White Pine Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 13) reviewed for range of motion (ROM) and nutrition, had the care plans revised, and one resident (R5) reviewed for falls, had the care plan revised out of 17 sampled residents. The deficient practices placed the residents at risk for not receiving the care based upon their needs. Findings include: Review of the Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised October 2023, revealed Chapter 4: Care Area Assessment (CAA) Process and Care Planning, 4.1 Background and Rationale .Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect 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, record review, and facility policy review, the facility failed to assist with a communication deficit for one of one resident (Resident (R) 10), reviewed for communication out of 17 sampled residents. Findings include: The facility's policy titled, Activities of Daily Living [ADL], Supporting, revised 03/03/24 revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .e. communication (speech, language, and any functional communication systems). Resident 10 (R10) R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24, revealed R10 had an admission date of 01/23/24. R10 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R10 had moderately impaired cognition, and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, stroke, and aphasia. R10's Personal…

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, record review, and facility policy review, the facility failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being for 1 of 17 sampled residents (Resident (R) 13). This failure had the potential to negatively impact R13's quality of life. Findings include: Review of facility's policy titled, Activity Evaluation, revised 03/03/24, revealed Policy Interpretation and Implementation .The activity evaluation is used to develop individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest .Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs .Through the interdisciplinary process, the activity evaluation and activities care plan identify if a resident is capable of pursuing activities independently, or if supervision and assistance are needed…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment to maintain or prevent further decrease in range of motion for 1 of 2 residents (Resident (R) 10) reviewed for range of motion out of 17 sampled residents. The deficient practice placed the resident at risk for developing decreased motion or contractures. Findings include: Facility policy titled, Restorative Nursing Services, revised 03/03/24 revealed, 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care . 5. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence 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 interview, record review, and facility policy review, the facility failed to ensure an investigation was performed and a root cause analysis was established for 1 of 1 residents (Resident (R) 5) reviewed for falls out of 17 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings include: Facility's policy titled, Fall Evaluation and Management, dated 03/03/24 revealed, .Post-Fall Documentation .After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse .Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified and resident's condition .The nurse completes orthostatic vital signs as able .The LN [licensed nurse] evaluated neuro checks for 72 hours for all falls unwitnessed by staff or falls that involve the resident's head striking a surface .The nurse completes a blood glucose reading at the time…

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, interview, record review, and facility policy review, the facility failed to provide interventions and meal assistance to address significant weight loss for one resident (Resident (R) 13) and ensure consistent weighing methods for one resident (R16) of the eight residents reviewed for nutritional status out of 17 sampled residents. This deficient practice placed the residents at risk for new or continued weight loss potentially impacting the resident's quality of life. Findings include: Facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss Clinical Protocol, revised 03/03/24, revealed: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. a. Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident patient wishes, overall condition and prognosis, etc.), and should not be based solely on lab [laboratory] or diagnostic test results…

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 review of facility policy, the facility failed to provide appropriate person-centered and individualized treatment and services for one of two residents (Resident (R) 19) reviewed for behavioral healthcare needs of 17 sampled residents. This failure placed the resident at risk for increased distress and a diminished quality of life. Findings include: A facility policy titled, Behavior Management, dated 03/03/24, revealed, .If a resident exhibits a new behavior symptom, staff implements the Behavior Monitor Flowsheet and notified the Social Services Director (SSD) and the IDT [interdisciplinary team] via the 24-Hour report .If the resident has an order for psychotropic medications or medications used for psychiatric diagnosis, the side effects are monitored and documented as indicated. The resident's record is reviewed for evidence of signs or symptoms of side effects related to psychotropic medication as part of the IDT review process . A facility policy titled, Suicide…

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 and record review, the facility failed to ensure the licensed consultant pharmacist performed a monthly medication regimen review for December 2023, for two of five residents (Residents (R) 16 and R18) reviewed for unnecessary medications of 17 sampled residents. This failure placed the residents at risk of the physician and nursing staff not being aware of irregularities. Findings include: Resident 18 (R18) An admission Record, provided by the Director of Nursing (DON), revealed R18 was admitted to the facility on [DATE] with diagnoses including alcohol induced dementia with violent behaviors and diabetes. R18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23, revealed R18 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R18 was severely impaired in cognition and was administered antipsychotic and antidepressant medications daily during the observation period. Review of the Medication Regimen Review book, provided by the DON,…

