Springmeade Healthcenter

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to timely initiate treatments to treat urinary tract infections. This affected one (#76) of three residents reviewed for antibiotic administration. The facility census is 87. Findings include: Medical record review for Resident #76 revealed an admission on [DATE] with diagnoses including dementia without behaviors, altered mental status, falls, hypertension, cerebral infarction without residual deficits, and benign prostatic hyperplasia with urinary tract symptoms. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 revealed an impaired cognition. Resident #76 requires moderate assist to dependent on staff for eating, toileting, bed mobility and transfers. Resident #76 was coded as incontinent of bowel and bladder. Review of the plan of care for Resident #76 revealed resident is incontinent of bladder related to benign prostatic hyperplasia with urinary tract symptoms, dementia, gait abnormality, 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 record review, staff interviews, family interview, policy review, Centers for Disease (CDC) guidance review, and hospital documentation review, the facility failed to ensure the prescribed duration of antibiotics had been provided for Clostridioides Difficile (C-Diff). This affected one (#24) of seven reviewed. The facility census was 86. Findings include: Review of medical record for Resident #24 revealed admission date of 01/21/25. The resident was admitted with diagnoses including liver cell carcinoma, congestive heart failure, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had significantly impaired cognition. She was independent with eating and required moderate assistance for bed mobility, transfers, and toileting hygiene. Review of the 01/30/25 progress note documented positive C-Diff results. The physician was contacted, and new orders were received for Vancomycin (antibiotic) four times a day for seven days. Review of the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to ensure medication was safely and appropriately stored. This affected three (#11, #68, #75) of three residents reviewed for medication storage. The facility census was 87. Findings include 1. Medical record review for Resident #11 revealed an admission on [DATE], with diagnoses including bipolar disorder, vascular dementia with agitation, type two diabetes, iron deficiency anemia, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 01/14/25 revealed resident had moderate cognitive impairment. Resident #11 required assistance for eating, maximum assistance for bed mobility and was coded as dependent for toileting and transfers. Resident #11 was incontinent of bowel and bladder. Resident #11 was at risk for pressures ulcers and was not coded with any current wounds. Review of the plan of care for Resident #11 revealed resident was at risk for skin breakdown 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, interview and policy review, the facility failed to notify a resident's responsible party of the need to change treatment to a pressure ulcer. This affected one (Resident #29) of three residents reviewed. The census was 92. Findings include: Review of the medical record Resident #29 revealed an admission date of 02/11/19. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, closed fracture of unspecified part of neck of left femur, need for assistance with personal care, and dementia with psychotic disturbance. Review of the admission screener for Resident #29, dated 07/31/23, revealed a pressure wound to the left heel measuring 5.5 centimeters (cm) in length, 11 cm in width and no depth. A progress note dated 09/06/23 at 1:12 P.M. revealed the previous area to the left heel was now open with serosanguinous drainage. The area was cleaned, and a new daily treatment was put into place. The Unit Manager and physician were notified. There was no documentation the resident's responsible party was notified of the change in the treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure interventions were implemented after a resident suffered a fall. This affected one (Resident #29) of three residents reviewed for falls. The facility censes was 92. Findings include: Review of the medical record Resident #29 revealed an admission date of 02/11/19. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, closed fracture of unspecified part of neck of left femur, need for assistance with personal care, and dementia with psychotic disturbance. Review of the Morse Fall Scale dated 07/28/23 indicated Resident #29 was a high risk for falling. No additional assessments were located in the medical record. No further fall risk assessments were located in the record. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #29 had impaired cognition. The resident was assessed as requiring extensive assistance of two staff with toileting, dressing, and transfers. Review of the progress…

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 water management program, staff interview, and review of a Centers for Medicare and Medicaid Services Survey and Certification memo, the facility failed to ensure preventive measures for Legionella were completed according to their water management plan. This had the potential to affect all 95 residents at the facility. The facility census was 95. Findings include: Review of the facility binder titled Water Management Program for Building/Water Systems, dated 2021, revealed the facility was to obtain water temperatures weekly. Interview on 06/23/22 at 8:03 A.M. with the Maintenance Supervisor #755 confirmed the facility was not obtaining weekly water temperatures as per their water management program. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo 17-30-Hospitals/Critical Access Hospitals/Nursing Homes, last revised 07/06/18, revealed the facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1. Conducts a facility risk assessment to identify where…

