Optima Care Harborview

Based on observation, interview and record review, it was determined that the facility failed to follow a physician's order for a fluid restriction for a resident that received hemodialysis for 1 of 1 resident reviewed for dialysis (Resident #14).This deficient practice was evidenced by the following:On 1/8/26 at 10:32 AM, the surveyor entered Resident #14's room, observed that the resident was not in the room, and the resident's breakfast tray was on the bedside table. The surveyor observed that the meal ticket did not have a fluid restriction listed and that it had listed 4 fl (fluid) oz (ounce) apple juice, 4 fl oz apple juice, and 4 fl oz hot tea (Decaf). The surveyor also observed an additional two 4 oz juices on the dresser and a 16-20ml bottle of soda on the bedside table. The Certified Nursing Assistant (CNA) stated that Resident #14 was at dialysis. On 1/9/26 at 9:11 AM, the surveyor interviewed Resident #14, who stated that they went to dialysis on Tuesday, Thursday, and Saturday, and left the facility at 5:00 AM ,and came back at 9:00 AM. The surveyor observed Resident…

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

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 3 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 1/8/26 at 9:05 AM, upon entry to the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted on a wall next to the reception area. The NHRCSR reflected a date of 1/7/26, Day Shift, Shift Hours 7:00 AM - 3:00 PM, and a Current Resident Census (CRS) of 140. The Director of Nursing (DON) stated that the current census was 139.On 1/9/26 at 9:23 AM, the surveyor observed a NHRCSR and a Facility Staffing Sheet (FSS) posted in the facility lobby. The NHRCSR reflected the number of Certified Nursing Assistant (CNA) on the shift as 19. The FSS reflected the number of CNA on the shift as 18. The FSS also reflected 1 CNA with c/o (called out) next to 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 observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), with a parameter according to the physician's order to meet the needs of the resident. The deficient practice was identified for 1 of 28 residents reviewed (Resident #11). The deficient practice was evidenced by the following:On 1/8/26 at 10:18 AM, the surveyor observed Resident #11 laying in bed with their eyes closed. A review of Resident #11's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness or partial paralysis on one side), hypotension (low blood pressure), and chronic atrial fibrillation (a continuous, irregular heartbeat that doesn't stop on its own, often lasting over a week or even years). A review of Resident #11's most recent quarterly…

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, interview, and record review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in 1 of 3 medication carts and one 1 of medication refrigerators inspected on 3 of 3 units. This deficient practice was evidenced by the following:On [DATE] at 10:47 AM, the surveyor began inspecting the medication (med) storage room located on the facility 3rd floor in the presence of the 3rd floor Unit Manager (UM3). The surveyor observed a package containing an opened vial of tuberculin, purified protein derivative, diluted. Aplisol. (PPD) (an injectable solution used for testing and diagnosing tuberculosis). The surveyor did not observe a date when the vial was opened marked on the vial or the box. The surveyor asked the UM3 if the vial should be dated when opened and if they could identify a date when the vial was opened and first used. The UM3 stated that the vial should be dated when opened and that 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 observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that all listed menu items were consistently provided at the meal during lunch meal rounds on 1 of 3 units (5th floor).The deficient practice was evidenced by the following:On 1/9/26 at 11:56 AM, the surveyor observed the 5th floor day room for lunch, there were four tables (1st table with 3 residents, 2nd table with 4 residents, 3rd table with 4 residents, and 4th table with 4 residents), 2 small tables (1 resident seated in a Geri chair and 1 small table with 1 resident), and with five staff assisting for lunch. At that time, the surveyor observed all residents received their lunch meals. The surveyor observed Resident #7 seated alone with lunch meal that included breaded fish fillet, yellow rice, seasoned green beans, 4 fluid (fl) ounce (oz) whole milk, 12 fl oz ginger ale diet, 6 fl oz regular hot tea which also corresponded to the diet slip that was on top of their table, except for a 4 oz of jello. The surveyor asked Certified Nursing Aide #1 (CNA…

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.

