Greenville Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews and Pharmacist interviews, the facility failed to provide care according to professional standards when Nurse #1 borrowed medication from Resident #6 to administer to Resident #5. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses that included diabetes with neuropathy (nerve pain). Physician orders dated 10/19/24 for Resident #6 revealed an order for gabapentin (a medication used to treat nerve pain) 100 milligrams (mg) to be administered once a day. The admission Minimum Data Set (MDS) assessment for Resident #6 dated 10/22/24 revealed she was cognitively intact. Resident #6 was no longer at the facility and was not available for interview. Resident #5 was admitted to the facility on [DATE] with diagnoses that included pain of lower extremities. Physician orders dated 10/19/24 for Resident #5 revealed an order for gabapentin 100 mg to be administered 3 times a day for pain. The admission Minimum Data Set (MDS) assessment 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 record review and interviews with facility staff and the Nurse Practitioner (NP), the facility failed to ensure there was effective communication during shift to shift report between facility nursing staff to avoid a lapse between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for quality of care. The findings included: A review completed of Resident #1's hospital lab results dated 10/30/24 revealed on 10/29/24 her hemoglobin was 8.4 (normal values 12.0-16.0) and her hematocrit was 27.7 (normal values 35.0-47.0). Resident #1 was admitted to the facility on [DATE] with diagnoses that included heart disease, anemia, a viral infection of the liver causing inflammation and swelling of the liver, diabetes, parathyroid disease, history of a stroke, and hypertension A progress note…

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 interviews with facility staff, Nurse Practitioner (NP), and the facility's contracted laboratory company, the facility failed to ensure there was effective communication between facility staff and the lab company to avoid a lapse of multiple days between the time Resident #1's STAT (immediately) lab was obtained to when the results for a STAT complete blood count (CBC) were received resulting in failure to identify critically low laboratory results timely. This deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for laboratory services. The findings included: A progress note dated 11/1/24 at 2:43pm stated the facility's NP was in the facility and notified Resident #1 having episodes of vomiting. The NP gave an order to have a STAT CBC lab drawn and notify the provider as soon as the lab results were available for review. Lab results dated 11/1/24 revealed the lab phlebotomist (medical professional who draws blood) obtained the blood sample on Resident #1 at 6:10pm on 11/1/24. The laboratory received the blood sample at 7:15pm from 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 interviews the facility failed to have a documented water management program for Legionella. The facility further failed to ensure hand hygiene was performed during medication administration for 1 of 2 nurses observed (Nurse #1). Findings included: 1. In an interview with the facility Assistant Maintenance Manager on 5/30/24 at 8:06 AM he stated the Director of Maintenance left the position a couple of months ago and he had been responsible for water management, including an assessment to identify where water borne pathogens could grow and spread. He further stated he had no knowledge of what the water management system entails, how they were to assess for or prevent Legionella or who should have been notified should there be a concern with Legionella in the building. An interview with the Administrator on 05/30/24 8:59 AM revealed he did not know what measures were in place to assess the growth or spread of Legionella in the facility water system. He was able to provide the water management system binder for review. A review of the water management…

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 remove an open and expired medication from 1 of 2 medication storage rooms observed (Hall 300/400) and failed to ensure 1 of 5 medication carts (Hall 300) and 1 of 1 wound treatment carts were secured while unattended. The findings included: 1. An observation of the Hall 300/400 medication storage room was conducted on 5/30/24 at 10:24 am with the Assistant Director of Nursing (ADON) and the following was observed. The ADON confirmed the findings before removal of the item. One open vial of tuberculin purified protein derivative solution (PPD solution/TB solution) with an open date of 4/25/24 noted on the box was observed in the medication refrigerator in the Hall 300/400 medication storage room. The manufacturer's recommendation for the tuberculin purified protein derivative noted on the package was once opened vial should be discarded after 30 days. An interview was conducted on 5/30/24 at 10:25 am with the ADON who reported she was not sure how long the open vial of the PPD solution was able to be…

