Dove Healthcare - Spooner

Based on record review and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 50 residents who reside in the facility. This is evidenced by: On 05/22/24 at 9:30 AM, Surveyor completed a record review for the month of May related to daily staff postings and noticed there were certain weekends where RN coverage hours were less than 8 hours. The dates of 05/04/24, 05/05/24, 05/18/24, and 05/19/24 all showed less than 8 hours of RN coverage. On 05/22/24 at 9:45 AM, Surveyor completed a record review of the time punches for the days of 05/04/24, 05/05/24, 05/18/24, and 05/19/24 and confirmed there were less than eight hours of coverage on those days. -On 05/04/24, only 4.5 hours were covered by a Registered Nurse. -On 05/05/24, only 4.5 hours were covered by a Registered Nurse. -On 05/18/24, only 4.5 hours were covered by a Registered Nurse. -On 05/19/24, there was no coverage from a Registered Nurse. On 05/22/24 at 1:25 PM, Surveyor interviewed Director of Nursing (DON) B…

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 record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect 48 of 50 residents within the facility that took nourishment from the kitchen. Opened milk in the refrigerator not labeled with open date. Staff touching ready to eat foods with contaminated gloves during food service. Staff did not perform hand hygiene between glove changes during food service. Findings: Milk not labeled: Facility policy titled, Infection Control, Sanitation, Safety the most current revision, states in part: .E. Storage Refrigerators/Freezers .7. Food must be covered and dated when stored . 10. Commercial products must be labeled as to date of initial opening and will be discarded per manufacturer's expiration date. On 05/20/24 at 9:06 AM, during initial tour of the kitchen, Surveyor noted that a gallon of milk did not have a date opened written on the container. Surveyor interviewed Dietary Manager (DM) L and asked, What date was this opened? DM L took…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 49 residents (R). The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. Staff provided high-contact care to residents on Enhanced Barrier Precautions (EBP) without wearing proper Personal Protective Equipment (PPE). (R32 and R17). The facility is not tracking the type of symptoms for all staff and resident infections. The facility is not providing alternative testing to rule out influenza or RSV cases when residents and staff become sick. Findings include: Facility policy and procedure entitled: Enhanced Barrier Precautions, dated 04/01/24, stated in part, Enhanced barrier precautions (EBPs) are utilized 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 record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 5 of 8 staff reviewed. This had the potential to affect all residents. Findings include: Facility policy and procedure entitled, Abuse Prohibition, last revised 11/28/16, stated in part, .Once an offer of employment has been made, the facility will submit a request to obtain a criminal history from the Department of Justice (DOJ). An electronic search will be conducted by the Department of Health and Family Services (DHFS) to check on the prospective employee's status in the following areas: the Nurse Aide Directory, Caregiver Finding of Abuse or Neglect of a client; or Misappropriation of a Client's Property, Denials or Revocations of Operating Licenses for Adult Programs, and any Rehabilitation Review Findings. In addition the Department of Regulation and Licensing (DRL) will also conduct an electronic search as to the status of Professional…

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 treat each resident with respect and dignity and care for each resident in a manner that promotes his quality of life. Resident (R43) was not provided privacy when lying in bed not fully clothed and covered while being visible from the hallway. For 1 of 13 sampled residents (R43). Findings include: R43 was admitted to the facility on [DATE] following a stroke. R43 was not able to speak but was able to nod head to yes and no questions. R43 had hemiplegia (paralysis) and hemiparesis (weakness) on the right side of the body following the stroke and was dependent on staff for all cares. R43's most recent Minimum Data Set (MDS) assessment, dated 4/23/24, identified R43 showed signs of mild depression with a PHQ-9 (depression scale) score of 09. On 05/20/24 at 11:03 AM, Surveyor observed R43 lying in bed in resident room. R43 was completely uncovered and only wearing an incontinent brief. The door to the room was open with no privacy curtain…

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, observation and interview, the facility did not implement a comprehensive individualized safety care plan to meet the needs of 1 of 14 residents (R). R34. This is evidenced by: R34 was admitted to the facility on [DATE] with diagnoses that included in part Alzheimer's disease, dementia, and cognitive communication deficit. On 03/24/24, a male resident was found in R34's room with his pants down urinating. One of the interventions from this incident was a stop sign barrier added to R34's entrance to her room to help prevent other residents from wandering into R34's room. R34's care plan, dated 03/24/24, with a target date of 05/29/24, states: .[R34] has a stop sign rope across doorway in room. Stop sign will prevent others from entering her room due to wondering behaviors. Intervention: Have stop sign on [R34]'s door if she is in her room at night while sleeping . R34's progress note on 03/30/24 stated, [R34] expressed concern about men going into her room. Nurse reassured resident that we…

