The Sanctuary At Tuttle Crossing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility policy review, the facility failed to conduct a medication regimen reviews at least monthly. This affected two (#28 and #32) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 01/24/21. Diagnoses include senile degeneration of the brain, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, hypothyroidism, and sleep apnea. Review of Resident #28's physician orders revealed the resident received antipsychotic, antidepressant, antianxiety, and opioid medications. Review of the pharmacy records revealed no documentation of the pharmacist reviewing Resident #28's medication regimen in February 2025. Additional review of the consultant pharmacist's medication regimen recommendation to the physician did not include a monthly review or recommendations for Resident #28 in February 2025. Interview with 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, medical record review, staff interview, review of a user guide, review of manufacturer instructions, and facility policy review, the facility failed to prime an insulin pen needle prior to selecting the ordered dose and administering the medication to a resident and failed to administer antibiotic and anticoagulant medications as ordered which resulted in significant medication errors. This affected three (#26, #44, and #113) of eight residents reviewed for medication administration. The facility census was 58. Findings include: 1. Review of Resident #113's medical record revealed a most recent admission date of 04/24/25. Diagnoses included infection following a surgical procedure, hypertension, muscle weakness, and diabetes mellitus type II. Review of Resident #113's physician orders revealed an order dated 04/24/25 for the resident to received Humalog insulin 12 units subcutaneously (SQ) before meals. Observation of medication administration on 05/15/25 at 2:44 P.M. revealed Registered…

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, resident interview, and staff interview, the facility failed to ensure resident who agreed to receive dental services was provided with the services in a timely manner. This affected one (#43) of one residents reviewed for dental services. The facility census was 58. Findings include: Review of the medical record for Resident #43 revealed an admission date of 04/29/24. Diagnoses included cerebral infarction, alcohol dependence, intellectual disabilities, and hypertension. Review of the plan of care dated 04/29/24, and revised 05/09/24, revealed Resident #43 had the potential for oral dental health problems related to his own teeth. Interventions included to coordinate arrangements for dental care, transportation as needed as ordered, dental consultation and follow-up as ordered, monitor and report to the medical director any signs or symptoms or complaint of oral pain, monitor the resident for any signs or symptoms of chewing/swallowing difficulties, weight loss, fever,…

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 documentation of a resident discharging from the facility against medical advice (AMA) was documented in the medical record. This affected one (#54) of three residents reviewed for discharges. The facility census was 58. Findings include: Review of the medical record for Resident #58 revealed an admission date of 02/11/25 and a discharge date of 02/15/25. Diagnoses included chronic heart failure, muscle weakness, and chronic kidney disease. Review of Resident #58's nursing progress note dated 02/15/25 at 2:53 P.M. revealed a nurse was notified by a nurse aide that Resident #58 left with wife without signing out at the nurses' station in the red book, and notifying the nurse. The nurse saw the wife walk past the nurse's station to the resident's room. The resident's wife did not say anything to the nurse about taking the resident. The nurse was assisting another resident before being notified by the 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, resident and staff interview, and policy review, the facility failed to ensure resident call systems functioned appropriately. This affected one (#9) of two residents reviewed for call lights. The facility census was 58. Findings include: Review of the medical record for Resident #9 revealed an admission date of [DATE]. Medical diagnoses included metabolic encephalopathy, generalized anxiety disorder, delusional disorder, obstructive sleep apnea, chronic pain, epilepsy, and obesity. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was assessed with intact cognition. Observation on [DATE] at 9:03 A.M. revealed Resident #9's call light button did not activate when the resident pushed the button. Resident #9 attempted to press the call light button several times without success. Further observation outside the resident's room revealed a nurse passing medications was notified and indicated she would assist Resident #9 with the call light…

