Life Care Center Of Carrollton

Refer to Event ID 1PK412. This deficiency is uncorrected. For previous examples, please refer to Statement of Deficiencies dated 1/5/24. Based on observation, interview and record review, the facility failed to ensure facility staff provided three of 15 sampled residents (Resident #2, #43, and #46), that were unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene, when staff failed to reposition or provide incontinent care within a timely manner. The facility census was 59.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to promote the residents right to make choices regarding foods served for Residents #10, #35, #53 and #58 out of 15 sampled residents. The facility census was 59. Review of the facility's Resident Rights policy, with a review date of 9/25/23, showed: -The resident has a right to a dignified existence and self-determination; -The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident; -The resident has a right to a safe, clean, comfortable and homelike environment including but hot limited to receiving treatment and supports for daily living. Review of the facility's Menus, Substitutions and Alternatives, revised 4/14/23 showed: -Residents with known dislikes of food and beverage items, are offered a substitute of similar nutritive value; -The facility menu has a planned alternate that is nutritionally equivalent; -Residents' preferences are followed to the extent possible;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview , the facility failed to keep the floors, doors and handrails in good repair. The facility census was 59. Review of the facility provided Daily Cleaning policy reviewed 7/19/23 showed: -The resident has the right to a safe, clean, comfortable, and homelike environment. -The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. The facility did not provide a policy on maintenance of floors, handrails and doors. Observations beginning on 1/3/24 at 2:26 P.M. showed areas of missing floor tile strips in multiple hallways that caused rough surfaces with crusted red and black debris and uneven flooring. These areas included: -five foot (ft) by 1 inch (in) strip outside of room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -four ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside the staff break room; -ten ft by 1 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 interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which there resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of practice when they did not clean the port of two insulin pens, which affected two of 15 sampled residents, (Resident #21, and #45 ), failed to clean the port on the vial of insulin for Resident #45, and failed to appropriately change a water humidification system for one resident (Resident #17) . The facility census was 59. Review of the facility's policy, for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections…

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 facility staff provided two of 15 sampled residents (Resident #2 and Resident #21), that was unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene. The facility census was 59. Review of the facility provided policy Activities of Daily Living (ADL's) Reviewed 8/23/23 showed: -The resident will receive assistance as needed to complete ADL's; -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene; -Assist residents with bed/wheelchair positioning as necessary to promote good body alignment and to prevent skin breakdown. 1. Review of the resident #2's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 11/6/23 showed: -Brief Interview of Mental Status (BIMS) of 99, indicated severe cognitive deficits;…

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 observations, record review and interviews, the facility staff failed to provide activities to four (Resident #49, #25, #40 and #44) out of 15 sampled residents. The facilty census was 59. Review of the activites policy dated 9/21/23 showed: - The activities will be directed by a qualified Activities Director (AD); - The AD develops, implements, and supervises the resident activities; - The faciliy should implement an ogoing resident-centered activity program that incorpaortes the resident's interests and prefernces; - The activity porgram should improve the resident's physical and psychosocial well being; - The acitivity program should create opprotunities for the residents to have a meaningful life. 1. Reveiw of Resident #49s quarterly Minimum Data Set, (MDS, a federally mandated assessmet completed by the facility staff), dated 10/3/23 showed: - The resident had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment; - He/She required assistance of one staff to get…

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 observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infections (UTIs) or the possibility of a UTI when staff failed to clean the drainage spout appropriately and placed the graduate ( a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected two of 15 sampled residents, ( Resident #21 and #39). The facility census was 59. Review of the facility's policy for indwelling urinary catheter (Foley) management, reviewed 8/24/23, showed, in part: - The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed: insertion , ongoing care and catheter removal protocols that adhere to to professional standards of practice and infection prevention and control procedures. 1. Review of Resident #39'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 observations, interviews, and record review, the facility failed to ensure staff administered medications with a less than five percent medication error rate (5%). Staff made seven errors out of 25 opportunities for error, which resulted in an error rate of 28%. This affected 2 out of 15 sampled residents, ( Resident #26 and #45). The facility census was 59. Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial; - Meal time administration - Humalog insulin may be given within 15 minutes before or immediately after a meal; - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum…

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 observations, interviews, and record review, the facility failed to ensure staff discarded an a expired open bottle of Lorazepam for Resident #46, failed to discard an expired open vial of house stock Lorazaepam, and failed to discard two bottles of expired house stock Fish Oil. The staff also failed to date and put the resident's name on an insulin pen after opening and failed to keep the medication cart free of loose pills. Additionally the staff failed to ensure resident's with medications at bedside (Resident #58 and Resident #29) had a physician's order to keep the medications at the bedside. The facility census was 59. Review of the facility's Storage and Expiration Dating of Medications and Biologicals, revised 8/7/23, showed: -The facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts and refrigerators and freezers; -Once any medication or biological is opened the facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened…

