Good Samaritan Society - Mary Jane Brown

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to utilize enhanced barrier precautions (EBP) for 1 of 3 residents observed for infection prevention. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE] indicated R3 had intact cognition with diagnoses including stroke, diabetes, and depression. R3's care plan dated 12/4/24 indicated R3 required EBP related to indwelling medical devices: urinary catheter and feeding tube. R3's care plan instructs to don (put on) gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, checking and changing, device care and/or use, and wound care. On 12/27/24 at 11:17 a.m., registered nurse (RN)-A and nursing assistant (NA)-A were observed entering R3's room with a full mechanical lift. A magnet on the doorframe of the room indicated enhanced barrier precautions were required for high contact resident care activities including…

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 complete a comprehensive bladder assessment and develop an individualized toileting program to restore, maintain, or prevent a decline in continence for 2 of 2 residents; R3 who had a change in mobility and R2 who had a documented decline in continence. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment with diagnoses of cancer, heart failure, arthritis, and Parkinson's disease. R3 had no impairment of range of motion and used a walker. R3 was independent with his activities of daily living (ADLs) except needed supervision with eating and oral hygiene. R3 had no history of falls. R3 was always continent of bowel and bladder and did not have a toileting program. R3's bowel and bladder assessment from the Nursing Admit Re-Admit data collection ([NAME]) tool, dated 6/6/24, indicated R3 was continent of bowel and bladder. No other bowel and bladder information was included on the assessment. R3's care…

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 accommodate the needs for 1 of 1 residents (R1) who required a two-handled cup for drinking liquids. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/5/24, directed staff to place table over bed lined up with paper on the wall, in front of R1 but not over his hands. R1 requires moderately thick water to be on the table in a double handled cup with a lid. On 2/6/24 at 4:51 p.m., R1 was observed laying in his bed which was along the wall, bed side table was noted to be in the middle of the room and had a one handled water pitcher on it. There was a bright orange sign posted on the wall, on R1's right side, that directed staff to place bedside table lined up with the paper and moderately thick water to be placed on the table in a double handle cup with a lid. There was also a plastic disposable cup with thickened water…

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 document review the facility failed to ensure an injury of unknown was consistently assessed and monitored for healing progress for 1 of 3 residents (R1) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/4/24, indicated R1 was at risk for pressure ulcer development and R1 always required heel protectors on while in bed. R1's physician progress note dated 1/9/24, revealed R1 was assessed, and no skin concerns were identified. R1's Skin Observation revealed: -On 1/21/24, R1 was noted to have a small brown area on left heel. -On 1/28/24, lacked evidence of R1's heel progress. -On 2/4/24, R1's left outer heel had a small, scabbed area. R1's Wound Data Collection dated 2/6/24, indicated R1 had a distal scabbed area on left heel and was noted to be 2 centimeters (cm) in length and 1 cm wide. Scab was noted to be firmly attached and no redness or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure an injury of unknown was consistently assessed and monitored for healing progress for 1 of 3 residents (R1) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/4/24, indicated R1 was at risk for pressure ulcer development and R1 always required heel protectors on while in bed. R1's physician progress note dated 1/9/24, revealed R1 was assessed, and no skin concerns were identified. R1's Skin Observation revealed: -On 1/21/24, R1 was noted to have a small brown area on left heel. -On 1/28/24, lacked evidence of R1's heel progress. -On 2/4/24, R1's left outer heel had a small, scabbed area. R1's Wound Data Collection dated 2/6/24, indicated R1 had a distal scabbed area on left heel and was noted to be 2 centimeters (cm) in length and 1 cm wide. Scab was noted to be firmly attached and no redness or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide an altered diet as prescribed for 1 of 2 residents (R3) reviewed for nutrition. Findings include: R3's quarterly Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included dementia, diabetes, and dysphagia. Further, MDS revealed R3 had severely impaired cognition and required a mechanically altered and therapeutic diet. R3's physician orders dated 10/2/23, indicated R3 required a pureed textured diet. R3's care plan as of 2/6/24, indicated R3 was able to independently eat at times however required cues from staff as R3 was noted to stop chewing. Staff were expected to assist R3 was eating if needed and give R3 small bites. On 2/6/24 at 5:45 p.m., R3 was served her dinner plate by dietary aid (DA)-A. Nursing assistant (NA)-A was seated on R3's right side, assisting R3 with her meal. NA-A was noted to say R3 would not eat for NA-A. R3 was observed to have mashed potatoes and pasta noodles with red sauce on her…

