Willow Tree Healthcare Center

Based on observations, interviews, and record reviews, the facility did not implement proper monitoring and assessments for a resident who had close contact with another resident diagnosed with Varicella. Additionally, the facility failed to recognize and assess the potential risks to other residents due to unrestricted access to all areas of the facility by this resident. This was a random opportunity for discovery. Resident Identifier: #63 and #38. Facility Census: 98. Findings include:a) Resident #38Findings included:On 07/23/25 at approximately 10:42 AM, Resident #38 was observed under contact isolation. Record review revealed that Resident #38 had been moved out of the room she shared with Resident #63. Further record review revealed the following:A note was entered on 07/23/25 at 9:10 AM for Valacyclovir HCl Oral Tablet 1 GM. Give 1 tablet by mouth every 8 hours for shingles for 7 Days.Valacyclovir is a prescription antiviral medication used to treat infections caused by herpes simplex virus (HSV) and varicella-zoster virus (VZV).Another note on 07/23/25 at 9:58 AM stated 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, observation, and staff interview the facility failed to ensure theresident environment over which it had control was as free from accident hazards aspossible. This failed practice was a random opportunity for discovery, Resident Identifier #69Facility Census 98 Findings Include:a) Resident #69During the facility entrance interview on 07/22/25 at 1:45 PM an observation revealed a medicine cup of ointment creme was left on the bedside table. Resident #69 stated it was ointment the nurse aides left there for her to use on her bed sores. In an interview with LPN # 6 on 07/22/25, at 1:48 PM, she stated she did not know what the medicine cup of ointment was and stated it should not have been left in the resident's room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow recognized standards of care, and in addition, failed to follow the facility's own policy and procedures with regards to monitoring residents after a fall. This citation is cited at past non compliance. Resident identifier: #111. Facility Census 107. Findings include: a) Resident #111 Record review on [DATE] at approximately 11:15 AM revealed that the resident had an unwitnessed fall in his room on [DATE]. Record review revealed that the resident was found on the floor on [DATE] at around 9:15 AM. On [DATE] at 10:58 AM the Nurse Practitioner (NP) 171's notes stated the following: Per nurse, his spO2 on 2 liters NC. He was confused but redirectable. He had taken off his oxygen and it was replaced. Per staff, he was found on the floor near some wet towels. Patient stated he was getting back into bed when he fell. He knew it was 2024. He knew his name but could not say where he was located. A post fall evaluation nursing note by Registered Nurse…

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 discharge electronic medical review (EMR) and staff interviews, the facility failed to complete a safe and complete discharge. Resident #103 was discharged to a homeless shelter which did not have an available space and could not meet the medical needs of the resident. This failed practice had the potential to affect a limited number of residents. Resident #103. Facility census: 99. Findings included: a) Resident #103 A review of the discharge EMR on 07/23/24 at 10:59 AM found Resident #103 was admitted on [DATE]. Diagnoses included Diabetes Mellitus type 2 (insulin dependent), traumatic brain injury, major depressive disorder, bipolar disorder, and unspecified dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/24 had a Brief Interview of Mental Status (BIMS) score of 12. The BIMS score of 12 denotes moderate cognitive impairment. Resident #103 had capacity to make decisions. On 07/24/24 at 12:15 PM in an interview with the Nursing Home Administrator (NHA)…

