River Run Healthcare Of Portsmouth

Based on record review and interview the facility failed to ensure the anti-histamine medication, Vistaril (for anxiety/agitation) was administered to Resident #11 with a current physician's order to ensure the medication was necessary. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #11 revealed an admission date of 02/23/22 with diagnoses including type two diabetes mellitus, altered mental status, sepsis, malignant neoplasm of prostate, dementia without behaviors, displaced intertrochanteric fracture of right femur, protein calorie malnutrition, dehydration and pneumonia. Record review revealed a physician's order, dated 04/21/22 for Vistaril (hydroxyzine pamoate), an anti-histamine medication sedative hypnotic medication 25 milligrams (mg) every eight hours as needed (PRN) for anxiety/agitation. The order for the medication was for 14 days. Review of the medication administration record Resident #11 received the Vistaril on 05/10/22 at 9:48 P.M. On 05/12/22 at 11:00 A.M. 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.

Based on observation, record review, medication insert review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.14% and included two medication errors of 28 medication administration opportunities. This affected two residents (#6 and #9) of three residents observed for medication administration. Findings include: 1. Record review for Resident #9 revealed an admission date of 10/29/19 with pertinent diagnoses of: fracture of superior rim of left pubis, overactive bladder, history of COVID-19, hypothyroidism, type two diabetes mellitus, hypertension, Alzheimer's disease, epilepsy, dementia, hyperlipidemia, Parkinson's disease, major depressive disorder, insomnia and tremor. Review of a physician's order, dated 03/31/22 revealed an order for Primidone Tablet 250 milligrams (mg) give one tablet by mouth in the morning for tremors. On 05/11/22 at 8:46 A.M. Registered Nurse (RN) #121 was observed administering medications to Resident #9. RN #121 obtained a blister pack containing the…

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

Based on record review and interview the facility failed to ensure annual performance evaluations and in-service education was completed as required. This affected two employees, STNA #116 and #120 who had worked in the facility for more than one year and had the potential to affect all 19 residents residing in the facility. Findings include 1. STNA #116 started to work at the facility on 02/03/16. Review of STNA #116's personal file revealed an employee evaluation dated 02/01/19, however it was not signed by STNA #116 indicating agreement with or review of the evaluation. The Assistant Director of Nurses (ADON) confirmed on 02/13/20 at 10:35 A.M. that STNA #116's evaluation had not been signed by the employee as required. Review of the facility policy, titled Performance Evaluation, dated 06/2010 revealed performance evaluations would be completed after 90 days of employment, yearly, and would be dated and signed by the employee acknowledging receiving the evaluation. In addition, review of STNA #116's annual in-service training documentation revealed no evidence the employee…

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, menu review and staff interview the facility failed to ensure the written menu was followed. This had the potential to affect all 19 residents residing in the facility. Findings include: Observation of the preparation of the ground chicken on 02/11/2020 at 11:00 A.M. revealed [NAME] #106 placed 12.8 ounces of chicken in the food processor to chop. According to the menu 21.2 ounces were needed for four servings of chicken for the lunch meal. Observation of tray line at 11:33 A.M. revealed [NAME] #106 served residents a four-ounce serving of chicken. Review of the menu revealed residents on a mechanical soft diet should receive 5.3 ounces. The menu did not identify the serving size for the chicken for the other diets served in the facility. [NAME] #106 served other diets a four-once portion. Interview with Dietary Supervisor (DS) #118 on 02/11/2020 at 12:00 P.M. confirmed the menus did not specify the serving size for chicken for the regular diet, the no added salt diet, and the carbohydrate-controlled diet. The menu for mechanical soft diet called for 5.3 ounces…

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 maintain the floor in the 100 hall and dining area in a clean and sanitary manner and to ensure the surface was safe for those who walk through this area. This had the potential to affect all 19 of 19 resident residing at the facility. Findings include: On 02/13/20 at 4:26 P.M. during tour of the facility with Registered Nurse (RN) #115 the flooring in the 100 Hall and part of the dining area was observed to be loose and in poor repair. Gaps between the laminate flooring up to two inches were noted, preventing cleaning due to exposure of the sub floor. The finish was coming off of some pieces of the laminate flooring exposing the particle board. Interview with RN #115 confirmed the above findings at the time of the observation.

