Lemay Nursing

Based on observation, interview and record review, the facility failed to assess one resident for the use of a belt restraint (Resident #44). The resident had a belt restraint on his/her wheelchair. The facility failed to assess the resident for its use, obtain a physician's order and document the use in the resident's care plan. In addition, the facility failed to ensure staff accurately documented medications, treatments, pain assessments, and behavior monitoring for two residents (Residents #19 and #6). The sample size was 13. The census was 46. Review of the facility's Restraints policy, dated 9/2/29, showed: -Policy Statement: Restraints are devices that prevent or restrict certain actions and/or behaviors and are not easily removed. There are Federal Regulations that govern the use of restraints on residents in long-term care facilities. Restraint usage can increase the scope and severity of injury. It is the goal of the facility to be restraint free in accordance with clinical best practices; -Policy: In order to provide the best possible care to residents, both physically…

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 care consistent with professional standards of practice when staff failed to transcribe a new order, resulting in the treatment not administered for one resident (Resident #24). The sample was 13. The census was 46. Review of the facility's Medical Provider Orders policy, dated reviewed/revised 4/17/22, showed: -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); Review of the facility's Medication Orders policy, dated effective 6/1/18, showed: -Orders sent with the resident from an office visit, the nurse on duty at the time the order is received enters it on the physician order sheet telephone order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the 100 hall and in the unlocked and accessible staff break room, between 105 degrees Fahrenheit (F) and 120 degrees F. This affected five sampled resident rooms, which included Resident #5. The temperatures at the sinks measured as high as 143 F. The sample size was 13. The census was 46. 1. Observations on 5/12/25 of the unlocked accessible employee break room handwashing sink, showed: -At 10:35 A.M., the water measured 137.8 F.; -At 11:50 A.M., the water measured 143 F.; -At 2:20 P.M., the water measured 139.0 F. Review of the facility's temperature logs, showed no documentation of temperatures for the employee break room. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Severe cognitive impairment; -Uses a manual…

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 policy when staff failed to ensure one resident's dialysis (a procedure that cleanses the blood of its impurities) communication logs were completed for all appointments (Resident #42). The facility identified one resident who received dialysis services. The sample was 13. The census was 46. Review of the facility's Dialysis Communication policy, dated 2/21, showed: -Director of Nursing (DON) or designee will contact dialysis unit to establish the communication, explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -The nurse in charge of the care of the resident on the days of scheduled dialysis shall initiate the dialysis communication form and will ensure the form is sent with the resident; -Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the…

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

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when one resident (Resident #3) had a significant increase in pain identified on 12/18/24 and had to wait over 12 hours for an x-ray order to be obtained. The x-ray completed on 12/19/24 showed the resident had a right hip fracture and the resident was sent to the hospital for further evaluation and treatment. The sample was 6. The census was 48. Review of the facility's Change in Condition Nursing Intervention policy, dated 2/18/16 and revised 9/19/19, showed: -Policy Statement: Because of the age and condition of residents in a nursing home, they are subject to many changes in condition. Changes in condition require assessment and documentation by a licensed nurse; -Policy: To assure that all residents receive appropriate care in accordance with acceptable medical practice and standards, changes in condition will be assessed in a timely manner with appropriate interventions and countermeasures as necessary.…

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 ensure services provided meet professional standards of practice when a facility nurse pre-pulled medications for residents, documented the medications as administered, and never administered the medications. This resulted in nine residents not receiving their ordered medications (Residents #4, #5, #11, #7, #9, #8, #10, #1 and #12). The census was 44. The sample was 14. The administrator was notified on 6/21/24, of the past non-compliance. The facility educated staff of the requirement to administer medications at the time they are pulled and that only the staff person who pulls the medications are allowed to administer the medication. The facility conducted an investigation to determine which residents were affected and are monitoring ongoing compliance. The deficiency was corrected on 6/10/24. Review of the Controlled Substance Policy, revised 2/2021, showed: Controlled substances are subject to special handling, storage. disposal and record-keeping requirements. The facility will maintain compliance with these special…

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 ensure one resident (Resident #2), diagnosed as having dementia with behavioral disturbance and exhibiting increased symptoms/behaviors such as striking the same resident (Resident #1) in the head twice on two separate occasions (3/4/24 and 4/24/24), received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being, by failing to implement an ordered psychiatric consult or update the resident's care plan until after the second incident. The first incident caused a laceration above Resident #1's left eyebrow. The sample size was 3. The census was 47. Review of Resident #2's hospital records, prior to the facility admission, dated 9/26/23, showed: Patient is presenting with concern for self neglect and possible injury to himself/herself with firearm. He/She was brought in by family to emergency room (ER) on 9/23 after reportedly hitting his/her head near the support beam of his/her car port. He/She reports to me no loss of consciousness. Apparently…

