Crown Pointe Care Center

Based on review of monthly infection control surveillance logs, staff interview, and facility policy review, the facility failed to to maintain a complete and accurate tracking system for all infections. This had the potential to affect all 86 residents residing in the facility. The census was 86. Findings Include: Review of the facility infection control monthly surveillance log on 03/13/24 revealed the facility failed to document the results of cultures for residents with suspected or actual infections from May 2023 through February 2024. On 03/13/24 at 10:20 A.M., interview with the Director of Nursing (DON) and the Regional Nurse #200 verified the infection control log was not tracking the bacteria being treated for community acquired and facility acquired infections. Review of the facility policy titled, Infection Surveillance, last revised 11/28/17, revealed data to be used in the surveillance activities may include but are not limited to 24-hour shift reports, laboratory (lab) reports, antibiograms obtained from lab, antibiotic use reports from pharmacy, and documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of investigations, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to timely report an injury of unknown origin to the State Survey Agency. This affected one (#6) of one residents reviewed for skin conditions. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastroesophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor 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 medical record review, review of investigations, staff interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#6) of one resident reviewed for skin conditions. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor for changes. Review of Resident #6's incident investigation dated 10/21/23…

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, and staff interviews, the facility failed to ensure adequate nail care was provided for dependent residents. This affected two (#22 and #42) of seven residents reviewed for activities of daily living. The facility census was 86. Findings Include: 1. Review of the medical record for Resident #22 revealed an initial admission date of 06/01/19 with the latest readmission date of 12/02/22. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebrovascular accident (CVA) with right sided hemiplegia, aphasia, hypothyroidism, hypertension, gastro-esophageal reflux disease, anemia, and anxiety disorder. Review of the plan of care dated 06/02/19 revealed Resident #22 required assistance with activities of daily living (ADLs) and may be at risk for developing complications associated with decreased ADL self-performance and indicated the resident used an electric wheelchair. Interventions included the resident wore incontinence briefs, required 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 medical record review, staff interview, review of activity calendars, and policy review, the facility failed to ensure activities were offered to residents throughout the week based on assessment, care plan, and resident preference to promote resident well-being. This affected two (#6 and #55) of two residents reviewed for activities. The facility census was 86. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's activity assessment dated [DATE] revealed she preferred activities in a one-on-one setting. Resident #6's preferred activities included watching television and listening to music or the radio. The assessment did not indicate what type of music or television she preferred. Review of Resident #6's comprehensive Minimum Data Set (MDS) 3.0 dated 10/18/23 revealed the resident was rarely or never…

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, and policy review, the facility failed to ensure fall interventions were in place and resident transfers were performed in a manner to prevent falls. This affected two (#12 and #50) of seven residents reviewed for falls. The census was 86. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 05/02/23 with diagnoses including type two diabetes mellitus, Parkinsonism, anxiety disorder, major depressive disorder, and combined systolic and diastolic heart failure. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had severely impaired cognition. Review of Resident #50's plan of care dated 05/11/23 revealed the resident was at risk for falls due to debilitation, weakness, disease process, and use of psychotropic medications. Interventions included encouraging and reminding the resident to ask for assistance, ensuring the call light was within reach, keeping commonly used…