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 toileting care plan for 1 of 14 sampled residents, Resident (R)7. This is evidenced by: The facility policy, entitled Incontinence, Catheters, & Urinary Tract Infections, last reviewed in January 2017, states in part: 7. The following items may be addressed in the care plan according to individualized resident needs: . interventions specific enough to guide the provision of services and treatment that are also dependent on resident choices and preference. R7 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified osteoarthritis, unspecified site, anxiety disorder, unspecified, pain in unspecified hip, and constipation, unspecified. R7's Minimum Data Set (MDS) assessment, dated 03/21/24, indicated that resident is always incontinent of bowel and bladder. On 05/20/24 at 10:42 AM, Surveyor observed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure activities of daily living (ADLs) of meal set-up, repositioning, and incontinence cares were provided for 1 of 15 residents (R21) reviewed. This is evidenced by: R21 was admitted to the facility on [DATE], with diagnoses including alcohol induced persisting dementia, malignant neoplasm of esophagus, Wernicke's encephalopathy, aphasia following cerebral infarction, and depressive disorder. R21's minimum data set (MDS) assessment, completed on 04/04/24, confirmed R21 is incontinent of urine and frequently incontinent of bowels. R21 requires supervision assistance with eating. R21 is dependent on staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R21's care plan was initiated on 03/28/24, and included the following: BED MOBILITY: -The resident requires assist of one staff to turn and reposition in bed. -Turn/reposition as needed. EATING: -Supervision/Set-up.…

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 a resident received adequate supervision and assistance to prevent falls and injury. This occurred for 1 of 3 residents (R) reviewed for falls, (R40). The facility was not following the intervention of utilizing a pressure alarm that was set in place to prevent further falls for R40. This is evidenced by: R40 was admitted to the facility on [DATE] with diagnoses that included in part unspecified mood disorder, cognitive communication deficit, illiteracy and low level literacy, major depressive disorder, and insomnia. R40's care plan, dated 12/06/23, states: .[R40] is a risk for falls due to impaired balance, poor safety awareness, impulsiveness, and history of falling .Intervention: Pressure alarm for bed and chair . R40's fall risk assessment, completed on 12/06/23, showed moderate fall risk. 01/12/24 and 03/07/24 fall risk assessments showed R40 was a high fall risk. R40 fell at the facility on 12/28/23, 01/11/24, 01/17/24, 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 observation, interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter. This occurred for 2 of 4 residents reviewed for urinary catheters. (R43 and R29). R43 was recently hospitalized with UTI and sepsis. Surveyor observed staff perform improper catheter care and did not use proper infection control practices for R43's catheter care. R29's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. Findings include: Facility policy and procedure entitled, Perineal Care, last revised February 2018, stated in part, .For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents (R) who are fed by enteral means receive the appropriate treatment and services of tube placement and storage of supplies to prevent complications of enteral feeding. This occurred for 2 of 2 residents observed for tube feedings. (R32 and R43). This is evidenced by: R32 was admitted to the facility on [DATE] with diagnoses including in part, type 1 diabetes mellitus with diabetic chronic kidney disease and ketoacidosis without coma, metabolic encephalopathy, chronic kidney disease stage 4, vascular dementia unspecified severity with agitation, paroxysmal atrial fibrillation, gastrostomy status, and dysphagia oropharyngeal phase following cerebral infarction. R32's minimum data set (MDS) assessment, completed on 01/29/24, confirmed R32 scored 11/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R32 has an activated power of attorney for healthcare decisions. R32 is dependent on…

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

Based on observation, interview, and record review, the facility did not have an effective Infection Prevention and Control Program to prevent the spread of COVID 19, hand hygiene was not performed appropriately for 2 of 2 residents observed for cares. The infection control surveillance was not accurate. There was no documentation of R40 being put on isolation, or on the line list accurately when symptoms started. Staff and resident line lists are not complete. Staff were not washing hands properly while providing cares for R21. R102 was provided morning bathing cares in which staff did not conduct hand hygiene when moving from a dirty task to a clean task. This is evidenced by: Example 1 Surveyor reviewed the facility policy titled, Surveillance for Infections. This policy is dated 2017. Under Collection and Recording it stated: For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: e. Pathogens g. Pertinent remarks, additional relevant information i.e., temperatures, other symptoms of specific…

