Wilshire At Lakewood Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the narcotic count was correct by not ensuring two nurses were counting the narcotic medications at the beginning and end of each shift, and signing at the time the nurses counted the medications; to ensure nurses were not pre-signing the medication count sheet before counting with the second nurse; to ensure the two nurses verified the amount in the medication container was the same amount that was on the medication sheet for three sampled residents, (Resident #109, #19, and #114), and to ensure there were no expired medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Medication Storage-Controlled Medication storage dated 11/'17 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state, 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 the medication carts were locked when staff was not in attendance of them, to ensure the keys to the medication cart which contained narcotics were not accessible to anyone walking by the medication cart, to ensure cleaning supplies were not in with the residents medications, to ensure other objects were not in with the residents medications, to ensure the residents prescribed medication had a date written on them after opening, and to have a policy of how to open the automated medication machine if the power went out. The facility census was 123 residents. Review of the facility's policy, Medication Storage, Controlled Medication Storage, dated 11/17 showed: -The Director of Nursing (DON) and the consultant pharmacist monitored for compliance with the federal and state laws and regulations in the handling of controlled medications. -Only authorized licensed nursing and pharmacy personnel would have access to controlled medications. -The medication nurse on duty maintained possession of the key to…

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 urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was kept off of the floor for one sampled resident (Resident #60) out of four residents sampled for urinary catheters and to properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Residents #10 and #218) out of five residents sampled for TB screening. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 123 residents. Review of the facility's policy titled Tuberculosis - Screening dated as revised on 10/24/22 showed: -The facility screened referrals for admission and readmission for information regarding exposure to, or symptoms of TB and checks results of recent (within 12 months) TB skin…

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 provide a Preadmission Screening and Resident Review [PASRR- a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed. A level I was required for all residents and a level II if the resident tested positive for any MI or ID] for two sampled residents (Residents #29 and #40) out of 25 sampled residents. The facility census was 123 residents. Record review of the facility's PASRR policy dated October 24, 2022 showed: -The Facility, as a Medicaid certified nursing facility, ensures that Level I of the PASRR is completed either by the transferring facility, upon admission, or as soon as practicable thereafter, by the Facility for all applicants, regardless of payer, to determine if they have a Mental Disorder (D) or ID. -The Facility also conducts Level I screen for current residents who have a MI or ID and experience a significant…

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 Comprehensive Care Plan (a document describing agreed goals of care, and outlining planned medical, nursing and allied health activities for a patient) was developed and implemented for one sampled resident (Resident #29) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's care plan policy dated October 24, 2022 showed: -The facility's Interdisciplinary Team (IDT) will develop a Comprehensive Care Plan for each resident. -The IDT may include the following individuals: --The attending Physician. --The Resident Assessment Coordinator. --The Director of Nursing (DON). -The Care Plan will include measurable objectives and time tables to meet a resident's medical, nursing, mental and psychosocial needs. -Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. -The IDT will revise the Comprehensive Care Plan as needed at the following intervals: --Per…

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 include and document participation of the resident and/or the resident's representative(s) regarding care plan development for two sampled residents (Resident #70 and Resident #61) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Care Planning policy, dated 10/24/2022, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. -The Care Plan served as a course of action where the resident, resident's family and/or guardian or other legally authorized representative, resident's attending physician, and the Interdisciplinary Team (IDT) worked to help the resident move toward resident-specific goals that addressed the resident's medical, nursing, mental and psychosocial needs. -The Comprehensive Care Plan was prepared by the IDT team, which included: --The resident and/or his/her family or legal…

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 address one sampled resident's motion sickness (Resident #37) and to ensure one sampled resident (Resident #92) took his/her prescribed medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's policy, Medication Administration, dated October 24, 2022 showed: -Medications may be administered one hour before or after the scheduled mediation administration time. -Medications would not be left at the bedside. 1. Review of Resident #37's progress notes dated September 2023, October 2023 and November 2023 showed no documentation regarding any nausea or vomiting. Review of the resident's comprehensive Certified Nursing Assistant's (CNA) shower review sheets dated September 2023 showed: -On 9/2/23, the resident received a bed bath. -On 9/30/23, the resident received a shower. Review of the resident's Medication Administration Record (MAR) dated September 2023 showed: -A physician's order for Zofran…

