The Lodge At Brookline

Based on observation and interview, the facility failed to ensure emergency call cord was available in a resident's bathroom for one (#2) of three sampled residents whose emergency bathroom call system was observed. The administrator identified 39 residents resided in the facility. Findings: The Call Lights: Accessibility and Timely Response policy, revised 10/21/24, read in part, The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. Resident #2 had diagnoses which included other abnormalities of gait and mobility. Resident #2's care plan for daily care, dated 10/01/24, documented the resident was able to use their call light to call for help. On 11/26/24 at 11:28 a.m., Resident #2 stated they fell in the bathroom and could not reach the emergency call system. On 11/26/24 at 11:31 a.m., Resident #2's bathroom had a red emergency switch by the side of the toilet. Resident #2 stated they had not been able to walk around and depended on a wheelchair for locomotion. A resident…

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

Based on observation and interview, the facility failed to ensure medication carts were secured when not in use for three observations at random times throughout the survey on hall 400. The Executive Director identified 43 residents resided in the facility. Findings: A Medication Storage policy, dated 7/2024, read in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. On 09/03/24 at 12:42 p.m., an observation of the nurse cart on hall 400 was unlocked and unattended. There were medications, insulin, needles, etc located inside. On 09/03/24 at 12:44 p.m., LPN #1 was observed exiting a resident room. They stated the cart was not locked and the policy was to lock it when step away. On 09/04/24 at 7:59 a.m., LPN #1 was observed to walk away from the medication cart on hall 400 with medication cups in both hands. The cart was unlocked. On 09/04/24 at 8:01 a.m., LPN #1 returned to the cart and stated they did it again and it was not locked. On 09/06/24 at 9:39…

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 and interview, the facility failed to ensure the appropriate dishwasher temperature and sanitization concentration levels were reached on a high temperature dishwasher. The ED identified 43 residents resided in the facility. Findings: A Dishwashing Machine Use policy, dated, 5/2024, read in parts, Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: c. 165 F for stationary rack, single temperature machines .Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than: a. 165 F for stationary rack, single temperature machines. b. 180 F for all other machines. The policy also read, A supervisor will ensure the dishwashing machine is checked for proper concentrations of sanitizer solution (measured as parts-per-million[PPM] or ml/L) .The supervisor will check the calibration of the gauge weekly . On 09/04/24 at 10:38 a.m. during the follow up tour of the kitchen, the high temperature dishwasher was observed. Dietary Aide #1 was asked to run the dishwasher and to check 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, record review, and interview, the facility failed to ensure: a. enhanced barrier precautions were utilized for two of two (#2 and #21) residents observed with indwelling devices and open wounds, b. infection control practices were adhered to after providing resident care. The Executive Director identified 43 residents resided in the facility. The Resident Matrix, dated 09/03/24, documented five residents that resided in the facility had gastric tubes, three of which had urinary catheters, and two also had pressure ulcers. Findings: A Standard Precautions policy, dated 9/2017, read in part, Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Place used disposable syringes and needles .and other sharp items in appropriate puncture-resistant containers located as close as practicable to the area in which 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 and interview, the facility failed to ensure residents were offered the choice to formulate an advanced directive for one (#44) of 12 sampled residents whose advance directive acknowledgements were reviewed. The Executive Director identified 43 residents resided in the facility. Findings: Resident #44 had diagnoses which included malignant neoplasm of the lungs and end stage renal disease. On 09/04/24 at 9:45 a.m., the ED was asked to locate the advanced directive acknowledgment. On 09/06/24 at 1:05 p.m., the ED was asked again to locate the advanced directive acknowledgement. They stated they were unable to locate the acknowledgement. They were asked for the policy. No policy was provided by the time of exit.

