Life Care Center of McMinnville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to assess a skin wound for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include: Resident 2 admitted to the facility in 11/2024, with diagnoses including malnutrition and colostomy. The 11/19/24 Hospital History and Physical indicated Resident 2's abdominal ostomy site had surrounding erythema (redness) and one spot of skin breakdown. The 11/20/24 admission Skin Assessment indicated no abdominal wounds. Resident 2's Progress Notes dated 11/22/24 through 11/24/24 and 11/26/24 through 12/2/24 described an abdominal ostomy with constant drainage, and the surrounding skin as red and inflamed. A 12/6/24 Progress Note indicated Resident 2's colostomy bag would not stay in place, her/his abdominal skin was excoriated, blistered, tender to touch and caused irretractable pain due to the constant colostomy drainage. Resident 2's skin was inflamed mid abdomen to the perineum…

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 physician supervised the resident's medical care and evaluated the effectiveness of wound care treatments for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for increased pain, worsening wounds and hospitalization. Findings include: Resident 2 admitted to the facility in 11/2024, with diagnoses including atrial fibrillation (irregular heartbeat), malnutrition and colostomy. The 11/19/24 Hospital History and Physical indicated Resident 2's abdominal ostomy site had surrounding erythema (redness) and one spot of skin breakdown. Resident 2's 11/20/24 and 11/27/24 Ostomy and Skin Care Plans revealed she/he had a colostomy and was at risk for a decline in skin integrity. Staff were to keep the skin clean, dry and protected from the ostomy drainage, and to clean and apply moisture barrier to the skin after each leaking episode. The 11/21/24 Physician Note revealed Resident 2 had a colostomy and indicated all chronic conditions were relatively stable. The note…

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 the facility maintained a medication error rate of less than 5%. There were six errors in 26 opportunities resulting in a 23% medication error rate. This placed residents at risk for adverse side effects from medications. Findings include: 1. Resident 152 admitted to the facility in 2024 with diagnoses including heart failure, gastroesophageal reflux disease (GERD) and fibromyalgia. a. The 11/1/24 physician order indicated Resident 152 was to receive duloxetine (antidepressant medication) delayed release 60 mg once daily for chronic pain. On 11/6/24 at 9:01 AM Staff 5 (Agency RN) was observed to prepare morning medications for Resident 152. Staff 5 prepared duloxetine 30 mg in the medication cup and continued to the next medication. The State Surveyor stopped Staff 5 and asked her to review the order since the prepared medication did not match the order. Staff 5 acknowledged she prepared duloxetine 30 mg instead of the ordered duloxetine 60 mg. Staff 5 then prepared the correct dose 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 observation, interview and record review it was determined the facility failed to ensure a resident received assistance with fingernail care for 1 of 4 sampled residents (#46) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: Resident 46 admitted to the facility in 2024 with diagnoses including stroke and left sided hemiparesis (paralysis to one side of the body). The 8/7/24 care plan indicated Resident 46 had left sided weakness and required assistance with ADL care. The 10/2024 TAR indicated Resident 46 received nail care on 10/31/24. On 11/4/24 at 12:43 PM Resident 46 was observed to have long fingernails. Resident 46 stated she/he requested to have her/his nails trimmed but staff did not provide nail care. On 11/6/24 at 2:10 PM Staff 7 (CNA) stated nail care was completed or offered for all residents on shower days. Staff 7 acknowledged Resident 46 was dependent on staff for nail care and her/his fingernails were long. On 11/6/24 at 2:15 PM Staff 2 (DNS) observed Resident 46's fingernails and acknowledged her/his fingernails…

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 a restorative program to prevent decline in range of motion for 1 of 1 sampled resident (#46) reviewed for RA. This placed residents at risk for physical decline. Findings include: Resident 46 admitted to the facility in 2024 with diagnoses including stroke and left sided hemiparesis (paralysis to one side of the body). The 8/7/24 care plan indicated Resident 46 had left sided weakness, impaired mobility and required assistance with ADL care. The 9/23/24 Physical and Occupational Therapy Discharge Summaries indicated Resident 46 made consistent progress throughout the plan of treatment and responded positively to techniques to stimulate functional performance and enhance safety to prevent further decline. Notes further indicated she/he had upper extremity hemiparesis which did not improve. The restorative program was, not indicated at this time. On 11/4/24 at 12:43 PM Resident 46 was observed to have her/his hand to be closed into a fist and stated she/he did not receive range of motion exercises…

