Tower Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews, the facility failed to refrigerate medications according to manufacturer's recommendations for 1 of 1 medication refrigerators located in the Medication room. Findings included: The manufacturer's recommendations for Insulin glargine, insulin degludec and Humulin R recommended that insulin be stored in a refrigerator at approximately 36 to 46 [degrees Fahrenheit] to avoid freezing. On 2/07/24 at 1:45 PM the Medication Room was observed with Nurse #4. The medication top-freezer refrigerator was observed with a secured lock on the refrigerator section. Inside the top-freezer was a white plastic basket containing: 1- Insulin glargine 10 milliliters (ml) multidose vial unopened 2- Insulin glargine 3 ml injection pens 2- Insulin deglu[DATE] ml injection pens 2- Insulin dulaglutide 0.5 ml injection pens 3- Humulin R 10 ml multidose vials unopened On 2/07/24 at 1:47 PM Nurse #4 stated the insulins should not have been placed into the freezer. Nurse #4…

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, staff interviews, and Medical Director interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 8/27/21 recertification and complaint investigation survey and the 10/15/22 recertification and complaint investigation survey. This was for 5 recited deficiencies on the current recertification and complaint investigation survey of 2/08/24 in the areas of Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plan (F656), Pharmacy Services/Procedures/Pharmacist/Records (F755), Free from Unnecessary Psychotropic Medications (F758), and Label/Store Drugs & Biologics (F761). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in 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 staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Pre-admission Screening and Resident Review (PASRR) for 2 of 19 sampled residents whose MDS were reviewed (Resident #56 and Resident #23). The findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder and anxiety. Review of the Pre-admission Screening and Resident Review (PASRR) Level II Determination Notification dated 3/14/23 revealed Resident #56 was appropriate for nursing home placement. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #56 was not coded to reflect his PASRR Level II status. An interview was conducted with the MDS Nurse on 2/07/24 at 10:40 am who confirmed Resident #56 had a PASRR Level II. The MDS Nurse stated she was not sure how she missed the PASRR Level II information for Resident #56 when she completed his annual assessment. An interview was conducted on 2/07/24…

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, and Responsible Party (RP) interview, the facility failed to develop a person-centered care plan for 1 of 1residents reviewed for activities (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included stroke and major depressive disorder. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Resident #5 reported the following activity preferences were very important: books, magazines, and newspapers to read, listen to music, participate in group activities, participate in religious services, and to be outdoors for fresh air when weather was good. Resident #5's care plan initiated on 10/16/23 and last updated on 2/05/24 revealed she had a care plan in place for daily preferences and activity preferences related to daily care. A care plan goal was in place for Resident #5's daily and activity preferences to be provided through the next…

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, record review and staff interviews, the facility failed to maintain an accurate count of a controlled antianxiety medication for 1 of 4 residents observed for controlled substance administration (Resident #56). Findings included: Review of Resident #56's February 2024 Medication Administration Record (MAR) revealed he received alprazolam 1 milligram (mg) at 8:00 AM, 12:00 PM and 4:00 PM daily. A medication administration observation was conducted on 2/07/24 at 8:20 AM with Nurse #2. The nurse verified Resident #56's medications, opened the locked narcotic box and retrieved Resident #56's alprazolam 1 mg tablets. The individual tablets were in a blister pack with each tablet numbered. Upon removal from the box, the blister pack showed there were 19 tablets. Nurse #1 removed one tablet and showed there were 18 tablets remaining in the blister pack. At the time of the observation a review of Resident #56's Controlled Substance Count Record for alprazolam 1 mg was completed with Nurse #2. There was a line for each tablet's administration documentation which…

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, Consultant Pharmacist interview, and Medical Director interview, the facility failed to address recommendations made by the Consultant Pharmacist based on the monthly Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #5). The findings included: The hospital Discharge summary dated [DATE] revealed Resident #5 was discharged with an order for trazodone (an antidepressant medication) 50 milligram (mg) tablet take 0.5 tablet (25 mg) by mouth nightly for 30 days. Resident #5 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. An active physician order entered by Nurse #1 and dated 10/06/23 for trazodone oral tablet 50 mg. Give 1/2 tablet by mouth one time a day for depression; give 25 mg by mouth nightly for depression. The physician order did not have a stop date. A telephone interview was conducted on 2/07/24 at 10:24 am with Nurse #1 who revealed she did not recall…