Based on record review and interview the facility failed to ensure residents had access to their personal funds account. This affected one resident (#20) and had the potential to affect 12 additional residents (#3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, and #21) who had personal funds managed by the facility. Findings include: On 02/09/20 at 3:53 P.M. during an interview, Resident #20 reported she could not get money from her personal fund account at any time requested. Resident #20 reported she had to wait until someone from the business office was in the facility to receive money from her personal funds account. On 02/13/20 at 1:54 P.M. interview with Business Office Manager (BOM) #125 and the Assistant Director of Nurses (ADON) revealed the facility did not provide residents' access to money after office hours or on the weekend. The ADON reported in the past they had left money in the medication cart, however this was not the current practice. The facility identified 13 residents, Resident #3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21 who had personal…

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 and interview the facility failed maintain receipts for items purchased from resident funds. This had the potential to affect 13 residents (#3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21) who had personal funds managed by the facility. Findings include: During review of resident personal accounts on 02/13/20 at 2:02 P.M., Business Office Manager (BOM) #125 reported residents would sign out an amount of money (for withdrawal) and the Assistant Director of Nurses (ADON) would go to the store and get what they wanted. BOM #125 reported she did not have any receipts reflecting what the ADON had purchased for the residents. BOM #125 revealed the ADON would give the residents what items they had wanted from the store, the receipt, and any change left from the amount withdrawn. BOM #125 revealed she did not receive any receipts from items purchased nor was any change returned to the resident account. The facility identified 13 residents, Resident #3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21 who had personal funds managed by 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, record review and interview the facility failed to ensure all residents received adequate and timely treatment and care as needed. The facility failed to ensure coordinated communication and care with Hospice for Resident #7, failed to ensure adequate preventative measures were in place for a non pressure related skin ulceration for Resident #18, failed to ensure adequate bowel monitoring was completed for Resident #20, failed to monitor bruising for Resident #13 and failed to ensure Resident #1 was adequately monitored for diarrhea, nausea and vomiting prior to the resident being hospitalized for a small bowel observation. This affected five residents (#1, #7, #13, #18 and #20) of 13 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, bipolar disorder, hypertension, dementia, anxiety, depression and suicidal ideation. Review of the quarterly Minimum Data Set (MDS) 3.0…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure residents were treated with dignity and respect. This affected one resident (#19) who did not receive her meal when other residents were served and one resident (#18) who was served last in the dining room after the hall trays were passed. The facility census was 19. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, anxiety, depression, malignant neoplasm of colon, malignant neoplasm of hepatic flexure and altered mental status. A review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/01/20 revealed Resident #19 had moderate cognitive impairment and was totally dependent for two person assistance for activities of daily living. No delusions or hallucinations were identified. Resident #19 was identified as having no problems swallowing, however held food in mouth or cheeks. Review of physician's orders for 02/2020 revealed Resident #19 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 medical record review and staff interview the facility failed to refer residents for a level II pre-admission screening and resident review (PASARR) when a newly evident or possible mental disorder was apparent. This affected two residents (#11 and #18) of two residents reviewed for PASSAR. Findings include: 1. Review of Resident # 11's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hernia without obstruction or gangrene, osteoarthritis, chronic obstructive pulmonary disease, opioid abuse, hypothyroidism, inhalant abuse, essential hypertension, atrial fibrillation, muscle weakness, constipation, major depressive disorder and type two diabetes. Review of Resident #11's PASSAR dated 05/10/18 revealed the PASSAR was not applicable. Review of Resident #11's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/28/19 revealed Resident # 11 had no level 2 PASSAR. Review of Resident #11's updated diagnoses list revealed on 05/10/19 she was newly diagnosed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #6 was provided the necessary equipment to maintain/improve mobility. This affected one resident (#6) of two residents reviewed for positioning. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dysphagia, diabetes mellitus, hypertension, depression and epilepsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, completed on 11/04/19 revealed Resident #6 had impaired cognition, required extensive assistance from staff for bed mobility, locomotion, dressing and total dependence from staff for personal hygiene, toilet use and transfers. On 02/09/20 at 11:29 A.M. Resident #6 was observed in the dining area with feet not positioned on the foot plate while in tile in space wheelchair. Resident #6's feet were observed resting against the foot place. On 02/09/20 at 1:30 P.M. Resident #6 was observed with feet not positioned on foot plate, but feet were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide timely and adequate nail care to Resident #14, who was assessed to be dependent on staff for activities of daily living care. This affected one resident (#14) of two residents reviewed for activities of daily living. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of the care plan dated 03/15/16 revealed Resident #14 was dependent on staff and all activity of daily living care and the resident's needs would be met. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, completed 01/01/20 revealed Resident #14 had moderate cognitive impairment and was totally dependent on staff for activities of daily living. On 02/09/20 at 10:28 A.M. an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of Resident #18. This affected one resident (#18) of three residents reviewed for activities. Findings include: Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, left artificial shoulder joint, overactive bladder, reactive psychosis, insomnia, type one diabetes, essential hypertension, intellectual disability, migraine, dependent personality, bipolar disorder, major depressive disorder, partial traumatic amputation of right mid foot and anxiety disorder. Review of Resident #18's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's speech was clear, she understands, was understood and her cognition was intact. Resident #18 had moderate depression, delusions and was verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure residents received nutritional interventions to prevent weight loss and fluids were not needlessly restricted. This affected two residents (#7 and #18) of seven residents reviewed for nutrition and hydration. Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the faciliy on 11/13/2019 with diagnoses that included malignant neoplasm of upper lobe right bronchus or lung, malignant neoplasm, chronic obstructive pulmonary disease and atherosclerotic heart disease. Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/29/2019 revealed her speech was clear, sometimes she was understood, sometimes she understands, her short- and long-term memory was impaired, she had no recall and her decision making was severely impaired. Resident #7 had no indicators of psychosis, no behaviors, and did not reject care. Resident #7 required extensive assistance of one staff for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #14 was administered oxygen per physician order. This affected one resident (#14) of one resident reviewed for oxygen therapy. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had moderate cognitive impairment and was totally dependent on staff for activities of daily living. Review of the current physician's orders included an order for oxygen at three liters per nasal cannula with humidified air for chronic obstructive pulmonary disease. The current care plan for Resident #14 revealed the facility would provide oxygen therapy per physician orders. On 02/09/2020 at 10:16 A.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 observation, record review and interview the facility failed to ensure monthly pharmacy reviews were completed for Resident #1 and failed to ensure a pharmacy recommendation for Resident #14 was acted upon timely. This affected two residents (#1 and #14) of five residents reviewed for unnecessary medication use. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, bipolar disorder, hypertension, dementia, anxiety, depression and suicidal ideations. The quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/17/2020 revealed Resident #1 had impaired cognition and required limited assistance with activities of daily living. Resident #1's physician's orders for February 2020 included an order for Lamotrigine (a medication used to treat bipolar disorder) 100 milligrams (mg) one tablet daily for bipolar disorder and Zoloft (an anti-depressant) 25 mg one tablet daily for depression. 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, record review and interview the facility failed to ensure Resident #14's psychoactive medication, Celexa was being administered at the most effective dose and as prescribed by the physician. This affected one resident (#14) of five residents reviewed for unnecessary medications. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/01/2020 revealed Resident #14 had moderate cognitive delay, hallucinations and delusions, and was totally dependent on staff for activities of daily living. Review of the physician's orders dated 01/20/2020 revealed to discontinue Celexa (a medication used to treat depression) 20 milligrams (mg) daily and start Celexa 10 mg daily. 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 observation, record review and interview the facility failed to ensure Resident #20 received fresh water daily as desired. This affected one resident (#20) of two sampled residents reviewed for hydration. Findings include: Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypothyroidism, major depressive disorder, gastro-esophageal reflux, generalized anxiety and vertigo. Review of Resident #20's plan of care, dated 05/14/2019 revealed she had the potential for alteration in hydration. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20's speech was clear, she understood, she understands and her cognition was intact. Resident #20 had no behaviors and did not reject care. Resident # 20 required extensive assistance of one staff for bed mobility, was dependent on two staff to transfer and required limited assistance of one staff to eat. Review of Resident #20's nutrition…

