Johnson Cntr/Falcons Landing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation review, the facility staff pre-selected the option on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #25 and #27) in a survey sample of 3 Residents, reviewed for such notices. The findings included: On 5/3/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which consisted of Resident #25 and #27. The notices issued to these Residents were reviewed and revealed the following: 1. For Resident #25, the facility staff provided a SNFABN notice prior to skilled care services ending, and below the options box had typed in, Additional information: I am choosing Option 3. Resident #25 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, as the facility had pre-selected/indicated the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 5 residents, Residents #2, #16, #19, #39, and #96, in a survey sample of 7 residents reviewed for COVID-19 vaccination. The findings include: 1. The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Residents #2, #16, #19, #39, and #96. On 5/3/23, clinical record reviews were performed and revealed the following: A. Resident #2 completed a primary COVID-19 vaccine series on 4/30/21, however there was no evidence that Resident #2 had been offered or received a COVID-19 bivalent booster dose. B. Resident #16 completed a primary COVID-19 vaccine series on 1/21/21, however there was no evidence that Resident #16 had been offered or received a COVID-19 bivalent booster dose. C. Resident #19 completed a primary COVID-19 vaccine series on 2/10/21, however there was no evidence that Resident #19…

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, record review, and review of facility policy, the facility failed to ensure the environment remained free of potential accident hazards (a portable heater) for one (Resident (R) 3) out of a survey sample of two. There was no evaluation of the resident's cognition, ambulatory status, and potential risks associated with the use of a portable heater completed prior to the use of the heater. Findings include: Review of a policy provided by the facility titled Incidents & Accidents, dated 01/09/23 failed to address potential environmental or equipment hazards. Review of a document provided by the facility titled Profile Face Sheet, indicated R3 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, difficulty walking, and dementia. Review of a document provided by the facility titled Care Plan dated 02/08/20 indicated R3 had impaired physical mobility and required assistance. In addition, the Care Plan indicated the resident had a decline 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.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide pharmaceutical services including procedures that assure accurate acquiring and dispensing of medications, for 1 Resident, (#95) in a survey sample of 25 Residents. The findings included: For Resident # 95 the facility staff failed to secure hard scripts for narcotic medications, and they were accessible in the Resident's chart. On 5/3/23 during clinical record review a review of the hard (paper chart) was conducted and it was found that there were prescriptions for Oxycodone (narcotic pain medication and controlled substance), as well as Lyrica (used for neuropathic pain and also a controlled substance) in the chart. On 5/3/23 at 4:00 PM and interview was conducted with LPN B who was asked the procedure for admitting a Resident from the hospital with new prescriptions. LPN B stated that the prescriptions should be faxed to the pharmacy and placed in the folder in the medication room for the pharmacy to pick up. When asked if the prescriptions should be kept in 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 interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary medications for 1 Resident in a survey sample of 25 Residents. The findings included: For Resident #37 the Medical Director ordered several narcotic medications including duplicate orders for PRN Oxycodone. On 5/2/23 at approximately 3:30 PM an interview was conducted with Resident #37 she stated that she used to go to pain management but no longer wants to go there. She stated that the doctor at the facility will manage her pain medications now. Resident #37 had been recently re-admitted to the facility after a hospital stay. Resident #37 had diagnosis that included but were not limited to cervical spinal stenosis causing upper body pain, and osteoarthritis. On 5/3/23 a review of the clinical record was conducted, and it was found that Resident #37 was prescribed the following medications for pain when re-admitted back to the facility after a hospital stay. 5/1/23 - Lyrica - (Pregabalin) 75 mg by mouth three times daily for pain. (Lyrica is…

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

Based on record review, staff interview, and facility documentation review, the facility staff failed to ensure that one Resident (Resident #145) was free from a significant medication error, where insulin was administered and was not ordered, in a survey sample of 25 Residents. The findings included: On 5/3/23, at approximately 8:30 AM, Resident #145 was visited in his room. During the interview, Resident #145 expressed concern over his blood sugars and said that he had several occurrences of hypoglycemia and was having difficulty managing his blood sugars. On 5/4/23, a clinical record review was conducted of Resident #145's chart. This review revealed that Resident #145 had orders for sliding scale insulin. The physician order read, Humalog Kwik Pen Insulin 100 unit/mL subcutaneous, Administer Humalog insulin per blood sugar sliding scale. Sliding scale subcutaneous 4 times a day at 7:30 AM; 11:30 AM; 4:30 PM and 10 PM as follows: Less than 70 follow hypoglycemic protocol and call MD. For BS [blood sugar] 70-150= No Insulin; 151-200= 3 units; 201-250= 6 units . Review 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, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements during a COVID-19 Outbreak within the facility for 2 out of 3 residential nursing units. The findings included: The facility staff failed to conduct COVID-19 testing on 1/11/23 and 1/13/23 on Nursing Units A and B, following the identification of a COVID-19 Outbreak on 1/9/23. All residents located on Nursing Unit C had tested positive for COVID-19 on 1/9/23. On 5/3/23, a group interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP). The IP stated that 2 residents on Nursing Unit C had tested positive for COVID-19 on 1/8/23 and on 1/9/23, all residents located on Unit C had tested positive for COVID. Unit C was quarantined and COVID testing was also conducted on Units A and B on 1/9/23. The DON and IP stated that 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 observations, interviews, record review, and policy review, the facility failed to consistently implement Centers for Disease Control and Disease Prevention (CDC) infection control measures in the quarantine unit for six of six residents (Resident (R) 18, R82, R81, R78, R77, and R79) and failed to keep urinary catheter tubing off the floor for one of one resident (R15) reviewed for urinary catheters out of a sample of 16 residents. These failures increased the risk of transmission of COVID-19 to the residents on the quarantine unit and urinary tract infection to R15. The facility had one positive COVID-19 resident at time of survey. Findings include: 1. Review of CDC guidance, Preparing for COVID-19 in Nursing Homes, updated April 30, 2020, revealed, . Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19 . Ideally the unit should be physically separated from other rooms…

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, policy review, and staff interview the facility failed to store frozen food in accordance with professional standards for food service safety. Findings: On 7/11/2018 at 8:10AM, an observation was made of the walk-in freezer. An open plastic bag containing 6 frozen sausage patties was noted as being unsealed and unlabeled. Employee A (the head Chef) was asked what the bag contained, and he stated it has the sausage from this morning that wasn't used. When asked for his observations of the food, Employee A stated it was on the tray line this morning. It should be put back in the original box, or sealed and labeled. A review of the provider's policy titled PROPER FOOD HANDLING AND SANITATION last revised March 2014 showed the following: 3.4 FREEZER STORAGE (walk-in and reach-in) 3.4.2 All stored food must be wrapped, stored in sealed containers or secured in a tied plastic bag. 3.4.3 All stored food must be properly labeled with date and product name. No further information was provided prior to exit.