Riverview Post Acute

Based on medical record review, observations, and staff interview the facility failed to provide timely and appropriate nail care for a resident who was dependent upon staff for assistance with activities of daily living (ADLs). This affected one (Resident #254) of two residents reviewed for ADLs. The facility census was 93. Findings include: Review of the medical record for Resident #254 revealed an admission date of 11/21/23 with diagnoses including Alzheimer's disease, acute cystitis without hematuria, retention of urine, and nondisplaced intertrochanteric fracture of right femur. Review of the care plan for Resident #254 dated 11/22/23, revealed the resident had an ADL self-care, mobility, and functional ability performance deficit. Interventions included staff should provide nail care as needed. Observation on 11/27/23 at 2:30 P.M. revealed Resident #254 was lying in bed and was alert and pleasantly confused. The resident fingernails were observed to be long and jagged and to have a layer of black debris caked underneath them. Observation on 11/28/23 at 10:34 A.M. revealed 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care. This affected one (Resident #25) of one resident who was reviewed for positioning during the annual survey. The facility identified two residents with pressure ulcers. The facility census was 93. Findings include: Review of the medical record for Resident #25 revealed an admission date of 04/08/20 with diagnoses including dementia, peripheral vascular disease, heart failure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 09/29/23 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. The resident was assessed to require extensive assistance from staff for bed mobility and toileting and to be dependent upon staff for transfers. Review of the care plan for Resident #25 dated 01/25/22, revealed the resident was at risk for altered skin integrity. Interventions…

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

Based on medical record review and staff interview the facility to ensure antibiotic medications were prescribed and administered only when necessary. This affected one (Resident #10) of the three residents reviewed for antibiotic use. The facility census was 93. Findings include: Review of the medical record review for Resident #10 revealed an admission date of 06/07/23 with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting. Review of the results of the urinalysis with culture and sensitivity (UA with C&S) for Resident #10 dated 11/22/23 revealed the presence of over 100,000 colony forming units per milliliter (CFU/ml) of mixed pathogens indicating probable…

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

Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure physician-ordered laboratory tests and specimens were obtained timely and as ordered. This affected two residents (#10 and #84) out of the eight residents reviewed for antibiotic use and unnecessary medications during the annual survey. The facility census was 93. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 06/07/22 with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting and to be independent for eating. The resident was assessed to have an indwelling foley catheter. Review of the physician's order…

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

Based on observation, interview, record review, and facility policy review the facility failed to ensure a Registered Nurse (RN) was providing services to the residents eight consecutive hours, seven days per week. This had the potential to affect all the residents residing in the facility. The facility census was 91. Findings include: Observation of the daily staff postings on 07/31/23 and 08/08/23 revealed no scheduled RN was working. Review of the staffing schedules and daily postings from 07/07/23 through 08/07/23 revealed 16 days without RN working hours: 07/08/23, 07/09/23, 07/10/23, 07/14/23, 07/16/23, 07/17/23, 07/18/23, 07/21/23, 07/22/23, 07/23/23, 07/25/23,07/30/23, 07/31/23, 08/04/23, 08/05/23 and 08/06/23. Interview on 08/07/23 at 1:56 P.M. with Registered Nurse (RN) #11 revealed the RN worked at the facility full time but did not usually work weekends. Interview on 08/07/23 at 2:06 P.M. with RN #69 revealed the RN worked the floor part time and did not work weekends. Interview on 08/07/23 at 3:35 P.M. with the Director of Nursing (DON) revealed the facility currently…

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, review of the Centers for Disease Control (CDC) guidelines, interview and facility policy and procedure review the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE), proper isolation procedures and during blood glucose monitoring to prevent the spread of infection inlcuding COVID 19. This affected eight residents (#62, #25, #329, #70, #61, #14, #28 and #75) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #14 revealed a physician's order on 08/16/21 to perform a finger stick blood sugar test before meals and at bedtime. On 10/19/21 at 11:00 A.M. Registered Nurse (RN) #975 was observed to perform a finger stick blood sugar test for Resident #14. RN #975 used a lancet to obtain a drop of blood from the resident's finger. The drop of blood was applied to a test strip which had been inserted into the blood…