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

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 59. Review of the facility's Department Leadership Requirements Policy, revised 8/15/22 showed: -The food and nutrition services department operates under the direction of a qualified individual who has appropriate competence and skills necessary to oversee the functions of the food and nutrition services. If a full-time dietician is not employed, the executive director designates a qualified person to serve as full time Director of Food and Nutrition Services with frequently scheduled consultations from a qualified dietician or other clinically qualified nutrition professional. -If a qualified dietitian or clinically qualified nutrition professional is not employed full time, the facility must designate a person to serve as the director of food and nutrition services who is: o A certified dietary manager or a certified food service manager;…

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, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 59. Review of the facility's Cleaning Schedule Policy, revised 12/17/21, showed: -The Director of Food and Nutrition Services develops a cleaning schedule with assistance from the Registered Dietitian to ensure the kitchen remains clean and sanitary at all times; -The cleaning schedule is posted in a location where it can be easily read; -The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately. Review of the facility's Food Safety Policy, revised 4/27/22, showed: -Food is stored and maintained in a clean, safe and sanitary manner to minimize contamination and bacterial growth; -Food is stored a minimum of six inches off the floor; -Pre-packaged food is placed in a leak proof, pest proof, sanitary container with a tight fitting lid;…

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 observations and interviews the facility staff failed to maintain an effective infection control program when staff did not wash or sanitize their hands when passing resident food trays, when assisting one resident to eat (Resident #25), when staff left and entered the dining room during the meal service and when no hand hygiene was completed when eye drops were administered to one resident (Resident #49). The facility census was 59. Review of the hand hygiene policy dated 6/13/23 showed: - AN alcohol- based hand rub is acceptable in most instances when the hand are not visibly soiled; - The staff should perform hand hygiene before and after contact with the residents; - The staff should perform hand hygiene before eating; - The staff should perform hand hygiene after contacts with objects in the residents environment. 1. Review of Resident #25's quarterly MDS dated [DATE] showed: -He/She had a BIMS score of 0, indicating severely impaired cognitive function; - He/She had no behaviors; - He/She was…

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

Based on observation, interview and record review the facility failed to provide adequate supervision during the noon meal in the dining room of the facility's memory care unit and failed to monitor the safety and choking risks of one resident (Resident #40) out of the 15 sampled residents; when the resident was observed eating food items from other residents' plates that were not appropriate for his/her mechanically altered diet as prescribed. Additionally, the nursing staff failed to remove the improper food items from the resident's grasp. Facility census was 59. No facility policy was provided regarding resident safety at mealtime. Review of Mechanically Altered Diet policy dated 3/13/22, states in part: This diet consists of foods that are mechanically altered by blending, chopping, grinding or mashing so they are easy to chew and swallow. Foods are soft and moist and are easily formed into a bolus. Meats are served ground and moist. Foods in large chunks or foods too hard to be chewed thoroughly should be avoided. 1. Review of resident #40's quarterly Minimum Data Set (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.

Based on observation, interviews and record review the facility failed to assist one resident (Resident #9) to eat when he/she was assessed as having a significant weight loss of 16.6 pounds, 10.3% in four months. The facility census was 59. Review of the nutrition policy dated 8/24/23 showed: - Each resident receives a sufficient amount of food to maintain acceptable national status; - If a meal or particular food item is refused by the resident, the staff were supposed to offer a substitute; - The staff were supposed to provide assistance as needed to help the resident consume meals; - An ongoing assessment of the residents ability to feed self and weight loss was supposed to be completed by the facility staff. 1. Review of Resident #9's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff) dated 12/13/23 showed: - He/She had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment; - He/She was independent for eating; - He/She required substantial assistance form the staff to personal hygiene 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.

