Brunswick Rehabilitation and Healthcare Center

Based on record review, observations, Administrator, and Maintenance Director interviews, the facility failed to remove the black greenish substance from the commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411), failed to repair resident's overhead lights that were non-functioning in resident rooms (202 and 411). These failures occurred on 3 of 5 hallways (200, 300, and 400 Halls) observed for a safe, clean, homelike environment and failed to maintain hot water temperatures in 2 of the 2 shower rooms on the 300-hall (Spa #1 and Spa #2) reviewed for hot water. Findings included: 1. An observation of the two 300-hall shower rooms was completed during a round on 02/17/25 which started at 9:45 AM with the Maintenance Director. The shower hot water temperature in Spa #1 fluctuated from 85 degrees Fahrenheit (F) to 89 degrees F, and the shower in Spa #2 hot water temperature fluctuated from 83 degrees F to 101 degrees F. Both shower water temperatures were obtained using the calibrated thermometer provided by the Maintenance Director and the temperatures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to provide bathing and showers (Resident #39, Resident #53, and Resident #60) and incontinence care (Resident #7) to residents who were dependent on staff assistance with activities of daily living (ADL). This occurred for 4 of 5 residents reviewed for ADL care. Findings included. 1a.) Resident #39 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. She had no rejection of care. She had impaired range of motion in her bilateral upper and lower extremities and was dependent on staff for activities of daily living (ADL). A care plan dated 1/16/25 revealed Resident #39 had ADL self-care performance deficit related to her diagnosis of Alzheimer's disease, primary osteoarthritis, diabetes, and hypertension. Interventions included to encourage participation in tasks. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Registered Dietician and Physician interviews, the facility failed to provide a nutritional supplement ordered twice a day for 30 days for wound healing to a resident who was at risk for malnutrition and had a facility acquired unstageable deep tissue injury of the right heel and a deep tissue injury to the left heel that developed into a Stage IV pressure wound. This occurred to 1 of 10 residents (Resident #60) reviewed for nutrition. Findings included. Resident #60 was admitted to the facility on [DATE] with diagnoses including muscle wasting with atrophy, dysphagia, and dementia. A wound physician's report dated 11/20/24 revealed Resident #60 had bilateral deep tissue injuries to her left and right heels. A care plan revised 11/25/24 revealed Resident #60 was at nutritional risk due to cognitive decline associated with dementia, dysphagia with a modified diet order, age-related physiological decline and debility, skin breakdown, diabetes, and aphasia. She was at risk 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.

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 13 of 275 days reviewed for staffing (04/6/24, 04/20/24, 04/21/24, 07/13/24, 07/27/24, 08/17/24, 09/07/24, 09/08/24, 09/28/24, 09/29/24, 10/05/24, 10/28/24, and 12/03/24). Findings included: The PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 1, 2024 (October 1 - December 31) documented the facility had no RN Coverage on 10/08/24, 11/19/24, 12/03/24, and 12/31/24. In addition, the PBJ Staffing Data Report Fiscal Year - Quarter 3, 2024 (April 1 - June 30) documented the facility had no RN Coverage on 04/06/24, 04/07/24, 04/20/24, and 04/21/24. In an interview with the Human Resources Director on 02/18/25 at 1:50 PM she stated she verified by reviewing the daily employee timecard punches that an Agency RN had worked 8 hours on the following dates: 04/07/24,10/08/24, 11/19/24, 12/31/24. She could not explain why the PBJ report did not recognize the hours worked by the Agency RN because she did punch the time clock. The Human Resources Director…

