Lebanon South Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment, for all resident when the facility failed to maintain a sanitary and orderly interior room for two residents (Resident #10 and Resident #15. The facility census was 65. Review of the facility's policy titled, Cleaning Guidelines-Bed Mattress, undated, showed the following information: -Mattress are to be cleaned when soiled, on bath days, and when the room is deep cleaned; -Bed linen should be removed and placed in dirty linen barrel and any debris should be removed; -Spray the mattress with disinfectant and wipe clean. Allow the bed to air dry; -Make the bed with fresh linen after mattress has dried. Review of the facility's policy, titled Pest Control, undated, showed the following information: -The facility will have a pest control contract which provides frequency treatment of the environment for pests; -Monitoring the environment will be done by the facility's staff; -Pest…

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 record review and interview, facility staff failed to complete a significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) within the required 14 days after hospice service admission for one resident (Residents #4) of twenty sampled residents. The facility had a census of 65. 1. Review of Resident #4's face sheet showed the following: -admission date of 06/01/23; -Diagnoses included Alzheimer's dementia, anxiety, arthritis, and type 2 diabetes. Review of the residents physician's orders showed an order, dated 06/25/24, for hospice consultation. Review of the resident's hospice agreement showed the agreement signed on 06/27/24. Review of the resident's care plan, last reviewed 04/03/25, showed on 12/20/24, staff care planned the resident had chosen to be placed on hospice services (186 days after hospice services were started). Review of the resident's quarterly MDS, dated [DATE], showed the the resident was not on hospice 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 record review, the facility failed to provide services that met professional standards of quality when the facility failed to document completion of proper notification and post fall assessments/monitoring for one resident (Resident #16) who was found on the floor by staff. The facility census was 65. Review of the facility's policy, titled Event Investigation, undated, showed the following information: -Complete a report of event form as soon as possible whenever there is an unusual, unexpected, and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor; -The form should be completed with falls or when a resident is found on the floor; -The report should include facility name, resident identification, date and time of the event, description of the event, witness information, primary diagnoses, cognitive status, location of the event, equipment involved, type of event, observations, location 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 respiratory care per standards of practice when staff failed to ensure oxygen and nebulizer tubing were stored properly when not in use when the nebulizer tubing and mouthpiece was noted to be on the floor and not in protective cover for one resident (Resident #2 ), noted to be on the chair and not in protective covering for one resident (Resident #4), and oxygen nasal cannula (thin, flexible tube that delivers oxygen through the nose) and tubing was on the back of the resident's wheelchair not in a protective bag for one resident (Resident #3) in a common area. The facility census was 74. Review of facility policy titled Oxygen Administration, undated, showed the following: -Purpose of policy was to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Connect nasal cannula tubing to humidifier outlet and adjust liter flow as ordered; -Place prongs of cannula into the resident's nares (nose); -Adjust elastic loosely around head above ears; -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 observation, record review, and interview, the facility failed to establish and maintain an effective infection prevention and control program when staff failed to educate staff on and implement a process for Enhanced Barrier Protection (EBP - are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) policy and procedure when staff did not wear gowns when completing catheter (a flexible tube that drains urine from the bladder) care for two residents (Resident #2 and #4). The facility census was 74. Review of the Centers for Disease Control and Prevention (CDC)'s Considerations for Use in Skilled Nursing Facilities, dated 06/2021, showed the following information: -MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents and increased costs for the health care system; -EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk…

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 keep all food safe from potential contamination when staff stacked clean, wet dishes tracking water in them, when staff failed to keep food containers sealed, when staff failed to keep the walk-in freezer clean, and when failed to complete proper hand hygiene and used bare hands to touch ready to eat food while proving meal assistance to six residents (Resident #36, #31, #8, #9, #20, and #62). The facility. The facility census was 64. 1. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such…

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 record review and interview, the facility failed to notify the resident and/or the resident's representative of a transfer or discharge to the hospital, including the reason for the transfer, in writing for three residents (Residents #23, #45, and #21) of 21 residents sampled. The facility census was 64. Review showed the facility did not provide a policy regarding written transfer notices. Review of a facility form letter Emergency Transfer Notice showed the following: -Staff should fill in the spaces for: date, resident name, responsible party/representative name and address, transferring facility name, effective date, Ombudsman information, hospital/facility name and address, facility contact phone number, and name of Administrator. 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admission date 12/28/19; -Diagnoses included high blood pressure, metabolic encephalopathy (abnormal brain function caused by infection or other body organ misfunction),…

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 record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #23, #45, and #21) who were transferred out to the hospital. A sample of 21 residents was selected for review in a facility with a census of 64. Review of the facility's form entitled Bed Hold Guidelines, undated, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for overnight leave of absence, the bed may be held by paying the current room rate for bed being reserved; -Medicaid will pay for up to three hospital leave days when certain criteria are met. The criteria is that…

