Accordius Health at Rose Manor LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to apply a right-hand palm guard for 1 of 1 resident reviewed for a range of motion (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia (complete paralysis) affecting the left nondominant side, contractures of multiple sites, and cognitive communication deficit. A physician's order for Resident #15 dated 1/26/23 revealed a green carrot (a green carrot palm guard is a therapeutic device designed to support and protect the fingers from the palm. It is typically made of smooth cotton fabric and packed with washable wool fleece, which helps keep the hand cool and dry while reducing friction and irritation.) applied to the right hand on at night and off during the day. Resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired. Resident #15 had impairments on bilateral…

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 written documentation in the medical record that advance directives information and/or opportunity to formulate an advance directive was provided or discussed with the resident or resident representative for 4 of 6 residents reviewed for advance directives (Resident #1, #11, #22 and # 49). Findings included: 1. Resident #1 was admitted to the facility on [DATE], and diagnoses included Diabetes Mellitus, chronic obstructive pulmonary disease and osteoarthritis. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. There was no documentation of education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered in Resident #1's medical record. In an interview with Social Worker #1 on 1/24/2024 at 1:58 p.m., she stated the Social Worker was responsible for discussing advance directives on admission and re-admission with the residents. 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 reviews, resident representative interview and staff interviews, the facility failed to conduct quarterly care plan meetings with cognitive residents and/or resident representatives (Resident #22 and Resident #59) and failed to revise a resident's care plan requiring 1:1 supervision for behaviors (Resident #70) for 3 of 28 residents reviewed for care planning. Findings included: 1. Resident #22 was admitted to the facility on [DATE], and diagnoses included dementia and Alzheimer's disease. The Social Worker recorded on 3/5/2023 an initial care plan meeting was held for Resident #22. There was no further documentation of care plan meetings held for Resident #22 in the medical record. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 was severely cognitively impaired and required assistance with all activities of daily living. Previous quarterly assessments for Resident #22 were conducted on 8/20/2023, 6/15/2023 and 3/15/2023. In a phone interview with 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 interviews, the facility failed to complete and document in the electronic medical record weekly assessments and measurements of a resident's pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses including a Stage 4 pressure ulcer to the buttocks. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact and was receiving treatments for two pressure ulcers. Resident #10's care plan dated revised on10/24/2023 include a focus for pressure ulcers, and interventions included administering, documenting and monitoring effectiveness of medications and treatments as ordered. Dietary documentation dated 10/27/2023 reported Resident #10 had been readmitted from the hospital due to osteomyelitis to the left hip and had a stage 4 left hip and ischium pressure ulcer. She reported Resident #10 received double meat 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 reviews, staff and Pharmacist/Pharmacist Consultant interviews, the facility failed to conduct monthly Medication Regimen Reviews (MRR) (Resident #9) and failed to maintain pharmacy recommendations from the MRR and address the pharmacy recommendations made by the Pharmacist Consultant based on monthly MRR (Resident #1 and Resident #65) for 3 of 5 residents reviewed for unnecessary medications. Findings included: 1. Resident #9 was admitted to the facility 10/23/23. Review of Resident #9's quarterly Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. Her active diagnoses included anemia, ulcerative colitis, end stage renal disease, diabetes mellitus, hyperlipidemia, and dementia. She received scheduled and as needed pain medication. Review of Resident #9's care plan dated 10/25/23 revealed she was care planned for use of anti-anxiety medication injection every Monday, Wednesday, and Friday before Dialysis for agitation. The interventions included 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews the facility failed to avoid duplication of an antipsychotic medication in a resident's orders for 1 of 5 residents reviewed for unnecessary medications (Resident #9). Findings included: Resident #9 was admitted to the facility 10/23/23. Review of Resident #9's orders revealed on 10/23/23 she was ordered chlorpromazine HCl (antipsychotic medication) oral tablet give 100 milligrams (mg) by mouth three times a day for dementia with agitation and aggression. Review of Resident #9's quarterly Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired and received antipsychotic medication with a documented clinical rationale for the administration of the medication. Review of a pharmacy recommendation dated 1/8/24 revealed the pharmacist recommended for chlorpromazine HCl oral tablet 100 mg by mouth three times a day for dementia with agitation and aggression start date 10/23/23 to have a gradual dose reduction. The…

