Pelican Health Randolph LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to empty urinary drainage bag and secure urinary catheter tubing with anchoring device to prevent trauma to urinary opening or dislodgment of the catheter. The deficient practice occurred for 1 of 2 residents reviewed for urinary catheter care (Resident #5).The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included cervical spinal cord injury and neurogenic bladder (a disorder or problem with the nerve control of continence and voiding function). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. The MDS indicated Resident #5 was unable to use upper and lower extremities and required maximum assistance for all activities of daily living. He was documented as having an indwelling urinary catheter. Resident #5's care plan dated 9/8/25 included the goal to provide urinary catheter to Resident #5 for neurogenic bladder. The interventions…

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 follow procedure for labeling a continuous gastrostomy tube (a tube surgically placed in the stomach to provide nutrition, hydration, and medications) feeding. This deficient practice was for 1 of 2 residents reviewed for enteral (the administration of nutrients directly into the gastrointestinal tract through a tube) feeding management (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. Resident #3 had diagnoses which included chronic respiratory failure with hypoxia, diabetes mellitus (DM), and gastrostomy tube status. A review of Resident #3's Physician orders revealed:1. 01/20/2025 Nothing by mouth (NPO).2. 01/30/2025 Change enteral feeding pump tubing, solution, and piston syringe (used for flushing gastrostomy tubes) nightly. 3. 01/30/2025 Water flush of 200 milliliters every 3 hours via feeding pump.4. 04/07/2025 Enteral nutritional feeding continuously via gastrostomy tube at 45…

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 reviews, and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 4 residents reviewed for respiratory care and services (Resident #3). The findings included:Resident #3 was admitted to the facility on [DATE]. Resident #3 had diagnoses which included chronic respiratory failure with hypoxia and cerebral infarction (occurs when blood flow to the brain is interrupted causing damage to brain tissue) with hemiplegia (a condition that causes paralysis on one side of the body). Review of Resident #3's electronic medical record (EMR) revealed a physician's order dated 01/29/2025 for oxygen at 2 liters per minute (LPM) via nasal cannula continuously. Review of the care plan revised on 08/03/2025 revealed Resident #3 was at risk for respiratory complications secondary to chronic respiratory failure with hypoxia requiring supplemental oxygen. The interventions included to administer oxygen as ordered and to 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, record reviews and staff interviews, the facility failed to follow their Enhanced Barrier precaution policy when Nurse #2 did not don (put on) a gown to administer medications via gastrostomy (tube in the stomach) tube and Nurse Aide (NA) #1 did not don a gown to provide care to a urinary catheter for Resident #5. Additionally, the facility did not follow their hand hygiene policy or their clean dressing policy when the Wound Nurse failed to clean and sanitize her hands while preparing for a wound dressing after coming in contact with unclean surfaces. The deficient practice occurred for 3 of 10 staff (Nurse #2, NA #1, and Wound Nurse) observed for infection control. The findings included: The findings included: 1. Review of the facility’s infection control policy titled, Enhanced Barrier Precautions (EBP) dated 03/28/2024 read in part, “Criteria for implementing EBP include residents with indwelling medical devices including feeding tubes. EBP will be utilized to provide targeted gown and glove use during high-contact resident care activities to reduce 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 observations, resident, and staff interviews, the facility failed to ensure the call light system was functioning properly for 1 of 2 residents who required assistance for activities of daily living (Resident #66). The findings included:Resident #66 was admitted on [DATE] with diagnoses including cerebral infarction, hypertensive heart disease and dysphagia.Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was assessed as cognitively intact and needed partial assistance from staff with bed to chair and toilet transfers. In addition, the quarterly MDS assessment indicated he was occasionally incontinent of bowel and coded Resident #66 as having an indwelling catheter. Review of the care plan focus area for activities of daily living revised on 6/18/25 described Resident #66 as requiring assistance with his activities of daily living (ADL). Interventions put in place included partial assistance with transfers, supervision assistance with bed mobility and bathing. An…

