Marquis Plum Ridge Post Acute Rehab

Based on observation, interview and record review it was determined the facility failed to ensure proper food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service and for 5 of 5 residents (#s 3, 6, 23, 37 and 266) sampled for food. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: 1. In an interview on 1/29/25 at 7:30 AM, Staff 27 (Dietary Manager) was aware residents complaints of food being served cold and not always being palatable. On 1/29/25 at 11:02 AM, nine residents attended the resident council meeting and expressed ongoing concerns regarding meals being served cold. On 1/29/25 at 12:56 PM, a lunch test tray and an alternative test tray were provided and sampled by the survey team. The lunch tray consisted of beef stroganoff with gravy, pasta, and green beans. The alternative meal test tray consisted of a French dip sandwich with au jus, grilled cheese, and tater tots. The survey team sampled the regular and alternative meals which revealed the following: *The beef…

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 interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) to the resident representative for 1 of 2 sampled residents (#1) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements. Findings include: Resident 1 was admitted to the facility in 2013 with diagnoses including a stroke and depression. The 12/19/24 Quarterly MDS revealed Resident 1 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. A review of Resident 1's clinical record revealed Witness 4 (Family Member) was the resident's designated power of attorney. No evidence was found that Witness 4 received quarterly PIF statements. In an interview on 1/28/25 at 10:00 AM, Witness 4 stated he was Resident 1's designated representative and the resident's PIF account was managed by the facility. Witness 4 stated he had not received any quarterly statements from the facility regarding Resident 1's PIF account. In an interview on 1/29/25 at 3:19 PM, Staff 3 (Office Manager)…

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 interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 3 of 4 sampled residents (#s 3, 7, and 37) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include: 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including weakness. A 3/8/24 Annual MDS revealed Resident 3 was cognitively intact. The 3/12/24 Interdisciplinary Care Conference notes revealed Resident 3 did not have an advance directive. On 1/27/25 at 2:20 PM Resident 3 stated staff did not offer her/him an advance directive and she/he would like to have her/his options reviewed. On 1/29/25 at 11:28 AM Staff 26 (Social Service Director) stated she would review options for residents regarding advance directives in their quarterly Interdisciplinary Care Conference. On 1/30/25 at 10:54 AM Staff 1 (Administrator) acknowledged staff were behind on quarterly Interdisciplinary Care Conferences, and advance directives were not being followed-up on. 2.…

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 interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (#68)reviewed for abuse. This placed residents at risk for loss of property. Findings include: Resident 68 was admitted to the facility in 4/2022 with diagnoses including cirrhosis (scarring)of the liver. On 11/8/24 a public complaint was received which alleged Resident 68 had money stolen from her/him. A 11/13/24 witness statement indicated on 11/6/24 Resident 68's bank card was run for her/his monthly liability and declined for payment. Staff 3 (Business Office Manager) notified Resident 68's power of attorney (POA) of the declined payment. On 11/8/24 Resident 68's POA notified Staff 3 Resident 68 was missing $3300 from her/his bank account and the POA made a police report. A 11/15/24 investigation indicated the Automated Teller Machine(ATM)withdrawals were made from an ATM near the facility. Law enforcement retrieved the video recording from the ATM and the parking lot. The facility assisted law enforcement with…