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, observation, and staff interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed. A Nursing Assistant (NA) was observed to not be wearing the proper personal protective equipment (PPE) when providing direct resident care to a resident in EBP due to a wound. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 99. Findings included: a) Resident #28 The facilty's policy and standard procedure titled Enhanced Barrier Precautions, with no implementation date given, stated the required Personal Protective Equipment (PPE) was gowns and gloves. The policy also stated PPE would be donned when providing high contact care activities as described above. Resident #28 had an order written on 04/04/24 for Enhanced Barrier Precautions related to: sacral pressure ulcer. A sign was posted on the door to the resident's room indicating EBP were in effect. The sign stated as follows: Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers 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 record review, and staff interviews, the facility failed to ensure injuries of unknown origin were reported in a timely fashion. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 103. Findings included: a) Resident #1 On 03/20/24 the facility reported an incident to all required entities. According to the reportable, Resident #1 was observed to have bruising of unknown origin. According to a progress note written on 03/19/24, the resident stated that his arm got banged while being transferred into the chair for bathing on 03/18/24. He denied pain to the extremity. Resident #1 is a [AGE] year-old male on hospice with multiple diagnoses including: dementia, muscle weakness, need for assistance with personal care, lack of coordination, right sided hemiparesis with flaccidity. The resident lacks the capacity to make medical decisions. The resident was receiving aspirin 325 milligrams (MG) daily due to a history of stroke. A side effect of aspirin therapy is a risk 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 record review and staff interview, the facility failed to revise the comprehensive care plan when the resident's capacity to make medical decisions changed. This was a random opportunity for discovery. Resident identifier: #58. Facility census: 103. Findings included: a) Resident #58 Review of Resident #58's medical records showed a Physician Determination of Capacity dated [DATE] which determined the resident had the capacity to make medical decisions. Another Physician Determination of Capacity was performed on [DATE] and determined the resident lacked the capacity to make medical decisions. Resident #58's comprehensive care plan contained the following focus, Resident has a CPR code Status Ability to make health care decisions, Disease process (Focus typed as written.) The focus had been initiated on [DATE] and had not been revised since then. On [DATE] at 4:42 PM, the Administer acknowledged Resident #58's care plan needed revised to reflect the resident no longer had capacity to make medical…

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 staff interview, the facility failed to ensure that an alleged violation involving resident neglect was reported within 24 hours of the event / allegation being brought to the facility's attention, to appropriate state agencies as required. Resident identifier: #7. Facility census: 103. Findings included: a) Resident #7 During a record review it was noted there was a written statement from CNA #96, dated 10/30/23. The statement indicated that once CNA #96 had picked up all resident breakfast trays on the hall she checked on Resident #7. Approximately 20 minutes later, Resident #96's family member reported the resident had bowel movement all over her. CNA #96 reported she immediately changed Resident #7 and gave her a complete bed bath. Additionally, CNA #96 stated she reported the family member's concern to the Administrator. On 01/16/23 at 11:30 AM, review of the facility's Abuse and Neglect policy revealed that an event may not be perceived by staff to constitute resident neglect; however, if a resident, family member, or visitor perceived the event 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 staff interview, the facility failed to complete a thorough investigation of a family member's allegation of resident neglect, maintain documentation that the alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. Resident Identifier: #7. Facility Census: 103. Findings included: a) Resident #7 During a record review it was noted there was a written statement from CNA #96, dated 10/30/23. The statement indicated that once CNA #96 had picked up all resident breakfast trays on the hall she checked on Resident #7. Approximately 20 minutes later, Resident #96's family member reported the resident had bowel movement all over her. CNA #96 reported she immediately changed Resident #7 and gave her a complete bed bath. Additionally, CNA #96 stated she reported the family member's concern to the Administrator. On 01/16/23 at 11:30 AM, review of the facility's Abuse and Neglect policy revealed -The accurate and timely…

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 resident interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident receiving dialysis services. This was true for two (2) of two (2) dialysis residents reviewed for dialysis services. Resident identifiers: #92 and #21. Facility Census: 103. Findings included: a) Resident #92 Record review on 01/15/24 at 9:00 AM of the facility matrix reflects that Resident #92 receives hemodialysis services. Upon record review, on 01/15/24 at 9:10 AM, Physicians orders reflected that Resident #92 had dialysis three (3) days per week at a local dialysis center. Upon review of the care plan in place there is no care plan developed for the dialysis center name, resident chair time for dialysis or special provisions needed to provide the resident with a morning meal prior to leaving for dialysis in the focus area for dialysis. Resident #92 has the following medical diagnosis documented which includes but are not limited to: Type 2 Diabetes Mellitus with other specified complications End Stage Renal disease Chronic Kidney…

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 resident interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice pertaining to dialysis orders, care plans and pre and post dialysis communication assessments. This was true for two (2) of two (2) residents reviewed for dialysis services. Resident Identifiers: #92 and #21. Facility Census: 103 Findings included: a) Resident #92 Record review on 01/15/24 at 9:00 AM of the facility matrix reflected Resident #92 received hemodialysis services. Upon record review, on 01/15/24 at 9:10 AM, there were no physicians orders for the dialysis with the dialysis center name, chair time or provisions to provide the resident with his morning meal prior to leaving the facility for dialysis. Resident #92 went to a local dialysis center three (3) days per week. Review of Pre and Post dialysis communication assessments found missing assessments. Review of the care plan reflects missing focus information. The facility policy for Hemodialysis Care and Monitoring states: Procedure: VIII Pre-Dialysis 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 observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The medication cart was unlocked and unattended. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 103. Findings included: a) On 01/16/24 at 8:41 AM it was observed that the medication cart on the 100 Hallway was unlocked. The nurse was not at the cart. In approximately four (4) minutes she returned from the direction of the 200 Hallway. The unlocked medication cart was confirmed on 01/16/24 at 8:45 AM with Unit Manager Registered Nurse #25 who was assigned to the cart.