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 records review, and staff interviews, the facility failed clarify code status in the residents' record for 1 (Resident #59) of 23 residents reviewed for Advance Directives. Findings included: Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, coronary artery disease, and diabetes. Resident #59's physical chart was observed to contain a Full Code (cardiopulmonary resuscitation (CPR) would be performed if the resident stopped breathing and heart stopped beating) Agreement dated [DATE] signed by Resident #59's family member. The chart further contained a Do Not Resuscitate (DNR) document dated [DATE] with no expiration date, and a physician's order dated [DATE] that indicated Resident #59's code status was a full code. A review of Resident #59's electronic medical record (EMR) and an order dated [DATE] revealed Resident's #59's code status was a full code. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that…

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 and Nurse Practitioner interviews the facility failed to protect a cognitively intact resident from verbal abuse by another cognitively intact resident that escalated into physical abuse when Resident #216 called Resident #51 a fat b and Resident #51 proceeded to purposefully run into Resident #216 with her electric motorized wheelchair (WC) resulting in an abrasion and bruising to Resident #216's right leg. This was for 2 of 4 residents reviewed for abuse. Findings included: Resident #51 was admitted to the facility on [DATE] with a diagnosis of stroke (disrupted blood flow to the brain). A review of Resident #51's care plan revealed in part a focus area initiated on 9/26/23 and last reviewed on 11/13/23 of verbally abusive behavior. The goal was for Resident #51 to decrease her instances of verbally abusive behaviors by 50 percent through the next review. Interventions included not to argue with Resident #51, and to reinforce the unacceptability of verbal abuse. A review of…

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 staff, nurse practitioner, and resident interviews and record review the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication (oxycodone) for 2 of 2 residents reviewed for misappropriation of property. (Resident #84, Resident #72) Findings included: a. Resident #84's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He was assessed to have rare pain which rarely or never affected his sleep, therapy activities, and day to day activities. Review of Resident #84's orders revealed on 2/14/23 he was ordered oxycodone 10 milligrams (mg) tablet by mouth at bedtime daily. Review of Resident #84's Medication Administration Record (MAR) for July 2023 revealed on 7/10/23 he was documented to have been administered oxycodone 10 mg at 9 PM by Medication Aide #1. Review of Resident #84's controlled drug reconciliation form for July 2023, used to keep track of the doses of oxycodone for Resident #84, revealed on 7/10/23 at 8 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of medications and diagnoses. This was for 2 of 5 residents reviewed for unnecessary medication (Resident #98 and Resident #262). Findings included: 1. Resident #98 was admitted to the facility on [DATE] with a diagnosis of stroke (disrupted blood flow to the brain). A review of Resident #98's quarterly MDS assessment dated [DATE] revealed she received injections on 5 days of the look back period of the assessment and insulin orders and insulin injections on 4 days of the look back period of the assessment. A review of Resident #98's physician orders and Medication Administration Record (MAR) for March 2024 did not reveal any physician's orders for injections, insulin or insulin injections, or documentation injections or insulin injections were administered to Resident #98 in March 2024. On 5/30/24 at 10:14 PM an interview with MDS Nurse #2 indicated she completed the medication…

