Star City Rehabilitation And Nursing

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a shower/bath was offered twice a week to one (1) of 17 residents (Resident #2). The findings include: The facility staff failed to ensure Resident #2 was offered a shower and/or full bath at least twice a week. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. Resident #2's clinical documentation indicated for the following five (5) weeks the resident only received one (1) shower/bath per week: (a) 10/20/24 - 10/26/24; (b) 11/10/24- 11/16/24; (c) 12/15/24 - 12/21/24; (d) 1/19/25 - 1/25/25; and (e) 1/26/25 - 2/1/25. 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.

2. For Resident #5 (R5) the facility staff failed to provide wound care daily per provider orders. The clinical record was reviewed. R5 was admitted with an order that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads (abdominal pads- a thick, absorbent nonadhesive dressing). Every shift. On 11/18/24, 11/20/24 night shift, there were blanks on the TAR indicating the treatments were not done. This order was discontinued on 11/23/24. On 11/23/24 an order was put in that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads. Two times a day for wound care. There were holes on the TAR for 12/9/25, 12/10/25, 12/12/25 all on day shift, 12/22/25 day shift and 12/23/25 day and night shift. This order was discontinued 12/27/25. An order dated 12/17/24 read, Clean surgical incision to lower ABD (abdomen) with wound cleanser and apply antifungal powder followed by dry gauze and ABD pads one time a day for wound treatment. There were blanks on the TAR for 12/22/24,…

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 treatment in accordance with provider orders to promote pressure area healing for 1 of 17 residents, Resident #9. The findings were: For Resident #9, facility staff failed to consistently provide pressure wound care as ordered by the provider. Resident #9's Minimum Data Set Assessment with an Assessment Reference Date of 12/26/24, assessed the resident should not have a brief interview for mental status conducted due to the resident was rarely/never understood. Section C (cognitive patterns) coded Resident #9 to have short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. Section M (skin conditions) assessed the resident for having 6 (six) Stage 3 pressure ulcers present upon admission and 1 (one) unstageable pressure ulcer present upon admission. Resident #9's clinical record contained wound care orders which included but not limited to: 1a. Right heel stage Right heel stage 3 pressure wound - cleanse daily with…

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 and clinical record review the facility staff failed to ensure medications and biologicals were stored and labeled correctly for 2 of 17 residents, Resident #3 and Resident #13. The findings included: For Resident #3 the facility staff failed to label/date tube feeding solution and placed a treatment belonging to Resident #13 in Resident #3's room. Resident #3's Resident #3's clinical record listed diagnoses which included but not limited to unspecified intracranial injury with loss of consciousness, personal history of traumatic brain injury, and dysphagia. Resident #3's most recent minimum data set with an assessment reference date of 01/09/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section K, Swallowing/Nutrition, coded the resident as receiving 51% or more of nutrition through tube feeding. Resident #3's comprehensive care plan was reviewed and contained a care plan for At risk of malnutrition r/t (related to) need for tube feed with NPO (nothing by mouth)…

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, clinical record review, and facility document review, the facility staff failed to address lab test recommendations for one (1) of 17 sampled residents (Resident #2). The findings include: The facility staff failed to ensure laboratory recommendations from a consulting medical provider was addressed by Resident #2's primary medical providers. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. Resident #2's clinical record contained communication from a brain injury center; this communication was dated 10/31/24 and was faxed to the facility on…

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 11/6/24 at 12:03 p.m., during the midday meal, the surveyor observed the dietary staff to be plating food for the residents. It was noted the menu included a dinner roll which was not being placed on the food trays sent to the resident units. Staff Member (SM) #6 (a dietary aide) reported that three (3) carts of food trays had been sent to the resident units without the dinner rolls. Dietary Manager #1 reported the trays should have included a dinner roll. Dietary Manager #1 obtained the dinner rolls from the freezer and had them baked for the rest of the meal trays. The menu for this meal also included for the residents to be provided oriental vegetables. The surveyor observed that peas and carrots were being served to the residents. Dietary Manager #1 confirmed the facility had mixed vegetables that should have been used for the 11/6/24 midday meal. Dietary Manager #1 reported the cook decided to cook peas 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 observations, staff interviews, and facility document review, the facility staff failed to ensure that food was served at a safe and/or appetizing temperature. The findings include: On 11/6/24 at 11:54, the surveyor observed dietary staff plating food from the steam table. The plated food was being placed on carts to be provided to the facility's residents. Food temperatures had not been documented for this meal. Dietary Manager #1 confirmed the food temperatures had not been documented for this meal. Dietary Manager #1 reported they were responsible for making sure the temperatures were checked. Dietary Manager #1 had the food temperatures checked. The pureed peas were 93 degrees Fahrenheit and the pureed chicken was 96 degrees Fahrenheit. Dietary Manager #1 had the food items that were below the desired temperatures reheated. On 11/6/24, the surveyor reviewed the food temperature logs with Dietary Manager #1. No food temperatures had yet to be documented for the month of November 2024. The food temperature binder included the following entries: - An undated page with only…