Complaint #2613337Based on interview, and review of other facility documentation, it was determined that the facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for a resident who was denied admission to the facility to provide services. This deficient practice was identified for 1 of 20 resident referrals reviewed, Resident #154.This deficient practice was evidenced by the following:According to the Centers for Disease Control (CDC) guidelines dated 4/24/24, which revealed, the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for Candida Auris (C. Auris) are similar to those used for other multidrug-resistant organisms (MDROs). In most instances, facilities equipped to care for patients with other MDROs . can also care for patients with C. Auris. In nursing homes and skilled nursing facilities, healthcare providers should use either Contact Precautions or EBP (infection control intervention to wear gown and gloves during high…

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, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that 1 of 3 residents (Resident #1) preference was honored by having a nurse removed from the resident's care team.This deficient practice was evidenced by the following:The surveyor reviewed Complaint #431358 submitted by Resident #1's family member. The complaint reflected that the facility allegedly continued to keep a nurse caring for the resident after the family member asked them not to on 4/11/25.The surveyor reviewed the electronic medical record (eMR) of Resident #1, and revealed the following: A review of the admission Record (an admission summary) reflected that the resident had diagnoses of but not limited to Alzheimer's Disease (progressive mental decline) and Dysphagia (difficulty swallowing).A brief interview for mental status (BIMS) (a cognitive screening tool) assessment dated [DATE], score of zero (0), which indicated the resident had severe cognitive…

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 interview, record review, and facility policy review, the facility failed to notify the resident's representative of a significant change in the resident's skin condition for one of two residents (Resident (R) 224) reviewed for pressure sores out of a total sample of 37. The facility failed to provide documentation that R224's representative was notified of a pressure area on the resident's heel when she returned to the facility after a recent hospitalization. Findings include: Review of the facility's Notification of Changes policy, dated 11/2022 and 06/2023, revealed, . The facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances may be . Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status . Review of R224's Face Sheet, provided by the facility, revealed an…

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, interview, and policy review, the facility failed to conduct a thorough investigation of an alleged incident of staff neglect for one resident (R375) of four residents reviewed for abuse out of a total sample of 37 after the family stated the resident told them staff dropped him during a transfer, and the resident was found to have a right femur fracture. This has the potential to affect all residents receiving care by staff who may put residents at risk for neglect during care. Findings include: Review of R375's admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R375 was admitted to the facility on [DATE]. R375, who required staff assistance for transfers, was transferred by staff at various times on the morning of 04/17/23 prior to a podiatrist appointment at 1:00 PM. After R375 returned from the appointment, he complained of pain in his right leg and was sent to the hospital for further evaluation. Xrays revealed a right femur fracture,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Assessment was completed accurately for two of three sampled residents (Resident (R) 108 and R79) reviewed for PASARRs out of a total sample of 45 residents. This had the potential to prevent or delay additional services to a resident that might qualify for a Level II PASARR. Findings include: 1. Review of R108's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, and hallucinations. Review of R108's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 08/07/24, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R108 had no cognitive impairment. Further review revealed R108 had active diagnoses 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.

Based on interview, record review, and facility policy review, the facility failed to provide food that accommodated resident allergies for one of seven sampled residents (Resident (R) 81) reviewed for food concerns out of a total sample of 37. This failure had the potential to cause residents harm due to allergic reactions. Findings include: Review of R81's undated admission Record, located in R81's electronic medical record (EMR) under the profile tab, showed a facility admission date of 05/10/24 and a re-admission date of 07/24/24 with medical diagnoses that included cerebrovascular disease, hemiplegia and hemiparesis, major depressive disorder. Review of R81's Food Preferences, dated 05/14/24 revealed, Dislikes fish. The form did not provide an entry for any type of food allergies. Review of R81's Care Plan dated 05/14/24 reveals, R81 has an allergy related to fish and powder eggs. Review of R81's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/24, revealed the facility assessed R81 to have a Brief Interview for Mental Status (BIMS) score of 14…

