Avamere Rehabilitation At Ridgemont

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 3 of 3 residents (Residents 16, 48 & 74) reviewed for IV therapy. The failure to ensure IV orders included routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and initial and then weekly measurements of IV catheters external length and the residents arm circumferences, placed them at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . <Facility Policy> Review of the facility's Vascular Access Device (VAD) Dressing Change, Needleless Connector Change, Flushing and Locking, and Peripheral Midline Catheter policies, dated 08/2021, showed VADs included PICCs, non-tunneled catheters (subclavian, jugular, femoral), Tunneled catheters, and implanted venous ports. Staff were directed 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 observation, interview and record review, the facility failed to assure residents received foods in the appropriate form and/or nutritive content as prescribed by a physician for 5 of 36 sampled residents (Resident 57, 22, 10, 52 & 74) reviewed for diet requirements. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits. Findings included . Review of the breakout menu for the lunch meal on 08/26/2024 showed residents on a: a) Regular diet was to receive an #8 scoop of apple crisp. b) Residents on a soft bite sized diet (SB6) or minced and moist diet (MM5) were to receive a #12 scoop of apple crisp. c) Residents on a pureed diet (PU4) were to receive a #10 scoop of apple crisp. d) Residents on limited carbohydrate, limited fat, limited salt, or limited potassium/phosphorus diets, were to receive a #16 scoop of apple crisp. Additionally, residents on a low potassium/phosphorus (renal) diets were to receive lemonade in lieu of milk and spiral pasta in lieu of cubed…

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 and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 11 of 11 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life. Findings included . On 08/21/2024 at 1:02 PM, Resident 3 said they had a family member open another bank account for them because they could not withdraw money from their personal funds account on the weekends. On 8/26/2024 at 9:37 AM, Staff H, Licensed Practical Nurse (LPN), said she did not know the process if a resident wanted to withdraw money from their personal funds account over the weekend or after hours. At 9:40 AM, Staff C, LPN Resident Care Manager, said she did not know how a resident could withdraw funds from their Personal Funds account on the weekends and she said she would contact the business office to find out. At 9:50 AM, Staff I, Receptionist, said 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 27 & 75) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds. Findings included . Facility policy, titled, Transfer or Discharge Notice, dated March 2021, documented Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Resident 27 was admitted to the facility on [DATE]. The admission Minimal Data Set, (MDS, an assessment tool) date 07/23/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of resident and make adjustments, as needed, to their care), for 1 of 2 sampled residents (Resident 13) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 4 of 21 sample residents (Residents 16, 48, 63, & 8) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, and a diminished quality of life. Findings included . <Care Plans> 1) Resident 48 admitted to the facility on [DATE]. Review of the 5-day Minimum Data Set (MDS, an assessment tool), dated 07/22/2024, showed the resident had intravenous (IV) access via a midline and received IV medications. A 07/27/2024 re-admission nurse's note documented the resident had a midline…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include providing oral care and assistance with shaving for 2 of 2 residents (Residents 63 and 10) reviewed for ADL's. The failure to assist dependent residents with oral care and shaving, placed residents at risk for embarrassment, dental caries, powerlessness and a diminished quality of life. Findings included . 1) Resident 63 admitted to the facility on [DATE]. Review of the 05/09/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was dependent on staff for oral hygiene and had no obvious or likely cavities or broken natural teeth. An ADL self-care care plan, initiated 05/20/2024, showed staff were directed to set Resident 63 up to self-brush, and staff were to assist to complete. On 08/21/2024 at 1:52 PM, Resident 63's family member said the resident was always clean shaven prior to admitting to the facility and systematically cleaned his hands…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure non-invasive mechanical ventilation via continuous positive airway pressure machines (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep) was provided in accordance with accepted professional standards of practice for 2 of 2 residents (Resident 25 & 63) reviewed for respiratory care. The failure to ensure active CPAP orders were in place and complete, to include the prescribed pressure settings, type of mask (e.g. nasal pillows, nasal mask, full face mask) to be used, direction to check and refill the humidifier reservoir, and the solution to be used to refill it, placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . 1) Resident 25 admitted to the facility on [DATE]. Review of the 01/17/2024 Annual Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of chronic lung disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide medication administration consistent with professional standards of nursing practice for 2 of 5 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for unmet care needs, diminished quality of life and potential for medical complications. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated, 11/01/2023, showed Resident 1 was cognitively intact. On 01/11/2024, at 1:02 PM, Resident 1 said they had not received their melatonin (medication to help with sleep) when Staff A, Licensed Practical Nurse (LPN), worked. Resident 1's physician's orders showed the resident had an order, dated 11/01/2023, for one melatonin per day for sleep. Review of a facility investigation, dated 12/15/2023, showed Resident 1 made an allegation against Staff A, LPN. The results of the investigation showed the facility removed Staff A from caring for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of phorid flies (a type of fly that breed in moist, decaying organic matter) in 3 of 4 resident care units (Hallway 100, 200 and 300), kitchen, dining room and common areas of the facility. This failure placed residents at risk for infection, distress and a decreased quality of life. Findings included . <RESIDENTS> On 11/08/2023 at 12:48 PM, Resident 1 said they were used to the flies and observed them frequently at mealtime or when food was present. Resident 1 said the flies would not land on their food because the resident would constantly move their fork to keep the flies from landing. The resident said if they stopped moving the fork the flies would land on the food. At 3:26 PM, Resident 2 said there were flies all over the place that landed on their face and food. The resident said there was nothing they could do except swat them away. At 3:55 PM,…