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 interviews and record review it was determined the facility failed to thoroughly investigate alleged verbal abuse from staff for 1 of 2 sampled residents (#7) reviewed for abuse. This placed residents at risk for physical and verbal abuse from staff. Findings include: The facility's 12/2020 Abuse Investigation Policy included: All reports of abuse, neglect, misappropriation of resident property, and injuries of unknown origin shall be promptly and thoroughly investigated. The investigation shall consist of: -A review of the completed Resident Incident Report Form. -An interview with the resident. -Witness reports in writing, signed and dated. Resident 7 was admitted to the facility in 8/2023 with diagnoses including respiratory failure. The 1/21/25 investigation report indicated Staff 8 (LPN) reported to Staff 28 (RNCM) Resident 7 reported an allegation of abuse. Resident 7 indicated she/he was forced out of bed and forced to take a shower by Staff 18 (RN). On 1/28/25 at 2:37 PM Resident 7 stated Staff 18 came to her/his room and stated she/he had to take a shower. 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 interview and record review it was determined the facility failed to conduct quarterly care conferences as required for 3 of 3 sampled residents (#s 3, 7, and 37) reviewed for care conferences. This placed residents at risk for lack of participation in care goals and unmet needs. Findings include: The 11/2017 facility Care Planning-Interdisciplinary Team Policy and Procedure indicated the resident's comprehensive care plan will be reviewed and updated at a minimal on a quarterly basis by the IDT (Interdisciplinary Team.) 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including weakness. A review of the 3/12/24 Interdisciplinary Team Care Plan Conference Form for Resident 3 revealed no quarterly care conferences were provided after 3/12/24. On 1/27/25 at 1:20 PM Resident 3 stated she/he had not had a care conference in months and had concerns she/he would like to discuss with staff. On 1/30/25 at 10:54 AM Staff 1 (Administrator) confirmed quarterly care conferences were not conducted with Resident 3 to address care plan needs quarterly. 2. Resident 7 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were accurately assessed, and care plans were followed for 2 of 4 sampled residents (#s 3 and 31) reviewed for pressure ulcers. This placed residents at risk for inaccurate assessment and worsening of wounds. Findings include: 1. Resident 3 was admitted to the facility in 2/2023 with diagnoses including a Stage 4 (penetration of all three layers of skin exposing muscles, tendons and bones) pressure ulcer. The 12/29/24, 1/5/25, 1/14/25, and 1/19/25 Wound Evaluation Form indicated Resident 3 had a Stage 4 pressure ulcer. The wound contained slough (dead skin tissue) which indicated an unstageable (with dead tissues making it impossible to determine the depth of the wound) pressure ulcer. On 1/29/25 at 1:36 PM Staff 2 (DNS) acknowledged Resident 6's wound was not a Stage 4 pressure ulcer but an unstageable pressure ulcer due to the slough in the wound, and the Wound Evaluation Form was 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.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 1 facility reviewed for misappropriation of property. This failure, determined to be a past non-compliance situation, resulted from the facility failing to ensure residents were free from misappropriation of property. Findings include: A FRI report dated 6/16/23 indicated a staff member found unrecognizable signatures in the Narcotic Log Book, brought it to the attention of the Resident Care Manager and Staff 2 (DNS) and an investigation was started. Multiple forged signatures were found in the skilled unit Log Book. The FRI indicated there was no resident theft as the facility covered the cost of medications. Staff 11 (Former CMA) was identified as a suspect and was suspended pending the outcome of the investigation. A Facility Investigation document dated 6/13/23 indicated during the investigation 102 instances of forged or false signatures were found. Staff 11 worked around the times of the discovered forged signatures. No other staff…

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 it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#45) reviewed for self-administration of medications. This placed residents at risk for improper medication administration. Findings include: Resident 45 was admitted to the facility in 2023 with dysphagia (difficulty swallowing) and a feeding tube (a tube in the stomach to receive nutrition) with diagnoses including malnutrition and kidney transplant. On 10/2/23 at 8:54 AM Resident 45 was observed sitting up in bed with two medication cups containing multiple medications on the bedside table and a cup of orange liquid medication. Resident 45 stated she/he was not sure what the medications were. No assessment was located in the medical record for self-administration of medications for Resident 45. On 10/2/23 at 11:23 AM Staff 36 (LPN) stated if Resident 45 did not administer her/his medications by 11:00 AM staff were to administer the medications via her/his feeding tube. Staff 36 stated she was not aware…