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 administer the pneumococcal vaccine to eligible residents for 2 of 5 residents reviewed for immunizations (Resident #65 and Resident #69). The findings included: The facility policy for Immunizations last revised on 10/2/20 read in part Pneumococcal Immunization: Residents will be offered the immunization upon admission, unless it is medically contraindicated or the resident has already been immunized, and the resident or the resident's representative refuses after receiving appropriate education and consultation regarding the benefits of pneumococcal immunization. Upon consent, the pneumococcal vaccine will be given according to the Centers for Disease Control and Prevention and Advisory Committee for Immunization Practice recommendations. a. Resident #65 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #65 was not up to date with…

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 interviews and staff interviews, the facility failed to conduct an initial care plan meeting (Resident #69) and quarterly care plan meetings (Resident #45, #51 and #4) for 4 of 4 residents reviewed for care plan meetings. Findings included: 1. Resident #69 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact. A review of Resident #69's electronic medical record revealed no social services notes indicating an initial care plan meeting was held. Nursing documentation revealed no documentation of an initial care plan meeting for Resident #69. In an interview with Resident #69 on 10/11/2022, she stated she had not met as a group with the different interdisciplinary team members to discuss her plan of care since admission. The facility's social worker was not present during the survey and was unavailable for an interview. In an interview with the admission Coordinator on 10/13/2022 at 12:01…

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. Resident #30 was admitted to the facility on [DATE]. A smoking assessment dated [DATE] revealed Resident #30 was assessed as a safe and independent smoker. Resident #30's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Resident #30's record review revealed monthly smoking assessments were not completed during the months of July, August, and September 2022. Resident #30's active care plan (initiated on 08/24/21) revealed she was care planned as a smoker who needed staff supervision. An interview was conducted with Resident #30 on 10/11/22 at 9:30 AM. She stated she smoked since she was admitted to the facility. Resident #30 stated she smoked without supervision up until approximately two weeks ago. She reported the Administrator spoke with her on 10/10/22 regarding her being a smoker who required staff supervision. She reported nursing staff kept her cigarettes and her smoking materials. An interview was conducted with the Administrator on 10/12/21 at 3:24 PM 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 and staff interviews, the facility failed to discard expired food stored for use in the dry goods storage room. This practice had the potential to affect 75 of 76 residents in the facility. Finding included: 1. On 10/10/2022 at 9:50 a.m. during the initial tour of the kitchen accompanied by the dietary manager, a large container of brown seasoning sauce with an expiration date written as 21, [DATE] was observed in the dry storage area dated open on 12/3/21. On 10/10/2022 at 9:50 a.m. in an interview with Dietary Manager, she stated expiration date on the container of brown seasoning sauce was unclear as written. She stated food items with questionable expiration dates needed to be removed from the storage area and discarded the brown seasoning sauce. On 10/10/2022 at 2:20 p.m. in a follow up interview with the Dietary Manager, she stated the dietary staff used individual bags of sauce instead of using the brown seasoning sauce in the large container. She confirmed the expiration date 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 record review and staff interviews, the facility failed to promote dignity by delaying answering a call bell device for 1 of 4 residents reviewed for dignity. (Resident #172) Findings included: Resident #172 was admitted to the facility on [DATE], and diagnoses included gastroenteritis, an inflammation of stomach and intestines. The care plan dated 10/5/2022 included a focus for gastroenteritis, and interventions included observing for nausea and administering medications as ordered by the physician. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #172 was cognitively intact. On 10/10/2022 at 11:15 a.m. in an interview with Resident #172, she stated she was nauseated, and she had rung the call bell device all night and all morning, and no one had come to her room to tell them she needed some medication for nausea. She stated the wash basin lined with clean paper towels observed at the foot of the bed was in case she vomited. She stated she had not vomited but was unable…

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, resident interview and staff interviews, the facility failed to place the call bell device within the reach for 1 of 1 resident reviewed for accommodation of needs. (Resident #171) Findings included: Resident #171 was admitted to the facility on [DATE]. The care plan dated 10/2/2022 indicated Resident #171 was at risk for falls, and interventions included keeping the call light within reach of Resident #171. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #171 was moderately impaired cognitively, required assistance with all activities of daily living and was incontinent of urine and stool. On 10/10/2022 at 11:11 a.m., Resident #171 was observed sitting in his recliner chair that was positioned four feet from the left side of the bed. The call bell device was observed wrapped around the bed rail located at the head of the bed on the left side of the bed out of reach for Resident #171. On 10/10/2022 at 11:19 a.m. in an interview with Nurse Aide…

