Surrey Place St Lukes Hospital Skilled Nursing

See the deficiency cited at LUGT12. Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. The pharmacy and the physician were informed the resident's reaction were only blood clots. The resident was administered Zosyn IV and thirty minutes later, he/she had difficulty breathing, was administered four…

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 upon document review and interview, the facility failed to ensure staff were trained in required infection control practices such as enhanced barrier protection (EBP) and/or other isolation precautions. The facility failed to have staff's competencies in relation to the infection control training. This failure placed all 80 residents at risk of infection. The lack of adequate training and evaluation of staff's competencies had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility. Findings include: Review of the course printouts for available education on the computer-based system provided by the facility revealed the Annual Mandatory Courses list indicated Bloodborne Pathogens as the only infection control related education. The Course and Curriculum Assignments by Group: Surrey Place . for different disciplines lists indicated Targeted COVID-19 Training as the only infection control related education. Review of Registered Nurse (RN)1's, RN3's, and Licensed Practical Nurse (LPN)3's Progress Report for completed education…

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, review job description, and facility policy review, the facility failed to ensure one of one dietary freezer, and three of three nourishment room (Alpine Park, Canyon Creek, and Dakota) refrigerators had all food labeled, dated and was free of dirt and sticky shelves. This failure has the potential to create the environment for food-borne illnesses to occur throughout the population of 80 residents. Findings include: Observation and interview on 07/29/24 at 9:34 AM, on the shelves in the dietary department walk-in freezer revealed an unsealed bag in a box of frozen fish, an unsealed bag of hashbrowns, and an unsealed bag of potato wedges. The Food Service Director (FSD) stated the bags should not be left opened and the bags should be labeled with the opened date after using them. Observation and interview with the FSD on 07/31/24 at 8:46 AM of the shelves of the refrigerator on the Alpine Park Unit revealed the following food items not labeled or dated: There was a three-compartment to-go container of meat and vegetables, a to-go container 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 record review, interview and policy review, the facility failed to conduct and document a comprehensive Facility-wide Assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The facility failed to ensure the Facility Assessment included infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who would was responsible for overseeing the infection control program. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for all 80 residents who resided at the facility. at the time of the survey. Findings include: Review of the undated Facility-wide Self-Assessment, provided supplied by the facility indicated the assessment failed to address the following pertinent characteristics affecting day-to-day operations and potential emergency situations: 1. Failed to include staffing requirements based on resident acuity…

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, record review, the facility failed to ensure two of three medication carts (Alpine unit and Canyon unit), and one of two treatment carts (Alpine unit) were locked and secured on three of three resident halls. This failure created a risk of medications being misappropriated or tampered with. Also, the facility failed to remove expired blood collection tubes from two of the three medication rooms (Alpine unit and Dakota Bluffs unit). Findings include: 1. On 07/30/24 at 2:15PM, observation of the Alpine unit medication room revealed the following: 31 of 31 BD vacutainer blood collection tubes with expiration date on 01/31/24. Three of 13 Kangaroo Epump Enplus Spike with Flush Bag (used for nutritional feeding) with expiration dates of 01/31/24 and 05/31/24 Interview on 07/30/24 at 2:31 PM, Licensed Practical Nurse (LPN) 4 stated that she was not sure who was responsible for removing expired medications and equipment from the medication room. 2. Observation on 07/30/24 at 2:29 PM, on the Alpine unit was an unlocked treatment cart at the nurse station.…

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, review of policies, interviews, and review of Centers for Disease Control (CDC) guidelines and Centers for Medicare & Medicaid Services (CMS) guidance, the facility failed to follow acceptable standards of practice for infection prevention and control when providing wound care for Resident #35. The facility also failed to ensure one (Resident (R)144) of one resident with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) was placed in contact precautions. This had the potential for MRSA to spread to staff and to other residents. The facility failed to ensure R1 and R36 were placed in enhanced barrier precautions (EBP) for wounds and R294, R6, R35 for use of a catheter. This had the potential for the residents to develop multi-drug resist organisms. The facility failed to ensure dedicated equipment, such as a stethoscope and blood pressure cuff, was assigned to R37 who was in contact precautions for a diagnosis of Clostridium difficile (C-diff). This had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to assess one of one sampled resident (Resident (R) 37) for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the resident's bedside where other residents could access them. Findings include: Review of the facility's policy titled Self-Administration of Medications Policy dated 10/23 indicated, .It is the policy of this facility that if a resident requests to self-administer medication(s), the interdisciplinary team (IDT) will assess the resident to determine if it is clinically appropriate to honor the resident's choice, in order to maintain the resident's highest practicable level of functioning. The resident has the right to defer responsibility to the facility. A resident may only self-administer medications after the IDT has determined which medications may be safely self-administered. Review of a facility document titled Resident Information…

