New Brighton Care Center

Based on observation and interview, the facility failed to ensure insulin flexpens and eye drops were appropriately labeled with an opened on date to prevent expired medications from being administered in 3 of 3 medication carts. In addition, the facility failed to ensure controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 3 medication carts, and 1 of 1 medication refrigerators. This had the potential to effect all residents. Findings include: On 10/15/24 at 7:36 a.m., the medication cart located on the [NAME] wing was reviewed. Licensed practical nurse (LPN)-A stated the top drawer contained an opened multidose bottle of Dorzolamide-timolol 2-0.5% eye drops. However, it had not been labeled with the date the bottle had been opened. On 10/16/24 at 4:26 p.m., the medication cart located on the East wing was reviewed. LPN-C stated the cart contained an opened Ozempic 4 mg/3 mL (insulin) flexpen. The flexpen and/or box had not been labeled with the date the insulin had been opened. On 10/16/24 at 4:42 p.m., the medication cart located 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 interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided to 2 of 3 residents (R194 and R195) reviewed for beneficiary notices. Findings include: R194's discharge Minimum Data Set (MDS) dated [DATE], indicated R194 was admitted on [DATE] and discharged on [DATE]. R194's Notice of Medicare non-coverage form-CMS-10123 (NOMNC-CMS-10123), undated, indicated R194's services would end on [DATE]. However, R194 remained in the facility until [DATE]. R194's undated SNF Beneficiary Protection Notification Review form, indicated the facility/provider initiated the discharge from Medicare Part A when benefit days were not exhausted. R194's medical record lacked evidence the SNFABN-CMS-10055 was provided to R194 or their representative as required. R195's death in facility tracking record MDS dated [DATE], indicated R195 was admitted on [DATE] under the Medicare A benefit which may…

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 a written notification of transfer was provided for 1 of 3 residents (R7) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 1 of 3 residents (R7), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's clinical record indicated R7 was hospitalized from [DATE] through 9/6/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked progress notes which indicated the circumstances of the transfer to the hospital on 9/4/24. R7's entry tracking MDS 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 interview and document review, the facility failed to provide a written notice of a bed hold at the time of transfer for hospitalization for 1 of 3 residents (R7) reviewed for hospitalization. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's clinical record indicated R7 was hospitalized from [DATE] through 9/6/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked a progress note indicating the reason for the transfer to the hospital on 9/4/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 9/6/24. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization. R7's clinical…

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 physician orders were followed for 1 of 1 residents (R7) reviewed for skin conditions. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's progress note dated 10/5/24 at 10:23 p.m., indicated R7 called 911 at 7:50 p.m. R7 wanted to go to the hospital because the cream (ammonium lactate) that was applied to her legs made them feel numb. R7's progress note dated 10/6/24 at 2:00 p.m., indicated R7 returned from the hospital at 1:30 p.m., with no change in condition noted, no new orders, and still complained of pain in her legs. During observation on 10/13/24 at 2:52 p.m., R7's lower extremeties were swollen and red with multiple blisters covering both legs from under the knees to the ankles. On 10/13/24 at 3:07 p.m., R7 stated approximately a week prior, she had…

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 infection control measures when performing wound care for 1 of 1 residents (R25) reviewed for wound care. Findings include: R25's annual minimum data set (MDS) dated [DATE], identified R25's cognition as intact and included diagnoses of diabetes mellitus (a blood disorder characterized by impaired ability of the body to maintain proper levels of sugar in the blood), heart failure and hypertension. Further, R25 had a stage 4 full thickness pressure ulcer (an injury to the skin and tissue due to pressure on the skin for a long time) with exposed bone, tendon, or muscle. R25's current care plan identified R25 had skin alteration related to stage 4 sacral ulcer. Nursing staff were to keep skin clean and dry, provide wound care per orders, observe for changes and update provider as needed. Furthermore, R25 was to receive a skin assessment per protocol and nursing staff to observe skin with personal cares. R25's nurse practitioner (NP)…

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 2 of 5 residents (R2, R3) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old, or an adult 19-[AGE] years old with specified immunocompromising conditions, had received the complete series (i.e., PPSV23 and PCV13) then the patient and provider (shared clinical decision-making) may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20). R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was [AGE] years old and diagnoses included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. R2's immunization report, dated…

