Regency Health And Rehabilitation Center

Based on observation, staff interview, and facility documentation, the facility staff failed to appropriately label medication with accepted professional principles in 1 of 2 medication carts. The findings included: For medication cart #1, the staff failed to document the date on the label when two multi-use bottles of over the counter medication were opened. On 2/6/2024 at approximately 4:00 p.m., an inspection of the medication cart was conducted after the medication administration observation. The names of the medications were placed on top of the bottle caps but there were no dates of when the bottles were opened. LPN (Licensed Practical Nurse)-F was asked what was missing on the routine stock multi-use bottle of Aspirin 81 milligrams and Multivitamins found in the cart. LPN-F looked at the 2 bottles and stated the date should have been placed on the label when the bottles were opened. When asked why that should happen, LPN-F stated, If you do not label it, you do not know when it was opened. LPN-F stated the nurses placed the names of medications on the caps of the routine…

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 documentation, the facility staff failed to maintain infection control practices and perform the required reporting of a communicable disease in accordance with the Centers for Disease Control and Prevention (CDC) and the Virginia Department of Health guidelines. The findings included: The facility staff failed to report newly confirmed COVID-19 infections to the local health authorities. On 2/6/24 at approximately 10:30 AM, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP). The IP stated, Our last COVID outbreak at the facility started on January 21st [2024], we had a resident who was showing symptoms and we tested her for COVID and it came back positive, we began testing everyone right away and found an additional 9 residents who were positive for COVID so that brought our total to 10 positive COVID cases that day. The name and phone number for the facility's contact at the local health department was requested. The IP stated, I have not spoken to anyone at the health department, I…

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 are free from misappropriation of property for 1 Resident (Resident #1) in a survey sample of 2 Residents. The findings included: For Resident #1 the facility staff failed to prevent the diversion of the resident's narcotic pain medication, Oxycodone 10 mg (milligrams). A review of facility documentation revealed that the facility discovered a discrepancy between 7/8/2023 at 6:00 AM and 7/8/2023 at 12:00 PM, regarding Resident #1's narcotic pain medication, Oxycodone 10 mg IR (Immediate Release). The facility documentation showed that 52 tablets of Oxycodone were documented on 7/8/2023 at 6:00 on the controlled medication utilization record which was the end of the record. A new record was started, and 44 tablets of Oxycodone were documented on 7/8/2023 at 12:00 PM, thus leaving pills unaccounted for. The facility failed to review each controlled medication utilization sheet for accuracy. On 11/20/23 Surveyor B in reviewing the Controlled Medication Utilization sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and clinical record review the facility staff failed to provide medication administration that meets professional standards of care for 1 of 2 medication carts. The findings included: For medication cart B, LPN B (licensed practical nurse-B), failed to administer medications following the facility policy and the accepted professional standard for signing off and administering controlled substances. On 11/20/23 at approximately 10:30 AM, 1 of the 2 medication carts were audited and LPN B was asked the process for shift-to-shift controlled drug count. LPN B stated that while the oncoming shift viewed the medication cards the off going shift would read the control sheet to verify the number of medications matched the sheet. When asked if she could demonstrate she stated that she could. While demonstrating she stated that she had not, Finished signing out her 9:00 AM narcs. While counting the controlled sheets and comparing to the medication cards there were a total of 9 Residents'…

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 provide pharmaceutical services to include procedures that assure the accurate reconciliation and accounting for all controlled medications for 1 Resident (Resident #1) in a survey sample of 2 Residents. The Findings included: For Resident #1 facility staff failed to ensure proper dispensing and accounting of controlled medications. A review of facility documentation revealed that although the facility discovered a discrepancy in the accounting of the narcotic pain medication, Oxycodone, for Resident #1, between 7/8/2023 at 6:00 AM and 7/8/2023 at 12:00 PM, they did not uncover the full extent of the discrepancy. The facility documentation showed that 52 tablets of Oxycodone was documented on 7/8/2023 at 6:00 AM on the controlled medication utilization record (which was the end of the record). A new record was started, and 44 tablets of Oxycodone were documented on 7/8/2023 at 12:00 PM, thus leaving pills unaccounted for. The facility failed to review each controlled medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility documentation and clinical record review, the facility staff failed to provide routine medications to 4 Residents (#'s 8, 36, 51, and 26) in a Survey sample of 21 Residents. The Findings included: 1. For Resident #8 the facility staff failed to ensure he had an adequate supply of routinely scheduled oxycodone (narcotic pain medication). Resident # 8, a 68 yr. old male admitted to the facility on [DATE] with diagnoses of but not limited to esophageal cancer, anxiety, depression, COPD, malignant neoplasm of supraglottis, cirrhosis of liver, chronic pain related to cancer, and calculus of gallbladder and bile duct (gall stones still present in gall bladder and bile duct) with acute and chronic cholecystitis. The most recent MDS was a Quarterly with an ARD of 4/14/21. Resident #8 was coded as having a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. Resident #8 is coded as being independent with most ADL's with the exception of eating…

