Columbus Alzheimer's Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, staff interviews, and policy review the facility failed to make a life insurance policy payment from a facility managed account for one resident (Resident #9) out of five residents reviewed for personal funds. The facility census was 99. Findings include: Review of Resident #9's record revealed the resident was admitted on [DATE] with diagnoses that included dementia, age-related osteoporosis, psoriasis, dysphagia, aphasia, Alzheimer's disease, history of other mental and behavioral disorders. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #9 was not interviewed for cognition because she was rarely or never understood. Resident #9 had poor short term and long-term memory and was unable to make daily care decisions on her own. Resident #9 displayed physical behaviors four to six days during the look back period. Resident #9 was unable to be interviewed for the resident screening process. Interview on 08/19/24 at 1:03 P.M. via…

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, staff interview, and review of the facility policy, the failed to ensure staff notified resident physicians of abnormal lab results in a timely manner. This affected one (Resident #72) of 25 residents sampled. The facility census was 99 residents. Findings include: Review of the medical record for Resident #72 revealed an admission date of 09/02/21 with diagnoses including Alzheimer's disease, venous insufficiency, open wound of the left lower leg, generalized anxiety disorder and major depressive disorder. Review of the MDS assessment for Resident #72 dated 07/18/24 revealed the resident was cognitively intact. Review of the physician's orders for Resident #72 revealed an order dated 08/21/24 to obtain a culture to the wound on the resident's left lower extremity. Review of the wound culture results for Resident #72 revealed the wound culture was obtained on 08/21/24 and the results were received on 08/24/24 at 2:06 P.M. indicating the wound was infected with a heavy growth of streptococcus pyogenes (bacteria) which was susceptible to penicillin 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, staff interview, policy review, and review of the facility assessment, the facility failed to effectively communicate with Resident #34. This affected one (Resident #34) of two residents reviewed for communication. The facility identified four residents who spoke an alternate language. The facility also failed to provide necessary assistance to maintain personal hygiene for one (Resident #35) of 25 reviewed. The facility census was 99. Findings include: Review of Resident #34's medical record revealed an admission date of 08/04/17. Medical diagnoses included dementia, depression, aphasia (difficulty forming words or speaking) and cerebrovascular accident (stroke). Review of Resident #34's minimum data set (MDS) 3.0 annual assessment, dated 07/01/24 revealed the resident's preferred language was French Creole. The resident was identified to not want the use of an interpreter. Resident #34 was recorded as rarely/never understanding others, and rarely/never was able to make…

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, and staff interview, the facility failed to provide activities to meet the needs and preferences of the residents. This affected three (Resident #27, #45, and #72) of 32 residents observed for activities. The Census was 99 Findings Include: 1. Review of Resident #27's medical record revealed an admission date of 03/14/23. Medical diagnoses included dementia, depression, osteoarthritis, and hypertension. Review of Resident #27's MDS Medicare/5-day assessment, dated 07/02/24, revealed the resident had a BIMS score of 11, indicating moderately impaired cognition. Review of Resident #27's Activity Assessment, dated 02/06/2, revealed the resident's former occupation was a carpenter and he had current interests in reading, music, spiritual/religious activities, and watching television and movies. The assessment indicated it was somewhat important to Resident #27 to listen to music he liked, be around animals such as pets, to do his favorite activities, to go outside to get…

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 follow physicians orders in obtaining daily weights. This affected one (Resident #4) of 25 residents records reviewed. The census was 99. Findings include: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with agitation, congestive heart failure (CHF), Psychotic disorder with delusions and paranoid schizophrenia. Review of the significant change minimum data set assessment dated [DATE] revealed her cognition was not intact. Review of the physicians orders revealed an order on 07/18/24 weigh daily at 6:00 A.M. notify if weight gain is three pounds in a day or five pounds in a week. This weight must be done every morning and charted at 6:00 A.M. by the night shift nurse. Review of the plan of care dated 07/17/24 revealed Resident #4 has need for cardiac assessment/potential for alteration in cardiac output Complete cardiac assessment, as clinically indicated,…