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 appropriate treatment for a resident receiving dialysis including monitoring of the dialysis site and communication with the dialysis provider for 1 of 1 sampled resident (#30) reviewed for dialysis. Findings include: Resident 30 admitted to the facility in 2022 with diagnoses including renal dialysis. a. The facility's Hemodialysis Offsite Policy, revised in 2023, indicated staff were to initiate the Pre/Post Dialysis Communication Form that was to be sent to the dialysis clinic with the resident. The policy further indicated upon return from dialysis the Pre/Post Dialysis Communication Form was to be completed. The 11/20/23 care plan indicated Resident 30 received dialysis three days a week on Tuesdays, Thursdays, and Saturdays. Review of the Pre/Post Dialysis Communication Form from 7/2024 through 10/2024 revealed the following: - 7/2024 five instances when the dialysis forms were not completed. - 8/2024 10 instances when the dialysis forms were not completed. - 9/2024 10 instances when 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 interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 2 of 5 sampled residents (#s 14 and 28) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication. Findings include: 1. Resident 14 admitted to the facility in 2021 with diagnoses including delusional disorder. Resident 14's 9/26/24 pharmacy recommendation indicated the following: -The resident received haloperidol (antipsychotic medication) 2.5 mg in the morning and 5 mg at bedtime for psychosis related to metabolic encephalopathy (brain dysfunction) and hallucinations. -Nursing assessments indicated no episodes of delusions or hallucinations in the last three months. -Please attempt a gradual dose reduction of haloperidol to 5 mg at bedtime. - The pharmacy recommendation was signed by the physician on 9/26/24 and indicated the recommendations were accepted and to be implemented as written. The pharmacy recommendation was not noted by Staff 2 (DNS) until 10/8/24 (13 days later). On 11/7/24 at 1:23 PM Staff 2 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.

Based on interview and record review it was determined the facility failed to promptly respond for 2 of 3 months of Resident Council minutes reviewed. This placed residents at risk for unresolved quality of life and care issues. Findings include: The facility's revised 9/27/23 Resident Council policy stated, the facility must act promptly upon the recommendations of such groups concerning issues of resident care and life in the facility. The Activities Director will facilitate follow-up on all suggestions and ideas presented at the council meeting and will report results at the next meeting. Each Department Director will be responsible for filling out a comment form prior to the next meeting. Resident Council Minutes were reviewed from 7/2024 through 9/2024 and indicated the following residents' concerns: *7/10/24: Do not close doors without permission, make sure call lights are within reach, beds have been squeaking, can people be informed? There was no follow up after the 7/10/24 Resident Council meeting regarding the residents' concerns and recommendations. *8/7/24: Cooler 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 interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of sexual abuse for 1 of 1 sampled resident (#1) reviewed for sexual abuse. This placed residents at risk for sexual abuse. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including anxiety and adult failure to thrive. A 8/18/23 a Progress Note revealed Resident 1 was sent to the hospital due to a change of condition. On 1/3/24 at 3:27 PM Witness 1 (Complainant) stated on 9/1/23 she was informed by a hospital social worker, Resident 1 reported she did not want to return to the facility from the hospital because they, indicating staff, were having sex with [her/him]. On 1/4/24 at 1:46 PM Staff 4 (Social Service Director) stated she contacted Witness 2 (Family Member) around Christmas time because Resident 1 had a box of items left at the facility. Witness 2 refused to step foot into the facility, claiming Resident 1 was raped every day at the facility. 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 interview and record review it was determined the facility failed to investigate an allegation of sexual abuse for 1 of 1 sampled resident (#1) reviewed for allegations of sexual abuse. This placed residents at risk for further sexual abuse. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including anxiety and adult failure to thrive. A 8/18/23 a Progress Note revealed Resident 1 was sent to the hospital due to a change of condition. On 1/3/24 at 3:27 PM Witness 1 (Complainant) stated on 9/1/23 she was informed by a social worker that Resident 1 reported she/he did not want to return to the facility from the hospital because they, indicating staff, were having sex with [her/him]. On 1/4/24 at 1:46 PM Staff 4 (Social Service Director) stated she contacted Witness 2 (Family Member) around Christmas time because Resident 1 had a box of items left at the facility. Witness 2 refused to step foot into the facility, claiming Resident 1 was raped every day at the facility. Staff 4 stated Witness 2 was very mad and angry about the situation. Staff 4…

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 the facility failed to provide care to prevent a pressure ulcer and accurately assess a pressure ulcer injury for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at risk for inaccurate wound assessments and worsening of wounds. Findings include: CMS Appendix PP defined an Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (yellow/white material in the wound bed) or eschar (a dry, dark scab or falling away of dead skin). Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4…

