Sunnyslope Nursing Home

Based on observation, record review and staff interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 5.1% and included two medication errors of 39 observed medication administration opportunities. This affected two residents (#38 and #95) of three residents observed during medication administration. Findings included: 1. On 05/10/22 at 8:00 A.M. observation of medication administration with Registered Nurse (RN) #143 revealed medications administered to Resident #95. The observation revealed Vitamin B12 was not administered as ordered at the time of administration. Review of Resident #95's medical record revealed an admission date of 04/28/22 with diagnoses that included dementia and anemia. Review of the physician's medication orders revealed vitamin B12 (vitamin supplement) 500 micrograms (mcg) two tablets every day. Review of the Medication Administration Record (MAR) indicated vitamin B12 was to be administered every day at 8:00 A.M. On 05/11/22 at 9:00 A.M. interview with the Director 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 review of personnel files, staff interview, and review of the facility abuse policy the facility failed to ensure 19 staff members were checked against the State Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 42 residents currently residing in the facility. Findings include: Review of personnel list and personnel files revealed the non-licensed staff including; Laundry Aide (LA) #15, LA #17, Housekeeping Aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DD) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, admission Director (AD) #26, Dietary [NAME] (DC) #27, DC #30, DC #33 and DC #40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 A.M., with Registered Nurse (RN) #53 verified she had no documented evidence the above…

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 physician failed to document, sign, and date each physician visit. This affected 11 (Residents #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, insomnia, hypercholesterolemia, Alzheimer's , hallucination, chronic kidney disease, Parkinson's, hyperparathyroidism, anemia, mood disorder, bipolar, depression, conduct disorder, glaucoma, venous insufficiency, respiratory failure, contractures, absence of right and left leg below knee, and edema. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. 2. Record review…

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 physician failed to ensure physician visits were provided timely and at the required frequency for all residents. This affected 11 (Resident #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The facility census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, insomnia, hypercholesterolemia, Alzheimer's , hallucination, chronic kidney disease, Parkinson's, hyperparathyroidism, anemia, mood disorder, bipolar, depression, conduct disorder, glaucoma, venous insufficiency, respiratory failure, contractures, absence of right and left leg below knee, and edema. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 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 record review, review of personnel files and policy review the facility failed to ensure administration was effective in regards to checking of non-licensed staff against the nurse aide registry, frequency of physician visits and physician documentation, and thorough implementation of an antibiotic stewardship program. This had the potential to affect all 42 residents currently residing in the facility. Findings include: 1. Review of personnel list and personnel files revealed the non-licensed (Laundry aide (LA) #15, LA #17, Housekeeping aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DA) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, admission Director (AD) #26, Dietary [NAME] (DC) #27, DC #30, DC #33 and DC 40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 A.M., with Registered Nurse (RN) #53 verified she had no documented evidence the above non-licensed staff were checked against the State NAR to ensure the employee did…

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 thoroughly implement an antibiotic stewardship program. This had the potential to affect all 42 residents currently residing in the facility. Findings include: Review of the facility infection control program revealed no evidence from May 2019 through July 2019 that the facility had antibiograms for antibiotic susceptibility review or that the consulting pharmacist attended infection prevention and control meetings to help guide antibiotic use. Interview on 09/05/19 at 10:00 A.M. with Registered Nurse (RN) #8 (Infection Preventionist), revealed the facility had not completed antibiograms for review and the consulting pharmacist has not attended any meetings to review antibiotic use. Review of the facility policy, titled Antibiotic Stewardship - Staff and Clinician Training and Roles, dated November 2017, revealed the Infection Preventionist (IP) will monitor over time and report to the Infection Prevention and Control Committee (IPCC) the antibiotic susceptibility patterns (antibiogram data for specific timeframe). 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, interview, and policy review the facility failed to ensure their policy and procedure relative to abuse prevention was implemented regarding timely reporting of an injury of unknown origin for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Additionally, based on review of personnel files, staff interview, and review of the facility abuse policy the facility failed to ensure 19 staff members were checked against the State Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Review of Resident #41's Health Status Note…

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 ensure residents were assessed for restorative nursing programs and the programs were initiated, implemented, monitored, and delivered as planned for Residents #4, #29, #3 and #23 to maintain function and/or prevent further decline. This affected four of five residents reviewed for restorative services. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included brain cancer and cerebral infarct with left sided hemiplegia. The resident was cognitively intact but dependent of staff for ADL's. The resident was discharged from occupational therapy (OT) on 08/06/19 with recommendations for the restorative nursing program to provide active range of motion (AROM) to the right and left upper extremities (UE) and grooming at the sink while seated in the wheelchair. Review of the current restorative program book revealed there was no evidence the resident was receiving restorative nursing services. On…

