Gateway Care And Retirement

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 an ongoing person-centered activities program for 1 of 1 sampled resident (#33) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 6/2018 Activity Program Policy indicated the following: -Activities were offered based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program was ongoing and included facility-organized group activities, independent individual activities and assisted individual activities. -Individualized and group activities were to reflect the personal preferences, schedules, choices and rights of the residents. -All activities were documented in the resident's medical record. Resident 33 was admitted in 11/2023 with diagnoses including depression. Resident 33's 11/15/24 Activity Care Plan revealed the following: -The resident enjoyed…

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 implement care plan interventions to prevent an elopement for 1 of 4 sampled residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include: Resident 1 was admitted to the facility in 2/2024, with diagnosis including nontraumatic intracerebral hemorrhage (bleeding of the brain without external trauma). Resident 1's 2/29/24 Care Plan indicated the resident presented as a high risk for elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was revealed to have convulsions related to seizure disorder. Resident 1's 12/5/24 Elopement Assessment identified she/he was a high risk for elopement. A 4/23/24 facility Progress Note revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located per facility report to have been found at a nearby hospital.…

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 abuse for 1 of 5 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: On 5/10/24, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was abuse. The Plan of Correction included: 1. Residents were placed on alert charting for psychosocial mood and behaviors. 2. The effected resident was evaluated for psychosocial harm by a licnesed provider and continued to receive mental health services on a regular basis. 3. All staff were educated for abuse, neglect including reporting abuse and neglect. 4. All residents were assessed for psychosocial distress with no noted safety or abuse concenrs. Adjustments have been made to the effected resident's care plan to ensure residents mood and behavior are continuously monitored by the facility. Resident 1 was admitted to the facility in 3/2024, with diagnoses including acute hypoxic (low oxygen) respiratory failure 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.

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 physician orders were followed and medical conditions were assessed for 3 of 3 sampled residents (#s 1, 2 and 5) reviewed for physician orders and weight. This placed residents at risk for worsening health conditions and unmet needs. Findings include: 1. Resident 5 admitted to the facility on [DATE] with diagnoses including pneumonia, acute respiratory disease, acute heart failure, hypertension, and vascular disease. Resident 5's 2/25/24 physician order directed staff to give 40 mg of Furosemide (diuretic medication) every 24 hours PRN for edema (fluid retention), shortness of breath, weight gain of three lbs (pounds) in 24 hours or a weight gain of more than five lbs in one week. Review of Resident 15's health record revealed the following weights: - admission weight: 2/15/24 at 243.8 lbs; - Gained three lbs in 24 hrs on; - 2/19/24 at 244.6 lbs to 2/20/24 at 248.3 lbs; - 3/14/24 at 252.8 lbs to 3/15/24 at 261.6…

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 safety interventions were in place to prevent elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This put residents at risk for potentially avoidable accidents. Findings include: The facility's undated Wandering and Elopements Policy indicates: If a resident is missing, initiate the elopement/missing resident emergency procedure: -Determine if the resident is out on an authorized leave or pass; -If the resident was not authorized to leave, initiate a search of the building(s) and premises; and -If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). Resident 1 was admitted to the facility in 11/2023 with diagnoses including peripheral vascular disease (a circulatory condition charactarized by reduced blood flow to the limbs) and cellulitis (a bacterial skin…

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 adhere to transmission based precautions for 1 of 1 sampled residents (#107) reviewed for transmission based precautions and failed to process and transport laundry to prevent potential cross contamination for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for infection. Findings include: 1. Resident 107 was admitted to the facility in 11/2023 with diagnosis including leg fracture. On 12/1/23 at 8:28 AM signage posted outside Resident 107's room indicated the resident was on transmission based precautions and staff were to don a mask, gloves, face shield and a gown when providing care. Staff 14 (CMA) donned gloves and an N95 mask then entered Resident 107's room to administer medications including a nasal spray and an inhaler. Staff 14 acknowledged she did not don a face shield or gown before entering the resident's room. 2. The facility's 9/2022 Laundry and Bedding, Soiled Policy Statement indicated the following: -Clean linen was to be stored separately,…

