Kingston of Ashland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, staff interview, and record review the facility facility failed to transcribe and implement physician ordered laboratory testing for Resident #90. This affected one (Resident #90) of three residents reviewed for laboratory services. The facility census was 88. Findings include: Closed medical record review for Resident #90 revealed an admission date of 09/08/23. Diagnoses included osteomyelitis (bone infection) of the right foot and ankle status post surgical debridement and malnutrition. Resident #90 was transferred to the hospital on [DATE]. Review of Resident #90's physician orders, dated 09/08/23, revealed an order for Vancomycin (antibiotic) one gram daily intravenously and Zosyn (antibiotic) 3.375 grams three times daily intravenously to treat osteomyelitis. Review of Resident #90's hand-written physician's orders, dated 09/11/23, revealed laboratory testing to include a complete blood count (CBC), a basic metabolic panel (BMP), a C-Reactive Protein (CRP) level, and a Vancomycin…

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, medical record review, resident interview, family interview and staff interviews, the facility failed to ensure a resident was provided with assistance of removing facial hair. This affected one (#64) of three residents reviewed for assistance with activities of daily living. The facility census was 93. Findings include: Review of Resident #64's medical record revealed an admission on [DATE], with medical diagnoses including: chronic lymphedema, Alzheimer's disease, history of Covid-19 virus and benign prostatic hypertrophy (BPH) with indwelling urinary catheter. The most recent facility quarterly minimum data set assessment (MDS) dated [DATE] identified the resident had moderately impaired cognition. The assessment identified Resident #64 required one-person physical assistance with Activities of Daily Living (ADL's). Review of a physician order dated 09/09/23 revealed an order for Resident not to shave himself. Observation on 09/25/23 at 8:02 A.M., revealed Resident #64 was in bed 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 medical record reviews, urinary drainage bag instructions, policy review, resident interview, family interview and staff interviews, the facility failed to obtain a urine specimen from urinary catheter and failed to ensure staff was knowledgeable of the procedure. This affected one (#55) of three residents reviewed with urinary catheters. The facility identified nine current residents utilizing urinary catheters. The facility census was 93. Findings include: 1. Review of Resident #55's medical record identified admission to the facility occurred on 10/07/22, with diagnoses including: stroke, diabetes, and congestive heart failure. Resident #55 was noted in the medical record to have an indwelling urinary catheter. The progress notes identified on 09/22/23 a urine sample was obtained to check for infection. According to the records identified on 09/24/23, the laboratory identified the sample was contaminated and a new sample needed to be recollected. Review of a physician order dated 09/24/23, revealed to recollect Urine for Urinalysis, culture and sensitivity (UA C&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.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 76 residents who received food from the kitchen. The facility identified three (#17, #21 and #284) residents who received nothing by mouth. The facility census was 79. Findings include: Observation during the initial tour of the kitchen on 05/15/23 from 8:02 A.M. through 8:15 A.M. revealed the ceiling and wall were peeling in the dry storage area, the exhaust fan above the dish machine had grease and dust covered on the louvers on the exhaust fan, and the tabletop mixer had dried food on the top where the attachments are inserted and on the bowl holder. Observation in the walk-in refrigerator revealed precooked French toast outside of its original container and sausage patties with no label or date on it. Observation of the reach-in refrigerator revealed standing water inside the refrigerator and there was dried food on the interior walls. Interview with Dietary Manager #298 verified the findings at time 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 observation, medical records review, resident and staff interview, and facility policy review, the facility failed to ensure residents were not administered antibiotics without an appropriate indication for use or a stop date per facility policy. This affected three (#17, #18 and #31) of seven sampled residents reviewed for antibiotic use. The facility identified 16 residents were currently receiving antibiotics. The facility census was 79. Findings include: 1. Review of Resident #18's medical record revealed an admission date to the facility occurred on 06/15/22 with medical diagnoses including chronic kidney disease, urinary tract infection, anxiety, and chronic respiratory failure. Further review of the medical record revealed Resident #18 was in the hospital from [DATE] through 04/19/23 with urosepsis related to an indwelling Foley catheter. The hospital discharge orders included removal of the urinary catheter. Review of the physician orders for Resident #18 revealed an order written by Certified…

