Sugar Creek Care Center

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans to reflect resident's current condition for one of 20 residents reviewed (Resident R38).Findings include: Review of facility policy entitled Care Plan Completion, Updating, Reviews, and Auditing Compliance Process dated 6/2/25, revealed that care plan reviews are required to be an interdisciplinary review and goal setting for each resident. Resident R38's clinical record revealed an admission date of 6/19/25, with diagnoses that included Cellulitis of Left Lower Leg (a skin infection caused by bacteria, most commonly affecting the lower legwith symptoms incluing swelling, pain, warmth, and redness), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Review of Resident R38's care plans on 8/28/25, revealed a focus or problem initiated on 6/30/25, Resident is on enhanced barrier precautions related PICC line and wounds. Clinical record progress notes revealed…

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 review of facility policy, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications and failed to appropriately discard outdated medications for two of three medication carts reviewed (Medication carts 400 and 600).Findings include: Review of facility policy entitled Administering Medication dated 6/4/25, indicated The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse., and The cart must be clearly visible to the personal administering medications. Review of manufacturer's guidelines revealed that an open pen of Aspart Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open pen of Victoza must be used within 30 days after opening or be discarded even if some medicine is…

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 review of facility policy, clinical records, resident council minutes, and resident and staff interview, it was determined that the facility failed to provide dental services in a timely manner for one of 20 residents reviewed (Resident R97). Findings include: The facility policy entitled Dental Services, dated 6/4/25, revealed Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting dental services; and the reason for the delay. Resident R97's clinical record revealed an admission date of 9/6/19, with diagnoses that included major depressive disorder, cerebral infarction (stroke-blood flow to the brain is interrupted), and hypothyroidism (thyroid gland does not produce enough thyroid hormones). Review of Resident R97's clinical…

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 review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, and staff interview, it was determined that the facility failed to follow nursing standards of practice to ensure physician orders were entered into point click care (PCC-a healthcare software used to track and administer healthcare operations in a long-term care facility) upon admission to ensure timely medication availability and timely medication administration for one of 17 residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to enter physician's orders timely resulting in a delay in treatment for one of 17 residents reviewed (Resident R1).Findings include: Review of facility policy entitled, Administering Medications 5/9/25, indicated, Medications are administered in a safe and timely manner, and as prescribed. Review of Resident R1's clinical record revealed an admission date of 3/4/23, with diagnoses that included idiopathic pulmonary fibrosis (a lung disease that causes irreversible scarring in the lungs), sleep apnea (breathing starts and stops during sleep), and acute and chronic respiratory failure. Resident R1's clinical record revealed he/she returned to the facility from the hospital on 6/12/25, at 4:15 p.m. His/her medication orders were not placed into point click care (PCC-a healthcare software used to track and administer healthcare operations in a long-term care facility) for floor nurses to be alerted when scheduled medications were due to be administered or for 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding Peripherally Inserted Central Catheter (PICC-a thin soft flexible tube placed in the vein of the upper arm also called an IV to deliver fluids and medications) dressing changes for two of three residents reviewed with PICC lines in the treatment record. (Residents R1 and R2) Findings include: Review of facility policy entitled Peripheral and Midline IV Dressing Changes dated 5/9/25, indicated Change the dressing if it becomes damp, loosened or visibly soiled and at least every 7 days . Review of Resident R1's clinical record revealed an admission date of 11/24/24, with diagnoses that included hypertension (high blood pressure), cellulitis (and infection of the skin), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R1's physician's orders for May 2025, revealed an order dated 5/5/25, to change PICC line dressing weekly. Review of 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 review of facility infection control program and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control from 4/10/25 to 5/25/25. Findings include: Review of facility policy entitled Infection Preventionist dated 5/9/25, indicated The Infection Preventionist has obtained specialized IPC training beyond initial professional training . and Evidence of training is provided through a certificate of completion . Review of Registered Nurse (RN) Employee E2's daily timecard revealed he/she worked as the facility's IP from 4/16/25, to 5/21/25. Upon request, the facility was unable to produce a certificate of completion for the IP specialized training for RN Employee E2. During an interview with Regional Clinical Director Employee E1 on 6/17/25, at 11:00 a.m. he/she revealed that RN Employee E2 started covering the IP position in the facility when the former IP left the position on 4/9/25, and he/she continued covering the position until 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 review of facility policy and clinical record, and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for one of 10 residents reviewed for medications (Resident R3). Findings include: Review of facility policy entitled Administering Medications dated 5/09/25, indicated Medications are administered in a safe and timely manner, and as perscribed. Review of Resident R3's clinical record revealed an admission date of 10/05/20, with diagnoses that included Rheumatoid arthritis, pain in shoulder and chronic pain. Review of Resident R3's clinical recorded revealed a physician's order dated 5/17/25, for Oxycodone (a narcotic pain medication) 5 milligrams one tab every six hours while awake for pain. Review of Resident R3's May 2025 Medication Administration Record revealed that Resident R3's Oxycodone was not administered for three doses on 5/18/25, for three doses on 5/19/25, and one dose on 5/20/25. During an interview on 5/22/25, at 12:05 p.m. the Nursing Home Administrator (NHA) confirmed…