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 review of the facility policy, the facility failed to ensure that indications and signs and symptoms for use of antibiotic medications were documented for 1 of 17 sampled residents (Resident (R) 2) resulting in the potential for adverse side effects from unnecessary medications. Findings include: Facility's policy titled, Urinary Tract Infection/Bacterial Protocol, dated 03/03/24, documented, .Empirical treatment should be based on a documented description of an individual's symptom and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors .Bacteriuria alone (an asymptomatic UTI) should not be treated routinely . and .decisions should be made primarily on the basis of clinical signs and symptoms . Resident 2 (R2) R2's undated admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, chronic respiratory failure, and hypertension. R2's…

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 Resident 2 (R2) R2's admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, chronic respiratory failure, and hypertension. R2's quarterly MDS revealed R2 had a BIMS score of 15 out of 15 which indicated R2 was cognitively intact. A Progress Note dated 02/28/24, revealed R2 went to the Emergency Department (ED) on 02/28/24 for acute kidney failure, based on elevated blood work. Upon return to the facility R2 had an indwelling urinary catheter and had been diagnosed with a urinary tract infection (UTI), and started on an antibiotic. R2's EMR revealed no order for the urinary catheter. On 04/16/24 at 3:00 PM, R2 stated had the catheter for a while, but was unable to state when it was put in. On 04/18/24 at 1:30 PM, the DON stated was unable to find a physician's order for the urinary catheter and the DON was unable to state when the urinary catheter was inserted, or rationale for it. On 04/18/24 at 3:00 PM, the DON acknowledged 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 observation, interview, record review, and review of facility policy, the facility failed to ensure hand hygiene and glove changes were performed for one of one resident (Resident (R) 3) reviewed for pressure ulcers of 17 sampled residents. This failure placed the resident at risk of infection. Findings include: Facility policy titled, Handwashing, Hand Hygiene, dated 03/03/24, revealed .Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before donning sterile gloves .Before handling clean or soiled dressings, gauze pads, etc.After handling used dressings, contaminated equipment . Resident 3 (R3)'s R3's admission Record, provided by the Director of Nursing (DON), revealed R3 was admitted to the facility on [DATE] with diagnoses which included a stroke, peripheral vascular disease, and chronic kidney disease. R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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 record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 hours within a 24-hour period on 10/29/22, 11/05/22, and 11/12/22. The facility census was 30. Findings include: Review of the daily staffing form titled, White Care Pine Center, revealed on 10/29/22, 11/05/22, and 11/12/22 there was not a registered nurse scheduled to work. Review of the payroll White Pines Care Center - Time > Timesheets, dated 10/29/22, 11/05/22, and 11/12/22 revealed no RN working on those dates. Interview with the DON on 03/09/23 at 2:47 PM confirmed that the above dates had no RN working.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of R232's face sheet revealed an admission date of 03/03/23. Review of R232's Diagnosis list revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). Review of R32's Care Plan revealed no care plan for the use of supplemental oxygen. R32's Physician's Orders revealed no orders for the supplemental oxygen to include the rate and how often oxygen was to be used by R232. Review of the baseline care plan dated 03/03/23 for R232 indicated b. Physician orders/medications: (include catheter or any DME equipment) see Medication Administration Record/ Treatment Administration Record (MAR/TAR). Review of the MAR/TAR revealed no orders for the rate of oxygen needed for R232. On 03/09/23 at 2:59 PM, the DON confirmed the baseline care plan was not completed by staff to include R232's oxygen. Based on record review, interview, and policy review, the facility failed to ensure a baseline care plan was provided for three of 18 sampled residents (Resident (R) 4, R29, and R232). Specifically, 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 3. Review of R26's electronic medical records (EMR) revealed the resident was admitted with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia. Review of the MDS with an ARD of 02/10/23 revealed a BIMS score of 14 out of 15 indicating R26's cognition was intact. The MDS indicated the resident was receiving oxygen therapy. Review of the resident's Physician Orders revealed R26 was on continuous oxygen (O2) at two liters (l) per nasal cannula (NC). The resident was also to have oxygen saturation (SPO2) (measurement of how much oxygen level in the blood) every shift. A review of the Vitals summary record located in the Weights/Vitals tab revealed from August 2022 to March 2023 the facility failed to obtain the SPO2 readings according to the physician's orders, 39 times. An interview with LPN2 on 03/07/23 at 10:01 AM revealed the resident had received oxygen therapy since the COVID outbreak in March 2022 when the resident had…

