The Nursing And Rehab Center At Stadium Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure a resident's person-centered care plan was reviewed and revised to reflect the resident's current code status. This was evident for 1 (Resident #68) out of 2 residents reviewed for care planning during the survey.The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted.Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest…

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

Based on observations, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a physician's order for tube feeding was accurately followed (Resident #12) who was reviewed for tube feeding. The findings include:On 7/15/2025 at 8:53AM, during an interview with Resident #12, the Surveyor observed the resident's tube feeding running at 75ml/hour and the flush bag was not labeled.On 7/15/2025 at 10:30AM, a review of Resident #12's electronic medical record revealed an active physician's order for Jevity 1.5kcal Up : 5 pm Down : 3 am TV : 75 mL/hr x 10 hrs.During an interview with the Director of Nursing on 7/21/2025 at 12:45PM, the Surveyor was informed that Resident #12's order for the tube feed to be started at 5PM and ended at 3AM. The tube feed should be labeled with the resident name, room number, name of the formula, formula rate, the date and time hung, and nurse initials. The flush bag should also be labeled with the resident name, flush rate, date and time hung, and the nurse initials. The Surveyor expressed the concern that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to document administration of as needed (PRN) pain medications in a resident's medication administration record. This was evident for 1 (Resident #66) of two residents reviewed for pain management during the survey.The findings include:Resident #66 was diagnosed with displaced closed fracture of the left tibia and admitted to the facility on [DATE].On 07/16/2025 at 11:24 AM Resident #66 stated that right leg pain occurs regularly and there had been a delay in the staff responding to the call bell which meant the resident was in pain for longer periods of time. The resident's spouse stated that he/she spoke to nursing staff regarding the delay in the delivery of pain medication and some improvements occurred, but the delays in the staff's response to the call bells still occur routinely. Resident # 66's spouse explained that the staff response to the call bell would…

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 reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 1 of 2 residents (Resident #66) reviewed for pain management and 1 of out of 4 residents (Resident #68) reviewed for accidents during the survey. The findings include: 1. Resident #66 was diagnosed with displaced closed fracture of the left tibia and admitted to the facility on [DATE]. On [DATE] at 11:24 AM Resident #66 stated that right leg pain occurs regularly and there has been a delay in the staff responding to the call bell which means the resident is in pain for longer periods of time. The resident's spouse stated that he/she spoke to nursing staff regarding the delay in the delivery of pain medication and some improvements occurred, but the delays in the staff’s response to the call bells still occur routinely. On [DATE] at 9:10 AM…

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

Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment for enhanced barrier precautions and failed to ensure a resident's order for enhanced barrier precautions was maintained and followed. This was evident for 2 (Resident #21 and #32) out of 14 residents reviewed for enhanced barrier precautions during the survey.The findings include:Enhanced Barrier Precautions (EBP) are an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms (MDROs). EBP's are used in nursing homes for residents who are infected with an MDRO, or those at risk for acquiring one, such as residents with wounds or indwelling devices.Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. PPE can include gloves, masks, safety goggles, and gowns. 1. On 7/16/2025 at 1:40PM, 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 medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #19, #201 and #202). This was found to be evident for 3 out of 6 residents reviewed for hospitalization during an annual survey. The findings include: 1. Review of Resident #201's medical record on 1/6/23 revealed the Resident was admitted to the facility on [DATE]. The Resident was transferred from the facility on 12/13/22 to the hospital. Further review of the Resident's medical record failed to reveal any documentation that a written notice regarding the transfer had been provided to the resident and/or the resident's responsible party. Interview with the Director of Nursing (DON) on 1/10/23 at 2:00 PM confirmed neither Resident #201 nor their responsible party had been sent a letter that notified them of the transfer 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 review and interview with resident and facility staff, it was determined that the facility staff failed to 1. appropriately code a residents suprapubic catheter on the quarterly Minimum Data Set (MDS). This was evident during the review of 1 of 1 residents identified as having suprapubic catheters (Resident #20). 2. accurately code significant weight loss (Resident #7), 3. accurately code the use of oxygen (Resident #35) and 4. accurately code the use of antibiotics (Resident #28). This was evident for 4 out of 50 residents reviewed during an annual survey. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: 1. Interview with Resident #20 on 1/4/23 at 9:39 AM revealed s/he has a suprapubic catheter (A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff completed MDS (Minimum Data Set) assessments without the proper qualifications (Residents #7, #17, #31, #37, #53, #201, #202). This was evident for 7 of 50 residents reviewed during an annual survey. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. MDS Section V Care Area Assessment (CAA) Summary contains B. Signature of RN (Registered Nurse) Coordinator for CAA Process. MDS Section Z Assessment Administration contains Z0500 Signature of RN Assessment Coordinator verifying assessment completion. During interview with the Regional MDS Coordinator on 1/18/23 at 9:30 AM she states she is a LPN (Licensed Practical Nurse) and not a RN. Review of the following Residents'…