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, interview and facility policy and procedure review the facility failed to ensure residents were assessed for oxygen use, had physician's orders in place for oxygen and/or failed to ensure oxygen tubing was dated and stored in a sanitary manner. This affected five residents (#15, #61, #226, #228 and #328) of six residents reviewed for oxygen therapy. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The assessment indicated the resident had not…

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, interview and review of the facility policy and procedure the facility failed to ensure each resident received food that was palatable and failed to ensure meals were served at appetizing temperatures. This affected seven residents (#12, #28, #47, #48, #67, #70, and #75) of 27 sampled residents. The facility census was 87. Findings include: The following food/meal concerns were identified during the annual survey: a. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including repeated falls, anxiety disorder, and rheumatoid arthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #12 had slightly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. The resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting. Interview with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #47 had the right to make choices about aspects of his/her life in the facility, including a change in rooms, that was significant to the resident. This affected one resident (#47) of two residents reviewed for choices. Findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 on a Minimum Data Set (MDS) 3.0 assessment, dated 09/03/21, indicating the resident had moderately impaired cognition. However, there was no documentation in the resident's medical record the resident was unable to make decisions for herself. Review of a social service progress note, written by Social Service Aide #635 on 10/01/21 at 4:25 P.M. revealed Resident #47 was requesting to be moved with her friend across the hall. The note indicated the resident was advised she would be moved on Saturday when housekeeping staff returned. Review of a social service…

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, interview and facility policy and procedure review the facility failed to notify Resident #15's family of a change in condition and new medication orders. This affected one resident (#15) of one reviewed for change in condition. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. A physician's order, dated 04/21/21 revealed the resident was admitted to Hospice services. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. Review of the mood and behavior section of the MDS revealed the resident displayed verbal…

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 Minimum Data Set (MDS) 3.0 assessments were complete and accurate. This affected two residents (#25 and #54) of 27 sampled residents whose MDS assessments were reviewed. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 04/03/19 with diagnosis including mood disorder, depression and dementia with behavioral disturbance. Review of the physician's orders for 07/2021, 08/2021, 09/2021 and 10/2021 revealed Resident #25 was not receiving any medications for mood disorder, depression or behavioral disturbances. Review of Resident #25's quarterly MDS 3.0 assessment, dated 08/04/21 revealed the cognitive patterns, mood and behavior section of the assessment were incomplete. The answer boxes contained dashes for the interviewer and staff portion of the assessment. Review of the progress notes for the look back period of the quarterly assessment did not reveal any abnormal behaviors noted. Review…

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, review of pre-admission screening review results and interview the facility failed to ensure Resident #67, a resident with a newly evident mental disorder was referred to the appropriate State-designated mental health authority for review for the need for level two services. This affected one resident (#67) of one resident reviewed for pre-admission screening and resident review (PASARR). Findings include: Medical record review revealed Resident #67 was admitted to the facility 02/25/20. Review of a pre-admission screening review, dated 02/25/20 revealed the resident had no indications of serious mental illness. Therefore, an in-person assessment was not required. A diagnosis of psychosis was added for the resident on 10/28/20. Review of nursing progress notes revealed on 10/26/20 at 3:28 P.M. Resident #67 had several behaviors on this date. The resident has been verbally aggressive towards staff. Resident has called family members making up stories on staff. Resident has yelled and screamed at this nurse and aide all day making negative comments and refusing…

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 obsesrvation, record review, interview and facility policy and procedure review the facility failed ensure baseline care plans for Resident #61 and Resident #226 included the use of oxygen. This affected two residents (#61 and #226) of 27 sampled residents whose care plans were reviewed. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's admission Evaluation dated 09/10/21 revealed the resident was admitted with no special treatment and/or procedure. The resident had no baseline plan of care related to oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate…

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

Based on observation, record review, staff interview and facility policy and procedure review the facility failed to develop a comprehensive plan of care related to oxygen use for Resident #15. This affected one resident (#15) of 27 sampled residents whose care plans were reviewed. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The resident required supervision with bed mobility, transfers and ambulation. The MDS indicated the resident had less than six months life expectancy 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.

