Windsor Calallen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label and include the expiration date for 2 of 4 medication carts (Hall #3 med-cart and Hall #5 med-cart) reviewed for storage and 1 of 1 medication room (med-room [ROOM NUMBER]) reviewed for labeling and storage. The facility failed to properly label from hall #3 med-cart a bottle of saline nasal spray that had been opened and used. The bottle was approximately half full. The facility failed to dispose of the medication from hall #3 med-cart Morphine (a narcotic pain medication) 30 MG tablets belonging to Resident #17 that expired on 04/11/24. The facility failed to dispose of the medication from hall #3 med-cart Pravastatin (a drug used to lower cholesterol) 20 MG tablets belonging to Resident #44 that expired on 04/08/2025. The facility failed to dispose of the medication from hall #5 med-cart a tube of Hydrocortisone Cream that expired in April of 2025. The facility failed to dispose of a large bin of single use Tuberculin…

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.

The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases. The facility failed to handle, store, process, and transport all linens to prevent the spread of infection for 2 of 2 (Bin #1 and Bin #2) laundry bins reviewed for infection control. The facility failed to ensure LA H and LA I properly washed and stored wet linen according to facility procedures. The facility failed to ensure LA H and LA I dried wet linen and resident clothing after washing them. These failures could place residents at risk for cross contamination and infection. The findings include: During an observation of the laundry facility on 05/06/25 at 04:35 PM, two bins, one with wet white linen and one with wet resident clothing were observed in the dryer area. In an interview on 05/06/25 at 04:45 PM, the HS stated the two LA ' s had left for the day and must have left the wet linen and wet resident clothing in the bins without drying them. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan to include measureable objectives and timeframes to attain or maintain the resident's highest practical physical, mental and psychosocial well-being for 1 of 5 residents (Resident #8) reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #8's care plan to reflect the habitual losing or misplacing of items and accusing others of theft. This failure could affect the resident by placing him at risk for not receiving appropriate interventions to meet his current needs. The findings included: Record review of Resident #8 ' s face sheet dated 04/09/25 revealed an [AGE] year-old male with an original admission date of 02/28/23, and a current admission date of 05/20/23. Diagnoses for Resident #8 revealed Dementia (a decline in cognitive function) and Anxiety (feelings of worry, fear, and apprehension). Record review of Resident #8 ' s Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #1) of five residents reviewed for infection control practices, in that: The facility failed to ensure CNA C performed hand hygiene after removing gloves during incontinent care. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #1's face sheet dated 04/09/25 reflected an [AGE] year-old-female with an original admission date of 10/01/16. Diagnosis included dementia (general decline in cognitive abilities that affects a persons ability to perform everyday activities). Record review of Resident #1's annual MDS dated [DATE] reflected 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 observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for 1 of 10 residents (Resident #1) reviewed for safe environment. The facility failed to ensure Resident #1's room temperature was maintained at or below 81 degrees. This failure could place residents at risk of living in an uncomfortable and unsafe environment and a diminished quality of life. Findings included: Record review of Resident #1's admission record, dated 04/04/25 reflected a [AGE] year-old female admitted to facility on 03/26/22. Her relevant diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and shortness of breath. Record review of Resident #1's quarterly MDS dated [DATE] revealed she had a BIMS score of 12, which indicated her cognition was moderately impaired. Record review of Resident #1's quarterly care plan dated 03/07/25 reflected she was on continuous oxygen therapy related 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 interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to develop a baseline care plan, or a comprehensive care plan in place of a baseline care plan, in place of a baseline care plan, for Resident #2 during the 20 days Resident #2 was at the facility. This failure could place residents at risk of not receiving effective person- centered care to achieve their highest practicable level of physical, mental, and psychosocial well-being. The findings included: Record review of Resident #2's admission Record reflected a female who was admitted to the facility on [DATE] and discharged on 09/26/24. Her diagnoses included aftercare following joint replacement surgery, left femur fracture (the long bone at the top of the leg)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of two residents reviewed for quality of care. The facility failed to ensure the Wound Care Nurse followed doctor's orders (pat dry wound) during wound care for Resident #1. This failure could place residents at risk for not receiving the appropriate care and treatment. The findings include: Record review of Resident #1's face sheet, dated 02/12/25, reflected a [AGE] year-old-female with an original admission date of 02/28/24. Resident #1 had diagnoses which included Dementia (loss of cognitive functioning that interferes with a person's daily life and activities), end stage renal (kidney) failure, and unspecified open wound of right breast. Record review of Resident #1's physician orders, dated 01/14/25, reflected: Cleanse nonhealing surgical wound…