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 and interview, the facility did not ensure residents (R) had the right to choose schedules consistent with their interests, for 5 of 5 residents (R4, R17, R21, R23, and R151). Facility developed a schedule for care, for staff convenience and without resident considering resident preference. Residents are placed at the medication cart to receive medications. Residents waited for nursing staff to administer medication, after receiving medication waited for staff to assist them to the dining room for breakfast. Residents waited approximately 50 minutes at medication cart. This is evidenced by: R4 has diagnoses of severe visual impairment and Type 2 Diabetes Mellitus with insulin dependence. Minimum Data Set (MDS), dated [DATE], R4 scored 5/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R4 requires total dependence for wheelchair locomotion. R17 has a diagnosis of dementia. MDS, dated [DATE], R17 scored 13/15 during BIMS, indicating intact cognition,…

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, interviews and record reviews, the facility did not complete care plan revisions for 6 of 13 residents (R) sampled. R5's care plan and orders were not updated to reflect the current dose of O2 and were not specific to how often it should be used. R21's care plan was not updated with information to use a washcloth in the right contracted hand. Facility did not complete assessment, monitoring, or update care plan for prescribing of Melatonin for R6. Facility did not update care plan to reflect R15's wanderguard. Facility did not update R3's care plan to reflect current and individualized activities. This is evidenced by: Example 1 R5 was admitted to the facility on [DATE]. R5 receives oxygen therapy due to a diagnosis of Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. On 4/10/23, 4/11/23 and 4/12/23, Surveyor observed R5 in their room sitting in recliner. R5 had on oxygen (O2) delivered via a nasal cannula. It was set to deliver 3L per minute. On 4/11/23,…

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 reviews, the facility did not provide an ongoing, individualized, and meaningful program to support the residents in their choice of activities, which was designed to meet their interests and support their physical, mental, and psychosocial well-being. This affected 4 of 4 residents (R3, R6, R15, and R40) reviewed for activity participation. Facility did not complete, implement, or revise activity assessments to obtain individualized preferences and interventions. This is evidenced by: Example 1 R3 was admitted to facility on 4/26/17. Diagnoses include Alzheimer's disease, dementia with agitation, osteoarthritis, history of falling, and pain. Minimum Data Set (MDS) MDS, dated [DATE], R3 scored 2/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Most recent annual MDS completed 1/22/22 confirmed that R3 reported, 'Very Important,' to do favorite activities. Physician orders indicate R3 takes anti-depressant medications. R3 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.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 1 Medication Technicians (MT E), completed appropriate competency to administer insulin. During the Medication Administration task, Surveyor observed MT E administer insulin to R41 (Resident). Upon review, the facility was unable to provide evidence that MT E completed the appropriate training and competency to administer insulin under the supervision of a registered nurse. This is evidenced by: On 04/12/23, Surveyor was observing medication administration. MT E administered 8 units of Insulin Novolin N to the right abdomen of R41 at 7:29 AM utilizing the correct technique. At 9:45 AM, Surveyor interviewed MT E on the procedure for insulin administration. MT E was able to verbalize the correct technique. At 9:55 AM, Surveyor requested from NHA A (Nursing Home Administrator) and DON B (Director of Nursing) the training and competency evaluation that was provided to MT E in order for her to complete this delegated nursing task. At 10:20 AM, NHA A provided Surveyor with the Certified Nursing…

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 provide the services necessary to maintain ROM (range of motion) for 1 of 1 resident (R) reviewed. (R21) R21's plan of care states under category Pressure ulcer that R21 should be wearing a palm protector at all times as he allows. Remove only for daily cleaning and PROM (Passive range of motion). To encourage physical activity, mobility, and ROM to maximal potential. This is evidenced by: R21 was a [AGE] year old admitted to the facility on [DATE]. R21 had a DX of Hemiplegia and hemiparesis following a CVA (stroke), Alzheimer's disease, Dementia. R21 stroke affected the right side of the body resulting in a contracture to the right hand. On 4/11/23 at 7:00AM, Surveyor observed CNA F doing cares with R21. CNA F washed R21's right hand on the outside, briefly attempted to open the right hand but his contracture is tight so CNA F stated she would ask the nurse to help open the hand so it could be washed. There was no attempt to apply a…

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

Based on interviews and record reviews, the facility did not provide services and treatment to restore or improve as much bladder function to the extent possible for 1 of 1 residents (R29) reviewed for bladder function. R29 (Resident) was admitted to the facility with an Indwelling Foley catheter following a Cerebrovascular Accident (CVA) affecting the left non-dominant side. The catheter has since been removed and the facility did not complete a comprehensive bladder assessment to assist R29 to improve or restore as much bladder function as possible. This is evidenced by: R29 was admitted to the facility 1/26/23 from another facility in which he resided for a short time following a stroke (CVA) with Hemiplegia and Hemiparesis that affected his left (non-dominant) side of the body. Other medical diagnoses include, but are not limited to Type 2 Diabetes Mellitus with other diabetic neurological complications, Chronic Kidney Disease, stage 2 (mild), Urinary Tract Infection and Depression. The admission Minimum Data Set Assessment completed for R29 was dated 2/3/23. According to this…

