Colonial Nursing Center Of Rockford

Based on medical record review, review of facility investigation report, resident and staff interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (#08) out of three residents reviewed for medication administration. The facility census was 25. Findings include: Review of the medical record for Resident #08 revealed an admission date of 07/24/24 with medical diagnoses of acquired left below the knee amputation (BKA), chronic obstructive pulmonary disease, congestive heart failure, obsessive-compulsive disorder (OCD), major depression, and peripheral vascular disease. Review of the medical record for Resident #08 revealed an admission Minimum Data Set (MDS) assessment, dated 07/29/24, which indicated Resident #08 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and bathing, supervision with transfers and set-up assistance with eating and bed mobility. The MDS indicated Resident #08 received antidepressant, anticoagulant, antibiotic, and opioid medications.…

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 review of the facility policy the facility failed to ensure resident funds were conveyed in a timely manner. This affected two residents (#20 and #23) of three reviewed for personal funds. The facility census was 19. Findings include: 1. Review of the medical record of Resident #20 revealed an admission date of [DATE] and a date of death on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, chronic obstructive pulmonary disease, anxiety disorder, emphysema, and quadriplegia C5-C7 incomplete. Review of the facility form titled, Transaction Report, dated [DATE] to [DATE] revealed Resident #20's account had a payment applied on [DATE] in the amount of $25,000.00. A second payment was applied on [DATE] in the amount of $7,000.00, and a third on [DATE] in the amount of $7,000.00. A refund of $7,500.00 was issued on [DATE]. There was a balance of $7,500. Interview on [DATE] at 10:30 A.M. with Business Office Manager…

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 the resident shower room provided adequate privacy. This had the potential to affect all 19 residents residing in the facility. The facility's census was 19. Findings include: Observation on 03/07/23 at 2:20 P.M. of the resident shower room revealed two separate shower suites for residents, with an open doorway to each suite. There were no doors or privacy curtains in place for resident privacy for either suite or near the shower itself. If a resident were to be receiving a shower, and a second resident or staff member entered, the first resident would be easily observed by the second resident and/or staff entering the shower room. Interview on 03/07/23 at 2:27 P.M. with State Tested Nursing Assistant (STNA) #136 verified there were no doors or privacy curtains in place in the resident shower room. Interview on 03/07/23 at approximately 3:45 P.M. with the Director of Nursing (DON) verified all 19 residents utilized the resident shower room. Review of facility policy, Resident Rights,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility smoking contract, the facility failed to ensure cigarettes were lit outside the facility. Furthermore, the facility failed to ensure the resident smoking area was free from cigarette butts. This had the potential to affect all 19 residents residing in the facility. Additionally, the facility failed to ensure alcohol was stored properly. This affected one (Resident #11) of one resident reviewed for alcohol storage. The facility census was 19. Findings include: 1. Observation on 03/06/23 at 3:43 P.M. revealed State Tested Nursing Assistant (STNA) #117 lighting the cigarettes of two male residents while they were inside the building, prior to them exiting to the courtyard patio. Observations of the courtyard revealed the presence of a large amount of cigarette butts on the ground, in the mulch, in the grass, and on the cement. STNA #117 verified the large amounts of cigarette butts throughout the courtyard. Interview on 03/06/23 at 3:45 P.M. with STNA…

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

Based on the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 19 residents in the facility. Findings include: Review of the facility's Legionella environmental assessment form dated 05/26/22 revealed the assessment was not fully completed and did not include all the required components. Further review revealed the facility did not complete a map/flow diagram of the facility and/or water temperature monitoring. Interview on 03/09/23 at approximately 1:50 P.M. with Maintenance Staff #128 revealed she had been working in the maintenance position since the end of November 2022. Maintenance Staff #128 admitted she was unaware what the requirements were for the water management program and verified she had yet to do anything regarding water management related to Legionella, including monitoring of water temperatures. Review of the undated CDC guidance titled,…

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 an accurate Preadmission Screen and Resident Review (PASRR) was completed and failed to ensure the PASRR Review Results were obtained timely. This affected five (Residents #01, #05, #20, #08, and #10) of five residents reviewed for PASRRs. The facility census was 19. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 07/02/21 with diagnoses of residual schizophrenia, major depression, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #01 was cognitively intact. Resident #1 required supervision with bed mobility, transfers, locomotion, and eating. Resident #01 required limited assistance with toileting and extensive staff assistance with bathing. Further review of the medical record revealed a PASRR screen was completed on 05/11/18. The Review Results indicated Resident #01 had no indications of serious mental…

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, employee file review, and staff interview, the facility failed to complete Behavioral Health training upon hire for new employees. This affected two State Tested Nurse Aides (STNAs #106 and #117) of four STNAs review for Behavioral Health training. Additionally, this affected four (Residents #2, #5, #20, and #1) of four residents reviewed for mental health diagnoses. The facility identified 16 residents with mental health diagnoses (Residents #1, #6, #2, #5, #12, #123, #18, #15, #7, #174, #3, #11, #20, #175, #8, and #10). The facility's census was 19. Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/11/2020 with medical diagnoses of schizoaffective disorder and paranoid schizophrenia. Review of the medical record for Resident #5 revealed an admission date of 04/29/21 with medical diagnoses of schizophrenia, bipolar disorder, and depression. Review of the medical record for Resident #20 revealed an admission date of 12/13/22 with medical diagnoses of post traumatic stress disorder (PTSD), anxiety,…