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 the comprehensive care plan in the area of anticoagulant (blood thinning) medication for 1 of 5 residents (Resident #98) reviewed for unnecessary medications. Findings included: Resident #98 was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation (an irregular heartbeat which can lead to blood clots). A review of Resident #98's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she received anticoagulant medication. A review of Resident #98's physician's orders revealed a current active order for apixaban (an anticoagulant medication) 5 milligrams (mg) twice daily for atrial fibrillation with a start date of 12/6/23. A review of Resident #98's March 2024, April 2024, and May 2024 Medication Administration Records revealed documentation apixaban 5 mg was administered to her twice daily as prescribed by her physician. A review of Resident #98's current comprehensive care plan dated last reviewed 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, resident, family and staff interviews, the facility failed to ensure residents rights and invite residents/resident representatives to participate in care plan meetings 3 of 7 residents reviewed for care plan meetings (Residents #31, Resident #53 and Resident #362). The findings included: 1. Resident #362 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and diabetes type 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 was moderately cognitively impaired. Review of care plan dated 4/23/24 revealed that a care plan had been developed on 4/11/24 and reviewed and revised on 4/18/24, and 4/23/24. Interviews with Resident #362 on 05/29/24 at 8:46 am and on 5/30/24 at 1:48 PM revealed she had not been invited to a care plan meeting since she was admitted to the facility on [DATE]. She indicated that no one had talked to her about her care. She further stated she could not say whether or not 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 observation, record review, staff interviews, and Pharmacist interview, the facility failed to maintain a medication error rate of less than 5%. Two (2) medication errors were observed out of 25 opportunities which resulted in a medication error rate of 8%. This occurred for 1 of 3 residents reviewed during a medication pass observation (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses which included asthma. The Minimum Data Set (MDS) quarterly assessment revealed Resident #7 had severe cognitive impairment. a. An active physician order was in place for ultra-lubricating eye drops to instill 2 drops in each eye daily for dry eyes. During a medication administration observation on 5/30/24 at 8:30 am, Nurse #1 was observed administering ultra-lubricating eye drops to Resident #7. The bottle of ultra-lubricating eye drops had a blue label attached which read shake well before use. An interview was conducted on 5/30/24 at 8:44 am with Nurse #1 who…

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 accommodate a resident's need for bed size as evidenced by a bedframe and mattress that was approximately 4 inches shorter than the resident's height for 1 of 1 resident reviewed for accommodation of needs (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses to include paraplegia and rheumatoid arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and 78 inches tall. An interview and observation were conducted with Resident #48 on 03/06/2023 at 11:25 P.M. Resident #48 was laying in bed on an air mattress. The head of the bed was raised at approximately a 90 degree angle, his feet were up against a pillow at the foot of the bed, and his head was approximately 4 inches above the top of the mattress at the head of the bed. Resident #48 stated that he was 6 feet 6 inches tall and that his bed was too short 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 record review and staff interviews, the facility failed to ensure the advanced directive information was accurate throughout the medical record for 3 of 7 residents (Resident #25, #31 and #395) reviewed for advanced directives. Findings included: 1). Resident #25 was admitted to the facility on [DATE] with diagnoses which included in part multiple sclerosis. Resident #25's electronic medical record indicated a [DATE] physician order for Full Code. Review of Resident #25's hard chart revealed a form titled No Code Agreement signed by Resident #25 on [DATE]. Resident #25's signature indicated that resident's wishes were that at the time of the absence of heartbeat or respirations, no extraordinary or heroic measures would be performed. Physician signed the No Code Agreement form on [DATE]. The No Code Agreement form indicated a physician's order for no extraordinary means was required. Resident #25's [DATE] admission Minimum Data Set (MDS) assessment indicated resident had mild cognitive impairment 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 staff, resident and Resident Representative (RP) interviews the facility failed to ensure the resident and/or the RP was involved in the review and revision of the comprehensive care plan by the interdisciplinary team (IDT) for 3 of 3 residents reviewed for care planning. (Resident #38, Resident #52, and Resident #42) Findings included: 1. Resident #38 was admitted to the facility on [DATE] with a diagnosis of stroke. A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. A review of Resident #38's current comprehensive care plan revealed 15 active focus areas last updated on 1/31/23. A review of Resident #38's medical record did not reveal any evidence of a care plan meeting was held for this updating of her care plan on 1/31/23. On 3/8/23 at 11:00 AM a telephone interview with Resident #38's RP indicated he used to regularly receive invitations to participate in Resident #38's care plan meetings from the facility. He…