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 toenail care or an appointment with a podiatrist for one sampled resident (Resident #60) out of 25 sampled residents who had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) which posed a risk to foot health. The census was 123 residents. Review of the facility's policy titled Grooming care of fingernails and toenails revised 10/24/22 showed: -Residents who had diabetes would not have their toenails trimmed by Certified Nursing Assistants (CNA). -High risk residents who had toenail issues such as thick toenails or toenails with a fungal infection would be referred to a podiatrist. 1. Review of Resident #60's medical record showed no podiatry progress notes. Review of the resident's care plan dated 9/22/23 showed the resident had a diagnosis of diabetes and required limited assistance of one staff member with personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by…

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 urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was in a safe place during a transfer for one sampled resident (Resident #60) out of four residents sampled for urinary catheters. The facility census was 123 residents. Review of the facility's catheter care policy dated as revised 10/24/22 showed instructions to ensure the catheter tubing was properly anchored to prevent urethral tear. 1. Review of Resident 60's care plan dated 9/22/23 showed the resident had a urinary catheter. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/4/23 showed the following staff assessment of the resident: -Cognitively intact. -Had an indwelling catheter. -Had a diagnosis of neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Used a wheelchair. Observation and interview on 11/14/23 at 11:30 A.M. with…

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

Based on interview and record review, the facility failed to produce a surety bond at an amount that sufficiently assured the security of all personal funds of residents deposited with the facility in the Resident Trust Fund (RTF). This deficient practice had the potential to affect 64 residents who held an account in the facility's resident trust. The facility census was 92 residents with a licensed capacity for 170 residents. 1. Record review of the Missouri Department of Health and Senior Services (DHSS) Active Bonds list dated 3/3/22 and printed prior to this survey, showed this facility's RTF bond amount coverage on file at their central office was $45,000.00. During an interview on 3/16/22 at 12:33 P.M. the Business Office Manager (BOM) said that the facility's new ownership told them to disregard their bond rider letter provided that was dated 2/1/22 and stated the bond limit was raised to $71,000.00 as of 1/27/22, and that the $45,000.00 was the correct amount. Record review of the facility's various other RTF documents provided by the BOM, showed the following: -As 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 keep the kitchen, dry storage, and walk-in refrigerator and walk-in freezer floors clean; to retain thermometers in all refrigerators to confirm adequate temperature ranges; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were thoroughly cooked to lessen the chance of bacterial contamination; and to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 92 residents with a licensed capacity for 170. 1. Observations during the Kitchen inspections on 3/14/22 at 8:57 A.M. and at 10:47 A.M. showed the following: -On the floor under the racks in the dry storage room there was a mustard packet, a plastic cup lid, paper, and a plastic fork. -One banana in a box of bananas by the dry storage room door had an end missing and the fruit inside was blackened. -On the floor under…

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 report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Agency (SA) immediately, but no later than two hours after the allegation of abuse was made and to inform the State of the results of the facility's Abuse Investigation within five days for one sampled resident (Resident #34) out of 20 sampled residents or to show in their Abuse Investigation why reporting an allegation of abuse was not necessary. The facility census was 92 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised July, 2017 showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies as defined by current regulations, but no later than two hours if the alleged…

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 fully investigate an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and to follow the facility policy and procedure to ensure the alleged perpetrators (AP) were removed from the facility during the time of the abuse investigation for one sampled resident (Resident #34) out of 20 sampled residents. The facility census was 92 residents. Record review of the resident's Abuse Prevention Program, revised December 2016 showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. -As part of resident abuse prevention the Administrator will: --Require staff training that include topics such as abuse prevention, identification and reporting, stress management, and handling verbally or physically aggressive resident behavior. --Identify and assess all possible incidents of abuse.…

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 written notice was given to the resident/resident's representative prior to transfer to the hospital for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Transfer or Discharge Notice policy, revised December 2016 included: -The facility would provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. -Under the following circumstance, the notice would be given as soon as it was practicable (able to be done or put into practice successfully) but before the resident's transfer or discharge: An immediate transfer or discharge was required by the resident's urgent medical needs. -The resident and/or representative would be notified in writing of the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred. 1. Record review of Resident…

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 the written bed hold policy notice was given to the resident/resident's representative prior to transfer to the hospital for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Transfer or Discharge Notice policy, revised December 2016 included: -The facility would provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. -Under the following circumstance, the notice would be given as soon as it was practicable (able to be done or put into practice successfully) but before the resident's transfer or discharge: An immediate transfer or discharge was required by the resident's urgent medical needs. -The resident and/or representative would be notified in writing of the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nail care was provided to one sampled resident (Resident #13) who was totally dependent upon staff for fingernail care out of 20 sampled residents. The resident's long fingernails prevented the resident from using his/her fingers to push buttons on his/her telephone. The facility census was 92 residents. Record review of the facility's Supporting Activities of Daily Living policy, revised 3/2018 showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning). 1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Rheumatoid…