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, resident and staff interview, the facility failed to assist Resident #78 with applying his corrective lenses. This affected one (Resident #78) of two residents reviewed for communication-sensory. The facility census was 99. Findings include: Review of Resident #78's medical record revealed an admission date of 05/14/22. Medical diagnoses included dementia, polyneuropathy, and hemiplegia and hemiparesis (weakness and paralysis) following a cerebrovascular accident (stroke). Review of Resident #78's Minimum Data Set 3.0 quarterly assessment, dated 07/01/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. The assessment noted the resident's vision was adequate with no corrective lenses. Resident #78 was identified as usually able to make himself understood and usually able to understand others. Review of Resident #78's care plan, initiated on 05/24/22 and revised 06/27/24, revealed the resident had a visual acuity deficit due to the aging process, he wears glasses some 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 and staff interview, the facility failed to maintain interventions to promote healing of pressure ulcers. This had the potential to affect three (Resident #1, #18 and #90) of four residents reviewed for pressure ulcers. The Census was 99. Findings include: Review of Resident #18's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition, pressure ulcer of the right ankle, open wound of the left lower leg, Alzheimer's disease, aphasia, anxiety and major depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was not intact. Resident #18 had no limitation in range of motion. Resident #18 had a Stage II pressure ulcer and an open lesion other than an ulcer coded on the assessment. Resident #18 was coded as having a pressure reducing device for her chair and the bed. Review of the physician's orders revealed an order for a pressure reducing cushion to her chair…

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, and staff interview, the facility failed to ensure tube feedings were administered at the rate ordered by the physician. This affected one (Resident #26) of two facility-identified residents with orders for tube feeding. The facility census was 99 residents. Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/29/21 with diagnoses including dementia with agitation, dysphagia, contracture of muscles, severe protein calorie malnutrition, paranoid schizophrenia, and diabetes. Review of the Minimum Data Set assessment for Resident #26 dated 05/22/24 revealed the resident was cognitively impaired. Review of the physician's orders for Resident #26 revealed an order dated 05/09/24 to administer Isosource 1.5 per gastrostomy tube via pump at 55 cubic centimeters (cc) per hour continuously. Review of the plan of care for Resident #26 dated 03/31/24 revealed the required a tube feeding related to having severe protein calorie malnutrition and dysphagia with interventions which included staff should…

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 policy review, the facility failed to ensure residents were free from significant medication errors related to insulin administration. This affected one (Resident #49) of five residents reviewed for medication administration. The facility identified eight residents whose medication regimens required insulin injections. The facility census was 99 residents. Findings include: Review of the medical record for Resident #49 revealed an admission date of 05/22/23 with diagnoses including type two diabetes and hemiplegia and hemiparesis following a cerebrovascular accident. Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 06/29/24 revealed the resident was cognitively impaired and received insulin injections. Review of the physician's orders for Resident #49 revealed an order dated 02/23/24 for Humalog insulin two units by subcutaneous injection three times daily before meals. The order specified to hold the medication if the blood glucose level was less than 140 milligram (mg)/deciliter (dl). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of personnel files, review of the Ohio Department of Health (ODH) Nurse Aide Registry, and staff interviews, the facility failed to ensure that three State Tested Nursing Aide's (STNA) registrations were not expired. This affected three (STNA #36, #123 and #131) out of three STNA's reviewed for active registrations and had the potential to affect all residents residing in the facility. The facility census was 97. Findings include: 1. Review of the personnel file for STNA #123 revealed a hire date of [DATE]. Review of the ODH Nurse Aide Registry revealed STNA #123's registration expired on [DATE] and had a registry status of expired. The registry stated expired: we have received no work verification in the past 24 months, therefore this individual is not eligible for employment in a long term care facility. Interview on [DATE] at 11:27 A.M. with STNA #123 revealed her STNA…

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, policy review, and review of the Centers for Disease Control (CDC) guidance and COVID-19 Data Tracker, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 95 residents residing in the facility. Findings included: As of 02/14/22, the facility was in outbreak for COVID-19 infection when one employee tested positive for the virus and had taken care of six residents. 1. Observation on 02/15/22 at 4:10 P.M. revealed Housekeeping Supervisor (HS) #25 and Receptionist #67 had on masks that had ear loop straps and the masks had gaps out of the sides of the cheeks. These masks had N-95 printed on them, but no number or National Institute for Occupational Safety and Health (NIOSH) approved. Interviews at the same time with HS #25 and Receptionist #67 verified they were not wearing the masks the facility had provided them which was an N-95 that had the straps that went on top of the head and around the neck. They…