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 shower room in a clean and sanitary manner. This affected three (Residents #181, #195, and #208) of three residents reviewed for clean environment and had the potential to effect 34 residents who used the shower room on the 200 hall. The facility censes was 49. Findings include: Observation on 09/23/24 at 1:00 P.M. of the 200 hall shower room revealed the floor had a large amount of black, stained areas, nearly covering the entire floor. The floor appeared to be a poured coating. The area directly surrounding the center floor drain was loose. When stepped on, water would bubble from underneath it. A small area of tile on the half wall dividing the two shower areas, had a portion of tile missing. The area was approximately three inches long and one inch wide. Interview on 09/23/24 at 1:30 P.M. with the Administrator revealed the facility has begun to locate contractors to get estimates to have the shower fixed, but have nothing definite yet. Interview on 09/23/24 at 1:10 P.M. with State Tested Nurse Aide…

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 staff interview, observation, record review, and facility policy review, the facility failed to maintain infection control procedures to prevent the development of infections when staff failed to wash or sanitize their hands before a dressing change and after gloves changes during a dressing change. This affected one (Resident #32) of three Residents reviewed for wounds. The facility census was 50. Findings include: Record review of Resident #32 revealed an admission date of 02/21/24 with pertinent diagnoses of: type two diabetes mellitus with other skin complications, paraplegia, muscular dystrophy, obstructive sleep apnea, need for assistance with personal care, non pressure chronic ulcer of left and right foot, atherosclerotic heart disease of native coronary artery, hypertension, spinal stenosis, disorder of kidney and ureter, hyperlipidemia, cardiac arrhythmia, hypothyroidism, anemia, peripheral vascular disease, chronic kidney disease, and chronic pain syndrome. Review of the 02/25/24 admission Minimum Data Set (MDS) assessment revealed the resident is cognitively…

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 interview and policy review, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all 52 residents residing in the facility. The census was 52. Findings include: Tour of the kitchen 12/16/23 at 11:30 A.M. through 12:47 P.M. revealed the following concerns: 1. The ice machine had brown streaks running from the screws onto the white plastic in each corner of the ice machine making up the chute. 2. The fronts of the stainless steel appliances were dirty, smeared, sticky, with dry debris which included the top surfaces of the oven, salad bar, refrigerators, and dishwasher. 3. There was no evidence of the facility recorded food temperatures for breakfast, lunch and supper tray line between 09/01/23 and the lunch meal of 12/13/23. 4. There was no evidence of the facility recorded refrigerator and freezer temperatures to ensure acceptable refrigeration temperatures were maintained since 09/01/23. 5. The walk in refrigerator had a white liquid pooled on the floor. There were two mugs on a shelf with liquid that…

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, resident interview, and staff interview, the facility failed to develop and implement appropriate interventions for a resident with dementia. This affected one (#16) of three residents reviewed for dementia care. The facility census was 53. Findings include: Review of Resident #16's medical record revealed an admission date of 04/19/21. Diagnoses included bipolar disorder, vascular dementia, depression, dysphasia, and vitamin deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired and was rarely, if ever, understood. Resident #16 required extensive assistance with bed mobility, limited assistance with transfers, and supervision for walking in the hallways. Review of the plan of care dated 09/11/23 revealed Resident #16 had impaired cognition and wandering behaviors. Interventions included assess risk factors, family conferences to discuss residents attempts to leave, involve in activities of choice,…

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 ensure therapeutic diets were served according to physician order. This affected one (#19) of three residents reviewed for diet order and preferences. The facility identified five residents with physician ordered pureed diets. The facility census was 53. Findings include: Review of Resident #19's medical record revealed an admission date of 07/08/22. Diagnoses included parkinson's disease, metabolic encephalopathy, malnutrition, dementia, atrial fibrillation, adult failure to thrive, and kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was moderately cognitively impaired. Review of the plan of care dated 09/27/23 revealed Resident #19 had a nutritional problem. Interventions included food preferences from family, informed consent waiver signed by resident, menu in room per family request, offer substitutes as requested, and serve diet as ordered. Review of a 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.

Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored, prepared, and distributed in a sanitary manner. This had the potential to affect 52 out of 53 residents who received meals from the kitchen. Resident #50 was identified by the facility as not receiving meals from the kitchen. The census was 53. Findings include: 1. Interview and observation with Licensed Practical Nurse (LPN) #106 of the 200 unit kitchenette on 08/02/23 at 10:50 A.M. revealed the counters were sticky and the drawers had a red and black sticky substance on them. 2. Observation on 08/02/23 at 10:21 A.M. and 12:00 P.M. revealed Dietary Aide #70 was working in the kitchen, had a beard, and was not wearing a beard cover. Interview with Dietary Aide #70 at the time of the observations verified he did not have a beard cover on. 3. Observation of the kitchen on 08/02/23 from 10:01 A.M. to 10:25 A.M. revealed the following findings which were verified with Dietary Manager #100 at the time of the observation. • The inside of the ice machine along the left and right side…

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 meal times, observations, staff interviews, and resident interviews, the facility failed to ensure nourishing snacks were offered to residents at bedtime. This had the potential to affect 40 (#10, #12, #14, #18, #20, #22, #26, #28, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, and #72) out of 41 residents on the 200 unit who receive meals from the kitchen. Resident #50 was identified by the facility as not receiving meals from the kitchen. The census was 53. Findings include: Review of the 200 unit meal times revealed dinner was served at 5:00 P.M. and breakfast was served at 8:00 A.M. There was 15 hours between dinner and breakfast. Interview on 08/02/23 at 9:49 A.M. with State Tested Nursing Assistant (STNA) #104 revealed there was a snack cart created between lunch and dinner, and the dietary department puts snacks in the kitchenette of unit 200. Interview on 08/02/23 at 10:21 A.M. with the Dietary Manager (DM) #100 revealed there were snacks available…

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 facility record review, the facility failed to employ a qualified director of food and nutrition services to provide oversight for the sanitation of the kitchen and serving of physician ordered diets. This had the potential to affect all residents except one resident (#46), who ate nothing by mouth. The facility census was 51. Findings include: Observations and interviews between 11/20/22 to 11/22/22 revealed the facility failed to store food appropriately, failed to prepare food appropriately, failed to maintain a clean, sanitary kitchen, failed to serve food that was palatable, and failed to serve serve meals according to physician orders. Interviews on 11/20/22 at 8:50 A.M. and on 11/21/22 at 11:20 A.M. with Dietary [NAME] #209 revealed the facility did not have a dietary manager at that time. Dietary [NAME] #209 reported she had received food safety certification but was not certified as a dietary manager. Interview on 11/21/22 at 4:11 P.M. with the Administrator revealed Dietary [NAME] #209 was acting as the kitchen manager, however,…

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

Based on record review, observations, staff interview, review of a cleaning schedule, and review of the facility policies, the facility failed to maintain the kitchen in a clean and sanitary manner, obtain food temperatures in a sanitary manner, and store food appropriately. This had the potential to affect all residents except one (Resident #46) who did not eat food from the kitchen. The facility census was 51. Findings include: 1. Observation of the kitchen on 11/20/22 beginning at 8:50 A.M. with Dietary [NAME] #209 revealed in the freezer, there were containers of flatbread, eggs, sausage, diced carrots, and breaded chicken and they were observed to be open and exposed to the cold air. Further observation revealed the three boxes on the top shelf were completely saturated in ice, these boxes contained pie shells, English muffins, and wild caught seafood. In the walk-in cooler, there was a large bag of onions sitting on the floor. Additional observation revealed an container of tomato soup dated 11/10/22 and a container of shredded cheese dated 10/07/22. Dietary [NAME] #209…

