Briarfield Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interviews, the facility failed to ensure incontinence care was provided in a timely manner for Resident #67. This affected one resident (#67) of two residents reviewed for incontinence care. The facility census was 67. Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, other fracture of head and neck of left femur, subsequent encounter for closed fracture with routine healing, difficulty in walking. Review of the Brief Interview for Mental Status (BIMS) dated 12/30/24 revealed Resident #67 scored 14 out of 15, indicating she was cognitively intact. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was always incontinent of bowel and bladder. The care plan dated 01/12/25 stated resident was on a scheduled toileting program and the goal was that the…

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

Based on record review, interviews, and review of facility policy, the facility failed to accurately and consistently monitor and record a physician ordered fluid restriction for Resident #58 and #29. This affected two residents (#29 and #58) out of nine residents reviewed for nutrition. The facility census was 67. Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 12/15/23 with diagnoses including chronic kidney disease, chronic diastolic (congestive) heart failure (CHF), atherosclerotic heart disease, and hyperlipidemia. Review of the modification of the annual Minimum Data Set (MDS) 3.0 assessment, dated 12/13/24, revealed Resident #58 was cognitively intact, received a therapeutic diet, had no significant weight changes, and had received a diuretic during the assessment reference period. Review of the care plan, created on 08/02/24, revealed Resident #58 was at risk for nutritional issues secondary to impaired medical status. Interventions included: provide medical nutrition therapy interventions per order and monitor, document, 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, interviews, review of the long term care facility compliance agreement, and review of communication sheets from dialysis, the facility failed to ensure communication between the facility and the dialysis center was being received after every dialysis treatment as required for Resident #31. This affected one resident (#31) out of one resident reviewed for dialysis. The facility identified Resident #31 as the only resident receiving dialysis. The facility census was 67. Findings include: Review of the medical record for Resident #31 revealed an admission date of 07/09/20. Diagnoses included end stage renal disease, diabetes mellitus with hyperglycemia (high blood sugar), dependence on renal dialysis, anemia in chronic kidney disease, and renovascular hypertension (a condition in which high blood pressure is caused by the kidneys' hormonal response to the narrowing of arteries in the kidneys). Review of Resident #31's physician orders revealed an order dated 10/24/24 for dialysis Monday,…

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, interview, record review, review of the Centers for Disease control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure infection control logs were accurate and appropriate isolation precautions were in place for Resident #57. This affected one resident (#57) of three residents reviewed for infection control. The facility census was 67. Findings include: Review of Resident #57's medical records revealed an admission date of 07/29/23. Diagnosis included Methicillin-resistant Staphylococcus aureus (MRSA) (bacterial infection). Review of the care plan dated 12/24/24 (revised 02/25/25) revealed Resident #57 had received intravenous (IV) therapy related to an acute infection. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 had impaired cognition. Resident #57 was dependent on staff for toileting and required maximum assistance with personal hygiene. Review of the physician orders for February 2025 revealed Resident #57…

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, facility policy and procedure review and interview the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected three residents (#10, #17 and #46) and had the potential to affect all 65 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed Resident #46 was cognitively intact and required two person assistance for bathing. Review of Resident #46's shower records from April 2022 through 06/15/22 revealed showers were scheduled every Monday, Wednesday and Friday. The facility provided documentation of showers completed on 04/05/22, 04/11/22, 04/12/22, 04/18/22, 04/20/22, 04/22/22, 04/27/22, 05/02/22, 05/04/22, 05/13/22, 05/18/22, 05/20/22, 05/30/22, 06/05/22,…

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 observation, record review, facility policy and procedure review, Centers for Disease Control (CDC) guidance and interview the facility failed to maintain proper infection control practices during blood glucose monitoring and for residents in quarantine and/or isolation for COVID-19 to decrease the risk of spreading infection, including COVID-19. This affected one resident (#58) of two residents observed for blood glucose monitoring, six residents (#4, #40, #43, #12, #211 and #212) reviewed related to COVID-19 and had the potential to affect all 65 residents residing in the facility. Findings include: 1. During the annual survey, the facility identified Resident #12 as the only resident in isolation for COVID-19 (the resident had a positive test). Resident #4, #40, #43, #12, #211 and #212 were identified to be in quarantine related to potential exposure to Resident #12, however as of 06/13/22, none of these six residents had tested positive for COVID-19. Review of the medical record for Resident #12 revealed an admission date of 03/17/22 with diagnoses including pressure…

