Maria Joseph Living Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident who consented to the influenza (flu) vaccine received the influenza vaccine. This affected one (#02) of the five residents reviewed for vaccines The facility census was 237 residentsFindings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (ESRD), diabetes mellitus type two, coronary artery disease and hypertension. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #02 had intact cognition and required moderate assistance for eating, maximal assistance for oral and personal hygiene, and was dependent for toileting, bathing, dressing, bed mobility and transfers. Review of the flu Vaccine Informed Consent Form for Resident #02 dated 09/18/25, revealed Resident #02 's representative specified consent for Resident #02 to receive an annual flu vaccine. Review of the Immunization 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure accurate documentation of medication administration. This affected one (#10) out of three residents reviewed for medication administration. The facility census was 245. Findings include: Review of medical record for Resident #10 revealed admission date of 05/22/25. The resident was admitted with diagnoses including end stage renal disease, type two diabetes mellitus, depression and hypertension. The resident was hospitalized on [DATE] and did not return. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required supervision for eating, extensive two-person assistance for bed mobility, toileting and dependence for transfers. Review of the physician orders revealed an order for Coreg (blood pressure) 6.25 milligrams (mg) one tablet twice daily. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm Hg). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interview, the facility failed to ensure infection control measures were followed during incontinence care. This affected (#11) out of three residents reviewed for infection control. The facility census was 245. Findings include:Review of medical record for Resident #11 revealed admission date of 04/08/25. The resident was admitted with diagnoses including end stage renal disease, diabetes mellitus, depression, gout, and anxiety. The significant change Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. He required supervision with eating, maximum assistance with dependent for toileting hygiene, bed mobility and transfers. Observation on 09/08/25 at 3:52 P.M. revealed Certified Nursing Assistant (CNA) #31 was assisted by CNA #10 in providing incontinence care for Resident #11. Both CNA's donned Personal Protective Equipment (PPE) for enhanced barrier precautions without concern. CNA #31…

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, and policy review, the facility failed to ensure appropriate infection control measures were completed during incontinence care. This affected one (#47) resident of three residents reviewed for incontinence care. The facility census was 234. Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/12/25. Diagnoses included anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD). Review of the Annual Minim Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require setup with eating, dependent with toileting and dressing, and substantial assistance with bathing and transfers. Observation on 03/20/25 at 11:10 A.M. revealed Certified Nursing Assistant (CNA) #13 performed incontinence care to Resident #47. Hand hygiene was performed, and gloves were applied prior 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 personal funds account review and staff interview, the facility failed to notify residents or their representatives of the need to spend down personal funds once the account reached $200 less than the Supplemental Security Income (SSI) resource limit of one person. This affected 19 (#3, #15, #20, #37, #41, #43, #44, #45, #54, #101, #111, #124, #127, #158, #183, #195, #198, #227, and #448) of 19 residents reviewed for personal funds. The census was 235. Findings included: 1. Review of Resident #3's personal funds account revealed a balance as of 06/07/23 of $20,424.70. 2. Review of Resident #15's personal funds account revealed a balance as of 06/08/23 of $2,534.72. 3. Review of Resident #20's personal funds account revealed a balance as of 06/01/23 of $2,366.34. 4. Review of Resident #37's personal funds account revealed a balance as of 06/05/23 of $22,686.10. 5. Review of Resident #41's personal funds account revealed a balance as of 06/02/23 of $4,664.31. 6. Review of Resident #43's personal funds account revealed a balance as of 06/08/23 of $5,835.42. 7. 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 Based on observation, menu review, and staff interview, the facility failed to ensure the planned menu was followed. This affected 32 (#22, #35, #38, #52, #78, #88, #94, #96, #102, #111, #118, #119, #136, #137, #141, #142, #149, #152, #161, #162, #170, #174, #181, #182, #186, #193, #204, #205, #206, #208, #225, and #450) of 32 residents who resided on the [NAME] Four unit. All 32 residents on the [NAME] Four unit were identified by the facility to received food by mouth. The census was 235. Findings included: Review of the planned breakfast menu for 06/06/23 revealed items consisting of a choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Observation of the breakfast tray line on 06/06/23 at 9:00 A.M. on the [NAME] Four unit revealed there were no hash brown potatoes being served as indicated on the menu. Interview with Dietary Aide (DA) #158 on 06/06/23 at 9:03 A.M. stated she did not notice there were no hash browns to serve to the residents, and 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected one (#348) of three residents reviewed for dignity and respect. The census was 235. Findings included: Medical record review for Resident #348 revealed an admission date of 09/23/20. Diagnoses included peripheral vascular disease, heart failure, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #348 was assessed with severely impaired cognition. Observation and interview on 06/06/23 at 9:05 A.M. revealed Resident #348 was sitting in the dining room at the table with his breakfast meal in front of him that State Tested Nurse Aide (STNA) #154 delivered to him. STNA #154 was asked if the resident was given a choice of cereal, and STNA #154 replied in front of Resident #348, He (Resident #348) was not asked if he wanted cereal and he got what he got. Further interview with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, menu review, and staff and resident interview, the facility failed to ensure food choices were provided for resident meals. This affected one (#348) of one residents reviewed for choices. The census was 235. Findings included: Medical record review for Resident #348 revealed an admission date of 09/23/20. Medical diagnoses included peripheral vascular disease, heart failure, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #348 was severely cognitively impaired and his functional status was extensive assistance for bed mobility, transfers, and toileting. The resident required limited assistance for eating. Review of the breakfast menu on 06/06/23 revealed there was choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Review of the breakfast menu on 06/07/23 revealed choice of juices, ham and cheese pocket, hash browns, choice of cereal, choice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to assist dependent residents with activities of daily living (ADLs). This affected two (#103 and #110) of six residents reviewed for ADLs. The facility census was 235. Findings include: 1. Review of Resident #103's medical record revealed admission to the facility on [DATE] with diagnoses of cerebral infarction, need for assistance with personal care, diabetes mellitus type II, dysphagia, repeated falls, and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 had moderate cognitive impairment. Resident #103's functional status was assessed as one to two person extensive assist with ADLs. The MDS assessment also revealed Resident #103 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 04/04/23 revealed Resident #103 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL…