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 a copy of a resident's advanced directive was accessible to direct care staff for 2 of 2 residents reviewed for advanced directives (Resident #40 and Resident #41). 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included hypertension and chronic obstructive pulmonary disease. A physician's order dated 9/9/22 indicated Resident #40 had a status of do not resuscitate. Resident #40's admission Minimum Data Set (MDS) assessment revealed she was assessed as having moderate cognitive impairment. Record review revealed no copy of Resident #40's advanced directive was in her electronic medical record. An interview was conducted with the Administrator on 10/11/22 at 3:00 PM who stated she would locate a copy of the Resident 40's advanced directive. She stated the facility social worker was on leave. On 10/12/22 the Administrator stated Resident #40's advanced directive was in the social worker's locked office. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interviews the facility failed to develop and implement an individualized person-center care plan for 2 of 20 residents reviewed for care plans (Resident #47 and Resident #30). 1. Resident #47 was admitted to the facility on [DATE] with diagnoses including flaccid neuropathic bladder and atrial fibrillation. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #47 had moderate cognitive impairment, required assistance with activities of daily living and had an indwelling urinary catheter. A review of care plans for Resident #47 revealed no plan had been developed for urinary catheter care. On 10/10/22 at 12:11 PM Resident #47 was interviewed. He stated he has had a urinary catheter since admission. Nurse #9 was interviewed on 10/12/22 at 11:48 AM and she reported Resident #47 had an indwelling urinary catheter. An interview with the MDS Nurse was conducted on 10/12/22 at 1:41 PM. She reported Resident #47 had an indwelling urinary catheter which 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 interviews, the facility failed to complete a recapitulation of stay at the facility for 1 of 1 resident reviewed for discharges (Resident #72). Findings included: Resident #72 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and hypertension. Review of Resident #72's's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #72's medical record revealed she was discharged Against Medical Advice (AMA) on 09/08/22. Further review of the record revealed there was no evidence the facility completed a recapitulation of stay for Resident #72. Review of a nursing note dated 9/8/22 specified Resident #72 left AMA to return home. Interview with the MDS nurse on 10/13/22 at 2:07 PM revealed a discharge summary and recapitulation of stay was not completed. The MDS nurse further stated she was not aware a discharge summary and recapitulation of stay needed to be completed for Resident #72.…

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, interviews, and observations the facility failed to provide nail care for a dependent resident for 1 of 26 residents reviewed for activities of daily living (Resident #25). Findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses including hypertension and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had moderate cognitive impairment. He required extensive assistance with bed mobility and transfers occurred once or twice. Supervision was required for eating and total assistance was needed for toilet use. The MDS indicated Resident #25 did not have behaviors of rejecting care. Resident #25's care plans updated on 8/31/22 revealed a care plan for activities of daily living/personal care. The goal included activities of daily living/personal care would be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Resident #25 was also care planned 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 2. Resident #172 was admitted to the facility on [DATE], and diagnoses included gastroenteritis, an inflammation of stomach and intestines. Physician orders dated 9/30/2022 revealed an order for Ondansetron 4 milligrams (mg) orally every eight hours as needed for nausea and vomiting. The care plan dated 10/5/2022 included a focus for gastroenteritis, and interventions included observing for nausea and administering medications as ordered by the physician. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #172 was cognitively intact. A review of the October 2022 Medication Administration Record on 10/11/2022 revealed Resident #172's last dose of Ondansetron 4mg documented on the MAR prior to 10/10/2022 was on 10/9/2022 at 7:46 a.m. Nurse #1 signed administering Resident #172 her 8:00 a.m. and 9:00 a.m. medications on 10/10/2022. On 10/10/2022 at 11:15 a.m. in an interview with Resident #172, she stated she was nauseated and she had rung the call bell device all night and all morning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews, the facility failed to perform wound care as physician ordered to a pressure ulcer for 1 of 2 residents reviewed with pressure ulcers. (Resident #69) Findings included: Resident #69 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the sacral and coccyx vertebrae. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact, required assistance with activities of daily living and was receiving wound care for a stage 4 pressure ulceration that was present on admission. The care plan dated 9/27/2022 included a focus for ulceration or interference with structural integrity of layers of skin caused by pressure related to immobility, and interventions included treatment as ordered by physician. Physician orders dated 9/30/2022 revealed an order to apply Santyl ointment, a medicine that removes dead tissue from wounds so they can start to heal, 250 units/gram topically 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, observations, resident interviews and staff interviews, the facility failed to attach urinary catheter tubing to a secure device to prevent tension and possible injury to the resident for 2 of 3 residents (Resident #69 and Resident #47) reviewed for urinary catheters. Findings included: 1. Resident #69 was admitted to the facility on [DATE], and diagnoses included osteomyelitis of sacral ulcer and sacrococcygeal vertebrae. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact, required assistance with toileting and used an indwelling catheter for elimination of urine. Resident #69's care plan included a focus for an altered pattern of urinary elimination with an indwelling catheter due to being at risk for infection related a stage 4 sacral pressure ulcer with osteomyelitis. Interventions included catheter care per facility protocol. A review of the physician's orders reviewed no order for the use of a secured device with an indwelling…

