) report misappropriation of a residents' fund, and 2) report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 4 (#75, #310, #69, #93) of 6 residents reviewed for abuse during a recertification/complaint survey. The findings include: 1) On 10/07/24 10:46 AM, Resident #75 was observed lying in bed with an elastic blue tie wrapped around his/her right arm with a key attached to it. Resident #75 stated that he/she used it for his/her locked drawer for his/her valuables. The surveyor asked Resident #75 about the missing money, he/she stated that last year his/her money went missing and could not remember the details. On 10/18/2024 at 10:43 AM, a review of MD00197124 and facility investigation documentation indicated that Resident #75 reported to the facility on 9/18/2023 that he/she was missing $200.00 from his wallet. He/she had just returned from a hospital visit 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 observation, interview, and record review it was determined the facility failed to ensure a resident's call device was accessible to the resident. This was evident for 1 (#145) out of 2 residents reviewed for call device functioning during the facility's recertification survey. The findings include: On 10/7/24 at 8:58AM, during the surveyor's initial tour of the facility, Resident #145 was observed sitting on the side of their bed with their call device attached to the side rail of the bed, which was in the down position. The resident's call device was observed resting on the floor underneath their bed. The surveyor observed the bedside table situated between the resident and where the call bell was laying on the floor. At this time, the resident was observed to be unable to reach their call device. On 10/7/24 at 9:01AM surveyors conducted a dual observation with Licensed Practical Nurse (LPN) #27 to observe the concern. At this time, upon surveyor's sharing of the concern, LPN #27 observed the resident did not have their call device within reach and proceeded to pick 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 review of a facility reported incident (MD #188565), record review and staff interviews it was determined the facility failed to take measures to protect the resident during an abuse investigation. This was evident for 1 (Resident #310) out of 6 residents reviewed for abuse during the facility's recertification survey. The findings include: On 10/8/24 at 11:46AM the surveyor conducted a review of the facility's investigation file for the facility reported incident MD#188565. During this review, it was noted that Resident #310 reported an allegation of abuse on 2/1/2023 to dialysis staff who then reported the allegation via email to the facility's Director of Nursing (DON), Assistant Director of Nursing (ADON), and the [NAME] President of Clinical Services on 2/1/2023 at 2:34PM. Review of the email response to the dialysis staff from the [NAME] President of Clinical Services revealed the facility was aware of the allegation on 2/1/23 at 2:38PM. Documentation of the allegation reported to the facility included the alleged abuse occurred for the past two nights On 10/16/24 at…

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

Based on record review and interview, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of completion and create a discharge assessment. This was evident for 3 (Residents #64, #146 and #148) of 3 residents reviewed for resident assessments during the recertification/complaint survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility failed to accurately document oral assessment in a resident's medical record and code the resident's oral status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #12) of 3 residents reviewed during the recertification/complaint survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. On 10/07/24 at 11:07 AM, Resident #12 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to develop, initiate, and ensure a care plan for a resident was comprehensive and person centered. This was evident for 3 (#50, # 312, #12) of 58 residents reviewed during a recertification/complaint 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) On 10/7/24 at 8:35AM, during the surveyor's initial tour, Resident #50 was observed in bed with two lower extremity prosthesis present on the floor within their room. On 10/8/24 at approximately 8:55AM the surveyor observed Resident #50 wearing their prosthesis. On 10/9/24 at 8:59AM the surveyor reviewed the medical record which revealed the following medical order for therapy that included prosthetic training: recertification for 9/26: PT to continue PT treatment x 2 visits/week x 30 days for therapeutic exercise, therapeutic activity,…

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 residents' representative interviews, resident record reviews, and staff interviews, it was determined that the facility failed to implement an interdisciplinary care plan with effective interventions to prevent the repeated removal of gastronomy tubes. This was evident for one (Resident #68) of 58 residents reviewed for care plans during the recertification/complaint survey process. Findings Include: A gastronomy tube (g-tube) is inserted through the abdomen's wall into the stomach. The g-tube allows air and fluid to leave the stomach and can be used to give medication and fluids to the resident. On 10/8/2024 at 11:51 AM, an interview with Resident #68's representative revealed that the resident had 5 incidents that required multiple g-tube replacements within an approximate 5-month period. On 10/9/2024 at 10:52 AM, a review of Resident #68's record revealed that the resident was admitted to the facility in December 2019, and the resident's g-tube was placed before admission. A review of the change in condition assessment forms revealed that the resident had multiple…