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 it was determined the facility failed to ensure staff wore gloves when assessing a wound for 1 of 2 sampled residents (#3) reviewed for pressure ulcers. This placed resident at risk for infections. Findings include: Resident 3 admitted to the facility in 9/2023 with diagnoses including left leg fracture, peripheral vascular disease, and right trans-metatarsal amputation (removal of the toes). On 1/3/24 at 11:17 AM Witness 5 (ALF [from an Assisted Living Facility]-LPN) stated she completed a skin assessment at the facility on 10/6/23 for Resident 3 to return to her/his ALF. Witness 5 stated she removed the sock from the left heel and the resident's left heel had an unstageable (full-thickness skin and tissue loss) pressure wound with eschar (dry, dark scab or falling away of dead skin), dead tissue and was approximately half a dollar coin sized. Witness 5 stated she reported this to Staff 3 (LPN-Resident Care Manager) and Staff 5 (LPN). Staff 3 entered the room to look at the wound and proceeded to pick up the resident's left foot without gloves and started to…

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

Based on observation, interview and record review it was determined the facility failed to ensure multi-dose insulin vials were labeled with an open date for 2 of 7 residents (#s 5 and 7) reviewed for medication storage. This placed residents at risk for expired medications. Findings include: 1. Resident 5 was admitted to the facility in 2/2020 with diagnoses including diabetes and Chronic Obstructive Pulmonary Disease. Resident 5's 6/10/23 physician's order indicated: -NovoLog (short acting insulin) Pen-inject six units subcutaneously (under the skin) two times a day for diabetes. -Lantus (long acting insulin) multi-use vial-inject 25 units subcutaneously in the morning related to diabetes. On 7/12/23 at 7:51 AM Staff 12 (LPN) administered two doses of insulin to Resident 5. The Novolog Pen and the Lantus multi dose vial did not indicate an opened on date on the pen or vial. On 7/12/23 at 9:58 AM Staff 12 stated she was unsure what the process was for medications without an open date on the bottle. Staff 12 acknowledged the medication could be expired. On 7/12/23 at 11:27 AM 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 give notification of financial responsibilities for 1 of 3 sampled residents (#37) reviewed for Medicare notification of non-coverage. This placed residents at risk for unknown financial liabilities. Findings include: Resident 37 admitted to the facility with Medicare Part A services on 4/10/23 for physical and occupational therapy. On 5/16/23 a Notice of Medicare Non-Coverage (NOMNC) was provided for Medicare A discharge on [DATE]. According to the SNF Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 5/18/23, pending Medicaid coverage approval. On 7/11/23 at 10:53 AM Staff 3 (Social Service Director) acknowledged Resident 37 was not provided appropriate notice to outline the resident's financial responsibilities.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to develop a comprehensive care plan related to the resident's umbilical hernia for 1 of 1 sampled resident (#29) reviewed for hospitalization. This placed residents at risk for unmet needs and rehospitalization. Findings include: Resident 29 admitted to the facility in 2022 with diagnoses including cirrhosis of the liver, anemia (low red blood cells), and umbilical hernia. A Progress Note dated 5/21/23 at 3:00 PM indicated Resident 29 asked the nurse to assess her/his hernia due to a change in appearance, experiencing nausea, and vomiting and pain with movement. The resident was sent to the emergency room via ambulance and had an emergent surgical repair of the hernia. A Hospital Discharge summary dated [DATE] indicated Resident 29 had a longstanding history of an umbilical hernia. Resident 29's 4/22/23 Care Plan did not include any information regarding her/his hernia. On 7/13/23 at 12:04 PM Staff 4 (LPN) confirmed Resident 29's 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 revise the resident's care plan related to severe chronic anemia for 1 of 1 sampled resident (#29) reviewed for hospitalization. This placed residents at risk for unmet needs and rehospitalization. Findings include: Resident 29 admitted to the facility in 2022 with diagnoses including cirrhosis of the liver, anemia (low red blood cells), and umbilical hernia. On 3/21/23 at 9:10 AM Resident 29's lab values revealed she/he had a critically low hemoglobin and hematocrit (red blood cell values). The resident was sent to the hospital and required a blood transfusion. Resident 29's Hospital Patient Discharge Report dated 3/22/23 indicated she/he was diagnosed with severe iron deficiency. On 3/23/23 Resident 29 returned to the facility and was started on the following medications: - Folic acid (supplement for red blood cell formation) - Ferrous Sulfate (Iron supplement) On 4/15/23 a Physician's Progress Note indicated Resident 29 would be referred to hematology for severe chronic anemia. The resident 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 interview and record review it was determined the facility failed to administer bowel medications according to physician orders for 1 of 5 sampled residents (#17) reviewed for medications. This placed residents at risk for complications of constipation. Findings include: Review of the facility Bowel Care list revealed the following bowel protocol: -If no BM (bowel movement) after day three staff would administer MOM (Milk of Magnesia) a laxative. -If no BM after MOM evening staff would administer a suppository. -If no BM after the suppository night shift staff would administer an enema. -If no results staff were to notify the physician. Resident 17 was admitted to the facility in 2022 with diagnoses including diabetes and chronic pain syndrome. Resident 17's BM records from 6/13/23 through 7/12/23 indicated the resident did not have a BM on the following dates: - 6/13/23 through 6/16/23 (four days) - 6/27/23 through 7/4/23 (seven days) No evidence was found in the resident's clinical record to indicate the bowel protocol was initiated. On 7/12/23 at 1:46 PM Staff 6 (LPN)…