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 physician orders for a referral to a gynecologist were processed timely. This affected one (#184) of one residents reviewed for referrals to outside providers. The facility census was 235. Findings include: Medical record review for Resident #184 revealed an admission of 01/24/23 with diagnoses including but not limited to bipolar disorder with severe psychotic features, diabetes, chronic obstructive pulmonary disease, anemia, morbid obesity, heart failure, mastitis without abscess, chronic pain syndrome, pulmonary embolism, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #184 had an intact cognition. Review of the physicians order for Resident #184 revealed an order for a referral to a gynecologist dated 05/07/23. Review of a progress note dated 05/07/23 at 4:27 P.M. revealed a new order given by the nurse practitioner to obtain a urinalysis 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 medical record review, observation, and resident and staff interview, the facility failed to ensure a physician order was in place for use of a continuous glucose monitoring device. This affected one (#28) of one residents reviewed for the provision of glucose monitoring devices. The facility census was 235. Findings include: Medical record review for Resident #28 revealed and admission date of 06/06/22 with diagnoses including but not limited to hypertensive heart, chronic kidney disease, fluid overload, morbid obesity, chronic obstructive pulmonary disease, major depressive disorder, hypertension, congestive heart failure, edema, diabetes mellitus, and interstitial pulmonary diseases. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed with intact cognition. Resident #28 required extensive assistance for bed mobility, transfers, and toileting with two staff members. Resident #28 received insulin daily during the assessment period. 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, resident and staff interview, and policy review, the facility failed to medications were stored in a safe and secure manner. This affected one (#55) of three residents reviewed for medication storage. The facility census was 235. Findings include: Medical record review for Resident #55 revealed an admission date on 08/23/16 with diagnoses including but not limited to chronic obstructive pulmonary disease, hypothyroidism, neuralgia and neuritis, pain in shoulder, diabetes mellitus, and chronic pain. Review of a physician order dated 05/25/23 revealed Resident #55 was ordered the topical pain medication Voltaren gel one (1) percent (%) applied to the back daily. Observation on 06/06/23 at 10:31 A.M. of Resident #55's bathroom shelf revealed an open, half used, labeled tube of Voltaren gel 1%. Interview on 06/06/23 at 10:31 A.M. with Resident #55 stated he used the Voltaren gel on his shoulder and back, and the staff would apply it for him. Resident #55 stated a nurse gave it to him to use on his shoulder a while ago and told him to keep it.…