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

Based on record review and staff and resident interviews the facility failed to obtain approval from a resident group for a greater than 14-hour time span between the evening meal and breakfast the following day. This affected residents on 5 of 5 resident meal carts (Station 1 1st cart, Special Care Unit (SCU) Hall cart, Station 1 2nd cart, Station 2 1st cart, and Station 2 2nd cart). Findings included: A review of the meal schedule revealed the Station 1 1st cart was scheduled for dinner at 5:00 PM and breakfast at 7:25 AM (indicative of a 14 hour and 25-minute time span between the 2 meals). The SCU Hall cart was scheduled for dinner at 5:15 PM and breakfast at 7:35 AM (indicative of a 14 hour and 20-minute time span between the 2 meals). The Station 1 2nd cart was scheduled for dinner at 5:30 PM and breakfast at 8:00 AM (indicative of a 14 hour and 30-minute time span between the 2 meals). The Station 2 1st cart was scheduled for dinner at 5:45 PM and breakfast at 8:15 AM (indicative of a 14 hour and 30-minute time span between the 2 meals). The Station 2 2nd cart was scheduled…

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, interview with Emergency Medical Service personnel, interview with a Resident Representative, interview with the Pharmacist/Pharmacist Consultant, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 5/11/21, the focused infection control and complaint investigation survey of 3/9/22, and the recertification and complaint investigation survey of 9/16/22. This was for 7 deficiencies that were cited in the areas of: Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plan (F656), Care Plan Timing and Revision (F657), Free of Accident Hazards/Supervision/Devices (F689), Drug Regimen Review, Report Irregular, Act On (F756), Free from Unnecessary Psychotropic Medications/PRN Use (F758), and Label/Store Drugs and Biologicals (F761). These deficiencies were recited on the current recertification and complaint survey of 1/29/24. The duplicate…

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, staff and resident interviews, the facility failed to provide the Resident Council with responses regarding grievances reported in the Resident Council meeting for 1 of 3 consecutive months (December 2023). Findings included: Review of the Resident Council minutes dated 12/5/2023 indicated the residents had voiced concerns of call lights not being answered in a timely manner and rounds not being done at night. Review of the Resident Council minutes dated 1/3/2024, revealed no updated documentation of concerns from 12/5/2023, Resident Council meeting in the new business and old business section of the minutes. During an interview with Activities Director Assistant #1 on 1/24/24 at 8:45 AM, she revealed she had assisted with the Resident Council meeting on 1/3/2024 since the Activities Director was in a meeting and was not available to attend the Resident Council meeting on 1/3/2024. Activities Director Assistant #1 stated that she did not inquire from the residents during the meeting if issues from the previous month had been resolved or discuss any action…

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 and implement individualized person-centered care plans in the areas of anticoagulant use and post-traumatic stress disorder for 2 of 28 residents reviewed for comprehensive care plans (Resident #91 and Resident #58). Findings included: 1. Resident #91 was admitted to the facility on [DATE] and was diagnosed with multiple fractures to both hands and right shoulder. Physician orders dated 9/7/2023 included an order for Enoxaparin Sodium (an anticoagulant used to prevent blood clots) prefilled syringe 0.4 milliliters subcutaneous injection once a day for deep vein thrombosis (blood clot) prophylaxis for thirty days. On 9/13/2023, physician orders indicated Enoxaparin Sodium injections were discontinued, and Eliquis (another anticoagulant) two five milligrams' tablets were ordered twice a day for a deep vein thrombus (DVT). Nursing documentation date 9/13/2023 reported Resident #91 diagnostic test reported a DVT in the right leg. 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 and staff interviews the facility failed to keep medications in a locked treatment cart for 1 of 1 treatment carts observed (Treatment Cart #1). Findings included: During observation on 1/22/24 at 2:04 PM Treatment Cart #1 was observed unlocked outside room [ROOM NUMBER]. The cart was placed diagonally in the hallway near room [ROOM NUMBER]. The lock was observed in the unlocked position. At 2:05 PM a housekeeper passed the unlocked treatment cart and at 2:06 PM a dietary staff member passed the unlocked treatment cart. During an interview on 1/22/24 at 2:06 PM Nurse #5 stated treatment carts were to be locked when unattended and she was responsible for Treatment Cart #1. She stated she left it unlocked because she was coming back to it but was then called to help a nurse clean a resident and left it unlocked. She concluded she should have locked it prior to leaving it unattended. During observation on 1/22/24 at 2:10 PM with Nurse #5, Treatment Cart #1 was observed to contain bacitracin…