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, facility documentation review and staff interview the facility failed to maintain appropriate water temperatures. This had the potential to affect 83 out of 95 residents in the facility. There were 12 residents (Resident #17, #18, #22, #24, #48, #51, #54, #58, #69, #78, #86, and #87) who did not have access to the water in the front bathroom, room [ROOM NUMBER], room [ROOM NUMBER], 100 hall shower room, and 200 hall shower room. The facility census was 95. Findings include: Observation on 06/22/22 at 5:20 P.M. of the front bathroom water temperature revealed a temperature of 126 degrees with the surveyor's thermometer. Observation on 06/22/22 at 5:28 P.M. with the Maintenance Supervisor (MS) #755 revealed the water temperature in room [ROOM NUMBER] was 129 degrees fahrenheit and the water temperature in room [ROOM NUMBER] was 125.4 degrees fahrenheit with the facility's digital thermometer. The water temperature in the shower room on the 200 hall was 128 degrees fahrenheit. The temperature…

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 2. Review of Resident #39's medical record revealed an admission date of 09/29/20. admission diagnoses included repeated falls, heart failure, acute kidney failure, diabetes, and neuromuscular dysfunction of bladder. Review of Resident #39's Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Review of the MDS revealed Resident #39 required limited assistance with one-person for toileting. Resident #39 required supervision with one-person assistance for personal hygiene. Review of Resident #39's plan of care dated 04/05/22 revealed the resident had a suprapubic catheter related to neurogenic bladder. Interventions included change drainage bag per policy and to provide catheter care every shift per policy. Observation on 06/21/22 at 12:55 P.M. revealed Resident #39 was in the common dining room eating her lunch with other residents on her hall. Resident #39 was seated at the dining table and her catheter bag was hooked onto her walker. The observation revealed the catheter bag 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 resident record review and staff interview, the facility failed to notify the resident/resident representative in writing of the reason for transfer/discharge to the hospital. This affected one (Resident #36) out of two residents reviewed for hospitalization. The census was 95. Findings include: Review of medical record for Resident #36 revealed an admission date of 08/11/21 with diagnoses including Alzheimer's disease, dementia, and atrial fibrillation, and congestive heart failure. Review of the medical record for Resident #36 revealed the resident had severe cognitive impairment. Further review of the medical record for Resident #36 revealed she was hospitalized on [DATE]. There was no evidence Resident #36's representative was notified in writing of the reason for the transfer to the hospital. Interview on 06/22/22 at 3:55 P.M. with the Director of Nursing verified there was no evidence Resident #36's representative was notified in writing of the reason for the transfer/discharge to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of medical record for Resident #36 revealed an admission date of 08/11/21 with diagnoses including Alzheimer's disease, dementia, and atrial fibrillation, and congestive heart failure. Review of the medical record for Resident #36 revealed the resident had severe cognitive impairment. Further review of the medical record for Resident #36 revealed she was hospitalized on [DATE]. There was no evidence Resident #36's representative was notified of the facility bed hold policy. Interview on 06/22/22 at 3:55 P.M. with the Director of Nursing verified there was no evidence of Resident #36's representative having been notified of the bed hold notice policy for Resident #36's hospitalization/discharge on [DATE]. Based on resident record review and staff interview, the facility failed to notify residents and/or resident representatives of the facility's bed hold policy when a resident was transferred to the hospital. This affected two (Resident #95 and #36) out of two residents reviewed for hospitalization. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, and staff interview, the facility failed to ensure a resident was provided adequate positioning while seated in a wheelchair. This affected one (Resident #86) out of three residents reviewed for positioning. The census was 95. Finding include: Review of the medical record for Resident #86 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, peripheral autonomic neuropathy, congestive heart failure, legal blindness, and weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #86 had severely impaired cognition. Review of the assessment revealed Resident #86's mobility devices included a walker and a wheelchair. The assessment further revealed Resident #86 was not steady and was only able to stabilize with human assistance when moving from a seated to standing position, walking (with assistive devices), and surface to surface transfers. Review of the care plan dated 10/31/19, 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 medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (Resident #40) out of five residents reviewed for medication administration. The facility census was 95. Findings include: Review of Resident #40's medical record revealed an admission date of 01/05/21. admission diagnoses included hemiplegia and hemiparesis following a cerebral infarction, heart failure, kidney failure, diabetes, and chronic respiratory failure. Review of Resident #40's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Review of Resident #40's physician order dated 05/20/22 revealed Polyethylene Glycol (medication used to treat constipation) 3350 Electrolyte Solution Reconstituted 236 grams. The instructions read to give eight ounces by mouth one time a day for colonoscopy prep for one day. Drink one eight-ounce glass every twenty minutes until two…