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 reviews, and interviews with staff, Hospice Nurse, Medical Director and Consultant Pharmacist, the facility failed to limit the duration of an antipsychotic medication (a drug that affects brain activities associated with mental processes and behaviors) ordered on an as needed (PRN) basis to 14 days and failed to monitor for abnormal involuntary movements on a resident receiving an antipsychotic medication (Resident #63) for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. Review of Resident #63's care plan revised 2/23/24 revealed Resident #63 had been care planned for psychotropic/ antipsychotic medication use. The care plan interventions included to monitor effects related to psychotropics. The quarterly Minimum Data Set, dated [DATE] indicated Resident #63 was cognitively impaired and coded for behaviors that included hallucinations. She…

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, Medical Director, Vascular Physician Assistant (PA), Nurse Practitioner (NP) interviews, the facility failed to prevent a significant medication error when a resident did not receive an antiplatelet medication as ordered. This deficient practice occurred for 1 of 1 resident (Resident #68) reviewed for significant medication errors. The findings included: Resident #68 was re-admitted to the facility on [DATE]. Her medical diagnoses included: chronic ulcer of left heel, peripheral vascular disease/ severe peripheral arterial disease (decrease blood flow to the lower extremities), cerebral infarction (stroke). A review of Resident #68's hospital Discharge summary dated [DATE] revealed she was hospitalized from [DATE] to 6/5/24 for peripheral arterial disease (PAD) with chronic heel ulcer. She was seen by vascular surgery during her hospitalization and had a drug coated balloon angioplasty (a procedure used to open an artery to re-establish blood flow to tissues) procedure performed…

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 interviews, the facility failed to have advanced directives accurate throughout the medial record for 2 of 3 residents (Resident #47 and Resident #45) reviewed for advanced directives. The findings included: 1. Resident #47 was admitted to the facility on [DATE]. A review of Resident #47's health directive Medical Orders for Scope of Treatment (MOST) revealed that on 5/13/24 Resident #47 wanted his health directive to change from a Full Code to a Do Not Resuscitate (DNR). The MOST form was signed by Resident #47 on 5/13/24 and in the health directive binder at the nurse's desk. The care plan with a revision date of 5/31/24 stated that Resident #47 health directive was a full code. An intervention was the health directive should be reviewed quarterly and as directed. An interview on 6/26/24 at 11:53 AM was conducted with the Social Services Director. She stated that she reviews health directives at admission, care plan meetings and re-admission from the hospital. The social…

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, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 2 errors out of 27 opportunities which resulted in an 7.41% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident # 14). The findings included: Resident #14 was admitted to the facility on [DATE]. Her medical diagnoses included: hypertension (high blood pressure), history of transient ischemic attacks (mini stroke), cerebral infarction (stroke). Dry eye syndrome of bilateral lacrimal glands. a. A Physician's order dated 8/11/21 read please crush medications and administer in applesauce, every shift for difficulty swallowing. A physician's order dated 8/12/23 read Nifedipine (blood pressure medication) extended release (ER) 24-hour oral 30 milligram (mg) tablet, give one tablet by mouth one time a day for hypertension give with 90 mg tablet to equal total combined daily dose of 120 mg. 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 observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protective equipment (PPE) while providing wound care for a resident requiring Enhanced Barrier Precautions (EBP). This deficit practice occurred for 1 of 3 residents reviewed for EBP (Resident #68). The findings included: Review of the facility's policy and procedure revised on 3/1/2023, entitled Enhanced Barrier Precautions read in part: - It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities. -Initiation of EBP- An order for EBP will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed…

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, resident and staff interviews, the facility failed to keep a urinary catheter drainage bag off the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident 2). The findings included: Resident #2 was admitted to the facility on [DATE]. Her cumulative diagnoses included obstructive and reflux uropathy (blockage in the urinary tract), overactive bladder, severe chronic kidney disease, stage 4, and a history of urinary tract infections (UTIs). Resident #2's catheter care plan revised 7/3/23 included the use of a suprapubic catheter related to her diagnosis of obstructive uropathy and history of UTIs. Staff interventions included monitoring for conditions and complications that may contribute to urinary infections. A 3/12/24 quarterly Minimum Data Set (MDS) assessment, indicated Resident #2 had adequate hearing/vision, able to understand and be understood, clear speech, intact cognition, and no impairment in upper body range of motion.…