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 staff failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 64. Review of the facility's policy titled Storage of Medications, undated, showed the following: -All medications are stored in a safe and secure area; -Medications requiring refrigeration are stored in a refrigerator located in the medication room located behind the nurses' station. -Medications are stored separately from food and are labeled accordingly. Review of the Centers for Disease Control and Prevention (CDC) guidelines for vaccines, dated 03/26/21, showed the following: -Never freeze refrigerated vaccines; -Ideal temperature of refrigerated vaccines is 40 degrees Fahrenheit (F); -Refrigerator temperature should be between 36 and 46 degrees F; Review of the Levemir (insulin) package insert, dated December 2022, showed the following: -Keep the Levemir pen or vial in cool storage at 36 degrees F to 46 degrees F;…

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 follow their infection control policies and procedures when staff failed to ensure the first and second step of a required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for three out of ten randomly chosen employees. The facility census was 64. Review of the facility's TB policy titled Tuberculosis Control, undated, showed the following information: -If a new hire is unable to show documentation of a current TB two step and the results, then the first step PPD (Mantoux method purified protein derivative (PPD - a skin test to determine if someone has tuberculosis)) will be administered by the nursing department; -This will be documented on the employee immunization record; -The results must be read prior to or no later than the staff member's start date; -The results will be documented in millimeters; -The Director of Nursing (DON) or designee will maintain records of required chest x-ray and documented…

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 staff treated all residents with dignity and respect when they failed to ensure two residents (Residents #8 and #20) were appropriately dressed in common areas. A sample of four residents was selected for review in a facility with a census of 64. Review showed the facility did not provide a facility policy addressing residents' right to dignity and respect. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 01/17/22; -Diagnosis included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), muscle wasting (thinning or loss of muscle tissue) and atrophy (gradual decline in effectiveness) multiple sites, abnormal weight loss, abnormal posture, and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) with mild non-proliferative diabetic retinopathy (eye…

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 promote and facilitate self-determination when staff failed to honor two residents' (Resident #15 and #35) reasonable shower preferences. The facility census was 64. Review of the facility's policy titled Bath (Shower), undated, showed the purpose was to maintain skin integrity, comfort, and cleanliness. 1. Review of Resident #15's face sheet (admitting demographic and payee information) showed the following: -admission date of 07/21/13; -Diagnoses included age-related cognitive decline, personal history of (healed) traumatic fracture, anxiety disorder, atrial fibrillation, and retention of urine. Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment completed by facility staff), dated 7/26/23, resident required assistance of one person for showering. Review of the resident's current care plan, last revised 07/27/23, showed staff did not address the resident's shower/bathing preferences. 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.

Based on interview, observation, and record review, the facility failed to provide consistent and timely showers/baths for all residents to maintain good grooming and personal hygiene when one dependent resident (Resident #8) did not receive timely showers and had hair that appeared oily and unkept. The facility's census was 64. Review showed the facility did not provide a policy specific to the scheduling of and/or providing assistance with residents' showers. 1. Review of Resident #8's face sheet (gives basic profile information), showed the following information: -admission date of 01/17/22; -Diagnoses included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), muscle wasting (thinning or loss of muscle tissue) and atrophy (gradual decline in effectiveness) multiple sites, abnormal weight loss, abnormal posture, and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) with mild non-proliferative diabetic…

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, record review, and interview, the facility failed to obtain physicians orders for use, complete a pre-use assessment, obtain informed consent, and ensure measurements were within safety guidelines prior to bed rails being placed on the beds of two residents (Residents #12 and #55) of two residents sampled. Staff failed to care plan the use of bed rails for one resident (Resident #12). The facility census was 64. Review of a facility policy and procedure entitled Bed Rails, undated, showed the following: -Bed rails (also referred to as side rails, safety rails, mobility bars, etc.) are constructed of metal or plastic, and are available in various sizes (e.g., full length rails, half rails, quarter rails). Bed rails may be positioned in various locations on the bed; upper or lower, one or both sides; -The objective of the bed rail use policy is to determine if resident use is safe and appropriate; -Prior to the use of bed rails the facility should complete the Bed Rail Observation including the following: observation detail, clinical assessment, alternatives…

