Harris Health Care Center North

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for antibiotics, Resident ID #7. Findings are as follows:Record review revealed the resident was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, cellulitis (a common bacterial skin infection) of the left upper limb. Record review of an acute care hospital Discharge summary dated [DATE] revealed, a physician's order for Amoxicillin-Clavulanate (an antibiotic prescribed to treat a wide range of bacterial infections, made up of two separate antibiotic's) 875-125 milligram (mg) tablet, twice a day, for seven days, from 10/4/2025 through 10/10/2025.Record review of the Medication Administration Record (MAR) for October 2025 revealed, an order for amoxicillin (an antibiotic used to treat simpler and common infections) 875 mg, twice a day, with a start date of 10/4/2025 and a discontinue date 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 surveyor observation, clinical record review, and staff interview, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task, there were 4 errors resulting in an error rate of 16% affecting Resident ID #s 2, 5, and 10. Findings are as follows:1) Record review revealed Resident ID #2 has a physician's order for Magnesium 200 milligram (MG) with instructions to administer 2 tablets, every day.During a surveyor observation during the medication administration task on 12/3/2025 at approximately 12:10 PM with Certified Medication Technician (CMT), Staff C, she was administered 1 tablet of Magnesium Oxide 400 MG, to ID #2.During a surveyor interview with Staff C, immediately following the above observation she acknowledged administering Magnesium Oxide instead of Magnesium as ordered stating, that's what I always give. 2a) Record review revealed Resident ID #5 has a physician's order for Lactulose 10 Gram (GM) packet with…

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

Based on clinical record review and staff interview, the facility failed to ensure residents are free from any significant medication errors for 1 of 1 resident reviewed with a hospital recommendation, Resident ID #1. Findings are as follows:Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, hypertension (high blood pressure). Record review of acute care hospital discharge orders, dated 10/9/2025 revealed, an order to discontinue Metoprolol XL (a long-acting form of medication taken daily to treat high blood pressure) 25 milligram (mg) daily and start Metoprolol Succinate (a long-acting form of medication taken daily to treat high blood pressure) 50 mg daily. Record review of a physician order with a start date of 10/9/2025 revealed an order for Metoprolol Tartrate (an immediate-release/short-acting form of medication taken at least twice a day to treat high blood pressure) 25 mg daily. Record review of the Medication Administration Record from October 9, 2025, through December 4, 2025, 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 surveyor observation, clinical record review, and staff interview, the facility failed to provide sufficient support personnel with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration the individual needs of 2 of 2 residents reviewed for modified diets, Resident ID #s 13 and 15, and to safely and effectively carry out the functions of the food and nutrition service for all residents. Findings are as follows:During the initial tour of the main kitchen on 12/3/2025 at approximately 8:40 AM, the Food Service Director (FSD) revealed that he works 7 days per week to provide all three meals to the residents, with an average work week of 60-65 hours per week. Additionally, he revealed that he receives some assistance from a Dietary Aid/Cook, Staff E. He further revealed that Staff E maintained a Food Handlers Certification, and not a Food Managers Certification, as required, to work independently, to safely and effectively carry out the functions of the food and nutrition services.Record review 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 surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided meet professional standards of quality and practices relative to 1 of 1 resident observed during wound care, Resident ID #5.Findings are as follows:Record review revealed that Resident ID #5 was readmitted to the facility in June of 2025, with a diagnosis including, but not limited to, type 2 diabetes.Record review revealed a physician's order dated 12/2/2025 to cleanse the sacral (coccyx) wound with wound wash, apply silver sulfadiazine (a wound cream) to the open area, then apply calcium alginate dressing (an absorbent dressing which creates a gel like substance that maintains a moist wound environment. Correctly sizing the dressing helps effectively manage fluid, prevent damage to surrounding skin, and promote an optimal healing environment).Review of Resident ID #5's care plan, last revised on 6/17/2025, revealed that s/he has pressure ulcers or vascular wounds to the buttocks with interventions including, but not limited to, keep the skin clean and…

