Complete Care At Dawnview LLC

Based on record review and staff interview, the facility failed to revise the care plan regarding a diagnosis of anemia, actual multiple falls with injuries, indicate the diagnosis of dehydration and the administration of intravenous fluids (IVFs), and the discontinuation of an anticoagulant for Resident #28 and Resident #18's transfer to hospice services. This was true for two (2) of 21 residents reviewed during the survey process. Resident Identifiers: #28 and #18. Facility Census: 59. Findings included: a) Resident #28 On 11/05/24 at 8:45 AM, a record review was completed for Resident #28. The review found the resident had multiple falls with actual injuries noted, laboratory results indicating elevated liver functions indicating dehydration as well as low hemocrit and hemoglobin, and the discontinuation of an anticoagulant due to the resident having multiple falls. The care plan was reviewed regarding the noted change of conditions which were found the resident record. The care did not have an indication of actual falls with injuries, abnormal laboratory results indicating…

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 provide an accident and hazard free environment as possible by having a treatment cart which would not lock properly on three occasions. These were random opportunities for discovery. Facility Census: 59. Findings Include: a) Treatment Cart On 11/04/24 at 11:40 AM, a treatment cart was observed unlocked behind the nurses' station which was unsecured and residents are able to ambulate in this area. On 11/04/24 at 11:43 AM, the Director of Nursing (DON) was notified of the treatment cart being unlocked and accessible to the residents. The DON stated, the lock is not working .I'll call Maintanence. At this time, the treatment cart was left in the same area behind the nurses' station. On 11/04/24 at 3:15 PM, the treatment cart was observed unlocked behind the nurses' station. At this time, observations of the unlocked treatment cart continued until 3:30 PM. No staff were observed near the unlocked treatment cart during this time. The Administrator was notified and stated, We have contacted the pharmacy and they are coming…

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 store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 59. Findings included: a) A bag of elbow macaroni was found open with no dates. A bag of loose tea bags was opened with no dates. One tea bag was found loose and lying out of the bag. On 11/05/25 the Nutrition Pantry was investigated and the findings confirmed by the CDM at 9:07am included: A can of ground roast coffee with a best by date of 02/29/24 was found. No open date was found on the can. The can was rusty and dirty on the bottom. The CDM reported it was, not stocked from the kitchen. CDM to follow up with the administrator. Findings confirmed by the Certified Dietary Manager (CDM) on 11/04/24 during the kitchen investigation initiated at 10:35 am included.

Based on record review and staff interview, the facility failed to thoroughly investigate allegations of abuse and neglect, by failing to have witness statements signed by witnesses an alleged incident involving Resident #11, and failing to complete witness statements, and notify the police regarding an allegation of misappropriation of funds for Resident #38. This was true for two (2) of four (4) residents reviewed for abuse and neglect during the survey process. Resident identifiers: 11, 38. Facility census: 59 Findings include: A) Resident #11 At approximately 3:30 PM on 11/05/2024, a review was conducted of a facility reported incident concerning Resident #11 on 10/07/2024. During the review, it was noted the administrator of the facility had conducted interviews with four (4) employees regarding the incident. These interviews were typed and signed only by the administrator, with no indication of employee acknowledgement. At approximately 1:00 PM on 11/06/2024 an interview was conducted with the administrator. During the interview, the administrator stated these interviews were…