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 interview and record review it was determined the facility failed to assist residents to formulate advance directives for 2 of 4 sampled residents (#s 55 and 68) reviewed for advance directives. This placed residents at risk for healthcare decisions to be in conflict with their wishes. Findings include: 1. Resident 55 was admitted to the facility in 2023 with diagnoses including stroke. A 6/23/23 admission MDS revealed Resident 55 was moderately cognitively impaired. A 7/5/23 Multidisciplinary Care Conference revealed there was no advance directive planning in place and Resident 55 wanted follow up to have options reviewed. On 10/3/23 at 3:14 PM Staff 24 (Social Services Director) confirmed Resident 55 did not have advance directive planning in place and options would be reviewed during her/his next care conference (approximately three months after Resident 55's request for advance directive follow-up). On 10/5/23 at 2:48 PM Staff 1 (Administrator) acknowledged follow up after a request for advance directive planning should be within a week. 2. Resident 68 was admitted 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 interview and record review it was determined the facility failed to notify a physician of an unavailable medication for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for lack of adequate treatment. Findings include: Resident 23 was admitted to the facility in 2023 with diagnoses including UTI and sepsis (harmful microorganisms in the blood leading to the malfunction of organs). A 5/31/23 physician order indicated Resident 23 was to receive Lactobacillus Rhamnosus (supplement used to restore normal intestinal bacteria and treat UTIs) each morning. The 9/2023 MAR indicated for 15 of 30 days the supplement was unavailable. A review of Resident 23's clinical record revealed the physician was not notified the supplement was unavailable. On 10/4/23 at 9:06 AM Staff 5 (RNCM) acknowledged Resident 23's physician was not notified the facility did not have the prescribed supplement available for the resident as above.

Based on interview and record review it was determined the facility failed to ensure a resident's grievance was resolved in a timely manner for 1 of 1 sampled resident (#31) reviewed for personal property. This placed residents at risk for unresolved concerns. Findings include: Resident 31 was admitted to the facility in 2019 with diagnoses including anxiety. A Concerns and Grievances Policy last revised 2016 revealed any resident or resident representative could report a concern. The social service director was responsible for overseeing the grievance process. The facility would investigate the concern and resolve the grievance promptly; within five days. The administrator would review the findings upon completion of the investigation. The resident would be notified of the summary of findings and outcome. A 6/2/23 Quarterly MDS revealed Resident 31 was cognitively intact and did not have delusions (beliefs that were firmly held, contrary to reality). A 6/15/23 Lost Resident Property Investigation Report revealed Resident 31 reported a pair of pants was missing. An 8/2/23…

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 it was determined the facility failed to ensure a resident care plans were updated and failed to conduct a care conferences for 2 of 3 sampled residents (#s 20 and 63) reviewed for dental care, and participation in care planning. This placed residents at risk for unmet care needs. Findings include: 1. Resident 20 was admitted to the facility in 2019 with diagnoses including dementia. A 6/3/23 Progress Note revealed a CNA found Resident 20's bottom denture in the denture cup and the denture was broken. A Care Plan last updated 12/2019 revealed the resident had both upper and lower dentures. On 10/3/23 at 3:55 PM Staff 4 (RNCM) acknowledged the resident's care plan was not updated after the resident's denture broke. 2. Resident 63 was admitted to the facility in 2023 with diagnoses including cancer. On 10/2/23 at 12:56 PM Resident 63 stated the facility kept her/him informed but did not recall a care conference with the team. On 10/4/23 at 9:02 AM Staff 23 (Resident Care Manager) stated the facility did not conduct initial care…

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 interview and record review it was determined the facility failed to ensure a resident was offered to walk for 1 of 3 sampled residents (#31) reviewed for ADLs. This placed residents at risk for increased weakness. Findings include: Resident 31 admitted to the facility in 2020 with diagnoses including heart disease. A care plan last revised on 2/24/23 revealed Resident 31 had a restorative program to improve the resident's endurance. Staff were to offer the resident to walk before lunch and the resident would decide if and how far she/he would walk. A 3/2023 Annual CAA revealed Resident 3 was alert, oriented and was able to transfer independently but was unstable. The resident used her/his walker and staff assisted with the management of the resident's oxygen equipment. Staff were to encourage the resident to walk. An 8/25/23 Quarterly Nursing Summary indicated Resident 31 was alert, oriented and had an ambulation program. The resident did not want to come out of her/his room due to COVID-19 but walked in her/his room. Staff were to continue to offer walks and the distance…