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 develop and/or implement a resident's interdisciplinary care plan (Residents #29, #37, #201). This was evident for 3 of 50 residents reviewed during an annual survey. 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. The findings include: 1. The facility staff failed to develop a vision care plan for Resident #37. During interview of Resident #37 on 1/3/23 at 11:37 AM, Resident #37 stated he/she needs glasses. Review of Resident #37's medical record on 1/11/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include Glaucoma. Glaucoma is a disease that damages your eye's optic nerve. Further review of Resident #37's medical record revealed the facility staff completed a MDS (Minimum Data Set) admission Assessment on 4/6/22. The MDS is a federally-mandated assessment tool that helps…

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 clinical record review, staff interview, and resident interview it was determined that the facility staff failed to ensure care plan meetings were held. This was evident for 4 (#28, #29, #37, #202) out of 50 residents that were part of the survey sample. The findings include: 1. The facility failed to ensure care plan meetings were held for a resident and failed to invite the resident. Resident #28 was interviewed on 1/3/23 at 10:28 AM. The resident stated that he/she has never been to a care plan meeting. A review of the resident's clinical record revealed that the last care plan meeting in the clinical record was for 1/27/21 and there was an absence of sign in sheets. Interview with the Director of Nursing on 1/18/23 at 10:40 AM revealed that evidence of care plans was not present in the clinical record. 2. During interview with Resident #37 on 1/3/23 at 11:35 AM, he/she stated doesn't have care plan meetings quarterly. Review of Resident #37's medical record on 1/6/23 revealed the Resident 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 medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #7, #46 and #201). This is evident for 3 of 4 residents reviewed for pressure ulcers during an annual survey. 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 the 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), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer…

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, observation and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #201, #29) and failed to ensure a resident room was safe (Resident #151). This was evident for 3 out of 50 residents reviewed during an annual survey. The findings include: 1. Review of Resident #201's medical record on 1/6/23 revealed the Resident was admitted to the facility on [DATE] and has a diagnosis of repeated falls. The facility staff completed a BIMS (Brief Interview of Mental Status) for the Resident on 8/19/22 and coded the Resident as a 2, indicating severe cognitive impairment. Further review of Resident #201's medical record revealed the Resident had a fall forward from his/her wheelchair on 6/14/22. The Resident was evaluated by Physical Therapy on 6/17/22 for use of the wheelchair. Review of the Physical Therapy assessment on 6/17/22 included, patient demonstrated poor trunk control, cognitive and sitting balance impairment resulting in higher…

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, observation and interview, it was determined the facility staff failed to failed to obtain weights on Resident #37 as recommended by the dietitian and facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for a resident Resident #7. This was evident for 2 of 5 residents selected for review for nutrition during the annual survey. The findings include: 1. The facility staff failed to obtain weights for Resident #37 as recommended by the dietitian. Review of Resident #37's medical record on 1/6/23 revealed he/she was admitted to the facility on [DATE] with diagnosis to include malnutrition. Further review of the Resident's medical record revealed a Nutrition/Dietary note on 5/5/22 that included, weekly weights times 4 weeks ordered. Review of Resident #37's weights revealed a weight on 5/5, 5/13 and 5/19/22. There was no weekly weight on 5/26/22. Further review of the Resident's medical record revealed 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 clinical record reviews, resident interviews, and staff interviews, it was determined that the facility staff failed to provide a comprehensive psychiatric evaluation and consultation for (#3), 6 months out of 12 possible months in 2022. This was evident in 1 out of 50 residents sampled as part of this survey. The findings are: Resident #3 was interviewed on 01/03/2023 at 10:48 am. Resident #3 stated the facility did not address his/her mood behavior consistently on a monthly basis. Review of Resident #3 medical record revealed that on 01/10/2022, 5/05/2022, 7/17/2022, 8/21/2022, 9/15/2022, and 12/03/2022 a Psychiatric evaluation and consultation for the resident was completed. The records include documentation that assessments of Resident #3 were done on these dates. Further review of Resident #3 clinical record revealed that a mental health consult did not occur for 6 months. There was no documentation of a consult for February, March, April, June, October, and November to address his/her depression.