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

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 2 of 2 residents reviewed for a change in condition related to bleeding, Resident ID #s 5 and 16.Findings are as follows:1) Record review revealed Resident ID #5 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, obstructive and reflux uropathy (when urine cannot flow through the urinary tract due to a blockage) and thrombocytopenia (a deficiency of platelets in the blood that causes bleeding).Record review of a progress note dated 11/24/2025 at 2:20 PM revealed, Resident ID #5 was noted to be bleeding from his/her genitalia, and a urology appointment should be scheduled.Record review failed to reveal evidence that the provider was notified, that a treatment was initiated, or that a urology consult was scheduled for Resident ID #5.During a surveyor interview on 12/5/2025 at 10:11 AM with the Medical Director, he revealed that he does not remember if he was notified about Resident ID #5's bleeding and would expect 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 surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for oxygen therapy, Resident ID #1. Findings are as follows:Record review of a facility's policy dated 11/13/2015 and titled, Oxygen Administration states in part, .Maintenance of Equipment.cannulas [a tubing that delivers oxygen through the nose] are to be changed as needed and at least weekly.Documentation.Document the date, time, amount, and method of oxygen administration.Ensure that there is evidence of oxygen administration for the duration of the therapy.Record review revealed the resident was admitted to the facility in October of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a progressive lung disease) and tracheostomy status (a patient having a surgically created opening in their windpipe for breathing). Review of a physician's order dated 10/9/2025 revealed an order for oxygen 2-4 liters (L) as needed. During surveyor…

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 surveyor observation and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 2 medication carts observed and 1 resident observed with medication at the bedside, Resident ID #1. Findings are as follows:Review of a facility policy titled Storage and Expiration Dating of Medications and Biologicals with a revision date of 6/30/2025, states in part, .Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.Once any medication or biological packed is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications.1) Surveyor observation of the medication cart on 12/4/2025 at 8:01 AM, in the presence of Registered Nurse, Staff A revealed, a Lantus insulin (a medication used to treat diabetes) pen opened and dated 10/1. Manufacturer instructions indicate to discard the insulin pen 28 days…

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 clinical record review and staff interview, the facility continues to fail to maintain complete and accurately documented medical records for 1 of 3 residents reviewed for medication administration, Resident ID #1.Findings are as follows:Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve pain caused by high blood sugar levels), tracheostomy status, abnormalities of gait and mobility, and schizophrenia.Record review revealed the following physician's orders:Amantadine HCl (a medication prescribed to treat sudden, uncontrolled movements), 100 milligrams (mg), 1 tablet twice per day, dated 12/7/2025Divalproex (an anticonvulsant medication prescribed to treat seizures and symptoms of bipolar disorder), delayed release, 250 mg, 1 tablet once per day, dated 10/9/2025Divalproex, delayed release, 500 mg, 1 tablet once per day, dated 10/9/2025Eliquis (a blood thinner), 5 mg, 1 tablet twice per day, dated 10/9/2025Gabapentin (a medication…

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 clinical record review and staff interview, the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 2 of 5 residents reviewed, Resident ID #s 6 and 27 Additionally, the facility failed to have updated policies regarding immunizations.Findings are follows:According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 (a type of pneumococcal conjugate vaccination), the PCV15 ( type of pneumococcal conjugate vaccine) or PCV20 (a type of pneumococcal conjugate vaccine) dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PCV13 (a type…

