Burnett Medical Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the provider was notified of significant change in condition for one resident (Resident (Resident (R) 1) of three sampled residents reviewed for change in condition in a total sample of six. This failure placed residents at risk of increased medical complications.Findings include. Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed that R1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), aortic valve insufficiency, and congestive heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an assessment reference date (ARD) of 10/07/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicated R1 was moderately impaired in cognition. Review of a 10/11/25 Plan of Care Note, located in the Progress Notes tab of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and review of facility policy, the facility failed to provide a transfer form to the hospital at the time of the transfer for one resident (Resident (R) 2) in a total sample of six. This failure placed residents at risk of lack of information being shared with the hospital.Findings include. Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed R2 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic kidney disease, and a history of urinary tract infections. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the Electronic Medical Record (EMR) revealed R2 had a BIMS score of 10 out of 15, which indicated R2 was moderately impaired in cognition. Review of an 09/16/25 Plan of Care Note located in the Progress Notes tab of the EMR revealed, . Upon inquiry of Res [resident] sitting in her chair with the light on, Res found to be not WNL [within normal limits] for her talking…

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, record review and facility policy review, the facility failed to ensure a complete and accurate medical record for two residents (Residents (R) 1, R2) in a total sample of six. The facility failed to completely describe an accurate description of a fall and document the neurological checks at the time of the fall for R1. This failure placed the residents at risk of unmet care and a diminished quality of life.Findings include: Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed R1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), aortic valve insufficiency, and congestive heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an assessment reference date (ARD) of 10/07/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicated R1 was moderately impaired in cognition. Review of 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 record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 1 of 3 residents (R) (R1) reviewed.R1 was a brittle diabetic who did not receive medications per physician orders and provider was not notified of abnormal blood glucose levels.This is evidenced by:Facility policy, titled, Change in a Resident's Condition or Status, with a revised date of 02/2021, states in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or…

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 did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility did not keep a complete surveillance line list which affects all residents (R), did not perform hand hygiene with glove changes during wound cares for 1 of 2 residents (R4), touched medications to be administer with bare hands for 2 of 8 (R6, R7) observations, and did not dispose of PPE properly when caring for residents on enhanced barrier precaution for 2 of 5 residents (R1, R17). This had the potential to affect all residents in the facility. Findings include: Example 1 Facility policy titled: Infection Prevention and Control Program, with a last revised date of 05/14/24, states in part: .Active Surveillance: Conducting surveillance activities that include infection detection, data collection and analysis, monitoring,…

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, record review and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure medication was labeled to determine the expiration date of opened medications for 7 of 13 residents (R) (R2, R12, R25, R3, R20, R14, and R18). Findings include: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy titled, Medication Labeling and Storage dated [DATE], which stated in part: -Medication Storage: #2: The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. -Medication Labeling: #1: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. -#2: The medication label includes, at a minimum: d.…

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 did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R17, R22, and R7) Findings include: Facility document titled Know Your Rights under Federal Nursing Home Regulations states in part, .You have the right to be treated with respect and dignity . Example 1: R17 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia and stroke. R17's Minimum Data Set (MDS) assessment dated [DATE] identified R17 had moderate cognitive impairment and required assistance with eating. On 10/21/24 at 12:30 PM, Surveyor observed Registered Nurse (RN) D assist R17 to eat lunch in the dining room. During the observation, RN D used the clothing protector multiple times to wipe R17's mouth and face rather than a napkin. Example 2: R22 was admitted 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 record review, the facility did not investigate, resolve, and record resolution of grievance for 1 of 13 residents (R) R28. R28's Activated Power of Attorney (APOA) K reported a personal item missing and a grievance was not completed. Findings include: Facility policy titled: Grievance Policy with a most recent review date of 03/28/22 stated, in part: The facility grievance process will be overseen by Social Services and the DON, who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, communicate with residents throughout the process to resolution .facility will provide a mechanism for filing a grievance/complaint, will provide residents, resident representatives and others a planned, systematic mechanism for receiving and promptly acting upon issues expressed and provide an ongoing system for monitoring and trending grievances and complaints. R28 was admitted to the facility on [DATE] with a diagnosis of vascular dementia.…