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 Resident 51 Review of Resident 51's admission Minimum Data Set (MDS, a required assessment tool) dated 03/12/2021, showed Resident 51 admitted on [DATE] with multiple health conditions including stroke and muscle weakness. The MDS further showed that the resident required extensive assistance with activities of daily living (ADL). Review of Resident 51's care plan dated 07/05/2023 showed that the resident required assistance with ADLs related to decreased mobility and weakness. The resident's goal was to participate in active assistive range of motion (AAROM) program to bilateral lower extremities (BLE) to prevent tone or contractures. In addition, staff were to implement these interventions one to two times per week. Multiple observations on 09/18/2023 at 9:35 AM, 09/18/2023 at 2:15 PM, and 9/19/2023 at 11:11 AM, showed Resident 51 was either in bed sleeping or watching television. Review of a document titled, RA Program Flowsheet dated 03/2023 to 07/2023, showed that Resident 51 was to have a restorative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain resident refrigerators to ensure temperatures were withing safe ranges for 2 of 4 refrigerators (room [ROOM NUMBER] and 203) when reviewed for Kitchen. This failure placed residents at risk of consuming expired food items, foodborne illness, and a diminished quality of life. Findings included . Review of the facility's Refrigerator Temperature Log form, which was attached to all resident refrigerators, showed, The temperature needs to be checked and documented by the housekeeping staff & report to maintenance personnel if temperature is under 35 degrees or over 40 degrees via the maintenance log. Review of room [ROOM NUMBER]'s Refrigerator Temperature Log form for September 2023 on 09/21/2023 showed two days without entries and 16 days with the recorded temperature greater than 40 degrees (total of 20 entries). Review of room [ROOM NUMBER]'s Refrigerator Temperature Log form for September 2023 on 09/21/2023 showed two days without entries 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 observation, interview, and record review, the facility failed to honor resident food preferences for 1 of 3 residents (Resident 61) reviewed for Choices. This failure placed the resident at risk of reduced nutritional intake, undesired weight loss, a lack of enjoyment in eating, and a diminished quality of life. Findings included . During an interview on 09/18/2023 at 12:47 PM, Collateral Contact FF, anonymous (CC), stated that Resident 61 preferred to eat ground meat, but that the facility would only provide cut meat. CC FF further stated that Resident 61 could not chew cut meat and would spit the meat out. Observation on 09/19/2023 at 1:22 PM showed Resident 61 with their meal tray on the overbed table. Observation of the meal tray showed a piece of meat, uncut, and other food items. Observation showed that Resident 61 consumed less than 10% of the meal. Observation on 09/20/2023 at 12:25 PM showed Resident 61 with their meal tray on the overbed table. Observation of the meal tray showed a piece of meat, uncut, and other food items. Review of Resident 61's physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to notify the physician for one of four residents (Resident (R) 30) reviewed for medication errors who missed seizure medications. This failure placed residents at risk for health complications and a diminished quality of life. Findings include . Review of the facility's policy titled Guidelines for Notifying Physicians of Clinical Problems dated 09/17 documented: These guidelines are intended to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner .Immediate Notification (Acute) Problems : The following symptoms, signs .should prompt immediate notification of the physician after an appropriate nursing evaluation .Thee situations include .seizure activity, medication error . Review of R30's Face sheet found in the electronic medical record (EMR) under the Admission tab revealed R30 was admitted to the facility on [DATE] and had diagnoses of epilepsy. Review 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 observation, interviews, record review, and facility policy review, the facility failed to develop a baseline care plan to include catheter use based on physician orders for one of two residents (Resident (R) 175) reviewed for catheter care. Failure to ensure an initial care plan addressed catheter care placed residents at potential risk for unmet needs, medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled Care Plan - Baseline, dated 12/16, revealed A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs .The baseline care plan will be used…