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

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 9 medication carts observed for compliance. One medication cart in the 600 hall was left unlocked and unattended by LVN C. This failure could place residents at risk of access and ingestion of non-narcotic medications. Findings were: Observation on 6/27/2024, at 1:41 p.m., one medication cart was unlocked (the button to lock the cart was out and a drawer opened when tugged on) on hall 600 without a supervised staff in view of the cart. The cart was unlocked for 2 minutes until LVN C exited a room and returned to the cart. During an interview on 6/27/2024 at 1:41 p.m., LVN C verbalized the unlocked cart was her cart. She verbalized she thought she locked the cart before entering a room to give medication to a resident. The cart had a variety of medications in it, but the narcotics were in a locked drawer. LVN C stated it was proper process to lock the carts when the cart was not in view or when not being utilized. She also states 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 observation interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 10 residents (Resident #24, Resident #58, Resident #55, and Resident #68), staff, and the public; in that: 1.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #24 and Resident #58 on 3/4/24 through 3/6/24. 2.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #55 and Resident #68 on 3/4/24 through 3/6/24. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. Findings Included: 1.) Observation on 03/04/24 at 4:45pm with the Maintenance Director and using the maintenance director'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure he accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts (hall 100 nurse's cart) reviewed for pharmacy services. 1. The facility failed to account for 2 of Resident #81's 0.5mg Lorazepam (medication to treat anxiety) tablets. 2. RN A and RN B failed to accurately document Resident #81's 0.5mg Lorazepam drug count on 03/04/24. This failure could place residents at risk for drug diversion and delay in medication administration. Findings included: Record review of Resident #81's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included mixed receptive-expressive language disorder (difficulty understanding words/sentences and difficulty speaking), need for assistance with personal care, dementia- mild- with agitation (organic brain disease causing…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition room reviewed for sanitation in that: 1. The facility failed to ensure juice dispenser guns were sanitary 2. The facility failed to ensure equipment was clean and sanitized 3. The facility failed to ensure dishwasher temperatures were at a safe temperature to sanitize dishes 4. The facility failed to ensure chemical logs were accurate and at safe sanitation levels 5. The facility failed to ensure dry goods were dated, labeled, sealed, and not expired 6. The facility failed to ensure spices were not left open to air 7. The facility failed to ensure items in the nutrition room refrigerator were not expired 8. The facility failed to ensure the kitchen was following their policies 9. The facility failed to implement an approved cleaning schedule These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two of six Residents (Resident #89, and Resident #70) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1.) The facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella (bacteria that grows and multiplies in moist areas that can cause respiratory illness) through a program that identifies areas in the water system where Legionella bacteria can grow and spread. 2.) Resident #89's ventilator mask and oxygen nasal cannula tubing were left unbagged for 2 days when not in use. 3.) The CNA C did not remove the dirty barrier linen underneath Resident#70's buttocks…