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, interview, and review of the facility's Legionella documentation the facility failed to have an adequate implemented Legionella program. This had the potential to affect all of the residents of the facility. The facility also failed to obtain an order for isolation precautions. This affected one Resident (#116) of two reviewed for infections. The facility census was 265. Findings include: 1. Review of documentation titled Monitoring Control Measures to Prevent Growth and Spread of Legionella revealed that a control limit be be checked was chlorine > (greater than) .3. Further review revealed that levels documented were 8.1 on 01/02/19, 7.4 on 02/03/19, 7.4 on 03/04/19, 7.3 on 04/02/19, 7.3 on 05/18/19, 7.3 on 06/20/19, 7.3 on 07/02/19, 7.6 on 08/01/19, 7.4 on 09/05/19, 7.4 on 10/10/19, 7.4 on 11/01/19, 7.3 on 12/05/19, and 7.3 on 01/20/20. The facility was unable to provide a completed Centers for Disease Control and Prevention (CDC) toolkit for water management to prevent Legionella growth. Interview on 01/30/20 at 1:06 P.M. with the Maintenance Director (MD)…

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, resident interview, and review of facility policy, the facility failed to conducted quarterly care conferences for residents. This affected four Residents (#39, #46, #78, and #110) of eight resident reviewed for care conferences. The facility census was 265. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including respiratory failure, malignant neoplasm (cancer) of the lung, and unspecified hearing loss bilaterally. Further review of the medical record revealed no documentation Resident #46 had, or ever been invited to a care conference since her admission conference on 09/23/19. Interview on 01/28/20 at 9:18 A.M., Resident #46 revealed she had not been invited to attend a care conference since initial review of her care. Interview on 01/28/20 at 2:38 P.M., Social Services (SS) #51 revealed residents were offered care conferences quarterly and by request. SS #51 verified Resident #46…

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

Based on observation, staff interview and review of facility policy, the facility failed to properly date and label food storage items in the kitchen to avoid contamination and spoilage. This had the potential to affect 264 out of 265 residents. The facility identified one resident (#521) as nothing by mouth (NPO). Findings include: Observation of the kitchen on 01/27/20 at 8:17 A.M. with Dietary Supervisor #196 revealed a bag of sausage links in the freezer which were opened to air and undated, a pouch of opened whipped topping in the refrigerator was undated, a bag of gravy mix open and undated in the dry food section, a bag of buns that were open to air and undated in the bread storage area, a pouch of grits open and undated in the dry food storage, and a bag of shredded lettuce in plastic wrap that was open and undated inside the refrigerator. Interview with Dietary Supervisor #196 on 0/27/20 at 9:00 A.M. confirmed the above food items were opened and undated but should have been dated when opened. Review of the facility policy titled Food Storage- Labeling and Dating, dated…

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

Based on observation, resident and staff interview, the facility failed to maintain resident wheelchairs in good repair. This affected three Residents (#44, #218, and #231) of three reviewed for wheelchairs. The facility census was 265. Findings include: Observation on 01/30/20 at 11:19 A.M. with Licensed Practical Nurse (LPN) #230 revealed Resident's #44, #218, and #231's wheelchairs had torn and missing fabric on the armrests and seats. The LPN verified at the time of the observation the resident's wheelchairs were not in good condition. LPN #230 stated the night shift staff were responsible for cleaning wheelchairs and should have reported the condition of the wheelchair to maintenance for repairs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for residents. This affected three Residents (#46, #78, and #110) of 33 reviewed for MDS assessments. The facility census was 265. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and unspecified hearing loss bilateral. Review of the the quarterly modification MDS assessment dated [DATE] revealed the resident was cognitively intact with no noted behaviors. The MDS revealed the resident had adequate hearing with no hearing aids. Observation and interview on 01/28/20 09:05 A.M. with Resident #47 revealed during the interview the resident was noted to be significantly hard of hearing, holding her hand up to her ear in attempt to better hear. Resident #47 revealed she was waiting to get hearing aids. Interview on 01/29/20 at 3:54…

