Fletcher Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician when pressure ulcers were identified on admission for 1 of 5 residents reviewed for pressure ulcers (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and moderate protein-calorie malnutrition. The admission data collection assessment dated [DATE] identified Resident #86 had existing pressure ulcers on the right, and left buttock and sacrum. A review of Resident #86's physician orders revealed no wound care treatments were put in place until 04/30/25. During an interview on 05/14/25 at 4:09 PM, Nurse #6 confirmed she was the admitting nurse when Resident #86 arrived at the facility, and she completed the admission data collection assessment dated [DATE]. She revealed when Resident #86's was admitted she identified pressure ulcers on the left, and right…

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, interviews with the resident and staff, the facility failed to protect a resident's right to be free from neglect when Nurse Aide (NA) #1 disregarded a resident's request for incontinence care and did not check the resident for incontinence prior to going on break (Resident #35). Resident #35 was left sitting in a chair in her room that had a strong odor resembling bowel incontinence for approximately one hour. When Resident #35's incontinence care was provided her brief was heavily soiled with a bowel movement that had leaked onto her inner thighs and clothing. Resident #35 voiced she could smell herself and it was not the first time that had happened to her. The deficient practice occurred for 1 of 2 residents reviewed for abuse/neglect. Findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, vascular dementia, cerebrovascular accident, hemiparesis (weakness) and hemiplegia (partial or total paralysis)…

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 the Care Area Assessment (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 1 sampled resident reviewed for comprehensive assessment (Residents #48). The findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, aphasia, dementia, and cognitive communication deficit. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #48 with severely impaired cognition. A review of Section V (Care area assessment summary) of the annual MDS assessment dated [DATE] revealed a total of 9 care areas were triggered for Resident #48. The MDS Coordinator did not provide any information in analysis of findings for 8 of the 9 triggered areas to describe the nature of Resident #48's problems, possible causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for 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, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered an antidepressant, diuretic, hypoglycemic and blood pressure medications to Resident #283 that were prescribed for Resident #86. This deficient practice occurred for 1 of 2 residents reviewed for medication errors (Resident #283). The findings included: 1. Resident 283 was admitted to the facility on [DATE] with diagnosis that included parkinsonism, type 2 diabetes mellitus, chronic kidney disease stage 3, myocardial infarction type 2 (a heart attack that occurs due to an imbalance between the hearts oxygen supply and demand), hypertension (high blood pressure), and edema (swelling). Review of the 5-day Prospective Payment System (PPS) assessment dated [DATE] revealed that Resident #283 was cognitively intact. He received antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medications.…

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, and interviews with the Medical Director, resident and staff, the facility failed to monitor the resident's urinary catheter for complications of skin breakdown and ensure the catheter tubing was kept clean. A buildup of a white colored substance was observed on the urinary meatus (the opening at the tip of the penis where urine exits the body) where the catheter tubing was inserted, on the scrotum and between the skin folds of the groin. There was redness and irritation present on the genitals and skin folds between the groin and a strong odor resembling yeast. The deficient practice occurred for 1 of 3 residents reviewed for urinary catheters (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and acute and chronic congestive heart failure. A review of Resident #86's active physician orders included tamsulosin (a medication used 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 observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a significant medication error when Nurse #1 administered a steroid medication to Resident #283 that were prescribed for Resident #86. In addition, the facility failed to request a prescription from the physician to avoid a gap in medication administration when refilling a controlled medication and failed to utilize medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications) which resulted in the Resident #11 missing 3 doses of nerve pain medication, 3 doses of diabetic medication, and 1 dose of insulin. This deficient practice occurred for 2 of 2 residents reviewed for significant medication error (Resident #283 and Resident #11). The findings included: 1. Resident #283 was admitted to the facility…

