Preakness Healthcare Center

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for 1 of 1 resident observed for tracheostomy care, (Resident #92), and was evidenced by the following: On 1/15/25 at 10:46 AM, the surveyor observed Resident #92 in a reclined lounge chair in their room. The resident had a tracheostomy (trach, a surgically made hole through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breathe), which was attached to a ventilation system (a breathing machine that helps or breathes for a person). The surveyor reviewed the medical record for Resident #92. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility and had diagnoses that included tracheostomy, anoxia (absence of oxygen), brain damage, and dependence on respirator (ventilator) status. A review of the quarterly Minimum Data Set…

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; a) complete the Hemodialysis Communication Record (HCR) to include a signature by the facility nurse that acknowledged review of the HCR for 14 of 14 days reviewed; b) document a complete assessment of vital signs and/or disposition of access site post dialysis treatment in the medical record; c) follow a recommendation for a change in medication; and d) had a diet order for 1 of 3 residents, Resident #169. This deficient practice was evidenced by the following: On 1/15/25 at 10:52 AM, the surveyor observed Resident #169 lying in bed, who stated that they were going to dialysis today and that they had a communication binder (binder for HCRs) that they took with to dialysis. A review of Resident #169's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dependence on renal dialysis (a state of chronic dependence on a machine and medical professionals to maintain life when the kidneys are…

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, record review, and review of pertinent facility documents, it was determined that due to a shortage of staff, the facility failed to a.) honor the resident's shower schedule for 1 of 5 residents, Resident #141 and b.) ensure residents were provided morning care in a timely manner for 2 of 5 residents, Residents #141 and #213 of Resident Council group. This deficient practice was evidenced by the following: On 1/17/25 at 11:01 AM, the surveyor conducted a resident group meeting with five residents who were alert and oriented and were selected by the facility to attend the group meeting. Resident#141 informed the surveyor that two weeks ago, not this past Monday (1/13/25), the resident did not get showered. Resident #141 did not mention the name of the Certified Nursing Aide (CNA) who told them that it was because of the shortage of staff which was why the resident did not get a shower. On that same date and time, Resident #141 informed the surveyor that there were concerns with short staff that affected the timeliness of care and caused the 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 interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 4 of 4 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on three Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. 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 and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, 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 observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 7 residents, Resident #43. The deficient practice was evidenced by the following: The surveyor reviewed Resident #43's medical record (MR) and revealed the following: A review of Resident #43's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute kidney failure, (when the kidneys are damaged and can't filter blood the way they should) and urinary tract infection. A review of Resident #43's Minimum Data Set (MDS), an assessment tool, dated 1/20/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #43 was cognitively intact. A review of the resident's list of medications (meds) reflected a Physician's order (PO) for Ondansetron 4 mg (milligram), 1 tablet (tab) orally every 6 hours as needed (PRN) 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.

Based on observation, interview, and record review, it was determined that the facility failed to properly a.) label, dispose and secure medications in 3 of 9 medication carts inspected and b.) store medication for 1 of 4 medication carts inspected according to facility's policy and standard of clinical practice. This deficient practice was evidenced by the following: 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 and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice…

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 Complaint # NJ00 181747 Based on interview, medical records (MR) review, and review of pertinent facility documents on 01/14/2025, it was determined that the facility failed to develop and implement a care plan (CP) focus to include behaviors for residents who were on psychoactive medications. The deficient practice was found in 2 of 4 residents, (Resident #1 and #2), reviewed for behavior monitoring and comprehensive care planning and was evidenced by the following: 1.According to the admission Face Sheet Record (AFSR), Resident #1 had diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypothyroidism, Essential Hypertension, and Hyperlipidemia. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 09/21/2024, under Section C showed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 08 indicating Resident's cognition was moderately…