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 upon admission to identify a mental diagnosis for Resident #36 and related diagnoses of dementia and PTSD for Resident #42 on the PASARR. This was true for two (2) of three (3) resident's reviewed under the area of PASARR. Resident identifiers: #42 and #36. Facility Census: 59 Findings included: a) Resident #42 Findings were confirmed by the Social Worker and the Admission's Director on 11/06/24 12:55 PM for Resident #42 included: 1) Diagnoses for PTSD and Dementia were not indicated on the initial PASARR. Diagnosis of dementia from the hospital H&P dated 5/11/22 listed PMH: Dementia 11/2021. 2) The State Surveyor interviewed the Social Worker concerning PASARR for Resident #42 .The Social Worker reported she does not have access to the attached order summary since they had changed companies. The Social Worker stated there was no access to Genesis to attach the diagnosis list. The Social Worker stated, We will have to redo all the summaries. The Social Worker stated, I don't redo them when they get there. (from 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 record review and staff interview, the facility failed to follow the proper procedures to appoint a healthcare surrogate for Resident # 35. This was true for one (1) of four (4) residents reviewed for advance directives during the survey process. Resident Identifier: 35. Facility census: 59. Findings include: A) Resident #35 At approximately 2:30 PM on [DATE], a review of Resident #35's electronic health record was reviewed. During this review, it was noted the resident had a Physician Orders for Scope of Treatment (POST) form on file, signed by someone that was not named as her healthcare surrogate. Resident #35 was admitted to the facility on [DATE] after a hospital stay. During her hospital stay, the hospital determined Resident #35 did not have capacity to make decisions on her own due to an Acute Cerebrovascular Accident, resulting in confusion and disorientation. The duration of incapacity was determined to be long term. Due to Resident #35 demonstrating incapacity to make informed choices, 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 maintain an accurate and complete record regarding transfer dates for Resident #28 and #36. This was true for two (2) of two (2) residents reviewed under the care area of hospitalizations. Resident identifiers: #28 and #36. Facility census: 59. Findings include: a) Resident #28 On 11/05/24 at 10:10 AM, a record review was completed for Resident #28. The review found the resident had been sent to an acute care facility on 08/11/24. However, the transfer form was dated 06/29/24. On 11/05/24 at 11:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the transfer date was incorrect in the medical record. b) Resident #36 On 11/05/24 at 11:00 AM, a record review was completed for Resident #36. The review found the resident had been sent to an acute care facility on 10/04/24. However, the date on the transfer form was 09/04/24. The review, also, found the resident had been sent to an acute care facility on 10/27/24. However, the date on the transfer form was 10/04/24. On 11/05/24 at 11:30 AM, the Director 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 record review, observations and staff interviews, the facility failed to ensure a resident maintained a continuous oxygen supply. Resident #50 failed to receive oxygen therapy from a portable tank and oxygen concentrator for approximately 20 minutes. This failed practice had the potential to affect all residents receiving oxygen therapy. Resident identifier: #50. Facility census: 49. Findings included: a) Resident #50 Resident #50 was admitted on [DATE]. Diagnoses included Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Lung Disease, Hypertension, End Stage Renal Disease, Stage 4, and Respiratory failure. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/23 had a Brief Interview of Mental Status (BIMS) score of 13. This represents the resident is cognitively intact. An addition quarterly MDS with an ARD of 01/19/24 had a BIMS score of 10 which indicated a decline in cognition. Resident #50 is currently in an acute care hospital and returned to 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 observation, record review, and staff interview, the facilty failed to ensure pharmaceutical services were provided to ensure routine medications were available to administer to residents in accordance with physician orders. This was true for three (3) of five (5) residents observed during the Medication Observation task of the LTCSP. Resident identifiers: Resident #5, Resident #39, and Resident #48. Census: 56 Findings included: a) Resident #5 A review of the physicians orders, for Resident #5, showed a current medication order for Bupropion ER (extended release) tablet with direction to administer 200 mg (milligram) every 12 hours. An observation, during the Medication Administration Observation task for the LTCSP, on 01/04/23 at 08:16 AM, Licensed Practical Nurse (LPN) #14, prepared medications to administer to Resident #5. The medication, Bupropion ER, was not found in the medication cart by LPN #14. When questioned, LPN #14, stated the medication was not available in the medication cart for the morning medication pass. LPN #14 also stated , after checking, 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.

b) Resident (R) #48 During an observation of medication administration on 01/04/23 at 08:10 AM, Quetiapine (Seroquel) 150 milligrams (mg) an atypical antipsychotic med used for treatment of schizophrenia and major depressive disorders was not available to be given To R#48 as scheduled. Registered Nurse (RN) #62 reported pharmacy delivers nightly and acknowledged the Seroquel was not refilled and available to be given to R#48 as prescribed. Random observations on 01/03/23 at 09:33 AM and 01/04/23 at 8:30 AM, found R#48 sitting up in her bed and crying. On 01/04/23 at 2:45 PM, the Activities Director (AD) #54 reported R #48 has intermittent crying episodes that usually last one to two days. Review of the medical record on 01/04/23, revealed R #48 was admitted to the facility with a diagnosis of Non-Alzheimer's dementia. Her current diagnoses include unspecified dementia, moderate with agitation, unspecified dementia, moderate, with psychotic disturbance, unspecified dementia, moderate with mood disturbance, and adjustment disorder with depressed mood. The current medications include…

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.

e) Personal Protective Equipment disposal containers 1) Resident #2 An observation , on 01/03/23 at 03:41 PM , revealed Resident #2 was in isolation precautions related to an infection which required staff to use PPE when caring for the resident. Further observation of the room, revealed there was no appropriate trash receptacle in place. The trash bin in the room, had no hands free lid which forced staff to come into contact with the lid prior to and/or after disposing of soiled items. 2) Resident #104 An observation, on 01/03/23 at 01:50 PM, revealed Resident #104 was in isolation precautions related to an infection which required staff to use PPE when caring for the resident. Further observation of the room, revealed the trash receptacle in place was not in good repair. the container lid was broken and could not be hinged and there was no foot pedal to assure hands free use. An interview, with the Director of Nursing (DON), on 01/04/23 at 11:20 AM , verified both the isolation trash receptacles, used in Resident #2's and Resident #104's isolation rooms, did not have hands free…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, staff interview, the facility failed to ensure residents' side rails were maintained in accordance with manufacturer's recommendation as evidenced by the use of zip ties to secure side rails. This was a random opportunity for discovery and found to be true during an observation of room [ROOM NUMBER]. This deficient practice had the potential to affect more than a limited number of residents. Census: 56. Findings included: A review of Policy CCG00540, pertaining to: Right to be Free from Restraints Policy and Procedure, no date, shows under procedure V. (D), if bed rail or side rail is used, the facility shall ensure correct installation, use and maintenance of bed rails and to follow the manufacturer's recommendations and specifications for installing and maintaining bed rails. An interview, with the Administrator, on 01/04/23 at 02:10 PM, revealed zip ties were used in the facilty to secure bedrails of residents with older beds so the rails could not be used and requested the Maintenance…