Based on record review and resident interview the facility failed to ensure that residents who required dialysis received services consistent with professional standards of practice. This was true for two (2) of two (2) dialysis residents reviewed for dialysis services. Resident identifiers: #92 and #21. Facility census: 103. Findings included: a) Resident #92 Record review, on 01/15/24 at 9:00 AM, of the facility matrix reflects that Resident #92 receives hemodialysis services. Upon record review, on 01/15/24 at 9:10 AM, there were no Physicians orders for the dialysis center name, chair time or provisions to provide the resident with his morning meal prior to leaving the facility for dialysis. The Minimum Data Sheet (MDS) and care plan were reviewed. The facility policy for Hemodialysis Care and Monitoring states: Procedure: VIII Pre-Dialysis a. Evaluation completed within four (4) hours of transportation to dialysis to include but not limited to: i. Accurate weight ii. Blood pressure, pulse, respirations and temperature. b. Medications administered or medication(s) withheld prior…

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 staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders for weekly weights for one (1) of three (3) residents reviewed for nutrition. The facility failed to ensure pain medications were administered in a timely manner for three (3) of three (3) residents reviewed for receiving pain medications. The facility failed to complete neurological checks after unwitnessed falls for two (2) of two (2) residents reviewed for falls. Resident identifiers: #64, #73, #8, #58, #76, and #98. Facility census: 98. Findings included: a) Resident #64 Resident #64 had an order written on 08/28/23 for weekly weights for four (4) weeks, on Mondays. The resident's last weight was documented on 09/06/23. A nursing progress note written on 09/11/23 at 2:33 PM stated, Weekly weights every day shift every Mon for 4 Weeks. Unable to be completed at this time. Will report to next charge nurse to attempt. A nursing progress note written on 09/18/23 at 3:03…

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 staff interview, the facility failed to ensure accurate and complete medical records for two (2) of two (2) residents receiving nutritional supplements. The amount of nutritional supplement consumed by the residents was not recorded. Resident identifiers: #64 and #98. Facility census: 98. Findings included: a) Resident #64 Resident #64 had an order written 08/23/23 for Ensure Plus oral liquid (nutritional supplement), give 237 milliliters (ml) by mouth three (3) times a day for weight loss. Supplement administration was documented on the resident's Medication Administration Record (MAR) but the amount of supplement consumed by the resident was not recorded. During an interview on 09/19/23 at 4:15 PM, Registered Nurse (RN) #48 confirmed the amount of Ensure Plus consumed by Resident #64 was not recorded. RN #48 acknowledged this could be useful information. b) Resident #98 On 08/23/23, Resident #98 had an order written for Ensure Plus oral liquid (nutritional supplement), give 237 milliliters (ml) by mouth three (3) times a day for nutritional support with…

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

Based on observations, staff interview and policy review the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Infection control issues were observed on two (2) of two (2) medication carts. Observation on one medication cart revealed a glucometer that had not been cleaned and was stored in a medication cart with other medications. Observations on the second medication cart revealed an insulin pen and inhaler laid directly on a resident ' s over bed table and then was also stored in a medication cart with other resident ' s medications. Resident identifiers: #53, #82. Facility census: #98. Findings included: a) Resident #53 On 09/20/23 at 8:20 AM observation was made of Registered Nurse (RN) #8 performing the fingerstick blood glucose monitoring on Resident #53. RN #8 carried the glucometer into the resident's room and placed it on the resident's nightstand. There was no clean surface between the nightstand and the glucometer. Additionally, the glucometer was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of pneumococcal vaccinations. Resident identifier: #15. Facility census: 98. Findings included: a) Resident #15 Resident #15 was a [AGE] year-old admitted [DATE]. Review of Resident #15's medical records showed the resident's representative consented for the resident to receive pneumococcal conjugate vaccine 20 (PCV20). The consent was not dated. There was no documentation the resident received PCV20 vaccination. On 09/19/23 at 10:47 A.M., the Infection Preventionist (IP) was interviewed. The IP confirmed Resident #15 had not received PCV20 vaccination. The IP stated someone else had obtained vaccination consent upon the resident's admission and she was not aware that the resident's representative had consented to pneumococcal vaccination. She…