Based on observation and interview, the facility failed to ensure: a. privacy was maintained during provision of care for two (Resident #25, and an unidentified resident) of four residents whose protected health information and privacy was reviewed during a tour of the facility, and b. protected health information was secure, for two, (Resident #21 and #40). The Executive Director identified 43 residents in the facility. Findings: A HIPAA Security Measures policy, dated 07/24/2024, read in part, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the residents identifiable information and/or records that are in electronic format. A Promoting/Maintaining Resident Dignity policy, dated 07/24/24, read in part, Maintain resident privacy. On 09/04/24 at 8:43 a.m., observation made of a cart on hall 500 to be unlocked and the laptop open exposing resident information of resident #21. There was no nurse near the cart. LPN #4 was also observed walking to the cart with gloves on and had 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 Resident Assessments were accurately coded for two (#21 and #34) of 13 residents reviewed for assessments. The Executive Director identified 43 residents resided in the facility. Findings: A Conducting an Accurate Resident Assessment policy, undated, read in part, qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 1. Resident #21 had diagnoses which included gastrostomy, pressure ulcer of sacral region stage 4, stage 4 right heel, osteomyelitis, and hepatitis C. An Annual Resident Assessment, dated 08/06/24, documented that anticoagulants were taken in the last 7 days and there was an indication for their use. There were no physician orders for anticoagulant use. On 09/06/24 at 10:48 a.m., LPN #1 stated the medication administration record for August does not show that resident #21 was taking anticoagulants. LPN #1 stated the MDS was coded…

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 baseline care plan was completed in a timely manner for one (#38) of 13 sampled residents reviewed for baseline care plans. The Administrator identified 43 residents resided in the facility. Findings: A Baseline Care Plan policy, undated, read in part, The baseline care plan will be developed within 48 hours of a residents admission. Resident # 38 admitted on [DATE] with diagnoses which included hemiplegia, malnutrition, gastrostomy, and chronic pain. There was not a baseline care plan put into place within 48 hours. The comprehensive care plan was created on 06/26/24. On 09/06/24 at 10:39 a.m., LPN #1 Stated the baseline care plan must be completed within 48 hours, they stated the baseline care plan was not completed within the 48 hours and it should have been. On 09/06/24 at 10:58 a.m., the Executive Director stated the policy was for the baseline care plan to be completed within 48 hours.

Based on record review and interview, the facility failed to ensure neurological checks were conducted and monitored after an unwitnessed fall for one (Resident #29) reviewed for falls. The ED identified 43 residents resided in the facility. Findings: Resident #29 had diagnoses which included epilepsy, end stage renal disease, cirrhosis of the liver. A Nurse Note, dated, 08/27/24 at 2:47 p.m., documented, resident presented on [their] bedroom floor, upon entering resident's room resident observed resident laying on [their] right side. Noted resident's chair in front of [them]. Resident stated My chair was hurting my back and I didn't want to wait for someone to help me into bed, so I did it myself, I fell and now I can't get up. Head to toe evaluation implemented, no noted injuries, resident stated that [they] did not hit [their] head, no noted abnormalities to [their] head, no bruising, no hematomas, no skin tears, resident able to move all four extremities without any difficulty. Neurological checks initiated noted blood pressure 136/74, temperature 97.6, pulse 72, respirations…

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 and interview, the facility failed to ensure staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census was updated. The ED identified 43 residents resided in the facility. Findings: On 09/04/24 at 9:08 a.m., observed the staffing sheet posted on the wall next to the nurses station window that did not have the name of the facility or the census or hours on it. On 09/06/24 at 10:54 a.m., observed the staffing sheet posted on the wall next to the nurses station window. It did not have the census, the name of the facility, nor the hours or total number of hours listed. On 09/06/24 at 11:00 a.m. the ED was asked what was required to be on the posted staffing sheet. They stated each discipline for direct care and for the shift that they were on, the date, and the census. On 09/06/24 at 11:04 a.m., the ED stated it did not have the required information.

Based on record review and interview, the facility failed to ensure medication was administered according to physician orders for one (#16) of five residents reviewed for medications. The Executive Director identified 43 residents resided in the facility. Findings: Resident #16 had diagnoses which included systemic lupus erythematosus, hypertension and diabetes mellitus. A Medication Administration, policy, dated 2/2023, read in parts, Medication are administered .as ordered by the physician . The policy also read, Review MAR to identify medication to be administered .Sign MAR after administration . A physicians order dated 8/31/24 documented to start Aquaphor to body two times a day one time only for 10 days. The September TAR had no documentation for the Aquaphor administration for 9/1/24 through 9/10/24. There were x for 9/11/24 through 9/30/24. On 09/06/24 at 2:34 p.m., Resident #16's left foot was observed to be red and inflamed with dry scaling on the leg. Resident #16 stated the foot hurt all over and stated there was cream for it. On 09/06/24 at 2:09 p.m., LPN #2 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.

