Medilodge of Lansing

Based on observation and interview the facility failed to provide and maintain therapy equipment in a manner that would allow for safe and consistent operation that meets the needs of all residents. Findings Include: An interview with Physical Therapy Manager (PTM) U, at 2:50 PM on 10/1/24, found that some equipment in therapy has not been working properly for all residents. When asked what issues have been occurring, PTM U went on to state that the parallel bars are not wide enough to be used properly for our residents who are bariatric. When asked how they are used for those residents now, PTM U stated that those residents have to use the side of the parallel bars and that makes them unable to use both sides to stabilize as they walk down. When asked about any other equipment, PTM U stated that the ScitFit elliptical bike doesn't seem to be working properly and that the resistance doesn't increase sometimes as the dial gets turned up. PTM U stated that some residents have noticed that as they want to increase the resistance and work harder on their recovery, the bike doesn't seem…

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 revise care plans for three (Resident #34, #57, and #62) of 16 reviewed. Findings include: Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included Parkinson's Disease and unsteadiness on feet. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/24 revealed R34 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the fall care plan initiated on 2/1/24 revealed the following interventions: - Place walker within reach of bed on the left side - Resident often chooses to use four wheeled walker despite therapy recommendations and education of risks. Therapy gave resident standard front wheeled walker - Encourage resident to slow down with his motorized wheelchair - Dycem to wheelchair Review of the Activities of Daily Living (ADL) care plan 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 prevent an elopement and respond timely to a door alarm for one (Resident #33) of one reviewed. Findings include: Review of the medical record reflected Resident #33 (R33) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified dementia, unsteadiness on feet and disorientation. The modified admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R33 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R33 was coded for wandering one to three days during the assessment look-back period that placed them at significant risk of getting to a potentially dangerous place, such as stairs or outside of the facility. On 10/01/24 at 10:10 AM, R33 was observed ambulating in the hallway, using a rolling walker. A wanderguard bracelet was observed on their left ankle. On 10/03/24 at 7:29 AM, R33…

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 monitoring of an antipsychotic medication according to provider recommendations for one (Resident #58) of five reviewed. Findings include: Review of the medical record reflected Resident #58 (R58) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included mood disorder due to known physiological condition, major depressive disorder and anxiety disorder. The modified quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/24, reflected R58 had short-term and long-term memory impairments. On 10/01/24 at 1:34 PM, R58 was observed seated on their bed. R58's medical record reflected an order for 25 milligrams (mg) of Quetiapine Fumarate (Seroquel/antipsychotic medication) to be given in the morning for mood disorder due to known physiological condition. An additional order reflected R58 was to receive 100 mg of Quetiapine Fumarate at bedtime for mood disorder due to known…

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 their medication error rate was below 5% when two medication errors were observed from a total of 25 opportunities for two residents (Resident #22 and Resident #36) of four reviewed resulting in a medication error rate of 8%. Findings include: Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urosepsis (urinary tract infection that leads to sepsis). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/24 revealed R36 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 10/1/24 revealed ertapenem sodium solution (antibiotic) 1 gram intravenously (IV) every 24 hours for infection, complicated urinary tract infection, for four days. Review of the Medication Administration Record (MAR) 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 This citation pertains to intake: MI00143250, MI00143278 Based on observation, interview, and record review the facility failed to insure that one resident #1 (R1) was free from significant medications errors out of four residents reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 03/17/2023 with diagnoses that included nontraumatic intracerebral hemorrhage (stroke), Schizoaffective Disorder Bipolar type, hemiplegia (paralysis) affecting right dominate side, post-traumatic stress disorder (PTSD), dysphagia (swallowing difficulties), depression, hypertension, adjustment disorder with mixed anxiety and depression, muscle weakness, cognitive communication deficit, and hypokalemia (lower than normal potassium in bloodstream). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2024, demonstrated R1 had 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 observation, interview, and record review, the facility failed to maintain a sanitary kitchen, date mark potential hazardous foods, and maintain the ice machine, resulting in the potential biological contamination of food products, affecting all residents that consume food from the kitchen. Findings include: On 7/18/23 at 8:07 AM, during an inspection of the kitchen, the floor/wall juncture behind the stainless steel coffee table was observed to be soiled with soil and food debris. Additionally, the floor tile grout around the dish machine drain board and underneath the dish machine was observed to be dissolving, leaving gaps for water to accumulate. During an interview on 7/18/23 at 8:23 AM, Dietary Manager L was queried on how often the floor are cleaned and stated, I don't really keep track. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during…