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 review of resident personal needs accounts (PNA), staff interview, and review of a facility policy, the facility failed to notify residents or resident representatives when resident accounts reached $200 less than the Social Security Income (SSI) resource limit. This affected two (#2 and #12) of five resident PNAs reviewed. The facility census was 79. Findings include: 1. Review of Resident #2's PNA account identified the current balance as of 05/17/23 was $3,911.31. The PNA account included monies from the CARES Act of $2,245.09 that was received on 04/09/21. The PNA account records identified no notifications of the need to spend down following 12 months from the receipt of the CARES Act stimulus check. 2. Review of Resident #12's PNA account identified the current balance as of 05/17/23 was $2,792.41. The PNA account included monies from the CARES Act of $1,617.24 that was received on 04/09/21. The PNA account records identified no notifications of the need to spend down following 12 months from the receipt of the cares act stimulus check. Interview with the Activities…

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 medical record review and staff interview, the facility failed to ensure the appropriate documentation was contained in the medical record for residents who were discharged . This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of Resident #281's five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed the resident was cognitively intact and required extensive assistance of one staff for a majority of the activities of daily living. The resident received oxygen, dialysis, and intravenous medications. Review of Resident #281's respiratory progress notes dated 04/27/23 and timed…

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 medical record review, staff interview, and policy review, the facility failed to ensure residents and resident resident representatives received notice of transfer as soon as practicable upon discharge to the hospital. This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of the census records for Resident #281 revealed the resident was transferred to a local hospital on [DATE] and then discharged . Review of both the electronic and paper charts revealed no evidence Resident #281 or the resident representative was provided with a notice of transfer or discharge. A discharge notice was issued when lack 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 medical record review, staff interview, and facility policy review, the facility failed to provide a resident with the option to hold a bed at the facility following a transfer and failed to ensure an accurate amount of bed hold days were conveyed to a resident. This affected two (#10 and #281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: 1. Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of the census records for Resident #281 revealed the resident was transferred to a local hospital on [DATE] and then discharged . Review of both the electronic and hard charts revealed no evidence Resident #281 or their representative was given a bed hold notice for their discharge…

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 medical record review, staff interview, and facility policy review, the facility failed to allow a resident to return to the facility following hospitalization. This affected one (#281) of five residents reviewed for hospitalization. The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admission date of 04/20/23. The resident was discharged from the facility while in the hospital on [DATE]. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of Resident #281's five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed the resident was cognitively intact and required extensive assistance of one staff for a majority of the activities of daily living. The resident received oxygen, dialysis, and intravenous medications. Review of Resident #281's respiratory progress notes dated 04/27/23 and timed 8:25 A.M.…

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 medical record review, observation, staff and resident interview and policy review, the facility failed to accommodate resident's need by ensuring resident call lights were within reach. This affected four (#68, #40, #55, #67) of 24 sampled residents. The facility census was 99. Findings include: 1. Medical record review revealed Resident #68 had an admission date of 08/28/15. Diagnoses included multiple sclerosis, dementia, anxiety, depressive disorder and Alzheimer's disease. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on two staff for transfers and dependent on one staff for locomotion. Observation on 02/24/20 at 3:08 P.M. revealed Resident #68 was in her bed calling out for help. The resident's call light was on a chair in her room not within the resident's reach. Interview on 02/24/20 at 3:08 P.M., State Tested Nursing Assistant (STNA) #140 verified the resident's call light was not within…

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 medical record review, staff interview and policy review, the facility failed to clarify and accurately reflect a resident's advanced directive choices throughout the medical record. This affected one (#38) of one resident reviewed for advanced directives. The facility census was 99. Findings include: Medical record review revealed Resident #38 had an admission date of 09/12/19. Diagnoses included interstitial pulmonary disease, atrioventricular block, dysphagia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of a physician order dated 09/13/19 revealed a Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest)- indicating comfort care protocol would be implemented in the event of a cardiac arrest or a respiratory arrest status. Review of a DNR identification form, signed by the resident's representative and nurse practitioner on 09/16/19, revealed the resident had elected a DNR Comfort Care (DNRCC) Protocol.…

