Deer Meadows Rehabilitation And Nursing

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure antibiotics were administered as order by the medical provider for one (1) of 11 sampled residents (Resident #6). The findings include: The facility staff failed to ensure that Resident #6's intravenous (IV) Ertapenem was administered as ordered by the medical provider. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Resident #6's medical record included the following antibiotic orders: - Ertapenem 1 gram intravenously (IV) for the morning of 8/21/24. - Ertapenem 1 gram intravenously (IV) in the morning for six (6) weeks to start on 8/22/24. - Cubicin 700 mg intravenously (IV) at bedtime for six (6) weeks to start on 8/21/24. The following…

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 staff interview, clinical record review and facility document review the facility staff failed to obtain a physician's order prior to obtaining a laboratory test for 1 of 11 residents, Resident #2. The findings included: For Resident #2 the facility staff failed to obtain a physician's order for a urinalysis. Resident #2's face sheet listed diagnoses which included but not limited to schizoaffective disorder and type 2 diabetes mellitus. Resident #2's most recent minimum data set with an assessment reference date of 93/31/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #2's clinical record was reviewed and contained a laboratory report dated 05/31/24 which read in part, Clinical Laboratory Results: Urinalysis: Urinalysis with Microscopic (Reflex Culture if indicated) .Comments: CULTURE TO FOLLOW. Surveyor reviewed Resident #2's physician's orders and could not locate an order to obtain a urinalysis. Surveyor spoke with the regional director…

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 staff interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for one (1) of 11 sampled residents (Resident #6). The findings include: Resident #6's clinical record failed to include: (a) wound assessment details/documentation and (b) complete wound orders. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Review of Resident #6's clinical documentation failed to provide evidence of an assessment of the resident's wounds which included wound measurements and a description of the wounds on admission. On 3/12/25 at 2:40 p.m., the Director of Nursing (DON) provided a copy of a spreadsheet that contained the wound assessments of three (3) different residents. This…

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 staff interviews and facility document review, the facility staff failed to have documented evidence of dietary staff training related to safe food handling. The findings include: The surveyor and the Regional Food Service Director (RFSD) reviewed the training and education of 12 dietary staff members who were working independently. These 12 dietary staff members did not have documentation of orientation. Nine (9) of the 12 dietary staff members reviewed did not have documentation of training related to safe food handling. On 8/1/2 at 10:00 a.m., the surveyor discussed the facility's dietary staff training with the RFSD. The RFSD reported the facility did not have written policies related to the orientation of its dietary staff. The RFSD reported the facility did not have written policies related to the training of its dietary staff. The RFSD provided the surveyor with a blank copy of a form titled ORIENTATION. This form did not specifically address safe food handling. The RFSD stated the topics on this form related to the overview of state and federal regulations would…

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 observations, staff interviews, and facility document review, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings include: On 7/31/24 at 1:15 p.m., the surveyor and the Dietary Manager made observations of the garbage disposal area outside of the facility but located on the facility's campus. The following observations were noted: - One (1) of the two (2) facility dumpsters was noted to have its two (2) doors partially open. The right door was open approximately four (4) inches; the left door was open approximately eight (8) inches. The left door was observed to have a bag, containing garbage, hanging partially out of the door. - Ten (10) medical gloves were noted to be on the ground to the right of and/or behind the facility's dumpsters. - Six (6) foam bowls were noted to be on the ground to the right of the facility's dumpsters. - One (1) meal size foam clam shell container was noted to be on the ground to the right of the facility's dumpsters. - One (1) bag of garbage containing disposable adult briefs 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 resident and staff interview, clinical record review, and facility document review, the facility staff failed to provide evidence of a bed hold policy being given to 5 of 27 residents in the survey sample, residents #13, 68, 36, 98, and 56. The findings included: For resident # 13 the facility staff failed to provide evidence that the resident or their responsible party was notified of a bed hold policy when the resident was hospitalized in June 2024. Resident # 13's minimum data set (MDS) assessment with an assessment reference date of 6/6/24 assigned the resident a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. Resident was not interviewable. The electronic medical record was reviewed and a progress note dated 6/6/24 at 11:18 AM read, Mobile images in for Venous/Arterial Doppler, blood clot to left lower extremity noted. Family informed, family raised concern that respiratory issues may be caused from blood clot that has traveled, (name omitted) FNP contacted and received order to send resident out for further evaluation.…

