Brookhaven Nursing & Rehab

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 the facility failed to follow consistently document and physician orders and failed to routinely document of notification of the physician and assessments in an elbow wound for one resident (Resident #60), out of 17 sampled residents. The facility census was 75. Review of the facility's policy titled Physician Orders, undated, showed the following information: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be reviewed and renewed; -Treatment orders must specify what is to be done, location, and frequency and duration of the treatment. Review of the facility's policy titled Resident Examination and Assessment, undated, showed the following information: -Examine and note the intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema, and rashes of the resident's skin; -Document the following…

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 residents with pressure ulcers received services consistent with professional standards of practice when the facility failed to document regular full wound assessments for one resident (Resident #60) out of 17 sampled residents, who had a pressure ulcer to the right hip. The facility census was 75. Review of the facility's policy titled Resident Examination and Assessment, undated, showed the following information: -Examine and note the intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema (swelling), and rashes of the resident's skin; -Document the following in the resident's chart the date and time the assessment was performed; name and title of individuals who performed the assessment; assessment data obtained during the assessment; how the resident tolerated the assessment; if the resident refused and why; the signature and title of the person recording the data; and notify the supervisor if the resident were to refuse; -Notify the physician of any…

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 provide pharmacy services to meet the needs of each resident when staff failed to have ordered medications on hand for administration for two residents (Resident #49 and #13). The facility census was 75. Review of the facility policy titled Medication Administration, undated, showed medications are given to benefit a resident's health as ordered by the physician. 1. Review of Resident #49's face sheet (brief information sheet about the resident) showed the following: -admission date of 05/11/23; -Diagnoses included vitamin B12 deficiency (condition that develops when the body cannot make enough healthy red blood cells because it doesn't have enough vitamin B12). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/17/24, showed the resident was cognitively intact. Review of the resident's care plan, last reviewed 11/26/24, showed the following: -Resident had the…

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

Based on record review and interview, the facility failed an medication error of less than 5 percent when staff made four medication errors out of 32 opportunities, affecting two residents (Resident #13 and #42) resulting in a 12.5 percent medication error rate The facility census was 75. Review of the facility policy, Medication Administration,' undated, showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Read the label three times before administering the medication. First when comparing the label with the medication sheet. Second when setting up the medication. Third when preparing to administer the medication to the resident; -Administer the medication; -Record the medication given on the medication sheet. 1. Review of Resident # 13's face sheet showed the following: -admission date of 02/02/21; -Diagnoses included Vitamin D deficiency, constipation, and pain. Review of the resident's physician orders, dated 12/01/24 through 12/13/24, showed the following: -An order, dated 12/31/21, for acetaminophen (generic for Tylenol) 325…

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 residents were free of significant mediation errors when the facility failed to provide a meal service and/or a snack for one resident (Resident #42) after administering rapid acting insulin. The facility census was 75. Review of the facility's policy titled Medication Administration, undated, did not show any direction regarding insulin administration and/or fast acting insulin requirements. Review of the publication of the National Library of Medicine, titled Optimal Prandial Timing of Bolus Insulin in Diabetes Management, dated 11/2016, taking rapid acting insulin 15 to 20 minutes before a meal provides significant improvements in post-meal control and is recommended whenever possible. Review of the Mayo Clinic's Insulin aspart,recombiant (intravenous route,subcutaneous (below the skin), updated 10/01/24, showed when used as a mealtime insulin, Novolog® and Insulin Aspart FlexPen® (a fast acting injectable insulin) should be taken within 5 to 10 minutes before a meal or immediately before 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.

Based on interview and record review, the facility failed to protect the resident's (Resident #1) right to be free from verbal and emotional abuse, by a staff member (Certified Nurse Aide (CNA) B) when staff yelled at and belittled the resident. The facility census was 70. Review of the facility's policy titled Handle with Care, Behavior Management System, Verbal Intervention Manual for Participants, latest publication 2012, showed the following: -Creating a universal perception of physical and psychological safety; -In order to act in the resident's best interest, staff need to be in control of their feelings and behavior; -Staff should interact with the resident during a crisis by allowing ventilation without becoming judgmental; considering the validity of the feeling if not the behavior, as it is impossible to tell another person how to feel; focus on one issue at a time; offer alternate choices the resident can make, contrasted by the inappropriate choices and the attached consequences; and persuade the individual to agree on the course of action to be taken. 1. Review 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 interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed and provided written statements regarding allegations verbal abuse of one resident (Resident #1) by a facility staff member. The facility census was 70. Review of the facility's policy abuse policy, undated, showed the following: -All allegations of abuse, neglect, exploitation, and mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately, but no later than the following timeframes; -If abuse is alleged or there is serious bodily injury, the allegation must be reported within two hours after the allegation was made; -If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24-hours after the allegation was made; -All employees of the facility are mandated reporters; -The facility will ensure all reports are made within two hours (abuse or serious…