Based on the tour of the four kitchens, observation, and staff interview it was determined that the facility staff failed to ensure food is stored and prepared in a properly maintained kitchen. This was evident for 4 out of the 4 kitchens. The findings include: A tour of the 2nd floor kitchen on 1/12/23 at 11:25 AM revealed that several of the cabinets had broken cabinet drawer faces. Observation of the 4th floor kitchen on 1/12/23 at 11:40 AM revealed that some of the cabinets had broken drawer faces, the freezer had six bags of unidentified food sitting in a box that was unlabeled and stuck to the bottom of the freezer, both ovens were dirty on the inside, and the electric stove top was cracked with a piece missing on the edge closest to the user. Observation of the 3rd floor kitchen on 1/12/23 at 12:15 PM revealed both ovens were dirty on the inside, the freezer had a box of 12 croissants in it with a hole in the shrink wrap along the upper right quadrant (roughly the size of a croissant). Staff #13 was interviewed on 1/12/13 at 11:30 AM. He said he was aware of the condition 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 upon interview and record review, the facility failed to 1. failed to follow the recommendations of a consultant (Resident #40) 2. ensure timely consult reports from the use of outside resources (Resident #17) 3. failed to ensure urology consults were obtained and recommendations followed (Resident #20), 4. failed to follow up and implement interventions for a resident with an identified impaired nutritional status (Resident #7). This was evident for 4 out of 12 residents with outside consults during the annual survey. The findings include: 1. Resident #40 was reviewed for general skin condition beginning on 01/03/2023 at 09:46 AM. During initial tour, this resident was concerned for a sore toe on their right foot that they did not feel was being checked on. The resident was admitted to the LTC facility on 12/09/2022. Hospital discharge record dated 12/09/2022 at 3:57 PM was reviewed for this resident. Surveyor's review of this record occurred on 01/05/2023 at 01:31 PM. The resident had a prominent ulcer…

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 the medical record in the most complete and accurate form for Residents (#17, #19, #24, #54 and #201). This was evident for 5 of 50 residents selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current, and complete documentation in the medical record is an essential component of quality resident care. 1. The facility staff failed to document the administration of medications for Resident #54. A medical record review for Resident #54 revealed the physician ordered: 1. On 11/17/2021 Dilaudid Tablet 2 MG Give 1 tablet by mouth every 4 hours as needed for pain take 1 for mild pain 1 - 5. 2. On 11/17/2021 Dilaudid Tablet 2 MG Give 2 tablets by mouth every 4 hours as needed for severe pain 5- 10. Dilaudid is a narcotic pain medication. Narcotic pain medications are potent and effective 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 a revisit of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance Program as evidenced by the identification of 7 repeat deficiencies. The failure to identify and develop appropriate plans of correction to correct quality deficiencies places all residents at risk. The findings include: The repeat deficiencies reviewed included areas of 1. In accordance with accepted professional standards and practices, the facility must: maintain medical records on each resident that are complete and accurately documented. 2. must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 3.the facility staff must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, and the resident's goals and preferences. 4. The services provided or arranged by the facility staff must meet professional standards of quality. 5. The facility must ensure that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of the residents and facility, and a review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning fly control (Resident #7), 2nd 3rd, and 4th floors of the facility. The findings included: On 3/17/23 at 8:30 AM, Resident #7 was eating breakfast and 2 flies were flying around the food. Resident #7 was swatting the flies away with his/her hand while eating breakfast on the fourth floor. On 3/17/ 23 at 10:20 am, a tour of the facility's 2nd floor revealed flies in rooms [ROOM NUMBERS]. Flies were noted in the long hallway on the second floor and in the kitchen area. A tour of the 3rd floor at 1:30 pm revealed that under the hand sink in the kitchen were approximately 30 dead flies in the cabinet. The Surveyors opened the pantry door and 2 flies were noted flying out. A tour of the 4th floor at 9 am revealed flies in the kitchen and conference room. The facility's pest control logs were…

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 upon observations and interview, the facility failed to ensure Resident #40 had laundered personal clothing available to wear in accordance with this resident's wishes in order to maintain the resident's dignity. On 01/05/2023 at 08:00 AM, Resident #40 was observed dressed in a hospital gown in the hallway, verbalizing that they had no clothes to wear. Staff #26: GNA (geriatric nursing assistant) #4, was seen in the hall by the laundry room and acknowledged the resident's clothes were in the laundry and not ready. On 01/05/2023 at 09:35 AM, the resident was observed by surveyors sitting in a chair in the community area dressed in the hospital gown and pants verbalizing that his/her own clothes were preferred but were not laundered yet. On 01/10/2023 at 08:30 AM, Resident #40 was observed sitting in a chair in the community area with an upset facial expression. At this time, the resident was interviewed by surveyors. The resident reported during the interview that they did not want to wear a hospital gown…

