Montgomery General Hospital

Based on observation and staff interview, the facility failed to maintain the environment of which it had control over to remain free of accident hazards due to the medication cart being unlocked. Facility Census: 28. Findings Include: a) Medication Cart On 05/28/25 at 4:34 PM, an observation of the medication cart sitting in the corridor by the elevators was unlocked and the computer screen was left unlocked. Licensed Practical Nurse (LPN) #34 was sitting in the employee lounge. There was no line of sight between LPN #34 and the medication cart. LPN #34 stated, I was just getting a drink. On 05/28/25 at 4:36 PM, the Director of Nursing (DON) was notified and stated, The medication cart and the computer should be locked.

Based on record review, resident representative interview and staff interview, the facility failed to document all meal intake percentages for Resident #26, who was identified with weight loss. This was true for one (1) of two (2) residents reviewed under the care area of nutrition. Resident identifier: #26. Facility Census: 28. Findings Include: a) Resident 26 On 05/27/25 at 4:34 PM, an interview was held via telephone with Resident #26's representative. The representative stated, She is not eating well .I'm concerned. She dislikes eggs. On 05/28/25 at 7:56 PM, a record review was completed for Resident #26. The review of meal percentages from 04/08/25 through 05/28/25 found no documentation for the following dates: --04/17/25 dinner --04/19/25 dinner --04/20/25 breakfast --04/20/25 lunch --04/20/25 dinner --04/28/25 lunch --05/06/25 dinner A further review of the resident's weights found a 5.1% of weight loss from 04/08/25 through 05/08/25. The following is a list of the resident's weights: --04/08/25 163.60 --04/10/25 162.70 --04/17/25 159.00 --04/24/25 157.40 --05/01/25 157.80…

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 resident interview, record review and staff interview, the facility failed to offer a pneumococcal vaccination to Resident #18. This was true for one (1) of five (5) residents reviewed under the care area of infection control. Resident Identifier: #18. Facility Census: 28. Findings Include: a) Resident #18 On 05/27/25 at 1:30 PM, Resident #18 asked, are you here to bring me my pneumonia shot? The resident was admitted to the facility on [DATE] and no documentation was found listing any immunizations the resident had received. On 05/29/25 at 11:25 AM, the Director of Nursing (DON) was interviewed regarding the pneumococcal vaccination for Resident #18. The DON stated, we have ordered them .but they haven't came in yet .the resident was not offered a pneumococcal vaccination since she has been here.

Based on observation and staff interview, the facility failed to ensure licensed nurse staffing information based on payroll information was accurately reported to the Centers for Medicare and Medicaid Services (CMS.) This has the potential to affect all residents at the facility. Facility census: 26. Findings included: a) Payroll Based Journal (PBJ) Review of the facility's Payroll Based Journal (PBJ) data from the Certification And Survey Provider Enhanced Reports (CASPER) found the facility did not have licensed nursing coverage 24 hours a day for 51 days during the third quarter of 2023: 04/01/23, 04/02/23, 04/05/23, 04/08/23, 04/09/23, 04/10/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/19/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/26/23, 04/29/23, and 04/30/23. 05/01/23, 05/06/23, 05/07/23, 05/10/23, 05/11/23, 05/13/23, 05/14/23, 05/17/23, 05/18/23, 05/19/23, 05/20/23, 05/21/23, 05/24/23, 05/27/23, 05/28/23, 05/29/23, and 05/31/23. 06/03/23, 06/04/23, 06/07/23, 06/10/23, 06/11/23, 06/12/23, 06/14/23, 06/15/23, 06/16/23, 06/17/23, 06/18/23, 06/21/23, 06/24/23,…

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

Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 26. Findings included: a) Grievance Forms A review of the facility policy titled Grievance/Concern with a revision date 03/21/18 and a reviewed date of 03/20 .PROCEDURE: A. Person making the complaint will notify the Charge Nurse on duty and ask for a complaint form. If present the charge Nurse will offer to all the Grievance Officer to speak with the patient/family/visitor. The federal guidelines indicate the following: 483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents ' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through…