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 Physician and Consultant Pharmacist's interviews, the Pharmacist failed to identify and address during the monthly medication regimen review that a residents Carvedilol 3.125 milligrams prescribed for hypertension was held 17 out of 31 days during December 2024. This occurred for 1 of 5 residents (Resident #54) reviewed for medication administration. Findings included. Resident #54 was admitted to the facility on [DATE] with diagnoses to include hypertension. A physician's order dated 6/10/24 for Resident #54 revealed Carvedilol (antihypertensive) 3.125 milligram tablets. Give one tablet orally two times a day for hypertension. There were no parameters on the order to hold the medication. Review of the Medication Administration Record (MAR) dated December 2024 for Resident #54 revealed Carvedilol 3.125 milligram tablets. Give one tablet orally two times a day for hypertension to be administered at 8:00 AM and 8:00 PM. There were no parameters on the MAR to hold the medication. 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 record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.)administer the antihypertensive medication Carvedilol 3.125 milligrams prescribed twice a day for hypertension. Resident #54 experienced no significant outcome by not receiving the medication. 2.) hold the blood pressure medication Midodrine (prescribed to increase blood pressure) when the systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Resident #43 experienced no significant outcome from receiving the additional doses. This occurred for 2 of 5 residents (Resident #54 and Resident #43) reviewed for medication administration. Findings included. 1.) Resident #54 was admitted to the facility on [DATE] with diagnoses to include hypertension. A physician's order dated 6/10/24 for Resident #54 revealed Carvedilol (antihypertensive) 3.125 milligram tablets. Give one tablet orally two times a day for hypertension. There were no parameters on the order to hold…

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 observations and staff interviews the facility failed to ensure that food items that were stored for use in 1 of 1 walk-in refrigerator, 1 of 1 reach-in refrigerator and the dry goods storage pantry were labeled, dated, or discarded when expired. This deficient practice had the potential to affect food served to residents. Findings included: An observation on 02/16/25 at 10:20 AM of the kitchen's walk-in refrigerator with the Dietary Manager in training revealed: a. (2) small glasses of nectar orange juice with no opened date b. (1) partially used plastic bucket of pears with no opened date c. (4) hot dogs in a zip lock bag with an expiration date of 02/11/25 d. (1) partially used container of apple juice with an open date of 01/29/25 (expired on 02/04/25) e. (1) tub of chocolate pudding partially used with no opened date f. (1) pitcher of partially used fruit punch with an expiration date of 02/07/25 g. (1) partially used container of thickened sweet tea with lemon with no opened date h. (1) partially used small bowel of apple sauce with no opened date i. (1) partially…

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 staff interviews, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program established and implemented effective systems to monitor and evaluate action plans previously developed to correct identified deficiencies. This failure resulted in the facility being unable to sustain compliance at F584, F677, F727, F732, and F812. During a complaint investigation and follow up survey of 02/04/23, the facility failed to maintain hot water temperatures in a shower room used by residents (F584). During a complaint investigation survey of 01/25/24, the facility failed to provide incontinent care to dependent residents (F677). During a recertification and complaint investigation survey of 03/27/24, failed to provide 8 hours of a Registered Nurse (RN) coverage (F727), accurately document the Daily Nursing Hours staff postings (F732), and ensure that food items that were stored for use were labeled (F812). On the current recertification and complaint investigation survey these identical deficient practices were repeated. 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.