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, facility policy and procedure review and interview the facility failed to ensure all medications were properly stored and failed to ensure insulin pens were dated when opened. This affected five residents (#19, #23, #46, #53 and #58) of eight residents reviewed for medication administration and/or involved in observations of three medication carts and one medication room. The facility census was 65. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the physician's orders for June 2022 revealed an order for the narcotic pain medication, Norco 5-325 milligrams (mg) one tablet every eight hours as needed for pain. Review of the medication administration record (MAR) revealed staff documented the resident was administered the Norco on 06/14/22 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.

Based on record review and interview the facility failed to ensure residents were assisted with showers as per their preference. This affected three residents (#10, #17, #46) of 18 residents interviewed regarding choices and showers. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed Resident #46 was cognitively intact and required two person assistance for bathing. Review of Resident #46's shower records from April 2022 through 06/15/22 revealed showers were scheduled every Monday, Wednesday and Friday. The facility provided documentation of showers completed on 04/05/22, 04/11/22, 04/12/22, 04/18/22, 04/20/22, 04/22/22, 04/27/22, 05/02/22, 05/04/22, 05/13/22, 05/18/22, 05/20/22, 05/30/22, 06/05/22, 06/10/22 and 06/15/22. This reflected instances of Resident #46 not receiving…

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 interview the facility failed to ensure residents were invited to participate in meetings discussing and developing their plan of care. This affected three residents (#10, #41 and #45) of 18 residents who were interviewed regarding participation in development of their plan of care. Findings include: 1. Review of Resident #10's medical record revealed diagnoses including multiple sclerosis, muscle spasms, diabetes mellitus, asthma, depression, chronic pain, and slow transit constipation. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/03/22 revealed Resident #10 was able to make herself understood, was able to understand others and was cognitively intact. Review of progress notes, dated 08/13/21 at 9:36 A.M., 12/17/21 at 9:51 A.M., 02/11/22 at 9:47 A.M. and 06/10/22 at 10:18 A.M. revealed plan of care meetings were held on these dates. Family were invited and did not attend. There was no documentation of resident attendance or input for the meetings. On 06/14/22 at 9:29 A.M. interview with Resident #10 revealed she was not invited 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 observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #41 and #45, who required staff assistance with activity of daily living care received timely and adequate oral hygiene and/or nail care. This affected two residents (#41 and #45) of five residents reviewed for activities of daily living. Findings include: 1. Review of Resident #41's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), Alzheimer's disease, depression, and chronic pain. On 12/16/21 a physician order was written for oral hygiene every shift and as necessary. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 indicated Resident #41 was usually able to make herself understood and was usually able to understand others. Resident #41 was assessed as moderately cognitively impaired and no rejection of care was documented. The MDS assessment revealed Resident #41 was dependent on staff for transfers and required extensive…

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

Based on record review and interview the facility failed to ensure Resident #10, who exhibited limited range of motion (ROM) received services to increase and/or maintain range of motion. This affected one resident (#10) of 25 residents reviewed and/or interviewed regarding range of motion. Findings include: Review of Resident #10's medical record revealed diagnoses including multiple sclerosis, diabetes mellitus, depression and chronic pain. A plan of care, initiated 06/15/15 revealed Resident #10 was at risk for contractures with a goal for Resident #10 to have no evidence of pain during ROM. Interventions included referring Resident #10 to physical and occupational therapy (dated 06/15/15) but was silent to other interventions to prevent contractures. Review of a restorative referral form, dated 12/11/20 revealed specific instructions for ROM and stretching to both lower extremities and assistive active ROM (AAROM - an exercise in which a manual or mechanical external force assists specific muscles and joints to move through their available excursion)/Passive ROM (gentle…