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 Council meeting and staff interviews, 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 a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 26 Findings Included: a) Activity Program During the Resident Council Meeting held on 10/31/22 1:16 PM, the residents group was asked the question, Are you satisfied with your involvement in group activities? The following concerns were voiced? The residents replied: -We only have group activities every other weekend. -We get packets to do on the weekends, they call that group activities. -Nothing to do in the evenings, we eat dinner and go to bed. -Sometimes they turn the TV on in the Dining Room for a ball game but no other weekend activities. During a review of three months of the monthly activity calendars revealed the following activities on weekends 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 documentation to support ongoing communication, coordination and collaboration between the nursing home and the dialysis center for one (1) of one (1) Resident reviewed for the care area of dialysis. In addition, there was no evidence to support an ongoing assessment of the resident's condition and monitoring for possible complications before and after dialysis treatments received at a certified dialysis facility. Resident identifier: 23. Facility census: 26. Findings included: a) Resident #23 During the initial resident screening process of the survey on 10/30/23, observation of the Resident's room at 11:30 AM on 10/30/23 found the resident was not present. When asked where the resident might be, Registered Nurse (RN) #26 said the resident was at the dialysis center and should return to the facility around 4:00 PM. Review of the current medical record on the morning of 10/31/23, found no physician's orders for dialysis services. On 10/31/23 at 10:49 AM, the Director of Nursing (DON) reviewed the medical record…

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 nurse staffing information was posted on a daily basis. This was a random opportunity for discovery and has the potential to affect all residents at the facility. Facility census: 26. Findings included: a) Staff posting At 10:40 AM on 10/30/23, observation revealed the nurse staffing information posted for public view at the nurses station was dated 10/27/23. The Director of Nursing (DON) confirmed the posting was not current for todays date - 10/30/23.

Based on observation and staff interview the facility failed to maintain proper infection control standards during wound care. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of fesidents. Resident identifier: #79. Facility census: 26. Findings included: a) Resident #79 Record review showed an order for Santyl ointment; 250 unit/gram for amount of a thin layer, topical. Special Instructions: Cleanse area to 5th right toe area with Normal Saline. Pat dry. Apply thin layer of Santyl, apply dry 4x4 gauze, wrap with Curlex daily. During observation of wound care on 10/31/23 at 11:22 AM, Licensed Practical Nurse (LPN) #43 did not disinfect the residents over bed table (OBT) or place a barrier down prior to initiating wound care. The Residents drink cup, half eaten cookie, and dirty napkin were left on the OBT. Dressing supplies were laid directly in a sticky substance on the table. LPN #43 laid the opened Santyl ointment tube directly down on the table. Ointment was protruding out of the tube opening and touched the table.…

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 administer and complete pneumococcal vaccines series for three (3) of five (5) residents reviewed for immunizations. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #23, #2 and #24. Facility census: 26. Findings included: a) Resident # 23 Resident #23's current admission date was 11/11/21, and the most recent return was on 06/28/23. Review of the Residents immunizations showed Resident #23 was administered the Pneumococcal polysaccharide vaccine (PPSV23) on 12/30/21. No other pneumococcal vaccines were given. Record review showed the Resident to have an immunocompromising condition of end stage renal failure and be [AGE] years of age. Per the Centers for Disease Control and Prevention's (CDC) pneumococcal guidelines, the Resident's age, diagnoses and previous vaccination history qualified the resident to receive a second pneumococcal vaccine (Prevnar 20, or Prevnar 15) one year past…

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 a dignified dining experience for Resident #1. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 26. Findings included: a) Resident #1 Observation at 12:53 PM on 10/30/23, revealed Resident #1 had not received her noon meal. The roommate, Resident #13, had already finished eating her lunch. Nurse Aide (NA) #40 said Resident #1 did not have a tray on the food cart when it arrived, but NA #40 said she had already requested a tray for Resident #1. NA #40 said Resident #1 returned from the hospital yesterday evening. NA #40 said she requested a grilled cheese sandwich from the kitchen when she returned yesterday, So the kitchen should know she is back. On 10/30/23 at 1:03 PM, a tray arrived for Resident #1. NA #40 confirmed the roommate, Resident #13 received her tray, 20 to 30 minutes earlier than Resident #1. At 12:49 PM on 11/01/23, the above observations were shared with the Director of Nursing.

Based on observation and staff interview the facility failed to ensure a call light device was always accessible to Resident #12. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of Residents. Resident identifier: #12. Facility census: 26. Findings included: a) Resident #12 On 10/31/23 at 11:15 AM, observation was made of Resident #12 lying in bed without access to a call light device. Licensed Practical Nurse (LPN) #47 located the resident's call light and found it to be tangled up between the bed frame and bed rail with the push button device lying under the resident's bed. LPN #45 verified the call light was not assessable to the Resident. LPN #47 stated to Resident #12, You couldn't have reached that to use if you had to! LPN #45 untangled the call light device and provided it to the resident.

