Fort Gibson Care & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure a comprehensive care plan was developed for resident to resident interaction related to wandering for one (#11) of 12 sampled resident whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: Res #11 was admitted to the facility on [DATE] with diagnoses of dementia and unspecified hallucinations. A care plan, dated 01/01/23, documented the resident was not a risk for wandering. An admission assessment, dated 01/12/23, documented the resident was severely impaired with cognition. An assessment for wandering, dated 04/09/23, documented the resident was moderate risk for wandering. An assessment for wandering, dated 07/10/23, documented the resident was moderate risk for wandering. A quarterly assessment, dated 07/15/23, documented the resident wanders daily. An incident report, dated 09/11/23, documented resident to resident altercation after…

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 residents received the supervision and assistance to prevent falls for one (#18) of three sampled residents reviewed for accidents hazards. The Resident Census and Conditions of Residents form, documented 45 residents resided at the facility. Findings: Res #18 had diagnoses which included COPD, dementia, and anxiety disorder. A care plan, dated 11/18/20, documented the resident was a high risk for falls. The care plan document the resident had altered sensory preception secondary to dementia. An incident report, dated 09/18/22, documented an unwitnessed fall for Res # 18. The resident was found on floor in their room on their knees with their hands and head resting in the seat of their wheelchair. The report documented the resident said they were trying to get out of bed and transfer to the wheelchair. The incident report documented there were no injuries. The incident report documented a fall alarm was placed on the bed. 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.

Based on record review and interview, the facility failed to ensure the physician was notified of a significant weight loss and residents received interventions to maintain nutritional status within acceptable parameters for one (#32) of two residents sampled for nutritional status. The Resident Census and Conditions of Residents form documented 45 residents who resided in the facility. Findings: 1. Res #32 had diagnoses which included Alzheimer's disease, encephalopathy, dementia, anxiety, and major depression. The weight record, dated 02/13/23, documented a weight of 155 lbs. The weight record, dated 03/6/23, documented a weight of 155 lbs. The weight record, dated 04/04/23, documented a weight of 144 lbs. A dietary note, dated 04/20/23, documented Res #32 had a significant weight loss of 7.1% in the last 30 days. The weight record, dated 05/05/23, documented a weight of 136 lbs. A dietary note, dated 05/31/23, documented Res #32 had a significant weight loss of 5.6% in the last 30 days and the dietician recommendation was to offer ice cream twice a day to the resident. There 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.

Based on record review and interview, the facility failed to ensure behaviors and/or side effects were monitored for the use of psychotropic medications for two of (#20 and #25) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 45 residents who resided in the facility. Findings: 1. Res #20 had diagnoses which included insomnia and major depressive disorder recurrent. A physician order, dated 05/08/23, documented Wellbutrin SR (an antidepressant) 450 mg one time a day related to major depressive disorder. A physician order, dated 05/22/23, documented trazodone (an antidepressant) 150 mg at bedtime related to insomnia. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident received antidepressant medication during the look back period. A care plan last revised 08/19/23, documented the resident received antidepressants. The care plan documented the resident had feelings of prolonged…

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 free from significant medication errors for one (#20) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: Res #20 admitted to the facility and had diagnoses which included heart failure, hypothyroidism, and diabetes mellitus. A physician order, dated 05/07/23, documented Novolog injection solution (insulin Aspart) inject as per sliding scale. A physician order, dated 05/11/23, documented Lantus subcutaneous solution (insulin Glargine) inject 50 units one time a day related to diabetes mellitus. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident had received insulin the seven days prior to the assessment. A care plan, last reviewed 08/19/23, documented the resident had unstable blood glucose levels related to hyperglycemia. The care plan documented to administer…

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 labs were obtained per physician order for one (#20) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: Res #20 admitted to the facility and had diagnoses which included heart failure, hypothyroidism, and diabetes mellitus. A physician order, dated 08/13/23, documented to perform a HgbA1c every three months in February, May, August, and November. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident received insulin seven days during the assessment period. A care plan, last revised 08/19/23, documented the resident has unstable blood glucose levels related to hyperglycemia. The care plan documented to obtain an HgbA1c on admit and every three months. On 09/18/23 at 1:09 p.m., The DON could not provide the August HgbA1c. The DON stated the HgbA1c had been missed 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.