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 resident needs and preferences related to lighting were accommodated for 2 of 2 sampled residents (#s 3 and 205) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: 1. Resident 205 was admitted to the facility in 11/2023 with a diagnosis including cardiac arrest. On 11/28/23 and 9:30 AM Resident 205 stated her/his overbed light cord was too short and she/he could not independently use the light without the extension of the plastic bag provided. On 12/1/23 at 1:16 PM Staff 6 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short. Staff 6 observed the plastic bag tied to the cord and stated the cord needed the proper extensions on them. 2. Resident 3 was admitted to the facility in 10/2023 with a diagnosis of cellulitis (a bacterial skin infection). A review of Resident 3's 10/18/23 admission MDS revealed she/he was cognitively intact. On…

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 the Office of the State Long Term Care Ombudsman was notified of resident hospitalization for 1 of 1 sampled resident (#33) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 33 was admitted to the facility in 10/2023 with diagnoses of atrial fibrillation and abdominal pain. An 11/10/23 Nursing Note indicated Resident 33 was sent to the hospital. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 33's hospitalization. On 12/4/23 at 9:54 AM Staff 11 (Social Services Director) stated he was unaware the Office of the State Long Term Care Ombudsman's office was to be notified when a resident was sent to the hospital. On 12/4/23 at 9:57 AM Staff 1 (Administrator) stated that historically the facility did not send out written hospital notifications to the Office of the State Long Term Care Ombudsman.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess a resident's dental status for 1 of 1 sampled resident (#46) reviewed for dental. This placed residents at risk for lack of dental care and weight loss. Findings include: Resident 46 was admitted to the facility in 10/2023 with diagnosis including infection. On 11/28/23 at 9:37 AM Resident 46 stated he was missing most of his teeth and needed to see a dentist. The facility told her/him they would refer her/him to a dentist but she/he had not heard anything since then. Resident 46's 10/24/23 Oral/Dental Status assessment indicated the resident did not have any dental issues. On 11/29/23 at 1:29 PM Staff 13 (RNCM) verified she completed the 10/24/23 assessment but she did not physically or visually examine the resident's teeth. Staff 13 and the surveyor then examined Resident 46's teeth. The resident only had one tooth in her/his upper gums and a few bottom front teeth. The teeth all appeared decayed and discolored. Resident 46 told Staff 13 her/his teeth bothered her/him…

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 resident call lights were answered timely for 1 of 4 sampled residents (#36) reviewed for sufficient nurse staffing. This placed residents at risk for untimely assistance with ADL needs. Findings include: Resident 36 was admitted to the facility in 10/2022 with diagnosis including stroke. On 11/28/23 at 10:56 AM Resident 36 stated it took staff 20 minutes to two hours to answer her/his call light, typically at night. A review of Resident 36's call light record from 11/1/23 through 11/29/23 revealed the following call light response times: - On 11/1/23 at 9:31 PM, the response time was 39 minutes. - On 11/4/23 at 10:02 PM, the response time was 25 minutes. - On 11/7/23 at 10:37 PM, the response time was 25 minutes. - On 11/9/23 at 8:46 PM, the response time was 27 minutes. - On 11/11/23 at 9:07 PM, the response time was 25 minutes. - On 11/14/23 at 9:00 PM, the response time was 28 minutes. - On 11/16/23 at 2:07 AM, the response time was 24 minutes. - On 11/19/23 at 6:28 AM, the response time was 26…

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 residents were free from a medication error rate of five percent or more for 2 of 8 sampled residents (#s 32 and 107) reviewed for medication administration. The facility's medication administration error rate was eight percent. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 32 was admitted to the facility in 8/2023 with diagnosis including diabetes. Resident 32's 11/2023 Diabetic Administration Record revealed the resident had a physician's order for insulin lispro before meals. On 11/29/23 at 11:49 AM Staff 15 (LPN) prepared Resident 32's insulin lispro pen for administration to the resident. Staff 32 did not prime the pen before preparing to administer the insulin. Staff 32 reviewed the instruction for the needle cartridges and acknowledged the pen was supposed to be primed each time it was used. 2. Resident 107 was admitted to the facility in 11/2023 with diagnosis including chronic sinusitis (inflammation of the nasal passages). On…