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 an initial observation prior to and of dining the facility failed to provide the residents with and environment that included comfortable sound levels with appropriate entertainment. This was evident during the first observation of dining occurring on the 4th floor. The findings include: Surveyor initiated observations of the community sitting area on 1/3/23 at 12:30 PM There were 4 residents observed gathered around the television, Resident #2, #17, #24 and #29. Surveyor was located near the exit of the unit and could hear from the kitchen music blaring. The lyrics were audible and identified as belonging to two prominent rappers. The music was overpowering the sound from the television. When the staff began serving the lunch meal trays to the residents at 12:42 PM they turned the music off. This concern was reviewed with the facility Administrator and DON during the exit conference on 1/23/2023.

Based on a review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with written notice of bed hold policy, at the time of the resident's transfer for hospitalization. This was evident for 2 (Residents #19 and #48) of 6 residents reviewed for hospitalization during an annual recertification survey. The findings include: 1. A review of the medical record for Resident #48 revealed the resident was transferred to an acute care facility on 10/9/2022. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 1/19/23 at 11:06 AM, the Administrator confirmed that Resident #48 and the Resident's responsible party did not receive the facility bed hold policy when Resident #48 was transferred to the hospital. 2. The resident and family were not notified of the facility bed hold policy at the time of the resident transfer to the hospital. A review of Resident #19's clinical record…

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 medical record review and interview, the facility failed to follow the standard of practice during medication administration for the care of the resident (Resident # 55). This was evident for 1 of 50 residents selected for review during the annual survey. The findings include: One of the recommendations to reduce medication errors and harm is to use the five rights. The Five Rights of Medication Administration are the right patient, the right drug, the right dose, the right route, and the right time. The facility uses an Electronic Medical Record (EMR) for the administration and documentation of medications for administration to the residents. The physician's orders for the medications are entered in the EMR with the times of medication administration. Medications must be given within 1/2 hour of the time that is listed on the medication log. This means that you have 1/2 hour before the medication is due, and 1/2 hour after it is due to administering the medication to be on time with medication administration. A medical record review for Resident # 55 revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility staff failed to provide grooming and personal hygiene services for a resident (Resident #204). This was evident for 1 out of 50 residents reviewed during an annual survey. The findings include: Observation of Resident #204 on 1/4/23 at 9:42 AM revealed the Resident to have elongated and dirty fingernails. Interview with the Resident at that time revealed the Resident would like to have his/her fingernails trimmed. Further observation of the Resident on 1/20/23 at 8:10 AM with the Administrator present revealed the Resident remains with elongated and dirty fingernails. Review of Resident #204's medical record on 1/5/23 revealed the Resident was admitted to the facility on [DATE] is dependent on the facility staff for his care, comfort and safety. The facility staff conducted a MDS (Minimum Data Set) assessment on 12/31/22 and coded the Resident in Section G Functional Status as a one person physical assist for personal…

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 interview, and staff interview it was determined that the facility staff failed to ensure a resident's bed had a complete pair of siderails. This was evident for 1 out of the 50 residents selected for the survey sample. The findings include: This surveyor was interviewing Resident #19 on 1/12/23 at 9:30 AM. During the interview it was observed that both of the resident's bed's siderails were missing the top wooden rail. Resident said it has been off since admission and they are stored in the bathroom. Resident stated that he/she uses the rails to move in bed especially when transferring to the wheelchair. Resident stated he/she can still maneuver in bed without the rails. The Administrator was informed and shown the bed on 1/12/23 at 9:40 AM. He called for maintenance staff to come fix the bed and had a geriatric nursing assistant come into the room to assist the resident to a wheelchair.

Based on medical record review and interview with facility staff, it was determined that the physician progress notes did not contain or address pertinent issues that were relevant at the time the notes were completed. This was evident during the review of 1 of 26 resident physician notes. (#7) The findings include: Review of the medical record for Resident #7 on 1/5/2023 at 10:18 AM revealed diagnosis including adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments), abnormal weight loss and the presence of multiple wounds. Further review of Resident #7 specifically focusing on his/her weights noted that according to the facility electronic health record (EHR) under weights and vitals noted the following weights: 12/7/22: 93, 12/14: 80.2, 12/28:81.2, 1/4/23:80.0, a 13 lb weight loss identified on 12/14 that was maintained through 1/4/23. The attending medical notes for Resident #7 were reviewed following the noted significant weight loss. The attending note completed by staff #22 on 1/6/23…