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, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected two residents (#38 and #58) of seven residents observed for medication administration. Findings include: 1. On 06/15/22 at 6:06 A.M., Licensed Practical Nurse (LPN) #604 was observed preparing and administering Lantus insulin to Resident #58 via an insulin pen. The pen was not primed after the needle was applied. The pen was set on 28 units for administration into the right lower quadrant of the abdomen. On 06/15/22 at 6:07 A.M. interview with LPN #604 verified she had not primed the insulin pen prior to administering the insulin. LPN #604 indicated she believed the pen only needed primed when the pen was originally opened. Review of the facility undated policy titled Insulin Flex Pen Policy revealed after attaching the needle to the flex pen, two units air shot was 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 closed record review and interview the facility failed to promptly notify the physician or nurse practitioner of laboratory results outside the clinical reference range for Resident #61. This affected one resident (#61) of five residents reviewed for unnecessary medication use. Findings include: Review of the closed medical record for Resident #61 revealed the resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disorder and aphasia. Review of the laboratory testing results, dated 05/11/22 revealed the resident had a critical lab, hemoglobin of 6.9 (low) (normal range 12.1 to 15.1). Review of laboratory results dated [DATE] revealed the resident's hemoglobin remained critically low at 7.6. Review of the progress note, dated 05/11/22 revealed no evidence the physician (MD) or the certified nurse practitioner (CNP) were notified of the critical lab on this date. A progress note, dated 05/16/22 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 observation, record review and interview the facility failed to ensure resident medical records were complete and accurate. This affected three (#41, #45 and #62) of 21 residents whose medical records were reviewed. Findings include: 1. Review of Resident #41's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), Alzheimer's disease, depression, and chronic pain. On 12/16/21, a physician order was written for oral hygiene every shift and as necessary. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 indicated Resident #41 was usually able to make herself understood and was usually able to understand others. Resident #41 was assessed as moderately cognitively impaired. No rejection of care was documented. The MDS assessment revealed Resident #41 was dependent on staff for transfers and required extensive assistance from staff for personal hygiene. Review of the June 2022 Treatment Administration Record (TAR) indicated nurses documented…

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 personnel files and interview, the facility failed to ensure prospective new employees were checked with the nurse aide registry to determine if they had findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry prior to their application and hire at the facility. This had the potential to affect all 95 facility residents. Findings include: On 07/16/19 at 3:25 P.M. during review of personel files, Human Resource staff (HR) #819 said unless a prospective employee was a nursing assistant the facility did not check the nurse aide registry to ensure that applicant did not have findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry prior to their application and hire at the facility. Review of the facility's abuse policy, revised 06/01/17, revealed as part of the screening process multiple interviews of potential employees would be conducted, employment references would be verified, and drug screening would be conducted. Background checks would be conducted on all employees and licenses…

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 assessment and interview, the facility failed to conduct, document, and update a comprehensive facility assessment. This had the potential to affect all 93 residents. Findings include: Review of the Facility Assessment indicated it was last updated on 05/28/18. The Facility Assessment indicated the average number of residents the facility could accommodate for elderly mental health was 12, for therapy services was 40, for nutritional needs was 9, and for dialysis was 4. The Facility Assessment indicated the average nursing staff scheduled on a daily basis. The Facility Assessment was silent as to provision of therapy services, dietary services, and mental health services. The Facility Assessment did not address activity needs, pharmacy services, laboratory services, or social service needs of the residents. The Facility Assessment was silent as to the use of any third party contracts. Health information technology resources were not addressed. On 07/17/19 at 11:37 A.M., the Director of Nursing (DON) and Administrator were interviewed regarding…

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 Residents #28, #30, #40, #87, #106, and #317 were notified in writing the reason for the discharge to the hospital in an easily understood language, and failed to notify the ombudsman's office of the residents discharge to the hospital. This finding affected six (Residents #28, #30, #40, #87, #106, and #317) of six residents reviewed for hospitalization. The facility census was 95 residents. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, major depressive disorder, and muscle weakness. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #30's progress note dated 07/08/19 at 2:20 P.M. indicated the resident was sent to the hospital on [DATE] and all parties were aware. Interview on 07/17/19 at 12:52 P.M. with Licensed Social Worker (LSW)…

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 store and label medications according to accepted professional standards. This affected two (Residents #104 and #12) of four residents who received medications administered by nurses at the facility. This also had the potential to affect 27 residents who received medications held in medication storage cart #2. The facility census was 95 residents. Findings include: 1. Record review revealed Resident #104 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (MS). Further review of Resident #104's medical record revealed a physician's order dated [DATE] for dimethyl fumarate (Tecfidera) 240 milligrams (mg) delayed release capsule two times a day (for MS). Review of Resident #104's medication administration record (MAR) from [DATE] to [DATE] revealed Tecfidera was administered 34 times. Observation of medication cart #2 on [DATE] at 1:17 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #802,…