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 staff failed to maintain a system that accounted for all controlled medications when staff failed to document administration of a controlled medication on the Control Substance and failed to ensure an accurate count of the controlled medication for one resident (Resident #14). The facility census was 64. Review of the facility policy titled, Controlled Substance Medication Policy, undated, showed the following: -Nurses are to count all narcotics at the beginning and end of every shift and sign the narcotic sheet prior to taking over the narcotic cart. 1. Review of Resident #14's face sheet (brief resident profile) showed the following information: -admission date of 07/06/23; -Diagnoses included weakness, anxiety, pain, hypertension (high blood pressure), and transient ischemic attack (TIA - a brief stroke-like attack). Review of the resident's care plan, revised on 10/05/23, showed the following information: -Resident was at risk for pain related to spinal fusion (surgery connecting two or more bones together) 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 observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet each resident's needs when staff staff failed to serve one resident (Resident #62) a physician ordered pureed diet. The facility had a census of 64. 1. Review of Resident #62's face sheet (a brief resident profile) showed the following information: -admission date of 08/04/23; -Diagnoses included cerebral infarction (stroke) and weight loss. Review of the resident's Physician Order Sheet (POS), current as of 10/06/23, showed the following orders: -An order, dated 08/04/23, for pureed diet; -An order, dated 08/04/23, for speech therapy to evaluate and treat as needed. Review of the resident's Speech Therapy Treatment Encounter notes showed the following: -Encounter note, dated 08/08/23, showed the resident should remain on puree diet due to lethargy (weakness) and right sided pocketing of regular hard solids; -Encounter note, dated 08/09/23, showed the resident was unable to chew fully and pocketed solid food on the left side. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four residents (Resident #9, Resident #18, Resident #21 and Resident #28) remained free from misappropriation of property, when the business office manager (BOM) withdrew cash from residents' bank accounts and did not give the money to the residents. The facility's census was 49. Record review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated 11/28/16, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Record review of the facility's policy titled Facility/BOM Resident Trust Workflow, undated showed the following: -Withdrawals: -Before issuing personal spending money to a resident, first check Matrix Resident Trust to ensure the funds are available; -Cash will be issued…

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 staff failed to maintain sufficient staff to provide timely monitoring of two residents (Resident #26 and #31) for needed incontinent care; to provide bath/showers as preferred/needed for two residents (Resident #31 and #46); to provide adequate staff to assist four residents (Resident #7, #20, #26, and #41) with meals; and to answer call lights timely. The facility census was 49. Record review showed the facility did not provide a policy regarding frequency of showers or how often staff should make rounds/observations on residents. 1. Record review of the Resident Census and Conditions form, (form staff required to complete on annual survey) completed by the Director of Nursing, dated 3/29/21, showed the following information: -Census of 49 residents; -Twenty-eight residents required assistance of one to two staff for bathing; -Fifteen residents dependent on staff for bathing; -Forty-one residents required assistance of one to two staff for eating…

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 residents were free of significant medication errors when staff failed to administer the correct dose of insulin per the physician's order for three residents (Resident #33, Resident #34 and Resident #39). The facility census was 49. Record review showed the facility did not provide a policy regarding administration of sliding scale insulin 1. Record review of Resident #34's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), hypertension (high blood pressure), and Type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel). Record review of the resident's quarterly…

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 wash or sanitize hands per nursing standards for infection control when providing incontinent care and/or grooming for six residents (Resident #7, #20, #26, #31, #41 and #152). The facility had a census of 49. Record review of the facility's policy titled, Nursing Guidelines Manual, Handwashing, dated March 2015, showed the following information: -Turn on the water and adjust temperature; -Soap hands well; -Rub hands briskly, paying special attention to area between fingers; -Use brush to clean under nails as necessary; -Rinse with hands lowered to allow soiled water to drain directly into sink; -Do not splash water onto clothing; -Do not allow hands to touch sink; -Use disposable hand towel to turn off faucet and dry hands well, especially between fingers; -Apply moisture barrier if desired. Record review of the facility's policy titled, Nursing Guidelines Manual, Hand Cleanser (Antiseptic), dated March 2015, showed the following information: -Place the container of antiseptic solution on the medication cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate nail care and personal hygiene assistance for two dependent residents (Resident #31 and #152) following incontinent episodes. The facility census was 49. Record review of the facility's policy titled, Bath (Partial) (Nursing Guidelines Manual, March 2015), showed the following information: -Care of fingernails and toenails is part of the bath. Be certain nails are clean. 1. Record review of Resident #152's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included psoas (lower back) muscle abscess (an enclosed collection of liquefied tissue) and intervertebral disc degeneration, lumbar region. Observation on 3/30/21, at 11:08 P.M., showed the following: -Certified Nurse Aide (CNA) C and CNA E entered the resident's room to answer the call light; -The resident was on the bed with feces covering his/her hands and under his/her fingernails; -The resident was incontinent of stool 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, record review, and interview, the facility failed to ensure staff followed physician orders regarding administration of the oxygen at the correct liters per minute (LPM - measurement of oxygen) and failed to keep water in the humidifier (bubble-type humidifier provides long-lasting moisture for utmost patient comfort during oxygen therapy) used with supplemental oxygen for one resident (Resident #48). The facility census was 49. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; -Oxygen therapy is usually combined with a humidification device, to prevent mucosal dryness; -Because oxygen concentrator tanks deliver absolutely dry oxygen, humidification is recommended by some; -If…

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.