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 employee files and interview with facility staff, it was determined that the facility failed to have competency skills list provided and available for Geriatric Nursing Assistance (GNA) upon hire. This was evident for 2 of 4 GNA employee files reviewed. The findings include: Review of the employee files for staff GNA #18 and #19 who were hired within the past 2 years failed to reveal a skills checklist with appropriate GNA competencies reviewed upon hire. There were two other GNA files reviewed however, they have been employed at the facility prior to the last survey and had their annual competencies completed up through the current administration. Employee files were reviewed, and missing information was requested from the DON on 1/23/23. The DON followed up with the survey team on 1/23/23 at 11:39 AM and stated that she was unable to locate any skills checklist for the identified GNA's.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview it was determined that the facility failed to ensure medications were destroyed after a resident expired or the medications were discontinued; and secure a medication storage room and properly label resident medication. This was found to be evident during observation of two of four medication storage rooms. The findings include: 1. During observations of Residents [DATE] at 1:16 PM, surveyor observed at the external nursing desk on the 4th floor in the overhead cabinets multiple bags of intravenous fluid and other nursing care supplies. Closer look in the unsecured cabinets and drawers found the following items: First identified for Resident #152, who passed away in the facility 10/2022, are items with his/her name specifically on it dressing change set 8 bags of 2-liter sodium chloride intravenous fluid (IVF) Vancomycin-antibiotic intravenous (2) 16 saline chloride syringes dated as delivered on [DATE] with a primary tubing set up, needless connector 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident's medication regimen was reviewed monthly (#19). This was true for 1 out of 50 residents that were part of the survey sample. The findings include: A review of Resident #19's clinical record on 1/9/23 and 1/10/23 revealed that the resident's primary physician prescribed Olanzapine 2.5 mg (antipsychotic), tamsulosin 0.4 mg (treats renal conditions), apixaban 2.5 mg (an anticoagulant), mirtazapine (an antidepressant), multi-vitamin tablet, Senna-Docusate 8.6-50 mg tablet (bowel regimen), Sennosides (bowel regimen), and Metoprolol 12.5 mg (hypertension). A pharmacy review for October 2022 was not in the clinical record. The Director of Nursing was interviewed on 1/11/23 at 11:14 AM. She stated that the resident was not seen by pharmacy in October 2022.

Based on random observations it was determined that the facility failed on multiple occasions to ensure that the code cart and the medication carts were secure. This was observed on different occasions and locations. The findings include: 1. During initial tour and observations, the facility code cart was observed without a red security tag sealing the cart closed on 1/3/23 at 09:13 AM. Surveyor was able to pull open all the drawers and observe needed code supplies including scissors, paramedic shears, 9 hypodermic needles and razors. Staff observed the surveyors at the code cart. On 1/3/23 at 12:34 PM surveyor observed a white plastic bag covering the code cart and a red tab interlocking the drawers for security. Additionally at this time 4 residents were observed sitting in the common area watching television. On 1/6/23 at 12:00 PM Surveyor took a closer look at the code cart and the red tag. Surveyor was able to still open all the drawers. The surveyor notified the DON on 1/6/23 at 12:37 of the observations when she arrived on the 4th floor. The DON stated that the cart 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 clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was screened for dental services (#28). This was evident for 1 out of 50 residents reviewed as part of the survey sample. The findings include: Resident #28 was interviewed on 1/3/23 at 10:30 AM. Resident stated that he/she has not been seen by a dentist since admission. Resident was noted to have debris between the teeth. A review of the resident's clinical record revealed that there has not been a dental consult within the last 12 months. Resident was interviewed on 1/18/23 at 1:35 PM. Resident stated that he/she would like to see a dentist and to have implants for both the upper and lower. The Administrator and Director of Nursing were informed of the findings at the exit conference on 1/23/23.

Based on observation, it was determined that the facility staff failed to follow infection control practices and guidelines by failing to maintain a sanitary environment to prevent the development and transmission of disease-causing organisms from exposed foam and underneath padding due to torn and cracked vinyl on stools. The findings: The observation was made, on 3/17/2023 at 10:20 AM in the 2nd-floor kitchen area: One stool at the counter with vinyl material was peeling off from 9 o'clock to 2 o'clock with the foam exposed. Another stool had random wear on the top and the sides with the foam exposed. The stools cannot be disinfected and cleaned properly to prevent the spread of microorganisms. The Director of Nursing and the Administrator were advised on 3/21/23 at 2:30 pm.

