Medilodge of Cass City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent the development of three (one Stage IV and two unstageable) pressure ulcers for one resident (Resident #31), resulting in, Resident #31 developing a right ankle unstageable wound, a left ankle unstageable wound and a Stage IV coccyx wound and delayed wound healing. Findings include: Resident #31: On 8/27/2024 at 10:55 AM, Resident #31 was observed sitting in the wheelchair after staff had completed morning cares. The resident was asked if she had any wounds on her body and she pointed to her coccyx area and stated it was painful. On 8/27/2024 at approximately 1:00 PM, a review was completed of Resident #31's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Diabetes, Dementia, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of left ankle and Pressure Ulcer of right ankle, Schizophrenia, Anxiety and Major Depressive Disorder. Further review revealed 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 implement and operationalize policies and procedures to ensure a thorough investigation, accurate documentation, and implementation of meaningful interventions for fall prevention for two residents (Resident #16 and Resident #23) of two residents reviewed for falls, resulting in a lack of accurate Minimum Data Set (MDS) documentation, comprehensive analysis of falls, a lack of updated and meaningful interventions to prevent falls, and the likelihood of unnecessary pain and injury. Findings include: Resident #16: On 08/28/24 at 9:01 AM, Resident #16 was not in their room. Resident #16's bed was observed to have bilateral, half-length side rails in place. The side rails were very loose and moved several inches with pressure. At 10:37 AM on 8/28/24, Resident #16 was not in their room. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included [NAME]…

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 positioning and follow care-planned interventions during enteral feeding for two residents (Resident #19, Resident #50) of two residents reviewed for enteral feeding assistance, resulting in the likelihood of aspiration and/or enteral tube malfunction. Findings include: Resident #19: On 8/27/24, at 10:51 AM, Resident #19 was resting in bed scooted down slightly sideways in their bed which was approximately 20 degrees. Their tube feeding was not hooked up. They did not have on an abdominal binder. On 8/27/24, at 12:01 PM, Resident #19 was in the same position in their bed. Their tube feeding was hooked up and running. They did not have on an abdominal binder. On 8/27/24, at 3:30 PM, a review of Resident #19's electronic medical record revealed an admission on [DATE] with diagnoses that included laceration of the cerebellum with loss of consciousness, impaired gastrointestinal status requiring enteral feeding and subdural hemorrhage.…

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 store and care plan Continuous Positive Airway Pressure (CPAP) masks appropriately, administer oxygen per physicians' orders and provide appropriate water for the CPAP machine for three residents (Resident #22, Resident #23, Resident #67) of three residents reviewed for Oxygen/CPAP use, resulting in the likelihood of infection and abnormal oxygen levels. Findings include: Resident #22: On 8/27/24, at 8:38 AM, Resident #22's CPAP mask was face down uncovered resting on their nightstand. On 8/27/24, at 3:15 PM, a record review of Resident #22's electronic medical record revealed an admission on [DATE] with diagnoses that included Obstructive Sleep Apnea, Diabetes Mellitus and Traumatic Subdural Hemorrhage. A review of the Physician orders revealed CPAP 14/5 Rate . at bedtime . Start Date 7/30/2024 . A review of the care plan revealed no care plan for the CPAP machine and need. Resident #67: On 8/27/24, at 8:38 AM, Resident #67's CPAP mask…

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 ensure that the medication error rate was less than 5% when three medication errors were observed from a total of 25 opportunities for three residents (Resident #56, Resident #501, and Resident #503) of five residents reviewed. This deficient practice resulted in a medication error rate of 12% and the potential for the risk of adverse medication effects and decreased medication efficacy. Findings include: Resident #56: On 8/28/24 at 12:45 PM, medication pass observation for Resident #56 was completed with Unit Manager Licensed Practical Nurse (LPN) L. LPN L prepared Valporic Acid (Depakote- used to treat seizures and as a mood stabilizer) oral solution (liquid) 250 milligram (mg)/5 milliliter (mL) for administration to the Resident. The ordered dose was 20 mL (1000 mg). LPN L was observed holding the medication cup in their hand and while dispensing the liquid Valporic Acid into the cup. LPN L then set the medication cup on the top of the medication cart. LPN L did not confirm the accuracy of the amount of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to perform hand hygiene and ensure proper Personal Protection Equipment (PPE) (gown, gloves) for one resident (Resident #19), resulting in the likelihood of contamination during wound care and incontinence care and the spread of infection. Findings include: Resident #19: On 8/27/24, at 3:30 PM, a review of Resident #19's electronic medical record revealed an admission on [DATE] with diagnoses that included laceration of the cerebellum with loss of consciousness, impaired gastrointestinal status requiring enteral feeding and subdural hemorrhage. Resident #19 required extensive assistance and had severely impaired cognition. A review of Physicians orders revealed an order for . Enhanced barrier precautions . Active Start Date 8/1/2024 . On 8/29/24, at 10:01 AM, an observation along with CNA P and CNA O of Resident #19's skin who required incontinence care. CNA O assisted with incontinence care with gloved hands. With the same gloved hands, CNA O entered…

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.