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 a facility list of residents identified as smokers, review of the facility assessment, staff interview, and review of facility policy, the facility failed to identify smoking residents. Additionally, the facility assessment failed to address the facility's smoking population's needs. This had the potential to affect eight (Residents #2, #3, #6, #10, #11, #12, #14, and #19) identified by the facility as smoking residents. The facility's census was 19. Findings include: Review of a facility provided list of residents identified as smokers, revealed eight residents (#2, #3, #6, #10, #11, #12, #14, and #19) smoked out of the 19 residents residing in the facility, equaling 42 percent (%) of the facility population. Review of the facility assessment dated [DATE] revealed the assessment did not identify the facility's resident smoking population, nor did it identify needed services and care for smoking residents. Further review revealed the assessment indicated the facility would provide…

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 the Centers for Disease Control and Prevention (CDC) guidance for Coronavirus 2019 (COVID-19) vaccination and boosters, the facility failed to ensure residents were offered COVID-19 vaccines in a timely manner. This affected five (Residents #3, #6, #5, #8, and #11) of five residents reviewed for COVID-19 vaccination. This also had the potential to affect all residents residing in the facility. The facility census was 19. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, borderline personality disorder, schizophrenia, hyperlipidemia, essential (primary) hypertension, nicotine dependence, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of COVID-19 vaccine documentation dated 11/04/21 revealed Resident #3's responsible party…

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 ensure residents had access to a clean bathroom. This affected two (Residents #02 and #12) of three residents reviewed for physical environment. The facility census was 19. Findings include: Observation on 03/06/23 at 9:43 A.M. of the bathroom shared by Resident #02 and #12, revealed three large light green stains to the bathroom floor around the toilet. The bathroom was noted to have a strong odor of urine. Interview on 03/07/23 at 7:35 A.M. with Housekeeper #108 stated the facility was aware of the stains to the floor and the strong urine odor to Resident #02 and #12's bathroom. Housekeeper #108 stated housekeeping had been cleaning the floor frequently and the stains had improved but they were unable to get rid of the urine odor or stains to the floor. Interview on 03/07/23 at 8:45 A.M. with Maintenance #128 confirmed the floor to Residents #02 and #12's bathroom had large green stains and the bathroom had a strong urine odor. Maintenance #128 stated the housekeeping staff have been working to remove the stains but…

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 and resident interviews, and policy review, the facility failed to conduct quarterly care conferences. This affected three (Residents #10, #11, and #18) of three residents reviewed for care conferences. The census was 19. Findings include: 1. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the social service progress notes dated 06/30/22 revealed a care conference was held for the resident. Further review of the medical record, including progress notes, revealed no other care conferences taking place, indicating care conferences were not completed quarterly. Interview on 03/08/23 at 11:37 A.M. with Social Services #115 verified Resident #11 had not had any care conferences since 06/30/22. 2. Review of the medical record revealed Resident #18 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 record review, staff interview, and policy review, the facility failed to complete monthly medication regimen reviews. This affected three (Residents #02 #05, and #10) of five residents reviewed for medication regimen reviews. The facility census was 19. Findings include: 1. Review of the medical record for Resident #02 revealed an admission date of 03/11/20 with medical diagnoses of schizoaffective disorder, paranoid schizophrenia, and extrapyramidal and movement disorder. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #02 was cognitively intact. Resident #02 required supervision with bed mobility, transfers, eating, and ambulation. Resident #02 required limited assistance with toileting and extensive assistance with bathing. Further review of the medical record revealed no documentation to support the pharmacy completed a monthly medication regimen review for 05/2022, 06/2022, 07/2022, and 08/2022. 2. Review of the medical record for Resident #05 revealed an admission date 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, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were stored properly. This affected one (Resident #19) of one resident reviewed for medications left at bedside. The facility's census was 19. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/12/22 with medication diagnoses of chronic obstructive pulmonary disease (COPD), pneumonia, anemia, and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #19 was cognitively intact. Resident #19 required supervision with bed mobility, transfers, ambulation, and toileting. Review of Resident #19's physician orders revealed an order dated 12/30/22 for guaifensin (Mucinex) extended release 600 milligram (mg) tablet one tablet daily by mouth and an order dated 01/07/23 for acetaminophen (Tylenol) 500 mg two tablets by mouth three times per day. Review of the medication self-administration safety screen dated 12/12/22…