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, it was determined that the facility failed to 1) follow professional standards of nursing practice when administering medications to residents and 2) administer the correct ordered medication form to the resident. It was evident for 1(Resident # 318) of 3 residents reviewed during medication administration during the recertification/complaint survey. The findings include: There are risks associated with opening capsules to drain the liquid. When this is performed, it alters the way the drug is absorbed in the body. This can result in people not getting enough dose. [Healtline.com February 2020] PAXIT is a 24-hour, unit-dose, medication management system in long-term care and it comes in easy to open bags. Omega 3 capsule is a dietary supplement made of gelatin and may have an enteric coating to prevent them from dissolving until they reach the small intestine. They are often tasteless and easy to swallow. Docusate Sodium is a medication utilized for managing and treating constipation. 1) On 10/16/24 at 8:51 AM, Licensed Practical…

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 complaint incident MD00209605, record review and staff interviews, it was determined that the facility failed to provide Activities of Daily Living (ADL) care for a dependent resident. This was evident for 1 (resident #66) of 4 residents reviewed for ADL care during the recertification/complaint survey. The findings include: On 10/08/24 at 8:17 AM review of a complaint incident MD00209605 sent in by resident's family reported that resident #66 has been in the facility for over 45 days and never received a full shower/Bathing. Review of the Physicians order on 10/10/24 at 11:43 AM had an order dated 7/11/24 that read: Skin Assessment: Bath Days on Monday and Thursday every evening shift. Review of the MDS with an Assessment Reference Date (ARD) of 7/15/24 revealed that resident #66 was coded as depended for showers and baths. Review of the GNA task sheet from July to October 2024 revealed that resident #66 did not get a shower on the assigned shower days, only bed baths. In an interview with staff #24 a Geriatric Nursing Assistant (GNA) on 10/11/24 at 9:51 AM, she was…

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

Based on the review of residents' medical records and interviews with facility staff, it was determined that the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice. This was evident for one (Resident #165) out of one resident who was reviewed for quality of care/ treatment in accordance with professional standards of practice during the recertification/complaint survey. The findings include: STAT means right now. The term STAT is usually used in medical orders. STAT term derived from the Latin word Statim, which translates to immediately, and denotes that medical order should be prioritized. A medical record review on 10/08/24 at 03:04 PM revealed that resident #165 sustained a fall on 09/03/23 around 8 PM, and the resident complained of a sharp radiating pain in the left leg, a pain level of 9/10. After pain progressively increased, on 09/04/2023 at 00:40, health status notes by Registered Nurse # 43 indicated that Resident #165 complained of 10/10 left leg pain. Resident #165 stated: It hurts right on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, record review and staff interviews, it was determined that the facility failed to order appropriate intervention and treatments for the maintenance of a Urostomy. This was evident for 1 (Resident #164) of 1 resident reviewed for urostomy during the recertification/complaint survey. The findings Include: A urostomy is an opening in the belly made during surgery to redirect urine away from a bladder that's not working as it should. A special bag called urostomy bags are used to collect urine from the urostomy. On 10/15/24 at 9:38 AM, review of a complaint incident MD00194576 revealed that Resident #164, who had a urostomy, complained that her urine bag was leaking near the surgical wound and that the bag was left full of waste from 5:30 AM to 10:30 AM. Further, the urine bag leaked everywhere when the resident attempted to walk and that this had happened more than once. Review of the resident's record on 10/15/24 at 9:42 AM revealed that this resident was admitted to the…

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

Based on medical record reviews, resident and staff interviews, it was determined the facility staff failed to ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 1 (Resident #16) of 4 residents reviewed for pain management during the recertification/complaint survey. The findings include During an initial pool screen of Resident #16 on 10/7/2024 at 1:30 PM, the resident stated that s/he was always in pain and the pain medication was not given most of the time. Resident #16 further stated that sometimes s/he waited for a long time for the nurse to bring their pain medication. S/he added that the pain was in their stomach, knees, and legs. Review of Resident #16's clinical records on 10/9/2024 at 12:37 PM revealed the resident was re-admitted to the facility in October 2024 with medical diagnoses that included but not limited to Chronic pain syndrome, unspecified Abdominal pain, and Prostate cancer. On 10/9/2024 at 1:02 PM, a review of active physician orders for Resident #16 revealed PRN (as needed) pain…