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

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of 25 residents (Residents 276) whose care plans were reviewed. Failure to establish care plans that accurately reflected assessed care needs, resident desired outcomes/goals, and provide direction to staff (interventions) related to activities placed residents at risk to receive less than adequate care. Findings included . Multiple observations throughout the day on 09/19/2023 and 09/20/2023 showed Resident 276 self-propelled in their wheelchair to the sidewalk adjacent to the facility to smoke a cigarette. Upon returning to the building the resident put their lighter and cigarettes in a small purse which was hanging on the wheelchair and returned to their room. Review of Resident 276's Electronic Health Record showed progress notes on 04/17/2023 that indicated the resident advised the Director or Nursing that they had no intention to stop smoking. On 05/26/2023 Resident 276 was observed smoking and reminded by staff of the non-smoking policy. On 07/12/2023 at 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 3. Review of R176's Clinical Census, located in the EMR under the Census tab, revealed an admission date of 09/07/23 with medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction and paraplegia. Review of R176's admission MDS located in the EMR under the MDS tab with an ARD of 09/12/23 revealed a BIMS score of 15 out of 15, indicating R176 was cognitively intact. The MDS revealed R176 required extensive physical assistance of two+ persons for bed mobility and transfers. During an observation and interview on 09/18/23 at 10:51 AM, R176 was observed in her room in bed. R176 stated she was admitted after a stroke. R176 stated she had been paralyzed 30 years, incomplete quad cervical fracture. I could use my left arm, but the stroke took that away. During an interview with R176 and her Collateral Contact (DD), on 09/19/23 at 8:50 AM, DD stated R176 got another skin tear last night because they transferred her on the Hoyer (mechanical lift) with only one person. DD stated, it's on her…

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 2. Multiple observations throughout the day on 09/19/2023 and 09/20/2023 showed Resident 276 self-propelled in their wheelchair to the sidewalk adjacent to the facility to smoke a cigarette. Upon returning to the building the resident put their lighter and cigarettes in a small purse which was hanging on the wheelchair and returned to their room. Review of Resident 276's Electronic Health Record showed progress notes on 04/17/2023 that indicated the resident advised the Director or Nursing that they had no intention to stop smoking. On 05/26/2023 Resident 276 was observed smoking and reminded by staff of the non-smoking policy. On 07/12/2023 at the quarterly care conference Resident 276 was reminded about the non-smoking policy and informed that they would have to sign the non-smoking agreement. Review of Resident 276's Comprehensive Care Plan on 09/19/2023 showed no documentation or interventions related to smoking. Review of Resident 276's Electronic Health Record on 09/19/2023 showed no smoking assessment had…