Based on observation, record review,and interview, the facility failed to follow the menu and provide pureed foods listed on the menu for the puree diets from the kitchen. The Resident Census and Conditions of Residents form documented 11 residents resided at the facility who had mechanically altered diets including pureed and all chopped food. Findings: The menu for week three, regular puree meal, documented puree pot roast, puree new potatoes, puree green peas, puree dinner roll, puree bread pudding, margarine, salt/pepper, milk, and water. On 09/19/23 at 11:36 a.m., the bread was not observed to be pureed for the noon meal. On 09/19/23 at 11:54 a.m., a puree meal was observed to be served roast with gravy, potatoes, green peas, and bread pudding were observed to be served. Pureed bread was not served with the puree meal. On 09/19/23 at 3:06 p.m., the DM stated the puree meals should have received what ever was on the menu.

Based on observation, record review, and interview the facility failed to provide food that was palatable and at an appetizing temperature for the residents. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: 1. Res #20 had a diagnosis of diabetes mellitus. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and was independent with eating. On 09/14/23 at 1:47 p.m., Res #20 stated the food had gone down hill lately, it was either bland or to salty. Res #20 stated the milk was warm this morning and tasted spoiled they could not drink it. Res #20 stated the drinks were brought out in the warmer with the food. The resident stated they preferred to eat in their room. On 09/19/23 at 10:22 p.m., Res #20 stated they keep sending orange juice with breakfast and they did not like orange juice. The resident stated the drinks are not cold when they get them but the food is cold. Res #20 stated the oatmeal was hard on top by the time it got to them. 2. Res #25's Medicare five day assessment,…

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 DNR was signed by the appropriate person for two (#7 and #3) of five residents reviewed for advance directives. The administrator identified 23 residents in the facility had a DNR. Findings: 1. Res #7 had diagnoses which included heart failure, renal failure, diabetes mellitus, and dementia. A DURABLE POWER OF ATTORNEY FOR FINANCIAL MANAGEMENT form, dated [DATE], documented in parts .This document does not authorize anyone to make medical or other health care decisions. You may execute a health care proxy (also known as a health care or medical power of attorney) to do this . A DNR form, dated [DATE], was signed by the individual designated as the POA on the Durable Power of Attorney for Financial Management form. A quarterly resident assessment, dated [DATE], documented the resident was cognitively intact. On [DATE] at 10:29 a.m., Res #7 stated he did not want to be a DNR. He stated he did want CPR in the event he stopped breathing or his…

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 notify the physician of blood pressure readings below normal limits for one (#5) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 48 residents resided in the facility. Findings: Resident #5 had diagnoses which included heart failure, COPD, hypotension, and end stage renal disease. A significant change assessment, dated 04/28/22, documented the resident was cognitively intact, and received dialysis. A care plan, reviewed 07/14/22, documented staff were to asses/monitor/document vital signs per protocol and report significant changes in pulse, respirations and blood pressure immediately, and post-dialysis care: monitor B/P, report hypotension or hypertension. A vital sign record on 07/18/22 at 1:46 p.m. documented the resident's B/P was 76/40. A vital sign record on 07/20/22 at 6:14 a.m. documented the resident's B/P was 97/46. A vital sign record on 07/22/22 at 2:48 p.m. documented the resident's B/P was 86/38. On 08/03/22 at 3:08 p.m., LPN #1 stated…

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 provide letters of NOMNC to residents discharged from Medicare covered part A stay with benefit days remaining in the last 6 months. Page three of the entrance conference worksheet documented six residents were discharged from Medicare covered Part A stay with benefit days remaining in the last six months. Findings: Res #35 was admitted to the facility on Part A Medicare stay on 07/01/22 and discharged from the facility to home on [DATE]. The facility provided an ABN notice to the resident but did not provide a NOMNC form. Res #40 was admitted to the facility on Part A Medicare stay on 07/14/22 and discharged from the facility to home on [DATE] with benefit days remaining. The facility provided an ABN notice to the resident but did not provide a NOMNC form. Res #103 was admitted to the facility on Part A Medicare stay on 01/04/22 and discharged from the facility to home on [DATE] with benefit days remaining. The facility provided an ABN notice to 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, observation, and interview, the facility failed to ensure assessments accurately reflected the residents' status for four (#5, 20, 44, and #45) of 20 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: The Resident Assessment Instrument manual, dated October 2019, read in parts, .Coding Instructions for N0350A Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received .N0410B, Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) .N0410D, Hypnotic: Record the number of days a hypnotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) .N0410E,…