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, it was determined that the facility failed to administer the correct ordered medication form to the resident. It was evident for 1(Resident #318) of 3 residents reviewed during the medication administration during the recertification/complaint survey. The findings include: PAXIT is a 24-hour, unit-dose, medication management system in long-term care and it comes in easy to open bags. Omega 3 capsule is a dietary supplement made of gelatin and may have an enteric coating to prevent them from dissolving until they reach the small intestine. They are often tasteless and easy to swallow. Docusate Sodium is a medication utilized for managing and treating constipation. On 10/16/24 at 8:51 AM, Licensed Practical Nurse (LPN #7), was observed preparing the medications of Resident #318. LPN #7 stated that Resident #318 took medications crushed. LPN #7 began popping the residents' medications from the blister packs, crushed and placed them in a small cup. He/she then proceeded to get an amber yellow semi-transparent gel capsule from a white…

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 staff interviews, it was determined that the facility failed to ensure that each resident was free from unnecessary antibiotic use. This was evident for 1 (Resident #19) of 3 residents reviewed for antibiotic use while performing infection control tasks during the recertification/complaint survey. Findings Include: According to the Center for Disease Control (CDC) COVID-19 (coronavirus disease 2019) is a disease caused by the SARS-CoV-2 virus. It can be very contagious and can spread quickly. The FDA has authorized or approved several antiviral medications to treat mild to moderate COVID-19 in people who are more likely to get very sick. Antiviral medications target specific parts of the virus to stop it from multiplying in the body once someone is infected, helping to prevent severe illness and death. On 10/15/24 at 08:35 AM, in an interview with Infection Preventionist RN (RN#26), the surveyor asked how the facility monitored antibiotic administration. RN #26 stated that the facility has an antibiotics stewardship program to monitor the unnecessary use…

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 environmental observation, record review and staff interview, it was determined that the facility failed to have an effective system to prevent and control infections for all residents, staff, volunteers and visitors by posting precaution signs in front of residents' rooms to prevent the transmission of infections. This is evident for 3 (Resident #66, #68, #85) of 32 residents reviewed for infection precaution signs during the recertification/complaint survey. Findings include: According to the Center for Disease Control Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds, or indwelling medical devices such as central lines, urinary catheters, feeding tubes and tracheostomies). On 10/10/2024 at 09:03 AM, an environmental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to have documented evidence to support that the facility assessed the vaccination status of the influenza and Pneumococcal of each resident as required. This is evident for 3 (Resident #16, #127, and #152) of 5 randomly selected resident records reviewed for the influenza and pneumococcal vaccination records during the recertification/complaint survey. Findings Include: Influenza (Flu) vaccines are used to help prevent influenza. Influenza (Flu) is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications (Centers for Disease Control and Prevention- vaccines and preventable disease). Pneumococcal vaccines are used to help prevent…