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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, and/or failed to involve the resident or resident representative in planning care, for 5 of 27 sampled residents, Resident #88, #23, #73, #28, and #82. The findings included: 1. For Resident #88 (R88), the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs. R88's diagnosis list indicated diagnoses that included, but were not limited to, Bipolar Disorder, Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction, Depression, Peripheral Vascular Disease, Congestive Heart Failure, Chronic Kidney Disease-Stage 5, and Polyosteorarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/22/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities,…

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 staff interviews, clinical record review, and facility document review, the facility staff failed to provide care and/or services for five (5) of 27 sampled residents (Resident #15, Resident #36, Resident #73, Resident #82, and Resident #258). The findings include: 1. The facility staff failed to have documented evidence of Resident #82 being assessed by a licensed nurse prior to facility staff assisting the resident back to their wheelchair after the resident experienced a fall on 7/11/24. Resident #82's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/29/24, was signed as completed on 7/8/24. Resident #82 was assessed as able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On the afternoon of 8/5/24, the surveyor interviewed the facility's Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) #8, Certified Nurse Aide (CNA) #6, and CNA #7. These three (3) staff…

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 staff interview, clinical record review and facility document review the facility staff failed to act on pharmacy recommendations for 4 of 27 residents in the survey sample residents # 83, 8, 56, 28. The findings included: 1. For resident # 83 the facility staff failed to provided evidence of completed pharmacy recommendations for the months of September 2023 and May 2024. Resident # 83's diagnoses included but were not limited to, unspecified dementia with unspecified severity and anxiety, epilepsy, generalized anxiety disorder, and psychotic disorder with delusions due to unknown physiological condition. Resident # 83's minimum data set (MDS) assessment with an assessment reference date of 6/22/24 assigned the resident a brief interview for mental status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. During a review of the electronic medical record a pharmacist note dated 9/13/23 at 11:00 AM read, MRR complete-see report. A note dated 5/28/24 at 2:29 PM read, MRR complete-see report. On 08/05/24 10:21 AM this surveyor asked the Assistant Director 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to store all medications and biologicals in a locked storage compartment on 1 of 2 nursing units, unit 1 hall C. The findings included: On 8/5/24 at 9:18 AM, this surveyor observed a medication cart in the hallway. The cart was unattended and unlocked. There was a staff member observed in room [ROOM NUMBER] interacting with a resident in the bed by the window. The staff member was not in the line of sight to the medication cart. At 9:24 AM Licensed Practical Nurse (LPN) # 2 exited room [ROOM NUMBER]. When asked if they were assigned to that medication cart they stated, Yes, that's me today. When surveyor pointed out that the cart was unlocked they stated, I never do that. Surveyor asked if the cart should have been locked while unattended and unobserved and they stated, Yes, I should have locked it before I went in there. This surveyor met with the Assistant Director of Nursing at 9:30 AM and discussed the concern. 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 observations, staff interviews, and facility document review, the facility staff failed to use the correct size of serving utensils when plating residents' food. The findings include: The evening meal menu for 7/29/24 included: (a) a 4 oz. serving of corn and (b) a 6 oz. serving of mechanical soft pizza. On 7/29/24 at 5:54 p.m., Dietary Staff Member (DSM) #1 was observed to be plating resident food. DSM #1 stated a 3 oz. serving utensil was being used for the corn and a 4 oz. serving utensil was being used for the mechanical soft pizza. After reviewing the menu, the Dietary Manager confirmed the serving size for the corn was to be 4 oz. and the serving size for the mechanical pizza was to be 6 oz. DSM #1 was observed to change the serving utensils to allow for the correct serving size of the corn and the mechanical soft pizza. On 7/31/24 at 1:45 p.m., the surveyor interviewed DSM #3 related to the serving size of the buttered noodles served during the midday meal on 7/31/24. DSM #3 reported they used a 3.25 oz serving utensil. The Regional Food Services Director reported…

