Parkview Northwest Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate regarding dental status. This affected two (#4 and #17) of 13 residents sampled. The census was 27. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 11/28/20 with a diagnosis of Alzheimer's disease. Review of the comprehensive MDS assessment for Resident #4 dated 12/05/20 revealed resident was not coded accurately regarding dental status and was not coded as edentulous (having no natural teeth). Review of the care area assessment worksheets for Resident #4 revealed resident did not trigger for care planning related to dental care. Review of the care plan for Resident #4 revealed it contained no documentation regarding dental care. Observation on 08/23/21 at 8:39 A.M. of Resident #4 revealed resident was edentulous. Interview on 08/23/21 at 8:39 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.

Based on record review, staff interview, the facility failed to ensure the resident's medical record included a Level II Preadmission Screening and Resident Review (PASARR) prior to admission to the facility. This affected one (#17) of 13 residents sampled. The census was 27. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/14/21 with diagnoses including dementia with behavioral disturbance, unspecified psychosis, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 07/22/21 revealed resident was cognitively impaired and required supervision and set up help of one staff with activities of daily living. Review of the medical record for Resident #17 revealed it did not include a Level II PASARR screen prior to admission. Interview on 08/25/21 at 9:00 A.M. with Regional Registered Nurse (RN) #99 confirmed the facility did not have evidence of completion of a Level II PASARR prior to admission for Resident #17. RN #99 confirmed Resident #17 had a diagnoses of psychosis which would require a Level II…

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, resident and staff interview, and review of facility policy, the facility failed to ensure resident care plans reflected resident dental status and/or elopement risk and residing in a secured unit. This affected three (#4, #17 and #19) of 13 residents sampled. The census was 27. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 11/28/20 with a diagnosis of Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #4 dated 12/05/20 revealed resident was not coded accurately regarding dental status and was not coded as edentulous (having no natural teeth). Review of the care area assessment worksheets for Resident #4 revealed resident did not trigger for care planning related to dental care. Review of the care plan for Resident #4 revealed it contained no documentation regarding dental care. Observation on 08/23/21 at 8:39 A.M. of Resident #4 revealed resident was edentulous. Interview 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 medical record review, staff interview and policy review, the facility failed to complete a recapitulation of a discharged resident's stay. This affected one (#23) out of three residents reviewed for closed records. The facility census was 27. Findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including displaced bicondylar fracture of right tibia, other fracture of upper and lower end of right fibula, fracture of nasal bones, anterior dislocation of left humerus, encounter for other orthopedic aftercare, acute pain due to trauma, pulmonary embolism, and alcohol abuse. Further review of Resident #23's discharge record revealed Resident #23 discharged home on [DATE]. Review of Resident #23's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and required supervision with bed mobility, transfers, dressing, toileting, personal hygiene and eating. Review of the discharge planning 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 medical record review, observations, resident and staff interview, and review of facility documents, the facility failed to offer activity programming per the activity calendar. This affected one (#17) of one residents reviewed for activities. The census was 27. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/14/21 with diagnoses including dementia with behavioral disturbance, unspecified psychosis, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 04/21/21 revealed resident was cognitively intact and required supervision and set up help of one staff with activities of daily living. Review of section F of the MDS dated [DATE] revealed Resident #17 considered the following activities to be very important: to have books, newspaper, and magazines, to listen to music he likes, to be around animals such as pets, to do things with groups of people, to do his favorite activities, to go outside when weather is good, 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 medical record review, observation, staff interview, review of facility policy, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure bed rails were used appropriately. This affected one (#4) of two facility-identified residents with rails to their beds. The census was 27. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/28/20 with a diagnosis of Alzheimer's disease with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 05/10/21 revealed resident was cognitively impaired, totally dependent on the assistance of two staff with bed mobility and is coded negative for the use of bed rails. Review of the side rail assessment for Resident #4 dated 11/28/20 revealed resident did not use the device to turn from side to side, resident did not express a desire to use the device, device is not in use due to a medical diagnosis. Further review of the medical record revealed the facility had not completed a reassessment regarding side rail use for 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, observations and staff interview, the facility failed to ensure residents have adaptive feeding equipment in place per the physician orders. This affected one (#4) of one residents with adaptive devices for eating. The census was 27. Findings include: Review of the medical record for Resident #4 revealed resident was admitted on [DATE] with a diagnosis of early onset Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 05/10/21 revealed resident was cognitively impaired and was totally dependent on assistance of one staff with eating. Review of physician orders for Resident #4 revealed an order dated 12/17/20 for resident to utilize a sippy cup with all liquids. Review of nurse progress note for Resident #4 dated 12/17/20 revealed resident's representative was notified of new physician's order for resident to utilize a sippy cup with liquids. Review of the care plan for Resident #4 dated 05/07/21 revealed resident was at risk for impaired…