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, and staff interview, the facility failed to ensure adequate fluids were available and provided throughout the day to promote hydration. This affected one (#6) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's nutrition assessment dated [DATE] revealed the resident required 2190 milliliters (ml) of fluid a day. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. The resident was on a mechanically altered and therapeutic diet. Review of Resident #6's fluid intake from 02/12/24 to 03/10/24 revealed fluid intake was only documented on six days. Fluid intake included 120 ml on 02/12/24, 360 ml on 02/13/24, 240 ml 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 observation, medical record review, staff interview, and review of a facility policy, the facility failed to administer supplemental oxygen as ordered. This affected one (#339) of one residents reviewed for oxygen administration. The facility census was 86. Findings include: Review of the medical record revealed Resident #339 was admitted to the facility on [DATE] with diagnoses including emphysema, chronic obstructive pulmonary disease, and fracture of lumbosacral spine and pelvis. Review of the care plan dated 03/08/24 revealed Resident #339 had a history of respiratory deficiencies and staff interventions include administering oxygen as ordered. Review of current physician orders for Resident #339 revealed an order for continuous oxygen at three liters per nasal cannula with a start date of 03/08/24. Observation on 03/11/24 at 1:34 P.M., on 03/12/24 at 9:36 A.M., and on 03/12/24 at 11:41 A.M. revealed Resident #339 was observed wearing supplemental oxygen set at 4.5 liters via nasal cannula.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure dialysis services were completed thoroughly including obtaining resident weights before and after dialysis services. This affected one (#8) of one residents reviewed for dialysis. The census was 86. Findings Include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type II diabetes, unspecified hemorrhoids, lack of coordination, weakness, dysphagia, end stage renal disease, atrial fibrillation, and dependence on renal dialysis. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was cognitively intact. Review of Resident #8's current physician orders revealed the resident had scheduled dialysis services three days a week, on Mondays, Wednesdays, and Fridays. Review of Resident #8 dialysis notes, dated 12/01/23 to 03/11/24, revealed there were no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered. This affected one (#35) of six residents reviewed for medications. The facility census was 86. Findings include: Review of the medical record for Resident #35 revealed an admission date of 09/14/22 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting an unspecified side, atherosclerotic heart disease, and vascular dementia. Review of Resident #35's plan of care dated 09/26/22 revealed the resident had altered health maintenance related diagnoses including hypertension and coronary artery disease. Interventions included administering medications as ordered, monitoring for signs of cardiac distress, monitoring for signs of infection, and monitoring for signs of bleeding. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had impaired cognition. Review of Resident #35's physician order…

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 identify and monitor target behaviors for the use of psychotropic medications. This affected one (#73) of six residents reviewed for medications. The facility census was 86. Findings Include: Review of Resident #73's plan of care dated 11/07/22 revealed the resident had trauma related to unwanted sexual contact. Resident #73 had triggers of hearing other people screaming at each other/other people becoming physical with each other. Interventions included consistent staff members, consult with psychiatry/psychology, and include the resident in decision making process. Review of the plan of care dated 02/08/22 revealed Resident #73 was at risk for adverse effects related to psychoactive medication use, dementia with behaviors, depression, and mood disorder. Interventions included give medications as ordered, laboratory values per order, update the physician as indicated, monitor for medication side effects, monitor…

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, review of an email correspondence document, staff interview, and policy review, the facility failed to timely complete an order for laboratory values and failed to notify the physician of abnormal laboratory results. This affected one (#78) of two residents reviewed for infections. The facility census was 86. Findings include: Review of Resident #78's medical record revealed an admission date of 01/01/24. Diagnoses included type two diabetes mellitus, chronic heart failure, and stroke. Review of the Minimum Data Set assessment completed on 03/05/24 revealed Resident #78 was severely cognitively impaired and was dependent on personal care. Review of Resident #78's medication administration record for Resident #78 revealed an entry dated 01/14/24 at 6:00 A.M. for collection of a urine analysis with a refusal documented. Review of an order audit report for Resident #78 dated 01/17/24 at 4:25 P.M. revealed an order summary to obtain urine for analysis. Review of an order audit report…

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, and staff interview, the facility failed to serve residents therapeutic diets as ordered. This affected one (#42) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #42 revealed an initial admission date of 01/12/24 with diagnoses including senile degeneration of the brain, diabetes mellitus, obstructive sleep apnea, chronic kidney disease, anemia, hyperlipidemia, atrial fibrillation, hypertension, benign prostatic hyperplasia, and altered mental status. Review of the admission assessment and baseline care plan dated 01/12/24 revealed Resident #42's admission weight was 193.4 pounds. The assessment indicated the resident was alert and confused. The assessment indicated the resident was edentulous and was dependent on staff for eating. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a severe cognitive deficit. Review of the plan 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 observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (#6 and #42) of five residents reviewed for environment. The facility census was 86. Findings include: 1. Observation on 03/10/24 at 10:33 A.M., 11:40 A.M., and 12:33 P.M., and on 03/11/24 at 12:15 P.M. revealed Resident #6 was in her bed which was observed against the wall. Further observation revealed the wall surface from the middle to the head of the Resident #6's bed had brown and red splatters of an unidentifiable substance, and in some areas, the splatters appeared to be dripping down behind the bed. Interview on 03/11/24 at 12:15 P.M. with State Tested Nurse Aide (STNA) #145 verified the brown and red splatter on the wall in Resident #6's room. STNA #145 indicated the wall needed to be cleaned.2. On 03/11/24 at 8:53 A.M., observation of Resident #42's room revealed the room had a strong odor of urine. Further observation revealed there was urine under the fall mattress on the floor and under the resident's bed. Interview with Licensed Practical Nurse…