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 interview and record review it was determined the facility failed to ensure a resident was provided a meaningful activity program for 1 of 3 sampled residents (#30) reviewed for activities. This placed residents at risk for lack of daily stimulation. Findings include: Resident 30 was admitted to the facility in 2019 with diagnoses including a stroke. An 4/26/23 Activities Summary revealed the resident continued to prefer to spend time napping, watching television, going outside when the weather was 80 degrees and looking out the window. A 7/26/23 Activities Summary revealed Resident 30 spent the majority of her/his time in her/his room sleeping and watching television. A Care Plan revised on 8/5/22 revealed the activity staff were to offer and assist Resident 30 outside when the temperature met the resident's preferred environmental temperature. Staff were to also offer to open the resident's window blinds. Review of Outdoor Activity documentation from 9/3/23 through 10/3/23 revealed the resident looked out the window on two occasions. There was no documentation to indicate…

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 interview and record review it was determined the facility failed to ensure medications were given per pharmacy guidelines for 1 of 1 sampled resident (#36) reviewed for antibiotics. This placed residents at risk for decreased medication efficacy (effectiveness). Findings include: Resident 36 was admitted to the facility in 2023 with diagnoses including a hardware infection. Epocrates online (web based pharmacy resource) revealed when doxycycline and calcium carbonate were administered together the efficacy of the antibiotic was decreased. An 10/2023 Order Summary Report revealed Resident 36 was to be administered calcium carbonate-vitamin D tablet (supplement) in the morning and doxycycline (antibiotic) two times a day. An 10/2023 MAR revealed Resident 36 was administered both the calcium carbonate-vitamin D and the doxycycline daily at 8:00 AM. On 10/2/23 at 10:10 AM and on 10/4/23 at 10:44 AM Resident 36 stated she/he had elbow surgery and was on an antibiotic. Resident 36 stated the antibiotic and calcium should not be given together and she/he told multiple staff…

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 ensure a resident was provided range of motion for 1 of 3 sampled residents (#30) reviewed for ADLs. This placed residents at risk for pain. Findings include: Resident 30 was admitted to the facility in 2020 with diagnoses including a stroke. A Physical Therapy Discharge summary dated [DATE] revealed the resident had a contracture (shortening of the muscle or tendon) to the left ankle and the resident and family did not want a brace or aggressive ROM to the ankle. The note indicated per care conference the resident was willing to do active ROM with the legs, a restorative nursing program was designed and instructions were given. A 11/18/22 Annual CAA revealed Resident 30 had a stroke and was not able to move her/his right side. The resident was dependent on others for assistance with most ADLs, but was able to feed her/himself. The resident did not always understand she/he required positioning assistance. The resident spent most 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.

Based on observation, interview and record review it was determined the facility failed to provide adequate urinary care for 1 of 4 sampled residents (#23) reviewed for urinary catheters. This placed residents at risk for lack of preferred urinary care treatment. Findings include: Resident 23 was admitted to the facility in 2023 with diagnoses including UTI and sepsis (harmful microorganisms in the blood leading to the malfunction of organs). A 6/5/23 admission Urinary Incontinence and Indwelling Catheter CAA revealed Resident 23 had a personal PureWick (external catheter system that draws urine away from body) system and asked to keep the PureWick system on at all times instead of bladder training. Staff were to clean and change the PureWick per manufacturer's instructions. A 6/7/23 revised care plan revealed Resident 23 used a Purewick system and staff were instructed to separate the resident's legs, gluteus (buttock) muscles and genitals and gently tuck the soft gauze side of the device between the gluteus and genitals and ensure the top of the gauze was aligned with her/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to provide dialysis services for 1 of 1 sampled resident (#24) reviewed for dialysis. This placed residents at risk for unmet dialysis needs. Findings include: Resident 24 was admitted to the facility in 2023 with diagnoses including kidney disease. A 7/15/23 revised care plan revealed Resident 24 had kidney failure with dialysis, and did not include the days of dialysis, location, and times. There was no information related to dialysis emergency procedures and blood pressure monitoring for Resident 24. On 10/2/23 at 3:18 PM Resident 24 was observed in bed and stated she/he recently returned from dialysis. Resident 24 stated staff took her/his blood pressure when she/he returned, but she/he had to remind staff not to use the arm with the dialysis access site to measure the blood pressure. Resident 24 stated this happened often. On 10/5/23 at 1:55 PM Staff 16 (CNA), and Staff 27 (CNA) stated they did not have dialysis…