This Citation pertains to Intake Numbers MI00134661 and MI00142794. Based on observation, interview and record review, the facility failed to provide a functional call light in a timely manner for two residents (Resident #9, Resident #30), resulting in delayed staff response to the residents' needs and feelings of frustration and worry. Findings include: Resident #9: On 8/27/24, at 11:23 AM, Resident #9 was resting in bed. There was an approximate 4-inch by 6-inch hole in the wall where the call device was once housed. Resident #9 stated it had been broken for about 4 days and that they were given a handheld bell to ring for help. Resident #9 rang the bell as loud as they could for 10 seconds. No staff came. Resident #9 offered that they ring it but often wait for long periods of time as much as an hour. The television (TV) in the room was audibly loud. The roommate (Resident #30) was resting with their eyes closed and the only remote to the TV was on their nightstand. Resident #9 rang the handheld bell again for 15 seconds with no staff response. On 8/27/24, at 11:29 AM, There 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 on observation, interview and record review the facility failed to implement infection control practices related to COVID-19 (COVID) for four residents (#2, #3, #4, #5) of 5 residents sampled resulting in missing Transmission Based Precaution (TBP) orders for residents positive with COVID, missing COVID positive care plans, missing trash cans for contaminated personal protective equipment (PPE), lack of PPE outside of the rooms and the potential for spreading COVID in the facility. Findings include: On 02/28/24 at 10:00 AM, observation revealed one large trash can outside of room B5/#2 for the whole hallway and missing trash cans outside of resident rooms (B7/#3, B9/#4, B13/#5) on transmission based precautions (TBP) for COVID. Observation revealed signs on the room doors that indicated anyone entering should wear gloves, a gown, a mask and a face shield. On 02/28/24 at 10:05 AM, RN 'A' was interviewed about the lack of trash cans outside of the rooms and where would you place wrappers that PPE came in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00142937. Based on observation, interview and record review, the facility failed to justify the use of a PRN/as needed antianxiety medication and document rationale for prolonged PRN use for one resident (#1), resulting in the potential for unnecessary medications and adverse effects. Findings Include: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #1 revealed an admission into the facility on [DATE] with diagnoses: Schizophrenia, heart failure, hypertension, Systemic Lupus (an autoimmune disorder), anxiety, depression, pathological dislocation of left hip (present on admission), and hypothyroidism. The MDS assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 revealing moderate cognitive loss. The resident needed some assistance with all care and was unable to walk. An interview with the Assistant Director of Nursing/ADON A on 2/28/2024 at 9:54 AM, revealed Resident #1 had several…

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 implement and operationalize policies and procedures to ensure safe and sanitary food storage, sanitary conditions in the kitchen, and ensure kitchen equipment was maintained and inspected, resulting in the potential for equipment malfunction, injury, and foodborne illness for all residents who consume food from the kitchen. Findings include: A tour of the facility kitchen began on 9/12/23 at 10:14 AM with Dietary Manager L. During the tour, the following items were identified in the Egg Fridge: - A container of diced tomatoes labeled as expired: 9/11. When asked, Dietary Manager L indicated the tomatoes should not be in the fridge and proceeded to remove them. - Uncovered eggs were observed sitting in an open cardboard egg holder on the bottom shelf. No date was present on the eggs. The cardboard egg holder was noted to have empty egg slots which had visible yellow colored egg yolk and semi clear colored egg white in the bottom. When queried why the eggs were sitting uncovered in the fridge, Manager L…

