Southbrook Healthcare Center

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed safe hand hygiene practices during medication administration and handling of resident food. This affected two (Residents #32 and #55) of 26 sampled residents. The facility census was 90 residents. Findings include: 1. Observation on 05/18/25 at 8:56 A.M. of Licensed Practical Nurse (LPN) #154 revealed the nurse was preparing medications to administer to Resident #32. LPN #154 removed medication from Resident #32's medication dose pack and placed the medication in her ungloved hand before placing the medication into a medication cup. Interview on 05/18/25 at 8:57 A.M. with LPN #154 confirmed she touched Resident #32's medications with her ungloved hands. Review of facility policy titled Medication Administration dated 2013 revealed nurses should not touch medications with ungloved hands. 2. Observation on 05/19/25 at 12:06 P.M. of main dining room revealed Certified Nurse Aide (CNA) #110 served Resident #55 a turkey club sandwich with a packet of mayonnaise, a slice…

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

Based on observation, staff interview, review of medical record, review of manufacturer insert, and review of facility reference guide the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens prior to administration. This affected one (Resident #82) of four residents reviewed for medication administration. The facility census was 81. Findings include: Record review of Resident #82 revealed and admission date of 08/30/18 with pertinent diagnoses of multiple sclerosis, asthma, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, anemia, convulsions, and chronic ischemic heart disease. Review of Resident #82's Physician Order dated 01/04/25 revealed Insulin Aspart FlexPen 100 units/milliliter solution pen-injector. Inject as per sliding scale: if 61 - 150 = 0 units no insulin; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 -300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401 - 500 = 20 units, subcutaneously before meals and at bedtime for diabetes mellitus…

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, policy review, and staff interview the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections when they failed to use proper hand hygiene during a dressing change, and failed to follow enhanced barrier precautions. This affected one (Resident #74) of three Residents reviewed for wounds. The facility census was 81. Findings include: Record review of Resident #74 revealed an admission date of 10/02/24 with pertinent diagnoses of Alzheimer's disease, encounter for gastrostomy, convulsions, anxiety disorder, major depressive disorder, dementia, hypertension, atrial fibrillation, and cognitive communication deficit. Review of the 01/04/25 five day Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired. Review of a Physicians Order dated 01/20/25 revealed left heel-cleanse with normal saline, pat dry, apply medical grade honey, cover with silicone bordered super-absorbent dressing every night shift for wound care and as needed. Review of a Physicians…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to follow infection control precautions when providing wound care to a resident. This affected one (#2) of three residents reviewed for infection control. The census was 81. Findings include: Review of Resident #2's medical record revealed an admission date of 07/16/22. Diagnoses listed included atherosclerotic heart disease, chronic kidney disease, peripheral vascular disease, osteoarthritis, depression, scoliosis, and and dysphagia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Observation of left leg wound care on 09/19/14 at 10:36 A.M. revealed Registered Nurse (RN) #100 removed a gauze dressing around Resident #2's left leg by cutting it with bandage scissors. RN #100 then laid bandage scissors on a bedside table. RN #100 then used the bandage scissors to cut a Xeroform (non-adherent wound dressing) to size before applying it to 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.

Based on medical record review, resident and staff interviews, review of self-reported incidents, and policy review, the facility failed to report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#79) of three residents reviewed for abuse. The facility census was 84. Findings include: Review of the medical record for Resident #79 revealed an admission date of 12/26/22. Diagnoses included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/26/24, revealed Resident #79 was cognitively intact. Interview on 05/09/24 at 10:15 A.M. with Resident #79 revealed he reported an allegation of abuse on 04/11/24 to the Administrator related to Licensed Practical Nurse (LPN) #203 sticking her finger in his face. Interview on 05/09/24 at 2:10 P.M. with LPN #203 verified Resident #79 did report to the Administrator an allegation of abuse, but stated the allegation was not true. Interview on 05/09/24 at 3:30 P.M. with the Administrator verified Resident #79…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of insulin pen manufacturer instructions, the facility failed to ensure a nurse primed an insulin pen prior to the administration of insulin, resulting in a significant medication error. This affected one (Resident #11) of three observed for medication administration. The facility census was 96. Findings include: Review of medical record for Resident #11 revealed an admission date of 06/08/23. Medical diagnoses included heart attack, depression, anxiety, type two Diabetes Mellitus, and sleep apnea. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of eight, indicating impaired cognition. Resident #11 required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Review of the physician orders for Resident #11 revealed an order for Lispro 100 units per (/) milliliter ml. Inject as per sliding scale: if 70 to 199, zero units; 200 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.