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, interview, record review, and review of facility policy, the facility failed to ensure: 1. the correct standard and transmission-based precautions were implemented and followed to prevent spread of infections for one of one resident (Resident (R)232) on isolation precautions, and 2. staff perform proper hand hygiene during meal service for three residents (R11, R18, and R24). The facility failure to adhere to correct isolation procedure and perform proper hand hygiene has the potential to result in the spread of infectious diseases throughout the facility. Findings include: 1. Observation on 03/07/23 at 12:00 PM during meal service on 300 hall revealed R232's room had an isolation cart outside the door. The cart contained yellow isolations gowns, gloves, and head coverings, however there was no signage posted as to the type of isolation. The Health Aide (HA) was observed to use hand sanitizer then donned isolation gown, and head covering. The HA then walked down to the nurses' station…

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 review of facility policy, the facility failed to develop an effective antibiotic stewardship program which includes the Infection Control Preventionist, Pharmacy Consultant, and Medical Director. Findings include: Review of the facility document titled Antibiotic Stewardship, with an effective date of 09/20/19, revealed the policy documented: It is the policy of [NAME] Pine Care Center to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. a. An ASP Team will be established to be accountable for stewardship activities. The ASP Team may consist of: ASP Physician Champion and/or Medical Director, Administrator,…

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 provide the Centers for Medicare and Medicaid Services (CMS) form 10055 to inform the responsible party for one of three residents (Resident(R) 31) reviewed for beneficiary notices out of a total sample of 15 residents that services were no longer covered by Medicare Findings include: Review of the electronic medical record (EMR) admission Record revealed R31 was admitted into the facility on [DATE]. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/22 revealed a Brief Interview for Mental Status (BIMS) of four out of 15, indicating R31 was severely impaired cognitively. R31 was presented a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form to sign and not the resident's responsible party, with the last covered day of Part A services was 02/25/22. There were no options checked on the form indicating which option would be selected for pay or appealing benefits.…

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 document review, the facility failed to ensure it thoroughly investigated an allegation of neglect and failed to ensure it reported its final findings to the state agency for 1 of 11 residents (Resident #6). Findings include: Resident #6 was admitted on [DATE] with atherosclerotic heart disease, hypertension, and diabetes mellitus type II. Resident #6 was readmitted on [DATE] with metabolic encephalopathy, dehydration, and acute kidney failure. On [DATE], Resident #6 was discovered deceased in bed without ordered oxygen tubing/cannula, which was on the floor. On [DATE], the Administrator initiated an investigation for resident neglect, suspended the assigned certified nurse assistant and self-reported the event to the state agency the same day. On [DATE], the Administrator terminated the certified nurse assistant for failure to provide adequate care by not ensuring 2 hour rounding was completed appropriately, and leaving resident without oxygen on as ordered. There was no…

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, interview, and policy review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment for dentition was accurately coded for one of 18 sampled residents (Resident (R) 4). The facility's failure to accurately assess relevant care areas about the resident's status, needs, strengths, and areas of decline had the potential to not plan for and provide necessary care. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered documented, revised 03/09/23 revealed, .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 2l days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Review of R4's face sheet revealed R4 was admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observation, and policy review, the facility failed to develop a comprehensive care plan for use of anticoagulant and antidepressant medications for one of six sampled residents (Resident (R) 17) reviewed for unnecessary medication and failed to implement interventions for two of five sampled residents (R4 and R29) reviewed for nutrition in a total sample of 18 residents. The facility's failure to develop comprehensive care plan to address the resident's medications and failure to implement interventions for nutrition had the potential to result in necessary care not being provided. Findings include: Review of the facility policy, dated 07/01/18, titled Baseline Care Plan and Comprehensive Assessment documented, .The comprehensive care plan will be completed when the Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) are completed by all disciplines .The plan of care must be based on the resident's comprehensive assessment and must be completed within seven (7)…