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 and interview, the facility did not develop a comprehensive care plan for 1 of 1 resident (R) R12 reviewed for indwelling catheter. R12 had an indwelling catheter in place. The facility did not develop a care plan to direct care for indwelling catheter. Findings include: R12 was admitted to the facility on [DATE] with pertinent diagnoses of syncope, orthostatic hypertension, atrial fibrillation, and repeated falls. R12's most recent quarterly Minimum Data Set (MDS) dated [DATE] stated a Brief Interview of Mental Status (BIMS) score of 15 indicating R12 is cognitively intact. R12 had no impairment to range of motion in upper and lower extremities and uses a mechanical wheelchair for ambulation. R12 did not have an indwelling catheter and is always continent. Surveyor reviewed R12's care plan. No indication of having an indwelling catheter was noted. Surveyor reviewed R12's nursing progress notes. No documentation of cares provided for catheter noted. Surveyor reviewed R12's urology clinic…

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 did not ensure care plans were revised and implemented to reflect changes in care for 2 of 5 residents (R) R12 and R22. R12 had a recent fall and care plan was updated with intervention to include 30 minute - 1 hour safety checks to be completed. This intervention was not completed. Facility did not follow fall care plan interventions for 15-minute checks for R22. Findings include: According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Example 1 R12 was admitted to the facility on [DATE] with pertinent diagnoses of syncope, orthostatic…

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, facility did not ensure pharmacy recommendation reports were acknowledged by a physician for 1 of 5 residents, (R) R12, reviewed. R12 had a pharmacy recommendation that was not acknowledged or acted upon by a physician. Findings include: R12 was admitted to the facility on [DATE] with pertinent diagnoses of syncope, orthostatic hypertension, atrial fibrillation, mood disorder, and repeated falls. Surveyor reviewed R12's orders and noted the following: Quetiapine fumarate (Seroquel) 200mg tab; give 1 tab by mouth at bedtime for insomnia. Start date: 02/04/22. Surveyor reviewed R12's Monthly Medication Review (MMR) reports and noted the following: 06/19/24 - recommend lowering Seroquel dose. Still continues pending from 01/21/23 no response from provider. On 10/22/24 at 10:42 AM, Surveyor asked Registered Nurse (RN) D for documentation of provider response for the MMR recommendation on 06/19/24. RN D stated not having one, that the provider is from the Veteran Affairs (VA)…

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 did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 2 residents (R25) reviewed for antibiotic use without adequate indication for its use. R25 was ordered and administered cefuroxime avetil (antibiotic) for Urinary Tract Infection (UTI). No documented symptoms to indicate antibiotic. No laboratory results indicating necessity for prescribed antibiotic. Findings include: Facility policy entitled: Antimicrobial Stewardship Program with a most recent reviewed date of 06/23/22 states in part: All prescribers at [NAME] Medical Center are expected to prescribe antimicrobial therapy according to the following key principles: dosage, route, frequency and diagnosis of prescribed antimicrobials will be appropriate for the individual, as well as the site and type of infection. According to Loeb criteria, the criteria used by facility to assess and monitor infections, the minimum set of signs and symptoms which indicate an infection is…

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

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 8 residents (R), R12 and R15, observed for medication pass. The facility had 26 opportunities and 3 medication errors resulting in an 11.54% error rate. Registered Nurse (RN) D administered insulin medication without checking the expiration date and without holding the insulin injection in the abdomen for at least 10 seconds for R12. Licensed Practical Nurse (LPN) C administered Morphine sulfate oral medication without checking the expiration date for R15. This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy titled, Administering oral medications dated on September 4, 2024, stated in part: -Steps in the procedure: -#7. Check expiration date on the medication . Surveyor reviewed policy titled, Subcutaneous Injections dated on March 2011, which stated in part: -Steps in the procedure: 11. After needle enters…