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 one resident's rights to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) hit the other resident in the eye. This resulted in a laceration. The census was 45. The sample was 3. The Director of Nursing (DON) was notified on 3/08/24, of the past non-compliance. The facility immediately took steps to protect the resident and set interventions in place to prevent further abuse. Staff were in-serviced on resident safety. The deficiency was corrected on 3/4/24. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family member or legal guardians, friend, or other individuals; -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 observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, three errors occurred, resulting in a 12% error rate (Residents #44, #254, and #30). In addition, the facility failed to have a policy to address when medications are due based on the codes entered into the medical record. The census was 49. 1. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Administer medications as ordered in accordance with manufacturer specifications; -Sign the medication administration record after administration. 2. Review of Resident #44's medical record, showed:…

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 medications were discarded according to the expiration date for one of two medication carts reviewed with expired medicine that remained in the cart. This resulted in one resident being administered expired insulin (Resident #44). In addition, the facility failed to permit only authorized personnel to have access to the keys to the medication room. The facility identified having one medication room and four medication/treatment carts. The census was 49. Review of the facility's Labeling of Medications and Biologicals policy, dated 9/1/21, showed: -All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications; -Medication labels must be legible at all times. Review of the facility's Medication Storage policy, dated 9/1/23, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication…

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 obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained. The facility failed to follow manufactures directions for blood glucose (sugar) test strips to ensure accurate results. Improperly stored test strips were used to check residents' blood sugar levels (Resident #7, #1, #25, and #44). The census was 49. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) certification of waiver, effective 9/1/22 and expiration 8/31/24, showed: -Laboratory name and address, listed the facility name and address; -The above named laboratory located at the address shown hereon may accept human specimens for the purpose of performing laboratory examinations or procedures. 1. Observation and interview on 12/12/23 at 12:47 P.M., showed Licensed Practical Nurse (LPN) C opened a medication cart and said there are two certified medication technician (CMT) carts, a treatment cart, and a nurse medication…

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 a resident only self-administered medications after the interdisciplinary team had determined which medications may be self-administered, for one of one resident observed to have medications left at the bedside for later self-administration, for two of three days of survey. The sample was 13. The census was 49. Review of the facility's Resident Self-Administration of Medication policy, dated 9/1/21, showed: -It is the policy of this facility to support each resident's right to self-administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; -The results of the interdisciplinary team assessment is placed in the resident's medical record; -The care plan must reflect resident self-administration and storage arrangements for such medications. Review of the facility's Medication Administration policy, dated 9/1/21, showed: -Medications are administered by licensed nurses, or other staff…

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 proper transfer techniques were utilized in the transfer of dependent residents. This failure occurred in one of one stand-by assist transfers observed, for one resident (Resident #13). The sample size was 13. The facility census was 49. Review of the facility's Transfer Techniques Policy, revised 4/17/19, showed: -The use of appropriate devices (lifts, gait belts, draw sheets, etc.) to provide a safe means of lifting or transferring residents, when used properly, protect both the resident and the employee from injury; -In order to prevent injury to staff or residents, employees shall use appropriate devices to transfer/ambulate/reposition residents; -Gait belts should be used for residents who are able to provide moderate assistance and are affected on one side of their body to ensure safe transfers/ambulation; -Assess resident needs when choosing transfer devices. It's always better to have more help than not enough, for you and the resident. Review of Resident #13's record, showed: -admission date 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 prevent a significant medication error when staff administered expired insulin to a resident (Resident #44). The census was 49. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Identify expiration date. If expired, notify the nurse manager; -Administer medications as ordered in accordance with manufacturer specifications; -Sign the medication administration record after administration. Review of Resident #44's medical record, showed: -Diagnoses included diabetes; -An order dated [DATE], for Novolog (short acting insulin), inject 3 units subcutaneously (under the…

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

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to follow manufactures directions for quality control check of the blood glucose (sugar) test machines to ensure accurate results. The census was 51. Review of the quality control solution for the blood glucose machine manufacturer's directions, also provided by the facility as the policy for completing quality control checks, titled Performing a Control Solution Test, showed: -You should check your meter and test strips using Assure Prism Control Solution. The control solution ranges are printed on the labels. Compare the results displayed on the meter to the control solution range printed on the vial or box. Before using a new meter or a new vial/box of test strips, you should conduct a control solution test; -Note: Check the expiration dates printed on the bottle. When you first open a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment for one resident who had wounds at the time of the assessment (Resident #9) and for five of five residents investigated for hospice who had a life expectancy of less than six months (Residents #5, #12, #16, #14 and #34). The facility identified 12 residents as receiving hospice services. The sample was 13. The census was 51. 1. Review of Resident #9's admission wound assessment, dated 6/17/21, showed a left lower leg stasis ulcer (breakdown of the skin caused by fluid build-up from poor vein function) was present on admission and measured 13 centimeters (cm) in length, 11 cm wide, and 0.3 cm deep. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/21, showed the total number of arterial (caused by poor blood supply) and venous (result from valve incompetence 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.