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, observation, resident interview, and staff interview, the facility failed to accurately document the dental status for two residents (#19 and #242) of the five residents reviewed for dental concerns. The facility census was 27. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 06/19/21 with diagnoses to include severe protein-calorie malnutrtion, dysphagia, adult failure to thrive, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/23/21, revealed this resident was cognitively intact and required supervision with set-up assistance for bed mobility, toileting, transfers, and eating. Review of the facility admission Assessment and Baseline Care Plan, dated 06/19/21, revealed Resident #19 was edentulous and did not have any broken or carious teeth. Review of the care plan for Resident #19 revealed it was silent regarding dental care. Observation of Resident #19 on 08/23/21 at 11:29 A.M. revealed Resident #19 had multiple teeth which were broken near the gum line and rotted.…

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, record review and staff interview, the facility failed to ensure a resident call light was functioning. This affected one (Resident #173) out of 16 residents reviewed for call lights. The facility census was 27. Findings include: Review of the medical record for Resident #173 revealed an admission date of 08/09/21 with diagnoses including dysphagia, weakness, type two diabetes mellitus, and chronic kidney disease. Review of Resident #173's admission initial evaluation dated 08/09/21 revealed Resident #173 was alert and cognitively intact. Review of Resident #173's activities of daily living care plan dated 08/11/21 revealed Resident #173 required assistance with activities of daily living. Interventions include place call light within reach, extensive assistance with ambulation, extensive assistance with bathing, extensive assistance with bed mobility, extensive assistance with dressing, extensive assistance with hygiene, extensive assistance with toileting, extensive assistance with transfers and supervision with eating. Observation of Resident #173's room 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.

Based on review of Safe Serve and staff interview the facility failed to have any dietary staff certified in food service management and safety. This had the potential to affect all residents in the facility. The facility census was 40. Findings include: Review of documentation of certification for dietary staff revealed Registered Dietician (RD) #1 was Safe Serv Level Two certified. During an interview with RD #1 on 02/20/19 at 11:18 A.M., she verified she held a Safe Serv Level Two certification and was in the facility on Wednesdays and Thursdays. At the same time, Dietary Manager (DM) #1 stated he was scheduled for the January class for Safe Serv Level 2 but it was canceled due to the weather. DM #1 stated he was scheduled for the class on 04/23/19. He further verified currently none of the facility dietary staff have Safe Serv Level One or Level Two certification. During an interview with DM #1 on 02/21/19 at 9:26 A.M., he stated he had an Associate degree in Culinary Arts obtained from a local Technical College in 2000 and documentation was requested. On 02/21/19 at 10:12 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 observation, staff interview, review of the resident census and review of facility policy the facility failed to maintain residents rooms in a clean and sanitary manner. Holes were noted on the walls with exposing dry wall and wood, and window blinds were dirty. This affected three rooms (7, 12 and 13) of 15 rooms on the lower level. The facility identified six Resident's (#1, #4, #20, #21, #22 and #190) who resided in the affected rooms. The facility census was 40. Findings include: 1. Observation and interview conducted on 02/20/19 at 11:21 A.M. Licensed Practical Nurse (LPN) #26 verified the wall in room [ROOM NUMBER] next to the bathroom had a quarter edge and dry wall missing, exposing the wood. LPN #26 verified there was noted patch work completed on the wall that appeared to be done sometime ago due to the patch work had new holes and scuff marks noted. LPN #26 stated she was unsure how long the holes had been on the walls and/or when the patch work was completed. Observation and interview…