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

Based on record review and staff interview, the facility failed to revise the care plan to remove the enhanced barrier precaution isolation focus. This was true for five (5) of thirty four (34) residents reviewed for care plans. Resident Identifiers: #199, #36, #88, #82, #63. Facility census: 98. Findings included: a) Resident #199 On 05/01/23 at 9:00 AM, an observation found that Resident #199 had an intravenous (IV) access. On 05/02/23 at 2:00 PM, record review found the care plan showed she was on enhanced barrier precautions. On 05/02/23 at 2:10 PM, during an interview with the Director of Nursing (DON) and Infection Preventionist (IP) #59 they informed the surveyor that she was not in isolation, that having an IV does not warrant isolation and the care plan was not revised. b) Resident #36 On 05/02/23 at 2:00 PM, record review found the care plan for Resident #36 showed he was on enhanced barrier precautions. The Resident has a history of open pressure wounds but they are resolved. On 05/01/23 at 2:10 PM, during an interview with the DON and IP #59 they informed the surveyor…

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, policy review, record review and staff and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was true for three (3) of three (3) Residents reviewed for the Activity Care Area during the Long Term Care Survey Process. Resident Identifier: Resident #37, Resident # 45 and Resident #53. Facility Census: 98. Findings Included: A review of a facility policy titled Activities Program with no date revealed the following. .Procedure: a. Designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs. .iii. Activities away from the facility . .x. Community activities . .f. reflect the schedules, choices and rights of the resident i. Are offered at hours convenient to the residents, including holidays and weekends . a) Resident #37 During an interview on 05/01/23 at 9:56 AM Resident # 37 stated there is nothing to do here, especially in 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 staff interview, the facility failed to follow physician orders regarding administering medication based on a pain scale for Resident #21, recording urinary catheter output for Resident #31, and administering medication on time for Resident #199. These were random opportunities for discovery. Resident identifiers: #21, #31, and #199. Facility census: 98. Findings included: a) Resident #21 On 05/01/23 at 12:15 PM, an interview was held with the resident. The resident stated, my back hurts The resident, also, stated the nurse gave me some pain medication. On 05/02/23 at 11:00 AM, the resident's medication administration record was reviewed for April, 2023. The review found the resident had two (2) physician's orders for pain based on the pain rating by the resident. The first physician's order dated 03/29/23 was Hydrocodone-Acetaminophen 5/325 mg (milligrams) every six (6) hours as needed for a pain level of seven (7) through 10. The second physician's order dated 04/12/23 was Acetaminophen 325 mg two (2) tablets as needed for mild pain one (1) through three…

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, policy review and staff interview the facility failed to ensure a resident who smoked had a current smoking assessment. In addition, the medication cart was found unlocked and unattended and hazardous chemicals were stored next to silverware, plates and cups. This was a random opportunity of discovery. Resident identifier: #82. Facility census: 98. Findings included: a) Resident #82 On 05/01/23 at 12:30 PM it was observed Resident #82 smoked. A record review found the last smoking assessment documented for Resident #82 was 10/28/22. According to the facility Resident Smoking Policy Smoking assessments for those residents requesting to smoke will be completed or re-evaluated i) on admission ii) Quarterly iii) Any change in clinical condition . There were no additional smoking assessments performed in January and April 2023. This was confirmed with the Director of Nursing on 05/02/23 at 10:27 AM. b) Medication Cart On 05/02/23 at 8:04 AM during the medication pass observed Licensed Practical Nurse (LPN) #133 fail to lock the medication cart 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 record review and staff interview, the facility failed to have competent staff to administer intravenous (IV) antibiotics. This was true for one (1) of one (1) residents reviewed for IV administration of antibiotics. Resident identifier: #199 Facility census: #98 Findings included: a) Resident #199 On 05/01/23 at 12:22 PM the Medication Review Audit Report was reviewed and compared against Licensed Practical Nurses (LPN) that have had IV administration education and training. It was found there were three (3) agency nurses that had administered the IV antibiotic for Resident #199 that have not had the appropriate education and training. On 04/10/23 at 9:00 AM LPN #135 administered the IV antibiotic. On 04/20/23 at 9:00 PM LPN #34 administered the IV antibiotic. On 04/25/23 and 04/26/23 at 9:00 AM LPN #136 administered the IV antibiotic. This was confirmed on 05/02/23 at 2:38 PM with the Director of Nursing. .