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, observations, resident and staff interviews, the facility failed to assess whether the self-administration of medications was clinically appropriate for 1 of 1 resident (Resident #1) who was observed to have a medication at bedside. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including acute posthemorrhagic anemia, end stage renal disease, dialysis, peripheral vascular disease, and diabetes. Resident #1 was readmitted to the facility on [DATE] and 2/23/24. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be cognitively intact without behaviors. Medication orders for Resident #1 revealed the following were ordered to be administered in the morning: Calcitriol 0.25 milligrams (mg) daily at 8:00 AM Clopidogrel 75 mg daily at 8:00 AM Edurant 25 mg daily at 8:00 AM Juluca 50/25 mg daily at 8:00 AM Nifedipine ER 60 mg daily at 8:00 AM Aspirin 81 mg daily at 8:00 AM Carvedilol 6.25 mg daily at 8:00 AM Cephalexin 500…

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, observations, resident and staff interviews, the facility failed to provide residents with their preferred method of bathing (Residents #135, #1, #12, #58, and #284) and failed to accommodate a resident's request to be assisted out of bed (Resident #70) for 6 of 8 residents reviewed for choices and dignity. Findings included: 1. Resident #135 was admitted to the facility on [DATE] with multiple diagnoses that included arthritis, left hand cellulitis, heart failure, and hypertension. The Nursing admission assessment dated [DATE] noted Resident #135 was alert and oriented to person, place and situation. The baseline care plan dated 02/07/23 revealed Resident #135 could communicate easily with staff, understand others and his daily preferences included receiving a shower. The undated Master Shower Schedule provided by the facility revealed Resident #135 was scheduled to receive his showers on Mondays and Fridays during the hours of 3:00 PM and 11:00 PM. Review of the February 2023 Nurse Aide…

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 and staff interviews the facility failed to repair jagged and splintered edges on the middle and lower portion of a bathroom door in the residents shared bathroom (room [ROOM NUMBER]); failed to clean the air vents and filters of the air condition and heating units in resident rooms (rooms 102, 106, 108, and 109); failed to maintain walls in good repair in a resident's room (room [ROOM NUMBER]-B) on 1 of 2 wings (West Wing). The facility failed to maintain a clean and sanitary side rail for a resident's bed (room [ROOM NUMBER]-A); failed to appropriately label and store personal care equipment in residents shared bathrooms (rooms [ROOM NUMBER]); failed to maintain functioning overhead lights in residents bathrooms (rooms [ROOM NUMBERS]); failed to provide functioning soap dispensers in residents bathrooms (rooms [ROOM NUMBERS]); and failed to provide a resident a pillow in good condition (room [ROOM NUMBER]-B) on 1 of 2 wings (West Wing). The findings included: 1. An observation on 02/20/23…

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 resident and staff interviews the facility failed to provide incontinence care (Resident #48), nail care (Resident #487, Resident #61, Resident #54, and Resident #185), and a shave (Resident #487) for 5 of 14 dependent residents reviewed for activities of daily living (ADL). Findings included: 1. Resident #48 was admitted to the facility 08/16/19 with diagnoses including cerebrovascular accident (abbreviated as CVA and meaning a stroke) and non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired, had no behaviors or rejection of care, and was always incontinent of bladder. Review of Resident #48's care plan last revised 01/18/23 revealed he was incontinent of bowel and bladder and interventions included checking him frequently and assisting with toileting as needed; providing incontinence briefs per manufacturer's recommendation; providing loose-fitting, easy to remove clothing; and providing…