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 document review, the facility failed to ensure sufficient staff to provide and meet the assessed needs for 4 of 4 residents (R26, R27, R35, R250) who voiced concern with lack of sufficient staffing in the facility and/or were observed to have assessed needs not provided per staff. In addition, the facility failed to ensure sufficient staff to provide assistance with meals. The lack of sufficient staff had the potential to affect all 47 residents who resided in the facility. Findings include: R26 R26's face sheet printed on 10/18/23, included diagnoses of Parkinson's disease (abnormal body movement), muscle weakness, atrial fibrillation (abnormal heart rate), gait abnormality, cognitive-communicative deficit (abnormal thinking/speaking), hypovolemia (low blood volume), hypotension (low blood pressure), abnormal coagulation (blood clotting), and frequency of micturition (frequency of urination) R26's significant change in status minimum data set (MDS) assessment dated [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 Based on observation, interview, and document review, the facility failed to mark/date opened containers of food stored in one of three kitchen refrigerators, stand-up freezer, and walk-in freezer, failed to ensure expired food were identified and removed, and failed to ensure the walk-in freezer vent was in safe working condition and food was stored away from leaking vent. This had the potential to affect all 47 residents who were served food and beverages from the facility kitchen. Findings include: During observation and interview of the kitchen on 10/16/23 at 12:36 p.m., with dietary manager (DM)-A, observed food items in the walk-in refrigerator, walk-in freezer, standup freezer, and resident refrigerator that were not dated or marked and/or were expired. DM-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators and freezers should be gone through at least weekly to check for expired or damaged food. DM-A indicated if any food or drink item…

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 document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 47 residents. Findings include: Review of quarterly QAPI meetings from January 2023 through April 2023, identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to analyze and document that process identified in: January 2023 1. The aim was to reduce falls with major injury, the data identified the state norm, the national norm, and the facility rate. The QAPI minutes lacked any indication of a measurable goal, or an action plan to improve the rate of falls with major injury. 2. The aim was to reduce significant weight loss with a goal to have less than 3 residents without a program trigger for significant weight loss. The data identified there were 4 triggered in November and 3 triggered in December. The QAPI minutes lacked any indication of an action plan or plan for…

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

Based on observation, interview, and document review, the facility failed to ensure the walk-in freezer vent was maintained in a safe and functional manner. This had the potential to affect all 47 residents who resided within the facility. Findings include: An initial walk through of the kitchen was completed with dietary manager (DM)-A on 10/16/23 at 1:07 p.m., observed the walk-in freezer had a large amount of condensation present to freezer vent, large amount of ice present on coiling, a 3-4 tier metal rack containing frozen food items directly below freezer vent, top tier containing frozen sealed loafs of bread were completely covered with large chunks of ice, sporadic smaller ice chunks on boxes containing frozen foods to rest of metal tiers, ice spots noted to walk-in freezer flooring next to metal rack. DM-A indicated awareness of condensation build-up to freezer vent over past 1-2 weeks, maintenance checked out and cleared condensation build-up, stated condensation continued. DM-A stated same issue occurred approx. 3-4 mos. ago, had to contact refrigeration company to fix.…

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 document review, the facility failed to follow proper infection control practice for 1 of 1 resident (R27) reviewed for urinary catheter. In addition, the facility failed to offer hand sanitization prior to serving meals to 3 of 3 residents (R1, R3, R39), who required staff assistance for to maintain clean hygiene, reviewed for dining. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact, had clear speech, was understood and able to understand others, was dependent upon staff for bed mobility, transfers, and toileting cares, did not walk, and used a wheelchair for mobility. R27's MDS also indicated R27 did not display any behaviors including rejection of cares, had an indwelling catheter for urination, was frequently incontinent of bowel, had diagnoses including cerebrovascular infarction (stroke), hemiparesis/hemiplegia (paralysis), diabetes mellitus (abnormal blood sugar), renal (kidney) insufficiency, obstructive…