Basedonobservations recordreview andstaffinterviews thefacilityfailedtoimplementthefacilitysinfectioncontrolpolicyandproceduresforEnhancedBarrierPrecautions(EBP when1.) Nurse#5 provideddirect careforResident#60'sStageIVandunstageablechronicfootwoundswithoutapplyingthenecessary personalprotectiveequipment(PPE and 2.) whentwonurseaides(NurseAide#1 andNurseAide#2) providedcare to Resident #7 withoutapplyingthenecessary PPE whohadastageIVpressureulcerandtubefeedingport Thisoccurredfor3 of3 staff(Nurse#5, Nurse Aide #1 andNurse Aide #2) observedforinfectioncontrolpractices Findingsincluded ReviewofthefacilityspolicyforEnhancedBarrierPrecautionsupdatedOctober2024 revealedEnhancedBarrierPrecautions(EBP requirestheuseofgownandglovesonlyforhighcontactresidentcareactivities Highcontactresidentcareactivitiesintheresidents roomsincludeddressing bathingshowering transferring providinghygiene changinglinens changingbriefsorassistingwithtoileting devicecareorusesuchascentrallines urinarycatheters feedingtubes tracheostomyventilatoruse andwoundcare 1.) During an observation on 02/16/25 at 4:50 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to provide a resident with their preferred number of showers a week for 1 of 1 residents reviewed for choices (Resident #38). The findings included: Resident # 38 was admitted to the facility on [DATE] with diagnoses that included spondylosis, muscle weakness, venous thrombosis, and anxiety. Resident #38's most recent Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairments. Resident #38 needed extensive to total assistance with activities for daily living: bed mobility, transfers, eating, toilet use, dressing, personal hygiene, and bathing. Resident #38's care plan dated 02/03/25 revealed Resident #38 was unable to participate in the usual daily routine and needed modified activities or some assistance when using her hands. Resident #38 had an Activities for Daily Living (ADL) self-care performance deficit related to diabetes, spondylosis with myelopathy, osteoarthritis, and muscle weakness.…

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 observations, record review, and staff interviews, the facility failed to protect a residents' right to be free from neglect when a nurse (Nurse#5) failed to perform the daily wound care to an infected Stage IV left heel pressure wound and an unstageable right heel pressure wound both of which were facility acquired. This failure occurred for 1 of 3 residents reviewed for neglect. Findings included. This tag is cross referenced to: F686: Based on observations, record review, staff, the Medical Director and the Wound Physician interviews, the facility failed to provide wound care according to the physician's order for a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel. This occurred for 1 of 3 residents (Resident #60) reviewed for wound care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, the Medical Director and the Wound Physician interviews, the facility failed to provide wound care according to the physician's order for a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel. This occurred for 1 of 3 residents (Resident #60) reviewed for wound care. Findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses including peripheral arterial disease, diabetes, hypertension, and dysphagia. A care plan dated 11/18/24 revealed Resident #60 had deep tissue injuries to her left and right heel and was at risk for further decline and infection. Interventions included in part to administer wound care treatments as ordered and monitor for effectiveness. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #60 had moderately impaired cognition. She had two deep tissue injuries. She had no rejection of care. The wound physician's note dated 2/12/25 revealed 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 observations, record review, staff, and resident interviews the facility failed to provide sufficient nursing staff to provide incontinence care to a dependent resident (Resident #7). Nurse Aide #2 reported she changed Resident #7's brief at approximately at 7:30 AM and had not checked the resident for incontinence needs again until 1:15 PM. This occurred for 1 of 24 residents reviewed for sufficient staffing. Findings included: Resident #7 was admitted to the facility on [DATE]. Diagnoses included history of urinary tract infections, muscle wasting and atrophy, and need for assistance with personal care. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and was coded for impairments to both sides of upper and lower extremities and dependent with one staff physical assistance for ADL care. Resident #7 was always incontinent of bowel and bladder. A review of the staffing assignment sheet on 02/16/25 revealed there was one nurse aide assigned to each…