Based on observation, record review, and interview, the facility failed to ensure emergency call cords were within reach for one dependent resident (#21) while lying in bed of 13 sampled residents reviewed for access to call light. The Executive Director identified 43 residents resided in the facility. Findings: A Call Lights: Accessibility and Timely Response policy, dated 11/28/23, read in part, Staff will ensure the call light is within reach of resident and secured, as needed. On 09/03/24 at 1:15 p.m., the call light was observed hanging between the head of the bed and the wall, out of reach of resident #21 who was lying in bed and was dependent on staff for all ADL's. They were moaning in pain and stated they just have to scream to get staff attention. On 09/03/24 at 1:25 p.m., CNA #1 stated the call button was out of the reach of the resident, they stated resident #21 just had wound care and they must have moved it. The call light is supposed to be on resident #21's chest. On 09/04/24 at 2:56 p.m., the Executive Director agreed that call lights are supposed to be within 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, record review, and interview, the facility failed to obtain finger stick blood sugars in a manner to prevent cross contamination for three of four observations. The administrator identified 15 residents who received finger sick blood sugars. Findings: 1. Resident #2 had diagnosis to include diabetes mellitus, hyperlipidemia, gout, anxiety, paroxysmal atrial fibrillation, acute kidney failure, sleep apnea, respiratory failure A current physician's order for Resident #2 documented they received Novolog injections four times a day per sliding scale. 2. Resident #3 had diagnosis to include diabetes mellitus. A current physician's order for Resident #3 documented they received Insulin Lispro injections per sliding scale three times a day. 3. Resident #3 had diagnosis to include diabetes mellitus. The current physician's order for Resident #4 documented they received Humalog injections per sliding scale before meals. On 05/29/24 at 11:41 a.m., LPN#1 was observed completing a finger stick blood…

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 address and document a grievnaces of clothing and medical equipment for one (#1) of four sampled residents reviewed for grievnaces. The administrator identified 43 residents currently resided in the facility. Findings: An undated facility policy, Resident and Family Grievances, read in part, .Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision .The facility will make prompt efforts to resolve grievances . Resident #1 was admitted to the facility on [DATE] with diagnosis to include severe protein Calorie Malnutrition, and end stage renal disease. A hand written social service note, dated 04/23/24, documented Resident #1 family had complained about missing wheelchair, purse, and clothes. A review of Resident #1 clinical record contained no additional documentation the resident or the family had any complaints or grievnaces and the resolution 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 and interview, the facility failed to complete a discharge summary with a recapitulation of stay for one (#1) of one sampled resident reviewed. The administrator identified eight residents who have discharged from the he facility since 04/02/24. Findings: Resident #1 was admitted to the facility on [DATE] with diagnosis to include protein calorie malnutrition, diabetes mellitus and cachexia. A review of the progress notes, dated 04/22/24, documented the resident was discharged from the facility and went home with their daughter. A discharge instruction form, dated 05/14/24, documented the resident went home with their daughter and medications were provided to them. There was no documentation of a complete summary of the residents stay. There was no documentation in the clinical record the facility completed a discharge summary for Resident #1 with a recapitulation of their stay. On 05/30/2024 at 10:48 a.m., the administrator was asked for the discharge summary for Resident #1. 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 and interview, the facility failed to ensure a SNF ABN form was provided when a resident discharged from Medicare Part A stay with benefit days remaining for two (#11 and #49) of three sampled residents reviewed for beneficiary notices. The MDS Coordinator identified 10 residents who had discharged from Medicare Part A stay with benefit days remaining in the past six months. Findings: An Advance Beneficiary Notices policy, revised 03/19, read in parts, .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .The facility shall inform Medicare beneficiaries of his or her potential liability for payment .For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) . 1. Resident #11's Medicare Part A skilled services start date was 12/17/22 and last covered day of Part A service was 01/20/23. The facility did not provide a SNF ABN form to the resident. 2. Resident #49's Medicare Part A skilled services start date was 03/09/23 and last covered day of Part 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 bathing was provided for one (#13) of three sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents required assistance with bathing. Findings: Resident #13 had diagnosis which included DMII, CKD, ASHD, and ESRD. A quarterly assessment, dated 07/08/23, documented Resident #13 required extensive assistance of one person with bathing. A care plan, dated 07/26/23, documented Resident #13 preferred showers and was able to help with some of the bathing, but needed staff to transfer and set up. A review of the May, June, July, and August 2023 bathing task documented Resident #13 had missed 6 out of 42 opportunities for bathing. On 08/02/23 at 8:14 a.m., Resident #13 stated they never received a shower because staff could not do it. They stated their last shower was on Sunday (07/30/23). Resident #13 stated they were supposed to receive a bath/shower on Sunday, Tuesday, and Friday. On 08/03/23 at 8:26 a.m., CNA #4 was asked when Resident #13 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 observation, record review and interview, the facility failed to ensure: a. the count was verified for controlled medications awaiting destruction for eight (#24, 49, 101, 102, 103, 104, 105 and #106), and b. the count was verified when controlled medications were acquired from pharmacy for three (#49, 101, and #102) of eight sampled residents whose narcotic sheets were reviewed during medication storage. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility. Findings: A Controlled Substance Storage policy, dated April 2015, read in parts, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations .A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications .The following information is completed on the accountability form 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.

