Courtney Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure sufficient nursing staff were available for a timely and adequate resident care for eight residents (R29, R38, R41, R61, R64, R80, R138, and Resident in room [ROOM NUMBER]B), of eight residents reviewed for adequate staffing resulting in long call light responses, unmet resident care needs, and late medication administration. Findings include: On 10/28/24 at 3:30 PM, a record review of Daily Staffing Assignment from 10/21/24 to 10/28/24 was reviewed with the staffing coordinator. Although there were daily call ins by staff, records and punch cards revealed that there was minimal staff assigned to each of the units because staff go through mandation or by volunteer for staffing coverages. For example, while accounting for staffing schedule per units, there was a daily trend of nurses filling some of the staffing shortages seen on days where there were call ins for license nurses. Some nurses work full their full shift (12.0 hours)…

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 the facility failed to ensure a medication error rate of less than 5% when 23 medication errors were observed for four residents (#35, #75, #78 and #82) from a total of 69 opportunities, of seven residents observed for medication administration, resulting in an error rate of 33.33% with the potential for adverse reactions related to the omission of medications and medications not administered timely with the potential of ineffective medication therapy and the exacerbation of medical conditions. Findings include: On 10/29/24 at 8:42 AM, the Medication Administration task of the survey was started. The following were observed: Resident #82: -At 9:42 AM, Nurse T was observed to prepare Resident #82's medications by removing the pills from the blister packets. Nurse S was observed to prepare the insulin. Nurse S uncapped the needle of the syringe, inserted the needle into the insulin vial, extracted the insulin and when completed with getting the amount needed from…

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, the facility 1) Failed to ensure that ongoing surveillance for signs and symptoms of infectious illnesses in residents was collected, documented, analyzed and reported and 2) Failed to ensure that Transmission-Based Precautions were identified and Personal Protective Equipment/PPE was worn when indicated, hand hygiene was performed, when necessary, needles were not recapped, personal items were labeled with residents' names in shared bathrooms, and hair nets were readily accessible without risk of cross-contamination in the kitchen, resulting in a lack of compliance with infection prevention and control standards of practice which could result in exposure to infectious organisms and an outbreak of illnesses. Findings Include: FACILITY Infection Control On 10/29/24 10:10 AM, during an interview with Infection Prevention and Control/IPC Nurse A she said she began the IPC role in June 2024. Reviewed with the IPC Nurse on 10/27/2024 at 1:09 PM, a Contact Precaution…

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, the facility failed to follow up on advanced directives with the proper POA signature of DNR consent and ensure that the care planning matches the desired code status for 2 residents (Resident #47 and Resident #71) of 2 residents reviewed for code status resulting in lack of accurate assessment and documentation of code status and the potential for a resident to receive life-sustaining medical treatment against their wishes. Findings include: Resident #47(R47): Advance Directives According to the Electronic Medical Record (EMR) reviewed on [DATE] at 3:30 PM, R47 was admitted to the facility on [DATE] with the diagnosis of Unspecified Dementia, Psychotic Disorder with Delusions, General Muscle Weakness and the need for assistance with personal care in addition to other diagnoses. According to the face sheet, R47's daughter is the established Power of Attorney (POA). R47's Brief Interview for Mental Status (BIMS) Score is 0/15. A 0-7 score indicates 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure comprehensive revised care plans for four residents (#26, #47, #53 and #68) out of five residents reviewed for care planning, resulting in unassisted unsafe ambulation, unassessed nutritional needs with the likelihood of unmet care needs and code status and the potential for a resident to receive life-sustaining medical treatment against their wishes. Findings include: Resident #26: On [DATE], at 9:24 AM, Resident #26 ambulated from the bathroom to their bed. Resident #26 was not assisted, was not wearing shoes and was not using any Assistive device. Resident #26 leaned forward and grabbed the foot of the bed. They used the bed for support to ambulate around to the right side of the bed where they sat down. On [DATE], at 11:04 AM, a record review of Resident #26's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, History of falling, legally blind and Urostomy. Resident #26 required…

