Pembroke Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with residents and staff, the facility failed to protect a resident's right to be free from neglect when two nurse aides (NA) on the 3:00 PM to 11:00 PM shift refused a dependent resident's (Resident #21) requests for transferring her to bed and incontinence care. Resident #21 was left sitting up in her electric wheelchair in her room that had a strong odor resembling bowel incontinence. When Resident #21's incontinence care was provided her brief was heavily soiled with a bowel movement that was caked and dried on her skin. Resident #21 was in a semi-private room, and she stated she was embarrassed and humiliated in front of her roommate by the NAs refusal of care. The deficient practice occurred for 1 of 4 residents reviewed for neglect. Findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left side, cerebral infarction (stroke), and anxiety disorder. The quarterly Minimum Data Set (MDS) dated…

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 quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD-referring to the last day of the observation period for 2 of 22 residents sampled for assessments (Resident #17 and Resident #21).Findings included:1a. Resident #17 was admitted to the facility on [DATE].Review of Resident #17's MDS assessments revealed that quarterly assessment with an ARD of 7/10/25 and the completion date was 7/30/25.b. Resident #21 was admitted to the facility on [DATE].Review of Resident #21's MDS assessments revealed a quarterly MDS assessment with an ARD of 7/23/25 and it was completed on 8/20/25.An interview with the MDS Clinical Reimbursement Coordinator (CRC) occurred on 11/16/25 at 9:19 AM. The MDS CRC stated that she knew several residents' quarterly MDS assessments had been completed late. She further stated that she worked for the company and traveled between several facilities and was not always able to get…

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 interviews with resident and staff, the facility failed to provide incontinence care to a dependent resident for 1 of 4 residents reviewed for activities of daily living (ADL) care (Resident #21). Findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left side, cerebral infarction (stroke), and anxiety disorder.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact with no rejection of care behaviors in the lookback period. Resident #21 was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene.The care plan revised 7/24/25 revealed Resident #21 had a self-care deficit in performing ADL related to a stroke with hemiplegia and hemiparesis. The care plan interventions included Resident #21 was dependent on the assistance of two staff members with the mechanical lift for all transfers and to provide incontinence care as needed.…

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 Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident (Resident #6) reviewed for quality of care. Based on observations, record review, staff interviews, the Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident reviewed for quality of care. Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia. A care plan dated 4/9/25 revealed Resident #6 was at nutritional risk related to frequent hospitalizations, multiple chronic disease processes, history of weight gain…

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 Wound Care Physician's interview, the facility failed to complete initial wound assessments upon admission to include the wound descriptions with measurements and obtain wound care orders upon admission and when the wound vac (vacuum assisted closure (vac), negative pressure wound therapy that uses suction to aid in wound healing) was not available in the facility for a resident admitted with multiple pressure wounds and osteomyelitis (infection of the bone tissue) requiring intravenous and oral antibiotics. This occurred for 1 of 6 residents (Resident #86) reviewed for wound care. Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including a Stage IV pressure ulcer of the left ischium (the lower and back portion of the hip bone), Stage IV pressure ulcer on the sacrum, Stage IV pressure ulcer of the right hip, Stage II pressure ulcer on the right buttock, a deep tissue injury of the left heel, osteomyelitis (an infection 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to provide care in a safe manner when Nurse Aide #8 provided incontinence care to a resident (Resident #39). This resulted in Resident #39 rolling off of the bed onto the floor sustaining a fracture to the first cervical vertebrae (C1) of the cervical spine. This occurred for 1 of 5 residents reviewed for accidents (Resident #39). Resident #39 was admitted to the facility on [DATE]. Her diagnoses included cerebral vascular accident (CVA), hemiplegia (paralysis or weakness on one side of the body), and dementia. A care plan dated 4/18/25 revealed Resident #39 required assistance with activities of daily living (ADLs) including bed mobility due to having limited mobility related to cerebral vascular accident (CVA) with hemiplegia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. She had no falls at the time of the assessment. Her weight was 168 pounds. She required…

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, Nurse Practitioner (NP), and Registered Dietitian (RD) interviews, the facility failed to determine the accuracy of a weight when a resident had a significant weight gain of 26.8 pounds in 19 days and failed to communicate the significant weight gain to the Registered Dietitian for a nutritional assessment for 1 of 5 residents reviewed for nutrition (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE] with a cumulative diagnosis including right above the knee amputation (AKA), atrial fibrillation (A-fib), hypertension (HTN), congestive heart failure (CHF), and peripheral vascular disease (PVD). A physician order dated 04/28/25 revealed an order to weigh Resident #62 every day shift every 1 month(s) starting on the 28th for 2 day(s), with start date of 04/28/2025. A review of Medication Administration Record (MAR) dated 09/15/25 for Resident #62 revealed: Eliquis (treat Atrial fibrillation), Entresto (treat chronic heart failure), iron,…