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, observations and staff interviews, the facility failed to discard expired foods stored for use in 1 of 1 walk-in refrigerator; label, date food items, monitor freezer and refrigerator temperatures, and provide a resident nourishment refrigerator solely for resident's food items brought into the facility; prevent potential cross contamination of food when a staff member (Certified Occupational Therapy Aide #1) placed a leftover food tray into the enclosed meal cart that had meal trays waiting to be served to residents for 1 of 2 meal observations; monitor temperatures on the wash cycle and the temperature during a chemical solution rinse cycle for the dish machine to ensure sanitation of dishes; and ensure 3 of 4 dietary staff (Dietary Aide (DA) #1 and Regional Director of Operations) had their hair covered while observed in the kitchen area. These practices had the potential to affect food served to 87 of the 88 residents. Finding included: 1. On 9/12/2022 at 10:15 a.m. in the initial tour of the kitchen accompanied by Dietary Aide (DA) #1, the following…

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

Based on record review, observations and staff interviews, the facility failed to maintain the dish machine in operating condition as evidenced by the temperature gauge not working during the wash and rinse cycles and failed to repair a sink allowing for draining in the kitchen area for 87 of 88 residents. Findings included: 1. A review of dietary work orders since December 2021 revealed no work orders for the dish machine thermometer. A label on the dish machine stated minimum water temperatures for the wash and rinse temperatures was 120 degrees F. On 9/15/2022 at 9:20 a.m., while observing the dietary staff washing the breakfast dishes, the dish machine thermometer was observed set at 90 degrees Fahrenheit (F) and not moving during the dish machine's wash and rinse cycles. Steam was observed escaping from the basin of water outside the dish machine. The Regional Director of Operations for dietary was observed using a manual thermometer to check the water temperature of the water released from the dish machine. The released wash water temperature was observed to measure 113…

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 (1) complete smoking assessments on residents observed unsupervised smoking in the facility's designated smoking area (Residents #65, #70, #80, # 81), (2) failed to supervise a resident who required supervision while smoking (Resident #69) and (3) failed to secure smoking materials for a resident (Resident #81) for 5 of 5 residents reviewed for smoking. A review of the facility's provided list of smokers on day one of the survey, 09/12/22, revealed Resident #65, Resident #80, and Resident #81 were not on the list. A revised smoker's list was submitted by the facility on 09/14/2022, day 3 of the survey, which included Resident #65, Resident #80. 1. Resident #65 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure and nicotine dependence. A review of Resident #65's admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and coded as a non-tobacco user.…

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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the 14-day time frame for 2 of 33 residents reviewed for resident assessments (Resident #19, Resident #75). Findings Included: Resident #19 was readmitted to the facility on [DATE]. On 9/12/2022, a SCSA MDS dated [DATE] indicated it was in progress and the care areas and care plan decisions were incomplete. On 9/14/2022 at 9:29 a.m. in an interview with the MDS Corporate Nurse, she stated the facility did not have a MDS nurse, and she filled in at times to complete resident MDS assessments until the facility hired someone to fill the role. She stated she realized MDS assessments were not being completed in the time frames. On 9/16/2022 at 2:28 p.m. in an interview with the Administrator, she stated Resident #19's significant change MDS should had been completed in the designated time frame. 2. Resident #75 was admitted to the facility on [DATE]. Review of 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 interview the facility failed to develop and implement an individualized person-centered care plan for 2 of 24 residents reviewed for activities of daily living and indwelling catheter. (Resident #32 and Resident #29). Findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses including urinary retention and dementia. The admission Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed he needed extensive assistance with transfers and toilet use. He needed limited assistance with bed mobility and supervision with eating. The MDS revealed Resident #32 had an indwelling catheter. A review of the care plans developed for Resident #32 revealed no care plans with goals and interventions were developed for activities of daily living and indwelling catheter. An interview was conducted with the MDS Corporate Nurse on 9/14/22 at 9:29 AM, and she stated the facility did not have a Social Worker or a MDS Nurse. She stated she was filling in from time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews, the facility failed to conduct a care plan meeting for 1 of 2 residents (Resident # 29) reviewed for care planning meeting and failed to revise the care plan for 1 of 1 resident observed using oxygen by nasal cannual (Resident #137) reviewed for the use of oxygen. Findings included: 1. Resident #29 was admitted to the facility on [DATE], and diagnoses included Diabetes Mellitus, anxiety disorder and major depressive disorder. The care plan dated 6/23/2022 for Resident #29 included two focuses: nutritional risk and skin infection. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact, required assistance with all activities of daily living and received insulin antianxiety and antidepression medications. There was no documentation of a care plan meeting in Resident #29's electronic medical record. On 9/12/2022 at 3:15 p.m. in an interview with Resident #29, she stated the facility had not conducted…