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, the facility failed to provide Activities of Daily Living (ADL) care for two residents (Resident #23, Resident #74) of 18 residents reviewed for ADL care, resulting in soiled hands, unkempt appearance, and a lack of showering/bathing. Findings include. Resident #74: On 10/29/24, at 10:51 AM, Resident #74 was in their room. They had a large amount of brown residue to their right-hand nails and nail beds. On 10/29/24, at 2:26 PM, an observation along with CNA E was conducted of Resident #74's nails. CNA E observed the brown residue and offered, oh yeah it didn't get done. CNA E shortly returned into Resident #74's room with supplies to provide nail care. A review of Resident #74's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Heart Failure and kidney disease. Resident #74 had severely impaired cognition and required assistance with all ADL's including PERSONAL HYGIENE: Resident (requires one assist Date Initiated:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ambulation supervision and ensure that a safety care plan was followed for two residents (Resident #71 and Resident #38) at risk for falls, and prevent/assess/document an injury from furniture in disrepair for one resident (Resident #68), of 4 residents reviewed for falls and safety, resulting in the potential for serious harm or injury from a fall and a delay in treatment for R#68's forearm cut from a sharp edge of broken furniture. Findings include: Resident #38 (R38): Accidents During the observation tour conducted at the 200 Hall on 10/27/24 at 1:00 PM, R38 got out of bed and was observed walking with an unsteady gait out in the hallway. The staff was busy and not in sight because they were attending to another resident in the other room. The surveyor called for the nursing assistant's (CNA F) attention, and CNA F immediately took R38 back to her room. CNA F confirmed that R38 needed supervision when ambulating and will need…

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, the facility 1) Failed to ensure that urostomy appliance changes were ordered timely, completed per physicians' orders, and there was a completion of a comprehensive bladder elimination care plan and 2) Failed to obtain a physician's order for a urinary indwelling catheter for two residents (Resident #23, Resident #26), resulting in delayed and missed urostomy appliance changes, unmet care needs with the likelihood of further missed care needs, infection and complications from an indwelling urinary catheter. Findings include: Resident #26: On 10/28/24, at 11:04 AM, a record review of Resident #26's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, History of falling, legally blind and Urostomy. Resident #26 required assistance with Activities of Daily Living. A review of the TREATMENT ADMINISTRATION RECORD 6/1/2024-6/30/2024 revealed no ostomy appliance changes from admission on [DATE] through the end of the month.…

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 the facility failed to assess, monitor and ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident #139) of 5 residents reviewed for food or nutrition, resulting in Resident #139 lacking nutritional assessments to aid in the identification of nutritional needs. Findings Include: Resident #139: Nutrition On 10/27/2024 at 2:38 PM, Resident #139 was heard yelling out and moaning. He was observed sitting in bed with his lunch tray at the bedside. The lid was on it and the resident said he did not feel like eating. He said after a while they would take his meal tray. He said he wished they wouldn't take it. A record review of the Face sheet and medical record indicated Resident #139 was admitted to the facility on [DATE] with diagnoses: acute respiratory failure, COPD, metabolic encephalopathy, weakness, need for assistance with personal care, diabetes, end stage kidney disease, acute kidney failure, need 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that orders from the dialysis center were communicated to the practitioner for 2 residents (Resident #23 and Resident #139) of two residents reviewed for dialysis care, resulting in the potential for missed medication regimen, treatment and complications of dialysis care. Resident #23: A review of Resident #23's medical record revealed an admission into the facility on 8/3/24 with diagnoses that included chronic kidney disease, muscle weakness, need for assistance with personal care, obesity, and dependence on renal dialysis. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathe self. On 10/27/24 at 1:31 PM, an observation was made of Resident #23 sitting in her recliner chair and was dressed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about dialysis and reported she went to dialysis…

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, the facility 1) Failed to ensure that narcotic medication reconciliation was completed, 2) Failed to ensure that residents received medications timely, and 3) Failed to ensure that the medication administration standards of practice were followed for four residents (#34, #75, #78 and #82) of seven residents observed for medication administration, resulting in medications not given as scheduled with the likelihood of ineffective medication therapy, exacerbation of medical conditions, medication/narcotic diversion, and medication administration errors. Findings include: On 10/29/24 at 8:42 AM, the Medication Administration task of the survey was started. The following were observed: -At 9:42 AM, Nurse T was observed to prepare Resident #82's medications by removing the pills from the blister packets. Nurse S was observed to prepare the insulin. Nurse S uncapped the needle of the syringe, inserted the needle into the insulin vial, extracted the insulin and when…