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 who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#2) reviewed for behavioral needs. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: Resident 2 was admitted to the facility 3/2023 with diagnoses including: PTSD (Post traumatic stress disorder). Resident 2's 3/17/23 Care Plan did not reveal any information regarding the resident's PTSD. A 4/13/23 Trauma Informed Care worksheet completed by Staff 3 (Social Service Director) revealed Resident 2 experienced physical assault. Resident 2 answered 'Extremely' to the following questions: -Felt upset when something reminded her/him of the stressful event; -Avoiding memories, thoughts, or feelings related to the stressful experience; -Having strong negative feelings such as fear, horror, anger, guilt, or shame; -Feeling jumpy or easily startled. On 7/10/23 at 9:40 AM Resident 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 pharmacy reviews were completed and recommendations were addressed by the physician for 2 of 5 sampled residents (#s13 and 20) reviewed for medications. This placed residents at risk for inappropriately managed medications. Findings include: 1. Resident 13 admitted to the facility in 2023 with diagnoses including dementia. Resident 13's current medications reviewed on 7/10/23 revealed the resident was administered Seroquel (antipsychotic) 25 mg each day at bedtime. A 6/23/23 Omnicare Consultation report, pharmacist review of medications, indicated Resident 13's antipsychotic required a specific diagnosis/indication requiring treatment that was based upon an assessment of the resident's condition and therapeutic goals. A list of the symptoms or target behaviors included their impact on the resident and documentation that other medications were considered, and that individualized nonpharmacological interventions were in place. In addition, the report indicated ongoing monitoring should have been…

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 there was appropriate evaluation and monitoring of psychotropic medications for 1 of 5 sampled resident (#13) reviewed for unnecessary medications. This placed residents at risk for adverse side effects. Findings include: Resident 13 was admitted to the facility in 2023 with diagnoses including dementia. A review of Resident 13's clinical record revealed the resident had orders for the following psychotropic medications: - Bupropion (Anti-depressant) - Quetiapine (Antipsychotic) - Duloxetine (Mood stabilizer) A 7/10/23 review of Resident 13's clinical record indicated no monitoring of indications for use were in place for the identified psychotropic medications. On 7/12/23 at 9:53 AM Staff 6 (LPN) confirmed there was no monitoring in place for behavioral symptoms or indications for use for any of Resident 13's psychotropic medications. On 7/12/23 at 10:16 AM Staff 18 (CNA) confirmed staff did not document any of Resident 13's behaviors. On 7/12/23 at 10:51 AM staff 4 (LPN/Resident Care 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 observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 3 of 7 sampled residents (#s 5, 7 and 14) during medication administration. There were five errors in 26 opportunities resulting in a 19.23% error rate. This placed residents at risk for adverse medication consequences. Findings include. 1. Resident 5 was admitted to the facility in 2/2020 with diagnoses including diabetes and COPD (Chronic Obstructive Pulmonary Disease). Resident 5's 6/26/23 physician's order indicated: -NovoLog (short acting insulin) Pen- inject 6 units subcutaneously (under the skin) two times a day for diabetes. -Lantus (long acting insulin) multi-use vial inject 25 units subcutaneously in the morning related to diabetes. On 7/12/23 at 7:51 AM Staff 12 (LPN) was observed to administer two doses of insulin to Resident 5. The Novolog Pen and the Lantus multi dose vial did not indicate an open date on the pen or vial. On 7/12/23 at 9:58 AM Staff 12 stated she was unsure what the process was for medications without…

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 obtain dental services for 1 of 2 sampled residents (#29) reviewed for dental. This placed residents at risk for difficulty eating. Findings include: Resident 29 admitted to the facility in 2022 with diagnoses including cirrhosis of the liver. Resident 29's 4/7/23 Annual Dental CAA indicated the resident was at risk for dental problems due to missing teeth, possible dental cavities, and resident report of missing dental crowns. Resident 29's dental care plan initiated on 4/12/22 included an intervention to coordinate arrangements for dental services as needed. On 7/10/23 at 10:06 AM Resident 29 stated it hurt when biting into hard food. The resident did not recall having been offered dental services since coming to the facility and wanted to be seen by a dentist. On 7/13/23 at 8:30 AM Staff 2 (DNS) was requested to provide any additional information which may have indicated Resident 29 was offered or received dental services and none was provided. On 7/13/23 at 1:30 PM Staff 2 verified Resident 29 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.