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 update the PASRR program level I screening as required, obtain existing Level II evaluation reports, and incorporate the evaluation reports into the residents' care plan for three, (#8, 27, and #44) of three residents reviewed for PASRR. The facility failed to: a. incorporate the evaluation report into the resident's care plan for Res #27. b. obtain an existing PASRR level II evaluation report for Res #8 on admission. c. contact OHCA when Res #44 obtained new psychiatric diagnoses. The administrator reported five residents who resided in the facility have PASRR Level II evaluations. Findings: 1. Res #44 was admitted to the facility on [DATE]. A PASRR level I screening, dated 11/12/20, documented Res #44 did not have evidence or a diagnosis of serious mental illness or a recent history of mental illness. On 10/21/21, Res #44 was diagnosed with recurrent major depressive disorder and unspecified psychosis not due to a substance or known…

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 develop and revise care plans for two, (#3 and #44) of 13 residents whose care plans were reviewed. The facility failed to: a. update fall care plans for Res #3 and #44. b. develop a care plan regarding psychosis and depression and/or the medication for these diagnoses for Res #44. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: 1. Res #3 had diagnoses which included osteoporosis, idiopathic epilepsy, and Alzheimer's disease. A fall care plan, with an update, dated 01/24/18, documented Res #3 was to have a bed alarm in bed. The care plan documented staff were to check placement and functioning every shift. An initial incident note, dated 12/14/22, documented Res #3 was standing up from the wheelchair and became unsteady and fell to the floor. The STPR was documented as continue all fall interventions in place. A fall care plan update, dated 12/31/21, documented facility staff were in-serviced on fall alarms. A facility incident report, 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 record review, observation, and interview, the facility failed to ensure residents received monitoring, interventions, and supervision to prevent falls for two, (#3 and #44) of two residents sampled for falls. The administrator reported 15 residents had fallen in the previous six months. Findings. 1. Res #3 had diagnoses which included osteoporosis, idiopathic epilepsy, and Alzheimer's disease. A fall care plan, with an update, dated 01/24/18, documented Res #3 was to have a bed alarm in bed. The care plan documented staff were to check placement and functioning every shift. An initial incident note, dated 12/14/22, documented Res #3 was standing up from the wheelchair and became unsteady and fell to the floor. The STPR was documented as continue all fall interventions in place. A fall care plan update, dated 12/31/21, documented facility staff were in-serviced on fall alarms. A facility incident report, dated 03/26/22, documented Res #3 attempted to transfer herself from her wheelchair to the couch. The incident report documented the alarm sounded but staff could not get…

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 designate an RN to serve as DON for the previous eight months. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: On [DATE] at 3:00 p.m., the facility staffing schedule was reviewed. The DON licensure was documented as LPN. On [DATE] at 3:45 p.m., the administrator confirmed the DON was an LPN. On [DATE] at 4:07 p.m., the administrator stated the facility was granted a 30 day waiver in [DATE] when the former DON stepped down. She stated the waiver had expired.

The facility failed to ensure medications were administered as ordered by the physician for one (#5) of five residents sampled for medication review. The Resident Census and Condition of Resident's documented 48 residents resided in the facility. Findings: Resident #5 had diagnoses which included heart failure, dependence on renal dialysis, end stage renal disease, and orthostatic hypotension. A physician order, dated 12/19/2020, documented to administer Midodrine tablet 10 mg one time a day every Monday, Wednesday, and Friday related to orthostatic hypotension. Administer prior to dialysis, send another tab with her to dialysis. A significant change assessment, dated 04/28/22, documented the resident was cognitively intact and required dialysis. The MAR for June 2022 documented the resident did not receive Midodrine as ordered on 6/6, 6/10, and 6/30. A physician order, dated 06/30/22, documented to give one tablet of Midodrine 5 mg every day related to dependence on renal dialysis. A care plan, reviewed 07/14/22, documented to administer medications as prescribed and to monitor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure drug regimen reviews were acted upon for two (#5 and #20) of five residents reviewed for medications. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: 1. A policy effective 2018, titled Drug Regimen Review, documented in part, .9. The resident's physician will be notified of the Pharmacy Recommendations. The facility will allow 10 days for the physician response to the recommendations. Any recommendations not completed within 10 days will be referred to the Medical Director. Resident #5 had diagnoses which included heart failure, dependence on renal dialysis, end stage renal disease, COPD, and orthostatic hypotension. A physician order, dated 03/02/21, documented Lexapro tablet 10 mg give one tablet at bedtime related to anxiety disorder. A pharmacy drug regimen review, dated 11/08/21, documented a request to decrease the resident's Lexapro at bedtime from 10 mg to 5 mg. A 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.