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

Based on record review, staff interview and resident interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for smoking for 2 of 2 residents reviewed who are smokers, Resident ID #s 10 and 23. Findings are as follows: 1. Record review revealed Resident ID #10 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder. Record review of the list of smokers provided by the facility revealed the resident is a smoker. Record review failed to reveal evidence that a smoking evaluation was completed upon admission or quarterly. Record review failed to reveal evidence of a comprehensive care plan that identifies the resident as a smoker which includes safety interventions. During a surveyor interview on 10/10/2024 at 12:45 PM with Resident ID #10, s/he revealed that s/he is a smoker. 2. Record review revealed Resident ID #23 was admitted to the facility in August of 2024 with diagnoses including, but not…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with a history of trauma, Resident ID #10. Findings are as follows: Review of the facility's form titled PC [Primary Care]-PTSD [Post Traumatic Stress Disorder]-5 states in part, .The primary PC-PTSD-5 is a 5-item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview . Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, anxiety disorder, schizoaffective disorder, bipolar type, major depressive disorder, personality disorder and autistic disorder. Review of the Primary Care PTSD Screen dated…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 5 residents reviewed for unnecessary medications, Resident ID #s 1. Additionally, the facility failed to follow the pharmacy recommendation for a gradual dose reduction (GDR) (psychotropic medications are required by federal guidelines in skilled nursing facilities) for 1 of 2 residents reviewed, Resident ID #23. Findings are as follows: 1a. Record review revealed that Resident ID #1 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, multiple sclerosis (a chronic disease damaging the central nervous system), bladder cancer, constipation and generalized muscle weakness. Record review of the physician's orders revealed an order dated 8/1/2024 for Baclofen (a medication prescribed to treat muscle spasms) 10 milligrams (mg) tablets, take 2 tablets four times a day at 8 AM, 12 PM, 4 PM and 8 PM. Record review of the August, September, and October 2024 Medication Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview, it has been determined that the facility failed to accurately document bowel movements (BM) in the resident's medical record for 2 of 2 residents reviewed for constipation, Resident ID #s 1 and 5. Findings are as follows: Review of the policy titled Bowel Function Management states in part, It is the facility's policy to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency .Every resident's bowel function is to be monitored every day on every shift .The CNA [Certified Nursing Assistant] is responsible to document the resident's BMs in the resident's electronic medical record or in the CNA flow charts as appropriate . 1. Record review revealed Resident ID #1 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, multiple sclerosis (a chronic autoimmune disease that damages the protective coating around nerve fibers in the brain and spinal cord) 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 surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 2 residents reviewed relative to wound care, Resident ID #22 and 1 of 1 resident observed receiving medications, Resident ID #16. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed Resident ID #22 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, cellulitis of the right and left lower extremities and non-pressure chronic venous ulcers (wounds to the lower extremities due to poor circulation of the blood). Record review of a Braden Scale for Predicting Pressure Score Assessment (a risk assessment tool…

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 surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication storage rooms observed. Findings are as follows: Review of a facility policy titled, .Storage and expiration dating of medication and biological's last revised on [DATE] states in part, .Facility should ensure that medications and biological's that .have an expired date on the label .have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier . During a surveyor observation of the medication storage room on [DATE] at 10:43 AM, in the presence of the Certified Medication Technician, Staff B, the following was observed: - Four, 16-ounce bottles of lactulose (a medication used to treat constipation) with a manufacturer's expiration date of 8/2024. - Two sealed 0.5 fluid ounce…

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

Based on record review, staff and resident interview, it has been determined that the facility failed to implement their smoking policy in accordance with federal, state, and local laws for 1 of 2 residents reviewed for smoking, Resident ID #10. Findings are as follows: Review of the policy titled, Smoking Policy states in part, .Residents who wish to smoke are to be evaluated by the interdisciplinary team for their ability to smoke in a safe manner .on admission .at least quarterly . Record review revealed Resident ID #10 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, schizoaffective disorder, bipolar type, anxiety disorder, and autistic disorder. Record review of the list of smokers provided by the facility revealed the resident is a smoker. Record review failed to reveal evidence of a smoking evaluation upon admission or quarterly. During a surveyor interview on 10/10/2024 at 12:45 PM with the resident, s/he revealed that he is a smoker. During a surveyor interview on 10/10/2024 at 12:51 PM with Registered Nurse, Staff A, she indicated…

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 2 of 5 residents reviewed for Trauma Informed Care, Resident ID #s 12 and 21. Findings are as follows: Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, last updated 2/3/2023 states in part, .'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . 'Trauma-informed care' is an approach to delivering care that involves…

