The Sharon at Southpark

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Resident Representative (RR) and staff interviews, the facility failed to notify the resident and/or the RR of the facility's bed hold policy when the resident was transferred to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #13). The findings included: Resident #13 was admitted to the facility 7/29/24. The 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had severe cognitive impairment. A review of the nurse's notes revealed Resident #13 was discharged to the hospital 8/19/24 and did not return to the facility. A review of Resident #13's electronic medical record (EMR) revealed there was no documentation that information regarding the bed hold policy was issued when he was transferred to the hospital or that the RR was contacted concerning the bed hold. A telephone interview conducted with the RR on 11/06/24 at 2:06 PM indicated she was notified by the facility on 8/19/24 that Resident #13 was transferred to the hospital but there was no…

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 Resident Representative (RR), Hospital Case Manager and staff interviews, the facility failed to permit a resident to return to the facility after being discharged to the hospital for evaluation due to a change of condition for 1 of 1 resident reviewed for hospitalization (Resident #13). The findings included: Resident #13 was admitted to the facility 7/29/24. The 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had severe cognitive impairment. A review of the nurse's note dated 8/19/24 at 8:05 AM indicated Resident #13 had an unwitnessed fall at 1:40 AM and was being monitored. Resident #13's vital signs were obtained around 5:00 AM and his temperature and heart rate had dropped. The on-call physician and RR were notified, and Resident #13 was transferred to the hospital for further evaluation. The discharge MDS dated [DATE] revealed Resident #13 had an unplanned discharge from the facility to the hospital and return to the facility was not anticipated. A review of 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 review and staff interviews, the facility failed to develop personalized comprehensive care plans in the areas of diuretic (reduce fluid build up in the body) therapy and anticoagulation (blood thinning) therapy for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (A-fib), edema, urinary retention, and congestive heart failure (CHF). A review of Resident #1's medical record revealed a physician order dated 10/1/2024 for Rivaroxaban (an anticoagulant medication) 15 milligram (mg), 1 tablet by mouth in the morning for A-fib (a heart condition that can lead to poor blood flow) and another order dated 10/24/2024 for Furosemide (a diuretic medication) 20 mg, 1 tablet by mouth in the morning every other day for CHF. A review of Resident #1's October and November 2024 Medication Administration Record (MAR) revealed she had been receiving the anticoagulant and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident (Resident #1) on two separate occasions for 1 of 2 residents reviewed for unnecessary medications. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Atrial fibrillation (A-fib), cardiac murmur, hyperlipidemia, congestive heart failure (CHF), Hypertension (HTN), edema, and chronic kidney disease. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had some mild cognitive impairment with no mood or behavior issues. The MDS also revealed that Resident #1 required partial assistance with her activities of daily living (ADLs). Review of Resident #1's current physician orders dated October 2024 revealed Resident #1 was ordered the following medications Flomax 0.4 milligrams (mg) times 2 capsules by mouth, Furosemide (to…