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 address one sampled resident's (Resident #49) order for and documentation of a rectal (having to do with the rectum, the last six to eight inches of the large intestine that stores solid waste until it leaves the body through the anus, the opening of the rectum to the outside of the body) treatment in the absence of documentation/assessment of the resident having a rectal wound, out of 20 sampled residents. The facility census was 92 residents. Record review of the Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised April 2018 showed: -The facility staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. -The physician will order pertinent wound treatments. -During resident visits, the physician will evaluate and document the progress of wound healing. -Current approaches should be reviewed for whether they remain pertinent to the resident's…

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 the weekly skin assessments were completed and signed by the nurse performing, that wound assessments were completed with measurements and description, and ordered treatments were performed for one sampled resident (Resident #251) out of 20 sampled residents. The facility census was 92 residents. On 3/22/22 the Administrator was notified of the past noncompliance. On 2/9/22 the facility administrator discovered skin and wound assessments and wound treatment documentation was missing, and an audit was started. On 2/21/22 a Performance Improvement Plan (PIP) was started, and nursing staff were inserviced regarding documentation of treatments, weekly skin assessments, reporting of wounds, and wound documentation, including measurements and description of wounds. The deficiency was corrected on 2/25/22. Record review of the facility's policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised April 2018 showed: -Full assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for Foley catheters (a tube with retaining balloon passed through the urethra into the bladder to drain urine), to have physician's orders for Foley catheter care for two sampled residents (Resident #29 and Resident #30); and to properly place a catheter bag during a transfer for one sampled resident (Resident #30) out of 20 sampled residents. The facility census was 92 residents. A policy was requested and the facility did not have a policy. 1. Record review of Resident #29's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Neuromuscular disorder of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems. Several muscles and nerves must work together for your bladder to hold urine until you are ready to empty). -Foley catheter. -Hemiplegia (total or partial paralysis of one side of the body that results from…

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 notify the resident's physician and Registered Dietician (RD) of a significant weight loss and put interventions in place timely for one sampled resident (Resident #10) and to ensure the interventions for weight loss were being offered and implemented for two sampled residents (Resident #10 and Resident #27) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Nutrition and Unplanned Weight Loss Clinical Protocol revised 9/2017 showed: -The staff would report any significant weight loss to the physician. -The physician would review for medical causes of the weight loss before ordering interventions. -The physician would help identify medical conditions, medications, and oral/swallowing issues. -The physician would document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status. -The physician and staff would monitor the individuals'…

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 ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments, to have ongoing communication with the dialysis center, and to have individualized care plan interventions to address the resident's wishes/non-compliance related to licensed nurse assessment of his/her dialysis site for one sampled resident (Resident #49) selected for review of dialysis services, out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Hemodialysis Access Care policy, revised September 2010 showed: -Care involves the primary goals of preventing infection and maintaining patency of the dialysis site (preventing clots). -To prevent infection…

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 monthly Drug Regimen Review (DRR- thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) recommendations were acted on for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Medication Orders policy, revised November 2014 showed: -When recording orders for medication specify: --The route (the way in which a drug enters the body). --The dosage (the quantity) of the medication. --The frequency of dose administration. --The strength (the proportion of active drug substance measured in units, volume or concentration) of the medication. Record review of the facility's Medication Utilization and Prescribing Clinical Protocol, dated April 2018 showed: -Based on input from the staff and resident, the physician would adjust…

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 receiving psychotropic medications (drugs which affect psychic function, behavior, or experience) with recommendations from the pharmacist were addressed and followed-up on by the resident's physician for one sampled resident (Resident #35) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Medication Utilization and Prescribing Clinical Protocol revised 4/18: -Based on input from the staff and resident, the physician would adjust medications based on efficacy, indications and the continued presence of clinically significant risks. -The consultant pharmacist should use the monthly and interim Drug Regimen Review (DRR) to help identify potentially problematic medications, including medication regimens that are not supported or based on clinical signs or symptoms. -The physician would document a clinically pertinent rationale for not modifying a medication in a situation where adverse drug…

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.