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

Based on observation, interview, and record review the facility failed to ensure residents have the right to personal privacy and confidentiality of his or her personal and medical records for 1 (Residents # 27) of 6 residents for personal privacy and confidentiality in that: On 03/04/2024, MA A did not lock the nurse's station computer that contained sensitive resident information such as medication administered, name, room numbers, and advance directives for Resident # 27. This failure could place residents at risk for having their personal and medical information exposed. Findings included: An observation on 03/04/24 at 10:18 AM revealed a medication cart at the nurse's station with the computer on and unlocked. On the screen was Resident #27's personal information including name, date of birth , medication administered, and code status. Observed MA A walking in from the front door of the facility, around the nurse's station, stopped at the medication cart with the opened computer, used ABHR, and walked into the nurse's station to another computer. In an interview and observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to develop and implement written policies and procedures that Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one resident (Resident#70) of four residents reviewed for abuse, neglect, and exploitation. The facility failed to conduct an investigation of Resident#70 injury of unknown origin. Resident #70 sustained a skin tear approximately 5.5cm X 0.1 cm to his left wrist. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings Included: Record review of Resident #70's electronic face sheet dated 03/05/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Osteoarthritis (degenerative joint disease), Essential Hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #18) of 16 residents reviewed for quality of care, in that: The facility did not implement the use of Prevalon Boots (heel protectors that help reduce the risk of bedsores by keeping the heel floated, relieving pressure) for Resident #18, as ordered by her physician to maintain skin integrity on 3/5/24. This deficient practice could affect residents receiving preventative skin care at risk for pressure ulcer development or a deterioration of a current pressure ulcer. The findings included: Record review of Resident #18's Face Sheet dated 03/05/2024 reflected a [AGE] year-old female with an original admission date of 07/21/2021 and a readmission date of 02/01/2023. Diagnoses included Dementia (decline in cognitive abilities that impacts a person's ability 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 interview and record review, the facility failed to ensure the drug regimen of 1 out of 1 resident (Resident #4) was reviewed at least once a month by a licensed pharmacist, in that: Resident #4 was missing monthly medication reviews documented for the months of January 2024 and February 2024. This deficient practice could place resident at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings included: A record review of Resident #4's face sheet dated 03/06/2024 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Cerebral Infarction (a stroke), Dementia, Atherosclerotic Heart Disease (thickening or hardening of the arteries), Anxiety, Hyperglycemia (high blood sugar), Anemia, Type 2 Diabetes Mellitus, Insomnia, Hyperlipemia (high cholesterol),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents on psychotropic drugs received a gradual dose reduction for 1 of 1 resident (Resident #4) reviewed for psychotropic drugs. The facility failed to ensure Resident #4 received a gradual dose reduction for Prozac (antidepressant), Xanax (anxiolytic), and Temazepam (sedative/hypnotic) since 09/2023. These failures placed residents at risk of unnecessary psychotropic drug use. Finings included: A record review of Resident #4's face sheet dated 03/06/2024 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Cerebral Infarction (a stroke), Dementia, Atherosclerotic Heart Disease (thickening or hardening of the arteries), Anxiety, Hyperglycemia (high blood sugar), Anemia, Type 2 Diabetes Mellitus, Insomnia, Hyperlipemia (high cholesterol), Depression, Essential Hypertension (high blood pressure). A record review of Resident #4's quarterly MDS assessment dated [DATE] reflected a BIMS score of 04, which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for one hall (Hall 300) of eight medication carts. On 03/05/2024, The facility failed to keep one medication cart locked on Hall 300 . These failures placed 24 residents on Hall 300 at risk of drug diversions or misuse of medications. Findings included: Observation on 03/05/24 at 3:25 PM revealed medication cart 1 was unlocked and unattended on Hall 300 near room [ROOM NUMBER]. Investigator noticed the drawers on medication cart 1 were slightly ajar. All the drawers of medication Cart 1 could be opened, and the medication was easily accessible. The cart was unattended for about 30 seconds until 3:26 PM when they were closed by LVN A. Interview with LVN A on 03/05/24 at 3:26 PM revealed staff were to secure medications and not leave medication carts unlocked and unattended. LVN A reported that she was the one that left it unlocked, but the locking mechanism on medication cart 1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood before transferring or discharging the resident for 1 of 5 residents (Resident #1) reviewed for transfer and discharge. 1. Resident #1, Resident #1's responsible party and the ombudsman were not notified in writing of the effective date of transfer on or discharge for Resident #1, the reason for the transfer/discharge, the location to which the resident would be transferred, or the right of appeal. Resident #1 was discharged on 9/1/23 to an acute behavioral hospital. This deficient practice could affect residents who are transferred or discharged from the facility at risk of having their discharge rights violated. The findings included: Record review of Resident #1's face sheet dated 1/24/24 reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE].…

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 interview and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #1) reviewed for discharge summaries. The facility did not complete a discharge summary for Resident #1 on the discharge date of 09/07/2023. This failure could affect residents who are discharged from the facility by not providing a recapitulation of the residents stay and a final summary of the residents' status for any continuation of care that may be required. Findings included: Record review of Resident #1's face sheet dated 1/24/24 reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Diagnoses included dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), depression (a mental state of low mood and aversion to activity), and anxiety (emotion which is characterized by an unpleasant state of inner turmoil). Record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 8 (moderate…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of 1 (100 hall medication cart) of 6 of the medication carts reviewed for storage, in that: On 11/19/2023,the facility failed to ensure the 100 hall medication cart was not left unlocked and unattended at the nurses station. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. Findings included: Observation on 11/19/2023 at 7:41am, revealed the 100 hall medication cart was left unattended and unlocked by the entrance of the 100 hall. There were no residents in the vicinity. There were 3 employees (LVN A, LVN B, ADON) around the area not facing the direction of the medication cart (approximately 3 feet away). LVN B was standing by the nurses' station and the other two staff members (ADON and LVN A) were guiding the Investigator to the conference room upon entrance of the survey investigation. The Investigator stopped in front 100 hall 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 interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 resident (Resident #43) out of 5 residents reviewed for significant medication errors, in that: Resident #43 was administered potassium chloride ER (extended release) 4 tabs (80 mEq) crushed and dissolved in water 24 times from 01/01/23 through 01/20/23, by MA A. This deficient practice placed residents at risk for serious injuries up to and including cardiac arrest. The findings include: Record review of Resident #43's admission record, dated 01/20/23, revealed age [AGE] year old female, with an admission date of 02/21/21, with diagnoses which included hypertension (high blood pressure), heart failure, obesity, atherosclerotic of left leg (a disease where plaque builds up in the wall of the blood vessels and thickens. This narrows the channel within the artery - reducing blood flow, lessening the amount of oxygen and other nutrients reaching the body) with ulceration (formation 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.