Mid-Del Skilled Nursing And Therapy

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify a resident's family member listed as the emergency contact, of a change in condition for 1 (#2) of 3 sampled residents reviewed for notification of change related to assess, monitor, and intervene. The ADON identified 38 residents resided in the facility. Findings: A policy titled Resident's Family or Physician Notification of Change Guideline, dated 12/01/09, read in part, The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or interested family member of the following events: .A significant change in the resident's physical, mental, or psychosocial status. (i.e. [that is/or in other words] a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. A quarterly resident assessment, dated 02/25/25, showed Resident #2 had a BIMS of 03 meaning severely impaired cognition. Resident #2's face sheet, 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 record review and interview, the facility failed to ensure a care plan was fully developed for 1 (#2) of 7 sampled residents whose care plans were reviewed. The ADON identified 38 residents resided in the facility. Findings: An undated paper copy labeled patient identification card showed Resident #2 had an insertable cardiac monitor (loop monitor). The document showed the monitor was implanted 08/21/23. Resident #2's face sheet, dated 09/04/24, showed the resident had diagnoses which included dysarthria and anarthria, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and unspecified dementia without behavior disturbance. A history and physical, dated 09/05/24, showed Resident #2 had a loop monitor recorder insertion. A progress note, dated 10/28/24, showed Resident #2 had no a-fibrillation on the implantable loop monitor. A quarterly resident assessment, dated 02/25/25, showed Resident #2 was admitted to the facility on [DATE] and had a BIMS of 03 meaning…

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 follow hospital transfer orders for 1 (#5) of 1 sampled resident reviewed for respiratory care . The ADON reported 38 residents resided in the facility. Findings: On 05/02/25 at 5:24 a.m., Resident #5 was observed laying in bed with eyes closed. Resident #5 was not observed to wear oxygen, CPAP or BIPAP. An undated medical diagnoses list for Resident #5 showed diagnosis of unspecified asthma. Resident #5's transfer orders from the hospital, dated 04/11/25, showed General Instructions for oxygen at 4 liters/minute by nasal cannula continuously. The orders showed a diagnoses of obesity hypoventilation syndrome and chronic respiratory failure, and CPAP/BIPAP instructions. Resident #5's care plan, initiated on 03/11/25, showed oxygen 1-4 liters as needed. The April and May 2025 treatment record for Resident #5 did not show continuous oxygen at 4 liters. The facility did not follow/implement the hospital orders for oxygen and CPAP/BIPAP. On 05/16/25 at 1:51 p.m., LPN #1 stated the process for new orders upon…

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 were instructed arbitration agreements were voluntary for 3 (# 5, 34, and #43) of 5 sampled residents reviewed for arbitration agreements The administrator identified 40 residents who had entered into a binding arbitration agreement. Findings: An undated document titled An Explanation to the Resident/Family, read in part, By signing our admission contract your electronic signature will be placed on the following forms, which you will receive copies of after signing. admission Agreement/Arbitration/Medical Records Release Form: This agreement allows for admission into the facility, gives the facility consent to provide medical care/treatment, consent to have your medical records, and bill for your medical care. An admission packet, revised 11/29/22, showed DocuSign (signature) was set up in which the resident/resident's legal representative agreed to everything inside of the admission packet with just one signature. The arbitration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure expired medications were removed from circulation for one (#42) of three sampled residents observed during medication pass and storage. The administrator identified 45 residents resided in the facility. Findings: The MEDICATION STORAGE IN THE FACILITY policy, dated 01/22, read in part, .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal . Resident #9 had diagnoses which included arthropathy and depression. A physician's order, dated 11/16/23, documented boswellia [NAME] 150 mg give two capsules one time a day. On 11/21/23 at 7:59 a.m., CMA #1 handed the surveyor a bottle of boswellia [NAME] 150 mg with Resident #42's name written on the bottle. The manufacturer's expiration date documented 05/23. There was no open date on the bottle. On 11/21/23 at 8:00 a.m., CMA #1 stated the manufacturer's expiration date documented on the bottle was 05/23. They stated 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 and interview, the facility failed to ensure a resident was not involuntarily discharged for one (#149) of one sampled residents reviewed for involuntary discharge. The administrator identified 45 residents resided in the facility. Findings: Resident #149 had diagnoses which included Alzheimer's disease and dementia. Resident #149's quarterly resident assessment, dated 05/16/23, documented the resident had severe cognitive impairment. A Social Service Note, dated 06/21/23, documented Resident #149 had memory issues and wandered a lot throughout the day and night. Resident #149's discharge return not anticipated resident assessment, dated 07/29/23, documented Resident #149 was discharged on 07/29/23. It documented Resident #149's decision making skills were moderately impaired. A Nurses Note, dated 07/29/23 at 3:15 a.m., documented Resident #149 was observed in another Resident's room exposed. It documented Resident #149 was discharged to the hospital and an emergency order of discharge…