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 follow up with therapy recommendations for a splint device. This affected one Resident (#195) of one reviewed for range of motion (ROM). The facility census was 265. Findings include: Review of the medical record for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses include left hand contractures, digits three through five, Parkinson's disease, and dementia without behavioral disturbances. Review of Resident #195's Occupational Therapy (OT) Discharge summary dated [DATE], revealed the resident's therapy goals were to increase left hand, digits three through five, extension to increase functional use of left hand, to prevent decline in ROM. Prognoses was good with consistent staff follow-through. Splint/orthotic recommendations were posey palm protector to left hand as tolerated. Discharge recommendations were bilateral orthotic with staff assistance and continued ROM. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation,staff interview, and review of facility policy, the facility failed to follow physician's oxygen administration orders for two Residents (#90 and #227) of three reviewed of oxygen administration. The facility census was 265. Findings include: 1. Review of Resident #90's medical record revealed an admission date of 04/18/19 with diagnoses including non-Hodgkin's lymphoma, and chronic obstructive pulmonary disease (COPD). Review of Resident #90's physician orders revealed an order dated 08/18/19 to administer oxygen at four liters per minute (LPM) via nasal cannula to maintain the resident's oxygen saturation level above 90%. Review of Resident #90's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was cognitively intact. The MDS further revealed the resident utilized oxygen. Observation of Resident #90 on 01/27/20 at 11:25 A.M. revealed the resident had an oxygen concentrator set to deliver oxygen at the rate of 2 LPM via a 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, staff interview, and review of facility policy, the facility failed to timely report medication irregularities to the physician. This affected one Resident (#6) of five reviewed for unnecessary medications. The facility census was 265. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, heart disease, psychosis, and obsessive-compulsive disorder. Review of physician orders dated 05/05/19 revealed Resident #6 was ordered Prozac (antidepressant/psychotropic) 20 milligrams (mg) daily for obsessive-compulsive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. The MDS revealed the resident received both antipsychotic and antidepressant medications seven of the seven day look back period. There had been no gradual dose reduction (GDR) attempted and the physician had not documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview; the facility failed to hold Coumadin (blood thinner) as ordered for one Resident (#415) of six reviewed for unnecessary medications. The facility census was 265. Finding include: Review of the medical record for Resident #415 revealed the resident was admitted to the facility on [DATE]. Diagnoses include disorder of kidney and ureter, malignant neoplasm (cancer) of endometrium, and atrial fibrillation (irregular heartbeat). Review of laboratory test results dated 01/27/20 revealed Resident #415's international normalized ratio (INR) (a test that measures the time for the blood to clot) was 3.6. The reference range for INR was documented as standard anticoagulant 2.0-3.0, and aggressive anticoagulant 2.5-3.5. The Certified Nurse Practitioner (CNP) ordered to hold two doses of Coumadin and restart on 01/29/20. Review of the Medication Administration Record (MAR) dated 01/20 revealed Resident #415 was administered Coumadin on 01/27/20 and 01/28/20. 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 observation, staff interview, and review of facility policy, the facility failed to properly store medications. This affected one of four medication rooms, and one medication cart of seven observed. The facility census was 93. Findings include: 1. Observation of the Brunner 3 medication room refrigerator on 01/30/20 art 10:32 A.M. revealed a open bottle of influenza vaccine (Afluria) dated opened 10/08/19. Review of an informational insert included in the Afluria medication box revealed that after the stopper of the vial was pierced it should be discarded after 28 days. Registered Nurse (RN) #36 confirmed during an interview on 01/16/20 at 10:32 A.M. that the opened Afluria bottle was outdated and should have been discarded. 2. A medication cart on the Brunner 2 was observed with RN #136 on 01/30/20 at 10:44 A.M. The medication cart was sitting in the hallway between rooms [ROOM NUMBERS]. Further observation revealed that the medication cart was unlocked and a nurse was not in direct view. RN #136…

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 review of facility policy, the facility failed to complete resident labs as ordered by the physician. This affected one Resident (#6) of five reviewed for unnecessary medications. The facility census was 265. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses psychosis, hyperlipidemia, Alzheimer's Disease, and hypertension. Review of physician orders dated 05/05/19 revealed Resident #6 was ordered laboratory draws for the comprehensive metabolic panel (CMP), lipid panel, and hemoglobin A1C (blood sugar) blood test in one week and every six months. Review of the facility laboratory results sheets dated 05/13/19 reveled all three labs were noted completed as ordered. Review of the six month draw dated 11/01/19 revealed Resident #6's CMP was completed however the lipid panel and A1C were not. Interview on 01/30/20 at 9:18 A.M., with Corporate Registered Nurse (CRN) #350 verified the facility…

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.