Waters Of McKenzie A Rehabilitation & Nursing Ctr

Based on facility document review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when 1 of 1 ice machine was observed to have a dark slimy buildup on the inner seal. The census was 46 with 44 residents receiving a tray from the kitchen. The findings: 1. Review of the undated, facility document titled, Physical Plant-Monthly Inspections, revealed .Ice Machines: Clean filters and check water filter and observe for proper operation. Look for any calcium, lime, or algae. Check to ensure it is in a clean and sanitized state. This includes all ice machines throughout the facility including Dietary . 2. Observation and interview on 4/14/2025 at 8:44 AM, with the Dietary Manager (DM) revealed the ice machine had a black, slimy substance all around the inside seal. The DM was asked who was responsible for cleaning the ice machine. The DM stated, Maintenance. The DM was asked if it was clean. The DM stated, No. Observation and interview on 4/15/2025 at 8:38 AM, with the DM revealed the ice machine had a black, slimy…

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 facility policy, medical record review, observation and interview the facility failed to ensure dignity and resident choice was met for 1 (Resident #33) of 1 sampled resident reviewed for activities of daily living. The findings include: 1. Review of the undated facility policy titled, CALL LIGHTS, revealed, .It is the policy of the facility to have a system in placed to allow the staff to respond promptly to a resident's call for assistance .Never make the resident feel as though you are too busy to give assistance. If you yourself cannot provide the requested assistance, assure the resident that you will take their request to the appropriate staff. Follow through with this commitment and follow up to see if the resident had the need met. NEVER TURN OFF A CALL LIGH THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED Review of the undated facility policy titled, Resident Rights, revealed, .The resident has a right to a dignified existence, self-determination, and communication with and access 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 resident (Resident #197) reviewed for self-administration of medication. The findings include: 1. Review of the undated facility policy titled, Medication Self Administration, revealed .procedures for determining if the resident can safely self-administer .Residents .will be assess at the time of admission .to determine if the practice is safe, based on the results of the Resident Assessment-Self-administration Tool .assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate . 2. Review of the medical record revealed Resident #197 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Liver Disease. Basic Interview for Mental Status had not been assessed due to recent admit and in process. Review of the Physician Order Sheet dated April 2025, revealed .Levalbuterol…

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 medical record review, observation, and interview the facility failed to implement interventions on care plan for 1 of 3 (Resident #26) sampled residents reviewed for accidents. The findings include: Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Dementia, Osteoarthritis, Difficulty in Walking, and History of Falling. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive abilities. Review of Resident #26's Progress Note dated 8/8/2024 revealed, .Note Text: Resident witnessed on floor beside bed. Bed was in low position. She states that she rolled over and slid onto the floor. She was lying on her right hip .Arms noted under her upper body. Legs straight .Nurse and CNA had been in resident's room [ROOM NUMBER] min prior to fall. She was lying in bed, facing the wall…

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 facility policies, record review, observations, and interviews the facility failed to provide Oxygen therapy as ordered by the Physician for 1 of 1 (Resident #13) reviewed for Respiratory Care. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration Guidelines, revealed, .Review order for oxygen administration to include .flow rate . Review of the facility policy titled, Guidelines For Physician Orders, dated 6/18/2023, revealed .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Acute Ischemic Heart Disease, Occlusion and Stenosis of Left Carotid Artery, Cerebral Infarction, and Hypertension. Review of the Care Plan dated 1/28/2025 revealed .Administer O2 [oxygen] as ordered per…

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 facility policy review, medical record review, observation, and interview, the facility failed to ensure PRN (as needed) psychotropic medications for 1 (Resident #26) of 5 sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or documented rationale for continued use of the medication. The findings include: 1. Review of the undated facility policy titled, GUIDELINES FOR PSYCHOTROPIC MEDICATION, revealed .Based upon each individual resident's comprehensive assessment, the facility will ensure that residents who have not previously been on a psychotropic drug (s) are not given these meds unless the medication is necessary to treat a specific condition/diagnoses .PRN [as needed] Orders for Psychotropic Medications: PRN orders for psychotropic drugs will be limited to 14 days, unless the physician identifies and documents rationale to extend he medication beyond 14 days. PRN antipsychotics drugs will be limited to 14…