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 interview and record review the facility failed to curate an Activities Program that met the interest of facility residents and consistent weekend programming for residents, resulting in an activities program being monotonous, lacking originality, weekend programming since April 2023 not consistently being conducted and residents expressing feelings of frustrations, discontentment, and unimportance. Findings include: On 9/13/2023 at 9:30 AM, Resident Council was held with seven facility residents, and they expressed their great displeasure with the activity program and past Activity Director X. They had multiple complaints regarding the program and iterated they informed upper management and floor staff of their concerns related to the program and poor disposition of the Activity Director, but it was not addressed timely. The residents shared the following: -Activities ran by the Activity Director X were not started timely. She would move the time back but still sit in the office at the start of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program including outcome and process surveillance, data analysis and reporting for all infections, and environmental cleaning/sanitization processes/procedures for all 48 facility residents. This deficient practice resulted in of lack of surveillance for potential infections and infections not requiring antimicrobial therapy, incomplete and inaccurate infection analysis, lack of thorough tracking and surveillance of employee illness, lack of comprehensive environmental surveillance, drain fly infestation, and the likelihood for the development and transmission of communicable diseases and infections for all residents. Findings Include: A review of facility provided Infection Control (IC) line listing for 2023 revealed the line listings provided for review did not include the Resident's name, signs and symptoms of infection, antibiotic start date (if applicable),…

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 provide a safe, functional, sanitary, and comfortable environment for the facility residents, resulting in (1) ineffective maintenance of residents' rooms (drywall exposed, unfinished drywalling projects, holes/gaps in walls,; (2) infestation of sewer flies, (3) facility tracking of pest/rodents, and (4) 10-month delay of B-Hall shower room repair. Findings Include: During initial tour on 9/12/2023, the following was observed in resident rooms: Room D2: Behind the resident's headboard was a large white area that appeared to be drywall that had been fixed but never painted. The area was not smooth but rough. Room D7: On the right- hand side of the wall, near the heat register were 3-4 gaps in the wall where the drywall met the baseboard. Across the top of the call light box was a 3-4-inch gap in the drywall. On the left side of the room (by the bathroom) were two large holes and the resident was unsure what they were from. Room D9: On the left-hand…

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 has Two Deficient Practice Statements (DPS). DPS One: Based on observation, interview and record review, the facility failed to ensure urinary catheter drainage bags were maintained in a dignified manner for one resident (Resident #24) of one resident reviewed, resulting in a lack of dignity covering for an indwelling urinary catheter drainage bag. Findings include: Resident #24: On 9/12/23 at 11:53 AM, Resident #24 was observed in their room. There was a noticeable lack of light, noise, and stimulation in the room. The Resident's bed was flat, and they were observed flat on their back with their eyes open staring up at the ceiling. An indwelling urinary catheter drainage bag was observed on the side of the bed. The drainage bag was exposed and not contained in a dignity bag and/or with a dignity covering. When queried how long they had had the catheter, Resident #24 indicated it had been in place for quite a while but was unable to provide a specific date. When queried regarding staff assessment…

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 maintain a homelike environment for two residents (Resident #27, Resident #38), resulting in a shared television, an unkempt bathroom sink and difficulty in bed mobility with the feelings of less self-worth and frustration. Findings include: Resident #27: On 9/12/23, at 11:05 AM, Resident #27 was lying in their bed. There was a television (TV) hanging in the corner at their head of bed out of sight and unplugged. Resident #27 stated the TV didn't work but his roommate would share the TV on the wall at the end of the beds. Resident #27 stated sometimes he wants it all to himself but his roommate would be going home soon so then he would be able to have it all to himself. On 9/13/23, at 9:00 AM, an observation of Resident #27's bathroom revealed an approximate 2 inch by 6 inch area in the bathroom sink where the enamel had worn off leaving the porous area of the sink exposed. Resident #27 was not in his room. Resident #27's roommate offered…

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 collaborate with hospice services for one resident (Resident #2), resulting in hospice and the facility failing to establish an effective communication and collaborative process for Resident #2, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. Findings Include: Resident #2: On [DATE], Resident #2 was observed watching television in her room. She provided yes and no questions to this writer as she had multiple tooth extractions the day prior. On [DATE] at approximately 2:00 PM, B Hall nurse was asked how hospice communicates with the facility. It was explained each resident had a hospice book that is at the nurse's station and she was asked for Resident #2's hospice book. B Hall nurse looked through many other hospice books and was unable to located Resident #2's book. On [DATE] at approximately 11:35 AM, 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 observation, interview and record review, the facility failed to ensure suprapubic catheter (surgically created connection between the skin to the urinary bladder used to drain urine from the bladder) care was completed, per professional standards of practice for one resident (Resident #7) of one resident reviewed resulting in lack of timely assessment/documentation, management, implementation of care, as ordered, and the likelihood for alterations in skin integrity and feelings of embarrassment utilizing the reasonable person concept related to leaking suprapubic catheter. Findings include: Resident #7: On 9/12/23 at 3:06 PM, Resident #7 was observed in a reclined Broda chair (padded, reclining wheeled chair with solid leg section for lower extremities and raised edges head) in their room. A urinary catheter drainage bag was noted on the chair. When spoke to, Resident #7 made eye contact but was unable to provide meaningful verbal responses. Record review revealed Resident #7 was originally admitted to…