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 interviews, and facility documentation review, the facility staff failed to label and date a biological in accordance with currently accepted professional principles which was located in one out of one medication rooms. Specifically, an opened multi-dose vial of tuberculin purified protein derivative was observed undated in the medication room refrigerator on 07/15/2021. On 07/15/2021 at 9:30 A.M., this surveyor and Licensed Practical Nurse A (LPN A) observed an opened box of tuberculin purified protein derivative. There were two dates handwritten on the box: 06/21/21 and 07/13/21. Inside the box, an opened vial of tuberculin purified protein derivative was observed. There was a clear solution in the vial and LPN A verified there was no handwritten date or initials observed on the vial. When asked about the meaning of the 2 dates handwritten on the box, LPN A stated I think this date is when we received it referring to 06/21/21 and LPN A stated that the other date [07/13/2021] was when it was opened. When asked about the expectation for labeling after…

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 documentation review, the facility staff failed to store food in accordance with professional standards for food safety in 3 of 4 food storage areas. The facility staff failed to label and date prepared food items, opened food items and discard foods that had exceeded the use by date in 3 of 4 food storage areas. The findings included: On 7/13/21 at approximately 12 Noon, an inspection was conducted of the kitchen. The Dietary Manager (Employee C), accompanied Surveyor D as observations were made. The following items were observed: 1. The 2 door stand-alone fridge located beside the coffee pot contained a sandwich, tossed garden salad, and 2 cups of fresh fruit. None of these items were labeled or dated to indicate when they were prepared or when they should be used by; nor the contents. 2. In the walk-in cooler a box of sweet potatoes were observed, that were soft to touch, with obvious signs/white spots of decomposition. 3. There was a pan of what appeared to be a soup on the top shelf, which was not labeled or dated, nor…

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 clinical record review, the facility staff failed to provide services in accordance with professional standards of practice for 2 Residents (Resident #2 and Resident #8), in a survey sample of 21 Residents. 1. For Resident #2 the facility staff failed to document the administration of Byetta insulin as ordered by the physician. The facility staff documented the administration of Bydureon insulin, despite this order being discontinued. 2. For Resident #8 the facility failed to give Oxycodone 20 mg every four hours as ordered by the physician, and failed to document why medications were held. The findings included: 1. For Resident #2 the facility staff failed to document the administration of Byetta insulin as ordered by the physician. The facility staff documented the administration of Bydureon insulin, despite this order being discontinued. Resident #2 was admitted to the facility 10/15/20. Diagnosis for Resident #2, included but were not limited 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 observation, Resident interview, staff interview and clinical record review, the facility staff failed to ensure Residents were free from significant medication errors for 2 Residents (Resident #2 and Resident #8), in a survey sample of 21 Residents. 1. For Resident #2 the facility staff documented the administration of Bydureon insulin three times after it was discontinued. 2. For Resident # 8 the facility failed to give routinely scheduled Narcotic Pain Medicine as ordered by physician to a Resident with a diagnosis of Cancer and is on comfort care. The findings included: 1. For Resident #2 the facility staff documented the administration of Bydureon insulin three times after it was discontinued. Resident #2 was admitted to the facility 10/15/20. Diagnosis for Resident #2, included but were not limited to: hemiplegia affecting left non-dominant side, sepsis, type 2 diabetes with diabetic polyneuropathy, and chronic kidney disease stage 3b. Resident #2's most recent MDS (minimum data set) (an…