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 observations, staff interviews, and facility document review, the facility staff failed to consistently follow menus for resident meals. The findings include: On the afternoon of 7/29/24, Dietary Staff Member (DSM) #1 was observed preparing the tossed salad for the evening meal. DSM #1 was observed to chop up the lettuce for the salad without first washing the lettuce. DSM #1 stated that they chopped up the salad prior to washing it. DSM #1 was observed to place onions and tomatoes into the lettuce. On 7/29/24 at 3:25 p.m., the surveyor and the Dietary Manager watched DSM #1 wash the mixture of the chopped lettuce, chopped tomatoes, and chopped onions. The recipe for the toss salad included carrots; the recipe did not include onions. The instructions for the tossed salad included: Wash and drain lettuce. Chop lettuce into bite size pieces. In a large mixing bowl, add lettuce, carrots and tomatoes. The evening meal menu for 7/29/24 included a 2 x 2 inch square of cake with icing. Observations of meal service for the evening meal for 7/29/24 revealed that cake without icing…

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 observations, resident interviews, facility staff interviews, and facility document review, the facility staff failed to provide food that is palatable and/or attractive. The facility staff failed to ensure cookies were provided to three (3) of 27 sampled resident in a manner that ensured the cookies were palatable when served to the residents (Resident #28, Resident #73, and Resident #96). The findings include: 1. The facility staff failed to ensure food was maintained on the steam table at a temperature to facilitate it being palatable when served to residents. On 7/29/24 at 5:35 p.m., the cook (Dietary Staff Member (DSM) #1) had completed checking temperatures of the food on the steam/holding table. DSM #1 reported that the temperatures were okay, and they were planning to start serving food to residents from the steam/holding table. The Dietary Manager was asked to review the documentation of the aforementioned temperatures; the Dietary Manager denied having concerns with the temperatures. The form the temperatures were documented on included the following statement:…