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 document completion of a full investigation of an allegation of employee to resident abuse towards one resident (Resident #1). The facility census was 70. Record review of the facility's Abuse Policy under the section, Investigation, undated, showed the following: -Designated facility personnel will begin the investigation immediately; -A root cause investigation and analysis will be completed; -The information gathered is given to administration; -The Administrator or designee will investigate the incident with the assistance of appropriate personnel; -The investigation will include who was involved; resident's involved statements; resident's roommate's statement; interviews with 3 to 4 residents receiving care from the alleged staff; interviews from 3 to 4 department staff (if possible); involved staff and witness statements of events; a description of the resident's behavior and environment at the time of the incident; injuries present including a resident assessment; observation of resident and staff behaviors; 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 interview and record review, the facility staff failed to notify one resident's (Resident #1) representative in a timely manner when the resident had a change in condition, including falls. The facility census was 69. Review of the facility's policy titled, Event Investigation, undated, showed the following: -Notify the resident's representative of a change of condition or any concerns that have been identified; -Detailed procedure for completing the Report of Event Form, Responsible Party: Document who and how related and date and time of notification. This must be documented in the medical record. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 05/16/22; -On hospice services; -Diagnoses included Alzheimer's disease and primary insomnia (decreased ability to fall asleep and/or stay asleep). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/09/23, showed the following information: -Severe impaired…

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 stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to keep ice machine free of white substances, failed to dispose of outdated refrigerated foods, and when stored clean, wet dishes on a tray. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 68. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's policy titled, Nutrition and Dining Services Manual, May 2015, showed wash the inside of the machine thoroughly with warm detergent solution, rinse with baking soda water, and dry monthly. Inside of the machine will be de-limed per facility guidelines monthly. Observations of the kitchen on 06/05/23, beginning at 9:01 A.M., and on 06/07/23, at 3:00 P.M., showed the inside of the ice machine, above the ice and around the hinges, had a white substance present. During an interview on…

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 provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the initiation, reduction, or termination of Medicare Part A benefits for three sampled residents (Resident #67, Resident #123, and Resident #124) who remained in the facility upon discharge from Medicare Part A services. The facility census was 68. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may…

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

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital for three residents (Resident #4, #16, and #17) out of a sample of eight residents. The facility census was 68. The Administrator and Assistant Director of Nursing (ADON) were notified on 05/01/23 of the Past Non-Compliance which had been ongoing and the ADON implemented an in-service for all nurses involved in sending residents to the hospital, provided transfer packets to all the nursing stations, began in-servicing of all nurses as they began their shifts, and began monitoring charts weekly to ensure no other incidents occur. The noncompliance was corrected on 05/02/23. Review of the facility policy titled Bed Hold Guidelines, undated, showed notice must be made as soon as practicable before transfer or discharge when an immediate transfer or discharge is required by the resident's urgent medical needs. 1. Review of Resident #4's nursing notes, dated 04/25/23, showed the resident transported via facility transport…

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 ensure all residents were free of significant medication errors when staff failed to administer medications as scheduled to three residents (Resident #13, #66, and #13) and when staff to prime an insulin pen and hold the insulin dose for six seconds at the site of administration as recommended by the manufacturer to ensure the resident received the full and correct dose of insulin for one resident (Resident #24). The facility had a census of 68. 1. Review of the facility policy, titled Medication, Administration Guidelines, undated, showed residents should receive their medications on a timely basis. 2. Review of Resident #13's face sheet (a brief resident profile) showed the following information: -admission date of 05/31/22; -Diagnoses included schizoaffective disorder (a condition of psychosis and mood disorder), Type 2 diabetes mellitus (high blood glucose), and major depressive disorder (sadness and loss of interest). Review of the resident's care plan, last updated on 06/08/23, showed the following: -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, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants when staff failed to use appropriate hand hygiene after performing incontinent care for one resident (Resident #4); failed to use appropriate hand hygiene before, during, and after performing glucometer (a machine used to check blood sugar) checks and failed to clean the glucometer after use for one resident (Resident #4); and when staff did not complete hand hygiene during medication pass and directly touched mediations for one resident (Resident #66). The facility census was 68. Review of the Centers for Disease Control and Prevention (CDC) website, updated 01/30/20, showed the following: -Hand hygiene (washing hands or using alcohol based hand rub) should be performed before putting on gloves; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident; -Hand hygiene should be performed after body fluid exposure or assisting…

