Scandinavian Home INC

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 reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 1 discharged residents reviewed with physician orders for Cymbalta (a medication prescribed to treat depression), Resident ID #4. Findings are as follows: Record review of Resident ID #4 revealed s/he was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, major depressive disorder. Record review of a pharmacy medication regimen review dated 8/1/2024 revealed a recommendation to decrease the resident's Cymbalta medication from 60 milligrams (MG) daily to 40 MG daily, after the current supply of medication is exhausted. Further review revealed that the provider approved the recommended dose reduction on 9/9/2024. Record review of a progress note dated 9/13/2024 revealed the new order of Cymbalta 40 MG daily should start on 11/5/2024, after the remaining supply is exhausted. Record…

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 a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with recommendations from a gastrointestinal specialist (a medical practitioner that specializes in the diagnosis and treatment of disorders of the gastrointestinal tract also known as the passageway of the digestive system), Resident ID #5. Findings are as follows: Record review revealed the resident was re-admitted to the facility in October of 2024 after s/he was hospitalized and diagnosed with a gastrointestinal bleed (bleeding from the gastrointestinal tract). Record review of a Continuity of Care Consultation and Referral Form dated 11/1/2024 revealed the resident was seen by the Gastroenterologist for a follow up visit. Further review of the document states, Below are the orders from today's visit: -Benefiber (a fiber supplement) one tablespoon daily for 1 month -high fiber diet -GERD diet (a low acidic diet, gastroesophageal reflux disease a chronic…

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 conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Last revised 2/3/2023 states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body .Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair . Review of a facility policy titled Bed Rail Policy last reviewed 6/10/2022, revealed in part, .The Maintenance Department will conduct inspections of all bed frames, mattresses, and bedrails, as part of a regular maintenance program to identify areas of possible entrapment upon admission, quarterly, yearly and as needed . 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 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 a suprapubic catheter (S/P tube, a catheter inserted through the abdomen into the bladder to drain urine) and Methicillin resistant Staphylococcus aureus infection (MRSA, an infection that is caused by a type of staph bacteria that becomes resistant to several antibiotics) in a lower extremity wound, for 1 of 1 residents reviewed for baseline care plans, Resident ID #272. Findings are as follows: Record review revealed that the resident was admitted to the facility in November of 2023 with a diagnosis to include, but is not limited to, retention of urine. A. Review of a progress note dated 11/17/2023 states in part, .s/p tube located on right leg . Record review of the physician's orders revealed an order dated 11/17/2023 to…

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

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 2 of 5 residents reviewed who use an air mattress, Resident ID #s 28 and 49, 1 of 1 resident with an order to not have straws with liquids, Resident ID #49, 1 of 1 resident reviewed with a hand contracture, Resident ID #33 and 1 of 2 residents observed during a treatment dressing, Resident ID #38. 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 . 1. Record review revealed Resident ID #28 was admitted to the facility in November of 2019 with diagnoses including, but not limited to, muscle weakness, hemiplegia and hemiparesis (weakness or paralysis to one side of the body) following a stroke. Record review revealed a physician's order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails for 1 of 5 residents reviewed for use of bed rails with an air mattress, Resident ID #28. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023 states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. Gaps can be created by movement or compression of the mattress which may be caused by resident weight, resident movement or bed position, or by using a specialty mattress, such as an air mattress .Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time .The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that 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 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 1 of 4 residents reviewed for parameters associated with blood pressure medication, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility with a diagnosis of, but is not limited to, hypertension (high blood pressure, BP). Record review revealed a physician order dated 8/29/2023 for Losartan (a medication used to treat high blood pressure), 50 milligrams (mg) once daily, with parameters to hold for systolic blood pressure (SBP, the top number which refers to the amount of pressure experienced by the arteries while the heart is beating) less than 100. Record review of the October 2023 Medication Administration Record (MAR) revealed on the following dates Losartan was not administered when the resident's SBP was not less than 100: - 10/16/2023: BP was documented as 100/58, with a note that states, Not Administered: Due to condition Comment: held bp 100/58 p [pulse] 64. -…