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 medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure a wound treatment was dated, timed and initialed in accordance with the facility policy. This affected for one (#26) reviewed for skin conditions. The facility census was 99. Findings include: Medical record review for Resident #26 revealed admission date 04/05/19. Diagnoses included end stage renal disease, depended on renal dialysis, hypothyroidism, and type II diabetes mellitus with hyperglycemia. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] limited assist of one person for bed mobility, transfers, and set up only for locomotion. Review of the physician orders dated 02/22/20 revealed cleanse wound to right lower anterior leg with normal saline, pat dry, apply silver alginate and cover with Allevyn at bed time. Observation on 02/24/20 at 3:50 P.M., of Resident #26 sitting at bed side in wheelchair has a right lower anterior bandage to leg. The bandage is not dated,…

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

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to follow a physician order for placement/function of a wanderguard. This affected one (#55) of one reviewed for wanderguard placement and function. The facility census was 99. Findings include: Review of the medical record for Resident #55 revealed an admission date of 05/21/19. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/24/20, revealed the resident had impaired cognition. The resident required extensive assist of one for bed mobility, transfer, ambulation and identifies motion sensor alarm used daily. Review of the physician orders dated 07/22/19 revealed wanderguard on left ankle-check placement and function every shift. Further review of the medication administration and treatment administration record (MAR/TAR) revealed an order for Resident #55 to wear a wanderguard on the left ankle-check placement and function every shift. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to attempt a gradual dose reduction (GDR) for a resident on an antipsychotic medication. This affected one (#29) of five residents reviewed for unnecessary medications. The facility identified 14 residents receiving antipsychotic medications. The facility census was 99. Findings include: Medical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, anxiety, hallucinations, and delusional disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a physician order dated 11/15/18 revealed Resident #29 was ordered Olanzapine 2.5 milligrams (mg) by mouth in the morning for dementia with behaviors including delusions. Review of a psychiatric progress note dated 05/14/19 revealed a trail discontinuation of the Olanzapine would be considered on the next visit. Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and policy review, the facility failed to ensure a urinary catheter drainage bag was properly maintained in a sanitary manner. This affected one (#68) of two residents reviewed for urinary catheters. Additionally, the facility failed to ensure staff wore personal protective equipment while caring for a resident on reverse isolation. This affected one (#67) of one resident reviewed for transmission-based precautions. The facility census was 99. Findings include: 1. Medical record review revealed Resident #68 had an admission date of 08/28/15. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, dementia and Alzheimer's disease. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Further review of the assessment revealed the resident had an indwelling catheter. Observation on 02/24/20 at 2:19 P.M. revealed the resident's urinary drainage bag was lying…

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, policy review and staff interviews, the facility failed to ensure all drugs were maintained in locked compartments to ensure unauthorized access. The facility identified seven Residents (#8, #18, #55, #66, #83, #151 and #156), whom resided in close proximity to the unsecured medication and that could potentially be affected. Facility census was 98. Findings include: Observation of the 200/500 medication cart on 12/10/18 started at 11:56 A.M., located outside of the nursing station. The medication cart was noted with a bottle of Dakin's solution; (dilute solution of sodium hydrochloride (corrosive properties/poisonous), used to clean wounds. The medication cart and bottle of medication was noted to be unattended. Continued observation identified Licensed Practical Nurse (LPN) #700 returned to the medication cart on 12/10/18 at 12:06 P.M., obtained medications from the cart and again left the bottle of Dakin's on the top of the cart unsecured. LPN #700 returned to the cart at 12:10 P.M. and removed medications, left the cart and the bottle of Dakin's solution,…

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 medical record review, observation, staff interview and review of facility policy, the facility failed to ensure bed pans, and bath basins were properly stored in resident rooms. Additionally, the facility failed to ensure proper placement of a urinary catheter collection bag. This affected nine (#3, #16, #45, #80, #82, #95, #248, #348 and #349) of 32 sampled resident rooms. The facility census was 98. Findings include 1. Observation on 12/12/18 at 1:24 P.M. revealed an uncovered urinal and graduate on the back of the toilet in the room of Resident #45. Interview on 12/12/18 at 1:24 P.M. with State Tested Nursing Assistant (STNA) #102 revealed the urinal and graduate were left uncovered on the back of the toilet. Observation on 12/12/18 at 1:30 P.M. revealed an uncovered bedpan on the back of the toilet in the room of Resident #82. Interview on 12/12/18 at 1:30 P.M. with STNA #102 revealed the bedpan should be stored in a bag. Observation on 12/12/18 at 1:32 P.M. revealed an uncovered bath basin 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 medical record review, staff interview and policy review, the facility failed to clarify and accurately reflect a resident's advanced directives choices throughout the medical record. This affected one (#82) of 32 residents reviewed for advanced directives. The facility census was 98. Findings include Medical record review revealed Resident #82 had an admission date of [DATE]. Diagnoses included a displaced fracture of the left femur, cardiac arrhythmia, hypertension, and type two diabetes mellitus. Review of Resident #82's medical chart revealed a signed do not resuscitate (DNR) identification form had been signed by the resident and a nurse practitioner on [DATE]. Review of a physician order dated [DATE] revealed Resident #82's advance directives included full code status indicating cardiopulmonary resuscitation (CPR) would be performed when required. Review of electronic and paper monthly physician orders dated 12/2018 revealed Resident #82's advance directives included full code status indicating…