Based on record review, observation, and interview, the facility failed to ensure the medication error rate was not five percent or greater. The Resident Census and Conditions of Residents documented 48 residents resided in the facility. Findings: On 08/03/22 at 7:30 a.m., CMA #2 was observed administering 20 ml of Lactulose 10 mg/5 ml to Res #25. Order reconciliation documented the resident's dose of Lactulose was to have been 30 ml. On 08/03/22 at 11:30 a.m., LPN #3 was observed during insulin pass. She was observed with a piece of lined paper with resident names on one side and sliding scale parameters on the other. She stated that all residents were on the same sliding scale per the facility physician. She was observed to administer four units of Novolog insulin to Res #15 according to the sliding scale written on the paper. Res #15's orders documented the resident was to receive a scheduled four units of insulin in addition to the sliding scale that was administered. On 08/03/22 at 11:57 a.m., LPN #3 stated Res #15 was supposed to get an additional four units, but he didn't.…

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 conduct a significant change assessment when the resident had an improvement in condition for one (#44) of 20 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: Res #44 had diagnoses which included heart failure, psychosis, and dementia. A quarterly assessment, dated 04/22/22, documented Res #44 required extensive assistance with bed mobility, transfers, and hygiene. The assessment documented the resident required limited assistance with walking, locomotion, and eating. A quarterly assessment, dated 07/23/22, documented Res #44 was independent with bed mobility, transfer, walking and eating. The assessment documented the resident required supervision with toileting. On 08/02/22 at 3:22 p.m., Res #44 was observed in her room and appeared calm and talkative and her speech was nonsensical. On 08/04/22 at 11:14 a.m., the DON confirmed Res #44's last quarterly assessment, dated 07/23/22, should have been a…

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 completed resident assessments were transmitted to CMS within the required time frame for one (#1) of one resident reviewed for MDS assessments greater than 120 days old. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: Res #1 had diagnoses which included coronary artery disease, congestive heart failure, and Alzheimer's disease. An annual assessment, dated 02/18/22, documented Res #1 was severely impaired in daily decision making and required extensive assistance for most ADLs. On 08/04/22 at 11:14 a.m., the DON stated Res #1 no longer resided in the facility. On 08/04/22 at 11:29 a.m., the DON reported CMS had rejected the batch which contained Res #1's subsequent MDS assessments and they had not been uploaded. He stated the rejection of the MDS assessments must have been missed.

Based on record review, observation, and interview, the facility failed to conduct routine assessments of pressure ulcers for one (#39) of one resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented two residents had pressure ulcers. Findings: Res #39 had diagnoses which included pressure ulcer of sacral region, altered mental status, and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. A physician order, dated 07/13/22, documented to apply barrier cream every shift to sacral/coccyx area three times a day for skin/wound. A weekly skin/wound assessment, dated 07/13/22, documented the resident had a stage II pressure ulcer to the coccyx measuring 0.5 cm x 0.3 cm. A five day assessment, dated 07/20/22, documented the resident was moderately impaired in cognition, required extensive assistance of one staff with bed mobility and personal hygiene, total assistance of two staff with transfers, and total assistance of one staff with toileting. The assessment documented the resident had one stage 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 record review and interview, the facility failed to ensure a PRN psychotropic medication duration order did not extend beyond 14 days and GDR of psychotropic medications were attempted for one (#20) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: Resident #20 had diagnoses which included generalized anxiety disorder, major depressive disorder, insomnia, and dementia with behaviors. A physician order, dated 03/14/22, documented trazodone tablet 150 mg, give one tablet by mouth at bedtime related to insomnia. A physician order, dated 03/14/22, documented Geodon capsule 60 mg, give one capsule by mouth two times a day related to major depressive disorder. A physician order, dated 03/23/22, documented lorazepam tablet one mg, give one tablet by mouth every four hours as needed for agitation. A physician order, dated 03/23/22, documented Ambien tablet 5 mg, give one tablet by mouth at bedtime related to insomnia. A pharmacy drug regimen review, dated 04/08/22,…

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 record review, observation, and interview, the facility failed to ensure the residents were free of significant medication errors. The Resident Census and Conditions of Residents form documented 48 residents resided in the facility. Findings: On 08/03/22 at 11:30 a.m., LPN #3 was observed during insulin pass. She was observed with a piece of lined paper with resident names on one side and sliding scale parameters on the other. She stated all residents were on the same sliding scale per the facility physician. She was observed to administer four units of Novolog insulin to Res #15 according to the sliding scale. Res #15 physician orders documented the resident was to receive a scheduled four units of insulin in addition to the sliding scale that was administered. On 08/03/22, at 11:57 a.m., LPN #3 stated the resident was supposed to get an additional four units. She stated the error occurred partially because she did not have the computer to verify the order and partially because of human error. On 08/03/22 at 12:00 p.m., the DON stated staff were supposed to verify 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.