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

Based on observation, interview and record review, the facility failed to provide enough healthy snack choices for all residents, resulting in Resident Council-voiced complaints, missing and low snack list items, and feelings of decreased over all well-being and frustration. Findings include: On 10/28/24, at 2:00 PM, During resident council task, the following complaints were voiced regarding not have healthy snacks and food choices: No fresh greens no fresh veggies no fresh fruit I dream about a beautiful red fresh tomato I would love a fresh ear of corn the meals are food of carbs if you want to gain wait, just eat the processed foods here you get the same thing for breakfast every day we want fresh cinnamon rolls the little butter packets are margarine we want real butter we don't want imitation cheese they run out of snacks they run out of honey buns you have to ask the CNA's for night time snacks and they say there isn't any The CNA's say they will go check for a snack but then they don't come back You have to go to the kitchen sometimes to get snacks you have to know who to go…

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, the facility 1) Failed to ensure: that sound levels of call lights were appropriate for the resident population in the 200 Hall and 2) Failed to ensure dignity in regard to call lights by not responding timely for two residents (Resident # 66 Resident #76), resulting in residents verbalizing complaints of lack of response, frustration, agitation, and the likelihood for behaviors. Findings include: Record review of the facility 'Guest/Resident Rights' policy, dated 5/1/2022, revealed that the facility protects and promotes the rights of each guest/resident. The guest/resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Record review of the facility 'Call Lights' policy, dated 2/15/2022, revealed that call lights will be placed within the resident reach and answered in a timely manner. Respond to the call light. Identify the location and answer 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 Resident #41: On [DATE] at 12:40 PM, a review was conducted of Resident #41's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Bacteremia, Cellulitis, Atrial Fibrillation, Heart Disease and Presence of Automatic Cardiac Defibrillator. Further review of Resident #41's record yielded the following results: Hospital Discharge Records: .AICD (automatic cardioverter/defibrillator) present . Facility admission Assessment [DATE]: - Pacemaker: Yes Care Plan: Focus: (Resident #41) is at risk for cardiac complications r/t multiple cardiovascular diseases, hypertension, atrial fibrillation, hyperlipidemia, CAD, hx of STEMI and presence of AICD. Progress Notes: [DATE] at 00:00: Notified by nursing the resident will be transferred to the hospital due to sternal abscess which has copious drainage. [DATE] at 06:34: Seeping serosangauness fluid from chest midline. There was no other documentation located from initial progress note on [DATE]…

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 This Citation pertains to Intake Numbers MI00135049 and MI00135826. Based on observation, interview, and record review the facility failed to ensure that there was adequate staff and/or that staff were utilized appropriately to provide Activities of Daily Living (ADL) and answer call lights timely, resulting in delays in incontinence care, increased call light response times of 30 minutes or more and other unmet care needs. Findings Include: During initial tour on 10/4/202, Resident #79 expressed complaints related to the facility's call light response times. Resident #79 shared sometimes facility staff complete check and changes and other times they do not. She stated she has not been changed since 5 AM and had urinated multiple times since then but no one had been in to check on her. This writer pressed Resident #79's call light at 11:15 AM and verified it had been activated on the call light box affixed to the wall. At 11:53 AM (43 minutes later) a CNA responded to the call light. The CNA was queried if it…

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

Based on observation, interview and record review, the facility 1) Failed to ensure: that ice machines in the 200, 400 and 900 halls were clean and sanitary and 2) Failed to ensure that the salad bar cabinet did not have standing water underneath and that items were not stored under the cabinet , resulting in the potential for the spread of foodborne illness to all residents receiving meal service from a census of 81 residents. Findings Include: FACILITY Kitchen On 10/04/23 at 10:25 AM, during a tour of the kitchen with the Certified Dietary Manager/CDM H and Kitchen Supervisor M, the salad bar cabinet in the main dining room was observed to have standing water underneath and inside the cabinet. A 5 gallon bucket was under the drain in the upper compartment of the cabinet. There were doors on the lower level of the cabinet and there were card board boxes with kitchen utensils stored inside it. The cardboard boxes were wet, and smelled like mold. The CDM removed all of the boxes and said she would have the water removed and no additional items would be stored under the cabinet. 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 This Citation pertains to Intake Numbers MI00135826 and MI00138777. Based on observation, interview and record review, the facility failed to ensure that infection control standards of practice were followed for: 1) Collection, analysis and reporting of infection surveillance data, 2) Multiple residents having a rash of unknown origin on the 200 Hall, and 3) Hand hygiene practices, resulting in the potential for resident, staff and visitor exposure to infectious illness. Findings Include: FACILITY Infection Control: Resident #56: On [DATE] at 1:29 PM, during a tour of the facility, Resident #56 was observed sitting in a wheelchair in the 200 hallway and stated, They are battling people that are itching here. I'll go out in the hall and you'll see people just scratching. They don't know what it is. I think some have it bad. Across the hall (Resident #65) has it terrible; he's constantly scratching. Resident #56 showed that he had 3 red raised dots on his left inner arm and said he told the doctor and showed him…