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 complete a performance review every 12 months for 1 of 1 nursing assistant (Nurse Aide #4) reviewed to ensure in-service education was designed to address the outcome of the performance review.Findings included:Nurse Aide #4's personnel file was reviewed and revealed the date of hire of was 7/30/24. The personnel file for Nurse Aide #4 did not include evidence that a performance review had been completed for Nurse Aide #4.An interview was conducted on 11/19/25 at 9:00 AM with the Administrator who stated the Director of Nursing (DON) was responsible for conducting the annual performance review for all Nurse Aides and she was aware the DON had not conducted the annual performance reviews.An interview was conducted on 11/19/25 at 9:05 AM with Nurse Aide #4. During the interview, Nurse Aide #4 stated her annual performance evaluation was due in 7/30/25 and she had not received a performance evaluation in the last year by the Director of Nursing (DON) and should have.A phone interview was conducted on 11/19/25 at 10:25…

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 Consultant Pharmacist's interview the facility failed to act on the Pharmacist's recommendation to remove a residents (Resident #3) discontinued narcotic pain medication (Hydrocodone- Acetaminophen 5-325 milligrams) from the medication cart. This resulted in 20 missing tablets. This occurred for 1 of 6 residents (Resident #3) reviewed for medication administration.Findings included:Resident #3 was re-admitted to the facility on [DATE] with diagnoses including a stage IV pressure wound and osteomyelitis (infection of the bone). A hospital physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for up to 5 days beginning 7/14/25. This order was administered to Resident #3 from 7/15/25 through 7/19/25 and completed. A second hard copy physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1…

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, the Pharmacy District Director, and the Wound Physician interviews, the facility failed to administer two intravenous (IV) antibiotics (Piperacillin Sodium Tazobactam - a broad-spectrum antibiotic used to treat moderate to severe bacterial infections and Vancomycin - an antibiotic used to treat severe infections) prescribed for the treatment of osteomyelitis (infection of the bone) following admission for a resident (Resident #86). This resulted in 4 missed doses of the Piperacillin and 4 missed doses of the Vancomycin. This occurred for 1 of 6 residents reviewed for medication administration. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Piperacillin Sodium Tazobactam. Use 3.375 grams intravenously every 8 hours for osteomyelitis for 18 days. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Vancomycin intravenous solution. Use 1 gram intravenously two times a day for osteomyelitis until…

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 hospice staff and facility staff interviews, the facility failed to coordinate a plan of care with the Hospice provider and ensure required Hospice documentation was in the medical record for 1 of 1 resident (Resident #5) reviewed for Hospice care. The findings included: Resident #5 was admitted to the facility on [DATE] with medical diagnoses which included Alzheimer's disease and end stage dementia. Resident #5's care plan dated 11/06/24 included the Hospice start date of 04/19/24 due to end stage diagnosis of dementia, and to provide activities for daily living (ADL) support, companionship and other interventions as desired by the resident, to promote comfort. An Election of Hospice Benefit form dated 02/13/25 for Resident #5 was the most current Hospice form noted in the resident's electronic medical record. The 04/18/25 annual Minimum Data Set (MDS) assessment revealed Resident #5 had severe cognitive impairments and hospice care was coded. Review of Resident #54's electronic…

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, Nurse Practitioner, and Consultant Pharmacist interviews the facility failed to 1.) follow a physicians order and apply an ace wrap to a residents left foot due to swelling sustained from a fall (Resident #17) and 2.) obtain a blood pressure prior to the administration of the antihypertensive medication Hydralazine 25 milligrams prescribed three times a day with parameters to hold the medication for systolic blood pressure less than 120 millimeters of mercury (Resident #5). This occurred for 2 of 2 residents reviewed for quality of care. Findings included. 1.) Resident #17 was admitted to the facility on [DATE] with diagnoses including dementia and repeated falls. A care plan dated 09/23/24 revealed Resident #17 was at risk for falls related to cognitive loss and lack of safety awareness. The goal of care was to remain free of injury. Interventions included in part to observe for changes in medical status and report to the physician. The Minimum Data Set (MDS)…