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 #64 (R64) Review of the medical record revealed R64 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses that included diabetes, lymphedema, major depressive disorder, acute kidney failure, hypertension, pain, and cellulitis. Review of the Nursing admission Evaluation dated 8/26/22 revealed R64 had a right heel pressure ulcer. Review of the Skin & Wound Evaluation dated 8/30/22 revealed R64's wound was a diabetic ulcer. Review of the Physician's Progress Note dated 9/22/22 revealed R64 had a right heel diabetic wound. Review of the Physician's Progress Note dated 9/26/22 revealed R64 had a diabetic foot ulcer. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/22 revealed R64 had an unstageable pressure ulcer. Review of the discharge MDS with an ARD of 9/27/22 revealed R64 had an unstageable pressure ulcer. In an interview on 07/19/23 at 10:19 AM, MDS Coordinator G reported she coded R64's skin based on the admission skin assessment. MDS…

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 revise care plans for four (Resident #17, #26, #35 and #38) of 16 reviewed for Care Plans, resulting in inaccurate care plans and the potential for unmet care needs. Findings include: Resident #26 (R26): Review of the medical record reflected R26 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, diabetes and vascular dementia. The Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/21/23, reflected R26 had short-term and long-term memory problems and required limited to total assistance of one to two or more people for activities of daily living (ADLs). On 07/20/23 at 7:44 AM, R26 was observed seated in a broda chair, watching TV in her room. R26 was non-verbal when spoken to. A Progress Note by the physician on 4/14/23, reflected, .I was requested 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 ensure current Letters of Guardianship were accessible in the medical record for one (Resident #43) of one reviewed for advance directives, resulting in the potential for medical and treatment decisions to be made by an inactive Guardian. Findings include: Review of the medical record reflected Resident #43 (R43) admitted to the facility on [DATE], with diagnoses that included traumatic hemorrhage of cerebrum, chronic respiratory failure and tracheostomy status. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R43 did not walk and required total assistance of one to two or more people for activities of daily living. On [DATE] at 8:02 AM, R43 was observed up, in a broda chair (specialty chair), with his eyes closed. Orthotic devices were in place to both hands, and pillow boots were in place to both feet. A pillow was observed between his knees. R43 was non-verbal. Upon review of R43's medical…

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 provide sufficient notice of medicare non-coverage for one (Resident #3) of three reviewed, resulting in Resident #3 not having sufficient time to allow for an appeal Findings include: Review of the medical record revealed Resident #3 (R3) admitted to the facility on [DATE] and readmitted [DATE]. Medicare A services began on 1/19/23 and ended on 5/2/23. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. The effective date listed on R3's NOMNC was 5/2/23. The form was signed by R3 on 5/2/23. In an interview, 07/19/23 at 3:57 PM, Nursing Home Administrator (NHA) A reported R3's last covered day of Medicare A services was 5/2/23 and R3 received the notice on 5/2/23. NHA A reported the facility was first notified on 5/2/23, via email, that R3's coverage was ending. When asked to provide documentation…