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, the facility failed to update a care plan for catheterization for one resident (Resident #80), resulting in the catheter interventions not addressing the resident's self-catheterization and accompanying education, which was to be provided per physician's order. Findings include: The State Surveyor's request for the facility's 'Resident Self-catheterization' policy on 10/6/2023 at 7:30 AM from the Director of Nursing (DON) revealed that the facility did not have a policy. Later that same day, 10/6/2023 at 9:03 AM, the DON e-mailed the surveyor a Lippincott procedure guideline. Record review of the facility 'Care Planning' policy, dated 06/24/2021, revealed that every resident in the facility will have a person-centered plan of care developed and implemented that is consistent with the resident's rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs…

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, the facility failed to educate and provide proper management of self-catheterization for one resident (Resident #80), resulting in the potential for bladder injury, cross contamination, and resultant urinary tract infection. Findings include: The State Surveyor requested facility's 'Self-catheterization' policy on 10/6/2023 at 7:30 AM from the Director of Nursing (DON) The DON revealed that the facility did not have a policy. Later that same day, 10/6/2023 at 9:03 AM, the DON e-mailed the State Surveyor a Lippincott procedure guideline. Record review was conducted of the facility-provided [NAME] 'Intermittent (straight) urinary catheter insertion, assigned male at birth' procedure (https://procedures.lww.com/lpn/view.do?pld=1670271&hits=cathers&a=true&ad=false&q=cather) link. Record review of pages 1 through 4 (revised 11/28/2022) revealed that the procedure guide revealed that intermittent urinary catheterization can be long-term or short-term depending 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 observation, interview, and record review the facility failed to ensure accurate completion of a trauma assessment for one trauma survivor, Resident #9, resulting in the facility not being aware of Resident #9's trauma history and subsequently not being able to deliver culturally competent trauma-informed care and identify triggers to minimize re-traumatization. Findings Include: Resident #9: On 10/4/2023 at approximately 2:30 PM, Resident #9 was observed resting in bed and was in a pleasant mood. The survey system indicated Resident #9 triggered for PTSD (Post Traumatic Stress Disorder) and she was queried if this was accurate, and she responded it was. The resident was asked if she was comfortable sharing a generalized statement regarding her trauma (type of trauma and if in childhood or adulthood). Resident #9 stated her trauma stemmed from a 25 year physically abusive marriage. A quick review was conducted of the most recent Social Work Assessment from 7/2023 and it showed Resident #9 did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have two nurses sign off on a Fentanyl patch removal and administration for one resident (Resident #3), resulting in the likelihood of narcotic diversion and the narcotic diversion going unnoticed. Findings include: Record review of the facility 'Controlled Substances (MI, OH, IN, and VA) policy, dated [DATE], revealed it shall be the policy of the facility to store and/or destroy all discontinued or expired controlled substances, in accordance with legal and regulatory requirements. Destruction of Controlled Substances: (1.) The Director of Nursing/designee and another nurse must destroy all discontinued and/or expired controlled substances ideally upon receipt. A Registered Nurse must always be present when controlled substances are destroyed . (5. C) With the Director of Nursing/RN designee and licensed nurse present the wasting of leftover, unadministered partial doses of controlled substances, like a dose that remains in a vial,…

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

Based on observation, interview and record review, the facility 1) Failed to ensure that 1 of 3 medication carts were free from loose tablets/medications and 2) Failed to perform hand hygiene during medication pass, resulting in the likelihood of cross contamination and ineffective medications. Findings include: Record review of the facility 'Medication Administration' policy, dated 10/14/2022, revealed that guest/resident medications are administered in an accurate, safe, timely and sanitary manor. Procedure: 1. (c.) Place medication into a souffle cup or medicine cup without touching the inside of the cup. (a.) If medications come into contact with bare hands of nurse, med tech, or with the cart, the medication should be disposed of per policy . An observation and interview on 10/05/23 at 06:32 AM with Registered Nurse (RN) E night shift nurse till 7:30 AM revealed RNE to come from another resident room, open medication cart and begin to finger through the medications of Resident #58. RN E gathered her blood pressure checking supplies and went into Resident #58's room and touched…

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.