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, staff, physician and nurse practitioner interviews the facility failed to follow up on a physician's recommendation on the hospital discharge summary. This was for 1 of 4 residents reviewed for hospitalization (Resident #70). Findings included: Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of obstructive sleep apnea (OSA is a sleep related breathing disorder). A review of the quarterly Minimum Data Set (MDS) assessment for Resident #70 dated 12/31/22 revealed she was cognitively intact. A review of the hospital discharge summary for Resident #70 dated 12/29/22 revealed a discharge diagnosis of OSA not on continuous positive airway pressure (CPAP) and a recommendation for nocturnal (nighttime) oxygen at 2 liters per minute until Resident #70 could have a sleep study and initiation of CPAP. A review of Resident #70's medical record did not reveal any physician's order for oxygen 2 liters per minute at night nor any…

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 observation and staff interviews, the facility failed to: accurately record an opened dated for a tube of eye ointment, a bottle of eye drops, and dispose of an expired inhaler on the 300 hall medication cart. The facility failed to accurately record an opened date for two bottles of eye drops, dispose of an expired inhaler and dispose of an opened Lantus insulin pen with no resident name or opened date on the 200 hall medication cart. This was for 2 of 3 medication carts observed for medication storage. The facility failed to dispose of an expired box of bisacodyl suppositories in 1of 2 medication storage rooms observed for medication storage. Findings included: 1). Observation on 3/08/23 at 10:47 AM of the 300 Hall medication cart with Nurse #3 in attendance revealed: Resident #10's tube of Systane nighttime eye ointment with no open date. Resident #62's bottle of olopatadine eye drop with no open date. Manufacturer information indicated discard 28 days after opening. Resident #72's Ipratropium bromide and albuterol sulfate inhaler with expiration date of 2/6/23.…

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, interviews with residents, staff and physician the facility failed to obtain dental extractions based on the dental provider's recommendations and failed to provide or obtain from outside sources routine dental services for 2 of 3 residents (Resident #65 & # 26) reviewed for dental. The findings included: 1. Resident #65 was admitted to the facility on [DATE]. His diagnoses included stroke, congestive heart failure, and diabetes. Resident #65's payor source was listed as Medicaid. The notes from the in-house dental provider documented on 4/6/22 and 5/8/22 indicated Resident #65 was not seen because he was at his scheduled dialysis. On 7/19/22 the note documented he was not seen due to his current medical condition. A review of the grievances revealed a grievance from Resident #65 dated 8/22/22 which read wants to go to the dentist to get new teeth. The resolution to the grievance read; Per ADON [Assistant Director of Nursing] conversation resident is requesting to have his remaining teeth…

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 resident, Resident Representative (RP) 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 the 3/11/22 focused infection control and complaint investigation survey and the 6/25/21 recertification/complaint survey .This was for 1 deficiency in the area of F761 Medication Storage and Labeling that was cited on the 3/11/22 focused infection control and complaint investigation survey and again cited on the current recertification and complaint investigation survey of 3/9/23 and 7 deficiencies in the areas of F550 Resident Rights, F561 Self Determination, F641 Accuracy of Assessments, F656 Develop/Implement Comprehensive Care Plan, F657 Care Plan Timing and Revision, F688 Range of Motion and Mobility and F761 Medication Storage and Labeling cited on the 6/25/21 recertification and complaint investigation survey that were cited again on the current recertification survey of 3/9/23. The continued…

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 and staff interviews the facility failed to honor a resident choice to get out of bed for 1 of 1 resident (Resident #52) reviewed for choices. Findings included: Resident #52 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was cognitively intact and required total assistance with two people for transfers. The MDS did not document Resident #52 refusing care. Resident #52's care plan dated 2-28-23 revealed the resident required assistance for mobility, transfers, dressing, grooming, toileting, and bathing related to hemiplegia. The care plan goal was for Resident #52 to be clean, dry, and dressed appropriately for the season. The interventions for the goal were in part for Resident #52 to be out of bed by 10:00am. Resident #52 was interviewed on 3-6-23 at 11:25am. The resident stated she was not able to get out of bed on the weekends because there were not enough staff. She explained on Sunday (3-5-23) she was informed…