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, menu review and staff interview the facility failed to provide therapeutic diets to residents as ordered. This affected two residents (#11 and #17) of 19 residents residing in the facility. Findings include: Review of Resident #11 and Resident #17's medical records revealed both residents had a current physician order for an 1800 calorie American Diabetic Association (ADA) diet. Review of the facility menu revealed the facility did not have a planned 1800 calorie ADA diet available to provide. Interview with Dietary Supervisor (DS) #118 on 02/11/2020 at 12:00 P.M. confirmed the facility did not have a menu for an 1800 calorie ADA diet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure resident medical records were maintained in a complete and accurate manner. This affected two residents (#19 and #13) of 13 sampled residents. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, anxiety, depression, malignant neoplasm of colon, malignant neoplasm of hepatic flexure and altered mental status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/01/2020 revealed Resident #19 had moderate cognitive impairment. The physician's orders for February 2020 indicated Resident #19 was to receive a regular diet. Resident #19's care plan identified she was non-compliant at times with refusal of personal care and refusal of diet orders. The care plan also identified Resident #19 was at risk for choking, however refused a special diet. During observation of noon meal on 02/09/2020 at 12:03 P.M., Resident #19 was observed sitting at 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 review review, review of the facility Hospice contract and staff interview the facility failed to ensure the Hospice contract contained all of the required elements. This affected one resident (#7) of one resident reviewed for Hospice services. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE] and she received Hospice services. Review of the facility Hospice contract revealed it did not contain all required elements. The contract did not contain a provision stating Hospice assumed responsibility for determining the appropriate course of Hospice care. The contract did not include a statement the Long Term Care (LTC) facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by Hospice personnel, to the Hospice administrator immediately when the LTC facility becomes aware of the alleged violation. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure an effective antibiotic stewardship program was implemented to identify the appropriate use of antibiotics for Resident #20. This affected one resident (#20) of one resident reviewed for urinary tract infections. Findings include: Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypothyroidism, major depressive disorder, gastro-esophageal reflux, generalized anxiety and vertigo. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment, dated 01/20/2020 revealed Resident #20's speech was clear, she understood, she understands and her cognition was intact. Resident #20 had no behaviors and did not reject care. Resident #20 required extensive assistance from one staff for bed mobility and was dependent on two staff to transfer. Resident #20 was always incontinent of bladder. Review of Resident #20's progress notes revealed on 12/19/19 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.