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

Based on interview and record review the facility failed to report allegations of abuse for one resident (#61) of 3 residents reviewed abuse resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 05/02/2023 with diagnoses that included supraventricular tachycardia, stage 4 kidney disease, atrial fibrillation, type 2 diabetes, ischemic heart disease, anemia (low red blood cell count), morbid obesity, adjustment disorder with anxiety and depression, gastro-esophageal reflux, hypothyroidism (low thyroid hormone), chronic congestive heart failure (CHF), major depression, hyperlipidemia (high fat in blood), pain of the right hip, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2023, revealed R61 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. R61 was discharged from 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 This citation pertains to Intake MI00138169 Based on interview and record review, the facility failed to shower/bathe one resident (Resident #64) of one reviewed, resulting in the potential for uncleanliness and embarrassment. Findings include: Review of the medical record revealed Resident #64 (R64) was admitted to the facility on [DATE] and discharged [DATE] with diagnoses that included diabetes, lymphedema, major depressive disorder, acute kidney failure, hypertension, pain, and cellulitis. The admission Minimum Data Set (MDS) revealed R64 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required total dependence on one person for bathing. R64's tasks revealed she was to receive a bath Mondays and Fridays. Review of R64's Bath Report revealed R64's first bath was provided on 9/11/22. R64 had been in the facility for 14 days before a shower/bath was documented. The medical record did not reveal any refusals of showers/baths during that time. In an interview 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 observation, interview and record review, the facility failed to 1) ensure coordination of care with an outside provider for one (Resident #28) of 15 reviewed for quality of care; and 2) identify, assess and monitor a wound for one (Resident #17) of 15 reviewed for quality of care, resulting in the potential for lack of care coordination, worsening wounds and delayed wound healing. Findings include: Resident #28 (R28): Review of the medical record reflected R28 admitted to the facility on [DATE], with diagnoses that included aphasia, tracheostomy status and history of malignant neoplasm of the larynx. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/17/23, reflected R28 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent with activities of daily living. On 07/18/23 at 9:07 AM, R28 was observed lying in bed. A Larytube (silicone tube designed to maintain an airway of a laryngectomy) was in…

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 tube feeding was provided according to physician's orders for one (Resident #43) of one reviewed for tube feeding, resulting in the administration of a tube feeding formula that was not ordered and the potential for weight loss and nutritional deficits. Findings include: Review of the medical record reflected Resident #43 (R43) admitted to the facility on [DATE], with diagnoses that included traumatic hemorrhage of cerebrum, chronic respiratory failure and tracheostomy status. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/23/23, reflected R43 did not walk and required total assistance of one to two or more people for activities of daily living. On 07/18/23 at 11:21 AM, R43 was observed lying in bed, with the head of the bed elevated. A tube feeding pump was observed to the left bedside, not actively infusing. A bottle of Jevity 1.2 cal tube feeding formula was hanging, dated 7/18, for what appeared…

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 an additional LaryTube (silicone tube designed to maintain an airway of a laryngectomy) was in the room for one (Resident #28) of one reviewed for respiratory care, resulting in the potential for delay in obtaining necessary supplies in an emergency situation. Findings include: Resident #28 (R28): Review of the medical record reflected R28 admitted to the facility on [DATE], with diagnoses that included aphasia, tracheostomy status and history of malignant neoplasm of the larynx. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/17/23, reflected R28 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent with activities of daily living. On 07/18/23 at 9:07 AM, R28 was observed lying in bed. A Larytube was in place, secured with a collar/strap. R28 was not able to speak, but she communicated by mouthing words or writing. R28…

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 follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of three medication carts resulting in the potential for controlled medication diversion. Finding Included: During observation of D hall 1st medication cart on 07/19/2023 at 11:20 a.m. it was observed that the facility Narcotic Shift Count record was last signed by two nurses on 07/18/2023 at 07:00 p.m. The off going nurse section was signed for the date of 7/19/2023 at 06:30 a.m. The on coming nurse section for the date of 07/19/2023 at 06:30 a.m. was blank. During this observation Licensed Practical Nurse (LPN) E signed the on coming nurse section for the date of 07/19/2023 at 06:30 a.m. During observation of D hall 2nd medication cart on 07/19/2023 at 11:32 a.m. it was observed that the facility Narcotic Shift Count record was last signed by two nurses on 07/18/2023 at 07:00 p.m. The off going nurse section was signed for the date of 7/19/2023 at 06:30 a.m. The on coming nurse section for the date of 07/19/2023…