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, the Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to accurately transcribe an antihistamine order (Hydroxyzine 25 milligrams) prescribed as needed for itching. This resulted in the resident receiving the medication daily instead of as needed. The resident experienced no outcome from receiving the medication. This occurred for 1 of 5 residents (Resident #59) reviewed for medication administration. Findings included. Resident #59 was admitted to the facility on [DATE] with diagnoses including paraplegia and dementia. Review of the hospital after visit summary dated 09/11/24 for Resident #59 revealed an order for Hydroxyzine 25 milligrams (mg) administer at bedtime as needed for itching. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #59 was cognitively intact. He required extensive assistance with activities of daily living. He had no rejection of care. Review of the Medication Administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews, the facility failed to protect a resident's right to be free from physical abuse. Resident #80 removed some of Resident #67's belongings from her room and when Resident #67 went to retrieve the belongings Resident #80 denied having them. Resident #80 then swung at Resident #67, and in response, Resident #67 punched Resident #80 in the forehead with a closed fist for 1 of 4 residents reviewed for abuse. Resident #80 was not injured. The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbance, altered mental status, and generalized anxiety disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #80 had severely impaired cognition. During the assessment look back period she had verbal behaviors directed toward others on 1 to 3 days. Wandering occurred daily and she wore a wander/elopement alarm. She was able 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, and resident, staff, Nurse Practitioner and Physician interviews, the facility failed to provide care safely to a dependent resident when Resident #46 fell off the bed during care on 7/30/24 and 9/20/24 resulting in minor injuries. This deficient practice affected 1 of 3 residents reviewed for falls. Findings included: Resident #46 was admitted on [DATE] with diagnosis of history of neoplasm of brain, hemiparesis (paralysis on one side of the body) left dominant side, stroke, weakness, and seizures. Review of Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, had impairment of the upper and lower extremities on one side, required extensive assistance of 2 people for bed mobility, total assistance of 2 people with transfers, toileting and bathing. Resident #46's height was recorded as 63 inches (5 feet 3 inches) and weighed 266 pounds. Resident #46 was coded as had pain in past 5 days and received scheduled and as needed…

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, resident, staff, Nurse Practitioner and Physician interviews, the facility failed to provide sufficient nursing staff to ensure the necessary supervision and assistance level was implemented in accordance with the resident's plan of care for the safe provision of activities of daily living care for a dependent resident. This deficient practice affected 1 of 3 residents reviewed for sufficient nursing staff. Findings included: This tag is cross referenced to: F689: Based on record review, resident, staff, Nurse Practitioner and Physician interviews, the facility failed to provide care safely to a dependent resident when Resident #46 fell off the bed during care on 7/30/24 and 9/20/24 resulting in minor injuries. This deficient practice affected 1 of 3 residents reviewed for falls. An interview was conducted with Resident #46 on 11/5/24 at 10:30 AM. Resident #46 stated she was supposed to have 2 people to provide her care, but the facility did not always have enough staff available, especially on night shift (11:00 PM to 7:00 AM). Resident #46 stated there was…

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

Based on record review and staff interviews, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage on 5 of 60 days reviewed. Findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 2, 2024 (January 1-March 31, 2024) documented the facility had no RN coverage on 02/18/24, 02/24/24, 03/02/24, 03/03/24, 03/16/24, and 03/17/24. In an interview with the Nursing Scheduler/Payroll Manager on 11/07/24 at 10:15 AM she confirmed there was no RN coverage in the building for 8 hours on the following dates: 02/18/24, 03/02/24, 03/03/24, 03/16/24, and 03/17/24. She examined the staff payroll punches for the noted dates and was surprised to discover Agency Nurse #14 and Agency Nurse #15 that she thought were RNs were actually LPNs (Licensed Practical Nurses) leaving the facility with no RN coverage on 5 days. She reported that the facility did have RN coverage in the building for 12 hours on 02/24/24. She explained Nurse #13 had worked on 02/24/24 and took off time later in the week to compensate because she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Consultant Pharmacist interviews the facility failed to act on the Pharmacist recommendations to clarify the dose of an antihypertensive medication (Hydralazine 25 milligrams) and to add blood pressure checks prior to administration. This occurred for 1 of 5 residents (Resident #5) reviewed for medication administration. Findings included. Resident #5 was admitted to the facility on [DATE] with diagnoses including hypertension. The Consultant Pharmacists monthly medication regimen review dated 07/12/24 for Resident #5 revealed the following order recommendation. Hydralazine oral tablets 25 milligrams (mg). Take 1 tablet (25 mg) by mouth in the morning, at noon, and at bedtime. Hold for systolic blood pressure less than 120 mm/hg (millimeters of mercury). The order does not have a vital signs order attached. The Pharmacist recommended to please review and update. Review of the Medication Administration Record (MAR) dated July 2024 and August 2024 revealed no blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to maintain communication and coordination of services provided by Hospice in the medical record for 1 of 1 resident reviewed for Hospice services (Resident #41). Findings included: Review of the Nursing Facility Hospice Services Agreement signed 08/19/17 revealed the following: Manner of Communication: The Hospice Designee contact information and Resident Patient care information shall be provided to Nursing Facility by Hospice at the time a Resident Patient is admitted to Hospice. A cover sheet will be placed in the Resident Patient ' s chart indicating the contact information for the Hospice Designee. All communications between the Hospice and Nursing Facility pertaining to the care and services provided to the Resident Patient shall be documented in the Resident Patient's clinical record. Resident #41 was admitted to the facility on [DATE] with diagnoses that included atherosclerosis heart disease of the native coronary artery without angina…