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

Based on observation and interview, the facility failed to provide a sanitary environment when the dietary and maintenance staff failed to ensure the fan located in the walk-in refrigerator and the vents on the ice machine were cleaned. The facility census was 68. 1. Review of the facility's policy titled Nutrition and Dining Services Manual, dated May 2015, showed the following: -The outside of the ice machine will be cleaned weekly; -Wash the outside with soft brush or cloth and dry; -Polish the outside with micro-shield or glass cleaner. Observations of the kitchen on 06/05/23, beginning at 9:10 A.M., and on 6/07/2023, at 3:00 P.M., showed the vents on each side of the ice machine had sticky substance and fuzzy lint. During an interview on 06/07/23, at 3:16 P.M., Dietary Aide A said dietary staff have a weekly deep clean and daily cleaning list for A.M. and P.M., staff. Dietary staff wipes and cleans the outside of the ice machine. During an interview on 06/07/23, at 3:20 P.M., Dietary Aide B said dietary staff wipe down the outside of the ice machine, he/she isn't sure who is…

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 interviews, record review, and observations, the facility failed to ensure all residents dignity was protected at all times when staff members failed to assist one resident (Resident #33), who attempted to disrobe in common area, in timely and failed to update the resident's care plan with new interventions related to the disrobing behavior. The facility census was 68. Review of the facility policy titled Resident Rights, undated, showed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. Resident rights are to be fully respected and adhered to. 1. Review of Resident #33 ' s face sheet showed the following: -admission date of 09/01/16; -Diagnoses included dementia (a group of conditions characterized by impairment of a least two brain functions, such as memory loss and judgment), generalized anxiety disorder, and cerebral infarction (stroke). Review of the resident's significant change Minimum Data Set…

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 incontinent care for one resident (Resident #68) in a manner that prevented possible infection when staff failed to following proper hand washing during incontinent care and failed to provide catheter care per stands of practice. The facility census was 68. Review of the Centers for Disease Control and Prevention (CDC) website, updated 01/30/20, showed the following: -Hand hygiene (washing hands or using alcohol based hand rub) should be performed before putting on gloves; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident; -Hand hygiene should be performed after body fluid exposure or assisting with toileting, performing would care, or performing a finger stick; -Hand hygiene should be performed after direct contact with a resident; -Hand hygiene should be performed after removing gloves. Review of the CDC website page for Catheter-Associated Urinary Tract Infections (CAUTI), updated 11/05/15, showed the following: -Use Standard…

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 complete side rail assessment, including a risk/benefit review and alternatives attempted prior to use, and failed to obtain informed consent for side rails for three residents (Resident #5, #57, and #65) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's Bedrails-Siderails-Grab Bars-Safety Rails policy, dated January 2017, showed the following: -Side Rail Assessment and Consent (Matrix (Matrix is electronic medical record system used by the facility) form) may be completed to determine if a side rail , bed rail, grab bar, or safety rail is the least restrictive device to restrain, resident' choice, and/or least restrictive device to treat a problem such as positioning in bed. 1. Record review of Resident #5's face sheet (brief resident information sheet) showed his/her diagnoses included reduced mobility. Record review of the resident's January 2020 physician's orders showed no order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when 16 residents' bathrooms did not have functioning exhaust vents. The facility had census was 75. 1. Observations on 1/30/20, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident bathrooms did not have functioning exhaust ventilation system when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. During an interview on 1/30/20, at approximately 1:00 P.M., the Maintenance Supervisor (MS) said he did not know the residents' bathroom exhaust systems did not work The exhaust systems worked off fans located on the roof.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure privacy for one resident (Resident #330) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's admission Packet of Resident's Rights included the following information: -Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. All persons, other than Division of Health Standards and Licensure or Department of Mental Health staff, as appropriate, shall be excluded from observing the Resident during any time of examination, treatment or care unless consent has been given by the Resident. 1. Record review of Resident #330's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia, acute kidney failure and urinary tract infection. Record review of 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 complete an investigation of an allegation of misappropriation of resident property for two residents (Resident #2 and Resident #14) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's Abuse Policy, revised 11/28/16 related to the facility investigative documentation showed the following: -A specific description of the incident; -Relevant information/documentation from the resident's medical record (i.e., face sheet, nurse's notes, MDS, care plan, physician notes and discharge information). -Names, addresses, home telephone numbers, date of birth , social security numbers and positions of staff involved in the incident. -Written statements by all persons with knowledge of the incident. Statements must be signed, dated and give specific details. -Documentation of interviews with other residents who might have been affected or that involved staff person worked with to determine if there were additional…