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 fall interventions were in-place per plan of care, fall care plans were revised, residents were transferred properly, and resident smoking was supervised. This affected two (Resident #29 and #31) of two residents reviewed for falls and 10 (Residents #12, #19, #8, #26, #342, #30, #15, #18, #6 and #34) of 11 residents identified by the facility as smokers. The facility census was 42. Findings include: 1. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including fracture of the neck of the left femur, history of transient ischemic attack, lack of coordination, difficulty in walking, muscle weakness, osteoarthritis of the knee, right leg pain, abnormalities of gait and mobility, contractures of the right ankle and left knee, syncope and collapse, and a history of falls. Review of Resident #31's fall plan of care revealed a self-releasing seat belt to the chair/wheelchair for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Residents #4 and #5 were served meals with regular dinner ware and failed to ensure Resident #35 was able to use the telephone when desired. This affected three of six residents reviewed for choices. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with brain cancer requiring chemotherapy (CTX) and cerebral infarct with left sided hemiplegia. The resident had isolation precautions posted. Review of the current care plans revealed there was nothing addressing the use of the plastic silver ware. Review of the nurses note dated 07/18/19 revealed the resident was requesting silverware. The resident indicated he was going to stab the resident who stole his bag of chips. Review of the physician's order dated 07/21/19 revealed the resident was to have plastic silverware for all meals. Review of the behavior note dated 07/21/19 revealed the resident told the nurse if he did not get regular silverware back they would be…

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 an injury of unknown origin was reported timely for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Review of Resident #41's Health Status Note on 01/06/19 at 11:29 A.M., authored by Registered Nurse (RN) #51, revealed the nurse noticed a bruise on the top of the resident's left hand, about softball-sized. State Tested Nursing Assistant (STNA) #10 stated the bruise was first noticed by staff during change of shift report on this morning around 6:00 A.M. STNA #5 stated the resident's left hand appeared swollen and reddened during change of shift report this morning around 6:00 A.M. Witness statements were collected, 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 observation, record review, interview and policy review, the facility failed to ensure a thorough investigation for injuries of unknown origin for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Resident #41's active comprehensive care plan for activities of daily living (ADL) revealed a self-care deficit due to impaired cognition, she was known to become combative during ADL care, and will strike out and become verbally aggressive. Care planned interventions included giving the resident space when she became combative and re-approach when appropriate and safe. Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired, she 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 observation, record review and interview the facility failed to ensure Resident #33's comprehensive fall risk plan of care was revised to include all fall interventions. This affected one resident (#33) of four residents reviewed for falls. Findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, contractures, and the absence of the right and left legs below the knee. Review of the physician's orders, dated October 2019 revealed an order for a fall mat to the right side of the bed for safety and an order for the bed to be in the low position, except during care. Record review revealed a current plan of care, dated August 2019 indicating Resident #33 was at risk for injuries from falls. However, the physician ordered interventions for the bed to be in low position and for a fall mat were not included on the care plan. On 11/06/19 at 9:02 A.M., Resident #33 was observed laying in bed with his eyes closed, his bed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #29 received assistance with meals and Resident #4 received nail care. This affected two of three residents received for activities of daily living (ADL). Findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia. Review of the quarterly MDS 3.0 dated 07/19/19 revealed the resident was not interviewable. Review of the current care plan revealed it was not specific to the resident's need for assistance during meals. Further review of the [NAME], a quick reference for the nurse aides, revealed the resident needed encouragement to eat and assistance with meals. Review of the occupational therapy Discharge summary dated [DATE] revealed the resident required moderate to maximum assistance for feeding. On 09/03/19 observation during the lunch meal at 12:00 P.M. revealed the resident was sitting at a table without any staff. His mechanical soft meal was delivered and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to timely follow up on gastric symptoms. This affected one (Resident #3) of six reviewed for unnecessary medications. Findings included: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including dysphagia, constipation, parkinsonism, Alzheimer's disease, bipolar disorder, schizophrenia, moderate protein-calorie malnutrition, and anemia. Review of Resident #3's current medication list revealed she was on Ranitidine 150 milligrams (mg) for indigestion, Miralax daily for constipation, and Compazine (antiemetic/antipsychotic) 5 mg before meals for nausea and vomiting. Review of Resident #3's progress notes dated 07/20/19 revealed the resident had a brown-colored liquid emesis. There was no evidence the physician was contacted/notified. On 09/01/19 the resident had a large, yellow-colored projectile emesis. Her lunch was held, and the physician was updated. Interview on 09/06/19 at 9:42 A.M., with Registered Nurse (RN)…