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 a call light system was adequately equipped to relay resident calls to caregivers for assistance on 2 of 2 hallways reviewed for call light response times. This placed residents at risk for lack of timely assistance and unmet needs. Findings include: Resident 100 was admitted to the facility in 2022 with diagnoses including a left knee replacement. On 10/4/23 at 4:36 PM Resident 100 stated during her/his stay in 11/2022 and 12/2022, call light times were frequently delayed. Resident 100 stated she/he required assistance for transferring, ambulating and toileting but often self-transferred and ambulated to the bathroom without assistance because it took so long for staff to respond to her/his call light. Resident 100 stated sometimes her/his call light was on for so long, she/he called the facility's main phone number and asked to have a staff member sent to her/his room for assistance. Resident 100 stated call lights were delayed 30 minutes to over an hour, at times. Resident 100's 11/28/22 through…

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 staff received annual training on abuse, neglect, exploitation of resident property and dementia management for 9 of 10 randomly selected staff (#s 17, 18, 20, 21, 22, 23, 26, 27 and 28) reviewed for sufficient and competent nursing staff. This placed residents at risk for abuse, unmet needs and diminished quality of life. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised 4/2021, indicated the facility provided staff orientation and training programs that included topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. On 9/8/22 at 4:08 PM Staff 31 (Regional Nurse Consultant) provided a spreadsheet of trainings and confirmed the following: -Staff 17 (RN) did not complete dementia management; completed abuse training. -Staff 18 (CMA) did not complete dementia management or abuse training. -Staff 20 (CNA) completed dementia management; no…

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 have a system in place to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 19, 20, 22 and 23) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: The facility's In-Service Training Program, Nurse Aide, last revised 10/2017, indicated annual in-services must be no less than 12 hours per employment year. On 9/8/22 at 4:08 PM Staff 31 (Regional Nurse Consultant) provided a spreadsheet of trainings and confirmed the following: -Staff 19 (CNA): 8 hours of training, -Staff 20 (CNA): 10 hours of training, -Staff 22 (CNA): 4 hours of training and -Staff 23 (CNA) 3 hours of training. On 9/12/22 at 3:00 PM Staff 1 (Administrator) and Staff 31 were notified of the findings of this investigation and acknowledged the identified CNAs lacked 12 hours of required annual training.

Based on interview and record review it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate advance directives for 4 of 4 sampled residents (#s 21, 44, 250 and 252) reviewed for advance directives. This placed residents at risk of not having their health care preferences followed. Findings include: 1. Resident 21 was admitted to the facility in 6/2022 with diagnoses including stroke and hypertension. No evidence was found in the resident's clinical record to indicate the facility discussed or received a copy of her/his advance directive. On 9/7/22 at 3:01 PM Resident 21 reported staff members did not discuss with her/him the benefit of creating an advance directive since admitting to the facility. On 9/8/22 at 9:09 AM Staff 6 (Assistant Administrator) confirmed the facility did not have a record stating they asked Resident 21 if she/he had an advance directive. She also confirmed the facility did not have a system in place to discuss the benefit of advance directives with residents upon admission or…

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 RN coverage for eight consecutive hours per day for 9 of 68 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 9/6/22 revealed on 7/11, 7/17, 7/23, 7/31, 8/1, 8/27, 8/28, 9/3 and 9/4 there was no RN coverage for eight consecutive hours. On 9/12/22 at 3:00 PM Staff 1 (Administrator) and Staff 31 (Regional Nurse Consultant) acknowledged the facility lacked RN coverage on the identified days.

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 medications and biologicals were secured and only accessible to authorized persons for 2 of 2 halls observed. This placed residents at risk for drug diversion. Findings include: The facility Storage of Medications Policy and Procedure, last revised 11/2020, indicated the following: - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended. On 9/7/22 at 10:58 AM Staff 8 (LPN) unlocked the treatment cart which contained insulin, needles and medicated creams, ointments and lotions. Staff 8 obtained supplies from the cart, left the cart…