Based on record review and interview the facility failed to revise Resident #17's plan of care related to range of motion following the discontinuation of therapy services. This affected one resident (#17) of 27 sampled residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/15/21. The resident was admitted from the hospital after treatment for a cerebral vascular accident. Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The resident was identified as having impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided with physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional…

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 #48 and Resident #61, who required extensive assistance/dependence on staff for activities of daily living received adequate and routine showers to maintain proper hygiene. This affected two residents (#48 and #61) of two residents reviewed for activities of daily living. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the plan of care, dated 09/13/21 revealed the resident had a self-care deficit as evidenced by weakness and limited mobility related to physical limitations due to a femur fracture with surgical repair. Interventions included to transfer with mechanical lift 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 record review and interview the facility failed to ensure collaborative and coordinated care with Hospice to meet the total care needs of Resident #15. The facility failed to maintain any documentation from Hospice with regards to care or services provided in the resident's medical record. This affected one resident (#15) of one resident reviewed for Hospice services. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's physician's orders revealed an order, dated 04/21/21 to admit resident for Hospice services. Review of the plan of care, dated 04/23/21 revealed the resident had a terminal prognosis related to dementia with restlessness and increased agitation.…

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 #54's left hip was comprehensively assessed prior to implementing a skin treatment and failed to ensure a physician order was in place for the treatment. This affected one resident (#54) of three sampled residents reviewed for skin/wound care. Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the care plan, revised 08/12/21 revealed Resident #54 was at risk for alteration in skin integrity and had a history of scratching arms and legs. Interventions included a low air loss (Hospice) mattress. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed 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 observation, record review and interview the facility failed to ensure fall risk interventions were in place as care planned to prevent falls for residents. This affected three residents (#24, #44 and #54) of three residents reviewed for falls. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression, and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed Resident #44 was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on, and leave bathroom door ajar. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility 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.

Based on observation, record review and interview the facility failed to ensure pharmacy services met the needs of Resident #4 when insulin was not available in the emergency supply stock. This affected one resident (#4) of seven residents observed for medication administration. Findings include: Record review revealed Resident #4 had a physician's order for Novolin N insulin 16 units daily (scheduled at 8:00 A.M.) for a diagnosis of diabetes mellitus. On 10/20/21 at 8:30 A.M. Registered Nurse (RN) #510 was observed administering medications for Resident #4. During the observation, RN #510 revealed the Novolin N insulin was not available for Resident #4. Staff then called the physician and got a physician's order to substitute Humulin N insulin, as the Novolin N insulin was not available in the facility stock medications. However, when RN #510 went to the stock medication, Humulin N insulin was not available either. Therefore, Resident #4 was unable to receive her scheduled insulin at that time. RN #510 indicated the pharmacy was notified and the insulin would be sent at a later…

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, interview, and review of the facility policy and procedure for medication administration the facility failed to maintain a medication error rate less than five (5) percent (%). The medication error rate was calculated to be 8.33% and included three medication errors of 36 medication administration opportunities. This affected two residents (#4 and #70) of seven residents observed for medication administration. Findings include: 1. Review of the medical record for Resident #70 revealed a physician's order dated 12/28/20 for Miralax 17 grams one time a day (scheduled for 8:00 A.M.) for constipation. On 10/19/21 at 8:05 A.M. Licensed Practical Nurse (LPN) #160 was observed to administer medications to Resident #70. During the administration, the LPN was not observed to administer Miralax (a laxative medication). However, the LPN signed off she administered the medication on 10/19/21 at 8:00 A.M. On 10/19/21 at 10:00 A.M. interview with LPN #160 verified she had forgotten to administer the Miralax medication to the resident but had documented it had…

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, interview and facility policy and procedure review the facility failed to ensure laboratory testing was obtained for Resident #61 as ordered by the physician to ensure proper and justified use of antibiotic treatment for a urinary tract infection. This affected one resident (#61) of six residents reviewed for laboratory testing and unnecessary medication use. Findings include: Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment indicated 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.