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 secure an opened tube of antifungal cream for 1 of 2 residents reviewed for medication storage (Resident #40). The findings included: Resident #40 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #40 with severely impaired cognition. A review of Resident #40's medical records revealed she had never been assessed for self-administration of medication. During an observation conducted on 05/12/25 at 9:40 AM, one opened tube of Miconazole nitrate cream (an over-the-counter antifungal medication used to treat fungal infections of the skin, such as athlete's foot, jock itch, and ringworm) with the concentration of 2% was left unattended on top of the bedside table in Resident #40's room and was ready to be used. An attempt to interview Resident #40 was unsuccessful. She was unable to answer questions. During a joint observation and subsequent interview conducted with Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to ensure a food preference listed on the meal card was received for 1 of 3 residents reviewed for preferences (Resident #67). Findings included: Resident #67 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and required setup or clean-up assistance with meals. A review of the active physician's order dated 7/15/24 revealed Resident #67 received a regular textured diet. A review of Resident #67's meal card revealed a bacon, lettuce, and tomato sandwich was included on the list of food items to be served for lunch. The meal card did not include the food items Resident #67 disliked. An observation of the lunch meal on 05/12/25 at 12:44 PM revealed Resident #67 was served a ham and cheese sandwich instead of the bacon, lettuce, and tomato sandwich. During an interview on 05/12/25 at 12:44 PM, Resident #67 revealed he received an extra sandwich…

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 post cautionary and safety signs that indicated the use of oxygen, ensure oxygen concentrators were clean of debris, and ensure nebulizer masks were covered when not in use for 4 of 10 sampled residents (Residents #2, #4, #5, and #6). Findings included: a. Resident #2 was admitted to the facility on [DATE]. Her cumulative diagnoses included respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). A physician's order dated 12/18/24 for Resident #2 read, oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate impairment in cognition and received oxygen therapy during the MDS assessment period. An observation conducted on 03/25/25 at 10:23 AM revealed Resident #2 lying in her reclining wheelchair receiving supplemental oxygen via nasal cannula at 2 LPM. There was dried…

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 protect a resident's right to privacy when the Assistant Director of Nursing (ADON) received a medical report from Emergency Medical Services (EMS) personnel about a resident returning to the facility while standing in the hallway by the resident's room for 1 of 1 sampled resident (Resident #1). A reasonable person would not have wanted their private medical information discussed out in the hallway where other staff, residents and visitors could overhear. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. During an observation on 03/25/25 at 10:38 AM, EMS personnel were observed bringing Resident #1 back to her room. The Director of Nursing (DON) was in the room assisting Resident #1's roommate as staff assisted Resident #1 back to bed. The ADON and EMS personnel…

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 ensure fluids were available within reach for staff to offer and assist a resident with fluid intake in-between meals for 1 of 3 residents reviewed for hydration (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Her cumulative diagnoses included dysphagia (difficulty swallowing), contracture of the right and left elbows, contracture of the right and left hands, and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate impairment in cognition, impairment on both sides of the upper and lower extremities and was dependent of staff for assistance with eating. A physician order dated 03/09/25 for Resident #2 revealed she was to receive a pureed diet with honey consistency thickened liquids. A care plan, last revised on 03/12/25, revealed Resident #2 was dependent on staff for feeding assistance, received a mechanically altered and thickened…