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 interviews, the facility failed to ensure physician visits were alternated with the Family Nurse Practitioner's visits every 60 days for 3 of 3 sampled residents reviewed for physician visits (Residents #3, #39 and #16). Findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hypertension, and dysphagia (trouble swallowing). The significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had moderate impairment in cognition. Review of Resident #3's Electronic Medical Record (EMR) revealed she was seen by the Medical Director on 03/03/22 and 04/07/22. There were no other progress notes of physician visits conducted by the Medical Director. Review of Resident #3's EMR revealed she was seen by the Family Nurse Practitioner (FNP) on 05/12/22, 05/30/22, 06/20/22, 06/23/22, 07/25/22, 08/22/22, 08/29/22, 09/22/22, 10/20/22, 11/17/22, 12/12/22, 01/10/23, and 02/02/23. During a telephone 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 observations, record review, resident, family and staff interviews, the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for bathing and not receiving transfer assistance when requested for 6 of 8 sampled residents (Residents #135, #1, #12, #58, #284, and #70). Findings included: This tag is cross referenced to: F561: Based on record review, observations, resident and staff interviews, the facility failed to provide residents with their preferred method of bathing (Residents #135, #1, #12, #58, and #284) and failed to accommodate a resident's request to be assisted out of bed (Resident #70) for 6 of 8 residents reviewed for choices and dignity. During a telephone interview on 02/24/23 at 2:18 PM, Medication Aide (MA) #1 revealed since the previous survey, she had been assisting with coordinating the nursing staff schedule. MA #1 explained she used staffing agencies as needed to supplement the nursing staff schedule and tried to have a minimum of 7 to 8 Nurse Aides (NA) for the day shift, 7 NA for the evening shift,…

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 date and label opened food and remove expired food from 1 of 3 reach-in refrigerators. This practice had the potential to affect food served to residents. Findings included: On 2/20/23 at 9:57 AM an observation of the kitchen reach-in cooler #3 revealed one 5-quart square plastic container located on the top shelf that was approximately 1/8 full of grape jelly. The container was covered with plastic wrap and did not contain a label or use by date. A quart size food storage plastic bag contained sliced deli meat on the bottom shelf that did not contain a label or use by date and an open bag of pre-cut slaw mix was missing a label and use by date. Additionally, the same reach-in refrigerator contained a head of cabbage with dried and yellow outer shell. The Dietary Manager (DM) stated in an interview on 2/20/23 at 12:46 PM that the food items missing labels and use by dates should have been dated and labeled before placed into the reach-in refrigerator. The cabbage head should have been thrown away when the cook checked…

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 Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation survey completed on 11/22/21 and a complaint investigation survey completed on 02/17/22. This was for one repeat deficiency in the area of activities of daily living provided for dependent residents originally cited on 11/22/21 during a recertification and complaint investigation survey and on 02/17/22 during a complaint investigation survey. In addition, there were four repeat deficiencies in the areas of comprehensive assessments and timing, accuracy of assessments, free of accident hazards/supervision/devices, and sufficient nursing staff that were originally cited on 11/22/21 during a recertification and complaint investigation survey and/or complaint investigation survey on 02/17/22. The continued failure of the facility during three federal surveys of record show a pattern of the facility'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 observations and staff interviews, the facility failed to maintain a resident's dignity by not providing incontinence care and oral hygiene when needed, ensuring bed linen and fall mat were clean and free of food debris, and ensuring the room was free of odor for 1 of 12 residents reviewed for dignity (Resident #48). The reasonable person concept was applied to this deficiency. Individuals would expect to receive care needed and would be upset if observed with dried food debris on their mouth, bed, and floor; lying on bed linen that was not clean; and if their room smelled of urine. Findings included: Resident #48 was admitted to the facility 08/16/19 with diagnoses including cerebrovascular accident (abbreviated as CVA and meaning a stroke) and non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired, had no behaviors or rejection of care, required set-up assistance with eating, and was always incontinent of bladder. a. While…

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, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 2 residents reviewed for self-administration of medications (Resident # 186). Resident #186 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #186 was assessed as being cognitively intact. Review of Resident #186's medical records revealed no assessment for self-administering medications was included. Review of physician orders revealed on 02/15/23 an order was written for triamcinolone acetonide external lotion 0.1 % to apply to affected area topically two times a day for 14 days for atopic dermatitis. On 02/17/23 and order was written for regular strength suspension 200-200-20 milligram (mg)/5 milliliters (ml) of Aluminum and Magnesium Hydroxide-Simethicone give 30 ml every 4 hours as needed for indigestion and do not exceed 6 doses in 24 hours. An observation and interview were…