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 interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of the administration of an antidepressant and history of falls prior to admission for 1of 23 residents (Resident #31) reviewed for MDS assessments. Findings included: Resident #31 was admitted on [DATE] with diagnosis which included in part fall with head trauma and major depressive disorder. Review of Resident #31's physician orders revealed a 1/31/23 order for paroxetine (a medication used to treat depression) 20 milligrams (mg) daily. Review of Resident #31's February 2023 Medication Administration Record (MAR) revealed resident received paroxetine 20 milligrams (mg) daily. Nursing progress note on 2/2/23 indicated Resident #31 had a fall from bed with a wound to the forehead and was sent to the emergency room. Progress note indicated Resident #31 returned to the facility from the emergency room later on 2/2/23 with no fracture. An orthopedic consult note on 2/6/23…

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 record review, observation, and resident and staff interviews, the facility failed to develop a comprehensive person centered care plan in the areas of psychotropic medications and falls for 1 of 7 residents (Residents #31) reviewed for comprehensive care plans. Findings included: Resident #31 was admitted on [DATE] with diagnosis which included, in part, fall resulting in head trauma and major depressive disorder. Review of Resident #31's physician orders revealed a 1/31/23 order for paroxetine (a medication used to treat depression) 20 milligrams (mg) daily. Review of Resident #31's February 2023 Medication Administration Record (MAR) revealed resident received: paroxetine 20 milligrams (mg) daily. Nursing progress note on 2/2/23 indicated Resident #31 had a fall from bed with a wound to the forehead and was sent to the emergency room. Progress note indicated Resident #31 returned to the facility from the emergency room later 2/2/23. Resident #31's 2/7/23 admission Minimum Data Set (MDS) 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 observation, record review, and staff interviews the facility failed to ensure mobility aides were provided as ordered for 1 of 1 resident (Resident #47) reviewed for range of motion. Findings included: Resident #47 was admitted to the facility on [DATE] with multiple diagnoses that included joint derangements of the right hand, joint derangements of the left elbow, joint derangements of the left hand and non-traumatic intracerebral hemorrhage. Physician order dated 1-8-23 revealed an order to apply elbow splint alternating from left to right for a maximum of 6 hours on each elbow as tolerated. Physician order dated 1-8-23 revealed an order to apply right- and left-hand splints for a maximum of 6 hours daily as tolerated. Physician order dated 1-12-23 revealed an order to apply protective boots to bilateral feet as tolerated. Remove boots for skin checks every shift. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired and required total assistance…

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, staff, physician and nurse practitioner interviews the facility failed to follow physician's orders for a change in medication. This was for 1 of 5 residents reviewed for unnecessary medication (Resident #73). Findings included: Resident #73 was admitted to the facility on [DATE] with a diagnosis of anemia (a lack of healthy red blood cells). A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. A review of her ferritin test (a blood test that helps the physician understand how much iron the body stores) dated 12/1/22 revealed the result was 848.70 (the normal reference range is 30 to 400) nanograms (ng) per milliliter (ml). A physician's order for Resident #73 dated 2/20/23 indicated to discontinue the ferrous sulfate (an iron supplement) 325 milligrams (mg) daily and start ferrous sulfate 325 mg every other day. It further indicated to discontinue the multivitamin. The order was written by…

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 the medical record contained dental consultation notes resulting in a delay with dental extractions needed to obtain dentures for 1 of 3 residents (Resident #65) reviewed for dental services. The findings included: Resident #65 was admitted to the facility on [DATE]. The Nurse Practitioner (NP) note dated 8/25/22 included the past history of previous physician/NP notes. This 8/25/22 note revealed the following information related to Resident #65's dental care needs: -The 3/10/22 routine physician visit indicated, in part, dental consult -The 5/11/22 routine physician visit indicated, in part, dental consult re: extractions (reordered from previously) A review of Resident #65's medical record did not reveal any information about Resident #65s' consultations with an out of the facility dental provider. On 3/8/23 at 2:35 PM the current Medical Records Clerk stated she was previously responsible for transportation and was aware of 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.