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 proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. In addition, the facility failed to store dishware in a manner preventing contamination. Further, the facility failed to ensure the ice dispensing machine was clean and free of excess mineral build up or cleaned on a regular schedule. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen and/or ice from the dining room ice machine. Dishwashing Machine During observation and interview on 11/20/23 at 12:38 p.m., the label on the side of the [NAME] AM-14 dishwasher indicated dish sanitization required a wash temperature of 150°F for a minimum of 40 seconds and rinse temperature of 180°F for a minimum of nine seconds. Dietary aide (DA)-A stated the…

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

Based on observation, interview and document review, the facility failed to ensure fans in the dish sanitization and storage area were maintained in a clean and sanitary manner to prevent dishware contamination. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: During observation of the dish washing room on 11/20/23 at 11:57 a.m., a large fan was attached to the wall near the ceiling on the dirty side where the soiled dishes came in and another smaller fan was attached to the wall on the clean side where the clean dishes were stored and put away. Both fans were turned on, oscillating, and moving air about the room, and both were covered in thick, brown dusty substance. The fan on the clean side was located approximately three feet from a shelf containing clean cups just above the counter where clean dishes were placed when removed from the dishwasher. During observation on 11/20/23, at 12:50 p.m. the smaller fan was blowing on two trays containing 16 clean cups and a tray…

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 hand hygiene was completed for 3 of 3 residents (R23, R25, R24) observed during wound cares. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R23) reviewed for toileting. Findings include: R23 R23's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and had diagnoses of chronic venous insufficiency (poor blood flow) and bilateral lower extremity vascular wounds. Furthermore, R23's MDS indicated R23 required assist of one for toileting. An observation on 11/21/23 at 7:10 a.m., licensed practical nurse (LPN)-A entered R23's room without performing hand hygiene. R23 requested to use the bed pan. Without hand hygiene, LPN-A donned gloves and obtained R23's bedpan from the bathroom. LPN-A assisted R23 to turn in bed and placed the bedpan. LPN-A then removed gloves and without performing hand hygiene left R23's room and walked down hall to obtain washcloths. At…

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

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R1, R9, R18, R21, R27) were provided education regarding risks and benefits, offered, and/or received the pneumococcal vaccine in accordance with the Centers for Disease Control (CDC) recommendations. R1's Medical Diagnosis list dated 11/22/23, included lung disease, heart failure, and opioid dependence. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 19-64 who have not received PCV15 or PCV20, with a risk factor of heart and lung disease and had a PCV13, Give one dose of PCV20 at least 1 year after PCV13. Or Give one dose of PPSV23 at least 1 year after PCV13. R1's Order Summary Report dated 11/22/23, included May receive Pneumovax if not already received unless contraindicated starting 11/2/23. R1's Immunization Report dated 11/22/23, indicated R1 refused the PPSV23 vaccine. R1's medical record lacked evidence of provision of education regarding risks and benefits. R9's Medical Diagnosis list dated 11/22/23, included autistic disorder and high blood pressure. The CDC's PneumoRecs…

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 assess residents for the ability to self administer medications for 1 of 1 resident (R2) reviewed for medications at bedside. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition and diagnoses of congestive heart failure, chronic kidney disease, and type II diabetes. R2 required extensive assistance with bed mobility, locomotion off the unit, and toileting, limited assistance with transfers and dressing, and supervision with locomotion on the unit. R2's physician's orders included orders for the following medications: 1. Albuterol Sulfate Aerosol Solution, inhale 2 puffs orally four times a day for shortness of breath. 2. Nystatin external powder 100000 unit/gram, apply to vulva topically two times a day for yeast active 9/22/2023 3. Nystatin Powder , apply to groin topically two times a day for yeast until resolved active 5/25/2021 4. Biofreeze external gel 4 %, apply to neck 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 Based on observation, interview, and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization which affected 1 of 1 resident (R13) reviewed for hospice services, and failed to ensure vascular wounds were assessed for 1 of 2 residents (R23) reviewed for wounds. Findings include: Hospice R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Further, the MDS indicated in section O R13 received hospice services in the past 7 days. Review of R13's significant change MDS date 6/9/23, indicated in section O R13 did not receive hospice services in the past 14 days. R13's Medical Diagnosis form indicated the following diagnoses: severe sepsis with septic shock (a life threatening complication of an infection), urinary tract infection, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow),…