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 provide respiratory services in a manner consistent with professional standards of care for 1 of 1 residents reviewed for respiratory care. Oxygen (O2) was being delivered to R5 at a rate higher than what was ordered by the physician. There was no documentation or evidence that the tubing was being changed. This was evidenced by: R5 was admitted to the facility on [DATE]. R5 was [AGE] years old with diagnosis of Acute Heart Failure, Chronic Respiratory failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea among others. R5 was an interviewable resident. On 4/10/22 at 10:00 am, Surveyor observed R5 in his recliner with O2 on per nasal cannula at 3L per min. Surveyor observed that the O2 tubing had no date on it indicating the last time it was changed. On 4/11/23, Surveyor observed R5 in his recliner, O2 was running at 3L per minute. There was no date on the O2 tubing indicating when it was last changed. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not ensure that residents (R) were free from unnecessary medication for 2 (R48 and R15) of 5 Residents. Facility did not ensure that as needed orders (PRN) for psychotropic drugs are limited to 14 days unless documented rationale is indicated and avoid duplicate therapy of same pharmacological class for R48. Facility did not implement non-pharmacological interventions, indicate rationale for continued and duplicate use for R15's psychotropic medications. This is evidenced by: Example 1: The facility policy for Psychotropic Medication Use states, in part .2. psychotropic medications are subject to prescribing, monitoring, and review requirements specific to psychotropic medications .12(a) PRN orders for psychotropic medications are limited to 14 days .12(a)(1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believe it is appropriate to extend the PRN order beyond 14 days, he or she will document…

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 did not ensure an intermediate-acting insulin administration was given timely within meal or beverage service for 1 of 2 residents (R41) observed for insulin administration. During the Medication Administration task, Surveyor observed MT E (Medication Technician) administer Insulin N, an intermediate-acting insulin to R41 (Resident). Beverages or meals were not served within the allotted time frame of onset of effects of the insulin. This is evidenced by: Medscape. com states the following in relation to Novolin N insulin: - Novolin N is a combination medicine of Insulin isophane, an intermediate-acting insulin and Regular, a short-acting insulin. This combination insulin starts to work within 10 to 20 minutes after injection, peaks in 2 hours, and keeps working for up to 24 hours. - Novolin N should be administered within 15 minutes before a meal or immediately after a meal. On 4/12/23 at 7:29 AM, Surveyor observed MT E administer 8 units of Insulin Humulin N to the right abdomen of R41. The meal trays arrived on the…

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

Based on record review and interview, the facility did not ensure that each resident eligible for influenza or pneumococcal vaccine was offered it to prevent pneumonia and influenza. This was discovered for 2 of 5 residents reviewed for immunizations. R5 and R9 did not have declinations on file, nor was there a progress note stating that these residents refused the vaccine and were educated on the importance of being immunized. This is evidenced by: On 4/12/23, Surveyor reviewed the resident vaccination matrix. Those that refused the vaccine for COVID 19 were included in the sample of 5. It was noted that R9 had refused the pneumococcal vaccine and the influenza vaccine. It was noted that R5's last influenza vaccine was 9/27/21. There was no information on the 2022 influenza vaccination. On 4/12/23, Surveyor requested the declinations for the refusals of vaccine, and requested copies of the progress notes for R9 and R5 indicating that they had refused and were educated on the vaccines. On 4/12/23, DON reported to the Surveyor that there were no declinations available and that there…

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

Based on record review and interview, the facility did not ensure that the medical record included documentation that the Resident or Resident Representative were educated on the risks and benefits of the COVID 19 vaccine for 3 of 5 residents reviewed for immunization. R5, R9, and R6 did not have documentation of having declined or been educated on the COVID 19 vaccine. This was evidenced by: On 4/12/23, Surveyor reviewed the resident vaccination matrix. Per the infection control task instructions 5 residents were chosen for review of Immunizations. Those that refused the vaccine for COVID 19 were included in the sample of 5. It was noted that R5, R6, and R9 had refused the COVID 19 vaccine. On 4/12/23, Surveyor requested the declinations for the refusals of vaccine, and requested copies of the progress notes for R9, R6, and R5 indicating that they had refused and were educated on the covid vaccines. On 4/12/23, DON B reported to the Surveyor that there were no declinations available and that there were also no progress notes found indicating that the residents in question had been…

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.