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, medical record review, review of a seat belt manufactures instructions and staff interviews, the facility failed to ensure an alarming seat belt was correctly applied to one (#83) out of 32 sampled residents. The facility identified no residents who use restraints. Facility census was 98. Findings include: Review of Resident #83's medical record revealed the resident was admitted to the facility on 0 2/06/18 with medical diagnosis including dementia. The record identified Resident #83 was high risk for falling and the facility implemented a alarming seatbelt for Resident #83, to alert staff in the event of an unassisted attempt to rise from the chair. The record identified the alarming belt was implemented on 02/22/18 and was to be evaluated monthly by staff to ensure Resident #83 was able to release the belt. The record identified on 11/10/18 Resident #83 had a fall in which the wheelchair was tipped over sideways. The record identified Occupational Therapist (OT) #1, implemented a lowered seat at the time to attempt to prevent further issues. Observation 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 medical record review, staff interview and policy review, the facility failed to update a resident's advanced directives choices in the plan of care. This affected one (#82) out of 32 residents reviewed for care plans. The facility census was 98. Findings include Medical record review revealed Resident #82 had an admission date of [DATE]. Diagnoses included a displaced fracture of the left femur, cardiac arrhythmia, hypertension, and type two diabetes mellitus. Review of Resident #82's medical chart revealed a signed do not resuscitate (DNR) identification form had been signed by the resident and a nurse practitioner on [DATE]. Review of plan of care initiated on [DATE] and last revised on [DATE] revealed Resident #82's advance directives included full code status indicating CPR would be performed when required. Interview on [DATE] at 8:49 A.M. with the Director of Nursing (DON) verified Resident #82's full code status had not been updated to a DNR code status in the electronic health record or in the…

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

Based on medical record review, policy review and staff interviews, the facility failed to ensure a physician was immediately notified of a critical laboratory result. This affected one (#32) out of five residents reviewed for medications. Facility census was 98. Findings include: Review of Resident #32's medical record identified admission to the facility occurred on 1/11/17 with medical diagnosis including Congestive heart failure (CHF), Alzheimer's disease, atrial fibrillation and long term use of anticoagulants. The medical record identified Resident #32 was receiving anticoagulant Eliquis until 11/05/18, when Resident #32's family elected hospice services, for end of life care. The medication administration record (MAR) dated 10/05/18 confirmed Resident #32 started receiving Coumadin (anticoagulant) medication with Eliquis being discontinued. The MAR further identified Resident #32 was additionally ordered an antibiotic medication starting 10/05/18. These medications when given concurrently can cause significant increase in toxicity. Review of hospice physician notes dated…

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

Based on review of the pneumococcal immunizations tracking records, review of medical/vaccine records, policy review and staff interviews, the facility failed to ensure policies and procedures were developed and residents were able to chose the newest form of pneumonia vaccine available. This affected two (#20 and #151) out of five residents reviewed for vaccines. The facility identified 50 residents who received the pneumococcal vaccine. Facility census was 98. Findings include: Review of the facilities tracking of all residents vaccines (influenza and pneumococcal vaccines) was conducted with infection control coordinator Registered Nurse (RN) #500,on 12/12/18 at 1:25 P.M. The review/interview confirmed the facility had not administered or offered the new pneumonia vaccine (PPSV-23), which protects against 23 strands of pneumonia to any residents. The interview confirmed at this time the facility only offers and administers PCV-13. Review of Resident #20's medical/vaccine records identified admission to the facility occurred on 08/25/16 with evidence of pneumococcal vaccine being…

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.