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 #: NJ171754 Based on observation, interview, record review, and review of other facility documentation on 3/1/2024, it was determined that the facility failed to notify and obtain a physician's order to change the form of a medication from liquid to tablets. The Physician order for this medication could not be filled by the Pharmacy because this medication did not come in liquid form. The facility failed to follow its policy titled Prescribing and Ordering of Medications. The deficient practice was identified for 1 of 4 residents( Resident #2) reviewed for medication administration, and was evidenced by the following deficient practice: 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 and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative 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 Complaint #: NJ157711, NJ159758, NJ162870, NJ162871 Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse / neglect and/or the investigations were submitted to the New Jersey Department of Health (NJDOH) within the time limits of the policy and federal regulation for three of seven residents (Resident (R)18, R409, R458) with NJDOH reportable incidents. Findings include: 1. Review of R18's printed Face Sheet showed a facility admission date of 12/19/17, readmission on [DATE], with medical diagnoses (from a printed Diagnosis list) that included acute respiratory failure, multiple sclerosis, polyneuropathy, trigeminal neuralgia, and lower extremity embolism and thrombosis. On 09/06/23 at 4:29 PM, a review of a Facility Reported Event (FRE) showed an incident reported by R18 of a nursing assistant using a full body lift without an assist on 03/22/23, however, the report was not sent to the State Agency until 03/24/23. During an interview on 09/06/23 at 6:42 PM, 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, document review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were eight errors observed out of 29 opportunities, resulting in a 27.59% error rate. This had the potential to place one (Residents (R) 410) at risk of not receiving the full benefit of their medication therapy. Findings include: Observation on 09/08/23 at 12:18 PM, Registered Nurse (RN) 1 prepared medications for R410, which included vitamin B-12 extended release (ER) 1000 micrograms (mcg) one tablet, vitamin D-3 25 mcg one tablet, Depakote 125 milligrams (mg) one tablet, Eliquis 2.5 mg one tablet, Cozaar 25 mg one tablet, Memantine 10 mg one tablet, Oxybutynin 15 mg one tablet at 08:30 AM, and Pot Citrate 10 milliequivalent (mEq) one tablet. After RN1 obtained all the medications needed for R410, he administered the medications. During medication pass, RN1 said that these medications were R410's 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 observation, interview, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) for three of three residents (Resident (R) 18, R140, and R232) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 267 of 267 residents who reside at the facility. Findings include: 1. Review of R18's printed Face Sheet showed a facility admission date of 12/19/17, readmission on [DATE], with medical diagnoses (from a printed Diagnosis list) that included acute respiratory failure, multiple sclerosis, polyneuropathy, trigeminal neuralgia, and lower extremity embolism and thrombosis. During an interview on 09/04/23 at 12:04 PM, it was noted R18 had bilateral assist bars, or bed rails. When asked about them, R18 stated his wife and he had to fight to get them and thought his wife had to sign something. 2. Review of R140's printed Face Sheet showed a…

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

Based on record review and interview, the facility failed to ensure six of six Certified Nurse Aides (CNA), two of two Licensed Practical Nurses (LPN), and two of two Registered Nurse's (RN) reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated as admittable in the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present. Findings include: Review of the Facility Assessment, reviewed 01/09/23, showed: .Preakness Healthcare Center accepts residents with the following diseases/conditions, physical and cognitive disabilities or combinations of these conditions that require complex medical care and management. Under the category of Psychiatric/Mood Disorders stated: If not a danger to self or others: Psychosis, Impaired Cognition, Mental Disorder, Depression, Bipolar, Schizophrenia, PTSD, Anxiety, Behavior that Needs Interventions . Review of the facility completed Resident Census and Conditions of Residents form…

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 interviews, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 218) of 34 sampled residents were treated with respect and dignity by providing care in a manner to enhance R218's quality of life. Findings include: During an interview with R218 on 09/04/23 at 10:50 AM, she said that on the night shift back in the summer, she had to be changed because she had a bowel movement (BM) in her incontinent brief. R218 said that staff took 30 minutes to answer the call light. R218 said that this made her feel like shit. R218 said that she does not like to sit in her own urine and/or feces. She said that mainly on the 3-11 shift staff do not ask her if she is wet and/or do not offer to change her throughout the shift until 8:30 PM when the staff lay her down for the night. R218 said that this makes her feel not good. R218 said that she would like to be changed more often. Continued interview revealed R218 said this past Friday (09/01/23), an agency nurse worked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that tube feeding poles were maintained in a sanitary manner for three (Residents (R) 51, R160 and R203) of 34 sampled residents. Findings include: 1. Review of R51's facility provided Face Sheet revealed that R51 was admitted to the facility on [DATE] with a diagnosis including dysphagia, anoxic brain damage, and dysphagia. Review of facility provided Physician Orders for September 2023 revealed R51 was to receive Diabetisource AC 1000 milliliters (ML)/day via gastrostomy (g-tube) using at 75 ml/hour (hr), to start at 6:00 PM until total volume infused. During the initial tour of the facility on 09/05/23 between 10:30 AM-12:00 PM, revealed the tube feeding pole had an unknown cream-colored substance all over the pole. During an observation on 09/06/23 at 09:10 AM, 12:17 PM and 2:30 PM, R51's tube feeding pole had unknown cream-colored unknown substance all over the pole. During an observation on 09/08/23 at 1:00 PM, R51's tube…

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, review of Facility Reported Incidents (FRI), and policy review, the facility failed to ensure that a thorough investigation was conducted regarding staff-to-resident abuse allegations involving one (Resident (R) 409) of 34 sampled residents. There was no evidence that the facility interviewed other current residents regarding the allegations. Findings include: 1. During an interview with R218 on 09/04/23 at 10:50 AM, R218 said that she witnessed agency staff grab R409's arm to go to the bathroom. R218 said that she let staff know but does not know the staff's name. R218 said that it happened a couple of days ago on the night shift. Review of R409's facility provided Face Sheet revealed R409 was admitted to the facility on [DATE] with a diagnosis including dementia, anxiety, and depression. Review of R409's facility provided Progress Note dated 08/14/23 revealed New admission day one hard of hearing (HOH) with periods of confusion. Ambulatory via rollator with slow movements.…