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, review of census list and review of facility policy the facility failed to maintain the canopy over the courtyard on the lower level. This had the potential to affect 16 residents (#1, #3, #4, #5, #8, #11, #15, #17, #18, #20, #22, #27, #36, #37, # 38 and #190) who resided on the secured unit and used the courtyard. Total census of the facility was 40. Observation on 02/19/19 at 11:32 A.M. of the lower level courtyard attached to the secured unit, revealed the canopy was in disrepair. Further observation revealed several holes in the canopy and a large area where the canopy was completely separated from the frame and hanging down. Interview on 02/21/19 at 11:10 A.M. with the Director of Nursing (DON), verified the canopy over the courtyard had several holes in it and a large area where the canopy was separated from the frame and hanging down. Review of census list revealed 16 residents (#1, #3, #4, #5, #8, #11, #15, #17, #18, #20, #22, #27, #36, #37, # 38 and #190) resided on the secured unit. Review of an undated policy/procedure titled…

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 and resident interview, and review of the facility policy, the facility failed to notify the physician of lab refusals for a resident. This affected one Resident (#29) of five reviewed for unnecessary medications during the investigation phase of the annual survey. The facility census was 40. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus with diabetic neuropathy, major depressive disorder, hypertension, heart disease, gastroesophageal reflux (GERD), diarrhea, anemia, end stage renal disease, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with rejection of care behaviors noted one to three days during the look back period. Review of Section G- Functional status revealed the resident required extensive two-person assistance with bed mobility, transfer, toileting, extensive one-person assistance…

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 review of medical record, observations, staff interview, review of facility incident log and review of facility policy the facility failed to implement their policies and procedures for residents with injuries of unknown origin. The facility failed to investigate and report to the state agency. This affected one Resident (#22) of one reviewed for accidents. Total census was 40. Findings include: Review of the medical record for Resident #22, revealed an admission date of 08/30/16. Diagnoses included schizophrenia, anxiety, major depressive disorder, dementia, drug induced subacute dyskinesia, obesity, muscle weakness, lack of coordination, bipolar, diabetes mellitus and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/08/19, revealed the resident was cognitively intact. The resident required extensive assistance for bed mobility, transfer, locomotion off unit, dressing and personal hygiene. Resident #22 required supervision for walking, locomotion on unit and eating.…

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 review of medical record, observations, staff interview, review of facility incident log and review of facility policy the facility failed to ensure an injury of unknown origin was reported to the state agency. This affected one Resident (#22) of one reviewed for accidents. Total census was 40. Findings include: Review of the medical record for Resident #22, revealed an admission date of 08/30/16. Diagnoses included schizophrenia, anxiety, major depressive disorder, dementia, drug induced subacute dyskinesia, obesity, muscle weakness, lack of coordination, bipolar, diabetes mellitus and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/08/19, revealed the resident was cognitively intact. The resident required extensive assistance for bed mobility, transfer, locomotion off unit, dressing and personal hygiene. Resident #22 required supervision for walking, locomotion on unit and eating. Resident #22 was dependent for bathing. Review of a smoking assessment dated [DATE],…

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 review of medical record, observations, staff interview, review of facility incident log and review of facility policy the facility failed to ensure an injury of unknown origin was investigated. This affected one Resident (#22) of one reviewed for accidents. Total census was 40. Findings include: Review of the medical record for Resident #22, revealed an admission date of 08/30/16. Diagnoses included schizophrenia, anxiety, major depressive disorder, dementia, drug induced subacute dyskinesia, obesity, muscle weakness, lack of coordination, bipolar, diabetes mellitus and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/08/19, revealed the resident was cognitively intact. The resident required extensive assistance for bed mobility, transfer, locomotion off unit, dressing and personal hygiene. Resident #22 required supervision for walking, locomotion on unit and eating. Resident #22 was dependent for bathing. Review of a smoking assessment dated [DATE], indicated 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 facility policy review the facility failed to notify the Ombudsman of a residents' discharge. This affected one (#20) of two residents reviewed for hospitalization. The facility census was 40 residents. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included hypertension, seizure disorder, manic depression, anxiety, psychotic disorder, schizophrenia and ileostomy. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely impaired for cognitive daily decision making skills and required supervision to extensive assistance of staff with his activities of daily living. Further review of the medical record revealed Resident #20 was discharged to the hospital on [DATE], 11/11/18 and 12/18/18. The facility provided the resident with bed hold notice but did not notify the Ombudsman of the discharges On 02/20/19 at 9:42 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 and staff interview, the facility failed to develop baseline care plan within the required 48 hour of admission. This affected one Resident (#29) of 13 reviewed during the investigation phase of the annual survey. The facility census was 40. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus with diabetic neuropathy, major depressive disorder, hypertension, heart disease, gastroesphageal reflux (GERD), diarrhea, anemia, end stage renal disease, and anxiety disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Section G- Functional Assessment revealed Resident #29 required extensive two-person assistance with bed mobility, transfer, toileting, extensive one-person assistance with personal hygiene, locomotion, dressing, and supervision setup with eating. Review of Section O-Special Treatments revealed Resident #29…