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 interviews, the facility failed to obtain a written physician's order for the use of oxygen and display cautionary signage indicating oxygen in use for 1 of 1 resident reviewed for respiratory care. (Resident #137) Findings Included: Resident #137 was admitted to the facility on [DATE], and diagnoses stage 4 chronic kidney disease and anemia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #137 was cognitively intact and was not experiencing shortness of breath or receiving oxygen. Nursing documentation dated 8/23/2022 revealed when Resident #137 developed shortness of breath, oxygen was applied. Nursing documentation dated 9/11/2022 revealed Resident #137 continued to use oxygen at 2 liters per minute via nasal cannula. Review of the physician's orders for Resident #137 revealed no written order for the use of oxygen in the electronic medical record. Review of Resident #137's August 2022 and September 2022 Medication Administration…

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 interviews, and the Pharmacy Consultant interview, the facility failed to respond to a Medication Regimen Review on the length of time for an as needed (PRN) psychotropic medication for 1 of 5 (Resident #58) residents reviewed for unnessary medications. Findings included: Resident #58 was admitted to the facility on [DATE], with a re-entry from a hospital on 3/11/2021. Resident #58 had cumulative diagnosis that included depression, bipolar, and schizophrenia. A physician's order initiated on 4/14/2022 read in part Lorazepam tablet 1 milligram (mg), give 1 tablet by mouth every six hours as needed. The order was discontinued on 8/8/2022. Review of a Consultant Pharmacist Recommendation dated 5/19/2022 for Resident #58 showed an order for lorazepam tablet 1 mg. The instructions read give 1 tablet by mouth every 6 hours as needed (PRN). The Consultant Pharmacist Recommendation read in part a PRN order for an anxiolytic which has been in place for greater than 14 days without a stop…

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 interviews, and the Pharmacy Consultant interview, the facility failed to obtain documentation of the rationale to extend PRN (as needed) psychotropic medication beyond 14 days and failed to have an adequate clinical indication for the use of a psychotic medication for 1 of 5 residents (Resident #47) reviewed for unnecessary medications. Findings included: Resident #47 was admitted to the facility on [DATE]. Resident #47 had cumulative diagnoses that included stroke and metabolic encephalopathy (a problem in the brain caused by a chemical imbalanced due to illness or organs not functioning as well as they should). The resident's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was able to make his own decisions for care. Resident #47 had no behaviors or rejection of care. The MDS further indicated Resident #47 had not received antipsychotic medication on 7 of 7 days during the look back period. A physician's order initiated on 9/1/2022…

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 and staff interviews, and physician interviews the facility's Quality Assessment and Assurance Committee failed to maintain and implement procedures and monitor interventions the committee put into place following the recertification and complaint survey on 5/11/21 and the recent recertification and complaint survey on 9/16/22. This was for 1 deficiency that was cited in the area of care plan timing and revision (F657) and recited on the current recertification and complaint survey of 9/16/22. The duplicate citations during 2 federal surveys of record shows a pattern of the facilities inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. (F657) Based on record review, resident interview and staff interviews, the facility failed to conduct a care plan meeting for 1 of 2 residents reviewed for care planning meeting and failed to revise the care plan observed using oxygen by nasal cannual for 1 of 1 resident reviewed for the use of oxygen. Based on observation, staff interview and record…

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