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 facility policy review, medical record review, observation and interview, the facility failed to accommodate dietary preferences for 2 of 2 (Resident #33 and #42) sampled residents reviewed for dietary preferences. The findings include: 1. Review of the undated facility policy titled, RESIDENT FOOD PREFERENCES, revealed .Food preferences will be honored unless contraindicated .The facility will offer residents food choices and preferences to include .personal preferences .The Food Service Manager or designee will interview the resident and obtain their food preferences .Food preferences will be updated accordingly and will be noted in the resident's tray card .The staff may follow the list of resident's food choices and preferences . 2. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses which included Muscle Wasting and Atrophy, Chronic Pain Syndrome, Need for assistance with personal care, and Anorexia. Review of the Nutritional Risk Quarterly Review 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 policy review, record review, observations and interviews the facility failed to ensure staff followed hand hygiene guidelines during wound care for 1 of 1 (Resident #13) reviewed for wound care. The findings include: 1. Review of the facility policy titled, Dressing Change, Clean, dated 1/1/2024, revealed .Procedure Purpose .To prevent infection and spread of infection .Perform hand hygiene .put on .disposable gloves .Cleanse wound .Apply prescribed medication .Apply dressings .Remove gloves .Wash hands . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Muscle Weakness, Abnormal Posture, Hemiplegia and Hemiparesis, and Low Back Pain. Review of Care Plan dated 1/28/2025, revealed .Skin .has disruption of skin surface .to labia .disruption of skin surface will remain free from infection . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS)…

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 policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advance Directive to residents or the residents' responsible parties for 3 of 16 sampled residents (Resident #13, #17, and #35) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Advance Directives Policy and Procedure, dated 1/1/2017, revealed .The facility provides the resident's the right to accept or refuse medical and surgical treatment, and at the resident's option, formulate an advance directive .Determine upon admission whether the resident/legal representative has an advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advance directive .Upon admission, the facility will provide written information to resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment…

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 policy review, medical record review, and interview the facility failed to ensure Physician Orders were followed for notification to the Physician for 1 of 6 sampled residents (Resident #26) reviewed for unnecessary medication. The findings include: Review of the facility's undated policy titled, PHYSICIANS ORDERS-(FOLLOWING PHYSICIAN ORDERS), revealed .It is the policy of the facility to follow the orders of the physician . Review of the facility's undated policy titled, BLOOD GLUCOSE MONITORING, revealed .Blood sugars found to be below 70 or above 400 will be reported immediately to the physician and resident's representative . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Diabetes, Heart Failure, and Anxiety. Review of the Physician Orders dated 7/3/2022, revealed .Insulin Lispro Solution 100 UNIT/ML [milliliters] Inject as per sliding scale .If BS [Blood Sugar] 60 or > [greater than] 400 notify MD/NP [Medical Doctor/Nurse…

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 policy review, medical record review, observation, and interview, the facility failed to document treatments and provide treatment orders for pressure ulcers for 2 of 3 (Resident #3 and #27) sampled residents reviewed with pressure ulcers. The findings include: 1. The facility's Wound Prevention and Management Program policy, revised 5/17 documented, .To identify Residents at risk of developing pressure ulcers and conduct appropriate interventions to maintain intact skin .Write a separate treatment order for each wound site .D. MANAGEMENT OF WOUND INFECTION: The purpose of this procedure is to prevent wound deterioration, and other complications .provide local management that optimizes healing potential . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Obesity, Polyneuropathy, Osteoarthritis, Dementia, Bipolar Disorder, Anxiety Disorder, Hypertension, and Heart Failure. The Comprehensive Care Plan dated 7/24/19 documented, .I am 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure physician orders were followed for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg, Diabetes, Anemia, Bipolar Disorder, History of Malignant Neoplasm of Cervix, Hypertension, Long Term Use of Insulin, Anxiety Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, and Long Term Use of Anticoagulants. The September 2019 Physician's Orders documented, .HUMULIN R 100 U [units] /1 ML [milliliter] SOLUTION (Insulin Human Regular) units Injection Before meals and Bedtime .0-200=0, 201-250=2u, 251-300=4u, 301-350=6u, 351-400=8 [u], > [greater than] 400 call MD [Medical Doctor] . The September 2019 Medication Administration Record (MAR) documented a blood glucose level of 486 on 9/17/19 and the MD was not notified. Interview with the Regional Nurse…

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 policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to insulin administration for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications and failed to ensure medical information was kept private and confidential for 1 of 13 (Resident #24) sampled residents. The findings include: 1. The facility's Medication Administration Subcutaneous Insulin policy, reviewed 1/14 documented, .Check prescriber's order for insulin .Determine the correct amount of insulin to be withdrawn . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg, Diabetes, Anemia, Bipolar Disorder, History of Malignant Neoplasm of Cervix, Chronic Obstructive Pulmonary Disease, Hypertension, Long Term Use of Insulin, Anxiety Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, and Long Term Use of Anticoagulants. The September 2019 Physician's Orders…

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.