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 funds accounts and interview, the facility failed to deposit the entirety of a resident's funds into her account. This affected one (Resident #24) of six residents whose accounts were reviewed. The facility census was 95 residents. Findings include: During review of Resident #24's account it was noted Resident #24 received a $50.00 credit each month with the exception of two months. In February 2019 no $50.00 credit was listed. In April 2019 a $68.00 credit was posted. On 07/17/19 at 10:32 A.M., Corporate Accounts Receivable personnel #913 verified Resident #24 was not provided her $50.00 in February 2019, stating there had been a change in her liability and there was some confusion regarding her account. Resident #24 had an additional $18.00 of the $50.00 paid in April so the balance due in her account was $32.00.

Based on review of resident fund accounts and interview, the facility failed to notify a resident or his guardian when the amount in his account reached $200 less than the limit permitted for Medicaid recipients. This affected one (Resident #45) of six residents whose accounts were reviewed. The facility census was 95 residents. Findings include: Review of Resident #45's quarterly account statements revealed a $1500 credit was posted to his trust on 03/11/19 raising his balance to $1830.02. The account remained over $1800. As of 07/15/19, the balance was $1970.11. On 07/17/19 at 9:30 A.M., Corporate Accounts Receivable personnel #913 said spend down notifications were generally sent out once a resident's balance was within $200 of a $2000 limit. Corporate Accounts Receivable personnel #913 verified Resident #45's balance had exceeded $1800 as of 03/11/19, stating $1500 was deposited from Resident #45's main account from a Medicare overage based on a request from the activity staff to purchase a chair. On 07/17/19 at 10:32 A.M., Corporate Accounts Receivable personnel #913 verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide comprehensive assessments related to medical diagnoses and conditions for one (Resident #157) of 29 residents whose records were reviewed for assessments. The facility census was 95 residents. Findings include: Review of Resident #157's closed medical record revealed an admission date of 06/12/19. Diagnoses included a deep vein thrombosis (DVT - blood clot) of both lower extremities. A list of medications provided by the hospital revealed an order for omnicef 300 milligrams (mg) every twelve hours for seven days. A nutritional assessment dated [DATE] indicated nursing reported Resident #157 had emesis (did not indicate if was an isolated occurrence or if greater than one). Nursing and Resident #157 reported they believed the emesis was related to antibiotic use. A nursing note dated 06/15/19 at 8:40 P.M. indicated Resident #157 was sent to the emergency room after having three episodes of brown liquid emesis. A nursing note dated 8:42…

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 the Narcotic Control Records accurately reflected the actual narcotic count following administration of resident narcotics. This affected one (Resident #39) of fourteen residents who received narcotics from medication cart #2. The facility census was 95 residents. Findings include: Observation of medication cart #2 with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #802 on 07/17/19 at 1:30 P.M. revealed, according to the Narcotic Control Record, Resident #39 had twenty-four norco tablets (hydrocodone 7.5 milligrams (mg) - acetaminophen 325 mg) remaining. Observation of the blister pack of norco at that time revealed twenty-three tablets remaining. LPN #802 was interviewed at the time of the findings and stated she had administered one tablet to Resident #39 at 9:00 A.M. and had not signed the Narcotic Control Record. LPN #802 signed the Narcotic Control Record for Resident #39 at the time of the interview. The DON was interviewed on 07/17/19 at 1:30 P.M. and stated the Narcotic…

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 maintain the appropriate infection control procedures during Resident #28's medication administration. This finding affected one (Resident #28) of five residents observed for medication administration. The facility census was 95 residents. Findings include: Observation on 07/15/19 at 10:52 A.M. with Registered Nurse (RN) #801 of Resident #28's medication administration revealed the nurse checked for residual by injecting air into the resident's stomach using a barrel and plunger type of syringe placed into the port of Resident #28's PEG tube (percutaneous endoscopic gastrostomy tube is a flexible feeding tube placed through the abdominal wall and into the stomach allowing nutrition, fluids and/or medications to be placed directly into the stomach). RN #801 removed the plunger from the barrel and placed the plunger on the bedside table. At this point, the nurse put gloves on. The plunger rolled off of the resident's bedside table and onto the resident's bed linens. The nurse picked up the plunger from the bed,…

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.