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, record review, and review of a product guide, the facility failed to prepare puree food in a palatable manner. This had the potential to affect three residents (#5, #7, and #31) of three residents identified by the kitchen to be on a puree diet. The facility census was 51. Findings include: Review of the kitchen's diet list revealed Resident #5, #7, and #31 were listed as being on a puree diet. Observation on 11/21/22 at 11:20 A.M. revealed Dietary [NAME] #209 preparing noodles for lunch. She filled a blender with about 10 to 12 ounces of water, she spooned an unmeasured amount of noodles, and began to blend the noodles and water. When Dietary [NAME] #209 finished blending it, the noodles were at a liquid texture. Dietary [NAME] #209 put it in a stainless-steel pan and then added an unmeasured amount of thickener to the food twice. She then began preparing the Swedish meatballs. Dietary [NAME] #209 reported she was just going to use the sauce for the meatballs as a liquid. She put an unmeasured amount of meatballs and sauce in the blender 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, staff interview, and policy review, the facility failed to ensure pureed food was prepared to an appropriate smooth texture prior to serving to residents on a pureed diet. This affected six residents (#15, #19, #29, #36, #55, and #65) out of six residents who were on a prescribed pureed diet. The facility census was 61. Findings Include: Observation on 02/06/23 at 3:44 P.M. with the Dietary Manager #139 of the pureed [NAME] sandwiches for the dinner meal revealed the DM #139 placed three pounds of sliced corned beef, an unknown amount of processed cheese slices, one fourth cup of sauerkraut, and one tablespoon of Thousand Island dressing into the puree blender. The DM #139 pureed the bread ahead of time and did not add any bread in to the blender. The DM #139 then added an unknown amount of water and a teaspoon of thickener to the mixture and continued blending. At 3:55 P.M., the DM #139 stopped the blender and tasted the mixture and determined it was not a smooth consistency. The DM #139…

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 staff interview and medical record review, the facility failed to provide written notification of the resident's transfer to the hospital and the reason for the transfer to the resident or resident representative and the Office of the State Long-Term Care Ombudsman. This affected one (Resident #18) of one resident reviewed for hospitalization. The facility census was 50. Findings include: Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, critical illness myopathy, severe protein calorie malnutrition, muscle wasting and atrophy, and cardiomegaly. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the progress notes dated 06/24/22, 10/29/22, and 11/17/22 revealed Resident #18 went out to a local hospital for a change in condition and was kept for several days at a local hospital. There was no evidence the resident and/or resident representative was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interview, and record review, the facility failed to ensure residents who were dependent on staff for assistance received showers or baths as scheduled. This affected two (Residents #50 and #108) of five residents reviewed for activities of daily living. The facility identified 49 residents required assistance from staff with bathing. The facility census was 51. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 08/05/22. Diagnoses included hematemesis, type two diabetes mellitus without complications, chronic kidney disease stage three, and atherosclerotic heart disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 required the physical help of one person in part of the bathing activity. Review of the plan of care dated 08/15/22 revealed Resident #50 had a self-care deficit requiring staff assistance with activity of daily living cares related to diagnoses,…

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 staff interview, observation, and record reviews, the facility failed to ensure activities were provided on weekends for cognitively impaired residents. This affected four residents (#1, #23, #35, and #46) of four residents reviewed for activities. This had the potential to affect 39 residents who the facility identified were cognitively impaired. The facility census was 51. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 09/26/22. Diagnoses included chronic obstructive pulmonary disease, cognitive communication deficit, vascular dementia, anxiety disorder, hallucinations, delirium due to known physiological condition, and mood disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition. Review of the plan of care dated 09/30/22 revealed Resident #23 had a potential for alteration in activities related to interest in pet visits and television and movies. Interventions…

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 of meal service, staff interview, review of the facility policy, and record review, the facility failed to ensure Resident #5 and #17 were served mechanically-altered diets as physician ordered. This affected two (#5 and #17) of 50 residents who consumed food from the kitchen. The facility census was 51. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 08/25/09 with diagnoses including dementia and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had severely impaired cognition and was on a mechanically altered diet. Review of the physician's order dated 09/06/22 revealed Resident #5 was to receive a regular diet with mechanical soft texture. Review of the tray ticket for lunch on 11/21/22 revealed Resident #5 was to receive a puree diet. Observation on 11/21/22 from 11:20 A.M. to 1:00 P.M. of the lunch meal service revealed Resident #5 received a puree diet, and this was confirmed by…