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 observations, staff interviews, and facility document review, the facility staff failed to appropriately prepare, store, and/or serve resident food items. The findings include: On 7/29/24 at approximately 1:30 p.m., a surveyor (with the Dietary Manager present) observed Dietary Staff Member (DSM) #1 and DSM #2 working in the kitchen food preparation area without wearing beard covers. The Dietary Manager confirmed that DSM #1 and DSM #2 should have been wearing beard covers. The following information was found in a facility policy titled Dietary Employee Personal Hygiene (with a reviewed/revised date of 12/2/22): All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. On 7/26/24 at 1:35 p.m., a surveyor (with the Dietary Manager present) made observations of the facility's food storage in the dietary department. The following was observed: - A metal pan containing chicken noodle soup was observed in the facility's freezer. This pan had foil between the lid and the pan. The lid was labeled with a date 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 staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that residents and/or resident representatives had the opportunity to develop an advanced directive for two (2) of 27 sampled residents (Resident #36 and Resident #46). The findings include: 1. The facility staff failed to ensure Resident #36 and/or the resident's representative had the opportunity to develop an advanced directive. Resident #36's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/3/24, was signed as completed on 5/14/24. Resident #36 was assessed as able to make self understood and as able to understand others. Resident #36's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Review of Resident #36's clinical documentation failed to provide evidence of the facility staff addressing whether the resident and/or the resident's representative desired to formulate an advanced directive. On 8/5/24 at 12:56 p.m., the facility's Director 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 staff interview, medical record review and facility document review, the facility staff failed to ensure appropriate information is documented and/or communicated to the receiving healthcare institution for 2 of 27 residents in the survey sample, resident # 13 and # 68. The findings included: 1. For Resident #13 the facility staff failed to complete a transfer form or document any information was compiled and sent to the hospital with the resident. Resident # 13's minimum data set (MDS) assessment with an assessment reference date of 6/6/24 assigned the resident a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. Resident was not interviewable. The electronic medical record was reviewed and a progress note dated 6/6/24 at 11:18 AM read, Mobile images in for Venous/Arterial Doppler, blood clot to left lower extremity noted. Family informed, family raised concern that respiratory issues may be caused from blood clot that has traveled, (name omitted) FNP contacted and received order to send resident out for further evaluation. 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 staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that written transfer notices were provided for three (3) of 27 sampled residents and/or residents' representatives (Resident #107, Resident #98, and Resident #56). The findings include: 1. The facility staff failed to provide Resident #107 or the resident's representative written transfer notice for the 6/7/24 transfer. Resident #107's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/12/24, was signed as completed on 3/18/24. Resident #107 was assessed as being able to usually make self understood and as being able to usually understand others. Resident #107's Brief Interview for Mental Status (BIMS) summary score was documented as a 11 out of 15; this indicated moderate cognitive impairment. Resident #107's clinical documentation indicated the resident was transferred to a local hospital on 6/7/24. No evidence of written notice of this transfer being provided to the resident or the resident's representative was found by or provided 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 staff interview, clinical record review and facility document review, the facility staff failed to screen for a mental disorder or intellectual disability for 1 of 27 current residents in the survey sample, resident # 95. The findings included: Resident # 95's PASRR included a document dated 11/7/23 and entitled, Notice of PASRR Level I Screen Outcome that read in part, Your Level I screen shows you have evidence of a serious mental illness or intellectual disability (IDD). Further PASRR review is not needed because you meet criteria for a short-term convalescence stay. This means you are approved for up to 60 days in a nursing home that takes Medicaid without additional PASRR review. Your level I screen lists any mental health and/or IDD services needed for you during your stay at the nursing home and they must give you the services listed. If you or your care provider thinks you need to stay longer than 60 days, then a nursing home staff member must submit a new level I screen to Maximus. This must be done by or before the 60 th day from the admission date to the nursing…

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 staff interview, record review and facility document review, the facility staff failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for one of 27 residents in the survey sample, resident # 95. The findings included: Resident # 95's PASRR included a document dated 11/7/23 and entitled, Notice of PASRR Level I Screen Outcome that read in part, Your Level I screen shows you have evidence of a serious mental illness or intellectual disability (IDD). Further PASRR review is not needed because you meet criteria for a short-term convalescence stay. This means you are approved for up to 60 days in a nursing home that takes Medicaid without additional PASRR review. Your level I screen lists any mental health and/or IDD services needed for you during your stay at the nursing home and they must give you the services listed. If you or your care provider thinks you need to stay longer than 60 days, then a nursing home staff member must submit a new level I screen to Maximus. This must…

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 staff interview, clinical record review and facility document review, the facility staff failed to develop and/or implement a comprehensive care plan for 2 of 27 residents in the survey sample, resident # 88 and resident # 258. The findings included: 1. For resident # 258, the facility staff failed to implement a care plan intervention to notify the physician of hematuria (blood in the urine). Resident # 258's diagnoses included but were not limited to displaced intertrochanteric fracture of the right femur, paroxysmal atrial fibrillation, and urinary retention. Review of the electronic medical record revealed that resident was on an anticoagulant medication (medications that prevent or treat blood clots in the heart or blood vessels) related to atrial fibrillation. The comprehensive person centered care plan included a focus that read, at risk for abnormal bleeding R/T use of anticoagulant for AFIB with an intervention that read, Observe for S/S bleeding and report to MD (bleeding gums, hematuria, joint pain, swelling, epistaxis, increased bruising, abdominal pain. 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for 2 of 27 residents in the current survey sample, Resident #88 and Resident #28. The findings included: 1. For Resident #88 (R88) the facility staff failed to provide an ongoing, person-centered, activity program two to three times a week for ninety days to support resident choice, interests, and physical, mental, and psychosocial well-being as indicated in the plan of care. R88's diagnosis list indicated diagnoses that included, but were not limited to, Bipolar Disorder, Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction, Depression, Peripheral Vascular Disease, Congestive Heart Failure, Chronic Kidney Disease-Stage 5, and Polyosteorarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/22/2024 assigned the resident a brief interview for mental…

