Edgewood Manor Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews with residents, interviews with staff, and review of facility policy, the facility failed to investigate an allegation of unlicensed staff administered unprescribed melatonin to residents. This affected four (Residents #3, #29, #55, and #60) of five residents reviewed for abuse. The facility census was 65. Findings include: 1. Review of the medical record for Resident #3 she was admitted on [DATE] with diagnosis of dementia. Review of the current physician orders from 07/24 for Resident #3 revealed she was prescribed melatonin 1 milligram (mg) at bedtime. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #3 revealed she was cognitively impaired. 2. Review of the medical record for Resident #29 revealed an initial admission date of 08/16/24 and a re-admission date of 03/08/24 with diagnosis of Alzheimer's disease Review of the significant change MDS dated [DATE] revealed he was cognitively impaired. Review of the current physician orders for 07/24…

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, resident representative interview, and facility policy the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected 28 (#3, #5, #14, #15, #18, #20, #22, #23, #26, #27, #29, #32, #33, #34, #36, #38, #39, #42, #43, #44, #45, #46, #51 #52, #55, #56, #60, and #61) residents residing in the memory care unit. The facility census was 65. Findings include: Observation on 07/01/24 at 10:16 A.M. of the memory care unit revealed the flooring of the edges of the hallways had a thick layer of dust and grime. Observation on 07/01/24 at 2:08 P.M. of Resident #60's room revealed the flooring, specifically around the corners and edges were unclean with built-up substance. Observation on 07/02/24 at 3:50 P.M. of the memory care unit revealed the flooring of the edges of the hallways had a thick layer of dust and grime. Resident #60's room flooring, specifically around the corners and edges remained unclean. In addition, Resident #45's room flooring around the corners and edges were unclean with a layer of dust.…

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 the facility Self-Reported Incident (SRI), review of the facility investigation, review of the facility census, resident interview, and staff interview, the facility failed to ensure a resident was free from staff to resident verbal abuse. This affected one (#16) of five residents reviewed for abuse. The facility census was 65. Findings include: Review of the SRI dated 05/14/24 revealed Resident #16 was stating that a State Tested Nurse Aide (STNA) was verbally abusive to her. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, sleep deprivation, urge incontinence, anxiety, depression, hyperlipidemia, and hypertension. Review of the quarterly Minimum Data Set assessment dated [DATE] identified the resident as cognitively intact. The resident was always incontinent of urine and bowel and required staff assistance for a majority of the activities of daily…

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 facility policy, the facility failed to provide adequate supervision to prevent resident elopement. This affected one (#54) of three residents reviewed for elopement. Additionally, the facility failed to ensure fall interventions were in place for one (#58) of three residents reviewed for falls. The facility census was 65. Findings include: 1. Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included noninfective gastroenteritis and colitis, cognitive communication deficit, muscle weakness, enterocolitis due to clostridium difficile, hypo-osmolality and hyponatremia, chronic obstructive pulmonary disease, acute embolism and thrombosis of unspecified deep veins of distal lower extremity, schizophrenia, and anxiety order. Review of the Minimum Data Set (MDS) assessment, dated 06/25/24, revealed the resident was rarely understood. The resident required the use of a wheelchair and was dependent for toileting 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 staff interview, the facility failed to ensure Resident #16 received oxygen at the correct rate as prescribed by the physician. This affected one (Resident #16) of two residents reviewed for respiratory care. The facility census was 65. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, sleep deprivation, urge incontinence, anxiety, depression, hyperlipidemia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was cognitively intact. The resident was always incontinent of urine and bowel and required staff assistance for a majority of the activities of daily living. The resident received oxygen. Review of Resident #16's physician orders for July 2024 identified a current order dated 08/03/23 for two liters of oxygen via nasal cannula. Review of Resident #16's plan of care,…

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 the facility policy, the facility failed to discard expired insulin. This affected three residents (#18, #32, and #38) reviewed for insulin storage. The facility census was 65. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of [DATE] with a diagnosis of diabetes mellitus type II. Review of the current physician orders for 07/24 for Resident #18 revealed an order for novolog flex insulin pen. 2. Review of the medical record for Resident #32 revealed an admission date of [DATE] with a diagnosis of diabetes mellitus type II. Review of the current physician orders for 07/24 for Resident #32 revealed an order for fiasp insulin pen. 3. Review of the medical record for Resident #38 revealed an admission date of [DATE] with diagnosis of diabetes mellitus type II. Review of the current physician orders for 07/24 for Resident #38 revealed an order for novolog insulin. Observations on [DATE] at 8:52 A.M. of the medication…