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, interview, and record review, it was determined that the facility failed to follow a Professional Standards of Practice by a.) not following a Physician's Order (PO) on application of hand rolls to maintain joint integrity for 1 of 4 residents reviewed with limited range of motion, Resident #71, b.) failed to label and date an Enteral feeding bottle for 1 of 2 residents reviewed for Enteral feeding, Resident # 58, c.) failed to assess a weight change for 1 of 5 residents reviewed for nutritional status which did not contribute to weight loss, Resident # 124 and, d.) Failed to have a valid physician's order and accurately document the administration of a controlled substance, Resident #61 and Resident #24. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical 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.

Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 18 of 29 residents (Resident #3, #118, #130, #63, #87, #84, #32, #71, #11, #70, #147, #117, #22, #7, #127, #38, #54, #37) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above which revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents: 1. Resident #3's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 2. Resident #118's hybrid…

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 interview and review of facility documentation, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 2 of 26 residents reviewed (Resident #130 and Resident #11). This deficient practice was evidenced by the following: 1. On 9/1/22 at 11:44 AM, two surveyors observed Resident #130 lying in bed. Resident #130 did not respond to surveyor questions. The resident's call bell (a bell used to summon staff) was observed on the floor behind the resident's bed. On 9/2/22 at 11:03 AM, two surveyors observed Resident #130 lying in bed. The surveyors observed the resident's call bell on the floor behind the resident's bed. The surveyors interviewed Resident #130 at this time. The surveyor asked Resident #130 how they call for staff to come help them. The resident stated that they, yell. The surveyor asked if there was a button for them to press to call for staff. The resident stated that they cannot find the button. On 9/6/22 at 10:56 AM, two surveyors observed…

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 interview it was determined that the facility failed to provide a homelike environment during meal service as evidenced by the following: On 9/6/22 at 11:59 AM, during the lunch meal service in the 5th floor dining room, the surveyor observed that all the meals in the dining room (DR) were served on meal trays and was left on the trays in front of the residents. Further observation revealed that the trays used to serve the resident's meals were observed to be warped. The surveyor also observed the Certified Nursing Assisntant (CNA's) who were providing assistance with set-up to the residents in the DR left the lid from the food plate on the table and placed all the empty packet of milk carton, straw papers and other trash in front of the resident. On 9/9/22 at 12:48 PM, the surveyor discussed the above concern to the Administrator, Director of Nursing and Regional Nurse. No further information was provided. N.J.A.C. 8:39-4.1(a)12

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 3 of 26 residents reviewed for resident assessment (Resident #3, Resident #11 and Resident #32). This deficient practice was evidenced by: On 9/6/22 at 12:45 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. 1.) Resident #3 was observed to have an Annual MDS with an Assessment Reference Date (ARD) of 7/11/22 and was due to be transmitted no later than 8/15/22. The MDS was not transmitted until 9/8/22. 2.) Resident #11 was observed to have an Annual MDS with an ARD of 8/1/22 and was due to be transmitted no later than 8/29/22. The MDS was not…

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

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 1 of 3 residents reviewed, Resident #103 as evidenced by the following: On 9/01/22 at 10:20 AM, the surveyor observed Resident #103 lying in bed watching TV. The surveyor also observed a nebulizer machine on the nightstand, labeled with the resident's name. The resident stated, he/she receives nebulizer treatments three times a day. The surveyor reviewed Resident #103's hybrid medical record. The admission Record reflected that Resident #103 was admitted with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Emphysema, and Rhabdomyolysis. The surveyor reviewed the September 2022 Physician's Order (PO) form, which showed that Resident #103 had a PO for Xopenex Nebulization Solution 1.25 MG/3ML (Levalbuterol HCl) 3ml inhale orally via nebulizer every 8 hours related to COPD. The surveyor reviewed Resident…