Based on record review and staff interview it was determined that the facility failed to implement an Infection Prevention Control Program (IPCP) to provide appropriate infection surveillance, an effective antibiotic stewardship program for residents, and review the IPCP annually . This deficient practice has the potential to affect all residents, staff, and visitors in the facility. Findings include: A record review was conducted on 3/8/2019 at 1:55 PM. Review of the facility's Infection Control Program policy failed to indicate protocols to determine antibiotic use and identified what infection assessment would be used to start antibiotic treatment for residents. Review of the submitted Quality Assurance Committee documentation and interview with the Director of Nursing and the Administration on 3/11/19 at 2:45 PM revealed that the facility did not maintain consistent documentation regarding antibiotic use reviews, monitoring of residents with infections or communicable diseases, or of staff call outs regarding illnesses. In addition there was no documentation submitted to support…

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 pertinent documentation and interview with facility staff, it was determined that the facility failed to have an active antibiotic stewardship program in place for the past year. This was evident after the attempted review of the facility's antibiotic stewardship program. This deficient practice has the potential to affect all residents. The findings include: Interview with the Director of Nursing (DON) on 3/11/19 at 2:43 PM revealed the antibiotic stewardship policy was not able to be located for surveyor review at the time of the survey. Interview with the Administrator on 3/11/19 at 3:47 PM revealed the DON is to be responsible for overall compliance. In addition the fact that surveyors were unable to determine when the policy was implemented and last reviewed was discussed with the Administrator at that time.

Based on medical record review and interview with the facility staff, it was determined that the facility failed to: 1.) provide notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment, and 2.) provide notification to residents that their Medicare coverage was ending within the required time frame. This was evident in 3 of 3, residents (Resident #247, #248 and #21) reviewed during beneficiary protection notification. The findings include: Advance Beneficiary Notice (ABN) is a written notice from Medicare, given to residents before receiving certain items or services notifying beneficiaries that Medicare may deny payment for that specific procedure or treatment. An ABN gives residents the opportunity to accept or refuse the items or services and protects residents from unexpected financial liability in cases where Medicare denies payment. The Notice of Medicare Non-Coverage (NOMNC) letter is intended to notify a Medicare member, in writing, that the member's Medicare health plan…

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 medical records and other pertinent documentation as well as staff interviews it was determined that the facility failed to ensure resident safety while an investigation was in process and failed to complete thorough investigations as evidenced by allowing an accused employee to work with residents prior to the completion of the investigation and failure to interview potential witnesses. This was found to be evident for 3 out of 4 residents (Resident #96, #297 and #146) reviewed for abuse during the survey. The findings include: 1) On 3/11/19 review of a facility report investigation revealed that on 10/13/17 Resident #96 made an abuse allegation involving Nurse #17 and Geriatric Nursing Assistant (GNA) #18. Review of the statement written by Nurse #17 revealed it was written on 10/15/17. Review of the final report sent to the state survey and certification agency, and was dated 10/17/17, revealed: After investigating the complaint that [resident] reported. The investigation is unfounded. On 3/11/19 interview with the Director of Social Services clarified 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.

Based on medical record review and interview with facility staff it was determined that the facility failed to accurately code a resident on the Minimum Data Set (MDS) regarding antipsychotic and anxiolytic usage. This was evident in the review of 2 of 6 residents (Resident #42 and #31) reviewed for unnecessary medications. The findings include: The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Review of medical record for Resident #42 on 3/7/19 at 9:52 AM revealed documentation on the Quarterly MDS that the resident received antipsychotics on an as needed basis and in addition failed to document that the resident received anxiolytic during the assessment reference date (ARD) of 2/11/19. The MDS Coordinator was interviewed on 3/7/19 at 11:39 AM and 12:18 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.

Based on review of the medical record and staff interview it was determined that the facility failed to have a system in place to provide a summary of the Baseline Plan of Care to the resident or responsible party. This was found to be evident for 1 out of 6 residents (Resident #39) reviewed for care planning in the investigative section of the survey process. 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. On 3/8/19 Resident #39's medical record review revealed that the resident was admitted to the facility in January 2019 for long term care and with diagnoses which included Heart Failure, Diabetes and Atrial Fibrillation (irregular heart rate). Review of the medical records for the Baseline Care Plan revealed that on admission the facility began to obtain information and assess the resident and from the gathering of information, the facility uses the information to build an interim care plan. That interim care plan or baseline care plan is discussed with…