Based on facility record review and staff interview, the facility failed to complete annual performance reviews for three (3) of four (4) nurse aides reviewed. This practice has the potential to affect more than a limited number of residents. Employee identifiers: #131, #91, and #122. Facility census: 98. Findings included: a) A review of nurse aide education and personnel records was completed on 05/02/23 with the Human Resource Manager. The employee files lacked annual performance reviews for nurse aides (NA) #131, #91, and #122. Employee #131 was hired on 12/23/21. Employee #91 was hired on 02/22/22. Employee #122 was hired on 11/18/17. During an interview of 05/02/23 at 1:00 PM, the Human Resources Manager, confirmed no annual staff reviews were completed. .

Based on observations, staff interview, and record review, the facility failed to provide each resident food that was palatable. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 98. Findings included: a) Anonymous interviews During Initial tours during the LTCSP on 05/01/23 multiple Residents throughout the facility verbalized the dislike of the food that they receive from the kitchen. The verbalized concerns where the food was not palatable, and the poor quality of the food served. b) Resident Council During the Resident Council Meeting held on 05/01/23 beginning at 10:05 AM the Residents as a group were asked the question, Are you satisfied with the meals? The following concerns were voiced: -The food is terrible -It is always cold. -Breakfast was cold this morning. -My meals are always cold, it's not just one certain meal. c) Tray Temperature On 05/03/23 at 12:12 PM an observation of the dining room lunch meal found the tray cart door was left open during the tray pass. On 05/03/23 at 12:35 PM the last tray temperature was…

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

Based on observation and staff interview, the facility failed to store flat ware and glasses in accordance with professional standards for food service safety related to storage. This has the potential to affect all Residents that get their nutrition from the kitchen. Facility census: 98. Findings included: On 05/1/23 at 8:30 AM during the initial tour of the Kitchen found a mop bucket, mop heads, 2 wet floor signs, Chemical Floor Cleaner Ecolab Oasis being stored near and against a shelf that had the clean unwrapped flatware and plastic drink cups. During an interview with the Administrator (NHA) 05/1/23 at 8:33 AM confirmed the cleaning items should not be stored with clean dining wear. The NHA removed the mop bucket at this time. A review of the Safety Data Sheet for Chemical Floor Cleaner Ecolab Oasis revealed warnings: In case of eye contact: --Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Get medical attention immediately. In case of skin contact: --Wash off…

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, medical record review, staff interview and resident interview, the facility failed to ensure a complete and accurate medical record. This was true for six (6) of 34 sample residents reviewed for the Long Term Care Survey Process. Resident identifiers: Resident # 37, #74, #29, #93, #11 and #2. Facility census: 98 Findings included: a) Resident #37 During a record review on 05/01/23 at 1:37 PM Resident #37's medical record revealed a Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on 01/06/23. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement…

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 staff interview, the facility failed to ensure call lights were accessible to residents in their rooms and bathrooms. Findings were random opportunities for discovery. Resident identifiers: #148. Room numbers: 301, 303, 304, 306, 308, and 309. Facility census: 98. Findings included: a) Resident (R) #148 An observation on 05/01/23 at 9:14 AM, found R#148 sitting in the wheelchair on the left side of the bed with his right arm propped up on a pillow. The call bell was attached to the bed rail on the far side of the bed out of reach. At 9:15 AM on 05/01/23, the Director of Nursing confirmed the call light was out of R #148's reach and immediately repositioned the call light in R #148's reach. b) Call lights in Resident's bathroom During the initial tour on 05/01/23 beginning at 9:00 AM the Resident's bathroom call lights cords were not accessible if the Resident was lying on the floor in the following rooms: -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER]…

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 and staff interviews, the facility failed to assure handrail were firmly secured and affixed to the corridor walls. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing on Unit three (3). Facility census: 98 Findings included: a) Handrails During a tour on 05/02/23 at 12:40 PM this surveyor discovered on Unit three (3) the following handrails were not firmly secured and affixed to the corridor walls. -The handrail between room [ROOM NUMBER] and room [ROOM NUMBER] -The handrail between the clean linen closet and the shower room -The handrail across from the stairway exit During an interview 05/02/23 at 12:52 PM, the Maintenance Technician #111 acknowledged the rails were not secure and needed repaired. .