Based on review of the staffing tool, review of staff punches, review of daily staff schedules, and staff interview, the facility failed to ensure a Registered Nurse (RN) worked in the facility at least eight consecutive hours, seven days a week. This had the potential to affect all 66 residents residing in the facility. The facility census was 66. Findings include: Review of the staffing tool on 11/15/22 revealed on Sunday, 11/13/22, the facility did not have an RN on the schedule. Review of the staff punches for 11/13/22 confirmed no RN was working on 11/13/22. Review of the daily staff schedules for 11/13/22, confirmed no RN was scheduled for that day. Interview with the Administrator on 11/15/22 at 2:00 P.M. confirmed the facility did not have an RN available to work on 11/13/22.

Based on observation, staff interview, review of standardized recipes, review of facility pureed standards, and policy review, the facility failed to ensure pureed food recipes were followed and pureed foods were prepared appropriately. This had the potential to affect seven (#10, #20, #21, #23, #25, #35, and #270) out of seven residents identified by the facility as receiving pureed foods from the kitchen. The facility census was 66. Findings include: Observation and interview on 11/16/22 at 11:04 A.M. revealed [NAME] #253 added eight servings of peas to the food processor. [NAME] #253 then started the food processor and added a small amount of broth to the processor. [NAME] #253 stated she added a half teaspoon of broth for every eight ounces of peas. [NAME] #253 then removed the cover from the processor, stirred the contents, and stated she adds bread if needed to reach the desired consistency. [NAME] #253 added one slice of bread and pulsed the food processor. [NAME] #253 then poured the contents of the food processor, which appeared to have a liquid consistency, into a pan.…

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.

2. Review of the medical record for Resident #23 revealed an admission date of 03/20/18. Diagnoses included but were not limited to Parkinson's disease, diabetes, and osteoarthritis. Review of the Annual Minimum Data Set assessment, dated 10/10/22, revealed Resident #23 was cognitively intact. Resident #23 required extensive assistance of one person for eating. Resident #23 had physical impairments of upper extremities on both sides. Resident #23 had loss of liquids/solids from mouth when eating and drinking, and was on a mechanically altered diet. Review of the plan of care, dated 09/19/22, revealed Resident #23 was dependent on staff for meeting activity of daily living needs with interventions including total dependence of one staff for eating at all meals and snacks. Resident #23 was at risk for nutritional problems with interventions including dys mech thin liquids, to provide assistance with meals as needed, provide meals according to the diet order, and provide speech and occupational therapy as needed. Review of Resident #23's physician orders dated 06/06/22 revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the beneficiary notice list, and staff interview, the facility failed to ensure residents were provided Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms appropriately. This affected two (Residents #52 and #273) out of three residents reviewed for beneficiary notices. The census was 66. Findings include 1. Review of the medical record for Resident #273 revealed Resident #273 was admitted on [DATE] and discharged [DATE]. Diagnoses included but were not limited to respiratory failure, muscle weakness, and diabetes. Review of the beneficiary notice list revealed Resident #273 was discharged from therapy on 10/05/22. 2. Review of the medical record for Resident #52 revealed Resident #52 was admitted on [DATE]. Diagnoses included but were not limited to dementia, chronic obstructive pulmonary disease, and femur fracture. Review of the beneficiary notice list revealed Resident #52 was discharged from therapy on 06/30/22. Interview on 11/16/22…

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.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were completed as appropriate. This affected one (Resident #13) of four residents reviewed for PASARR. The facility census was 66. Findings include: Review of the medical record of Resident #13 revealed an admission date of 07/30/20. Diagnoses included but were not limited to generalized idiopathic epilepsy, dementia without behavioral disturbance, hemiplegia and hemiparesis, major depressive disorder, malignant neoplasm of brain, and bipolar disorder. Review of the quarterly Minimum Data Set assessment, dated 08/19/22, revealed Resident #13 had severely impaired cognition. Review of Resident #13's medical record revealed no evidence of a PASSAR having been completed since admission. Interview on 11/16/22 at 8:07 A.M., with Social Services Director (SSD) #236 verified there was no evidence a PASARR had been completed for Resident #13. SSD #236 stated Resident #13 admitted from another facility. Review of the facility policy 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.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were completed following changes to the resident's mental health diagnoses. This affected one (Resident #63) out of four residents reviewed for PASARR. The facility census was 66. Findings include: Review of the medical record of Resident #63 revealed an admission date of 08/06/22. Diagnoses included but was not limited to cerebral infarction, anxiety disorder, schizoaffective disorder, other psychoactive substance dependence, and depression. Review of the quarterly Minimum Data Set assessment, dated 10/04/22, revealed Resident #63 had moderately impaired cognition. Review of Resident #63's most recent PASARR, completed on 08/04/22, revealed it did not include Resident #63's diagnosis of schizoaffective disorder. Review of the medical record revealed Resident #63 received a new diagnosis of schizoaffective disorder on 08/12/22. Interview on 11/16/22 at 8:09 A.M., with Social Services Director (SSD) #236 verified a new PASARR was 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 medical record review, staff interview, and policy review, the facility failed to ensure residents and/or their responsible parties were routinely invited to participate in care planning. This affected one (#05) out of two residents reviewed for care planning. The facility census was 66. Findings include: Review of the Resident #05's medical record revealed Resident #05 was admitted to the facility on [DATE] with diagnoses which included but were not limited to cerebral palsy, moderate intellectual disabilities, epilepsy, bipolar disorder, delusional disorders, and cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. Review of Resident #05's quarterly Minimum Data Set assessment, dated 11/08/22, revealed the resident was severely cognitively impaired. Review of Resident #05's care conferences from 11/14/21 to 11/14/22 revealed on 10/11/22, a care conference was conducted. There were no additional care conferences held between 11/14/21 and 11/14/22. 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.