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, review of facility pest control records, resident family and staff interview, and review of the facility pest control policy, the facility failed to maintain a pest free environment. This affected one (#13) of 24 resident's rooms observed. The census was 86. Findings Include: Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, emphysema, type II diabetes, unspecified protein-calorie malnutrition, complete traumatic amputation of one lesser toe, muscle weakness, dysphagia, bipolar disorder, and congestive heart failure. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 02/20/24, revealed the resident had a mild cognitive impairment. Interview with Resident #13's family member on 03/10/24 at 2:05 P.M. stated there were ants that crawled all over Resident #13's sink. Resident #13's family member stated the facility was aware of it, but she was not certain…

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

Based on interview, resident record review, video and audio footage review, and facility policy review the facility failed to ensure a resident was not verbally abused by staff. This affected one resident (#65) of three residents reviewed for abuse. The facility census was 87. Findings included: Review of Resident #65's medical record revealed an admission date of 10/15/21 with diagnoses including chronic obstructive pulmonary disease, morbid obesity due to excess calories, essential hypertension, hyperlipidemia, and hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of Resident #65's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. The resident was totally dependent on two people for bed mobility, transfers, and toileting. The assessment revealed the resident did not exhibit physical behaviors, verbal behaviors, or other symptoms not directed towards others. Review of Resident #65's plan of care, dated 03/14/23, revealed she had a history or diagnosis of depression 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 observations, staff interviews, and facility policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all 80 residents who received food from the kitchen. Findings Include: 1. Observation of dining in the locked dementia unit on 08/23/21 at 12:27 P.M. during the lunch meal revealed Activities Aide (AA) #101 washed her hands at the sink and donned clean gloves. AA #101 was observed touching the handle of the serving cart with her gloved hands to wheel the resident's food around to the tables and serve the residents. AA #101 was observed serving ravioli to each resident and then reached into a plastic bag of dinner rolls and removed one roll for each resident and placed it on each resident's place without changing her gloves or washing her hands after touching the serving cart. There were 16 residents eating in the dining room and each was served a roll. After serving all the residents, AA #101 removed her gloves and washed her hands at the sink. Interview on 08/23/21 at 1:05 P.M. with AA #101 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of the Center for Disease Control (CDC) guidelines and COVID-19 Nursing Home data, and facility policy review, the facility failed to follow infection control protocols when they did not maintain transmission-based precautions (TBP) for two residents (Residents #334 and #337), failed to use appropriate signs to inform visitors and staff of isolation precautions for one resident (Resident #39), and failed to ensure staff were wearing appropriate eye protection while administering medications. This affected four residents (#12, #39, #334, and #337) reviewed for infection control. The facility census was 80. Findings include: 1. Review of the medical record for Resident #334 revealed an admission date of 08/21/21 with diagnoses including malignant neoplasm of stomach and major depressive disorder. Review of the admission assessment and baseline care plan, dated 08/21/21, revealed the resident was on droplet precautions. Review of the physician's orders,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide a bed hold notification to a resident who was discharged to the hospital. This affected one (Resident #84) of two residents reviewed for hospitalization. The facility census was 80. Findings include: Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 05/18/21, revealed the resident was cognitively intact. Review of the progress notes revealed Resident #84 was discharged from the facility on 06/02/21. The progress notes stated the wound on her left foot was not healing as the nurse practitioner wanted, so the order was made to send Resident #84 to the hospital for assessment/treatment after she was done with dialysis. There was no documentation in the resident's medical record the facility provided a bed hold notification to the resident or her family at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility failed to apply a physician ordered palm guard device for Resident #55. This affected one resident (#55) of one resident reviewed for range of motion. The facility identified 22 residents with contractures. The facility census was 80. Findings include: Review of the medical record for Resident #55 revealed he was admitted on [DATE]. Diagnoses included a history cerebral infarction (stroke) and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/06/21, revealed the resident had impaired cognition. The resident required supervision assistance for bed mobility, and limited assistance of one staff for dressing. Review of the physician orders, dated 10/14/19, revealed an order to apply a palm guard to the right hand in the afternoon as tolerated, remove for skin care and hygiene. The orders stated Resident #55 was to wear the…