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 interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 2 of 32 residents reviewed (Residents #18 and #29). Findings included: 1. Resident #18 was admitted on [DATE]. A DNR (Do Not Resuscitate) form dated 11/2/22 for Resident #18 was located in the advance directive book at the nurses' station. A review of Resident #18's medical record revealed a physician's order dated 11/2/22 for a DNR. Resident #18's care plan dated 2/15/23 revealed her to be a full code. The MDS Coordinator stated on 2/21/23 at 3:32 PM Resident #18's advance directive code status change should have occurred in real-time when the physician's order was signed. When the care plan was reviewed on 2/15/23, the advance directive code status should have been changed by the MDS coordinator who updated the care plan. The Administrator was interviewed on 2/24/23 at 4:13 PM and stated Resident #18's advance directive should have been reflected on the care plan with 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 record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare Part A skilled services to 1 of 3 residents reviewed for beneficiary notification review (Resident #27). The Findings Included: Resident #27 was admitted to the facility on [DATE]. A review of Resident #27's medical record revealed no evidence a NOMNC and SNF ABN were provided to her or her Responsible Party (RP) which explained Medicare Part A coverage for skilled services would end on 10/31/22. Resident #27 remained in the facility. A joint interview was conducted with the Social Worker (SW) and Minimum Data Set (MDS) Nurse #1 on 02/22/23 at 9:36 AM. MDS Nurse #1 explained the Business Office Manager was responsible for issuing the SNF ABN when notified a resident had received a NOMNC. During an interview on 02/23/23 at 3:44 PM, the SW confirmed…

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 and staff interviews the facility failed to ensure that a resident was free from neglect when it failed to provide incontinence care for 1 of 3 residents reviewed for incontinence care (Resident #48). The reasonable person concept was applied to this deficiency. Individuals would expect to receive the care needed and would be upset if left in a wet bed. Findings included: Resident #48 was admitted to the facility 08/16/19 with diagnoses including cerebrovascular accident (abbreviated as CVA and meaning a stroke) and non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired, had no behaviors or rejection of care, and was always incontinent of bladder. Review of Resident #48's care plan last revised 01/18/23 revealed he was incontinent of bowel and bladder and interventions included checking him frequently and assisting with toileting as needed; providing incontinence briefs per manufacturer's recommendation; providing…

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 interviews, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 2 of 32 sampled residents (Residents #75 and #135). Findings included: 1. Resident #75 was admitted to the facility on [DATE]. Review of Resident #75's medical record at revealed an admission MDS assessment with an ARD of 12/11/22 was marked as completed on 12/27/22. During a telephone interview on 02/24/23 at 12:03 AM, MDS Nurse #2 explained she worked for the facility remotely, usually in the evenings or weekends, on a part-time basis assisting with MDS assessments. MDS Nurse #2 verified Resident #75's admission MDS assessment dated [DATE] was not completed within the regulatory time frame but was not sure why. During an interview on 02/24/23 at 3:54 PM, the Administrator stated Resident #75's admission MDS assessment should have been completed within 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 interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and hospice for 2 of 32 sampled residents reviewed for MDS accuracy (Resident #45 and #34). Findings included: 1. Review of Resident #45's medical record revealed a North Carolina Medicaid Long Term Care form (a preadmission form which describes a patient's medical condition and the amount of care they need when placed in a long term care facility) dated 10/18/21 that indicated Resident #45 had a time-limited Level II PASRR determination. Resident #45 was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder and major depressive disorder. The annual MDS assessment dated [DATE] indicated Resident #45 was not currently considered by the state Level II PASRR process to have a serious mental illness. During a telephone interview on 02/24/23 at 12:03 AM, MDS Nurse #2 reviewed the MDS annual assessment…