Based on medical record review and staff interview, the facility failed to develop comprehensive care plans that addressed residents' current medical and nursing needs. Resident (R) #149's care plan includes interventions for Enhance Barrier Precautions (EBP), which the facility is currently not practicing. R# 45's care plan fails to identify the resident's need for assistance with showers. This is true for two (2) of 34 residents reviewed during the survey process. Resident identifiers: #149 and #45. Facility census: 98. Findings include: a) Resident (R) #149 Review of the medical record on 05/02/23, revealed R# 149 was admitted to the facility after a prolonged hospitalization for treatment of respiratory failure secondary to pneumonia, bowel perforation, osteomyelitis, and wound care. The care plan dated 04/03/23, identifies an infectious disease process, including the administration of intravenous antibiotics and a peripherally inserted central catheter (PICC). Interventions include: Enhanced barrier precautions during cares. On 05/02/23 at 2:10 PM, the Director of Nursing 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, record review and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of personal hygiene. This was true for two (2) of three (3) residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifier: #59 and #45 Facility census: 98. Findings included: a) Resident #59 On 05/01/23 at 9:10 AM, an interview with Resident #59 was conducted. The resident appeared disheveled and dirty fingernails were noted. On 05/01/23 at 11:00 AM, a record review was completed for Resident #59. The record review found on the care plan the resident was supposed to bathe twice weekly with one (1) staff member's assistance due to the resident being dependent for ADL care. On 05/02/23 at 9:00 AM, a review of the bathing and shower documentation for the last 30 days from 04/04/23 through 05/02/23 was completed. The review found no documentation of showers for Resident #59. The review also found no refusals documented throughout…

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

Based on resident interview, staff interview, and medical record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regards to monitoring pain levels. This is true for two (2) of two (2) Residents reviewed for pain during the Long-Term Survey Process. Resident identifier: #89 and #62. Facility census: 98. Findings included: a) Resident #89 During an Interview on 05/01/23 at 10:44 AM Resident #89 stated that he asked for pain medication, and he is still waiting. A medical record review at this time revealed Resident #89's Physician orders for pain management: oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet orally every 4 hours as needed for pain with start date 03/21/23. A continued review of Medication Administration Record (MAR) revealed: --03/19/23 at 12:11 AM pain level 0 - Oxycodone HCI tablet given. --03/20/23 at 7:48 AM pain level 0 - Oxycodone HCI tablet given. --03/27/23 at 11:31 AM pain level 0 - Oxycodone HCI tablet given. --03/27/23 at 4:01 PM pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, staff interview and vendor interview, the facility failed to provide Residents with a safe, clean homelike environment. The facility failed to keep rodent feces out of multiple personal resident belongings, contained rooms with multiple rodent traps and failed to keep room walls in a homelike condition. These were random opportunities for discoveries. The practice had the potential to affect an unlimited number of residents. Resident identifiers: #52, #64, #60, #37, #45 and #6. Facility census: 93. Findings included: a) Resident #52 During an interview on 02/28/22 at 3:00 PM, Resident # 52 stated that there were rodent sightings daily and had to get a plastic container with lid to keep the rodents out of personal food. An observation on 02/28/22 at 3:01 PM, showed two (2) rodent trap boxes on the floor of room [ROOM NUMBER]. During an interview on 02/28/22 at 3:15 PM, Nurse Aide (NA) #88 stated that there are rodents all the time in rooms 120, 122 and 124. NA #88…