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 and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed relative to falls, Resident ID #19. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses to include, but not limited to, dementia with behavioral disturbance and history of falling. Additional record review revealed the resident has a physician's order dated 10/8/2020 which states, May have floor matt at bedside to avoid or reduce injury in the event of fall to floor. Review of the SH [Safe Handling] Fall Risk (Acuity) assessment dated [DATE], revealed the following: - Mental status: disoriented, Diminished Safety Awareness - Ambulation: Impaired Mobility - Medication Use: Antihypertensive (medication used to treat high blood pressure), Antipsychotics/Neuroleptics (medication used to treat mental illness) - Resident has the following conditions:…

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, 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 for 2 of 4 residents reviewed for skin conditions, Resident ID #'s 14 and 45. Findings are as follows: Record review of a facility policy titled, Skin Care Program states in part, .With each dressing change or at least weekly .documentation must be present .location .wound bed: color and type of tissue/character including evidence of healing .The MD [Medical Director] and the resident's responsible party shall be made aware . 1. Review of Resident ID #14's record revealed s/he was admitted to the facility in March of 2021 with diagnoses including, but not limited to; unspecified dementia without behavioral disturbance and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4, indicating severe…

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 residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 8 residents reviewed relative to weight monitoring, Resident ID #48. Findings are as follows: Review of the facility's policy and procedure titled, Weight Monitoring states in part: POLICY: it is the policy of this facility to monitor the weight of every resident on a regular basis and to carry out appropriate interventions when necessary to assure the optimum level of health possible for the individual resident . How to weigh the resident: 6. Weights that are + or minus 3 pounds from the last reading must be reported to the nurse who will then be required to supervise an immediate re-weight to double check the accuracy of the reading. The nurse is to enter the supervised reading to verify its accuracy. All re-weights are to be completed within twenty-four (24) hours . 7. Weights obtained that are + or - 3# [pounds] are to be reported to MD [medical doctor] and responsible party .…

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, staff and resident interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 2 of 3 sample residents reviewed for oxygen therapy, Resident ID #s 38 and 45. Findings are as follows: Record review of the facility policy titled Oxygen Administration revised 2/14/2008, states in part, .PROCEDURE: 1. Check physician's order for liter flow .7. Masks and nasal cannula's will be changed weekly. 1. Record review revealed Resident ID #38 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease. Record review of the physician orders revealed an order dated 8/17/2022 which states, May provide Oxygen at 2 liters as needed via nasal cannula to maintain pulse ox [oxygen] above 91% or with reports of SOB [shortness of breath] As needed. During surveyor observations on the following dates and times, the resident was observed receiving oxygen therapy at…

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 each resident's drug regimen is reviewed by a licensed pharmacist and includes a review of the resident's medical chart for 1 of 6 residents reviewed for unnecessary medications, Resident ID #11. Findings are as follows: Review of the resident's record revealed s/he was re-admitted to the facility in June of 2022 with diagnoses which include, but are not limited to, encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive and urinary systems), Alzheimer's disease, and dysphagia (difficulty swallowing). Record review of the resident's monthly drug regimen review document dated 8/18/2022 revealed, This resident is receiving Remeron (mirtazapine) 7.5 mg [milligrams] at bedtime with the off label diagnosis of appetite stimulation. At low doses this agent carries higher sedative properties and could increase this resident's risk of drowsiness and falls. Although there is evidence to support that this medication, at low doses, can…

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 provide food prepared in a form designed to meet individual needs for 1 of 8 residents, Resident ID #15. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2013 with diagnoses including, but not limited to, diabetes mellitus, dementia, and nutritional deficiencies. Record review of the physician's orders revealed a diet order dated 7/31/2022, which states in part, .Texture; ground, small bite size pieces (including breads) . During a surveyor observation of the lunch meal on 9/7/2022 at 12:13 PM revealed the resident's plate consisted of penne pasta, large chunks of zucchini, and non-bite sized pieces of chicken parmesan. During a surveyor observation on 9/8/2022 at 8:17 AM, Nursing Assistant, Staff E, was observed serving the resident breakfast which included two whole slices of toasted raisin bread. Further observation revealed a dietary slip on his/her tray which indicated a regular diet. During a 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.