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 observations, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a medication was available for administration for one (1) of four (4) residents included in medication administration observations (Resident #14). The findings include: The facility staff had to contact Resident #14's medical provider because the ordered Lidocaine Pain Relief patch was not available. The medical provider changed the order to a patch that was available. Resident #14's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/17/24, was signed as completed on 7/26/24. Resident #14 was assessed as able to make self understood and as able to understand others. Resident #14's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. On 8/1/24 at 8:27 a.m., Licensed Practical Nurse (LPN) #9 was observed to administer medications to Resident #14. Resident #14 had orders for a Lidocaine Pain Relief patch. LPN #9 reported they would have to go…

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 staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a correct diagnosis for the use of a psychotropic medication for one (1) of 27 sampled residents (Resident #56). The findings include: The facility staff failed to ensure the correct diagnosis for a psychotropic medication ordered for Resident #56. Resident #56's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/20/24, was signed as completed on 7/29/24. Resident #56 was assessed as able to make self understood and as able to understand others. Resident #56's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #56's clinical documentation included a consultant pharmacist recommendation dated 3/27/24 which stated, This resident is receiving the antipsychotic agent Aripiprazole (currently listed for mood), but lacks an allowable diagnosis to support its use. This pharmacist recommendation provided a list of diagnoses/conditions for the medical…

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 observations, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 30 opportunities for a medication error rate of 6.67%. These medication errors affected Resident #14. The findings include: The facility staff failed to ensure a medication error rate of less than 5% as evidenced by two (2) medication administration errors occurring during 30 opportunities witnessed during medication pass observations. Resident #14 was administered the incorrect dose of (a) fluticasone nasal spray and (b) furosemide tablets. Resident #14's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/17/24, was signed as completed on 7/26/24. Resident #14 was assessed as able to make self understood and as able to understand others. Resident #14's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. On 8/1/24 at 8:27 a.m., Licensed Practical Nurse (LPN)…

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 staff interviews, clinical record reviews, and facility document review, the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of 27 sampled residents (Resident #15). The findings include: Resident #15's Durable Do Not Resuscitate (DDNR) form, dated 5/1/24, was incomplete. Resident #15's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/16/24, was signed as completed on 5/30/24. Resident #15 was assessed as being able to sometimes make self understood and as being able to sometimes understand others. Resident #15 was assessed as having moderate impairment with making decisions regarding tasks of daily life. The DDNR form has a section where the individual completing the form certifies that the resident is either capable or incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This section was not answered by the individual completing Resident #15's DDNR Order form. The DDNR form has a section that is to be…

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, staff interview and facility document review, the facility staff failed to perform hand hygiene between residents during a medication pass and pour observation. The findings included: On 8/1/24 at 8:39 AM Licensed Practical Nurse (LPN) # 1 failed to perform hand hygiene appropriately between residents during a medication pass and pour observation. LPN # 1 administered medications to included an inhaler to a resident in the first bed. They handled items on the residents bedside table as well. They then went back to the medication cart and pulled all the medications for the window bed resident. They did not perform hand hygiene until after all medications were administered. When surveyor asked what the policy was for performing hand hygiene during a medication pass, they stated, I should have done it before I started the next ones medications. On 8/1/24 surveyor requested and received the policy entitled, Medication Administration with a revised date of 12/1/22, that confirmed hand hygiene is expected to be done before and after administering medications to 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 interviews and the review of documents, it was determined the facility staff failed to ensure the director of food and nutrition services possessed the required education and/or certification. The findings include: The facility's Dietary Manager/Director did not have the required food service/dietary certification and/or education. On 10/27/21 at 2:05 p.m., the facility's interim Administrator and Dietary Manager were interviewed about dietary staff training; a regional staff member from the facility's dietary contract group participated in this interview via telephone. It was confirmed that the facility's dietary director/manager did not hold a certification for dietary services. On the afternoon of 10/28/21, the facility's interim Administrator provided the survey team with a copy of the Dietary Director's job description. Under the Job Requirements heading of this document was found the following statement: Must possess Certified Dietary Manager (CDM) certification. The Dietary Director/Manager had signed this job description on 1/16/21. The facility's interim…