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

Based on record review, and staff, Nurse Practitioner, and Medical Director interviews, the facility failed to provide effective orientation and education to 2 of 2 agency nurses (Nurse #1 and Nurse #2) to ensure competency when administering medications to 1 of 1 resident (Resident #1) resulting in Resident #1 receiving the wrong medication on 2 separate occasions. This deficient practice affected 1 of 1 resident reviewed for a medication error. The findings included: This tag is cross referenced to F658 Based on record review, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident (Resident #1) on two separate occasions for 1 of 2 residents reviewed for unnecessary medications. F760 Based on record review, observation, and staff, resident, and facility Nurse Practitioner (NP) and Medical Director interviews the facility failed to prevent a significant medication error when Resident #1 received Metoprolol and Apixaban. The Apixaban was not prescribed to 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 record review, observation, and staff, resident, and facility Nurse Practitioner (NP) and Medical Director interviews the facility failed to prevent a significant medication error when Resident #1 received Metoprolol and Apixaban. The Apixaban was not prescribed to Resident #1, however she had an order for Metoprolol prescribed at a different dose. Nurse #1 administered medications prescribed to an Assisted Living Resident to Resident #1 on 10/23/2024 which included a different dose of Metoprolol, 100 milligrams (mg) used to treat hypertension (HTN), Angina (Chest pain) and Congestive Heart Failure (CHF). (This medication acts by decreasing blood pressure and heart rate which can cause tiredness and shortness of breath). On 10/24/2024 Resident #1 was given medication prescribed to an Assisted Living Resident by Nurse #2 that included Apixaban 2.5 mg (blood thinner). This deficient practice affected 1 of 1 resident reviewed for significant medication error (Resident #1). The findings included: 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 failed to discard spoiled food stored in the lower-level refrigerator, failed to discard expired food items stored for use in the lower-level dry goods storage room and in the rehabilitation hall nourishment refrigerator. This practice had the potential to affect food served to residents. The findings included: 1. An observation on 9/25/23 at 11:20 AM with the Culinary Director revealed the following: -The refrigerator located in the lower-level kitchen storage revealed had 4 green peppers covered in white/ grayish fuzzy substance and wilted brownish iceberg lettuce. -The dry storage room in the lower level kitchen revealed a) 20 8 ounce (oz) jars of sushi pickled ginger with a best buy date of 11/7/2021; b) 26 4oz cans of curry paste with a best buy date of 6/2022; c) 20 4oz cans of curry paste with a best buy date of 2/2022; d) baking flour use by date of 4/9/23; e) caramel paste best buy date of 7/4/2022; f) candy sprinkles use by date of 3/21/23; g) hazel nut paste best buy date of 7/20/22; h) chocolate…

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 remove loose garbage, food, and debris from around 1 of 1 trash receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents. The findings included: An observation (with the Director of Environmental Services) of the outdoor trash receptacle area on 9/26/23 at 3:15 PM revealed trash and food littered around the trash receptacle. During the observation, flies were swarming around the trash receptacle. The Director of Environmental Services indicated he was filling in for the Maintenance Director who was out of the office and that the Maintenance Department was responsible for maintaining the trash receptacle and the trash removal company removed the receptacle once weekly, dumped the receptacle off-site then returned it to the facility within 2 hours. During the 2-hour period, maintenance usually removed littered trash and cleaned the area before the trash receptacle was returned. Maintenance may or may not know what time the receptacle was…

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 dining observations, staff interviews and record review, the facility failed to provide or assist 4 of 4 residents with hand hygiene before meals during 2 of 2 dining observations (Resident #157, #207, #208, and #209). The findings included: The facility policy, entitled Handwashing/Hand Hygiene, revised August 2019, recorded in part, this facility considers hand hygiene the primary means to prevent the spread of infections. Residents will be encouraged to practice hand hygiene. Use an alcohol-based hand rub or alternatively, soap and water for the following situations: before and after eating or handling food. 1a. A continuous observation of the lunch meal on the rehab unit occurred on 9/25/23 from 12:47 PM until 12:55 PM. Residents #207, #208 and #209 were assisted in their rooms by Nurse Aide (NA) #4 with meal set up for the lunch meal. Meal trays were removed from the meal cart, taken into each resident's room, placed on the overbed table, and set up for each resident, per their preference. Residents #207, #208 and #209 were not asked if hand hygiene had already been…

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 secure a controlled substance in a permanently affixed compartment of the refrigerator in 1 of 1 facility medication room (Medicare Hall medication room). The findings included: On 9/26/23 at 3:13 PM an observation and interview were conducted with Nurse #2. The refrigerator in the Medicare Hall medication room was not locked and had a clear permanently affixed lock box that was locked and contained a 30 ml (milliliter) multi-dose bottle of Lorazepam/Intensol (a controlled substance) oral concentrate 2 mg (milligrams/ml). In another clear lock box that was locked, but not permanently affixed in the refrigerator, contained a 30 ml multi-dose bottle of Lorazepam/Intensol (a controlled substance) oral concentrate 2mg/ml and four 2 mg/ml vials of lorazepam for injection. Nurse #2 stated the unaffixed lock box was used for pyxis (automated medication dispensing system) removal. If a resident needed a stat dose of lorazepam, they would go to the pyxis and remove the key to open that lock box. She indicated she did 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.