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 observations, record review and staff interviews the facility failed to maintain a medication error rate of less than 5%. There were 3 medication errors observed out of 25 opportunities which resulted in a medication error rate of 12%. This occurred for 2 of 4 residents reviewed during a medication pass observation (Resident #79 and #66). Findings included: 1). A medication pass observation on 02/19/25 a 8:30 AM with Nurse #6 revealed Resident #79 was administered Metoprolol (medication to treat high blood pressure) 25 milligrams (mg). Nurse #6 was not observed obtaining Resident #79's blood pressure prior to administering the Metoprolol 25 mg tablet. Nurse #6 stated she completed her medication pass for Resident #79 at 8:45 AM on 02/19/25. The medication reconciliation on 02/19/25 of Resident #79's medications revealed Resident #79 had an order for Metoprolol 25 mg with an order to hold the blood pressure medication if the systolic blood pressure (SBP) was less than 110 mm/Hg (millimeters of mercury). An interview was conducted with Nurse #6 on 02/19/25 at 10:35 AM. Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, Nurse Practitioner, Rehabilitation Director, and Registered Dietician interviews, the facility failed to implement a written order for occupational therapy evaluation for 1 of 10 residents (Resident #7) reviewed for nutrition. Findings included: Resident #7 was admitted to the facility on [DATE]. Diagnoses included history of diabetes, protein calorie malnutrition, gastrostomy (the insertion of a feeding tube via the stomach) and need for assistance with personal care. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and had impairments to both sides to upper and lower extremities. She was required to be set up with clean up assistance with meals. Resident #7 had a feeding tube and was on a mechanically altered diet and therapeutic diet. Resident #7 was receiving 51% or more through the feeding tube and 501 milliliters (ml) per day of fluid through the feeding tube. A care plan review updated on 01/07/25 revealed 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 record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage on 28 of 45 days reviewed. Findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 1, 2024 (October 1-December 31, 2023) revealed the facility had no Registered Nurse (RN) coverage on 10/08/23, 11/19/23, 12/03/23 and 12/31/23. Review of the daily assignment schedules from October 1, 2023 through March 19, 2024 revealed the facility failed to provide 8 hours of RN coverage on the following dates: 10/08/23, 11/13/23, 11/14/23, 11/18/23, 11/29/23, 11/23/23, 12/03/23, 12/16/23, 12/20/23, 12/21/23, 12/22/23, 12/26/23, 12/30/23, 12/31/23, 01/13/24, 01/14/24, 01/27/24, 01/28/24, 02/10/24, 02/11/24, 02/14/24, 02/16/24, 02/15/24, 02/28/24, 03/04/24, 03/07/24, 03/29/24, and 03/10/24. In an interview with the facility Scheduler on 03/19/24 at 4:30 PM she reported the facility had been short RN coverage every other weekend for several months but could not remember how long it had been since the last RN Weekend Supervisor had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Nurse Practitioner interviews, the facility failed to follow the physician order and provide sliding scale insulin to 2 residents (Resident #60 and Resident #2) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in Resident #60 not receiving a total of 21 doses of sliding scale insulin from 03/08/24 through 03/17/24 and Resident #2 not receiving a total of 6 doses of sliding scale insulin from 03/01/24-03/17/24. This was for 2 of 2 residents reviewed for insulin administration. There was no significant outcome to either resident. Findings included: 1. Resident #60 was readmitted to the facility on [DATE] with diagnosis including diabetes with diabetic polyneuropathy. Review of Resident #60's care plan revealed a 2/28/24 focus of at risk for hypo or hyperglycemia due to diabetes. The goal indicated Resident #60 would not exhibit signs of hypo or hyperglycemia. Interventions indicated to administer medications as ordered and observe…

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 observations and staff interviews the facility failed to ensure refrigerated meat items stored for use in the walk-in refrigerator for resident sandwiches were dated and sealed. This practice had the potential to affect food quality. The findings include: An observation on 03/18/24 at 12:00 PM of the kitchen's walk-in refrigerator, with the Dietary Manager (DM) revealed; two clear plastic bags of sliced sandwich ham (16 & 8 once), not sealed or dated and were open to air. The DM was unable to explain why food stored in the kitchen's walk-in refrigerator was not dated and open to air. During an interview with the DM on 03/18/24 at 12:30 PM she said she monitored the items in the refrigerators and freezers weekly when conducting inventory. She stated the two bags of sliced ham should have been dated and sealed and not opened to air. During an interview with the Administrator on 03/21/24 at 2:45 PM, he reported it was his expectation the facility's kitchen staff follow all regulatory guidelines for food and kitchen sanitation safety.