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 a resident (R2) was assessed to safely use and store a curling iron for 1 of 1 resident reviewed for accidents. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition and diagnoses of congestive heart failure, chronic kidney disease, and weakness. It further indicated R2 was independent with personal hygiene after staff set up the supplies. R2's care plan dated 11/15/23, indicated R2 had a self care performance deficit related to weakness with an intervention of assistance of one staff with personal hygiene. During observation on 11/20/23 at 12:39 p.m., R2 was laying in bed. Next to the bed (on the right side) there was an extension cord with four outlets and one of the outlets had a curling iron plugged into it and the curling iron was laying inside the second drawer of the nightstand. During observation and interview on 11/21/23 at 8:30 a.m., licensed practical nurse (LPN)-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 interview and document review the facility failed to ensure coordination of dialysis care for 1 of 1 resident (R25) who required dialysis (treatment to filter blood when kidneys are no longer able). Findings include: R25's admission Minimum Data Set (MDS) dated [DATE], indicated R25 was cognitively intact and had diagnoses of diabetes and kidney failure. Furthermore, R25's MDS indicated R25 required dialysis treatment. R25's provider order dated 9/30/23, directed the morning nurse to ensure dialysis communication form goes with R25 for dialysis treatments every Monday, Wednesday, and Friday. R25's care plan dated 10/20/23, indicated R25 refused scheduled dialysis treatments and a goal of no missed appointments through the next review period. R25's dialysis communication sheets and dialysis run sheets were requested however not received. When interviewed on 11/20/23 at 5:08 p.m., R25 stated he had never been sent with any paperwork from the facility when going to dialysis appointments. When interviewed…

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 re-evaluate the continued use of an as needed (PRN) antianxiety medication every 14 days as required for 1 of 1 residents (R13) reviewed for PRN antianxiety medication. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severely impaired cognition. R13 was assessed to have depression. R13 had behaviors of refusing cares 1 - 3 times a week. R13 had diagnoses of depression, acute kidney failure, and atrial fibrillation. R13 received an antianxiety on a routine and PRN basis. R13's Medication Administration Records (MAR) for October 2023, and November 2023, identified R13 had an order for Lorazepam (an antianxiety)1 milligrams (mg) by mouth every four hours as needed for anxiety/restlessness. The order originated on 10/16/23, and there was no end date indicated on the MAR. R13 received the PRN medication 10 times in October and 15 times in November. R13's completed pharmacy Consultation Report with recommendation…

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 ensure a resident's environment remained free from accidents as possible to prevent falls for 4 of 4 residents (R3, R5, R6, and R7) reviewed for falls when there was a lack of evaluation of factors to prevent future falls. Findings include: R3's 5-day MDS dated [DATE], noted R3 had intact cognition, required extensive assistance of one for most activities of daily living (ADL's) and had diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, COVID-19, and type II diabetes mellitus. R3's fall risk evaluation dated 8/7/23, noted R3 was a moderate risk for falls. R3's care plan initiated on 8/7/23, noted R3 was at risk for falls due to chronic atrial fibrillation, history of falls, loss of vision. Interventions noted R3 should have his call light within reach and answered timely and to remind him to ask for assistance with transfer and ambulation. A progress note dated 8/14/23, noted R3 had a fall at 11:10 p.m.…

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 ensure that an agency nurse was oriented to the facility medication administration system for 5 of 5 resident (R1, R2, R3, R4, and R5) reviewed for medications when a nurse did not perform blood glucose testing or administer insulin. Findings include: R1's 5-day Minimum Data Set (MDS) dated [DATE], noted she was cognitively intact, required limited assistance of one person for most activities of daily living (ADL's). Her diagnoses included fracture of the left humerus, obesity, lymphedema, and type II diabetes mellitus with chronic kidney disease. R1's physician order dated 7/31/23, to check blood sugar levels before meals and at bedtime. R1's electronic medical record (EMR) contained a diabetic (DIAB) administration report for August of 2023, noted blank spaces for scheduled blood sugar checks on 8/10/23, for 7:00 a.m. and 11:00 a.m. R1's blood glucose logs for August of 2023, noted her blood glucose was checked at 4:43 p.m. and was 152 and checked…

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.