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 pharmacy recommendation, review of the medical record, staff interview, and review of the facility policy, the facility failed to ensure laboratory tests were completed per pharmacist recommendation and physician order. This affected one (#53) of one resident reviewed for laboratory testing. The facility census was 65. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with diabetic polyneuropathy, obesity, muscle weakness, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 as cognitively intact. Review of the plan of care, revised 08/23/23, revealed Resident #53 had an impaired metabolic status related to diabetes and obesity. Interventions included monitoring labs/diagnostic testing per physician order. Review of Resident #53's medical record including laboratory results revealed the last Hemoglobin A1C (HbA1c) test…

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 council minutes review, resident and staff interviews, the facility failed to serve hot and palatable foods. This had the potential to affect 65 of 65 residents who receive food from the kitchen. The facility census was 65. Findings include: Interview with Resident #21 on 08/15/22 at 3:48 P.M., revealed the food was horrible, cold and not at all appetizing. Interview with Resident #24 on 08/15/22 at 11:41 A.M., revealed the food was cold and not palatable. Interview with Resident #33 on 08/15/22 at 10:27 A.M., revealed the was food cold and there is no variety. Interview with Resident #60 on 08/15/22 at 10:33 A.M., revealed the food was cold and terrible. He stated he would send the food back to be reheated but would be cold again by the time the staff brought it back. Resident #60 stated the facility used to give out a monthly menu, but they discontinued to do so. The menu failed to be followed when it was distributed. Interview with Resident #64 on 08/15/22 at 10:50 A.M., revealed all meals were served cold and were not palatable. Review of the test…

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 in the kitchen. This has the potential to affect 65 of 65 residents receiving food and drink from the kitchen and who reside in the facility. The census was 65. Findings include: Observation on 08/16/22 between 9:27 A.M. and 10:00 A.M., of the kitchen, with Kitchen Manager #437 revealed: the box refrigerator with cartons of milk contained a white frosty substance halfway down all four sides of the walls of the refrigerator. The white substance flaked off the side walls and fell to the bottom of the refrigerator. The ceiling above the serving station and the lights above the stove and steam table contained dust and dirt. The water dispensing silver colored valve contained a quarter inch long black substance. Interview, at the time of the observation, with Kitchen Manager #437 revealed uncertainty of the last time the water dispensing machine machine was cleaned. Kitchen Manager #437 removed the substance from the dispenser and the black, slimy substance smeared in the paper…

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, interview and policy review, the facility failed to provide showers for residents dependent on staff for activities of daily living. This affected six (Residents #36, #41, #45, #60, #64 and #20) of six residents reviewed for showers and baths. The census was 67. 1. Review of Resident #36's medical record revealed an admission date of 06/27/22. Diagnosis included peripheral vascular disease, chronic kidney disease, prostate cancer, and atherosclerosis. Review of Resident #36's admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed the resident had a moderate cognitive function. The resident required an extensive assist of one person for personal hygiene, bathing, and dressing. Review of Resident #36's most recent care plan revealed the resident had an activity of daily living self-care performance deficit related to chronic kidney disease, fluctuating activities of daily living, and generalized weakness. During an interview on 08/15/22 at 10:05 A.M., Resident #36 stated he…

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 employee file review, staff interview, and policy review, the facility failed to complete annual evaluations on State Tested Nursing Aides (STNA). This affected four (#322, #327, #420, #424) of four STNA employee files reviewed. This had the potential to affect all 65 residents. The facility census was 65. Findings include: Review of STNA #322's employee file revealed a hire date of 04/22/14. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #327's employee file revealed a hire date of 07/03/19. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #420's employee file revealed a hire date of 01/25/05. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #424's employee file revealed a hire date of 12/05/18. The employee file did not contain a yearly employee evaluation for the past 12 months. Interview on 08/18/22 at 9:16 A.M., with the Director of Nursing verified STNAs, #322, #327, #420, and #424 failed to have their annual…