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 ensure medications were administered as ordered by the physician. Observation of medication administrations by two nurses, revealed 31 medications were observed given to seven residents. Six medications errors were identified, which resulted in a medication error rate of 19.35 percent. This affected two residents (#11 and #43) of seven residents observed during medication administration. The facility census was 60. Findings include: 1. Review of the current physician's orders for Resident #11, dated 06/2019, revealed an order for Aspirin tablet 81 milligrams (mg) enteric coated (EC). Observation on 06/12/19 at 8:40 A.M., revealed Licensed Practical Nurse (LPN) #256 placed the Aspirin EC tablet into a plastic pouch which contained other due medications for Resident #11 and crushed the medications. LPN #256 then administered the medications to Resident #11. On 06/12/19 at 9:15 A.M., LPN #256 confirmed she had crushed the enteric coated aspirin. 2. Review Resident #43's current physician's…

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 provide a transfer/discharge notice to two residents and/or their representatives when they were transferred to the hospital. This affected two residents (#13 and #17) of two reviewed for hospitalizations. The facility census was 60. Findings include 1. Review of medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including cirrhosis of the liver, and kidney disease. Review of comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #13's progress note dated 04/13/19 at 12:53 P.M., revealed an abnormal assessment and abnormal laboratory findings for the resident. An order received to send the resident to the Emergency Department (ED) for an assessment. The family was notified. A bed hold notice was given to the resident/representative at the time of transfer. The Ombudsman was notified of the transfer. The 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 medical record review, observations and staff interviews, the facility failed to implement fall precautions as ordered. This affected one resident (#37) out of one resident reviewed for falls. The facility census was 60. Findings include: Medical record review for Resident #37 revealed an admission date of 01/26/18 with diagnoses including dementia, spondylolisthesis of the lumbar region, glaucoma, insomnia and repeated falls. Review of Resident #37's plan of care dated 03/26/19 revealed a self-care performance deficit related to limited dementia. Interventions included the resident required extensive assistance of one to two staff for transferring and the encouragement to use the call light for assistance. The resident was also care planned for falls related to unsteady gait and muscle weakness, and actual falls. Interventions included non-skid strips to the floor next to Resident #37's bed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record and interview the facility failed to obtain ordered laboratory tests for one resident (#17) of one reveiwed for laboratory tests. The facility census was 60. Findings include Review of medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), and type two diabetes. Review of comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #17's current physician orders revealed a laboratory (lab) order to complete a Glycated Hemoglobin (Hgb A1c to measure the average blood glucose every three months. An order for a Basic Metabolic Panel (BMP) to measure potassium level, on the 12th of each month. An order for a Complete Blood Count (CBC) to evaluate overall health every six months. Review of medical records revealed the most recent Hgb A1C was obtained on 12/18/18. The Hgb A1c was not obtained in March 2019 or June 2019 as ordered. The most recent…

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 interviews and review of the facility policy, the facility failed to safeguard resident's information contained on individual medication packets. This affected six residents (#11, #15, #19, #27, #36 and #43) of seven residents observed during medication administration pass. The facility census was 60. Findings include: Observation on 06/11/19 from 1:20 P.M. to 1:55 P.M., revealed Licensed Practical Nurse (LPN) #300 disposed of the individual medication packet after removing the resident's medication into the trash bin located on the side of the medication cart. The medication packets contained the resident's full name, their room number and the medication administered. LPN #300 was observed to dispose of the empty medication packets for Residents #15, #19, #27 and #36 in this manner. Observation on 06/12/19 from 8:39 A.M. to 10:46 A.M., revealed LPN #256 also disposed the empty medication packets for Residents #11 and #43 into the trash bin on the medication cart. On 06/12/19 at 11:07 A.M., Housekeeper #325 confirmed she collected the trash from 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.