Based on observation, record review, and interview, the facility failed to ensure medication error rate did not exceed five percent. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility. Findings: Resident #22 had diagnoses which included unspecified atrial fibrillation and essential hypertension. A physician's order, dated 03/17/23, documented Amlodipine Besylate 5mg daily. A physician's order, dated 03/17/23, documented Digoxin 125 mg daily, hold if pulse below 60 bpm. A physician's order, dated 03/17/23, documented Metoprolol Succinate ER 100 mg daily. A physician's order, dated 08/01/23, documented Cozaar 25 mg daily, call attending physician for blood pressure greater than 145 systolic or 90 diastolic or Less than 105 systolic or 65 diastolic. On 08/01/23 at 7:45 a.m., CMA #1 was observed removing the blood pressure machine from Resident #22's room which read 113/62 with a pulse of 68. CMA #1 was observed gathering Resident #22's morning medication and stated they were holding some of their medication because…

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 develop a comprehensive care plan for one (#24) of 15 residents reviewed for comprehensive care plans. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility. Findings: A Comprehensive Care Plans policy, revised October 2022, read in parts, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that are identified in the resident's comprehensive assessment . The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care .The services…

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 had an appropriate diagnosis for use of an antipsychotic medication for one (#36) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 33 residents received psychoactive medications. Findings: A Medication Regimen Review policy, revised February 2023, read in parts, .The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities . Resident #36 had diagnoses which included neurocognitive disorder with Lewy bodies, unspecified dementia, unspecified severity, with other behavioral disturbance, adjustment disorder with mixed anxiety, and depressed mood. A Pharmaceutical Consultant Report, dated 05/18/23, documented Resident #36 had an order for Zyprexa (antipsychotic medication) 10mg at hour of sleep for…

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

Based on observation, record review, and interview, the facility failed to ensure there was not a significant medication error for one (#22) of four residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility. Findings: Resident #22 had diagnoses which included unspecified atrial fibrillation and essential hypertension. A physician's order, dated 03/17/23 documented Digoxin 125 mg daily, hold if pulse below 60 bpm. A physician's order, dated 03/17/23 documented Metoprolol Succinate ER 100 mg daily. On 08/01/23 at 7:45 a.m., CMA #1 was observed removing the blood pressure machine from Resident #22's room which read 113/62 with a pulse of 68. CMA #1 was observed gathering Resident #22's morning medication and stated they were holding some of their medication because the vitals were too low. On 08/01/23 at 7:53 a.m., CMA #1 administered Resident #22's medications. CMA #1 did not administer the resident's Digoxin, and metaprolol. On 08/01/23 at 2:14 p.m., CMA #1 was asked…