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 and interview, the facility did not review and revise the comprehensive care plan for 1 of 3 sampled residents, Resident (R)3. Findings include: Record review identified that R3 was admitted to the facility on [DATE]. R3's diagnoses included, in part, Alzheimer's, aphasia, unspecified dementia, type 2 diabetes mellitus, epilepsy, pressure ulcer of the heel, and long-term use of insulin. R3's Brief Interview for Mental Status score (BIMS) was deemed 00 as a staff interview could not be performed, indicating severe cognitive impairment. The Minimum Data Set (MDS) assessment dated [DATE] indicated R3's functional status needs total assistance and assistance of two with bed mobility and transfers. Review of R3's record identified the following transfer care plan: Transfers: The resident is total care-dependent, transfer EZ-stand must use leg straps, harness size medium on 08/23/23, and EZ-Lift . On 12/27/23 at 11:15 AM, Surveyor observed inside R3's closet door and identified the transfer care…

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 did not ensure that 2 of the 3 residents reviewed for transfers (R3, R2), received adequate supervision and assistance to prevent accidents. This is evidenced by: The policy titled, Low lift program/safety with Mechanical lifts, including in part, .facility uses EZ Way, INC equipment and follow their operating instructions, accuracy care/replacement guidelines, and safety/maintenance checklist as found in the EZ Way manual attached to each machine, or online at http://www.ezlifts.com/downloads/ . The manufacturing instructions for the EZ stand titled, EZ way smart stand operating instructions, included in part, .As patients vary in size, shape, and weight, these conditions must be taken into consideration when deciding EZ way harness; the weight of patient and circumference of patients torso where the harness is applied . Example 1 Record review identified that R3 was admitted to the facility on [DATE]. R3's diagnoses included, in part, Alzheimer'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 interview and record review, the facility did not ensure a system was in place to adequately assess and supervise residents more closely to prevent elopement for 2 of 3 residents (R) who were reviewed for wandering/elopement (R1, R3). R1, upon admission to the facility on [DATE], was not assessed for wandering/elopement. R3 was admitted to the facility on [DATE]. R3 has never had an assessment conducted for wandering/elopement. Findings include: Example 1 The facility's policy titled Wandering and Elopements dated 2001 MED-PASS, revised March 2019, states, in part: .Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . The facility policy titled, Continuing Care Center Policy [CCC] and Procedure…