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 staff interview and clinical record review, the facility staff failed to complete a required PASARR (Pre-admission Screening and Resident Review) for 1 of 21 residents in the survey sample, Resident #60. The findings included: For Resident #60, the facility staff failed to complete a Level 1 PASARR A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Resident #60's diagnosis list indicated diagnoses, which included, but not limited to Schizoaffective Disorder Bipolar Type, Bipolar Disorder, Chronic Pain Syndrome, Irritable Bowel Syndrome with Constipation, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/24/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. A review of Resident #60's clinical record revealed a Notice of PASRR…

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, staff interview, and clinical record review the facility staff failed to ensure that residents receive treatment and care by following physician's orders for 1 of 21 residents. Resident #41. The findings included: For Resident #41, the facility staff failed to follow physician's orders in regards to obtaining the Residents BS (blood sugar) and administering insulin. The residents (EHR) electronic health record included the diagnosis of type 2 diabetes. Section C (cognitive patterns) of Resident #41's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 09/18/21 included a (BIMS) brief interview for mental status summary score of 15 out of 15 points. Indicating the resident was alert and orientated. Resident #41's comprehensive care plan included the focus area Diabetes Mellitus. Interventions included, but were not limited to, administer medication as ordered. Resident #41's physician orders included an order for Humulin R insulin give per sliding scale before meals and at bedtime. 10/26/21 at 12:32 p.m., the surveyor observed…

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, staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure enteral feedings were provided to meet resident needs for one (1) of 21 residents (Resident #65). The findings include: The facility staff failed to ensure Resident #65's tube feeding set (which included the flush bag and infusion tubing) was changed every 24 hours. Resident #65's clinical documentation included a minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/6/21. Resident #65 was assessed as sometimes able to make self understood and as sometimes able to understand others. Resident #65's Brief Interview for Mental Status (BIMS) summary score was documented as a four (4) out of 15. Resident #65 was documented as receiving nutrition via feeding tube and mechanically altered diet. Resident #65 was documented as being dependent on others for dressing, eating, toilet use, personal hygiene, and bathing. Resident #65's diagnoses included, but were not limited to: anemia, heart failure, high blood pressure,…

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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assist residents in obtaining dental care from an outside source for 1 of 21 residents in the survey sample, Resident #60. The findings included: For Resident #60, the facility staff failed to assist the resident in obtaining a dental consult. Resident #60's diagnosis list indicated diagnoses, which included, but not limited to Schizoaffective Disorder Bipolar Type, Bipolar Disorder, Chronic Pain Syndrome, Irritable Bowel Syndrome with Constipation, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/24/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. On 10/26/21 at 12:11 pm, surveyor spoke with Resident #60 who stated they need to have some teeth pulled and also needed a root canal. A review of Resident #60's clinical record revealed the following…

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, staff interview, and facility document review, the facility staff failed to 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 1 of 2 facility units, Unit 2. The findings included: LPN (licensed practical nurse) #1 failed to sanitize a blood pressure cuff between resident uses of this shared equipment. On 10/27/21 at 8:12 am, surveyor observed LPN #1 obtain a resident's blood pressure by placing the reusable cuff on the resident's bare arm. After obtaining the blood pressure reading, LPN #1 removed and cuff and then immediately placed the blood pressure cuff on another resident's arm without sanitizing it in between use. On 10/27/21 at 9:01 am, surveyor notified the Unit Manager of the above observation. Surveyor requested and received the facility policy entitled Cleaning and Disinfection of Resident-Care Equipment which states in part: 1. Resident-care equipment is categorized based on the degree…