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 document review, the facility failed to ensure 3 of 5 residents (R5, R38, and R41) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 30 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior…

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 document review, the facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care when transferred emergently to the hospital for 1 of 4 residents (R26) reviewed for accidents. Finding include: R26 was admitted to the facility on [DATE]. R26's diagnoses listed on face sheet received on 10/18/23, included Parkinson's disease (abnormal body movement), muscle weakness, atrial fibrillation (abnormal heart rate), gait abnormality, cognitive-communicative deficit (abnormal brain/speech processing), hypotension (low blood pressure), abnormal coagulation (blood clotting), frequency of micturition (frequency of urination), and urinary tract infection (UTI). R26's medicare 5-day minimum data set (MDS) assessment dated [DATE], identified R26 had intact cognition, had clear speech, was able to understand and understood by others. R26 required limited assist from staff for transfers, extensive assist from 1…

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 document review, the facility failed to provide a written copy of the bed hold policy for 1 of 4 residents (R26) reviewed for accidents, who was transferred emergently to the hospital. Findings include R26 was admitted to the facility on [DATE]. R26's diagnoses listed on face sheet received on 10/18/23, included Parkinson's disease (abnormal body movement), muscle weakness, atrial fibrillation (abnormal heart rate), gait abnormality, cognitive-communicative deficit (abnormal brain/speech processing), hypotension (low blood pressure), abnormal coagulation (blood clotting), frequency of micturition (frequency of urination), and urinary tract infection (UTI). R26's medicare 5-day minimum data set (MDS) assessment dated [DATE], identified R26 had intact cognition, had clear speech, was able to understand and understood by others. R26 required limited assist from staff for transfers, extensive assist from 1 staff with toileting. R26 used a walker and wheelchair for mobility. Facility transfer…

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 revise the care plan for 1 of 1 resident (R5) after being updated multiple times by family of R5's preference to wear a brassiere (bra) daily. Findings include: R5's 8/15/23, quarterly Minimum Data Set (MDS) identified R5 was cognitively impaired and had diagnosis of depression, stroke, obesity, muscle weakness, and cognitive communication deficit. Interview on 10/16/23, at 5:44 p.m., with FM-(A) identified that he had asked at care conference multiple times to make sure R5 had a bra on each morning, however when FM-A comes to visit in the afternoon, R5 does not have a brazier on. FM-A identified that when family expresses concern at care conference, they notice a change for a week or two, then things go back to the way they were, he stated care conference feels like a waste of my time. R5's undated, current care plan printed 10/18/23, identified R5 required extensive assistance with dressing, bed mobility, and is dependent on staff for transfers and toileting. R5's care plan lacked any indication that she…

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 document review, the facility failed to provide activities of daily living (ADLs) including shaving and bathing cares for 1 of 4 residents (R250) reviewed for ADLs, and who required supervision to limited staff assistance to maintain good personal hygiene. Findings include: R250's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R250 had intact cognition and required supervision to limited staff assistance with personal hygiene and bathing cares. R250's care plan was revised and printed on 10/18/23; indicated R250 was an early riser, staff to offer to assist or supervise with AM/PM cares, required supervision and cues with personal hygiene- offer to assist if required, and staff to assist with bathing cares twice weekly on Tuesday and Saturday during day. During an observation and interview on 10/16/23 at 2:40 p.m., R250 was observed to have long facial hair present above lips, facial hair approx. 1-2 cm in length. R250 indicated needing assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure restorative services were completed to maintain and/or improve mobility for 1 of 3 residents (R27), who required range of motion (ROM), reviewed for mobility. Findings include: R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 had intact cognition, had impairment to left upper extremity and bilateral lower extremities, required extensive assist from 2 staff for bed mobility and transfers, did not walk and used a wheelchair for mobility. R27's diagnosis report printed on 10/18/23, indicated hemiplegia and hemiparesis (paralysis) of left side of body, cerebral infarction (stroke), type 2 diabetes mellitus ((DM)- abnormal blood sugar), cognitive communicative deficit (abnormal processing of thinking/speaking), muscle weakness, major depression (mood disorder), and pain. R27's order summary report printed on 10/18/23, indicated orders for activity level as tolerated with assistance and restorative services…