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care relative to bilateral lower extremity edema (swelling caused due to excess fluid accumulation in the body tissues) for 1 of 2 new admissions, Resident ID #179. Finding are as follows: Record review revealed the resident was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). During a surveyor observation on 11/14/2023 at 9:25 AM, the resident was observed to have bilateral lower extremity edema. Review of the resident admission document tilted admission Observation dated 11/10/2023 states in part .left foot 2+ pitting edema (indentation that remains in the edematous area after pressure is applied) .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, surveyor observation and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 3 residents reviewed for COVID-19, Resident ID #28, and 1 of 2 residents reviewed for new admissions, Resident ID #179. Findings are as follows: 1. Review of a facility policy titled Care of the COVID-19 Positive Resident/Patient last updated [DATE] states in part, .The residents care plan will be revised to reflect the infection status and care of the individual resident's needs . Closed record review revealed that Resident ID #28 was readmitted to the facility in September of 2021 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, lung disease) and type II diabetes mellitus. Review of a progress note dated [DATE] states, Resident at baseline, coughing more than usual. Positive covid at this shift.…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 1 of 5 residents reviewed, Resident ID #24. Findings are as follows: Record review for the resident revealed that s/he was admitted to the facility in July of 2023 with diagnoses including, but not limited to, fusion of spine (neurosurgical or orthopedic surgical technique that joins 2 or more vertebrae), type 2 diabetes mellitus, and hypertension (high blood pressure). Record review of the document titled [Pharmacy] Consultation Report revealed that on August 28, 2023, the following laboratory tests were recommended to be obtained for the resident: - Monitor A1C (glycohemoglobin - a test used to monitor how well a person's blood sugar level is being managed). - Monitor fasting lipid panel (a blood test that measures the amount of certain fat molecules called lipids in the blood). - Monitor serum creatinine (a blood test 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.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities observed during the medication administration task, there were 2 errors resulting in an error rate of 8%. Findings are as follows: 1. Record review revealed Resident ID #3 has a physician's order dated 8/17/2018 for Lactulose (a medication used to treat constipation) Oral Solution 10 GM (gram)/15 ML (milliliter), administer 30 ml by mouth twice a day, every morning and evening. During a surveyor observation of the medication administration task with Certified Medication Technician (CMT), Staff C, on 11/15/2023 at 9:15 AM, revealed she administered 22 ml of Lactulose instead of 30 ml as ordered by the physician. During a surveyor interview immediately following the above observation with Staff C, she acknowledged she did not administer the Lactulose as ordered. Staff C stated I can't see very good. 2. Record review revealed Resident ID #5 has 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 3 residents reviewed for COVID-19, Resident ID #28. Findings are as follows: a. Record review revealed that the resident was readmitted to the facility in September of 2021 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, lung disease) and type II diabetes mellitus. Record review revealed that the resident expired on [DATE]. Review of the banner on the electronic medical record revealed that the resident's advanced directives were full code (wants resuscitation and all life saving measures performed in a medical emergency). Review of the resident's closed medical record revealed a signed Advanced Directive for Do Not Resuscitate (DNR) and comfort measures (CMO). During a surveyor interview on [DATE] at 11:54 AM with Registered Nurse (RN), Staff A, she revealed that the resident's signed advanced…

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 surveyor observation and staff interview, it has been determined that the facility failed to follow standard precautions (basic level of infection control that should be used at all times, example: hand hygiene) to prevent the spread of infection relative to hand washing during the Medication Administration task for Resident ID #s 3, 5, 18 and 180 and placement of a glucometer supply basket during the morning blood glucose monitoring for Resident ID #s 13, 24, 79 and 129. Findings are as follows: Review of a facility policy titled General and Medication Administration .Procedure states in part, .2. Prior to preparing or administering medications, authorized and competent Facility staff should follow facility's infection control policy (e.g., handwashing) . 1. During a surveyor observation on 11/15/2023 of the Medication Administration task with Certified Medication Technician, Staff C, she was observed administering medication to the following residents without performing hand hygiene between residents at the following times: - 8:22 AM - Resident ID #5 - 8:41 AM - 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 record review and staff interview, it has been determined that the facility failed to conduct periodic accurate, comprehensive, standardized reproducible assessment of each resident's functional capacity for 3 of 4 residents reviewed, Resident IDs #2, 3, and 4. Findings are as follows: 1. Record review for Resident ID #2 revealed s/he was admitted to the facility in June of 2023. Further record review failed to reveal evidence that a quarterly assessment was completed in September. 2. Record review for Resident ID #3 revealed s/he was admitted to the facility in September of 2023. Further record review failed to reveal evidence that an admission assessment was completed. 3. Record review for Resident ID #4 revealed s/he was admitted to the facility in June of 2020. Further record review failed to reveal evidence that a quarterly assessment was completed in July of 2023. During a surveyor interview with the Minimum Data Set (MDS) Assessment Coordinator on 10/18/2023 at 1:43 PM, she acknowledged that the above assessments were incomplete. During a surveyor interview with 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.