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, resident interview, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety for 4 of 6 resident care units and the facility kitchen. The findings included: On the Juniper resident care unit, the facility staff failed to maintain a clean and sanitary refrigerator and microwave, failed to store foods under sanitary conditions, failed to discard out of date foods, and failed to label and date perishable food items. On 11/06/24 at 11:45 AM, surveyor entered the Juniper resident care unit kitchen. The kitchen area was separated from the resident dining and living area by only a counter and a half gate. Surveyor observed a minimum of 20 small, black, gnat-sized, flying insects flying about the kitchen area and present on the walls and cabinets. The exterior of the refrigerator was soiled with dried, sticky splattered substances and debris particles. The inside of the refrigerator…

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, resident interview, staff interview, and facility document review, the facility staff failed to maintain an effective pest control program for 1 of 6 resident care units (Juniper). The findings included: On the Juniper resident care unit, the facility staff failed to maintain an effective pest control program to address the presence of small, black, gnat-sized flying insects. On 11/06/24 at 11:45 AM, surveyor entered the Juniper resident care unit's kitchen. The kitchen area was separated from the resident dining and living areas by a counter and waist-high gate. Surveyor immediately observed a minimum of 20 small, black, gnat-sized flying insects flying about the kitchen area and present on the walls and cabinets. The shelf under the unit microwave was soiled with food crumbs and debris. On 11/06/24 at 1:16 PM, surveyor spoke with Resident #7 who stated there were gnats in the kitchen and it needed a thorough cleaning. On 11/06/24 at 1:19 PM, surveyor spoke with Resident #2 who stated for the past two weeks there had been a bunch of gnats on the unit. On…

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 complete a comprehensive admission assessment for one (1) of eight (8) sampled residents (Resident #1). The findings include: Review of Resident #1's clinical record, on the morning of 11/7/24, indicated the facility staff failed to complete an admission/comprehensive Minimum Data Set (MDS) assessment for Resident #1 when the resident was readmitted to the facility after being discharged with a return not anticipated. Resident #1's MDS assessment, with an Assessment Reference Date (ARD) of 10/18/24, was signed as completed on 11/6/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1'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 11/7/24 at 10:30 a.m., Registered Nurse (RN) #1 confirmed Resident #1 had been discharged return not anticipated therefore resulting in the need to have had an admission/comprehensive assessment…

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 clinical record review, the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time limits for one (1) of eight (8) sampled residents (Resident #1). The findings include: Review of Resident #1's clinical record, on the afternoon of 11/6/24, revealed an incomplete quarterly MDS assessment with assessment reference date (ARD) of 10/18/24. Resident #1's previous MDS assessment had an ARD of 7/18/24. Resident #1's MDS assessment, with an ARD of 10/18/24, was signed as completed on 11/6/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1'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 11/6/24 at approximately 5:00 p.m., the surveyor interviewed Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3 about Resident #1's incomplete MDS assessment with an ARD of 10/18/24. RN #1 confirmed this assessment was late. On 11/7/24 at 4:05 p.m., the survey team met…

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, clinical record review, and facility document review, the facility staff failed to follow medical provider orders for two (2) of eight (8) sampled residents (Resident #1 and Resident #3). The findings include: 1. The facility staff failed to ensure Resident #1's medication was administered according to the medical provider ordered timing. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/18/24, was signed as completed on 11/6/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #1's clinical record, reviewed on 11/7/24, included a current provider order for facility staff to administer 0.25 ml of morphine (20mg/5ml) by mouth 15 minutes prior to wound care as needed. Resident #1's medication administration record (MAR) indicated this medication was administered on 11/7/24 at 9:57 a.m. Resident #1's treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This requirement was not met as evidenced by the facility staff failed to discard out of date perishable food items, failed to store uncooked meat separately from other food, failed to cover, date and label perishable food items, and failed to store foods under sanitary conditions in the facility Main Kitchen and in 4 out of 4 unit kitchen service areas; Countryside (1st floor), Rainbow(1st floor), Emerald(2nd floor) and Juniper(2nd floor). The findings include: The facility staff failed to discard out of date perishable food items, failed to store uncooked meat separately from other food, failed to cover, date and label perishable food items, and failed to store foods under sanitary conditions in the facility Main Kitchen and in 4 out of 4 unit kitchen service areas; Countryside (1st floor), Rainbow(1st floor),…

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 the 2023-2024 COVID-19 vaccine to three (3) of five (5) residents sampled for immunization review, the three (3) who consented to receive the vaccine. (Resident #15, #63, and #65). The findings include: According to the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) approved and authorized the 2023-2024 updated Covid-19 vaccine in September and October 2023. The CDC recommended everyone aged 5 years and older should get 1 (one) dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. The facility staff failed to provide the vaccine to three residents who affirmed their desire to receive the vaccine in October 2023. The five sampled residents' clinical records contained evidence that in October 2023, the facility staff contacted them and/or their representatives via email or phone for consent to participate in an upcoming COVID-19 vaccine clinic. Three of the five residents' clinical records…