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 facility staff interview and document review it was determined the facility staff failed to conduct quarterly quality assurance meetings with a medical director present. Findings: On 5/2/19 at 10:30 AM the quality assurance program was reviewed with the facility administrator. The administrator provided the surveyor with sign-up sheets for the quality assurance meets conducted since the last survey. The eight meetings were conducted on the following dates: 1. 3/8/18 2. 4/24/18 3. 6/19/18 4. 9/28/18 5. 10/5/18 6. 10/17/18 7. 12/28/18 8. 2/28/19 On 4/24/18, 9/28/18, and 12/28/18 the medical director did not register on the sign in sheets. The administrator told the surveyor the medical director had been out on maternity leave and another physician was supposed to fill in for her during her absence. The physician had attended one meeting and signed in--but was unable to attend all the meetings as they were scheduled. No additional information was provided prior to the survey team exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Based on resident interview, staff interview and resident council meeting minutes, facility staff restricted access to building amenities based on residents' room location for 1 of 2 nursing units and failed to make telephones available for resident use. Prior to attending the resident council meeting, the surveyor reviewed resident council meeting minutes on 5/01/19. The minutes from January 25 2019-- The administrator attended to tell residents about changes to the building which included closing the doors between side 1 (short term for rehab) and side 2 and restricting residents' use of the dining/day room on that hall to residents on the hall. Residents asked about their current use to visit with family or watch TV and the administrator told them to use the side 2 day room. Five of the residents in attendance asked specific, individual questions about their past use and were told to use other rooms. The surveyor had heard about this policy from Resident #54 on 4/30/19 during the initial screening process.…

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 staff failed to notify the physician of changes in Resident condition for 2 of 26 Residents in the survey sample, Resident #74 and Resident # 12. The findings included: 1. The facility staff held physician ordered Lantus for Resident # 74 without notifying the physician. Resident # 74 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, type 2 diabetes mellitus, anemia, major depressive disorder, and chronic kidney disease. The clinical record for Resident # 74 was reviewed on 4/30/19 at 2:15 pm. The most recent MDS (minimum data set) assessment for Resident # 74 was a quarterly assessment with an ARD (assessment reference date of 3/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 74 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 74 was cognitively intact. 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 and resident interview, facility staff failed to create a home-like environment by providing a chair in the resident's room. Resident #54 was admitted to the facility on [DATE]. Diagnoses included heart failure cardiopulmonary disease, hypertension, diabetes mellitus, generalized muscle weakness, unsteady gait, insomnia, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 3/19/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During the initial screening process on 4/30/19, the resident reported having been banned from using the big room on unit 1 when family visits. The resident said they have been told to use the dining room, which has no chairs for them, or the conference room which is locked on weekends. The resident has no chair for visitors in her room. Her only chair is a wheelchair. She stated that the last time her family…

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, staff interview and clinical record review it was determined the facility staff failed to provided personal privacy during an examination and treatment for 1 of 26 residents (Resident #60.) Findings: Resident #60 was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, hypertension, and chronic obstructive pulmonary disease. Resident #60's MDS (minimum data set) dated 4-6-19 coded the resident as cognitively unimpaired. The resident required staff assistance for all the activities of daily living. The resident's CCP (comprehensive care plan) implemented on 4/24/19 documented the resident required assistance with all the ADLs (activities of daily living) and was admitted to the facility with pressure ulcers. The staff was directed to follow the physician's order to treat the pressure ulcers. The physician's orders, signed and dated on 4-3-19, documented a daily treatment for pressure ulcers on both feet and the left calf. On 05/01/19 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 clinical record review and staff interview, the facility staff failed to ensure that the appropriate information was communicated to the receiving facility upon transfer to the hospital for 1 of 26 Residents in the survey sample, Resident # 65. The findings included: The facility staff failed to ensure that the comprehensive care plan goals were sent with Resident # 65 upon transfer to the hospital. Resident # 65 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to; major depressive disorder, hypertension, anxiety disorder, and chronic obstructive pulmonary disease. The clinical record for Resident # 65 was reviewed on 4/30/19 a 4:09 pm. The most recent MDS (minimum data set) assessment for Resident # 65 was a quarterly assessment with an ARD (assessment reference date) of 3/26/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 65 had a BIMS (brief interview for mental status)…