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 and interview, the facility failed to ensure medication carts left unattended were securely locked at all times for one of two medication carts observed. The Resident Census and Condition of Residents report, dated 07/31/23, documented 46 residents resided in the facility. Findings: An Equipment and Supplies for Administering Medications policy, dated April 2015, read in parts .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. On 08/01/23 at 7:53 a.m., CMA #1 was observed during medication administration for Resident #22, to walk away from the medication cart with medications in hand. The medication cart was not locked. CMA #1 went into Resident #22's room located across the hall from the medication cart, not directly in front of the resident's room, and not in view of the CMA. On 08/01/23 at 8:00 a.m., CMA #1 was asked what…

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, and record review, the facility failed to complete a 48 hour base line care plan for two, (#29 and #31) of 13 residents whose care plans were reviewed. The Census and Conditions of Residents form documented 37 residents resided at the facility. Findings: 1. Resident (Res) #29 was admitted on [DATE] and had diagnoses which included fracture of left femur, congestive heart failure, anxiety disorder, and diabetes mellitus. A review of Res #29's medical record did not document a 48 hour base line care plan had been completed. A baseline care plan template, dated 1/17/2022, was present in Res #29's care plan tab in the electronic medical record, however the template had not been filled out with Res #29's information. An admission MDS assessment, dated 01/24/22 documented Res #29 was moderately impaired in cognition and required extensive assistance with most activities of daily living (ADL) needs. The Care Area Assessment (CAA) triggered psychotropic drug use, cognitive loss, ADL…

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 The facility failed to develop comprehensive person-centered care plans for four (#29, 30, 31, and #41) of 12 sampled residents whose care plans were reviewed. The administrator identified 37 residents who resided in the facility. Findings: 1. Resident (Res) #30 was admitted to the facility on [DATE] with diagnoses which included endocarditis, MRSA infection, protein-calorie malnutrition, DM, emphysema, hypothyroidism, GERD, HTN, and dysphagia. An admission assessment, dated 02/01/22, documented the resident was moderately cognitively impaired, required limited to extensive assistance with ADLs, was frequently incontinent of bowel and bladder, received scheduled pain medication, had a stage II pressure ulcer, and received anticoagulant and antibiotic medication. On 03/07/22 at 8:13 a.m., the resident stated she had a sore on her bottom which was present when she admitted to the facility. She stated the facility staff were applying cream treatments. The resident's record did not contain a care plan to address 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.

2. Res #33 admitted to the facility with diagnoses which included COPD, diabetes mellitus with diabetic polyneuropathy, major depressive disorder, and anxiety disorder. A MMR, dated 7/22/21, documented the pharmacist requested a reduction of Buspirone and/or Mirtazapine. The physician documented ''No'' to a dose reduction on 08/18/21. The physician did not provide a rational to the request. A MMR, dated 01/22/22, documented the pharmacist requested a reduction for Lexapro and/or Remeron. The physician's response to the MRR was not available in the resident's EHR. On 03/09/22 at 3:04 p.m., the administrator stated she was not able to find a response from the physician for the MMR form dated 01/22/22. The administrator stated she was not aware if the form had been sent or seen by the physician. 3. Resident #38 was admitted to the facility with diagnoses which included major depressive disorder, vascular dementia, chronic pain, and anxiety disorder. A spread sheet documented a MMR was conducted on 7/22/21, and the pharmacist asked for a reduction. There was no documentation provided…