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 the record review and staff interview, it was determined that the facility failed to have documentation to support that the facility provided COVID-19 vaccine education regarding the benefits, risks, and potential side effects of the vaccines. This is evident for 1 (Resident #129) of 5 randomly selected residents reviewed for COVID-19 vaccination records during the recertification/complaint survey. Findings Include: On 10/11/24 at 12:51 PM, a review of Resident #129's vaccination records revealed that upon the resident's admission in March 2023, the resident refused the COVID-19 vaccine; however, a review of Resident #129's immunization report in the electronic medical record, documented the vaccination education for the COVID-19 as no. Thus, revealed that the vaccination education was not provided to the resident or their representative. On 10/15/24 at 08:35 AM, in an interview with Infection Preventionist Nurse (Staff#26), she stated that the facility's routine was to give the residents the opportunity to be vaccinated, and that education was routinely provided at 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, observation and interview, it was determined the facility staff failed to provide care to promote the highest well-being for Residents (#106, #161 and #172). This was evident for 3 of 69 residents selected for review of quality of care during the annual survey process. The findings include: 1. The facility staff failed to ensure a laboratory blood test for Resident #106 was appropriate. Medical record review for Resident #106 revealed the resident had been administered the blood thinning medication Coumadin for deep vein thrombosis (DVT). Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Most deep vein clots occur in the lower leg or thigh. A deep vein thrombosis can break loose and cause a serious problem in the lung, called a pulmonary embolism. A common treatment to prevent blood clot formation is the administration of a blood thinner. Coumadin is used to treat blood clots (such as in deep vein thrombosis-DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body. For persons taking 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 the facility staff failed to provide Residents (#122) with the most dignified existence related to meals. This was evident for 1 of 3 residents reviewed for dignity during the survey process and 1 of 69 residents selected for review during the annual survey. The findings include: Surveyor observation of Resident #122's breakfast revealed on 8/12/19 at 8:06 AM the resident's tray was in the room. It was noted, the lid was off the bottom plate with scrambled eggs and muffin exposed. The resident noted to be sleeping and not eating. There were no noted staff in the room at the time. Further observation revealed the facility staff nurse #8 entered the room at 8:42 AM and started to feed the resident; however, the facility staff failed to re-heat the food for Resident #122 after the food had been sitting in the room for at least 36 minutes prior to being fed. Although Resident #122 was noted to be eating, the most dignified manner would have been to either re-heat the food to be more palatable or obtain a new tray. Interview with 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 notify the physician of weight gain as ordered for Residents (#45 and #172). This was evident for 2 of 2 residents selected for review of notification and 2 of 69 residents selected for review during the annual survey process. The findings include: Congestive heart failure (CHF): Inability of the heart to keep up with the demands on it, with failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs, such as the brain, liver, and kidneys. It is important to monitor the weight because: weight gain is the first sign that heart failure is getting worse and residents can gain up to 10 pounds of extra weight from fluid before feeling bad or swelling. If you gain more than 3 pounds in one day or 5 pounds in one week, call the doctor as the normal standard of CHF protocol. 1. The facility staff failed to notify the physician of a weight gain for Resident #45 as ordered. Medical record review for Resident #45…

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 surveyor observation and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all residents. The findings include: On 8/7/2019 at 8:33 AM Room C104 was observed with a large, dried urine stain on the toilet seat in the bathroom. Further investigation of this unit revealed that Resident #179 in Room C136 was using a wheelchair with a torn right armrest rendering it not easily cleanable. The armrest was observed to be loosely mounted to the wheelchair and wobbled when touched. On 8/8/2019 at 8:34 AM during an interview with Resident #184 multiple bug traps were observed in the residents room with accumulated dirt and debris stuck to them. The Administrator, Director of Nursing and [NAME] President of Resident Services were made aware of these findings on 8/15/2019 during the exit conference.

Based on medical record review and interview it was determined the facility staff failed to code the Resident (#172) medications accurately on the Minimum Data Set (MDS). This was evident for 1 of 69 residents selected for review during the annual survey process. The findings include: The Long-Term Care Minimum Data Set (MDS) is a health status screening and assessment tool used for all residents of long-term care nursing facilities certified to participate in Medicare or Medicaid, regardless of payer. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities and can be used to present a nursing home's profile. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers…

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 interview, it was determined the facility staff failed to develop a baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Residents #407) of 69 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. Review of Resident #407's medical record on 8/13/19 revealed Resident #407 was admitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a baseline care plan was developed within 48 hours of admission and a copy was provided to the resident/resident representative. The facility failed to develop a baseline care plan and provide the resident/resident representative with a copy within 48 hours of admission to the facility. Interview with the Director of Nursing on 8/13/19 at 12:26 PM confirmed the facility staff failed 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.