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

Based on observation, interview, and record review, the facility failed to follow a therapeutic diet as ordered for 1 of 5 residents (Resident 61) when reviewed for Nutrition. This failure placed residents at risk for difficulty eating, possible choking hazard, reduced nutritional intake, unintended weight loss, and a diminished quality of life. Findings included . During an interview on 09/18/2023 at 12:47 PM, Collateral Contact FF, anonymous, stated that the facility cut Resident 61's meat into pieces. Review of Resident 61's 12/22/2022 initiated care plan showed a focus area related to diet and included an intervention of soft and bite-sized meats. Observation on 09/19/2023 at 1:22 PM showed Resident 61 with their meal tray on the overbed table. Observation of the meal tray showed a piece of meat, uncut, and other food items. Observation showed that Resident 61 consumed less than 10% of the meal. Observation on 09/20/2023 at 12:25 PM showed Resident 61 with their meal tray on the overbed table. Observation of the meal tray showed a piece of meat, uncut, and other food items.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen services were provided in accordance with professional standards of practice for 1 of 1 resident (Residents 275) reviewed for respiratory care. Failure to ensure there was a Physician's order for oxygen placed the resident at risk for unmet care needs and potential negative outcomes. Findings included . Resident 275 admitted to the facility on [DATE]. According to the 09/01/2023 Quarterly Minimum Data Set (MDS, an assessment tool) the resident had no chronic respiratory diagnoses but required supplemental oxygen during the assessment period. Observations on 09/18/2023 at 10:49 AM and 09/19/2022 at 12:45 PM showed Resident 275 was receiving oxygen (O2) at seven liters per minute (7L/min) via nasal cannula (NC). Review of Resident 275's Electronic Health Record showed no physician order for oxygen. Review of Resident 275's Medication Administration Record (MAR) showed no area for documentation of the oxygen administration.…

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, the facility failed to maintain sufficient staffing levels to provide exercise programs to maintain/prevent range of motion for 3 of 5 residents (Residents 9, 51, and 276) when reviewed for Sufficient Nurse Staffing. Failure to maintain staffing to provide these services placed residents at risk of deconditioning, loss of range of motion, inability to complete activities of daily living (ADL), and a diminished quality of life. Findings included . During an interview on 09/20/2023 at 9:54 AM, Staff C, Assistant Director of Nursing/Restorative Coordinator (ADON/RC), stated that the facility was having trouble consistently providing exercise programs. Staff C stated that the facility had previously had two aids responsible for providing exercise programs, but that these staff were re-assigned to other duties. Staff C further stated that a physical therapist aid had then instituted a group exercise program, but that this staff was promoted and could not continue this function. Staff C stated that the only exercise program provided by the facility was a group exercise…

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 observations, record reviews, interviews, and facility policy review, the facility failed to prevent significant medication errors for two of four residents (Residents (R)30 and R59) reviewed for medication errors. The facility failed to administer Clobazam (used to treat seizure disorder) between 08/18/23 and 08/24/23 with R30 experiencing a seizure on 08/24/23 and failed to administer Clobazam according to physician order for R59. This failure placed residents at risk for health complications and a diminished quality of life. Findings included . Review of the facility policy titled [Company Name]-Medication Error Guidelines, dated 02/21, revealed If a medication error is identified at any time, the Licensed Nurse discovering the error will notify the Physician and the Director of Nursing Service (DNS). Review of the facility policy titled Seizures and Epilepsy-Clinical Protocol, dated 11/18, revealed If a new or recurrent seizure is identified or suspected, the physician will evaluate the need 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 observation, interview, and facility policy review, the facility failed to detect and discard unopened, expired medications from one of two medication storage rooms reviewed. These failures placed residents at potential risk for receiving compromised or ineffective medications with unknown potency Findings included . Review of the facility's policy titled Storage of Medications dated 11/20 documented .Outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed . During an observation of the facility's medication room on the 300 unit with Registered Nurse (Staff S) on 09/21/23 between 11:14 AM and 11:23 AM, the following expired medications were observed: -Two enema saline laxatives with expiration dates May 2001 and February 2003. -Biotene dry mouth spray with expiration date 01/23/23. -One bottle of magnesium citrate liquid 10-ounces with expiration date December 2022. -One container of vitamin B6 100 milligram (mg) with expiration date August 2023. -One container of meclizine 25 mg with expiration date May 2003. -One container of Coenzyme Q-10 30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure enteral nutrition (delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach or small intestine) was administered in accordance with physician's orders for 1 of 3 residents (Resident 1) reviewed for enteral nutrition. This failure placed the resident at risk for inadequate nutrition, dehydration, hunger, and potential adverse outcomes. Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 07/04/2023, showed the resident received their nutrition through a feeding tube. Review of Resident 1's physician orders, dated 01/19/2023, showed orders for 220 milliliters (ml) of Glucerna 1.2 formula, via enteral feeding, every four hours. Review of Resident 1's progress notes, dated 08/08/2023 at 6:37 AM, showed that the nurse observed an incorrect setting on the enteral feeding pump (the equipment that administers the formula over a set period)…

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.