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, clinical record review, and facility documentation review, the facility staff failed to accommodate a resident's food preference for 1 resident (Resident #42) in a survey sample of 21 residents. For Resident #42, the facility staff served a pork chop for lunch service with a documented food preference indicating, No Pork. The findings include: Resident #42 was admitted to the facility on [DATE] following a recent hospital admission and receiving wound care and intravenous antibiotic therapy. Resident #42's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/21 was coded as an admission from an acute care hospital. Resident #42 was coded with a Brief Interview of Mental Status (BIMS) score of 13 out of possible 15, indicating that Resident #42 was cognitively intact. On 7/14/21, at approximately 12:30 PM, Resident #42 was observed in her room with her lunch tray placed in front of her. Resident #42 stated, They served me a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility documentation the facility staff failed to maintain an effective pest control program. On 7/13/21 approximately 1:00 PM during initial tour of the facility it was noted that there were small flies or gnats in room [ROOM NUMBER], in the kitchen area, and surveyors also killed 2 or 3 of them in the conference room on 7/13/20. The gnats were seen several times over the 3 days on survey. The Administrator was made aware of the issue on 7/13/21 during the end of day conference and a request to see the pest control log was made. On 7/14/21 at 10:00 AM the pest control logs were reviewed and excerpts are as follows: 7-6-21-The pest Control Company notes the facility is on the Cockroach/ rodent program, large fly program and the ant program. Sanitation issues: location: Kitchen area interior Open since: 5/12/21 Findings: Excess water noted in the drain action needed keep area dry. 6/2/21: Sanitation issues: location: Kitchen area interior Open since: 5/12/21 Findings: Excess…

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 documentation review, the facility staff failed to store and distribute food in accordance with professional standards for food service safety for the following: 1) There was expired milk in the refrigerator 2) The food in the 'walk-in' fridge and 'walk-in' freezer was not shelved to allow air circulation 3) The internal temperatures for the 'reach-in' fridge, the 'walk-in' fridge, and the 'walk-in' freezer were not being monitored 4) Coffee and milk temperatures were not being monitored 5) There was half-melted ice cream and popsicles in the pantry freezer 6) Handwashing by kitchen staff was not performed according to guidelines The findings include: On 10/30/2018 at 11:30 AM, it was observed the outside temperature reading for the reach-in refrigerator was 39 degrees Fahrenheit. When asked about the internal temperature reading, Employee E looked at the thermometer, tapped it, and stated it was not working. On 10/30/2018 at 11:35 AM, Employee E and surveyor entered the walk-in refrigerator. The outside temperature reading was…

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 the facility failed to ensure resident rights were implemented for one of 26 residents. (Resident #14) For Resident #14 the facility failed to assist in obtaining a Responsible Party or Power of Attorney for a resident with Dementia and severe cognitive impairment. The findings included: Resident # 14 an [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Major Depressive Disorder, Cognitive Communication Deficits, adult failure to thrive, and muscle weakness. The Resident's most recent (Minimum Data Set) MDS with an ARD (Assessment Reference Date) of 08/11/2018 coded Resident as having a (Brief Interview of mental status) BIMS score of 99 indicating severe cognitive impairment. According to MDS information Resident #14 has been in the facility since May of 2017 with a BIMS of 99 with no POA or Guardian Ad Litem. Prior to 2017 MDS data showed that the Resident had a BIMS of 15 indicating no…

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 clinical record review, the facility staff failed to determine if it was safe for Resident to self-administer Afrin Nasal Spray for one Resident (Resident #1 ) in a sample of 26 residents. The findings include: Resident #1, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included hypertension, atrial fibrillation, atherosclerotic heart disease, generalized muscle weakness, anxiety, and dementia. The Resident was admitted to skilled care recovering from a motor vehicle accident where she sustained a left radial/ulnar fracture and chest bruising. On 10/30/2018 at 4:10 PM, the Resident was not in her room but a container of unsealed Afrin nasal spray was observed on Resident's tray table at the bedside. On 10/31/2018 at 8:40 AM, the Resident was observed in bed, fully dressed, and she just finished eating her breakfast. The Afrin nasal spray was observed next to her food tray and when the Resident was asked about it, she…

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 documentation the facility failed to ensure that a PASARR Screening was done for 1 Resident (#14) in a survey sample of 17 Residents. For Resident #14 the facility failed to ensure PASARR Screening obtained prior to admission. The findings include: Resident #14 an [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Major Depressive Disorder, Cognitive Communication Deficits, adult failure to thrive, and muscle weakness. Resident most recent (Minimum Data Set) MDS with an ARD (Assessment Reference Date) of 08/11/2018 coded Resident as having a (Brief Interview of mental status) BIMS score of 99 indicating severe cognitive impairment. On 10/29/2018 during clinical record review it was discovered that the PASARR screening was not done prior to admission nor during the time since admission. On 10/30/2018 during end of day conference Administrator notified that Resident #14 had no PASARR. He stated he…