2) On 8/14/2019 Resident #184's medical record was reviewed and revealed and Minimum Data Set (MDS) admission Assessment from 8/29/2018. An MDS Assessment is a comprehensive assessment of a residents functional capabilities and health needs and are completed upon admission, discharge, quarterly, annually and when the resident experiences a significant change in condition. The MDS from 8/29/2018 specified that Resident #184 required Two + persons physical assist when bathing. Resident #184's Care Plan from 8/31/2018 was reviewed and under interventions for bathing/showering stated The resident requires (one staff assistance) with (bathing/showering) and as necessary. contrary to the resident's admission MDS assessment which specified Two + persons physical assist. The findings were discussed with the Administrator, Director of Nursing and [NAME] President of Resident Services during the exit conference on 8/15/19. Based on review of the medical record and interviews with staff, it was determined that the facility failed to 1)accurately develop a comprehensive anxiety care plan 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 medical record review, observation and staff interview, it was determined the facility staff failed to have an interdisplinary team review and revise a care plan (#63). This was evident for 1 of 11 residents reviewed for nutrition. Findings include: Resident #63 has a swallowing problem or dysphasia, recent weight loss, dementia and is ordered 1:1 supervision for eating assistance. On 6-2-19 Resident #63 weighed 154 lbs and on 8-6-19 132 lbs, a -14.29% weight loss. Resident #63 required speech therapy to identify the swallowing problem and provide swallowing strategies. Resident #63 is totally dependent on the facility for care. On 6-12-19 during the quarterly care plan meeting Resident #63 had 2 family members present, facility social worker, recreational therapy representative and the unit manager. The facility failed to have a dietitian and speech therapist attend and others to address the current problem of weight loss and swallowing concern. On 8-9-19 at 10:30 AM the Director of Nursing confirmed that the 6-21-19 care plan meeting did not include a dietitian or a…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication to Resident (#103) in accordance with the standard of practice. This was evident for 1 of 6 residents observed for medication pass and 1 of 36 opportunities for medication error. The findings include: Medical record review for Resident #103 revealed on 5/23/19 the physician ordered: Breo Ellipta Aerosol Powder 200-25, 1 puff every day. Once-daily BREO 100/25 is a prescription medicine used long term to treat chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema, or both, for better breathing and fewer flare-ups. BREO is not used to relieve sudden breathing problems and won't replace a rescue inhaler. BREO can cause serious side effects, including: fungal infection in the mouth or throat (thrush). Rinse the mouth with water without swallowing after using BREO to help reduce the chance of getting thrush. Observation of medication pass on 8/13/19 at 8:30 AM revealed Certified Medicine Aide #22 administered the BREO inhaler 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, medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressure ulcers to (Resident #407). This is evident for 1 of 5 Residents selected for review of pressure ulcers during the survey process. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). The findings included: Resident #407 was admitted from the hospital on 3/5/19 without any pressure ulcers. Review of Resident #407's medical record revealed a BRADEN scale assessment for predicting pressure sore risk. The Braden Scale is an evidenced-based tool, that predicts the risk for…

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

Based on observation and staff interview it was determined the nursing staff failed to follow physician orders and the established care plan to provide 1:1 supervision during meals to prevent a choking hazard (Resident #63). This was evident for 1 of 1 residents reviewed for accident hazards. Findings included: On 8-8-19 at 8:30 AM Resident #63 who has dementia and dysphagia (swallowing difficulty) was observed in his/her room in bed with a carton of milk, water in a cup, and a red liquid in a plastic glass on the overbed table. Each item had a straw. Resident #63 was trying to drink the milk but unable to hold the carton due to arthritis in the hands and spilled the milk. On 8-9-19 at 8:25 AM Resident #63 was observed in her bed, asleep, and sitting up with the breakfast tray set on the overbed tray. On 8-8-19 at 9:20 AM a medical record review revealed physician orders for 1:1 supervision for meals and a care plan for 1:1 supervision for meals. On 8-6-19 when the speech therapist discharged Resident #63, the orders to the nursing staff were to use safe swallowing strategies…

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, it was determined the facility staff failed to provide nutritional services to Residents (#122 and #188) as ordered. This was evident for 2 of 11 residents selected for review of nutrition and 2 of 69 residents selected for review during the survey process. The findings include: 1. The facility staff failed to provide Resident #122 with supplements as ordered by the physician. Medical record review for Resident #122 revealed on 3/20/19 the dietician in collaboration with the physician ordered: house shake, 4 ounces 3 times a day with meals and magic cup, 4 ounces 3 times a day between meals. House shake provides added calories and protein and is fortified with vitamins and minerals. Magic Cup is a 4 oz frozen cup that provides 290 calories and 9 grams of protein. Surveyor observation of the resident's breakfast on 8/7/19 at 8:00 AM and 8/12/19 at 8:10 AM revealed the facility staff failed to provide dietary services as ordered by the physician. It was noted at that time Resident was served both the house shake and magic cup…

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 clarify a pain medication order (Resident#69) to specify where the pain patch should be administered. This was evident for 1 of 4 residents selected for pain assessment and 1 of 5 residents reviewed for pain management. The findings include: Resident #63 has pain in his/her right shoulder and lower back. On 3-4-19 an order was written to apply a lidocaine patch 5% to affected areas topically in the morning for pain. On 8-9-19 at 8:10 AM LPN #26 was asked how he/she knew where to apply the lidocaine patch? LPN #26 said Resident #69 would tell him/her where to place the patch. LPN #26 was then asked what they would do if Resident #69 had pain in the right shoulder and the lower back and answered, well, I guess I would call the doctor. The facility failed to specify what the affected area was for the lidocaine patch so the order was clear for any staff passing medications. On 8-9-19 at 10:00 AM the Director of Nursing confirmed the unclear order for pain medication.