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 and resident interviews, and review of facility policy, the facility failed to provide care conference/care planning quarterly for residents. This affected one Resident (#39) of one reviewed for care conferences/care planning during the investigation phase of the annual survey. The facility census was 40. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including type two diabetes, major depressive disorder, osteoarthritis, cerebral infarction, hemiplegia of left side, and muscle weakness. Review of the quarterly Minimum Data Set(MDS) dated [DATE] revealed the resident was cognitively intact, with no behaviors noted. Review of Section G-Functional Status revealed the resident required extensive two-person assistance with bed mobility, toileting, transfer, extensive one-person assistance with walking, locomotion, dressing, personal hygiene, and supervision and setup with eating. Review of section K-…

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, staff interview, review of resident list and review of facility policy the facility failed to ensure the residents environment was free from accident hazards. This affected one room (12) of 15 rooms on the secured lower level. room [ROOM NUMBER] had exposed wires. The facility identified 14 Residents (#3, #5, #8, #11, #15, #17, #18, #20, #22, #27, #36, #37, #38 and #190) as being cognitively impaired and ambulatory who resided on the secured lower level. Total census of facility was 40. Findings include: Observation on 02/21/19 at 10:25 AM, revealed exposed and uncapped wires sticking out from underneath the affixed heating unit located inside room. 12. Interview on 02/21/19 at 10:55 A.M. with Maintenance Director # 56, verified there were exposed, uncapped wires sticking out from underneath the affixed heating unit in room [ROOM NUMBER]. Review of resident list identified 14 Residents (#3, #5, #8, #11, #15, #17, #18, #20, #22, #27, #36, #37, #38 and #190) as being cognitively impaired and…

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

Based on observation, staff interview, review of the narcotic logs, and review of facility policy, the facility failed to ensure a nurse documented in the narcotic log in a timely manner after administration of a narcotic. The facility also failed to ensure administration of a narcotic when it was signed out of the narcotic log. This affected two (#25 and #26) of 24 residents the facility identified as receiving medications from the medication cart on floor two. The facility census was 40. Findings include: Observation of the Team 1 and Team 2 medication carts on the second floor and staff interview with Registered Nurse (RN) #21 was conducted on 02/20/19 at 3:58 P.M. At the time of the observation a review of the narcotic logs revealed Resident #25's Alprazolam (anxiety medication) 0.5 milligram (mg) count sheet noted a count of nine tablets however there were only eight tablets noted in the packet. RN #21 stated he provided Resident #25 the alprazolam at 12:20 P.M. and forgot to sign it out on the narcotic log. RN #21 then signed the medication out on the log. Further review 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to remove/dispose of discontinued medication. This affected one of three medication carts observed during the annual survey. This directly affected one Resident (#16) who had expired medications in the medication cart. The facility census was 40. Findings include: Review of Resident #16's medical record revealed a physician order dated 12/09/18 for Risperdal Solution, two times a day for dementia/behaviors mix with food or drink. Further review revealed the Risperdal Solution was discontinued on 12/26/18. Observation of the Team 2 medication cart on the second floor and staff interview with Registered Nurse (RN) #21 was conducted on 02/20/19 at 3:58 P.M. Observation revealed a bottle of liquid Risperdal Solution (antipsychotic) that belonged to Resident #16, noted in the side drawer of the medication cart. RN #21 stated the medication was discontinued and needed to be removed from the medication cart. Interview conducted on 02/21/19 at 1:53 P.M. Corporate 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.