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 interviews of residents, family, resident representative, and staff, the facility failed to provide nail care for dependent residents (Resident #s 32, 41, 45, and 50) and failed to provide hair wash for dependent residents (Resident #s 13, 32, 41, and 45) for 5 of 6 residents reviewed for activities of daily living. Findings included: 1. Resident #13 was admitted to the facility on [DATE] with the diagnosis of muscular weakness. Resident #13's quarterly Minimum Data Set, dated [DATE] documented the resident was unable to participate in the brief interview for cognitive status. The resident required 2-person physical assist for bathing. There was no refusal of care. Resident #13's care plan dated 10/17/23 documented she had an activity of daily living deficit and was dependent on staff for bathing and personal care. Resident #13 was unable to be interviewed. On 11/13/23 at 2:30 pm the resident was observed in her room. The resident's hair was greasy appearing and tightly…

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, Pharmacy Manager, Nurse Practitioner, and the Medical Directors interviews the facility failed to provide pain management by a.) not administering an as needed dose of the opioid medication Oxycodone prescribed for pain to a resident (Resident #222) who experienced frequent pain and b.) not following up with the Pharmacy regarding the anticonvulsant medication Lyrica prescribed three times a day for pain which resulted in the resident not receiving 11 doses of the medication and having complaints of pain for 1 of 1 resident (Resident #222) reviewed for pain management. Findings included. Resident #222 was admitted to the facility on [DATE] with diagnoses including Fibromyalgia (a disorder characterized by widespread musculoskeletal pain), Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Chronic Kidney Disease, and Left below knee amputation. The baseline care plan for Resident #222 dated 09/20/23 did not include pain management with goals and interventions. a.) A progress…

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 record an opened date on multi dose oral inhalers and record an opened date on ophthalmic drops on 3 of 3 medication carts reviewed for medication storage. Findings included. An observation of the 300/400 hall medication carts on 11/13/23 at 12:00 PM revealed two Incruse Ellipta multidose oral inhalers that had been used with no opened date recorded. The label on the inhaler instructed to discard 6 weeks after opening. An observation of the 300/400 hall medication carts on 11/13/23 at 12:00 PM revealed an opened bottle of Latanoprost ophthalmic drops with no opened date labeled on the bottle. The manufacturer's guidelines indicated to discard Latanoprost 6 weeks after opening. During an interview on 11/13/23 at 12:30 PM Nurse #9 stated she was the assigned nurse for the 300/400 hall medication cart. She stated expiration dates should be checked prior to administering the medications. She stated she was an agency nurse and had only worked in this building 3 or 4 times over the last year. She stated 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.

Based on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 7/6/21. This was for a deficiency originally cited in the area of Label/Store Drugs and Biologicals (F761). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F761: Based on observations, record review, and staff interviews the facility failed to record an opened date on multi dose oral inhalers and record an opened date on ophthalmic drops on 3 of 3 medication carts reviewed for medication storage. During the recertification and complaint investigation survey of 7/6/21 the facility failed to discard two opened and accessed bottles of eye drops per the pharmacy label on the box and failed to store an opened and accessed bottle of liquid nebulizer 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, staff, and the Pharmacy Managers interviews the facility failed to obtain a medication (Lyrica) prescribed for pain from the Pharmacy resulting in the resident not receiving 11 doses of the medication for 1 of 1 resident (Resident #222) reviewed for the provision of pharmacy services. Findings included. Resident #222 was admitted to the facility on [DATE] with diagnoses including Fibromyalgia (a disorder characterized by widespread musculosketal pain), Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Chronic Kidney Disease, and Left below knee amputation. A physicians order dated 09/20/23 for Resident #222 revealed Pregabalin (Lyrica) Oral Capsule 200 milligrams (mgs). Give 1 capsule by mouth three times a day for pain. Review of Resident #222s Medication Administration Record (MAR) dated September 2023 revealed he received Lyrica three times a day from 09/22/23 through 09/25/23. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed Resident #222 was cognitively intact.…

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 protect a resident ' s right to be free from abuse when a cognitively impaired resident (Resident #1) had a physical altercation with another cognitively impaired resident (Resident #2). Resident #1 punched Resident #2 in the face on 08/10/23. Resident #2 was assessed with redness to his face and a small abrasion to his nose and forehead; his emotional response was assessed as baseline (no change). This was for 1 of 2 residents reviewed for abuse. Findings included: Resident #1 was admitted to the facility with diagnoses that included dementia with behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had moderately impaired cognition with no moods or behaviors during the assessment look back period. He had an impairment on one side for both upper and lower extremities. He required extensive assistance for most activities of daily living. He was independent for locomotion on 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.