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, observation, and interview, the facility failed to ensure a physician's order had been obtained for oxygen for one (#43) of one sampled resident reviewed for oxygen services. The administrator identified six residents with orders for oxygen. Findings: A Respiratory Therapy policy, dated 08/10/04, documented oxygen therapy would be administered as needed and directed by the ordering physician. It documented to obtain an order from a physician. Resident #43 readmitted on [DATE] with diagnoses which included acute respiratory failure and COPD. A Baseline care plan, dated 10/21/22, documented the resident used oxygen at four LPM. On 10/23/22 at 1:58 p.m., Resident #43 was observed in his room lying in bed. The resident had a nasal cannula in place and was receiving oxygen at 6 LPM from an oxygen concentrator. Resident #43's physician's orders did not document an order for oxygen. On 10/23/22 2:07 p.m., LPN #2 was asked what Resident #43's order was for oxygen. The LPN was observed to look in…

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 a dialysis resident was assessed before and after dialysis for one (#43) of one sampled resident reviewed for dialysis. The Resident Census and Conditions of Residents report, dated 10/24/22, documented four residents received dialysis services. Findings: Resident #43 readmitted on [DATE] with diagnoses which included end stage renal disease requiring dialysis services. A facility calendar documented the resident received dialysis services three times weekly on Mondays, Wednesdays, and Fridays. April 2022 dialysis assessments had been conducted three out of 11 opportunities. May 2022 dialysis assessments had been conducted one out of 13 opportunities. June 2022 dialysis assessments had been conducted zero out of 13 opportunities. July 2022 dialysis assessments had been conducted one out of 13 opportunities. A care plan, dated 07/21/22, documented the resident received dialysis three times weekly, to check the dialysis port for patency and signs…

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 a medication error rate of less than 5 percent. The medication error rate was 19.23 percent. The Resident Census and Conditions of Residents report, dated 10/24/22, documented 47 residents resided in the facility. Findings: A Preparation for Medication Administration policy, revised on 08/14/07, documented medications were administered as prescribed, and the medication and dosage on the residents' MAR was compared with the medication label. 1. Resident #18 had a physician's order, dated 04/12/21, for phenytoin suspension 100mg/4ml, give 4 ml by mouth three times daily. On 10/23/22 at 11:12 a.m., ACMA #1 was observed to administer five mls of phenytoin to Resident #18. 2. Resident #10 had physician's orders, dated 01/10/22, for hydroxychloroquine sulfate 200 mg (Plaquenil), two tablets daily and Prednisone 2.5 mg, give three tablets daily. Resident #10 had a physician's order, dated 02/01/22, for artificial tears one drop in both eyes three times daily. On 10/23/22 at 11:31 a.m., CMA #2 was observed 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 record review, observation, and interview, the facility failed to ensure medications were secured for one of two treatment carts observed for medication storage. The facility identified two treatment carts. Findings: A Medication Storage in the Facility policy, documented medications and biologicals are stored safely, securely and carts are locked when not attended by persons with authorized access On 10/23/22 at 11:25 a.m., a treatment cart for hall 200 was observed with keys in the lock, and unsecured without staff present. LPN #1 was observed to exit a room at the end of the hall. On 10/23/22 at 11:30 a.m., LPN #1 was asked how they ensured medications were secured. LPN #1 stated by locking the cart. LPN #1 was made aware of the keys observed in the treatment cart lock. They were asked the policy for securing medications. LPN #1 stated to keep the cart locked and to always have keys with them.

Based on record review, observation, and interview, the facility failed to ensure a catheter bag drainage bag was properly placed to avoid cross contamination for one (#38) of one sampled resident reviewed for urinary catheters. The Resident Census and Conditions of Residents report, dated 10/24/22, documented four residents with catheters. Findings: A Catheter Care policy, revised 04/05/13, documented to never allow any part of the drainage bag or tubing to touch the floor. Resident #38 had diagnoses which included chronic respiratory failure and stage four pressure ulcer. On 10/23/22 at 12:16 p.m., Resident #38 was observed in bed supine. A catheter drainage bag was observed secured to the lower bed frame. The drainage was observed to be open. On 10/23/22 at 12:44 p.m., CNA #2 was observed to lower Resident #38's bed. When the bed was lowered, the catheter drainage bag with the open drain was observed laying on the floor. On 10/23/22 at 1:40 p.m., LPN #2 was asked what the policy was for positioning a catheter drainage bag to prevent cross contamination. They stated to keep 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.