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 meeting minutes, Resident Council group interview, and staff interview, the facility failed to follow up on resident concerns of staff not passing out evening snacks. This had the potential to affect three (#14, #51, and #74) residents present in the Resident Council meetings. The facility census was 106. Findings include: Interview with the Resident Council on 07/17/19 at 10:43 AM revealed Resident #14, Resident #51, and Resident #74 stated they complain about bedtime snacks at almost every Resident Council meeting. They see snacks come to the unit on a cart but the snacks are not passed to residents on a consistent basis. They stated sometimes snacks are passed after residents are sleeping and they find the snack on their table the next morning and quite often snacks are just not passed. Review of Resident Council meeting minutes of 02/05/19 revealed residents report they have not been receiving snacks regularly the past month. The minutes dated 03/05/19 revealed residents reported continued issues with snacks in the evening. The minutes 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.

Based on resident funds record review, medical record review, staff interview, and review of facility policy, the facility failed to notify the resident and/or responsible party when the trust fund account balance was within $200.000 of the Medicaid limit for two (#20 and #43) of five residents reviewed for funds managed by the facility. The facikity identified 26 residents with trust fund accounts. The facility census was 106. Findings include: 1. Review of the medical record of Resident #20 revealed an admission date of 08/17/18. Diagnoses included dementia without behavioral disturbance, mild cognitive impairment, muscle weakness, oral phase dysphasia, cognitive communication deficit, hypertension, major depressive disorder, hyperlipidemia, anxiety disorder, atherosclerotic heart disease, angina pectoris, gastro-esophageal reflux disease, osteoarthritis, and other abnormalities of gait and mobility. Review of the 06/30/19 quarterly statement for Resident #20's trust account, from 04/04/19 through 06/11/19 revealed Resident #20's balance was over the $2,000.00 limit set by…

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 the facility's bed hold and reserve bed payment policy when the resident representative elected to have the resident transferred to the hospital. This affected one (#102) of two residents reviewed for hospitalization. The census was 106. Findings include: Review of the medical record for Resident #102 revealed the resident was admitted to the facility on [DATE]. Diagnoses include metabolic encephalopathy, hypertension, cognitive communication deficit, and atrial fibrillation. The medical record revealed Resident #102's payer source was Medicare. Review of a progress note dated 05/05/19 at 11:08 A.M. revealed the resident refused all medication after several attempt. Documentation revealed the residents family member and physician was made aware of the medication refusal. Review of a progress note dated 05/05/19 at 11:32 A.M. revealed the resident's family member insist the resident be sent out…

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 Minimum Data Set (MDS) 3.0 assessments were submitted to the Centers for Medicaid/Medicare Services (CMS) for one (Resident #2) of one resident reviewed for MDS submission. The facility census was 106. Findings include: Review of the medical record of Resident #2 revealed an admission date of 02/14/19. Diagnoses included displaced fracture of left femur, displaced transcondylar fracture of right humerus, muscle weakness, dysphasia, oropharyngeal phase, cognitive communication deficit, hypertension, gastro-esophageal reflux disease without esophagitis, bronchitis not specified chronic or acute, chronic obstructive pulmonary disease, hypo-osmolality and hyponatremia, old myocardial infarction, unspecified dementia without behavioral disturbance, and chronic kidney disease. The resident discharged on 03/23/19. Review of Resident #2's five-day/other MDS assessment revealed an assessment reference date (ARD) date of 02/21/19 and a completed dated of 03/20/19. There was no evidence this assessment was transmitted 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 resident record review and staff interview; the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected two (#79 and #93) of 22 resident records reviewed for accuracy of MDS assessments. The census was 107. Findings include: 1. Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, hypotension, diabetes mellitus type two, obstructive sleep apnea, osteoarthritis, hypertension, hyperlipidemia, heart disease, and bipolar two disorder. Review of the medication administration record dated 06/19 and 07/19 revealed no evidence Resident #79 had orders for or was administered antibiotic medication from 06/30/19 to 07/06/19. Review of a 30 day MDS assessment dated [DATE], revealed Resident #79 was administered antibiotic medication on five days during the seven day reference period. Interview on 07/17/19 at 10:16 A.M. with MDS Nurse #288 revealed Resident #79 was not administered antibiotic…