Based on interview and record review, the facility failed to ensure dialysis services received meet professional standards of practice for one resident who received dialysis services (Resident #17). The facility failed to ensure staff completed post dialysis assessments per their policy and acceptable standards of practice. The facility identified as only having one resident on dialysis services. The census was 51. Review of the facility's Dialysis Resident Care policy, dated 10/14/18, showed: -Policy statement: To maintain best clinical practices for shunt (dialysis access site) care and resident's receiving dialysis; -Policy: To monitor and educate staff and residents about good post-dialysis care; -Procedure included: -Assess residents upon return from dialysis treatment and document in nurse's notes: -Monitor blood pressure, report low or high blood pressure; -Watch for bleeding-apply direct firm pressure on area for 7-10 minutes if bleeding occurs. If bleeding cannot be controlled/continues longer than 30 min, call 911; -Assess access site for bruit (the sound heard as blood…

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 drugs and biologicals were not kept past their expiration date and that medications for residents who were no longer in the facility were removed from the active medication supply for one of one medication room, one of one medication cart and one of one treatment cart observed. In addition, the facility failed to store all drugs and biologicals in locked compartments and controlled substances behind two locked compartments when the medication room door was left propped open with no staff present and as a resident walked independently past the door (Resident #15). The facility identified having one medication room, three medication carts and one treatment cart. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated June 1, 2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, 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 and record review, the facility failed to provide palatable food and serve what was listed on the menu for one resident (Resident #5) out of six residents who received a pureed diet. The facility also failed to follow the recipes for pureed diets and provide the amount of food specified on the menu. The census was 51. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/21, showed: Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and eating; -Diagnoses included: Cachexia (general weight loss occurring during course of chronic disease), progressive neurological condition, high blood pressure, high cholesterol, non-Alzheimer's dementia and anxiety disorder. Record review of the resident's electronic physician order sheet (ePOS), showed regular diet, pureed texture, and regular consistency. Review of the residents, medical record,…

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 label and date food when it was removed out of the original container. The census was 51. Review of the facility's policy dated 8/12/18, regarding Food Safety Storage Labeling and Dating, showed: -Foods will be properly stored, labeled and dated according to current practice standards; -All items must be dated when received and not kept longer than three days after receipt; -Items past the safe use by date will be discarded; -Administrator will check in dietary and nursing refrigerators at least weekly. Observation on 9/22/21 at 9:26 A.M. and showed the following -In the freezer, three bags hash browns not dated and taken out of the original box; -In the freezer, four bags of spinach not dated and taken out of the original box; -In the freezer, one bag of mixed vegetables in a zip lock bag, 2 bags of peas, 4 bags of green beans, 5 bags of vegetables not dated, one bag of approximately 30 chicken patties in a zip lock bag not dated; one bag of several pizza crusts not in its original bag not dated; -In 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 and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infections. Staff failed to follow proper hand hygiene and infection control procedures for four of four perineal (the area to include the buttocks and the genitals) care observations (Residents #19, #5, #29 and #42). Staff failed to perform proper hand hygiene before adjusting or assisting a resident with their face mask (Resident #10). Staff touched a resident's sandwich with bare hands. Staff failed to properly sanitize a shared Hoyer lift (mechanical lift) before and/or after use (Resident #36). Staff used resident personal care items to turn on and off the water prior to using them on the resident (Resident #2). In addition, staff failed to ensure a resident who provided services for the facility, followed the same infection control practices expected of staff when setting up…

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 protect residents' personal privacy during personal care. One resident was left naked and exposed while staff allowed housekeeping into the room to clean (Resident #19). In addition, staff failed to ensure a resident was not visible from the hallway when partially dressed while staff were present and that the resident was not visible to the roommate during incontinence care (Resident #5). This affected two of four residents observed during incontinence care. The census was 51. Review of the facility's admission packet, provided to residents upon admission to the facility, showed Know Your Rights: You have the right to privacy in medical treatment and personal care. You should be treated with consideration and respect, with full recognition of your dignity and individuality. Review of the facility's Incontinence Care policy, dated 10/1/99, showed: -Each resident deserves to be clean and dry; -Policy: To ensure adequate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two mechanical lift transfers one of three stand by transfers observed (Residents #2 and #29). The census was 51. Review of the facility's Transfer Techniques policy, dated 4/17/19, showed: -Policy statement: Use of appropriate devices (lifts, belts, draw sheets, etc.) provide a safe means of lifting or transferring residents and, when used properly, protect both the resident and the employee from injury; -Lifts: Use for totally dependent residents or anyone with contractures (tightening of the tendons and joints resulting loss in range of motion), amputations, obesity, etc. Do not attempt to use the lift unless you have been trained and feel comfortable with the procedures. Do not lift alone, there must always be 2 staff members when using one of the lifts. Make sure to widen the base of the lift before use. Never use a frayed or ripped sling.…

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 are free from any significant medication errors, for one resident (Resident #16) who was administered expired insulin. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated [DATE], showed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Review of Resident #16's electronic medical record, showed: -Diagnoses included diabetes mellitus with ketoacidosis (a serous diabetes complication where the body produces excess blood acids) without coma and type 1 diabetes (a chronic form of diabetes that typically appears in adolescence) with unspecified complications; -Review of the resident's electronic physician order sheet, showed: -An order dated [DATE], 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.