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 care was provided in a manner to promote a resident's dignity. The facility failed to ensure staff covered a Foley catheter drainage bag for Resident #45. This failed practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: Resident #45. Census: 56 Findings included: a) Resident #45 An observation, on 01/03/23 at 01:04 PM, revealed Resident #45 lying in bed with the door open to the resident's room. Further observation , from the 200 Hallway, revealed Resident #45's Foley catheter bag was not covered. A staff interview, with Nursing Assistant (NA) #30, on 01/03/23 at 01:05 PM, verified Resident #45's catheter bag was not covered and could be viewed from the hallway. NA #30, further stated, the catheter bag should have been covered for dignity concerns. .

Based on observation, resident interview and staff interview, the facility failed to secure personal and medical information in a manner that protected a resident's health related information from the public view. The facility posted personal health information, which included treatment modalities and health related information, on the wall in the resident's room in plain sight of anyone entering the resident's room. This was identified on a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #1. Census: 56. Findings included: a) Policy Review A review of the Policy for Protected Health Information (PHI), dated 2020, noted all protected health information would be used and disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPPA) Privacy standards and other applicable laws. PHI included all oral, written, or otherwise recorded information related to a resident's physical or mental health or a health condition and would be protected in any form. b) Resident #1 An observation,…

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 the facility was maintained with a clean and safe environment in good repair. The facility failed to ensure carpeted resident areas were clean and free of stains or frayed areas, failed to ensure floor tiles were secured and unbroken and failed to ensure a bedside table was intact and free of loose parts. This failed practice was identified through a random opportunity for discovery and for two (2) of two (2) current residents reviewed for environment during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #2 and Resident #13. Census: 56. Findings included: a) Hallway observation An observation on 01/03/23 at 02:45 PM, of the 100 and 200 hallways, revealed the carpet was worn and had stained areas throughout the halls. The carpet was frayed and pulled loose at the door of the clean utility room on the 200 hall and the clean linen room on the 100 hall. An interview, with the Maintenance Director, on 01/10/23 at…

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, and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with mental and psychosocial needs. This was found for two of five reviewed for unnecessary medications. Resident identifiers: 48 and 17. Facility census: 56. Findings include: a) Resident (R) #48 A random observation on 01/03/23 at 09:33 AM, found R#48 sitting up in her bed and crying. When asked if she was okay, she asked the writer to sit down and talk with her. The resident continued to cry and ramble word salad about the death of a little boy for a few minutes and then said thank you for listening. A follow up observation on 01/04/23 at 8:30 AM found R #48 sitting up in bed and crying. On 01/04/23 at 2:45 PM, the Activities Director (AD) #54 reported R #48's son recently passed and she now has intermittent crying episodes that usually last one to two days. Review of the medical record on 01/04/23, revealed R #48 was admitted to the facility with a diagnosis of Non-Alzheimer's dementia. Her current diagnoses include…

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 and resident interview, the facility failed to provide treatment to a resident, in accordance to professional standards of practice, when the resident was assessed with limited range of motion (ROM) and had physician orders for treatment modalities. This deficient practice was identified for one (1) of one (1) resident reviewed for positioning/range of motion (ROM) during the Long Term Care Survey Process ( LTCSP). Resident Identifier: Resident #1. Census: 56 Findings included: a) Resident #1 A record review for Resident #1 showed a physician's order for Easy Care 2000 dark green splint to be donned to the left upper extremity hand contracture after breakfast and removed by dinner or per resident tolerance. An observation, on 1/03/23 at 12:57 PM , revealed Resident #1 was not wearing a splint on the left hand. When the resident was questioned, Resident #1 stated the staff have not put that on yet. An observation ,on 01/10/23 at 08:27 AM, revealed Resident #1 had finished breakfast, however, the splint was not in place on the left hand. Observations…

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.