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 interview the facility failed to allocate sufficient staff to answer call bells (Resident #172), perform wound care (Resident #69) and perform smoking assessments. The findings included: 1. This tag is cross referenced to F550. Based on record review and staff interviews, the facility failed to promote dignity by delaying answering a call bell device for 1 of 4 residents reviewed for dignity. (Resident #172) 2. This tag is cross-referenced to F686. Based on record review, resident interview and staff interviews, the facility failed to perform wound care as physician ordered to a pressure ulcer injury for 1 of 2 residents reviewed with pressure ulcer injuries. (Resident #69) An observation was conducted on 10/10/12 at 5:31 PM and there was no one at the center nursing station. Director of Nursing (DON) #1 stated there was not a nursing supervisor assigned. She reported there was not a permanent nursing supervisor assigned on day shift. DON #1 reported she felt that staffing levels were beginning to improve but had difficulties during 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 staff interviews, the facility failed to establish a secured and effective system to contain and record control drugs to be returned to the pharmacy for a discharge resident (Resident #174) 1 of 1 discharged resident (Resident #174) reviewed for returning control drugs to the pharmacy. Findings Included: The pharmacy's Procedure for Returning Controlled Substance dated 06/2021 stated facility staff members must complete the Return of Drugs Form and place the medications in a self-sealing controlled bag and document the serial number on the Return of Drugs form. The sealed bag of medication and the Return of Drugs form shall be kept locked in the controlled substance locked drawer of the medication cart until the courier arrives for pick up. Return of Drugs must be faxed to the pharmacy before 4 p.m. for pick up that evening and forms received after 4:00 p.m. would be accepted by the courier on the following business day. 1. Resident #174 was admitted to the facility on [DATE], 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 Medical Director interview, the facility failed to implement a 14-day stop date for an as needed psychotropic medication for 1 of 5 resident's reviewed for unnecessary medications (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses which included restlessness and agitation. Resident #52's physician order dated 09/27/22 revealed he was ordered lorazepam 2 milligram (mg) per one milliliter (ml) inject 0.5 mg intramuscularly (IM) every eight hours as needed for agitation with a stop date of indefinite. A review of the Medication Administration Record (MAR) for Resident #52 revealed he had not received lorazepam 0.5 mg intramuscularly. Attempts were made to reach the Pharmacist Consultant but were unsuccessful. An interview with the Medical Director on 10/14/22 at 11:10 am revealed she wrote the order for lorazepam IM without a stop date by accident and didn't put a stop date. The Medical Director further stated on the day she wrote 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, observation, resident interview, and staff interviews, the facility failed to 1.) date two opened medications for 1 of 2 medication carts used for medication administration on 100 Hall and 2.) store medication in a locked cabinet for 1 of 1 resident reviewed for medication administration. (Resident # 172). Findings included: 1. On 10/14/2022 at 8:43 am, observation of the medication administration cart known as 100-Hall with Nurse #2 revealed the following medications were open and without an open date: budesonide 0.5milligram/2milliliters foil pack with four of five single doses which had a sticker that read, expires 2 weeks after opening with a pharmacy delivery date of 09/21/2022 for Resident #70 and one timolol 0.25% eye drop bottle with the seal broken and approximately half full for Resident #272. An interview with Nurse #2 on 10/14/2022 at 8:45 am revealed there should be an open date on all opened medications. She further stated any medications opened without a written date 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 record review, observations, and interviews the facility failed to provide routine dental care for 1 of 1 resident reviewed for dental care (Resident #63). Findings Included: Resident #63 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE] revealed Resident #63 had moderate cognitive impairment. He was coded to have no issues with broken teeth and no facial or mouth pain. On 10/10/22 at 3:00 PM Resident #63 was interviewed and he stated he would like to see a dentist, but he had not seen the dentist since his admission to the facility. He stated he does not have any pain and does not have any trouble with eating. An observation at the same time of the interview of Resident #63's teeth revealed he had missing teeth, they were grayish in color, and his lower teeth appeared to be jagged. The Social Worker was not in the facility and was unavailable for interview. The Administrator was interviewed on 10/13/22 at 2:57 PM and she stated the facility utilized a dentist who came…

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.