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 review of facility policy, facility documentation, and clinical records and staff interview, it was determined that the facility failed to review and/or revise comprehensive care plans to reflect the current necessary care and services for one of eight residents reviewed (Resident R1). Findings include: A facility policy entitled Care Plans, Comprehensive Person-Centered dated 5/09/25, revealed that each resident's care plan describes the services that will be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; which specialized services are responsible for each element of care; assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change; and the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. Resident R1's clinical record revealed an admission date of 12/14/24, with diagnoses that included muscle wasting, depression, diabetic foot ulcer, with Parkinson's…

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 review of Pennsylvania Code Title 49 and Title 55: Professional and Vocational Standards, clinical records, facility staffing, and facility policy, and staff interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services including timely medication administration, and post-fall assessments for three of eight residents reviewed (Residents R5, R7, and R8). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.145 a. Prohibited Acts revealed a Licensed Practical Nurse (LPN) may not administer medications or fluids via arterial lines. Review of Pennsylvania Code Title 55. Additional Assessments 2800.225 revealed an LPN, under the supervision of a Registered Nurse (RN), or an RN shall complete additional written assessments for each resident. A facility policy entitled Administering Medications dated 5/09/25, indicated that staffing schedules are arranged to ensure that mediations are administered without unnecessary interruptions, and that medications are…

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 review of facility policy, facility documents and clinical records, and staff interviews, it was determined that the facility failed to make certain residents receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one of eight residents reviewed (Resident R1). Findings include: A facility policy entitled Behavioral Health Services dated 5/09/25, indicated behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care, and residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Resident R1's clinical record revealed an admission date of 12/14/24, with diagnoses that included muscle wasting, depression, diabetic foot ulcer, with Parkinson's disease (age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate, and is best known for causing slowed movements, tremors, balance problems and more) being documented throughout 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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for two of two residents reviewed for medications (Residents R1 and R2). Findings include: Review of facility policy entitled Medication Orders Controlled Substance Prescriptions dated 5/01/24, indicated If a new prescription is not obtained by the pharmacy before the medication would be due again, the facility is notified. Review of Resident R1's clinical record revealed an admission date of 5/13/23, with diagnoses that included Psychotic disorder with delusions (a mental disease that include delusions a false belief based on an incorrect interpretation of reality), and Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R1's clinical recorded revealed a physician's order dated 9/11/24, for Ativan, Benadryl, Haldol, Reglan (ABHR-combined medications for topical application) gel apply to wrist topically four…

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 review of a facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two unit refrigerators reviewed (East Unit and [NAME] Unit). Findings include: A facility policy entitled Use and Storage of Food and Beverage brought in for Residents dated 5/1/24, revealed it is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. Additionally, the facility procures food from sources approved or considered satisfactory by federal, state, or local authorities. This includes storage, preparations, distribution, and serving food in accordance with professional standards for food service safety. A facility policy entitled Preventing Foodborne Illness - Food Handling dated 5/1/24, revealed Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Observations on 9/19/24, at approximately 9:45 a.m.…

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure a foley catheter (tubing inserted into the bladder to help drain urine from the bladder) was emptied and the amount was documented every shift per physician's orders for one of 21 residents reviewed (Resident R21) Findings include: Review of a facility policy entitled Catheter Care, Urinary dated 5/1/24, revealed Observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to the physician or supervisor. Follow the facility procedure for measuring and documenting input and output. Resident R21's clinical record revealed an admission date of 3/27/23, with diagnoses that included retention of urine (bladder does not empty completely), heart failure, and hypertension (high blood pressure). Review of Resident R21's physician's orders dated 6/01/24, revealed an order to empty the foley catheter every shift and document the amount. Review of R21's Treatment Administration Record for…

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

Based on a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate tracking and safe disposition of controlled medications for one of three closed records reviewed (Closed Record Resident CR87). Findings include: Review of the facility policy, entitled Discarding and Destroying Medications, dated 5/1/24, revealed Schedule II, III, and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; h. Signature of witnesses. Review of Resident CR87's clinical record revealed admission to the facility on 6/17/24. Resident CR87 ceased to breathe on 6/24/24. Review of Resident CR87's…