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, observations, and staff and resident interviews, the facility failed to ensure resident rooms and facility corridors, lobby and unit hallways temperatures were between 71 to 81 degrees Fahrenheit. This affected two (Resident #30 and #31) of 25 residents reviewed for physical environment. The facility census was 95. Findings include: 1. Medical record review for Resident #30 revealed an admission dated of 01/28/21. Diagnoses included dementia, chronic atrial fibrillation, and chronic systolic heart failure. On 02/14/22 at 7:50 A.M., an interview and observation with Resident #30 revealed his room to be very cold. Resident #30 explained, it was always cold. The maintenance man has come in numerous times, but it was not fixed. The heater was blowing cold air. The heater dials were set on heat and at the highest temperature. On 02/15/22 at 9:15 A.M., an observation of Resident #30 siting in dining area drinking coffee. He said, his room was too cold to enjoy drinking his coffee. Observation…

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 record review, resident and staff interview, review of the resident council minutes, and policy review, the facility failed to ensure activities were provided for cognitively impaired residents and provided according to the activity calendar. This affected two (#36 and #41) of four residents reviewed for activities. The facility census was 95. Findings include: 1. Medical record review for Resident #36 revealed an admission date of 08/29/16. Diagnoses included unspecified dementia with behavioral disturbances, diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/03/22, revealed Resident #36 was severely cognitively impaired. Functional status was total dependence for bed mobility, extensive assistance for transfers and toilet use and she was supervision for eating. Review of the activities care plan, dated 01/14/22, revealed Resident #36 enjoyed music/entertainment, arts/crafts, movies, television, spirituals,…

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 and staff interview, the facility failed to ensure call lights in the bathrooms were functioning properly for two of 25 bathrooms reviewed during the annual survey. The facility census was 95. Findings include: Observation of the bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] on 02/14/22 from 9:51 A.M. to 9:53 A.M. revealed the cord for the call light was missing from the wall. Interview with Maintenance Supervisor (MS) #28 on 02/16/22 at 10:37 A.M. confirmed the cords for the call lights in the bathrooms of room [ROOM NUMBER] and room [ROOM NUMBER] were missing. He said he checked the cords for the call lights in the bathrooms, but didn't document it.

Based on record review, observation, staff interviews and review of the facility's policies, the facility failed to ensure the storage of frozen and refrigerated foods in a manner to protect against spoilage. The facility also failed to ensure the staff washed their hands moving from dirty dishes to touching clean dishes. In addition, the facility failed to ensure the temperature of the hamburgers served at lunch, had been cooked to the appropriate temperature. This had the potential to affect all 97 residents who received food from the kitchen. The facility census was 97. Findings include: 1. On 04/22/19 between 8:25 A.M and 9:00 A.M., a tour of the kitchen was conducted with the Dietary Manager (DM) #1. Observation of the walk-in refrigerator revealed a large plastic container, covered with foil, containing an orange pureed substance. The container was dated but had no label. Observation of the walk-in freezer revealed one plastic bag with breaded meat patties with no label and open to air. Another bag containing several large pieces of light-colored meat, had no label.…

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, staff interview, and facility policy review, the facility failed to follow infection control procedures when treating and monitoring potentially infections skin conditions. This affected three (#41, #75 and #89) of four residents reviewed for scabies. This had the ability to affect all 97 residents residing in the facility. Findings Include: 1. Record review for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, scabies, sepsis and pneumonia. Review of his Brief Interview for Mental Status (BIMS) assessment score, dated 01/18/19, revealed it was not completed due to his inability to answer the questions. This indicated he was severely cognitively impaired. Further review of Resident #41's medical records revealed when he was discharged from the hospital on [DATE]. In review of a physician's progress note, dated 01/16/19, revealed Resident #41 was in the hospital and was diagnosed with severe…

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 medical record and staff interview, the facility failed to ensure the advanced directives were accurate according to the physician's orders and/or code status sheet signed by the resident's responsible party. This affected two (#40 and #88) of 32 residents reviewed for advance directives. The facility census was 97. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 09/05/19 with diagnoses including dementia with behavioral disturbance, diabetes mellitus and atrial fibrillation. Review of the advance directives, dated 09/05/19 revealed the resident's responsible party signed the resident wishes a DNRCC (do not resuscitate comfort care). Review of the current physician's orders for 04/2019 revealed a physician's order for DNR-CC-arrest - DNI (do not intubate). Interview on 04/25/19 at 9:12 A.M. with Licensed Practical Nurse (LPN) #3 confirmed the advance directives signed by the resident's wife did not match the physician's orders. She agreed this needed to be clarified. 2. Review of the medical record for Resident…