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 interview, the facility failed to provide to the resident and/or their representative, a written notice of the reason for transfer for two (Residents (R) 191 and R98) of three residents transferred to the hospital and provided that notice to the Ombudsman. Findings include: 1.Review of R191's paper chart revealed an admission date of 12/30/22 with diagnoses including dementia, depression, and schizophrenia. R191 experienced a change in condition on 08/12/23 and was transferred to the hospital. The paper record lacked evidence the facility provided the resident and/or representative, in writing, of the reason R#191 was transferred to the hospital. The record also lacked evidence the Ombudsman was notified of R#191's transfer. 2. Review of R98's paper chart revealed an admission date of 03/09/23 with diagnoses including diabetes, respiratory failure, and dependence on a ventilator for respiratory support. R98 was transferred to the hospital for a change in condition on 04/05/23. 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 interview, the facility failed to provide to the resident and/or their representative, a bed hold policy to two (Residents (R) 191 and R98) of three residents transferred to the hospital. Findings include: 1.Review of R191's paper chart revealed an admission date of 12/30/22 with diagnoses including dementia, depression, and schizophrenia. R191 experienced a change in condition on 08/12/23 and was transferred to the hospital. The paper record lacked evidence the facility provided the facility's bed hold policy. 2. Review of R98's paper chart revealed an admission date of 03/09/23 with diagnoses including diabetes, respiratory failure, and dependence on a ventilator for respiratory support. R98 was transferred to the hospital for a change in condition on 04/05/23. The paper record lacked evidence the facility provided R98 and/or representative the bed hold policy. R98 was readmitted [DATE]. R98 was transferred to the hospital for a change in condition on 05/02/23. The paper 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 observation, interview, record review, and facility policy review, the facility failed to ensure that three of three residents (Resident (R) 18, R140, and R232) and/or Resident Representative (RR) reviewed for bed rail use had documented safety assessment for the use of bed rails and were advised of the risks and/or benefits of rail use. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use. Findings include: 1. Review of R18's printed Face Sheet showed a facility admission date of 12/19/17, readmission on [DATE], with medical diagnoses (from a printed Diagnosis list) that included acute respiratory failure, multiple sclerosis, polyneuropathy, trigeminal neuralgia, and lower extremity embolism and thrombosis. During an interview on 09/04/23 at 12:04 PM, it was noted R18 had bilateral assist bars, or bed rails. When asked about them, R18 stated his wife and he had to fight to get them and thought his wife had 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.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were administered in a manner that prevented cross-contamination for one (Resident (R) 410) of 34 sampled residents. Findings include: During an observation on 09/08/23 at 12:18 PM, Registered Nurse (RN) 1, without performing hand hygiene, prepared medications for R410, which included vitamin B-12 extended release (ER) 1000 micrograms (mcg) one tablet, vitamin D-3 25 mcg one tablet, Depakote 125 milligrams (mg) one tablet, Eliquis 2.5 mg one tablet, Cozaar 25 mg one tablet, Memantine 10 mg one tablet, Oxybutynin 15 mg one tablet at 08:30 AM, and Pot Citrate 10 milliequivalent (mEq) one tablet. After RN1 obtained all the medications needed for R410, he administered the medications. R410 did not swallow Pot Citrate, vitamin B-12 ER and vitamin D-3 pills. At 12:30 PM, RN1 placed on a pair of gloves, and had R410 spit the medications in his gloved left hand, while cleaning R410's mouth with a 4x4 gauze square with his gloved right-hand. Then he threw the gauze square into the trash,…

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 assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders and resident's lab results. This deficient practice continued over numerous months for 2 of 35 residents reviewed, Resident #54 and #153 residing on two different facility units. The deficient practice was evidenced by the following: 1. On 7/7/21 at 10:47 AM, the surveyor observed Resident #54 seated in a wheelchair with eyes closed. The surveyor approached the resident for an interview, but the resident was not alert or oriented. The surveyor was unable to interview Resident #54. The surveyor reviewed the admission Record Face sheet (one-page summary of important information about a resident) for Resident # 54. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were not limited to Multiple Sclerosis, Hypertension, Anxiety, Depression,…

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 in person physician visits were conducted in and documented at required intervals. This deficient practice was identified for 2 of 35 residents, Resident #54, #153 reviewed. The deficient practice was evidenced by the following: 1. On 7/7/21 at 10:47 AM, the surveyor observed Resident #54 seated in a wheelchair with eyes closed. The surveyor approached the resident for an interview, but the resident was not alert or oriented. The surveyor was unable to interview Resident #54. The surveyor reviewed the admission Record Face sheet (one-page summary of important information about a resident) for Resident # 54. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were not limited to Multiple Sclerosis, Hypertension, Anxiety, Depression, Dysphagia, Peg (feeding tube) Placement, Mood Disorders, and Hyponatremia. A review of the Minimum Data Set (MDS), 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 observation, interview, record review and review of facility documents, it was determined that the facility failed to: a.) utilize disposable dining ware for a resident on Transmission Based Precautions (TBP) in accordance with facility policy; and, b.) practice appropriate use of personal protective equipment (PPE) in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This was identified for 1 of 2 residents reviewed for TBP (Resident #12). This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2: Personal Protective Equipment-HCP who enter the room of a patient with suspected or confirmed…

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.