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 staff interviews, the facility failed to ensure a safe environment for residents who smoke. There was no visible fire extinguisher and an open Smoker Tower with smoldering cigarette butts. This was a random opportunity for discovery. Residents identifiers: #8, #85, #39, #2, #22, #24. Facility census: 93. Findings included: a) Observation On 03/01/22 at 2:20 PM an observation was made of six (6)residents (#8, #35, #39, #2, #22, #24)smoking outside at the front entrance of the facility. There were two (2) Smoker Towers with one (1) having the lid off with paper in the container and smoldering. The base of the container was half full of cigarette butts. There was no observable fire extinguisher. Nurse Aide (NA) #24 was asked where was the fire extinguisher. NA #24 stated that there was one on the inside of the entrance door. No fire extinguisher was found on the inside of the entrance door. Another observation was conducted with the Nursing Home Administrator (NHA) on 03/02/22 at 9:46 AM. The NHA confirmed the Smokers Tower did not have the lid in place 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, staff interview and record review, the facility failed to label and date foods, store clean dishes properly, ensure the stove and drip pan were clean and the ice machine contained a black and pink substance on the inside lip. This failed practice had the potential to affect all residents who receive nutrients from the kitchen and pantries. Facility Census 93. Findings included; a) Labeling and Dating On 02/28/22 at 10:00 AM, the initial tour of the kitchen with the Culinary Director (CD) #1 found in the walk in refrigerators in kitchen and in the pantry refrigerators, items not labeled or dated as follows: ~water pitcher ~large container of lemonade ~ one (1) gallon of ice tea ~one (1) package of cheese not covered not labeled or dated ~one (1) package of bologna open and not covered, labeled or dated ~seven (7) frozen entrees in pantry on 300 Hall with no name or date CD #1 immediately took care of items not label and dated. b) Storage of dishes On 02/28/22 at 10:10 AM, during initial tour with the CD #1 found 48 drinking glasses stacked one on top 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 observation, medical record review, facility documentation review and staff interview, the facility failed to post signage on a door of a room on transmission based precautions (TBP). Staff failed to properly don personal protective equipment (PPE) upon entering rooms on TBP and did not utilize hand sanitize between medication passes. The infection control policies were not current. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #286, #192 and #188. Facility census: 93. Findings included: Record review of the facility's policy titled Standard Precautions and Transmission Based Precautions, reviewed on 06/25/21, showed that droplet precaution rooms staff would utilize the proper PPE's upon entering the room or cubical area including gloves, mask, and eye protection. A N95 mask, face shield, gown and gloves are required when caring for a resident with suspected Covid-19. a) Resident #286 An observation 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, resident interview, staff interview and vendor interview, the facility failed to ensure an environment for residents that was free of rodents. These were random opportunities for discoveries. The practice had the potential to affect more than a limited number of residents. Resident identifiers: #52, #64, #60, #73, #45 and #53. Facility census: 93. Findings included: a) Resident #52 During an interview on 02/28/22 at 3:00 PM, Resident # 52 stated that there were rodent sightings daily and had to get a plastic container with a lid to keep the rodents out of personal food. An observation on 02/28/22 at 3:01 PM, showed two (2) rodent trap boxes on the floor of room [ROOM NUMBER]. During an interview on 02/28/22 at 3:15 PM, Nurse Aide (NA) #88 stated that there are rodents all the time in rooms 120, 122 and 124. NA #88 stated that the rodents come out all the time but more at night. During an interview on 03/01/22 at 10:30 AM, Owner of American Pest Control was present in the facility. 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, resident representative interview, and staff interview, the facility failed to honor a resident's preference for no meat other than chicken. This was a random opportunity for discovery. Resident identifier: #6. Facility Census: 93. Findings included: a) Resident #6 During an interview on 02/28/22 at 2:56 PM, Resident #6's legal guardian/family member stated, We are mostly vegetarians. We only eat chicken. [Resident's First Name] should not receive pork, sausage, or beef. She can have chicken. Today she was supposed to have cheese ravioli but the kitchen sent beef instead. Resident #6's legal guardian/family member added, This isn't the first time they have sent meat other than chicken. A brief record review, completed on 02/28/22 at 3:10 PM, found the following dietary order, Regular diet, Dysphagia Ground texture, Thin consistency, 1:1 assist, NO BREAD / BEEF / PORK / ICE CREAM / CHOCOLATE, double portion veggies, thin liquid in 5cc sips via syringe if unable to contain cup sips (no straws unless used as pipette only). During an interview on 02/28/22 at 3:15…

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 staff interview, the facility failed to ensure two (2) of 22 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: Resident #6 and Resident #65. Facility census: 93. Findings included: a) Resident #6 A medical record review, completed on 02/28/22 at 2:43 PM, found the following: - A Physician Determination of Capacity, dated 08/29/21, indicating Resident #6 lacked capacity to make medical decisions. - Court Appointed Guardianship paperwork, dated 12/18/20, indicating Resident #6's family member was the legal decision-maker. - POST form, dated 08/27/21, 2017 edition. Section C of the POST form, entitled Medically Administered Fluids and Nutrition, directed Resident #6 should have IV (intravenous) fluids for a trial period of no longer than ______. The specified time-period was left blank and was 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.