2. Review of the medical record for Resident #23 revealed an admission date of 03/20/18. Diagnoses included but were not limited to Parkinson's disease, diabetes, and osteoarthritis. Review of the Annual Minimum Data Set assessment, dated 10/10/22, revealed Resident #23 was cognitively intact. Resident #23 required extensive assistance of one person for eating. Resident #23 had physical impairments of upper extremities on both sides. Resident #23 had loss of liquids/solids from mouth when eating and drinking, and was on a mechanically altered diet. Review of the plan of care, dated 09/19/22, revealed Resident #23 was dependent on staff for meeting activity of daily living needs with interventions including total dependence of one staff for eating at all meals and snacks. Resident #23 was at risk for nutritional problems with interventions including dys mech thin liquids, to provide assistance with meals as needed, provide meals according to the diet order, and provide speech and occupational therapy as needed. Review of Resident #23's physician orders dated 06/06/22 revealed an…

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 policy review, the facility failed to ensure the physician addressed a resident's pharmacy recommendation in a timely manner. This affected one (#24) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #24's medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses which included but were not limited to schizophrenia, unspecified dementia mild with other behavioral disturbance, and diabetes mellitus due to underlying condition with other skin ulcer. Review of Resident #24's quarterly Minimum Data Set assessment, dated 11/04/22, revealed the resident was severely cognitively impaired. Review of Resident #24's physician order, dated 08/12/22, revealed Resident #24 was ordered Depakote (anticonvulsant) oral tablet delayed release 500 milligrams (mgs) give three tablets by mouth at bedtime for schizophrenia. Review of Resident #24's pharmacy recommendation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure psychotropic medications were ordered for a appopriate conditions. This affected one (#269) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of the medical record for Resident #269 revealed Resident #269 was admitted on [DATE]. Diagnoses included sepsis, bactermia, bipolar disorder and chronic obstructive pulmonary disease. Review of Resident #269's physician orders dated 11/10/22 revealed orders for the following three psychotropic medications: Buspirone HCl oral tablet (antianxiety) 10 milligrams (MG) with instructions to give three times daily for mental/mood health. Lurasidone HCl ora tablet (antipsychotic) 80 MG with instructions to give one tablet at bedtime of mental/mood health. Trazodone HCl Oral tablet (antidepressant) 50 MG with instructions to give one tablet at bedtime for mental/mood health. Review of the care plan, dated…

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

Based on review of the facility's Legionnaires prevention documentation and staff interview, the facility failed to develop and implement an adequate Legionella control plan with identified control measures. This had the potential to affect 82 of 82 residents who reside in the facility. Findings include: Review of the facility's undated policy titled, Water Management System Control Measure/Monitoring, revealed water temperatures would be checked weekly for temperatures form 105 Fahrenheit (F) to 120 F. Water heaters would also be visually inspected every six months to determine if interior cleaning was required and a water management team would meet quarterly. Review of facility documentation revealed water temperature checks were completed for hot water temperatures form 105 F to 120 F. An annual water quality check of city water was completed. However, there was no documentation of water heater inspections or quarterly water management team meetings provided. Interview with Maintenance Worker (MW) #231 on 12/19/19 at 4:10 P.M., revealed room water temperature checks 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.