Based on record review, Nurse Practitioner interview and staff interviews, the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification survey completed on 10/26/21 and an on-site revisit survey and complaint investigation survey completed on 02/04/23. This was for three repeat deficiencies originally cited in the areas of Posted Nurse Staffing Information (F732), Residents Are Free of Significant Med Errors (F760) and Resident Records - Identifiable Information (F842). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross-referenced to: F732: Based on record review and staff interviews, the facility failed to accurately document the Daily Nursing Hours postings for 2 of 45 Daily Nursing Hours reports reviewed. During the recertification survey of 10/26/21 the facility failed to post accurate nurse staffing information. F760:…

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 staff interviews, the facility failed to accurately document the time and date in the electronic Medication Administration Record (eMAR) 5 out of 28 times when prescribed as needed narcotic pain medications were removed from the narcotic dispensing cards for 2 of 2 residents reviewed (Residents #46 and #177). Findings included: A. Review of the physician orders for Resident #46 included the following order: Percocet 10 mg-325 mg tablet: Administer 1 tablet by mouth every 24 hours as needed for pain (Oxycodone HCL/Acetaminophen). Start date 02/07/24. Review of the Controlled Drug Receipt/Record/Disposition Form for Resident #46 revealed Nurse #1 had removed one dose of Percocet 10-325 mg from the locked narcotic drawer on 03/19/24 at 6:49 PM. Review of the electronic Medication Administration Record (eMAR) for Resident #46 did not document that Oxycodone-APAP 10-325 had been administered to the resident on 03/19/24 at 6:49 PM. In an interview with Nurse #1 on 03/21/24 at 2:18 PM via phone she stated she had given Resident #46 Percocet 10-325 mg on 03/19/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, #10, #11, and #12) who were unable to carry out activities of daily living (ADL's) without staff assistance and were reviewed for needing assistance with ADLs. Findings included. 1.) Resident #5 was admitted to the facility on [DATE] with diagnoses including muscle weakness, chronic pain, neuropathy (dysfunction of the peripheral nerves causing numbness or weakness in the hands or feet), and the need for personal assistance. A care plan dated 12/12/23 revealed Resident #5 required staff assistance with toileting and bowel and bladder incontinence. The goal of care was to receive the appropriate level of staff assistance for toileting and incontinence care. Interventions included to provide one person assistance with toileting and incontinence care. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact. She was incontinent…

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 observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following the complaint investigation survey of 3/8/21, the recertification survey of 10/26/21, and the recertification and complaint investigation survey of 12/16/22. This was for two deficiencies in the areas of Activities of Daily Living (ADL) Care Provided to Dependent Residents (F677) and Nutrition and Hydration Status Maintenance (F692). These areas were subsequently recited during the current revisit and complaint investigation survey of 01/25/24. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross-referenced to: F677: Based on observations, record review, and staff interviews the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, #10, #11, and #12) who were unable to carry out activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff, Registered Dietician and Physician interviews, the facility failed to: a) follow the physician orders to administer a nutritional supplement twice daily with lunch and dinner for weight loss; and b) obtain weekly weights as ordered for a resident (Resident #2) who had a weight loss. This was for 1 of 1 residents reviewed for weight loss. Findings included: Resident #2 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and dysphagia (difficulty with swallowing). A review of Resident #2's care plan dated 07/12/23 revealed a plan of care for weight loss with interventions to include: provide verbal encouragement/cueing, quiet dining environment, snacks in between meals, to monitor assistance needed with nutritional intake and notify physician of changes, maintain list of food likes and dislikes, allow sufficient time to feed/eat, and serve diet as ordered. The Minimum Data Set quarterly assessment dated [DATE] revealed 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.

Based on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following the complaint survey of 05/10/21 for one deficiency that was originally cited in area of abuse (F600), and during a recertification survey of 10/26/21 for two deficiencies that were originally cited in the areas of abuse (F600) and not following abuse policy (F607). These deficiencies were subsequently recited on the current complaint survey on 12/11/23. The continued failure during 2 or more surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F600: Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to protect residents' right to be free from sexual abuse (Resident #2) and intentional inappropriate touching (Resident #6) perpetrated by Resident #1. In the evening of 11/26/23 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.