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

Based on observation, review of the Institute of Safe Medication Practices and staff interview, the facility nurse failed to meet professional standards during routine medication administration when the nurse used another resident's medication when a medication was not immediately available. This affected one (#38) of five residents observed during medication pass. (Resident #38) Findings include: Observation on 04/24/19 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #116 prepared the medications for Resident #38. When he came to the Divalproex (anticonvulsant) 125 milligram (mg.) medication, he stated it was not available in the cart. He stated he would borrow the medication from Resident #51 and then after he was finished passing morning medications, he would get the medication from the emergency drug kit (EDK) box and return his dose. He proceeded to use Resident #51's medication to administer to Resident #38. Interview on 04/24/19 at 9:15 A.M. with Licensed Practical Nurse (LPN) #2 stated the nurses were not ever to borrow medications from another resident. She stated we…

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 ensure resident falls were thoroughly reviewed to implement relevant interventions and failed to implement fall interventions per the resident's care plan. This affected two (Resident #56 and Resident #76) of five resident reviewed for accidents. The census was 97. Findings Include: 1. Record review for Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, difficulty walking, postpolio syndrome, anxiety disorder, and mid-cervical disc disorder. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 02/19/19, revealed the resident was severely cognitively impaired. Review of Resident #56 medical records revealed she had an unwitnessed fall on 01/28/19. She was assessed and sent to the emergency room (ER) for evaluation, which determined she had a fractured arm. In review of the fall incident…

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 and staff interview, the facility failed to provide routine medications for resident when a medication was not available during medication administration. This affected one (#38) of five residents observed during medication pass. The facility census was 97. Findings include: Observation on 04/24/19 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #116 prepared the medications for Resident #38. When he came to the Divalproex (anticonvulsant) 125 milligram (mg.) medication, he stated it was not available in the cart. He stated he would borrow the medication from Resident #51, and then after he was finished passing morning medications, he would get the medication from the emergency drug kit (EDK) box and return his dose. He proceeded to use Resident #51's medication to administer to Resident #38. Interview on 04/24/19 at 9:15 A.M. with Licensed Practical Nurse (LPN) #2 stated the nurses were not ever to borrow medications from another resident. She stated they have a EDK box to get medications from or if there was none available in there, the nurse should call…

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 and staff interview, the facility failed to provide the appropriate diagnosis for the use of an antipsychotic medication. This affected one (Resident #51) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: A medical record review for Resident #51 revealed an admission date of 01/30/18. Diagnoses included dementia with behavioral disturbance, aphasia, unspecified psychosis, conversion disorder with seizures, heart failure, major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/07/19, revealed Resident #51 had severe cognitive impairment and required limited assistance for his daily care from the staff. Review of the current physician's order set for Resident #51, dated 04/2019, revealed an order Seroquel (an antipsychotic medication) 75 milligrams (mg.) by mouth every night for insomnia. In addition, Depakote (an antipsychotic) 500 mg. by mouth at 10:00 A.M. and 2:00 P.M. and 750 mg at 10:00 P.M. for the diagnosis of wanting to leave. On 04/25/19 at 1:48 P.M., an…

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

Based on observation, record review, staff interview and review of the policy and procedure for medication administration, the facility failed to ensure their medication error rate was less than 5% as three medication errors were noted out of 29 opportunities for a medication error rate of 10.34%. This affected three (Resident #22, #38 and #53) of five residents observed for medication administration. Findings include: 1. Observation on 04/24/19 at 8:14 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #116 prepared medications for Resident #38. The medications were prepared and taken to the room of Resident #38. The resident was standing at the bathroom door at the time the nurse entered the room. He handed the resident his medications and the resident placed the medications in his mouth from the medication cup, dropping one on the floor. The nurse picked up the dropped pill and disposed of it. He then went on to pass medications to the next resident. The nurse was not observed identifying the pill prior to disposing of it. The nurse did not bring a…

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