Based on record review and staff interview the facility failed to report in a timely manner and not to appropriate agencies. This was a random opportunity for discovery. Resident identifier- #47. Facility Census 93 Findings included; a) Resident #47 On 02/28/22 at 1:31 PM, when review of resident # 47 reportable of fall with major injury, found reportable to show that the fall occurred on 2/03/2022 and reportable was not completed and faxed until 2/09/22. Resident had a fracture of the C6 (spinal cord injury) and fax conformation sheet was only faxed to Office of Health Facilities and Certification (OHFLAC). Interview with the Administrator on 3/1/22 at 10:50 AM, asking what agencies was reportable faxed to. The Administrator stated, only to OHFLAC because there were no issue of abuse so Adult Protective Services (APS) was not notified. .

treatment and care in accordance with professional standards of practice. The facility failed to ensure a dietary order was followed for Resident #6. This failed practice was true for one (1) of 22 residents reviewed in the long-term care survey process . Resident Identifier: #6. Facility Census: 93. a) Physician Order A brief record review, completed on 02/28/22 at 3:10 PM, found the following dietary order, Regular diet, Dysphagia Ground texture, Thin consistency, 1:1 assist, NO BREAD / BEEF / PORK / ICE CREAM / CHOCOLATE, double portion veggies, thin liquid in 5cc sips via syringe if unable to contain cup sips (no straws unless used as pipette only). Additionally, there was an order directing ENCOURAGE PT. TO DRINK EXTRA 100ML OF H20 EVERY MED PASS. DO NOT USE STYROFOAM CUP, USE HARD CUP. (DUE TO PT. CHEWING). b) Observation During an observation in Resident #6's room on 03/01/21 at 12:10 PM, it was noted there was a Styrofoam cup of water with a straw present on Resident #6's over-the-bed tray table. 03/01/22 at 12:30 PM, LPN #70 confirmed the Styrofoam cup with straw was…

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

Based on facility documentation, record review and staff interview, the facility failed to provide assessments of the resident's condition and monitoring for complications before dialysis treatments. This was true for one (1) of two (2) residents reviewed for dialysis. Resident identifier: #189. Facility census: 93. Finding included: A record review of the facility's policy titled Hemodialysis Care and Monitoring, revised on 06/24/21, showed a pre-dialysis evaluation should be completed within four (4) hours before transport to dialysis treatment to include an accurate weight, blood pressures, pulse, respirations and temperature. a) Resident #189 Review of Resident #189's medical record showed progress notes that stated Resident #189 went out of the facility on 02/25/22 and 02/28/22. The medical record did not show any pre-dialysis evaluation or assessment prior to transport taking Resident #189 to dialysis treatment. During an interview on 03/01/22 at 12:10 PM, Licensed Practical Nurse (LPN) #41 stated that when a Resident goes out to dialysis the pre-dialysis assessment should be…

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, staff interview, and policy review, the pharmacist failed to identify irregularities for medication in excessive does related to acetaminophen. This was true for one (1) of six (6) reviewed for unnecessary medications. Resident identifier #73. Facility census: 93. Findings included: Record review of the facility's policy titled, Medication Regimen Review, with a revision date 09/23/19 showed: -- Unnecessary Drug: any drug when used in excessive dose. -- Irregularity includes, but not limited to any drug meets the definition of unnecessary drug. --The pharmacist will report any irregularities to the attending physician, the facility's medical director and director of nursing. a) Resident #73 A medical record review for Resident #73 found, Physician orders as follows: --Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for breakthrough pain not to exceed 3 Grams (gm)/24 hours (Alert: Resident already receiving scheduled Tylenol twice daily (BID) with start date of 08/15/21. --Tylenol Tablet 325 MG (Acetaminophen) Tylenol…

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, staff interview, and policy review, the facility failed to ensure resident #73 was free from unnecessary medications. This was true for one (1) of six (6) reviewed for unnecessary medications. Resident identifier #73. Facility census: 93. Finding included: A record review of the facility's policy titled, Medication Regimen Review, with a revision date of 09/23/19 showed the Director of Nursing or designee will be responsible for addressing all medication irregularity reports the attending physicians in a manner that meets the needs of the resident. a) Resident #73 A medical record review for Resident #73 found, a physician order as follows: --Singulair Tablet 10 MG (Montelukast Sodium) Give 10 mg tablet by mouth at bedtime for allergies with an order date of 04/25/21. Continued record review revealed a pharmacist recommendation made on 10/15/21 Singulair for allergies, it is noted that she is on Zoloft for depression. Singulair can cause mood changes, depression, and other mood disorders. Physician prescriber response on 10/20/21: Make Singulair as needed…

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.