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 and resident interviews, and policy review, the facility failed to provide a resident with a functioning call light. This affected one (Resident #05) resident of 19 residents reviewed for functioning call lights. The facility census was 19. Findings include: Review of the medical record for Resident #05 revealed an admission date of 04/29/21 with medical diagnoses of left sided hemiplegia, schizophrenia, unspecified, history of cerebral infarction due to thrombosis, bipolar disorder, major Depression, diabetes mellitus (DM), and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #05 had moderate cognitive impairment. Resident #05 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene, and was dependent upon staff for transfers and bathing and was non-ambulatory. Observation on 03/06/23 at 9:00 A.M. revealed Resident #05 lying in bed with no call light within reach. Further observation revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, staff interviews, and policy review; the facility failed to implement standard precautions when a resident's used/dirty urinary catheter bag was placed in another resident's storage basin which contained personal hygiene products. This affected one (#13) of 16 resident reviewed during the initial pool process for infection control. Additionally, the facility failed to implement a water management program for the prevention and spread of Legionella. This had the potential to affect 24 of 24 residents who reside at the facility. The census was 24. Findings include: 1. Observation on 07/01/19 at 10:12 A.M. of Resident #13's shared bathroom revealed a storage basin was sitting on the counter next to the sink. The storage basin was noted to contain multiple denture cleaner tablets, a tube of tooth paste, body wash, and other bottles of hygiene products. Laying directly on top of the denture cleaner tablets, tube of tooth paste, body wash, and other hygiene products was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview; the facility failed to provide a skilled nursing facility advanced beneficiary notice (SNF ABN) (form CMS-10055) to a resident who was discharged from Medicare A services when benefit days were not exhausted and the resident remained at the facility. Additionally, the facility failed to provide a notice of medicare non coverage (NOMNC) (form CMS 10123) to a resident who had was discharged from Medicare A services when benefit days where not exhausted and the resident immediately discharged from the facility following the last covered skilled day. This affected two (#21 and #76) of two residents reviewed for liability notice. The census was 24. Findings include: 1. Review of the medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses include schizoaffective disorder, psychosis, alcoholism, cocaine abuse, hypertension, major depressive disorder, anxiety disorder, psychoactive substance abuse, bipolar disorder,…

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 resident record review and staff interview; the facility failed to provide the resident/resident representative a written summary of the baseline care plan. This affected two (#12, #73, and #13) of three residents reviewed for baseline care plans. The census was 24. Findings include: 1. Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, post traumatic stress disorder, and diabetes mellitus type one. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #12 had intact cognition. Review of the medical record for Resident #12 revealed no evidence of a written summary of the baseline care plan being given to the resident. Interview on 07/02/19 at 1:30 P.M. with the Director of Nursing (DON) verified there was no written summary of the baseline care plan given to Resident #12. The DON…

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 resident record review and staff interview; the facility failed to develop and implement a person-centered comprehensive care plan for the use of psychoactive, anticoagulant, and diuretic medications. This affected one (#12) of five residents reviewed for unnecessary medication. The census was 24. Findings include: Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, post traumatic stress disorder, and diabetes mellitus type one. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #12 was administered antianxiety, anticoagulant, and diuretic medication on seven days during the seven day reference period. Review of the medication administration record dated 06/19 and 07/19 revealed Resident #12 was administered xanax (antianxiety medication) one milligram (mg), one tablet by mouth twice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review and resident and staff interviews, the facility failed to ensure a resident was adequately secured on the facilities transportation bus. This affected one (#73) of one resident reviewed for accident/hazards. The census was 24. Findings include: Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE]. Diagnoses include insomnia, chronic pain, anxiety, major depressive disorder, muscle spasms, chronic fatigue, multiple spasms, and multiple sclerosis. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed Resident #73 had intact cognition. The resident required limited assistance of one staff for transfers. Documentation revealed the resident's mobility devices was a wheel chair (manual or electric). Review of the nurse progress notes dated 06/20/19 at 3:15 A.M. revealed Resident #73 complained of nausea and headache. Vital signs were systolic blood pressure 130 millimeters of mercury (mmHg) 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 and staff interview; the facility failed to treat an urinary tract infection to maintain bladder function for a resident who utilizes an indwelling urinary catheter. This affected one (#13) of one resident reviewed for urinary catheter. The census was 24. Findings include: Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition. The resident was totally dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. The resident utilized an indwelling urinary catheter. Review of a physician order dated 06/21/19, revealed Resident #13 was ordered the antibiotic medication ciprofloxacin 500 milligram (mg), take one tablet by mouth two times 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 resident record review and staff interview; the facility failed to implement antibiotic stewardship protocol to ensure appropriate antibiotic use. This affected one (#13) of one resident review of a urinary tract infection. The census was 24. Findings include: Review of the the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, anxiety, major depressive disorder, diabetes mellitus type two, spastic hemiplegia, bipolar disorder, and hydronephrosis. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition. The resident was totally dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. The resident utilized an indwelling urinary catheter. Review of a physician order dated 06/21/19, revealed Resident #13 was ordered the antibiotic medication ciprofloxacin 500 milligram (mg), take one tablet by mouth two times a day for 10 days. Review of 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.