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

Based on observation, interview, and record review, it was determined that the facility failed to review and revise a care plan to reflect changes to a resident's nutritional care for 1 of 3 residents (Resident # 58) reviewed. The deficient practice was evidenced by the following: On 9/1/22 at 10:10 AM, the surveyor observed Resident #58 lying in the bed and observed Glucerna 1.5 tube feeding running at 50ml/hr. The resident was pleasant during the interview process. A review of the admission Record for Resident #58 revealed that he/she was initially admitted with diagnoses that included but not limited to: Encounter for surgical aftercare following surgery on the digestive system, Cerebral infarction, Adult failure to thrive, and Dysphagia, Gastrostomy status (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support.) A review of an Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/7/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 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 observation, interview, and record review, it was determined that the facility failed to develop a plan of care and failed to perform a smoking assessment to determine the level of supervision required for 1 of 3 residents reviewed for smoking, Resident # 22. The deficient practice was evidenced by the following: On 9/1/22 at 11:05 AM, the surveyor spoke with Resident # 22 in the resident's room while the resident sat in a chair. The resident stated they smoked at the facility three times a day, at 9 am, 1 pm, and 7 pm. The resident said the cigarettes were locked up in the recreation department as well as the lighters. The resident said the staff supervised the smokers, distributed the cigarettes, and lit the cigarettes for the residents. On 9/8/22 at 12:51 PM, the surveyor reviewed the residents hybrid medical record which revealed the following: An admission Record with diagnoses which included, Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis, Hypokalemia, Major Depressive Disorder,…

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, interview, and record review, it was determined that the facility failed to perform post dialysis assessments for 1 of 1 residents reviewed for dialysis care and services, Resident # 127. The deficient practice was evidenced by the following: On 9/1/22 at 11:51 AM, the surveyor observed Resident # 127 laying in bed in the residents room. The resident didn't answer when spoken to. The resident was covered with a blanket. The Registered Nurse (RN) who was assigned to the resident confirmed that the resident went out for hemodialysis every Tuesday, Thursday, and Saturday. On 9/8/22 at 10:39 AM the surveyor reviewed the resident's record which revealed the following: An admission record with diagnoses that included Type 2 Diabetes, End Stage Renal Disease, Hypertensive Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis. A current Physician's Order Sheet (POS) with an order that read; Dialysis at [name redacted] every Tuesday, Thursday, and Saturday. The date of the order was 7/27/22.…

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, interview and review of medical records and other facility documentation, it was determined that the facility failed to a) accurately follow the facility documentation policy related to the inventory control wasting of opioids and benzodiazepam control substance classes of medications for 2 of 20 residents who were receiving controlled substance medications inspected on the 5th floor, Resident #61 and Resident #24, b) remove a discontinued control substance medication from stock, and c) keep an accurate physical inventory of back up narcotics stored in a CUBEX system (automated medication dispensing system). This deficient practice was evidenced by the following: a) On [DATE] at 11:59 AM, the surveyor conducted a unit inspection which included an inventory comparison of the Individual Patient Controlled Substance Administration Record (CSAR) and physical controlled substance inventory with the RN Nurse Manager(RNNM). When the RNNM presented the CSAR for Tramadol 50 mg belonging to Resident…

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

Based on observation, interview, and record review, it was determined the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's needs. This deficient practice was identified for 1 of 29 residents, Resident #87, reviewed for hospice/end-of-life care. The deficient practice was evidenced by the following: On 9/6/22 at 10:56 AM, the surveyor observed Resident #87 in bed sleeping. On 9/7/22 at 11:53 AM, the Licensed Practical Nurse (LPN) informed the surveyor that Resident #87 was on hospice care. The LPN further stated that the hospice nurse came to the facility once or twice a week. The surveyor reviewed the resident's medical records which revealed the following: A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with a diagnosis that included but was not limited to Unspecified Dementia without Behavioral Disturbance and Hypertension. A recent quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 6/17/22, revealed…

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.