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 document review, the facility failed to ensure 1 of 1 resident's (R1) oxygen had been administered per physician orders. Findings include: R1's August 2023, admission record identified diagnoses of pulmonary hypertension (high blood pressure that affects the arteries in the lungs), asthma, abnormal heart rhythm and heart failure. R1's 9/23/23, Physicians Order Summary Report identified R1 was to receive oxygen at 2 liters (L) per minute (PM), continuously via nasal cannula (NC). There was no mention R1 had orders to titrate her oxygen for supplemental purposes at any other rate other than the 2 LPM. R1's 9/25/23, 5 Day Minimum Data Set (MDS) assessment, identified R1's cognition was intact. The MDS failed to identify R1 used oxygen therapy. R1's progress notes identified on: 1) 10/3/23, 10/5/23 and 10/6/23, R1 was administered oxygen at 1.5 LPM via NC. 2) 10/7/23, 10/15/23 and 10/18/23, R1 was administered oxygen at 1 LPM via NC. R1's undated, current care plan identified R1 had asthma and required scheduled nebulizing medications use to enhance…

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 document review, the facility failed to individualize the care plan to include target behaviors for psychotropic medication use for 3 of 5 (R1, R38, and R40) residents. Findings include: R1's August 2023, admission Record identified a diagnoses of vascular dementia, schizoaffective disorder (mental illness that can affect your thoughts, mood and behavior), depression, and anxiety. R1's 9/25/23, 5-day Minimum Data Set (MDS) assessment identified R1 had no behaviors noted. R1 required assistance with activities of daily living. R1's 10/12/23, signed medication review report identified the following: 1) risperidone (antipsychotic) 2mg at night, start date of 8/22/23. 2) vilazodone (antidepressant) 20mg daily and buproprion (antidepressant) 300mg daily, start date of 8/23/23. R1's undated, care plan indicated, R1 was prescribed risperidone related to vascular dementia without behavioral, psychotic, mood disturbance and anxiety. Staff were to monitor resident on guidelines related to use of risperidone and consult pharmacy to consider dosage reduction 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 document review the facility failed to ensure staff followed the facility policy and protocols to verify narcotic count to prevent potential diversion for 1 of 1 resident (R18). Additionally, the facility failed to ensure insulin pens were appropriately labeled according to manufacturer's guidelines with an open date for 2 of 3 residents (R2 and R21). Findings include: Observation and interview on 10/18/23 at 3:05 p.m., of registered nurse (RN)-B and licensed practical nurse (LPN)-B, and the regional consultant identified they were in the process of verifying the narcotic count of medication in the west wing medication cart. RN-B revealed R18's liquid morphine sulfate was unaccounted for during narcotic count. RN-B reported R18's morphine had been delievered the evening R18 had passed away (10/2/23). The medication was meant to be sent back to the pharmacy for credit and had not logged the morphine into the bound book but with time constraints that evening that had not occurred. RN-B and LPN-B confirmed pharmacy delivers medications/narcotics 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.

Based on document review and interview, the facility failed to ensure 1 of 1 required members (infection preventionist) and/or thier designee attended and documented the attendance at the quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the January 2023, through July 2023, quarterly Quality Assurance and Performance Improvement (QAPI) meeting minutes attendance record did not identify the facility infection preventionist was present at the July 2023 meeting. Interview on 10/17/23, at 11:54 a.m., QAPI coordinator identified the infection preventionist could not make it to the meeting and they did not delegate anyone to stand in her place. Interview on 10/18/23, at 4:04 p.m., with administrator identified it was his expectation that the appropriate people would be at QAPI as required and as identified in the QAPI plan and would have expected the infection preventionist to delegate another team member with similar qualifications to go in her place if she was not able to attend. Review of the 2023 QAPI plan identified the medical director,…

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.