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 interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 23 was admitted to the facility in 2023 with diagnoses including inflammation of the spine. A 5/30/23 physician order indicated Resident 23 was to receive one percent Diclofenac Sodium External Gel (topical pain relief) applied to the affected area four times a day for pain. A 7/25/23 Pharmacist's Report to Nursing and 8/30/23 Pharmacist's Recommendation to the Provider indicated instructions for the Diclofenanc Gel was to include maximum limits of eight grams per day to Resident 23's upper extremity or 32 grams per day over her/his entire body. On 10/4/23 at 9:06 AM Staff 5 (RNCM) stated Resident 23's pain was related to her/his back. Staff 5 acknowledged the pharmacy recommendation for Resident 23 was not addressed and an improved process to review pharmacy recommendations was needed.

Based on observation, interview, and record review it was determined the facility failed to ensure the medication error rate was less than 5 percent. There were 31 medication administration observations with 12 errors; a 39 percent medication error rate. This placed residents at risk for ineffective medications. Findings include: Resident 45 was admitted to the facility in 2023 with dysphagia (difficulty swallowing) and a feeding tube. The 9/1/23 Physician Order indicated Resident 45 was to receive the following medications by mouth: -Amlodipine (for blood pressure) by mouth -Vitamin D (supplement) by mouth -Potassium (supplement) by mouth -Apixiban (blood thinner) twice a day by mouth -Escitalopram (for depression) by mouth -Pantoprazole (for GERD) by mouth -Prednisone (steroid) by mouth -Super B complex (supplement) by mouth -D-Manose (supplement) by mouth -Mycophenolate (immnosuppressant) twice a day by mouth -Omega 3 (supplement) twice a day by mouth -Cyclosporine (immnosuppressant) twice a day by mouth On 10/4/23 at 11:18 AM Staff 36 (LPN) crushed Resident 45's medication and…

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

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 3 of 4 sampled residents (#s 23, 28, and 36) reviewed for urinary devices. This placed residents at risk for urinary infection. Findings include. 1. Resident 23 was admitted to the facility in 2023 with diagnoses including UTI and sepsis (harmful microorganisms in the blood leading to the malfunction of organs). A 6/5/23 admission Urinary Incontinence and Indwelling Catheter CAA revealed Resident 23 had a personal PureWick (external catheter system that draws urine away from body) system and asked to keep the PureWick system on at all times instead of bladder training. Staff were to clean and change the PureWick device per manufacturer's instructions. A 6/7/23 revised care plan revealed Resident 23 used a PureWick system. The care plan did not indicate how the gauze was to be stored if not in use. On 10/2/23 at 8:55 AM and 10/3/23 at 2:24 PM Resident 23 was observed with her/his PureWick not in use. The PureWick gauze was uncovered and placed on top of…

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

Based on interview and record review it was determined the facility failed to ensure residents received vaccines and education for 3 of 5 sampled residents (#s 16, 30, and 39) reviewed for immunizations. This placed residents at risk for infections. Findings include: 1. Resident 16 was admitted to the facility in 2022 with diagnoses including diabetes. a. Resident 16's record revealed she/he received the flu vaccine on 11/5/22. The resident's record did not have documentation to indicate the resident received the risk and benefits of receiving the flu vaccine prior to administration. On 10/5/23 at 10:41 AM a request was made to Staff 2 (DNS) to provide documentation the risk and benefits of the flu vaccine were provided to the resident prior to the vaccine. No additional information was provided. b. Resident 16's record revealed the resident received a pneumonia vaccine in 2001 outside of the facility. Resident 16 was eligible for an additional pneumonia vaccine. There was no documentation in the resident's record to indicate the resident was offered additional pneumonia vaccines.…

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.