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 physician of a new wound and obtain a physician's order for wound care. Staff applied wound treatments without a physician's order, failed to apply a treatment as ordered, and failed to use proper hand hygiene according to facility policy, during and after wound care for one resident (Resident #57) out of a sample of 20. The facility census was 75. Record review of the facility's (undated) Physician's Order Policy, showed for treatments orders: Specify what is to be done, location and frequency, and duration of the treatment. Record review of the facility's Wound Care and Treatment Policy, dated March 2015, showed the following: -Universal precautions and strict hand washing procedure for all wound care and/or patient contact; -It is the purpose of this facility to treat all wounds; -Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -Hand washing must be done as outlined 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.

Based on observation, interview, and record review, the facility failed to obtain a physician order for continous oxygen, and failed to identify, develop and implement interventions for Oxygen use for one resident (Resident #58) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's policy, dated March 2015, titled Oxygen Administration, showed the following information: -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -Place cannula tubing in plastic bag attached to concentrator when tubing is not in use; -Check resident's respiration and observe at regular intervals to assess need for further oxygen therapy after oxygen has been discontinued. 1. Record review of Resident #58 face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 12/18/19; -Diagnoses included heart Attack, Congestive Heart Failure (CHF) (a chronic progressive condition in which fluid builds up around the heart and causes it to pump inefficiently), and pneumonia 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 ensure staff administered medications with an error rate of less than 5%. Facility staff made two errors out of 26 opportunities, resulting in an error rate of 7.69%, which affected two residents (Resident #24 and #52). The facility census was 75. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, showed the following information: -Humalog insulin should be administered 15 minutes before a meal or immediately after a meal; -Hypoglycemia (low blood sugar) is the most common adverse reaction to insulin therapy and may be life-threatening. Symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death. -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly; If you do not…

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 residents were free from significant medication errors when staff failed to prime an insulin pen and administer the insulin (medication used to lower blood sugar levels) as directed by the manufacturer for one resident (Resident #52), during a random medication pass observation. The facility census was 75. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, included the following information: -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; If you do not prime before each injection, you may give too much or too little insulin; -To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle pointing up. Push 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 record review and interview, the facility failed to ensure temperature-sensitive medications were stored at the appropriate temperatures for two refrigerators in one of two medication rooms. The facility census was 75. Record review of the facility's Storage of Medications Policy, dated March 2015, showed the following: -Biologicals or medications must be kept in a separate, securely fastened refrigerator, at or near the nurse's station within a locked medication room; -Drugs stored in the refrigerator must be stored between 36 and 46 degrees Fahrenheit. 1. Record review of the January 2020 Refrigerator Temperature Log for refrigerator 1 (the top refrigerator), located in the CDE medication room, showed the following: -Staff did not document refrigerator temperatures for 21 days (1/2/20, 1/4/20, 1/7/20-1/16/20, 1/18/20-1/21/20, 1/23/20, 1/24/20, 1/27/20, 1/28/20, and 1/30/20; -On 1/17/20 staff documented the refrigerator's temperature measured 34 degrees Fahrenheit (F). Staff did not document follow-up to the out-of-range temperature. -On 1/29/20 staff documented 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, and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 75. 1. Record review of the facility's dietary staffing schedule showed the facility employed a Dietary Manager (DM). An interview on 1/31/20, at 10:25 A.M., showed the following: -The DM said he worked at the facility for two years as a Certified Nursing Assistant (CNA). -Approximately two months ago, he started working as the DM but he had no experience working in food management in long term care. -The facility gave him a book to study and to use for the Dietary Mangers' certification test. -He was not a Certified Dietary Manager. He had one year to take the certification test. -The Registered Dietitian (RD) came to the facility and reviewed residents' medical records and menus. The RD answered all questions and was always on call. During an interview on 1/31/20 at 1:00 P.M., the nurse consultant said the facility was working to ensure compliance.