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

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not assist residents (R) with hand hygiene prior to meals in the dining room during observations of breakfast meal on 07/25/23 and breakfast meal on 07/26/23. This affected 13 of 37 residents. (R28, R1, R4, R3, R17, R9, R6, R32, R12, R13, R10, R23, and R18.) Findings include: Surveyor reviewed policy for hand washing/hand hygiene which stated in part, .residents will be encouraged to practice hand hygiene through the use of alcohol-based hand rub or alternatively, soap and water before and after eating or handling food . On 07/25/23 at 8:10 AM, Surveyor observed R1 brought to the dining room by Certified Nursing Assistant (CNA) I. No staff offered or assisted R1 with hand hygiene. On 07/25/23 at 8:18 AM, Surveyor observed the following residents brought to the dining room for breakfast: R6, R28, R9, R10, R23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not report injuries of unknown source to the proper authorities and failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for resident (R). (R15) R15 had an injury to right wrist on 05/25/23 with unknown origin. This serious injury was not reported to the state agency or reported as a reasonable suspician of a crime. Findings include: Facility policy entitled Abuse, neglect, mistreatment and misappropriation of resident property, last revised 05/22/23, stated in part, .The facility will ensure that all alleged violations including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and the Division of Quality Assurance (DQA) in accordance with state law through established procedures . R15 was admitted on [DATE]. R15 had the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a thorough investigation was completed to identify the cause of the injury to rule out abuse. Findings include: Facility policy entitled Abuse, neglect, mistreatment and misappropriation of resident property, last revised 05/22/23, stated in part, .It is the policy of this facility that reports of abuse (injuries of unknown source) are promptly and thoroughly investigated. Investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out potential abuse. The facility will immediately begin a thorough investigation, collect information that corroborates the incident, document the findings, and process the investigation. R15 was admitted on [DATE]. R15 had the following diagnoses, in part, dementia, glaucoma, depression with anxiety, bradycardia, and hypothyroidism. On 07/24/23 at 11:59 AM, Surveyor observed R15 wearing a splint on the right wrist. R15's representative indicated that R15 had broken 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 Based on interview and record review, the facility did not complete the quarterly Minimum Data Set (MDS) assessments within the required timeframe for 1 of 13 residents (R) reviewed. (R27) R27's quarterly Minimum Data Set was not completed timely. Findings include: R27 was admitted to the facility on [DATE]. On 07/25/23 at 11:18 AM, Surveyor reviewed R27's medical record. The most recent quarterly MDS assessment found on R27's medical record had an Assessment Reference Date (ARD) of 03/01/23. Surveyor was unable to find another MDS assessment completed or in process after that date on R27's medical record. This was greater than the required timeframe of every three months for quarterly MDS assessments. On 07/25/23 at 11:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D, who was responsible for completion of MDS assessments for the facility. Surveyor asked LPN D if there was an MDS assessment completed for R27 since the quarterly assessment dated [DATE]. LPN D reviewed R27's medical record and did not…

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 did not revise care plans to reflect the current transfer and repositioning status being performed for 2 of 12 sampled residents (R) (R15, R32). R15's care plan was not updated to identify how often repositioning was to occur. R32's care plan was not updated to identify the current transfer status being performed with transfers. This is evidenced by: Example 1 R15 was admitted on [DATE] with diagnoses including, in part, dementia, glaucoma, depression with anxiety, bradycardia, and hypothyroidism. Surveyor reviewed R15's care plan which, stated in part, .for prompted toileting plan: take to bathroom every two hours; for risk/fall prevention: toilet every two hours; for Risk/alteration in skin integrity: reposition in chair every hour and every two hours when in bed . On 07/26/23 at 9:30 AM, Surveyor observed nurse aide care plan located on inside of closet doors in R15's room. The nurse aide care plan stated in part, .up to three times a day in wheelchair 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, record review and interviews, the facility did not ensure that 1 of 3 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R15) R15 did not receive repositioning or toileting every two hours as care plan stated. Findings include: R15 was admitted on [DATE]. R15 had the following diagnoses, in part, dementia, glaucoma, depression with anxiety, bradycardia, and hypothyroidism. R15's nursing care plan, stated in part, for toileting plan: .take or prompt to bathroom every two hours . Intervention under falls care plan stated in part: .toilet every two hours . Intervention under risk/alteration in skin integrity care plan to prevent skin breakdown stated in part: .reposition in chair every hour and every two hours when in bed . R15's nurse aide care plan located on inside of closet door in resident's rooms stated in part, .up to three times a day in wheelchair for 1-2…

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 record review, the facility did not ensure residents received care consistent with professional standards of practice for 1 of 1 resident (R36) sampled for pressure injury (PI). The weekly wound assessment documentation did not include measurements or descriptions to show the weekly progression of R36's PIs. This is evidenced by: The Resident Assessment Instrument (RAI) manual classifies a stage 2 PI as, Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The facility's policy titled Pressure Injury Risk Assessment, states, The risk assessment should be conducted as soon as possible after admission .Repeat the risk assessment weekly for the first four weeks .The following information should be recorded in the resident's medical record utilizing facility forms: the condition of the resident's skin (i.e., the size and location of any red or tender areas), if…

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.