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 21 residents reviewed (Resident R75). Findings include: Review of facility policy entitled Administering Medications dated, 5/1/24, indicated Medications are administered in accordance with prescriber orders including any required time frame. and The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review Resident R75's clinical record revealed an admission date of 6/20/24, with diagnoses that included diabetes (a health condition that causes by the body's inability to produce enough insulin), hypertension (high blood pressure), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R75's physician's orders revealed, an order dated 6/20/24, for Humalog…

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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (West medication room) and failed to appropriately discard outdated medications for one of two medication rooms reviewed (West medication room). Findings include: Review of facility policy entitled Storage of Medications dated 5/1/24, revealed that Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Review of facility policy entitled Administering Medications dated 5/1/24, revealed that When opening a multi-dose container, the date opened is recorded on the container. Observation of drug storage on 9/17/24, at 11:35 a.m. of the [NAME] medication room refrigerator revealed an open multi-dose vile of Tubersol (a solution used for tuberculosis testing upon admission and employment) with no date indicating when the vile was open. Further observation of the refrigerator revealed a shelf with 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 review of clinical records and Title 49. Professional and Vocational Standards, and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow up resident wound assessments for two of two residents with wounds (Residents R33 and R92). Findings include: Review of the Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 7/29/23, indicated that under Responsibilities of the RN, 21.11, General Functions. (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions, Practice of practical nursing revealed The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of the licensed professional nurse, a licensed physician or a licensed…

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 review of facility documents and staff interviews, it was determined that the facility failed to fully complete the Notice of Medicare Non-Coverage (NOMNC) letter for one of four residents reviewed (Closed Record Resident CR1). Findings include: Review of Resident CR1's closed clinical record revealed an admission date of 3/17/23, with diagnoses that included stroke, dementia, intestinal hemorrhaging, low red blood cell count, low platelet levels, and muscle wasting. The clinical record revealed a physician's order dated 4/25/23, to admit to Hospice services. Further review of Resident CR1's closed clinical record revealed payor sources Medicare part B, AETNA Medicare, and Private Pay. Review of a NOMNC indicated that verbal notification was issued to Resident CR1's representative on 3/29/23, and that written confirmation of understanding, and receipt of the notice was provided to Resident CR1's representative on 3/30/23, that indicated Medicare services would end on 4/01/23. There was no documented evidence that Resident CR1's representative was notified that…

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 review of clinical records and staff interview, it was determined that the facility failed to provide the resident and resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for one of 21 residents reviewed (Resident R78). Findings include: Review of the facility policy entitled Bed Hold Policy dated 3/2023, indicated that at the time of discharge to hospital the resident or responsible party should be given the bed hold information. The policy also indicated a bed hold authorization form should be completed. Review of Resident R13's clinical record revealed an initial admission date of 3/8/23, with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically), depression, Chronic respiratory failure (a condition were your lungs don't exchange air properly), Dysphagia (difficulty swallowing), and diabetes. Review of 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 review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for one of 21 residents reviewed (Resident R54). Finding include: Review of MDS instructions for section O0100 indicated that if Hospice services were provided while a resident of this facility and in the last 14 days to code 2 (While a Resident), in Section O0100K. Review of Resident R54's clinical record revealed an admission date of 3/20/18, with diagnoses including dementia, high blood pressure, difficulty walking and swallowing, and muscle weakness. The clinical record revealed a physician's order dated 8/13/23, to admit Resident R54 to Hospice. Review of a Significant Change MDS with a reference date of 8/22/23, under Section O0100K, lacked coding to identify that Resident R54 received Hospice services while a resident at the facility. During an interview on 10/19/23, at 11:27 a.m. 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 review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to demonstrate the necessary clinical condition for the use of urinary catheter (tubing inserted into the bladder to drain urine into a bag) for one of 21 residents (Resident R8). Findings include: Review of the facility policy entitled Catheter: Indwelling Urinary-Insertion and care of, dated 3/2023, indicated that a physician must provide written justification of the need for catheterization. Review of Resident R8's clinical record revealed an admission date of 12/2/19, with diagnoses that included, Alzheimer disease (a disease that affects short term memory and the ability to think logically), hypokalemia (a condition where you have low potassium level), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident R8's clinical record revealed a physician's telephone order dated 10/16/23, to reinsert foley catheter. Resident R8's clinical record lacked evidence of necessary clinical condition for the use of 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of fourteen days for two of 19 residents reviewed (Residents R31 and R50). Findings include: Review of a facility policy entitled Psychotropic Drug Management dated 3/2023, indicated PRN orders for psychotropic medications (antipsychotic, anxiolytic, antidepressant and sedative/hypnotic) will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Resident R31's clinical record revealed an admission date of 3/20/2020, with diagnoses of Alzheimer's Dementia (a disease of the brain that affects decision making, memory, mood and behavior), atrial fibrillation (the heart's upper chambers beat out of coordination with the lower chambers causing an irregular heart rate and poor blood flow),…

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.