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 physician ordered parameters upon the administration of blood pressure medications for one (Resident #56) of five residents reviewed, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record revealed Resident #56 (R56) admitted to the facility on [DATE] with diagnoses that included starvation, bipolar disorder, and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/23 revealed R56 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 7/18/23 at 8:23 AM, R56 was observed lying in bed. Review of the physician's order dated 6/2/23 revealed an order for metoprolol 25 mg by mouth in the morning for hypertension (high blood pressure). Hold for systolic blood pressure less than 110 or heartrate less than 60. This order started on 6/3/23 and ended 7/14/23. Review of the Medication Administration…

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 clinical justification for the use of psychotropic for two residents (#26,#38) of five residents reviewed for unnecessary medication, resulting in the potential for unnecessary medication. Findings Included: Resident #38 (R38) Review of the medical record revealed R38 was admitted to the facility 11/17/2022 with diagnoses that included stage 4 pressure ulcer to right buttock, pressure ulcer of right upper back, stage 4 pressure ulcer of left elbow unstageable stage 2 pressure ulcer of sacral region, anemia (low red blood cells in blood), severe protein calorie malnutrition, quadriplegia (paralysis of all four limbs), cervical disc displacement at cervical 5 through cervical 6 level, hypotension, major depression, migraines, post-traumatic stress disorder, bradycardia (low heart rate), chronic pain, anxiety disorder, colostomy, and neuromuscular dysfunction of the bladder. The most recent Minimum Data Set (MDS), with an 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 ensure the medication error rate was less than 5% when two medication errors were observed from a total of 25 opportunities for one resident (Resident #49) of six residents reviewed for medication administration, resulting in a medication error rate of 8% and the potential for adverse reactions/side effects. Findings include: Review of the medical record revealed Resident #49 (R49) admitted to the facility on [DATE] with diagnoses that included pseudobulbar affect and anxiety. On 7/19/23 at 7:27 AM, Licensed Practical Nurse (LPN) E was observed prepared and administered medications to R49 which included a Nuedexta 20-10 milligram (mg) tablet and a hydroxyzine pamoate 25 mg tablet. R49 took the medications by mouth. Review of the physician's order dated 6/15/23 revealed hydroxyzine (Vistaril) was ordered to administer through R49's feeding tube. The physician's order dated 6/21/23 revealed Nuedexta was ordered to administer through R49's…

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 track and provide the pneumococcal vaccination timely for one (Resident # 13) of five residents reviewed for immunizations, resulting in the potential for incomplete vaccination, and the potential for serious illness and complications from pneumococcal disease. Findings include: Review of the medical record revealed that Resident #13 (R13) was readmitted to facility 8/16/2021 with diagnoses including Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, and Vascular Dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/23 revealed that R13 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Section O of the same MDS indicated that R13 received the Influenza Vaccination on 10/28/2022 and that R13's Pneumococcal Vaccine was up to date. Review of the paperwork titled Letters of Guardianship, scanned into R13's medical…

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

Based on interview and record review, the facility failed to provide a requested COVID-19 bivalent booster in a timely manner for one (Resident #7) of five residents reviewed for immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings included: Review of the medical record revealed that Resident #7 (R7) was admitted to facility 4/12/23 with diagnoses including Unspecified Dementia, Parkinson's Disease, and unspecified heart failure. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/23 revealed that R7 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Durable Power of Attorney for Health Care (DPOA-HC) paperwork indicated that R7 named his son as DPOA-HC, and to make decisions for R7, when he was no longer able to make his own decisions. Review of R7's prior vaccination history contained within Immunization tab reflected that R7 had received a COVID 19 vaccination on 1/30/21 and 2/27/21 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.