b) Resident #14 On 01/03/23 at 12:20 PM, based on staff observation, resident #14 observed with nasal cannula tubing running to her nose which had an attached tag which was dated for 11/27/22. On 01/03/23 at 2:00 PM, based on record review, resident #14 has the following physician's order in her chart, Change oxygen tubing and ensure to place new padding on tubing for behind the ears, label with date and initials, every night shift every Sat. The order date is 12/6/2022. On 01/03/23 at 3:35 PM, Licensed Practical Nurse (LPN) #23 interviewed as to what the date on a nasal cannula meant. She stated that they date the cannula was placed into service on the cannula. LPN #23 was notified that the nasal cannula for resident #14 had a date of 11/27/22 and she stated it would be immediately changed for the resident. Based on observation, resident interview and staff interview, the facility failed to maintain respiratory equipment consistent with professional standards of practice. Oxygen tubing was not changed, an oxygen concentrator filter was not clean, a continuous positive airway…

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, family interview and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with dementia. This is true for two of five reviewed for unnecessary medications. Resident identifiers: 48 and 17. Facility census: 56. Findings include: a) Resident (R) #48 A random observation on 01/03/23 at 09:33 AM, found R#48 sitting up in her bed and crying. When asked if she was okay, she asked the writer to sit down and talk with her. The resident continued to cry and ramble word salad about the death of a little boy for a few minutes and then said thank you for listening. A follow up observation on 01/04/23 at 8:30 AM found R #48 sitting up in bed and crying. A telephone interview was completed with the husband on 01/03/23 at 11:18 AM. He reported he use to visit daily and now doesn't because his wife R #48 becomes agitated and upset with his visits. On 01/04/23 at 2:45 PM, the Activities Director (AD) #54 reported R #48's son recently passed and she now has intermittent crying episodes that…

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 policy review, staff interview and medical review, the facility failed to develop and maintain a policy for the monthly drug regimen review with time frames for the different steps in the process. The pharmacist failed to identify a drug irregularity for a psychotropic medication order without an adequate indication for use. This is true for one of five residents reviewed for unnecessary medications. The policy related to monthly drug review has the potential to affect a limited number of residents. Resident identifier: #16. Facility census: 56. Findings include: a) Drug regimen review policy The facility policy titled Medication Regimen Review and Reporting dated 09/18 states the pharmacist reviews the medical records of each resident at least monthly. Findings are communicated to the Director of Nursing (DON) or designee and the medical director. Resident specific recommendations are documented and acted upon by the nursing care center and/or the physician. The policy lacks time frames for the different steps in the process and steps the pharmacist must take when he or…

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

Based on medical record review and staff interview, the facility failed to ensure a resident's psychotropic medication was prescribed with an adequate indications for use. This is true for one of five residents reviewed for unnecessary medications. Resident identifier: #16. Facility census: 56; Findings include: a) Resident (R) #16 Review of the medical record on 01/10/23, revealed R#16's diagnoses includes hallucinations, delusions, anxiety and depression. Her current medication orders include Trazodone (antidepressant)100 milligrams at bedtime for sleep. The record is silent for a diagnosis of insomnia or sleep disorder. On 01/10/23 at 10:24 AM, the Director of Nursing (DON) reviewed R#16's medical record and confirmed there is no diagnosis for a sleep disturbance. The DON acknowledged the medication order for R#16's Trazadone inaccurately displays a reason for use. .

Based on observation, staff interview, medical record review, and resident interview, the facility failed to assure medications were available to be administered as prescribed and scheduled. Resident (R) #22's blood sugars increased when Insulin was not available to be given as ordered. Bumetanide (a loop diuretic) was not available for a resident with heart failure and an identified risk of fluid overload. This was true for one of five residents observed during medication administration and a random opportunity of discovery. Resident identifiers: #39 and #22. Facility census: 56. Findings include: a) Resident (R) #39 During medication administration on 01/04/23 at 8:28 AM, Bumetanide 1 milligram (mg) a loop diuretic was not available for administration to R #39. Registered Nurse (RN) #62 reported the Bumetanide was ordered but not delivered by pharmacy and available for the morning dose. RN #62 noted the pharmacy delivers daily in the evening, but prescribed medications are frequently not available for the residents. Review of the medical record on 01/09/23, revealed R#39's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored, and labeled in accordance with current accepted professional practices. The facility failed to ensure medications were dated when opened and put in to use or was expired and still being stored for use. This was true for medications stored in one (1) of two (2) medication carts and one (1) of one (1) medication storage rooms inspected. This practice had the potential to affect a limited number of residents. Facility census: 56 Findings included: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on [DATE] at 08:50 AM, revealed the following medications in the medication cart that was not dated when opened and put into use: - one (1) bottle of Tylenol 325 mg was found with no date when the bottle was opened. An interview with LPN #14, on [DATE] at 08:50 AM verified the Tylenol was being used, however, there was no date when the medication was opened and put…

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.