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

Based on interview and record review, the facility failed to protect one resident (Resident #38) from misappropriation of property when a staff member took the resident's wallet, and used his/her credit card to purchase take-out food and groceries. The census was 79. The administrator was notified on 7/24/24 of the past non-compliance. The facility had completed their investigation, interviewed staff and residents, notified the police and terminated Certified Nurse Aide (CNA) A. The deficiency was corrected on 7/24/24. Review of the Abuse and Neglect (Suspected) Policy, revised March 2022, included the following: -Residents have the right to be free from any type of abuse, including verbal, physical, psychological, sexual, and emotional abuse and/or exploitation; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #38's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility…

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 residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. The pharmacy and the physician were informed the resident's reaction were only blood clots. The resident was administered Zosyn IV and thirty minutes later, he/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 observations, interviews, and record review, the facility failed to regularly offer/assist a resident with removal of facial hair to maintain good grooming and hygiene for 1 (Resident #100) of 2 sampled residents reviewed for activities of daily living. Findings included: A review of Resident #100's History and Physical Reports indicated the resident had diagnoses that included carpal tunnel syndrome (a condition that causes pain, tingling and numbness in the hand), spinal stenosis of the lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back), anxiety, and depression. A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #100 required limited assistance with personal hygiene. Review of a Care Plan, dated as initiated on 12/07/2022, revealed Resident #100 was care planned for activities of daily…

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 and interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when all residents' bathrooms on the C hallway did not have functioning exhaust vents. This affected all residents on the C hallway. The facility had a capacity of 80 residents with a census of 67. 1. Observation on 8/21/19 beginning at 9:00 A.M., showed the exhaust ventilation system, in all residents' bathrooms of the C hallway, did not work when tested. During an interview on 8/21/19, at approximately 3:15 P.M., the maintenance supervisor said he did not know the residents' bathroom exhaust system did not work. He said the facility had recently had some work done and the ventilation was worked on at that time.

Based on interview and record review, the facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) for one sampled resident (Resident #5) out of three sampled residents. The facility census was 67. Record review of Resident #5's SNF Beneficiary Protection Notification Review showed the following: - The resident's Medicare Part A skilled services episode had a start date of 3/16/19; - The resident's last covered day of Part A service was 3/28/19; - A SNF ABN, Form CMS-10055 was not provided to the resident because the resident was discharged from the facility and did not receive non-covered services. Spoke with POA (Power of Attorney) who was not concerned about charges but wanted to ensure patient was able to be in Medicaid bed and bill Medicaid for coverage. Record review showed the resident did not discharge from the facility after Medicare Part A services ended, but continued to reside in the facility. Record review showed there was not a SNF ABN, CMS-10055 form completed for the resident's Medicare Part A Stay. During an…

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 staff failed to provide written notification of transfer to the resident or the resident's representative for four residents (Residents #7, #20, #34, and #66) who transferred to the hospital. The facility census was 67. 1. Review of Resident #7's medical records, showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's transfer form, dated 7/27/2019, showed staff documented there was a medical reason for transfer because the resident fell a day ago and now showed symptoms of pain and swelling in his/her left hip. Review of the resident's nurses notes, dated 7/27/2019, showed the resident complained of pain in the left upper leg. When turning the resident to change his/her brief and when the resident stood for the transfer his/her pain level became intolerable. The resident had a hard swollen area to the left hip and the physician was notified and gave orders to send the resident to the hospital. Review of the…

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