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, interview, and record review, the facility failed to ensure controlled drugs along with other drugs subject to abuse were stored in locked compartments with a separately locked, permanently affixed compartment. The census and conditions form documented 37 residents resided in the facility. Findings: An undated facility policy, titled Medication Storage read in part . a. Schedule II drugs and back-up stock of Schedule III, IV, and V medications are stored under double-lock and key . b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator . On 03/09/22 at 11:15 a.m., the administrator was interviewed regarding an unlocked cabinet in the DON office which contained a locking steel container, identified as the controlled medication storage for discontinued medications, which could be easily removed from the cabinet. The administrator stated this was not adequate for controlled medication storage. The administrator stated she did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents report documented 37 residents resided at the facility. Findings: On 03/07/22 at 5:57 a.m., a bell pepper with mold on it was observed in the refrigerator with an date opened of 02/14/22. On 03/07/22 at 6:01 a.m., a staff member in the kitchen was observed with a head wrap but no hair net covering the hair sticking out the top of wrap. On 03/07/22 at 1:18 p.m., the dietary manager (DM) stated the food in the refrigerator had either a use by date or opened date. At 1:23 p.m., the DM stated hair nets were to be used in the kitchen at all times. She stated she looked daily in the refrigerator and threw out any food expired or not usable. On 03/08/22 at 2:12 p.m., a dietary staff member was observed without a hair net covering braids which are not contained in a head wrap. At 10:20 a.m., a dietary staff member was observed with a hair net on but it was not 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 observation, interview, and record review, the facility failed to provide a clean, comfortable, and sanitary environment for one (31) of 16 residents reviewed for environment. The Resident Census and Conditions of Residents report documented 37 residents resided at the facility. Findings: 1. On 03/07/22 at 5:43 a.m., a dirty table observed in the dining room it had various food items left from a meal the night before. Trash was observed on another table and trash and debris on the dining room floor. A resident came into the dining room for a drink and sat at a table with used napkins on the table. On 03/07/22 at 6:13 a.m., dietary aide (DA) #1 stated she got there at 6:00 a.m., and cleans the dining room before breakfast. On 03/07/22 at 6:21 a.m., the tables in the dining room were observed still dirty with food and trash on them. On 03/07/22 at 1:26 p.m., the dietary manager (DM) stated the dietary staff leave at 7:00 p.m. She stated when she left at 6:4., last night there were no plates on the tables…

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 interview and record review, it was determined the facility failed to complete and transmit a discharge minimum data set (MDS) assessment in a timely manner for one (#2) of one resident sampled for transmission of assessments. The Census and Conditions of Residents form documented 37 residents resided in the facility. Findings: Resident (Res) #2 was admitted on [DATE] with diagnoses which included traumatic amputation of two or more toes, osteomyeletis, and aseptic necrosis of right fingers. Res #2's medical record documented the resident was discharged from the facility on 11/21/21. The medical record did not document the discharge, return not anticipated, MDS assessment had been completed. On 03/08/22 at 4:59 p.m., the administrator reported a corporate registered nurse (RN) #1, who was familiar with MDS assessments, checked the residents medical records and reported the discharge MDS had not been completed or transmitted for Res #2.

Based on observation, interview, and record review, the facility failed to provide showers or baths to dependent residents for one (#34) of three residents reviewed for ADL assistance. The Resident Census and Conditions of Residents report documented 37 residents resided at the facility. Findings: Resident (Res) #34 was admitted to the facility and had diagnoses which included acute respiratory failure, COPD, diabetes mellitus with chronic kidney disease, osteoarthritis and Parkinson's Disease. A significant change assessment, dated 12/26/22, documented the resident was cognitively intact and required total assistance with bed mobility, transfers, locomotion, toilet use, and bathing. The care plan last reviewed 01/13/22, documented the resident needed assistance with daily care. The care plan documented for bathing the resident preferred showers and did not need staff to give her assistance with bathing. A five day assessment, dated 02/05/22, documented the resident was cognitively intact and required total assistance with bed mobility, transfers, locomotion, dressing, toilet use,…

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, interview, and record review, the facility failed to administer and observe the resident taking medication for one (#1) of 16 sampled residents observed on initial tour. The administrator identified 37 residents who resided in the facility. Findings: Resident (Res) #1's admission assessment, dated 02/25/22, documented the resident was cognitively intact and required limited assistance with activities of daily living and supervision with eating. The assessment documented the resident received antianxiety, opioid, and antibiotic medications during the look-back period. The current physician orders documented to administer buspirone 5 mg for anxiety, pantoprazole 40 mg for GERD, gabapentin 300 mg for diabetic neuropathy, oxycodone-acetaminophen 7.5-325 mg for hip pain, and Colace 100 mg for constipation every morning. On 03/07/22 at 8:22 a.m., Res #1 was observed in his room. Medications were observed in a small plastic cup sitting by his breakfast meal on an overbed table. The resident refused to be interviewed. On 03/09/22 at 5:01 p.m., certified medication aide…

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.