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, interview, and policy review the facility failed to accurately assess, treat, and develop a plan of care for a pressure ulcer. This affected one (Resident #33) of one reviewed for pressure ulcers. Finding include: Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, Alzheimer's disease, hallucinations, chronic kidney disease, Parkinson's disease, anemia, mood disorder, bipolar, depression, venous insufficiency, respiratory failure, contractures, absence of right and left leg below the knee, and edema. 1. Review of Resident #33's skin/pressure ulcer assessments dated 07/29/19 to 09/02/19 revealed: -07/29/19 moisture associated skin Damage (MASD) was acquired to the left buttocks measuring 5.5 centimeters (cm) by 3.0 cm by 0.0 cm. Medi honey (debriding agent) was ordered to treat the area. -08/05/19 MASD continued to the left buttock measuring 3.0 cm by 1.5 cm…

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 ensure Resident #7 had antithrombolitic compression stockings (TED) and setopress compression bandage wrap dressings in place as ordered. This affected one of two residents reviewed for compression stockings. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, muscle wasting, chronic obstructive pulmonary disease and diabetes mellitus. The resident did not get out of bed. Review of the physician order dated 08/30/19 revealed to apply TED stockings, an antithrombolic compression stocking used to guard against or prevent further progression of venous disorders. Then apply setopress wraps, a compression bandage, over the TED stockings bilaterally from the toes to the knees. These were to be put on the in morning and removed each night. On 09/03/19 at 11:50 A.M., 3:27 P.M. and 6:40 P.M., the resident was observed in bed without anything on her lower extremities. On 09/03/19 at 6:41…

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 ensure a non-pharmacological interdisciplinary approach with a behavior modification plan was in place for Resident #5's behaviors. This affected one of one residents reviewed for behavior modification. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression and difficulty walking. Review of the 03/08/19 quarterly minimum data set (MDS) 3.0 revealed the resident was cognitively intact and had behaviors including verbal and other behavioral symptoms one to three days and rejection of care four to six days during the reference period. Review of the current care plan, initiated 03/13/19, revealed the resident was disruptive, socially inappropriate, refused care, threw objects in his room and out into hallway and yelling out at staff. Goals included the resident would demonstrate fewer episodes of verbally and/or physically abusive behaviors and would voice anger and/or…

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 residents received the lowest effective dose of psychotropic/sedative medication to prevent sedation/lethargy. This affected one (Resident #3) of six reviewed for unnecessary medications. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including dysphagia, constipation, parkinsonism, Alzheimer's, bipolar, schizophrenia, adult failure to thrive, moderate protein-calorie malnutrition, and anemia. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. There was no evidence the physician had visited the resident every 60 days. Review of Resident #3's current medication list revealed the resident was receiving the following scheduled medication that could induce sedation/lethargy; Melatonin 9 milligrams (mg) at bedtime for insomnia, Compazine (antipsychotic/antiemetic) 5 mg before…

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 laboratory tests were completed as ordered for Resident #8 and Resident #33. This affected two (Resident #8 and Resident #33) of five residents reviewed for unnecessary medications. Findings include: 1. Resident #8 was admitted on [DATE] with diagnoses including bipolar disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder. Resident #8's physician orders revealed he received Depakote, 500 milligrams, three tablets by mouth, for mood stabilization. Resident #8's physician orders revealed on 09/14/17 he was ordered laboratory testing for valproic acid (Depakote) levels on the fourteenth day of every month. Review of Resident #8's laboratory results since March 2019 revealed valproic acid level results were found for March, June, July, or August 2019. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse #8 confirmed laboratory testing for Resident #8's valproic acid levels were not completed as ordered. 2. 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 and record review the facility failed to ensure Resident #39, who needed teeth extracted, was provided the service timely. This affected one of one resident reviewed for dental services. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis. Review of the dental visit dated 08/27/18 revealed the resident had poor oral hygiene, a build up of plaque, loose and decaying teeth and teeth numbers 14 and 19 needed extracted. There was no evidence this was completed. Review of the significant change minimum data set (MDS) 3.0 dated 08/08/19 revealed the resident was cognitively intact but was totally dependent on staff for activities of daily living including brushing her teeth. On 09/06/19 at 9:10 A.M., interview with the Licensed Practical Nurse (LPN) #3 revealed the facility needed to get approval for the teeth extraction from Medicaid and the authorization paperwork was never submitted until June 2019.