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 secure nasal sprays and medicated creams stored in resident rooms in clear view at the bedside for 3 of 10 sampled residents (Residents #3, #4 and #5). Findings included: a. A Nurse admission Data Collection assessment dated [DATE] noted Resident #3 was alert and oriented to person, place and time with intact short-term and long-term memory recall. It was further noted Resident #3 did not wish to self-administer medications. During an observation and interview on 03/25/25 at 9:47 AM, in clear view on Resident #3's overbed table was a 2-ounce tube of skin protectant paste with an active ingredient of 17% zinc oxide. Resident #3 stated the skin protectant was applied by staff and they must have left it in the room. During an observation and interview on 03/25/25 at 4:48 PM, the Director of Nursing (DON) observed the skin protectant paste on Resident #3's overbed table and stated it should not have been left in the room. 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 interviews with staff and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medication for 5 of 5 residents (Resident #40, #126, #128, #129, and #130) reviewed for misappropriation of resident property. The findings included: The facility's Abuse Prevention, Intervention, Reporting, and Investigation policy, last revised February 2021, revealed in part the facility would ensure all residents were free from misappropriation of property. A review of the initial allegation report dated [DATE] revealed the facility became aware of the incident on [DATE] at 8:30 AM when 5 tablets of Ativan (medication used to treat anxiety) for Resident #128 and 6 tablets of oxycodone (pain medication) for Resident #129 were reported missing. All the Residents were in the facility when the incident occurred on [DATE]. Residents #126, #128, #129, and #130 had been discharged from the facility when the surveyor started the investigation on [DATE]. 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 interviews with the Resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to provide recommendations when the facility failed to transcribe four physician orders for a scheduled opioid pain medication to the medication administration record (MAR) from [DATE] through [DATE] and ensure there was a current order on the MAR to administer the pain medication for 1 of 5 residents reviewed for unnecessary medications (Residents #30). The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses including osteoarthritis. A review of Resident #30's care plan for pain dated [DATE] revealed he was at risk of pain due to osteoarthritis. The goal was to decrease the frequency and intensity of pain. Interventions included administering pain medications as ordered. A review of the physician's order dated [DATE] indicated Resident #30 had an order to receive 1 tablet of oxycodone 10 milligrams (mg) by mouth once every 6 hours…

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 cover, label, and date open food items in 1 of 1 walk-in cooler; discard potentially hazardous food from 1 of 1 walk-in cooler; label and date food stored in 1 of 1 kitchen; indicate the expiration date of thawed milkshakes and label and date food and beverage items in 2 of 2 nourishment room refrigerators and freezers (100/200 Hall and 400 Hall); and maintain clean refrigerator and freezers in 2 of 2 nourishment rooms (100/200 Hall and 400 Hall). These practices had the potential to affect food and drink items served to residents. Findings included: 1. An initial tour of the walk-in cooler on 01/28/24 at 10:31 AM revealed the following: (a). a re-sealable plastic bag of sliced tomatoes with no date (b). a metal pan containing pureed bread with no date (c). a box of apple pie open to air with no open date (d). an opened and undated container of chicken salad (e). a bag of sliced onions with a use by date of 01/27/24 2. An observation of the kitchen on 01/28/23 at 10:42 AM revealed a bin of sugar and a bin of flour…

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 Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #30 and #58). The findings included: 1a. Resident #30 was admitted to the facility on [DATE] with diagnoses including depression. A review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was coded with intact cognition. A review of Section V which consisted of care area assessment summary indicated the care area for psychotropic drug use was triggered for Resident #30. Other than checking a list of psychotropic drugs received by Resident #30 and the adverse consequences of using the psychotropic drugs, the facility did not provide any information in analysis of findings that described the nature of Resident 30's problems, possible causes and contributing factors, risk factors related to the care area, and reasons to proceed with care…

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 and interviews with the Family Member, Medical Doctor, and staff, the facility failed to obtain a physician's order and initiate wound care treatments and failed to document characteristics including the location, size, and type of wound upon first observation of an existing venous ulcer for 1 of 1 resident reviewed for professional standards (Resident #30). Findings included: Resident #30 was admitted to the facility on [DATE] with the current diagnoses including diabetes mellitus, hypertension, and chronic respiratory failure. The skin assessments for Resident #30 revealed on 07/15/23 the skin was intact and on 07/22/23 the skin was not intact. Both assessments were completed by the Wound Care Nurse. The skin assessment dated [DATE] did not provide information including a description, size, or location of the skin that was not intact. Review of the nurse progress notes revealed no documentation Resident #30's skin was not intact, or treatment was provided on 07/22/23…