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, observation, and review of facility policy, the facility failed to provide care to the gastrostomy tube (G Tube) insertion site for one (#309) of two residents in the facility and reviewed for G Tube care. The facility census was 106. Findings include: Review of the medical record for Resident #309 revealed an admission date of 07/05/19. Diagnoses include respiratory failure, aphasia, dysphagia following cerebral infarction and type two diabetes mellitus. Review of the July 2019 physician orders, medication administration record (MAR), and treatment admiration record (TAR) revealed no order for the care of the G tube site. Interview on 07/15/19 at 2:29 P.M. with Resident #309's husband revealed he had never observed any nurse clean around his wife's G tube. The spouse stated there was crusty material around the tube insertion site. Observation on 07/15/19 2:40 P.M. of Resident #309's G tube, revealed there was no dressing around the G Tube and there was dried, crusty matter around the G Tube insertion site. Observation on 07/17/19 at…

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 offer/provide non-pharmacological interventions prior to the administration of as needed (prn) psychotropic medication. This affected one (#79) of five residents reviewed for unnecessary medication. The facility identified 28 residents receiving antianxiety medication. The census was 106. Findings include: Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, hypotension, diabetes mellitus type two, obstructive sleep apnea, osteoarthritis, hypertension, hyperlipidemia, heart disease, and bipolar two. Review of the care plan dated 06/28/19, revealed Resident #79 was at risk for side effects and complications of psychotropic drug use related to anxiety. Interventions include offer, monitor, and document any non-pharmacological interventions used to deter behaviors prior to the administration of medication. Review of Resident #79's physician orders…

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, and staff interview, the facility failed to administer insulin as ordered by the physician. This affected one (#63) of one residents observed for insulin administration. The census was 106. Finding include: Observation and interview on 07/17/17 at 8:38 A.M. of Licensed Practical Nurse (LPN) #295 revealed the LPN was preparing insulin for Resident #63. LPN #295 reported Resident #63's finger stick blood sugar was 201 and the resident was to be administered, per subcutaneous injection, a total of eight units of Novolog (aspart) insulin. Continued observation revealed LPN #295 withdrew nine units of Novolog insulin into the syringe. LPN #295 then walked into Resident #63's room, donned gloves, and cleansed the residents injection site with an alcohol prep pad. The LPN was preparing to inject the medication. The surveyor then asked LPN #295 to verify the insulin dose that was about to be administered before continuing with the procedure. LPN #295 walked out of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and physician interview, and review of facility policy, the facility failed to notify the physician of abnormal laboratory results for one (#316) of seven residents reviewed for unnecessary medications. The total resident census was 106. Findings include: Review of the medical record of Resident #316 revealed an admission date of 07/09/19. Diagnoses included agranulocytosis secondary to cancer chemotherapy, diffuse large B-cell lymphoma, hypothryroidism, hyperlipidemia, hypertension, hyponatremia, seasonal allergic rhinitis, gastro-esophageal reflux disease, Barrett's esophagus without dysplasia, abdominal hernia without obstruction or gangrene, polyarthritis, and benign prostatic hyperplasia. Review of the hospital transfer orders upon admission on [DATE] included laboratory orders for a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) to be completed on 07/09/19. Review of the orders verified with the facility attending physician, Medical Director #231, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review; the facility failed to ensure staff maintained good infection control practices, including hand hygiene, while administering medication. This affected two (#37 and #63) of five resident observed during medication administration. The census was 106. Findings include: Observation on [DATE] from 8:24 A.M. to 8:46 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #295 was preparing medication for Resident #37. While removing medication from the packages, one of Resident #37's medication tablets fell onto the medication cart. LPN #295 picked up the tablet off of the cart, with ungloved fingers and placed the tablet into the medication cup. LPN #295 then walked to Resident #37's room and gave the resident the cup of medication and a cup of water. While Resident #295 was taking the medication, LPN #295 tidied up the resident's bedside table, which included placing two plastic cups in the trash can. After Resident #37 had swallowed all 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.