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 store food at the appropriate temperature to prevent the spread of food-borne illness and failed to provide a designated hand hygiene sink in 1 of 1 kitchen reviewed for food storage and hygiene. This placed residents at risk of food-borne illness and cross contamination. Findings include: 1. The facility Refrigerators and Freezers Policy Statement, last revised 12/2014, indicated the following: -Acceptable temperature ranges are 35°F to 40°F for refrigerators and less than 0°F for freezers. During the initial kitchen tour on 9/6/22 at 9:46 AM the temperature in the cook refrigerator was observed to be 50°F. The cook refrigerator contained sliced meat, bacon, eggs, and vegetables to be readily accessible to the Cook. Staff 3 (Cook) confirmed the temperature was too warm and stated it jumped up. She also reported they had problems with the temperature in the cook refrigerator all the time. A review of the facility's Monthly Record of Refrigerator and Freezer Internal Temperatures revealed 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 obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications. Findings include: Resident 17 was admitted to the facility in 12/2019 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed). Resident 17's 7/7/22 Quarterly MDS indicated the resident received an anti-depressant medication. A 7/29/22 physician order included Effexor XR Capsule 37.5 mg (psychotropic drug used to treat major depressive disorder) by mouth one time a day related to major depressive disorder. Resident 17's 7/2022, 8/2022 and 9/2022 MARs revealed the resident received the Effexor XR daily. Resident 17's healthcare record revealed no signed consent and no evidence the resident was provided information regarding the risks and benefits of the Effexor XR. On 9/13/22 at 10:38 AM Staff 12 (LPN Resident Care Manager) stated when changing…

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 bathing assistance for 3 of 4 sampled residents (#s 20, 36 and 42) reviewed for ADL care. This placed residents at risk for lack of personal hygiene. Findings include: 1. Resident 42 was admitted to the facility in 12/2013 with diagnoses including diabetes and depression. Resident 42's 1/21/22 bathing Care Plan indicated the resident required physical assistance of one person for bathing. Resident 42's 7/30/22 MDS indicated the resident had intact cognition. Resident 42's 8/2022 and 9/2022 Bathing Documentation Reports indicated the resident preferred bathing between 5:30 PM and 6:30 PM. The following was reported: -8/3/22 bathing offered at 2:01 PM: refused, -8/10/22 bathing offered at 3:14 PM: refused, -8/12/22 bathing offered at 9:13 PM: accepted, -8/17/22 bathing offered at 7:46 PM: refused, -8/19/22 bathing offered a 9:15 PM: accepted, -8/24/22 bathing offered at 2:01 PM: refused, -8/26/22 bathing offered at 2:05 PM: refused, -9/2/22 bathing offered at 9:10 PM: refused and -9/7/22 bathing…

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 residents with limited ROM received appropriate care and services to maintain their level of functioning for 1 of 2 sampled residents (#19) reviewed for positioning and mobility. This placed residents at risk for decreased ROM. Findings include: Resident 19 was admitted to the facility in 6/2022 with diagnoses including a fracture of the second and fourth metacarpal (finger) bones of the right hand. Resident 19's 7/2022 MDS indicated the resident had intact cognition and an upper extremity impairment on one side. The ADL and Functional Potential CAA indicated Resident 19 had right hand fractures. Resident 19's 8/9/22 Plastic and Hand Surgery follow up visit summary indicated Resident 19's right hand splint was removed. At that time, it was observed the resident's right ring finger was contracted with limited range of motion. Recommendations indicated Resident 19 required aggressive hand therapy to help regain range of motion to her/his fingers and wrist. An 8/9/22 physician order…

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 administration error rate of less than 5%. There were two errors in 27 opportunities resulting in a 7.41% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: The facility 4/2019 Administering Medications Policy and Procedure indicated medications were to be administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication and preventing potential medication or food interactions. 1. Resident 8 was admitted to the facility in 8/2022 with diagnoses including aftercare following surgery on the digestive system. Resident 8's 8/5/22 physician orders included the following six medications to be administered in the morning: - pantoprazole sodium (medication used to treat digestive problems) packet…

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 implement therapy orders in a timely manner for 1 of 1 sampled resident (#20) reviewed for therapy services. This placed residents at risk for a decline in mobility and lack of quality of life. Findings include: Resident 20 was admitted to the facility in 11/2021 with diagnoses including breast cancer, diabetes and dementia. On 7/29/22, Resident 20's physician ordered PT and OT evaluations and treatment to be completed. There was no documented evidence in Resident 20's clinical record to show she/he received PT or OT evaluations or treatment. On 9/12/22 at 10:59 AM Staff 31 (Regional Nurse Consultant) stated Resident 20's PT and OT evaluation and treatment orders were not completed. On 9/12/22 at 11:09 AM Staff 32 (Rehab Director) confirmed Resident 20's PT and OT evaluation and treatment orders were not completed.