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

Based on review of the facility's policy, staff interview and record review, the facility failed to administer a physician ordered medication for Resident #12. This affected one (Resident #12) of six residents reviewed for physician ordered medications. The facility census was 80. Findings include: Review of Resident #12's medical record revealed the resident had a readmission date on 01/06/21. Diagnoses included hypothyroidism. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/24/21, revealed Resident #12 had severely impaired cognition. Review of the physician's orders, dated 01/06/21, revealed Resident #12 had an order for Levothyroxine Sodium (Synthroid) Tablet 25 micrograms (mcg.) orally daily for hypothyroidism. The resident did not have a routine physician order for the thyroid stimulating hormone (TSH) lab draw. Review of the Medication Administration Record (MAR) for March 2021 revealed Levothyroxine Sodium Tablet 25 mcg was scheduled for administration at 5:00 A.M. Resident #12 did not receive the medication on 03/02/21, 03/04/21, 03/05/21,…

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 the facility's policy, observation, staff interview, and record review, the facility failed to ensure their medication error rate was less than five percent. There were 26 medications administered with four errors made, resulting in a medication error rate of 14.8%. This affected three residents (Residents #22, #33, and #44) of four residents reviewed for medication administration. The facility census was 80. Findings include: Observation of medication administration on 08/25/21 and 08/26/21 for four residents (#19, #22, #33, and #44) by three nurses revealed 26 medications to be administered and four errors to be made, resulting in a medication error rate of 14.8%. 1. Review of the medical record for Resident #44 revealed the resident to be admitted to the facility on [DATE]. Diagnoses include diabetes, schizophrenia, bipolar and hypertension. Review of the physician orders, dated 11/11/20, revealed an order for insulin isophane and regular suspension pen injector (70-30) 100 unit per…

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, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors when one resident (#44) was administered the wrong doses of insulin. This affected one resident (#44) of four residents observed for medication administration. Findings include: Review of the medical record for Resident #44 revealed the resident to be admitted to the facility on [DATE]. Diagnoses include diabetes, schizophrenia, bipolar and hypertension. Review of the physician orders, dated 11/11/20, revealed an order for insulin isophane and regular suspension pen injector (70-30) 100 unit per milliliter (ml) (long acting insulin), inject 14 units subcutaneously two times per day. The physician order, dated 06/09/21, revealed orders for Novolog solution 100 units per ml (short acting insulin), inject subcutaneously before meals for type two diabetes, per sliding scale: if 151-200 = two; 201-250 = four; 251-300 = six; 301-350 = eight; 351-400 =…

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

Based on review of resident diets, review of dietary spreadsheets, observation, and staff interview, the facility failed to follow the dietary spreadsheet for residents on a pureed diet. This affected four (Residents #1, #7, #40, and #47) of four residents who were prescribed a pureed diet. The facility census was 80. Findings Include: Review of the Diet Type Report, dated 08/23/21, revealed Residents #1, #7, #40, and #47 were prescribed a pureed diet. Review of the dietary spreadsheet for the lunch meal on 08/25/21 revealed residents on a pureed diet were to receive eight ounces of pureed tortilla casserole, one pureed corn shape, six ounces of tomato juice, two ounces of pureed cornmeal muffin, 2.67 ounce of pureed snickerdoodle cookie, four ounces of milk, eight ounces of water, one packet of margarine, and two tablespoons of sour cream. Observation on 08/25/21 from 12:00 P.M. to 12:45 P.M. of preparation for the lunch meal showed the kitchen staff provided two ounces of salsa in small plastic container cups with lids on every resident's lunch tray. None of the plastic cups…

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.