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 interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 3 residents reviewed with a Level II PASRR (Resident #45). Findings included: Resident #45 was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder and major depressive disorder. Review of Resident #45's medical record revealed a North Carolina Medicaid Long Term Care form (a preadmission form which describes a patient's medical condition and the amount of care they need when placed in a long term care facility) dated [DATE] that indicated Resident #45 had a time-limited Level II PASRR ending in an E. Review of the North Carolina Skilled Nursing Facility PASRR authorization codes document revealed a PASRR ending in E indicated Level II: 30-day rehabilitation services authorization only. Review of Resident #45's medical record on [DATE] at 12:57 PM revealed no evidence a PASRR evaluation was requested or a new PASRR 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 and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical status for 1 of 3 residents diagnosed with a mental health disorder (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder. A PASRR determination notification letter dated 09/21/21 indicated Resident #29 had a Level 1 PASRR effective 09/21/21 with no expiration date and noted in part, no further PASRR screening is required unless a significant change occurs with the individual's status. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry dated 02/21/23 revealed Resident #29 had a PASRR review on 09/21/21. There were no requests for re-evaluation after 09/21/21. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was not currently considered by the state Level II PASRR process to have a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a comprehensive, individualized care plan that addressed Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 3 sampled residents reviewed for PASRR (Resident #45). Findings included: Review of Resident #45's medical record revealed a North Carolina Medicaid Long Term Care form (a preadmission form which describes a patient's medical condition and the amount of care they need when placed in a long term care facility) dated 10/18/21 which indicated Resident #45 had a 30-day Level II PASRR determination. Resident #45 was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder and major depressive disorder. Review of Resident #45's active care plans, last reviewed/revised 01/21/23, revealed no care plan that addressed the Level II PASRR determination. During a telephone interview on 02/27/23 at 12:52 PM, MDS Nurse #1 explained the Admissions Director or Social Worker notified MDS when 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 observations, record review, resident and staff interview the facility failed to supervise 1 of 4 residents reviewed for smoking (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disorder (COPD), and cognitive communication deficit. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively intact and was coded for current tobacco use. Review of the care plan dated 12/15/22 for Resident #22 revealed he was a supervised smoker and would not smoke without supervision. Interventions included to instruct the resident about the facility policy on smoking, locations, times, safety concerns, monitor oral hygiene, notify charge nurse immediately if resident is suspected of violating the smoking policy, observe clothing and skin for signs of cigarette burns, and staff will supervise resident during smoking sessions for safety. Review of the smoking assessment dated [DATE] revealed…

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 Pharmacy Consultant, Nurse Practitioner (NP), and staff interviews the facility failed to attempt a gradual dose reduction (GDR) of antipsychotic ordered 07/27/22 and antidepressant medication ordered 03/12/22 for 1 of 5 residents reviewed for unnecessary medication (Resident #34). Findings included: Resident #34 was admitted to the facility 02/14/22 with diagnoses including non-Alzheimer's dementia and encephalopathy (a disturbance in brain functioning). Review of Resident #34's orders revealed an order dated 03/12/22 for Mirtazapine (an antidepressant) 30 milligrams (mg) at bedtime for encephalopathy. Resident #34 also had an order dated 07/27/22 for Quetiapine Fumarate (an antipsychotic) 25 mg 1 tablet twice a day for agitation. Review of Resident #34's Medication Administration Records (MARs) from March 2022 through February 2023 revealed he received Mirtazapine and Quetiapine Fumarate as ordered. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was severely…

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 and staff interviews the facility failed to keep unattended medications stored in a locked medication cart for of 1 of 4 medication carts (East A medication storage cart) and they failed to ensure medications were under direct observation by the administering nurse who left medications unattended at the bedside for 1 of 2 residents (Resident #1) reviewed for medication storage. Findings included: 1. A continuous observation of the East A medication cart on 02/24/23 from 11:12 AM until 11:29 AM revealed there were 7 medication cards lying on top of the medication cart and Nurse #8 was not in view of the medication cart. During the observation 1 resident in a wheelchair propelled by the medication cart, 1 resident using a rolling walker walked by the medication cart, and 4 staff members walked by the medication cart. No residents or staff members noticed the unattended medications. The medications were within reach of every person that passed by the East A medication cart on 02/24/23 from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, and staff interviews, the facility failed to ensure the call light annunciator panel located at the nurses' station functioned to identify the room number and sound an alarm and failed to ensure the light above the room entry door worked when the call light at the bedside and bathroom were engaged for 1 of 17 residents (Resident #16) reviewed for call lights on 1 of 2 wings (West Wing). The findings included: Resident #16 was admitted on [DATE] with diagnoses including debility and heart failure. Review of quarterly Minimum Data Set, dated [DATE] revealed Resident #16 was assessed as having moderately impaired cognition and was independent with bed mobility and needed supervision with transfers and extensive assistance with toilet use. Review of the care plan focus area for activities of daily living revised on 07/09/22 described Resident #16 as having a self-care deficit related to an intolerance to activity due to diagnoses. Interventions put in place included encourage…

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.