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

Based on observation, interview and record review, the facility failed to operationalize policies and procedures for a Peripherally Inserted Central Catheter (PICC line - catheter inserted in the body through the arm that extends to the heart and is utilized for long term administration of intravenous [IV] medications) care for one resident (Resident #24) of one resident reviewed, resulting in a lack of dating on a PICC line dressing, Resident verbalization of concerns related to lack of care, and the likelihood for infection and alteration in overall health status. Findings include: Resident #24: On 9/12/23 at 11:53 AM, an observation and interview were completed with Resident #24 in their room. The Resident was in bed, positioned on their back. A PICC line was noted in the Resident's Right Upper Extremity (RUE). The PICC line dressing was undated. Resident #24 was asked why they had a PICC line and replied, Chemo. When queried if the facility staff maintained, assessed, and cared for the PICC line including completing dressing changes, Resident #24 revealed they are not going to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, monitor and provide oxygen per physician's orders for one resident (Resident #6), resulting in a low oxygen saturation, no oxygen application with the likelihood of confusion and continued decreased oxygen blood saturation and respiratory complications. Findings include: Resident #6: On 9/12/23, at 10:28 AM, Resident #6 was resting in their bed with their eyes closed. There was an oxygen concentrator pushed between the bed and nightstand. The oxygen tubing was curled up inside a plastic bag hooked on the concentrator out of reach. On 9/12/23, at 3:00 PM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Pacemaker and depression. Resident #6 required extensive with Activities of Daily Living and had impaired cognition. A review of the COPD care plan revealed OXYGEN SETTINGS: O2 via nasal prongs @ 2L (liters) continuous.…

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 interview and record review, the facility failed to administer Levothyroxine per physician's orders and alone on an empty stomach for three residents (Resident #6, Resident #26, Resident #38) resulting in increased dosages with the likelihood of malabsorption and increased signs and symptoms of Hypothyroidism. Findings include: Resident #6: On 9/12/23, at 3:00 PM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Pacemaker and Hypothyroidism. Resident #6 required extensive with Activities of Daily Living and had impaired cognition. A review of the Medication Administration Record for September 2023 revealed Levothyroxine Sodium 88 MCG Tablet Give 1 tablet by mouth at bedtime for hypothyroid -Start Date- 06/08/2023 2000 Carvedilol Tablet 3.125 MG Give 1 tablet by mouth two times a day . 2000 . -Start Date- 06/08/2023 2000 Resident #26: On 9/13/2023, at 4:15 PM, a record review of Resident…

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

Based on observation, interview and record review, the facility failed to administer insulin correctly for two residents (Resident #26, Resident #28), resulting in the incorrect administration with the likelihood of not receiving the entire dose of insulin. Findings include: Resident #26: On 9/14/23, at 8:10 AM, During medication observation task, Nurse K was observed preparing Resident #26's morning insulin's. Nurse K prepared a Novolog Pen for injection. Nurse K cleaned the end of the Pen, applied a needle and turned the dial to 4 units. Nurse K then cleaned the end of Basaglar Insulin Pen for Resident #26. Nurse K cleaned the end of the Basaglar Pen, applied the needle and turned the dial to 15 units. Nurse K gathered the two insulin pens entered Resident #2''s room. Nurse K cleaned their skin, injected the Novolog Insulin Pen, pushed the dial down and waited 4 seconds. Nurse K then cleaned another area of their skin, injected the Basaglar Insulin Pen, pushed the dial down and waited 4 seconds. Resident #28: On 9/14/23, at 8:40 AM, Nurse K was observed preparing morning…

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 store and label medications for one medication cart and the medication room, resulting in a multi-dose vial of Lidocaine left opened and undated and a medication cart being left unlocked and unattended for 7 minutes with the likelihood of cross-contamination, theft or medication misuse. Findings include: On 9/13/23, at 12:05 PM, the Medication cart in the B hall was pushed against the wall. The medication cart was unlocked. The drawers were facing out towards the hallway. There was one staff member sitting at the nurses' station on the phone. The nurse at the station hung the phone up and walked out of view. The Medication cart remained unlocked and out of view of any nurses. On 9/13/23, at 12:12 PM, the Assistant Director of Nurses (ADON) walked near the nurses' station. The ADON was asked if the medication carts are normally left unlocked while unattended and the ADON stated, no and locked the medication cart. On 9/13/23, at 2:49 PM, during medication storage task, an observation of the main medication room…

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.