Based on medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Residents (#4) and the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident (#172) receiving Nystatin cream for 4 months. This was evident for 2 of 6 residents selected for unnecessary medication review during the annual survey process and 2 out of 69 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to act upon the consultant pharmacist recommendation in a timely manner. Medical record review for Resident #4 revealed the Consultant Pharmacist was in the facility on 1/23/19 and made a recommendation for Resident #4 related to the resident receiving very little insulin doses related to finger sticks. Finger stick uses a lancet which lightly pricks the skin to obtain the blood and a meter displays the current blood sugar. The physician determines the amount of insulin to 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 clinical record review and staff interview it was determined that the facility staff administered pain medication to a resident who was not in pain (#124). This was evident for 1 resident out of 5 reviewed for unnecessary medications. The findings include: A review of Resident #124's clinical record revealed that the resident had an order for Oxycodone (pain medication) 5mg give 2 tablets by mouth every 6 hours as needed for pain. A review of the clinical record revealed that on 8/3/19 at 9:22 PM the nurse asked the resident to rate pain on a 0-10 scale with 0 meaning no pain. The resident replied 0 and the nurse administered the medication. The nurse noted the medication to be effective. A review of the clinical record revealed that on 8/3/19 at 9:46 PM the nurse asked the resident to rate pain on a 0-10 scale with 0 meaning no pain. The resident replied 0 and the nurse administered the medication. The nurse then noted the pain medication to be effective. The Director of Nursing (DON) was interviewed on 8/15/19 at 8:37 AM. She stated that she believes the nurse did not…

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 obtain laboratory blood test as ordered for Resident (#45). This was evident for 1 of 69 residents selected for review of laboratory results during the annual survey process. The findings include: Medical record review for Resident #45 revealed on 3/14/19 the facility staff received the results of a Comprehensive Metabolic Panel. The comprehensive metabolic panel (CMP) is a frequently ordered panel of 14 tests that gives a healthcare provider important information about the current status of a resident's metabolism, including the health of the kidneys and liver, electrolyte and acid/base balance as well as levels of blood glucose and blood proteins. Abnormal results, and especially combinations of abnormal results, can indicate a problem that needs to be addressed. Some components of the CMP are: sodium, potassium, chloride, carbon dioxide, and albumin. Record review revealed the potassium level for Resident #45 was reported as 3.4 mmol/L, and normal is 3.5-5.1. Further record review…

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 maintain a medical record in the most accurate form for a resident (#158). This was evident for 1 of 1 residents reviewed for accurate medical records. 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. On 7-18-19 Nurse Practitioner #19 wrote on a progress note that Resident #158 had an unwitnessed fall earlier that day. When questioned on 8-13-19 about the fall the Director of Nursing(DON) said Resident #158 had not had a fall on 7-18-19. On 8-14-19 at 11:30 AM Nurse Practitioner #19 confirmed that Resident #158 had not had a fall on 7-18-19 but he/she was adding onto a 4-18-19 note by another nurse practitioner and needed to clarify which was her note of 7-18-19 and which was another nurse practitioners note. On 8-14-19 at 11:20…

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 interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Resident (#307). This was evident for observation of meal delivery of breakfast on the 2 north nursing unit and 1 out of 69 residents selected for review of infection control during the survey process. The findings include: Observation of breakfast tray delivery for Resident #307 on the 2 North nursing unit for breakfast on 8/7/19 at 8:27 AM revealed the facility staff provided Resident #307 with the tray; however, it was noted the resident was not eating the food. Further observation revealed the facility staff then provided Resident #307 with toast and at that time Geriatric Nursing Assistant (GNA) #9 used bare hand food contact to make an egg sandwich for the resident. It was observed that GNA #9 used her bare hand to cut the toast, put egg on the bread and hand the sandwich to Resident #307. Although, the facility staff may wash their hands or use hand sanitizer, it is still 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.