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

Based on observation, staff interview, review of staff in-services, review of Centers for Disease Control for Prevention (CDC)guidance, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of COVID-19. This had the potential to affect all 65 residents in the facility. The facility census was 65. Findings include: Observation of the kitchen area on 08/15/22 between 9:00 A.M. and 9:32 A.M. revealed the following: Dietary Aide (DA) #313 was noted scooping topping onto cakes in small round white foam containers. DA #313 was observed without a face mask as required by current recommendations. DA #313 had face mask pulled down under chin. Cook #418 was observed cleaning dishes and cooking at the stove top without face mask as required by current recommendations. [NAME] #418 was observed with face mask below chin. Additional observations on 08/15/22 from 11:35 A.M. to 12:50 P.M. revealed the following: At 11:35 A.M., [NAME] #418 took food temperatures without face mask to cover nose and mouth, as…

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 interview the facility failed to provide a dignified dining experience for residents. This affected seven (Residents #5, #24, #38, #40, #50, #53 and #122) of fourteen residents observed for lunch in the dining room. The facility census was 64. Findings include: Observation of the dining room on 08/15/22 between 12:15 P.M. and 12:50 P.M. revealed three tables with two residents each and eight tables with one resident. The three tables with two residents at each table were not served together. Resident #53 and #122 shared the last table along the left wall. Resident #122 received food after Resident #53 had eaten and left the dining room. Resident #40 and Resident #50 sat at a table together in the middle of the dining room in front of the vending machine. Resident #50 was served at 12:25 P.M. and Resident #40 was served at 12:32 P.M. Resident #50 waited to eat until Resident #40 received food. Resident #24 and #38 shared a table to the left of the kitchen window. Resident #38 received food at 12:28 P.M. and Resident #24 received food at 12:35 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to reassess the effectiveness of interventions and failed to review and update the comprehensive care plan for a resident. This affected one (Resident #53) of 22 residents whose care plans were reviewed. The facility census was 64. Findings include: Resident #53 was admitted on [DATE] with diagnoses including diabetes mellitus type II, acute kidney failure, displaced intertrochanteric left femur fracture, hypertension, depression, morbid obesity, osteoarthritis, and iron deficiency. Review of the Minimum Data Set (MDS) assessment, dated 07/15/22, revealed Resident #53 had moderate cognitive impairment. Resident #53 required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and required the assistance of two personal for bathing. Resident #53 was independent with eating. Review of the physician order dated 04/10/22 revealed a regular diet with mechanical soft ground meats. A physician…

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, interview and policy review, the facility failed to ensure an indwelling urinary catheter was maintained to prevent infection. This affected one (Resident #44) of one resident reviewed for catheter care. The census was 65. Findings include: Review of Resident #44's medical record revealed an admission date of 06/27/22. Diagnosis included infection and inflammatory reaction due to indwelling urethral catheter, dysphasia, Huntington's disease, gout, and diabetes mellitus. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive function. The resident had an indwelling catheter and was always continent of bowel. Review of Resident #44's most recent care plan revealed the resident had a need for an indwelling catheter related to acute urinary retention due to benign prostatic hypertension. Catheter care was required each shift. Review of Resident #44's medical record revealed a physician's order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review, the facility failed to ensure a resident who required dialysis was receiving the care and treatment according to physician orders and failed to maintain communication with the dialysis center on coordination of care. This affected one (Resident #61) of one resident reviewed for dialysis. The facility census was 65. Findings include: Review of Resident #61's medical record revealed an admission date of 07/16/22, with diagnoses that included: end stage renal disease, morbid obesity, chronic obstructive pulmonary disease, atrial fibrillation, hyperkalemia, congestive heart failure, diabetes mellitus, type II, anemia, and hypertension. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #61 was cognitively intact, had clear speech and was able to understand others and able to make self-understood. Resident #61 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene and required total dependence 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 record review, staff interview and policy review, the facility failed to ensure accurate and complete medical records were maintained. This affected one (Resident #61) of 22 resident records reviewed. The facility census was 65. Findings include: Review of Resident #61's medical record revealed an admission date of 07/16/22, with diagnoses that included: end stage renal disease, morbid obesity, chronic obstructive pulmonary disease, atrial fibrillation, hyperkalemia, congestive heart failure, diabetes mellitus, type II, anemia, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE], Resident #61 was cognitively intact, had clear speech and was able to understand others and able to make self-understood. Resident #61 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene and required total dependence for transfers. Resident #61 was occasionally incontinent of urine and was dependent on renal dialysis. Review of physician orders revealed an order 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 and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one resident (#17) of 19 reviewed during the annual survey. The facility census was 64. Findings include: Medical record review revealed Resident #17 admitted to the facility on [DATE]. Diagnoses included fracture of the first lumbar vertebra, fracture with delayed healing and low back pain. Review of the resident's physician orders revealed an order dated 11/13/18 to administer Tramadol (opioid pain medication) 50 milligrams (mg) two tablets every six hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for 03/2019 revealed the resident was administered two Tramadol 50 mg tablets on 03/27/19 at 4:22 A.M., 03/28/19 at 12:03 P.M. and 03/31/19 at 3:39 P.M. Review of the resident's comprehensive MDS assessment, dated 04/02/19, section N0300 H, revealed the resident did not receive an opioid pain medication during the seven…