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 2. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 02/02/22 indicated the following information under Manage Residents with Close Contact: *Manage Residents who had Close Contact with Someone with SARS-CoV-2 infection: *Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP (healthcare personnel) caring for them should use full personal protective equipment (PPE) (gowns, gloves, eye protection, and N95 or higher-level respirator). The facility's infection control policy under COVID-19 Response Guidelines revised on 06/27/22 indicated HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield that covers the front 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, Medical Doctor (MD), Nurse Practitioner (NP) and staff interviews, the facility failed to notify the MD or NP of laboratory results when received for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #54 with intact cognition and was receiving dialysis. A physician's order for Resident #65 dated 06/06/22 read in part, liver function test (blood test to check the status of the liver) and thyroid-stimulating hormone (blood test to check if the thyroid hormone is functioning as it should) every six months, in June and December. Review of Resident #65's medical record revealed no lab results for liver function and thyroid-stimulating hormone tests obtained in June 2022. The laboratory results for Resident #65's liver function and thyroid-stimulating hormone tests were provided for review by the Medical Records staff member on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff the facility failed to develop a comprehensive care plan to address diabetes care for 1 of 7 residents reviewed for unnecessary medications (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes mellitus (DM). Review of physician's order dated 03/23/22 revealed Resident #42 was ordered to receive sliding scale Novolog before meals and at bedtime. On 05/07/22, the physician added an order for Resident #42 to receive 15 units of Levemir subcutaneously once daily at bedtime. Review of medication administration records (MARs) from May through July 2022 indicated Resident #42 had received both insulins as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period. Review of Resident #1's comprehensive care plans on 07/26/22 revealed no care plan was developed…

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 resident, staff and the Wound Doctor interviews, the facility failed to provide wound care to pressure ulcers per physician orders for 1 of 3 residents (Resident #33) reviewed for pressure ulcers. The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the sacrum and pressure ulcer to the right heel. Resident #33's care plan initiated on 5/25/22 indicated Resident #33 had a pressure ulcer to her sacrum and right heel. Interventions included treatments as ordered, routine wound assessment, pressure reducing device to bed, observe for signs/symptoms of infection and notify physician as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with all activities of daily living and was always incontinent of urine. The MDS further indicated Resident #33 was at risk of developing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to provide nectar thickened liquids as ordered by the Physician for 1 of 6 residents reviewed for nutrition (Resident #59). Findings included: Resident #59 was admitted to the facility 06/23/22 with a diagnosis of dysphagia (difficulty swallowing) following a cerebral infarction (stroke). Review of Resident #59's Physician orders dated 06/23/22 revealed an order for nectar thickened liquids. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #59 was severely cognitively impaired and had a swallowing disorder which included loss of liquids or solids from mouth, holding food in mouth/cheeks, coughing/choking with meals/medications, and having pain or difficulty when swallowing. The MDS also indicated Resident #59 received a mechanically altered therapeutic diet. The nutrition care plan for Resident #59 initiated 06/30/22 revealed in part she was at risk for aspiration (the accidental breathing of food or fluids into 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, observations, and interviews with resident, staff and the Medical Director, the facility failed to administer oxygen as prescribed by the physician for 1 of 2 residents reviewed for oxygen therapy (Resident #52). The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). A physician order dated 6/14/22 for Resident #52 indicated oxygen therapy at 2 liters per minute via nasal cannula continuous for COPD every shift. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with most activities of daily living and used oxygen therapy while a resident at the facility. Resident #52's Treatment Administration Record (TAR) for July 2022 included an order for oxygen therapy at 2 liters per minute via nasal cannula every shift. During an initial observation and interview…