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 document review, the facility staff failed to ensure one (1) of 19 current sampled residents were able to access personal funds deposited with the facility (Resident #15). The findings include: Resident #15 was unable to access a sufficient amount of their personal funds in order to make desired purchases in November 2023. Resident #15's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/16/23, was signed as completed on 12/26/23. Resident #15 was assessed as being able to make self understood and as able to understand others. Resident #15's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #15 was assessed as being depended on others for eating, hygiene, dressing, and bathing. On the afternoon of 2/8/24, Resident #15 reported they were unable to obtain money from their personal funds deposited with the facility to make a purchase. On 2/9/24 at 8:40 a.m., the surveyor asked the facility's Administrator about the process for 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 document review, the facility staff failed to provide a resident's responsible party and the ombudsman with written information related to a discharge/transfer for one (1) of 22 sampled residents (Resident #11). The findings include: The facility's staff failed to provide Resident #11's responsible party with a written transfer notice. The facility staff failed to provide the ombudsman with notice of facility transfers. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/22/23, was signed as completed on 11/30/23. Resident #11 was assessed as sometimes able to make self understood and as being rarely/never able to understand others. Resident #11 was assessed as having problems with both long-term memory and short-term memory. Resident #11 was assessed as requiring assistance with oral hygiene, dressing, toilet hygiene, and bathing. Resident #11's documentation indicated the resident was transferred to a local emergency department on 1/24/24, at a little after 12:00 noon, where the resident was subsequently admitted…

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 document review, the facility staff failed to provide a resident's responsible party with written bed hold information for one (1) of 22 sampled residents (Resident #11). The findings include: The facility's staff failed to provide Resident #11's responsible party with written bed hold information when the resident was admitted to a local hospital. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/22/23, was signed as completed on 11/30/23. Resident #11 was assessed as sometimes able to make self understood and as being rarely/never able to understand others. Resident #11 was assessed as having problems with both long-term memory and short-term memory. Resident #11 was assessed as requiring assistance with oral hygiene, dressing, toilet hygiene, and bathing. The following information was found in a facility document titled Bed Hold Notice Upon Transfer (with a reviewed/revised date of 12/1/22): - At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or 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, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 22 residents in the survey sample, Resident #54. The findings included: For Resident #54, the facility staff failed to revise the person-centered care plan to include the need for isolation precautions. Resident #54's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, and Hypothyroidism. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 11/05/23 assigned the resident a brief interview for mental status (BIMS) summary score of 2 out of 15 indicating Resident #54 was severely cognitively impaired. On 2/07/24 at 3:05 PM, surveyor observed a contact precautions isolation sign present on Resident #54's door and personal protective equipment (PPE) present. Resident #54's physician's orders included an order dated 1/30/24 for Contact Precautions for ESBL…

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, and clinical record review, facility staff failed to provide pressure ulcer dressing changes as ordered for 1 of 22 residents in the survey sample (Resident #32). Resident #32 was admitted to the facility with diagnoses which included chronic congestive heart failure, essential hypertension, chronic kidney disease, generalized muscle weakness, clostridium difficile enterocolitis, and stage 3 sacral ulcer. On the Minimum Data Set Assessment with Assessment Reference Date 1/14/24, 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 initial tour on 2/7/24, the resident reported being generally happy with care with the exception of wound care. The resident reported not having wound dressings changed on 2 night shifts the previous week. Clinical record review revealed a physician order dated 1/26/24 for Vashe Wound External Solution 0.033 % (Wound Cleansers) Apply to sacrum topically two times a day for sacral decubitus VASHE wet 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 interviews and document review, the facility staff failed to ensure residents' drug regimen were free from unnecessary drugs for two (2) of 22 sampled residents (Resident #24 and Resident #60). The findings include: 1. The facility staff failed to ensure Resident #24 was free of an unnecessary medication, sertraline. (Sertraline is an antidepressant medication.) Resident #24's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/9/24, was signed as completed on 1/26/24. Resident #24 was assessed as usually able to make self understood and as usually able to understand others. Resident #24 was assessed as having problems with both short-term memory and long-term memory. Resident #24 was assessed as being dependent on others for eating, oral hygiene, personal hygiene, dressing, and bathing. Resident #24's clinical record included a Consultant Pharmacist Medication Regimen Review form dated 12/14/23. This document indicated Resident #24 was receiving sertraline one (1) 50 mg…

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, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 37 opportunities for a medication error rate of 5.41%. These medication errors affected Resident #291. The findings included: For Resident #291, the facility staff failed to administer Aspirin and a Nicotine Patch as ordered by the physician. Resident #291's diagnosis list indicated diagnoses, which included, but not limited to Aftercare following Joint Replacement Surgery, Pneumonia, Generalized Muscle Weakness, Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Hyperlipidemia. A 2/09/24, Admission/re-admission Screening form documented the resident as being lethargic and oriented to person only. On 2/13/24 at 9:28 AM, surveyor observed licensed practical nurse (LPN) #6 prepare and administer Resident #291's medications. LPN #6 applied a Nicotine 21 mg/24-hour Patch to the resident's left shoulder area. Surveyor reconciled Resident #291's administered…

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.