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 staff interview and clinical record review the facility staff failed to provide a written notice of bed hold for 1 of 26 Residents in the survey sample, Resident # 65. The findings included: The facility staff failed to issue a written notice of bed hold for Resident # 65. Resident # 65 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to; major depressive disorder, hypertension, anxiety disorder, and chronic obstructive pulmonary disease. The clinical record for Resident # 65 was reviewed on 4/30/19 a 4:09 pm. The most recent MDS (minimum data set) assessment for Resident # 65 was a quarterly assessment with an ARD (assessment reference date) of 3/26/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 65 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 65 was cognitively intact. On 5/1/19 at 3:02 pm, the surveyor observed 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 clinical record review, and facility document review, the facility staff failed to ensure that 1 of 26 Residents in the survey sample were free of unnecessary psychotropic medications, Resident # 79 . 1. Facility staff failed to ensure Resident # 79 was free from unnecessary psychotropic medications. Resident # 79 was ordered Ativan as a PRN (as needed) medication for longer than 14 days, and without a stop date. Resident # 79, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, vascular dementia, delusional disorder, depressive disorder, hypertension, constipation, history of coronary artery bypass graft, and pacemaker placement. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 4/2/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Review of the Electronic Medication Administration Record (EMAR) in…

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, clinical record review, and facility document review, the facility failed to ensure a med error rate less than 5 percent. There were 3 errors in 25 opportunities for a medication error rate of 12%. The findings included: The facility staff failed to administer Flonase, Lactulose, and Memantine. The record review revealed that Resident # 9 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; constipation, hypertension, anxiety, and major depressive disorder. On 5/1/19 at 8:43 am, the surveyor conducted a medication pass observation with LPN (licensed practical nurse) # 1. The surveyor observed LPN # 1 prepare and administer the following medications; Toprimate, Ferrous sulfate, Calcium +D, Oxybutin ER, Lisinopril, Paroxetine, Vitamin C, and Lorazepam. LPN # 1 stated, She gets Flonase. The surveyor did not observed LPN # 1 administer Flonase to Resident # 9. On 5/1/19 at 9:00 am, the surveyor observed LPN # 1 prepare and administer the following medications,…

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 facility document review, the facility staff failed to ensure that 1 of 26 Residents in the survey sample was free of significant medication errors, Resident # 74. The findings included The facility staff failed to administer physician ordered Lantus on 4/15/19, 4/19/19, 4/20/19, 4/26/19, and 4/29/19. Resident # 74 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to; type 2 diabetes mellitus, anemia, major depressive disorder, and chronic kidney disease. The clinical record for Resident # 74 was reviewed on 4/30/19 at 2:15 pm. The most recent MDS (minimum data set) assessment for Resident # 74 was a quarterly assessment with an ARD (assessment reference date of 3/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 74 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 74 was cognitively intact. 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 observation and facility document review, the facility staff failed to provide a safe sanitary environment to help prevent the development and transmission of communicable diseases and infections during medication pass observation, and observation of wound care. The findings included The facility staff failed to appropriately wash hands and sanitize medical equipment during a medication pass observation. The facility staff failed to appropriately wash hands during a wound care observation. On 5/1/19 at 8:43 am, the surveyor was conducting a medication pass observation with LPN # 1 (licensed practical nurse). The surveyor observed LPN # 1 as she administered medications to Resident # 9. The surveyor observed LPN # 1 as she washed her hands, turned off the faucet, and then dried her hands with a paper towel and discarded the used paper towel into the trash. On 5/1/19 at 9:00 am, the surveyor observed LPN # 1 as she administered medication to Resident # 44 (not sampled). LPN # 1 informed the surveyor that she needed to assess Resident # 44's vital signs prior to 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.