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, the facility failed to revise the care plan to include physician orders to receive oxygenation saturation (SPO2) (measurement of how much oxygen is in the blood) readings every shift for one resident (Resident (R) 26) out of a sample of 15 residents. Findings include: Observation on 03/06/23 at 12:23 PM revealed R26 in the resident's room sleeping in the wheelchair wearing nasal oxygen (O2) cannula. Review of the resident's electronic medical records (EMR) revealed R26 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Review of R26's five-day Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 02/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R26 had intact cognition. Review of the MDS indicated the resident was receiving oxygen therapy. Review of the Physician Orders dated 03/09/23, revealed an order 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 interview and record review, the facility failed to ensure a written discharge summary form was completed for one of two residents (Resident (R) 30) reviewed for discharge planning out of a total sample of 15 residents. Findings include: Review of R30's face sheet revealed an admission date of 11/21/22 and discharge date of 01/04/23 for R30. Review of the resident's Care Plan revealed no discharge planning. Review of the EMR revealed no recapitulation summary. Interview on 03/08/23 at 4:05 PM, the Social Service Director (SSD) stated was unaware of what a recapitulation summary was and had not completed one. The SSD stated completes a form that includes where the resident is being discharged to and the medications provided to the resident. Interview on 03/08/23 at 4:11 PM with the SSD and Licensed Practical Nurse (LPN) 2, both stated when a resident is discharged home the pharmacist will supply a 30-day supply of medications and if the medications are a narcotic, the facility staff will get the resident or responsible party (RP) to sign with two staff members and a copy 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, interview and document review, the facility failed to ensure 1 of 11 residents (Resident #6) received cardiopulmonary resuscitation (CPR) and activation of emergency medical services when needed. Findings include: Resident #6 was admitted on [DATE] with atherosclerotic heart disease, hypertension, and diabetes mellitus type II. Resident #6 was readmitted on [DATE] with metabolic encephalopathy, dehydration, and acute kidney failure. On [DATE] at 6:15 AM, Resident #6 was discovered deceased in bed without ordered oxygen tubing/cannula, which was on the floor. There was no documented evidence or interview evidence an employee witnessed the resident's last breath or how long the resident had been without oxygen. On [DATE] at 6:15 AM, the Medical Director was informed the resident had no pulses and had cold skin. On [DATE] at 8:00 AM, the Medical Director confirmed the resident as obviously deceased with rigor mortis, documenting 6:15 AM as the time of death. On [DATE] in the afternoon, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure monitoring for an anticoagulant medication (medication that can cause increased risk for bleeding) was conducted for one of six sampled residents (Resident (R) 17) reviewed for unnecessary medication in a total sample of six residents. This failure had the potential to negatively impact the residents' quality of life. Findings include: Review of R17's face sheet revealed R17 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (irregular heartbeat that causes the heart to beat rapidly). Review of the Physician Order dated 09/12/22, revealed an order for Eliquis (anticoagulant medication) 5 milligram (mg), two times a day for atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R17 was moderately cognitively impaired and received an anticoagulant in the last…

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 ensure monitoring for an antidepressant medication was conducted for one (Resident (R) 17) and failed to have a stop date for a psychotropic PRN (as needed) medication for one resident (Resident (R) 31) out of six sampled residents reviewed for unnecessary medications out of a total sample of 15 residents. Findings include: Review of facility's policy titled Psychotropic Medications, 07/22 and provided by the Administrator, revealed .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior Drugs .considered .psychotropic .Anti-anxiety medications Psychotropic medication management duration .PRN [as needed] orders for psychotropic medications are limited for 14 days . Residents receiving psychotropic medications are monitored for adverse consequences, including: a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to hold the administration of Clonidine (a medication used to lower blood pressure) prescribed by the physician to treat dementia related behaviors in light of low blood pressures and falls in one resident (Resident (R) 31) out of a total of 15 sampled residents. This failure increased the risk of R31 to have additional low blood pressure readings and increased falls. Findings include: Review of the facility's policy titled Medication Therapy, dated 04/07 and provided by the Administrator, revealed .Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risk .All medication orders will be supported by appropriate care processes and practices . Review of the facility's policy titled Adverse Consequences and Medication Errors, dated 04/14 and provided by the Administrator, revealed . The interdisciplinary team evaluates medication usage in order 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.