Based on review of resident council minutes and facility policy, staff and resident interviews, the facility failed to address resident concerns identified during Resident Council meetings. This affected five (#16, #27, #41, #63 and #73) of five residents interviewed for concerns and resolutions presented at resident council meetings. The facility census was 82. Finding include: Interviews on 12/19/19 from 11:08 A.M. to 12:00 P.M., with Residents (#16, #27, #41, #63 and #73) revealed several concerns were brought up continually to the facility and they stated the issues have not been resolved. All five residents stated they have asked the facility if a bathroom close to the center of the building where meals and activities are held, could be designated as a resident restroom, or a staff member could be available during activities to assist residents to the restroom when needed. All five resident also identified there were times when they had not received evening snacks. Review of the Resident Council meeting minutes dated 12/2018 through 11/2019, revealed multiple concerns 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 medical record review, policy review and staff interviews, the facility failed to accurately assess residents in the Minimum Data Set (MDS) assessment. This affected three (#11, #33, and #132) of five residents reviewed for unnecessary medications. The census was 82. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 01/09/18. Diagnoses included peripheral vascular disease, depressive disorders, kidney failure, and dependence on renal dialysis. Review of of physician orders revealed an order dated 09/13/19 for Depakene (Depakote) solution 250 milligrams (mg) per 5 milliliters (ml) give 10 ml via gastronomy tube three times a day for seizures. Review of physician documentation dated 09/24/19 revealed Resident #33 received Depakote three times a day for seizures. Review of a quarterly MDS assessment dated [DATE] revealed Resident #33 was not assessed as having a seizure disorder or epilepsy. Interview with the Corporate MDS nurse #235 on 12/18/19 at 1:55 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to follow a physician order for dialysis dressing removal. This affected one (#33) of one resident reviewed for dialysis. The census was 82. Findings include: Review of Resident #33's medical record revealed an admission date of 01/09/18. Diagnoses included peripheral vascular disease, depressive disorders, kidney failure, and dependence on renal dialysis. Resident #33 was assessed by staff as having moderate cognitive impairment in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders revealed and order dated 09/07/19 to take off dialysis dressing every other evening after dialysis treatment Tuesday/Thursday/Saturday. Review of treatment administration records (TAR) for December 2019 revealed the removal of Resident #33's dialysis dressing was documented as being completed on 12/17/19. Observation of Resident #33's right lower arm fistula on Wednesday 12/18/19 at 10:52 A.M. revealed a dialysis…

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

Based on observations, medical record review, resident and staff interviews, the facility failed to ensure a resident's medications were administered and not left at bedside. This affected one (#55) of six residents observed during medication administration. The census was 82. Findings include: Review of Resident # 55's medical record revealed an admission date of 08/04/17. Diagnoses included: atherosclerosis of coronary artery, muscle weakness, chronic pain syndrome, congestive heart failure, hypertension, and chronic kidney disease. Resident #55 was assessed as being cognitively intact in a Minimum Data Set (MDS) dated Interview on 12/17/19 at 4:43 PM an interview with Resident #55 revealed she was experiencing back pain and was upset because the nurse wants her to take an anxiety pill for the pain. Resident #55 explained the nurses bring the anxiety pill to her at bedtime in a medicine cup. When the nurse leaves, she takes the pill out of the cup and wraps it in a tissue and throws it away in her bed side waste basket. Observation of the waste basket during the time of interview…

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 staff interview, the facility failed to ensure an appropriate diagnosis was obtained to justify the use of an anti-anxiety medication for one resident. This affected one (#55) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of Resident # 55's medical record revealed an admission date of 08/04/17 with no cognitive deficits noted. Diagnoses included atherosclerosis of coronary artery, coronary angioplasty, and chronic kidney disease. A care plan relative to medical and psychological needs revealed individualized interventions with measurable goals. Review of Resident #55's medication administration record revealed on 12/13/19, Resident #55 was prescribed and given Cymbalta Capsule Delayed Release Particles 30 mg 1 capsule by mouth daily at bedtime for anxiety. Review of Resident #55 nurses notes revealed no areas of concern with Resident #55 having anxiety. Review of the Medication Administration Records (MAR) from 12/01/19 to 12/18/19, revealed Resident #55 started the medication on 12/13/19, for…

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

Based on record review and staff interview, the facility failed to document the administration of medications for three residents. This affected three (#2, #132, and #133) of seven residents reviewed for medications. The census was 82. Findings include: 1. Review of Resident #2's record revealed an admission date of 08/19/19. Diagnoses included anemia, hypertension, muscle weakness, and chronic kidney disease. Review of the medication administration records (MAR's) for December 2019, revealed Resident #2 was not documented as receiving 9:00 P.M. doses of Trazodone 50 milligrams (mg), Baclofen 20 mg, and Ferrous Sulfate 325 mg on 12/11/19. Administration boxes for those times were blank and not completed on the MAR. 2. Review of Resident #132's record revealed an admission date of 12/05/19. Diagnoses included fracture of left leg, osteoporosis, cardiac pacemaker, and hypothyroidism. Review of the MAR's for December 2019, revealed Resident #132 was not documented as receiving a 9:00 P.M. dose of Simvastatin 40 mg on 12/11/19 and a 6:00 A.M. dose of Levothyroxine Sodium 100 micrograms…

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.