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, family interview, clinical record review and facility documentation the facility failed to develop and implement a comprehensive care plan that is Resident Centered for 1 Resident (#102) in a survey sample of 26 Residents. For Resident #102 the facility failed to address total knee replacement surgical care, hip pin removal, and discharge planning in the comprehensive care plan. The Findings Include: Resident #102 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Osteoporosis, Hypertension, Diabetes, chronic kidney disease and acute kidney failure. Resident #102 was a new admission and therefore did not have an MDS (Minimum Data Set). On 10/29/2018 the resident observed in bed with Knee Immobilizer in place to Left knee. On 10/30/2018 at 2:30 PM an interview was conducted with Resident #102 and Family members that were visiting. The Resident stated that she went to the hospital for a total knee replacement. Family member stated…

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, facility documentation review, clinical record review, and during a complaint investigation, the facility staff failed to follow the professional standards of nursing for 1 Resident (Resident #11) in the survey sample of 26 residents. For Resident #11, the facility staff failed to obtain finger stick blood sugar parameters. The Findings included: Resident #11 was admitted to the facility on [DATE]. Resident #11's diagnoses included; Diabetes Mellitus, Hypertension, high cholesterol, anemia, and chronic kidney disease resulting in hemodialysis, The most recent Minimum Data Set for Resident #11, was a Quarterly Assessment with an Assessment Reference Date of 8-9-18. This MDS coded Resident #11 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. The Resident was also coded as requiring only supervision, and some physical assistance from 1 staff person for Activities of daily living such as transferring, hygiene, dressing, and bathing. 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 observation, clinical record review, and staff interview, the facility staff failed to apply hand splints for one Resident, (Resident #30) in a sample of 26 residents. For Resident #30, the facility staff failed to provide hand splints as ordered by the physician. The findings included; Resident #30, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include cerebrovascular disease, respiratory failure, hemiplegia, contractures, dysphagia, and diabetes. Resident #30 is in a vegetative state on hospice care with a tracheostomy, oxygen therapy, gastrostomy tube, and enteral feedings. Resident #30's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/2018 was coded as a quarterly review. The Brief Interview of Mental Status was not completed but cognitive skills for daily decision-making was coded as severely impaired. The MDS quarterly review also indicated Resident #30 received passive range of motion and had a splint or brace applied. On 10/30/18…

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 documentation the facility failed to ensure that 1 Resident (#36) was free from accident/hazard in a survey sample of 26 Residents. For Resident #36 the facility failed to ensure that Resident received adequate supervision to prevent accidental rolling off of bed. The findings included; Resident # 36 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to hypoglycemia, Bradycardia Alzheimer's Disease, Transient Ischemic Attack (Stroke), Major depressive disorder and muscle weakness. The most current MDS (Minimum Data Set) prior to fall was coded as a Quarterly MDS with an ARD (Assessment Reference Date) of 6/10/2018. Her MDS coded the Resident as having a (Brief Interview of Mental Status) BIMS of 99 indicating the resident has severe cognitive impairment. Her MDS also coded her under Functional Status Section G - #4 Total Dependence- Requiring Full staff participation and coded her as a # 3 for Support- Two…

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 expired medications were not available for use, for one resident (Resident #32) out of 26 residents in the survey sample. The medication cart had two opened vials of Lantus that were past the expiration date. In addition, a vial of Pneumovax was not dated upon opening. The findings include: On 10/31/18 at 3:11 PM, The medication carts were checked for expired medication. Lantus for Resident #32 was opened on 10-1-18 and another was opened on 9-29-18, however, both vials were still in use. The stickers on bottles read to discard 28 days after opening. Review of the medication refrigerator revealed one vial of Pneumovax had been opened and was not dated. On 10/31/18 at 4:08 PM, the staff development nurse brought in a form from the pharmacy in which showed a vial of Pneumovax was sent to the facility on 1-30-18. The staff development was asked about what the standard of nursing when opening a new vial was: They are supposed to date it upon opening. When asked about the vials 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.