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, staff interview, and review of facility policy, the facility failed to ensure resident safety while smoking. This affected three residents (#20, #24, and #48) of four residents reviewed for smoking. In addition, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one resident (#19) of three reviewed for falls. The facility census was 64. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 08/28/17. Diagnosis included diabetes mellitus type 2, hemiplegia, and atherosclerotic heart disease. Resident was noted to be cognitively intact. Interview on 08/25/19 at 2:34 P.M. with Resident #20 revealed the resident maintains cigarettes and lighter in his/her personal possession. Review of Resident #20's annual Smoking Safety Screen dated 07/31/19 revealed staff were to keep the resident's cigarettes and lighter. Observation on 08/26/19 at 3:12 P.M. revealed 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 and staff interview, the facility failed to timely transmit a quarterly Minimum Data Set (MDS) assessment to The Centers for Medicare and Medicaid Services (CMS). This affected one (#1) of 22 residents reviewed during the investigation stage of the survey. The census was 64. Findings include: Review of Resident #1's medical record revealed an admission date of 03/14/17. Diagnoses included unspecified fracture of upper end of unspecified tibia, secondary Parkinsonism, and dysphagia. Review of Resident #1's MDS assessments revealed the most recently completed annual MDS assessment was completed and transmitted on 01/11/19. Resident #1 had quarterly MDS assessments completed on 04/08/19 and 07/01/19, however, the quarterly MDS assessment completed on 07/01/19 was not transmitted to CMS. During review of Resident #1's MDS assessments, the quarterly MDS assessment dated [DATE] was marked as completed, however not locked, or transmitted to CMS as of 08/28/19 at 9:00 A.M. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of a facility policy, the facility failed to ensure pharmacy recommendations were addressed timely. This affected two residents (#33 and #28) of six reviewed for unnecessary medications. The facility census was 64. Findings include: 1. Medical record review revealed Resident #33 admitted to the facility on [DATE]. Diagnoses included major depressive disorder and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 07/22/19, revealed the resident had impaired cognition. Review of the resident's physician orders revealed the resident was prescribed Buspirone 10 milligrams (mg) every morning and at bedtime for anxiety. Review of the resident's monthly pharmacy review report, dated 03/22/19, revealed it was a repeated recommendation for the physician to consider a gradual dose reduction from 10 mg twice a day to 7.5 mg twice a day. The date of the original recommendation request was 01/27/19 and the facility was asked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital records, staff interview, and review of a facility policy, the facility failed to ensure residents did not receive unnecessary medication. This affected one resident (#204) of six reviewed for unnecessary medications. The facility census was 64. Findings include: Medical record review revealed Resident #204 admitted to the facility on [DATE]. Diagnoses included protein-calorie malnutrition, unspecified chronic pain due to trauma, anxiety. Review of the resident's discharge orders, dated 08/19/19, from an acute care hospital revealed the resident was not ordered any antibiotic medications. Review of the resident's 08/19/19 facility admission orders revealed the resident was ordered Zithromax (antibiotic) 250 milligrams (mg) daily for infection. Review of Resident #204's Medication Administration Record (MAR) revealed the resident was administered Zithromax 250 mg daily, in the morning, from 08/20/19 through 08/27/19. Interview on 08/27/19 at 1:44 P.M., 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.