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

Based on medical record review, observation, and interview it was determined that the facility failed to ensure the development and implementation of comprehensive care plans as evidenced by: 1.) failure to update care plan to reflect that restorative services were on hold, 2.) failure to establish a care plan for restorative nursing services, 3.) failure to include safety measures in regard to dining precautions, 4.) failure to develop an individualized care plan related to a residents diagnosis of congestive heart failure (CHF), and 5.) failure to follow the resident care plan by ensuring that regularly scheduled medications were available to administer to the resident. This was found to be evident for 5 of 23 residents (Resident #28, #9, #25, #31, and #23) investigated during the survey. Findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1.) On 3/6/19,…

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 with staff it was determined that the facility failed to have an effective system in place to ensure restorative nursing services were provided as ordered. This was found to be evident for 1 out of 3 residents (Resident #9) reviewed for activities of daily living. The findings include: On 3/6/19 review of Resident #9's medical record revealed a Restorative Nursing Program had been established for the resident in September 2018. A review of the physician orders revealed the following, 9/21/18: restorative 6x/week starting 9/22/18: PROM (passive range of motion) to bilateral upper extremities. Apply right upper extremity resting hand splint up to 8 hours or to tolerance. Review of current care record, where the geriatric nursing assistants record care, revealed a place for documentation of restorative but only included the splint for 8 hours. No documentation was found on the care record regarding the passive range of motion. Review of the 12/19/18 Minimum Data Set (MDS) assessment revealed the resident did not receive range of motion…

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, interview and observation it was determined that the facility failed to ensure a resident received 1:1 supervision during meals as ordered by the physician, and failed to implement the speech therapist recommendation of no straws for a resident with a swallowing dysfunction. This was found to be evident for 1 out of 1 resident (Resident #25) reviewed for potential accidents. The facility also failed to ensure pureed food was of a smooth pudding like consistency. This was found to be evident for 1 out of 1 pureed test tray obtained during the survey but has the potential to affect any resident receiving a pureed diet. The findings include: 1. On 3/5/19 at 9:10 AM Resident #25 was observed in bed with a breakfast tray with cut up pancake and sausage on the tray. No staff was present in the resident's room at the time of this observation. After the initial observation of the resident Geriatric Nursing Assistant (GNA #5) was briefly interviewed in the hall. The GNA #5 reported that she checks on the resident every few minutes and that the nurse assigned…

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 administrative record review and interviews with the resident and facility staff it was determined the facility failed to have enough staff to: 1.) ensure that a resident's regularly scheduled medication was available as ordered as to prevent missing doses at the time of administration, and 2.) provide physician ordered meal supervision. This was found to be evident for 2 of 23 residents (Resident #23 and #25) reviewed during the facility's annual Medicare/Medicaid survey. Findings include: 1. Complaint # MD00135007 was reviewed on 3/6/19 and 3/7/19. According to the complainant, nursing staff did not administer regularly scheduled medications to Resident #23 because the medications were not available. Review of the medical record on 3/7/19 revealed Resident #23 was admitted with the following but not limited diagnoses; Quadriplegia, Neuromuscular Dysfunction of Bladder, Orthostatic Hypotension (low blood pressure), Major Depressive Disorder, Fibromyalgia (pain). An interview was conducted with Resident #23 on 3/5/19 at 8:46 AM and s/he stated the following: that…

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

Based on review of employee files and staff interviews it was determined that the facility failed to have an effective system in place to ensure both nurses and geriatric nursing assistants (GNA) demonstrated skills competency prior to working independently with residents. This was found to be evident for 2 out of 3 recently hired GNA's (GNA #10 and #11) and 2 out of 2 recently hired nurses (Nurse #12 and #13). The findings include: On 3/8/19 at 8:10 AM the Administrator reported that newly hired GNA's and nurses work with a partner during a 5 day period in which a skills checklist is completed. She went on to report that staff should be giving this checklist back to her to put in the employee file. 1. On 3/8/19 review of GNA #10's employee file revealed a hire date of 2/18/19 but failed to reveal documentation of a skills checklist. Review of GNA #11's employee file revealed a hire date of 1/7/19 but failed to reveal documentation of a skills check list. During an interview, at 12:35 PM, regarding no documentation of skills checklist the Administrator reported: I had to ask [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 review of employee files and staff interview it was determined that the facility failed to have an effective system in place to ensure geriatric nursing assistants (GNA) were currently certified. This was found to be evident for 1 out of 4 GNA's (GNA #20) files reviewed for GNA's that had worked at the facility for more than one year. The findings include: Of Note: this facility was cited for this issue during the annual survey in 2015. On [DATE] review of a list of nurses and GNA's revealed GNA #20 had been hired in [DATE]. Review of GNA #20's employee file failed to reveal documentation of an annual evaluation. On [DATE] at 10:55 AM when asked about this, the Administrator reported that this GNA had gone to work for housekeeping in August of 2017 and she was not sure of the date the employee had returned to working as a GNA. On [DATE] at 2:12 PM review of state board of nursing website revealed GNA #20's GNA certification expired on [DATE] and had not been renewed. Interview with the Administrator…