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

Based on record review and staff interviews, the facility failed to provide sufficient nursing staff to provide wound care for 1 of 3 residents reviewed for pressure ulcers (Resident #33). The findings included: This tag was cross-referenced to F-686: F-686: Based on record review, observation and resident, staff and the Wound Doctor interviews, the facility failed to provide wound care to pressure ulcers per physician orders for 1 of 3 residents (Resident #33) reviewed for pressure ulcers. A review of the Resident Council Meeting minutes dated 2/24/22 indicated a concern brought up by the residents about staffing on second and third shift being too thin and on 6/23/22 about not having enough staff on the weekends. An interview with Nurse #6 on 7/27/22 at 10:18 AM revealed staffing on second shift and the weekends was still a problem but it was not as worse as when she first started working at the facility. Nurse #6 stated she still had to stay over and work second shift once or twice every 2 weeks to help out. An interview with Nurse #7 on 7/27/22 at 11:41 AM revealed there 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 reviews and interviews with staff and Medical Director (MD) the facility failed to acquire and administer insulin per physician order. As a result, Resident #42 missed 3 doses of insulin within 8 days. This affected 1 of 7 residents reviewed for unnecessary medications (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE] with multiple diagnoses included diabetes mellitus (DM). Review of physician's order dated 03/23/22 stated Resident #42 was to receive sliding scale insulin (SSI) before meals and at bedtime. She would receive 2 units of Novolog, fast acting insulin, with capillary blood glucose (CBG) of 151 - 200 milligram per deciliter (mg/dl), and 4 units with CBG of 201- 250 mg/dl. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period. Review of the medication administration records (MAR) for July 2022 indicated Resident #42 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Physician interviews, the facility failed to prevent a significant medication error when they failed to acquire and administer insulin as ordered by the physician. As a result, Resident #42 missed 3 doses of insulin within 8 days. This affected 1 of 7 residents reviewed for unnecessary medications (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE] with multiple diagnoses included diabetes mellitus (DM). The physician's order dated 03/23/22 stated Resident #42 was to receive sliding scale insulin (SSI) before meals and at bedtime. She would receive 2 units of Novolog, rapid acting insulin, with capillary blood glucose (CBG) of 151 - 200 milligram per deciliter (mg/dl), and 4 units with CBG of 201- 250 mg/dl. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period. Review of the medication administration records (MAR) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to remove expired medications in accordance with the manufacturer's expiration date for 1 of 2 medication storage rooms (Main medication storage room), failed to lock the medication cart for 1 of 4 medication carts reviewed for medication storage, and failed to store eye drops prescribed for glaucoma in the medication cart for 1 of 1 resident observed with medications at bedside (Resident #68). The findings included: During an observation made on 07/27/22 at 10:28 AM, 7 unopened boxes of Flucelvax quadrivalent 2021-2022 formula influenza vaccines expired on 06/30/22 were found in the refrigerator in the main medication storage room. Each box contained 10 doses of 0.5 milliliter (ml) single-dose prefilled influenza vaccine, and they were available for use. An interview conducted with Nurse #2 on 07/27/22 at 10:32 AM revealed she did not know who was responsible to check the medication storage room on regular basis. She stated when she pulled…

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 interviews with staff the facility failed to accurately document in the medical record an influenza vaccine was not administered for 1 of 6 residents reviewed for immunizations (Resident #20); and failed to accurately document in the medical record a pressure ulcer treatment was not provided for 1 of 5 residents reviewed for pressure ulcers (Resident #33). The findings included: 1. Resident #20 was admitted to facility on 01/08/21 with diagnoses including dementia and history of stroke. Review of Resident #20's consent form for the influenza vaccine revealed it was declined on 01/07/21. Review of the significant change Minimum Data Set (MDS) dated [DATE] assessed Resident #20's cognition as being severely impaired. The MDS documentation indicated Resident #20 received the influenza vaccine in the facility on 10/19/2021. Review of the electronic medical record for immunizations revealed Resident #20 received an influenza vaccine on 10/19/21 in the facility and included the lot number…

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.