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering the insulin which affected one of 15 sampled residents, ( Resident #45). The facility census was 59. Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis…

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 record review and interview, the facility failed to ensure they utilized the correct SNFABN form, a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility, for five residents sampled for beneficiary notifications (Residents #55, #56, #52, #26, and #57). The facility census was 60. Review of the facility policy, Denial or End of Benefits, dated March 2021, showed: -Upon end of coverage under Medicare, the resident and family will receive a notice that specifically states the reason for non-coverage. -The policy did not address using the correct updated forms. Review of Resident #55's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 10/7/21. The resident signed the form on 10/5/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #56's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for two out of fifteen sampled residents (Resident #25 and #41) when staff failed to document meal intakes as directed from the care plan. Staff also failed to care plan the use of a restraint for one resident (Resident #5) not follwoing the facility policy and procedure, and standards of practice. Facility census was 60. Review of facility policy, Nutritional Intake, dated December 2021, showed: -Purpose: to ensure documentation of nutritional consumption and to identify any residents at risk for compromised nutritional status. -Nursing staff is responsible for documentation of nutritional intake on each individual resident. -Food intake at each meal is recorded by percentages. -Nutritional intake documentation will be part of the individual resident's permanent medical record. -Notify the nurse if there are any concerns related to the resident's nutritional intake. Review of facility policy,…

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 3. Review of facility policy Administration of Medication dated 7/14/21 showed in part: -All medications are administered safely and appropriately per physician order to address resident's diagnosis and signs and symptoms. -Medication Error : preperation or administration of medications which is not in accordance with manufacturer's specifications Review of Mosby's 2021 Nursing Drug Reference book showed: -Brovana inhalation : use this product before other medications allow 5 minutes between each. -Albuterol metered dose inhaler: give inhalation at least 1 minute apart Review of Quarterly Minimum Data Set ( MDS a federally mandated assessment tool) dated 10/19/21 showed: - Brief Interview of Mental Status (BIMS) of 13. (indicates little to no cognitive imapairment) -Independent for Activities of Daily Living (ADLs: collectively describes the fundamental skills needed to care for oneself) -Diagnosis of Chronic Obstructive Pulmonary Disease (COPD: a condition involving constriction of the airways and difficulty 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 record review, the facility failed to ensure staff stored and prepared food in a safe and sanitary manner and disposed of food in a timely manner. The facility census was 60. A review of the facility's Policy on Food Safety, dated 11/28/17, showed: -Food is stored and maintained in a clean, safe, and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. -Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product, when applicable. The use by date guide is easily accessible to all associates involved with resident food storage. -The First in First Out method is used in food storage or according to state regulation -Leftovers are dated properly and discarded after 72 hours unless otherwise noted. -Opened packages…

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, facility staff failed to maintain proper documentation and monitoring for the use of a physical restraint and to document assessments to assess the use of a seat belt and a hand mitt as a restraint device or an enable for one resident (Resident # 5). The facility census was 60. Review of facility policy Restraint and Position Change Alarm Use dated 6/22/21 showed in part: -A physician's order is required for the use of a specific type of restraint; should include the specific type of restraint, condition/symptom that warrants the use, where and how the restraint is to be applied, and the time and frequency the restraint should be released. -The care plan is revised as needed and must contain: -the specific type of restraint -the Resident's condition and medical symptoms that warrant the use. -the length of time the restraint is anticipated to be used - who may apply and release the restraint -the time and frequency the restraint should be released -the type of specific direct monitoring and supervision provided during the use of…

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, facility staff failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, 2 errors occurred, resulting in a 7.69% error rate, which affected 1 of 6 sampled residents (Resident #29) The facility census was 60. Review of facility policy Administration of Medication dated 7/14/21 showed in part: -All medication s are administered safely and appropriately per physician order to address resident's diagnosis and signs and symptoms. -Medication Error : preperation or administration of medications which is not in accordance with manufacturer's specifications Review of Mosby's 2021 Nursing Drug Reference book showed: -Brovana inhalation : use this product before other medications allow 5 minutes between each. -Albuterol metered dose inhaler: give inhalation at least 1 minute apart Review of Quarterly Minimum Data Set ( MDS a federally mandated assessment tool) dated 10/19/21 showed: - Brief Interview of Mental Status (BIMS) of 13. (indicates little to no cognitive imapairment) -Independent for Activities of…

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

Based on observation, interview and record review, the facility failed to provide a diet that meets the resident's daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Staff failed to follow provided recipes when preparing pureed meals. The facility census was 60. The facility's Policy on Pureed Food, dated 10/29/21, showed: -The Pureed Diet is designed to minimize the amount of chewing required and to facilitate the ease of swallowing food. - It is indicated for residents who have a fractured or wired jaw and those who are missing teeth or dentures. - This diet is also for residents who have neurological disorders and/or a generalized weakness that affects chewing. - Effort is made to prepare the pureed food without the addition of a thickening agent, since the texture, taste, and nutritional content may be altered. - Some residents placed on a Pureed Diet may already be nutritionally compromised by the time the diet is implemented. Therefore, every effort should be made to ensure adequate calorie and protein intake. Observation…

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.