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 with staff it was determined that the staff failed to have a system in place to ensure that the pharmacist recommendations were reviewed/addressed by the physicians in a timely manner and failed to ensure that a prn (as needed) order for an anti-psychotic medication was limited to 14 days and then obtain a new order for the medication only after evaluation from the physician. This was evident for 1 of 6 residents (Resident #12) reviewed for unnecessary medications in the investigative stage of the survey process. The findings include: On 3/11/19 Resident #12's medical records were reviewed. This review revealed that the pharmacist had completed the monthly medication reviews and made a written recommendation to the physician on 1/10/19. This pharmacy review revealed the following: Recommended discontinuation/re-evaluation of the following Olanzapine 2.5 mg every 24 hours as needed. Further review of the medical record failed to reveal any documentation that this recommendation had been addressed by the physician. PRN (as needed) orders…

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 with facility staff, it was determined that the facility staff failed to administer medication according to physician orders. This was evident during the review of 1 of 6 unnecessary medications (Resident #21). The findings include: Review of the medical record for Resident #21 on 3/8/19 at 1:38 PM revealed diagnoses including chronic viral hepatitis and polyneuropathy due to toxic agents. Further review revealed an order for Tylenol 2 tablets as needed every 12 hours for temperature over 100 degrees. In addition, an order to administer 2 tablets of Tylenol every 12 hours as needed for mild pain 1-5. A review of the January 2019 Medication Administration Record (MAR) revealed documentation that the Tylenol was administered on 1/7/19, 1/10/19 and 1/11/19 for a temperature of 97.2, 97 and 97.2 respectively. The Director of Nursing (DON) was interviewed and made aware of the documentation on the MAR and lack of corresponding nursing notes for those days on 3/8/19 at 1:38 PM. She stated that the employee that documented the administration 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 medical record review and interview with staff it was determined that the facility failed to ensure that a PRN (as needed) order for an anti-psychotic medication was limited to 14 days and then obtain a new order for the medication only after evaluation from the physician. This was found to be evident for 1 out of 7 residents (Resident #12) reviewed for unnecessary medications during the investigative stage of the survey. The findings include: PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. On 3/11/19 a review of Resident #12's medical records revealed diagnoses which included dementia and altered mental status. Review of the current medication orders revealed the following in effect since January 3, 2019: Olanzapine 2.5 milligram (mg), give 1 tablet by mouth every 24 hours as needed for agitation QHS (at night) only. Review of the Medication Administration Record (MAR) for January thru March 2019 revealed…

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 and observation of medical records, Controlled Drug Count Verification sheets, observation of the medication room refrigerators, and interview with staff it was determined that the facility failed to ensure the temperature on the medication refrigerator was documented daily. This was found to be evident for 3 out of the 3 nursing medication room refrigerators. The findings include: Review and observation of the refrigerator logs of Unit 2, 3 and 4 medication rooms on 3/11/19 between 3-3:30 PM revealed 'daily refrigerator temperature logs' with missing daily temperatures for the month of March 2019. Further review of the temperature logs for January and February of 2019 for all 3 units revealed sporadic documentation that the temperature was checked. The documentation on the 3rd floor 'Daily refrigerator temperature log' documented that for March 2019 the temperatures ranged from 46-50 degrees and with no subsequent interventions. According to the log, the refrigerator temperature is to be maintain between 35-41 degrees Fahrenheit. This concern was reviewed 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 with staff it was determined that the facility failed to ensure residents were offered the flu vaccine annually. This was found to be evident for one out of five residents (Resident #3) reviewed for immunizations during survey. The findings include: Review on 3/11/19 at 10:29 AM of the selected residents flu vaccines for 2018 revealed that Resident #3 was not offered the flu vaccine for 2018. Interview with the Director of Nursing (DON) on 3/11/19 at 10:49 AM revealed that the although the previous DON was responsible for tracking the immunizations she would look into the concern and look for the vaccine logs. On 3/11/19 at 11:55 AM according to the paper work provided by the DON, Resident #3 was offered the flu vaccine in 2017 however, the facility had no documentation that the flu vaccine was offered in 2018. According to the facility 'Resident Immunization Policy,' 2. All elder should receive annual influenza immunization unless contraindicated. This concern was reviewed with the DON at that time and again at 2:30 PM on 3/11/19.