Based on observation and staff interview, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. Ceiling tiles were observed to be stained in three (3) resident rooms, a resident lounge area and an office. This failed practice was a random opportunity for discovery and had the potential to only affect a limited number of residents. Resident identifiers: #24, #27, #18. Facility census: 26. Findings included: a) Observations on 10/30/23 at 12:06 PM revealed Resident #24's room had five ceiling tiles with watermarks with areas that appeared to have a black substance on the tile. During an interview with the Director of Nursing (DON) she acknowledged the condition of the ceiling tiles and said, Sometimes it overflows from up there. She further stated she would make maintenance aware. Maintenance Director #6 was present in the hallway and stated he was in the process of changing out ceiling tiles due to the water stains. Ceiling tiles were also observed to be stained in Resident #27 and Resident #18 rooms. The ceiling tiles were also observed…

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 ensure appropriate information was communicated to the receiving hospital to ensure a safe and effective transition of care. This was true for one of three (3) hospitalizations reviewed during the long-term care survey process. Resident identifier: Resident #279. Facility Census: 26. Findings included: a) Resident #279 During record review, on 10/31/23 at 9:54 AM, Resident #279's medical record revealed she was discharged to the local emergency room (ER) on 10/16/23. Further record review revealed the following notes: (typed as written) -10/16/23 Resident was discharged from the ECU (Extended Care Unit) to the ER on [DATE] and later transferred to (a local hospital) ICU (Intensive Care Unit). She is expected to readmit to the ECU. She is a long term care patient here. -10/16/2023 ER called unit to notify resident was being admitted to (a local hospital) ICU for pos occult blood and critical hemoglobin level. -10/16/2023 at 12:30 PM Resident to ER…

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 one (1) of two (2) residents reviewed for the care area of pre-admission screening and resident review (PASARR) were referred for a Level II screening when a serious mental disorder was evident. Resident identifier: #23. Facility census: 26. Findings included: a) Resident #23 An initial PASSAR, completed by the referring hospital and signed by a physician on 11/11/21, did not reveal the resident had any mental illness. As a result, the resident did not receive a Level II evaluation. A review of the medical record found the resident received a diagnosis of bipolar disorder on 01/20/22. On 10/07/23 a new PASSAR was completed by the facility. The facility did not disclose the resident had a diagnosis of bipolar disorder even though a diagnosis of bipolar disorder was a choice on the MI/MR (mental illness / mental retardation) assessment section of the PASSAR. In addition, the Resident was receiving the antipsychotic medication, Seroquel for treatment which was not disclosed on the PASSAR. The purpose of a Level…

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 interviews, the facility failed to ensure the resident's Pre admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASARR. Resident #279 was diagnosed with Bipolar Disorder. Resident identifier #279. Census 26. Findings Included: a) Resident #279 Record review, on 11/01/23 at 9:25 AM, of Resident # 279 medical record revealed admitting diagnoses included the following: Bipolar disorder current episode depressed, severe, with psychotic features. Further review of the medical record revealed a PASARR dated 08/03/23, Section 30 titled Current Diagnosis, was coded None. Further record review revealed an Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/12/23 Section I titled Active Diagnosis was coded Bipolar. During an interview, on 11/01/23 at 9:29 AM, the Director of Nursing (DON) acknowledged the PASARR was not coded correctly. The DON stated, I will let the Social Worker know so she complete a new one now.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to implement care plans for three (3) of 26 Residents whose care plans were reviewed during the long-term care survey process. Resident #17's care plan was not implemented for nutritional needs. Resident #23's care plan was not implemented for a receiving dialysis services. Resident #27's care plan was not implemented for fall prevention. Resident identifiers: #17, #23, and #27. Facility census: 26. Findings included: a) Resident #17 Review of the care plan found the current care plan, updated on 09/21/23, stated, Potential for altered nutrition related to no added salt diet with puree consistency. Finger foods The goal stated, Resident will maintain desired weight within five pounds through next review. On 11/01/23 at 12:03 PM, the Director of Nursing (DON) was interviewed and asked how the facility would provide finger food to a resident on a pureed diet. The DON said, I don't have an answer for that, you need to ask the dietary manager. At 12:10…

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 staff interview and record review, the facility failed to revise the care plan after Resident #1's dentures were lost. This was true for one (1) of fifteen residents whose care plans were reviewed during the long-term care survey. Resident identifier: #1. Facility census: 26. Findings included: a) Resident #1 On 10/30/23, at 12:05 PM, Resident #1 said she had no lower dentures. Resident #1 said, They threw them away, about 2 months ago. She said she put her teeth in a Styrofoam cup on her over - the - bed table and someone threw the cup away. She said, They don't pay attention. Review of the current care plan dated 10/30/23 reflected the Resident had poor oral status related to use of upper and lower dentures. The goal associated with the problem revealed the resident would have no signs or symptoms of infection or decreased nutritional status. Interventions included: Encourage the resident to perform oral care at least twice daily with toothbrush, toothpaste and mouthwash. On 11/01/23 at 10:55 AM the Director of Nursing (DON) was asked if the Resident had an appointment to…

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

Based on observation, record review and staff interview, the facility failed to ensure a resident receiving oxygen had a physician's order for usage. This was found for one (1) of one (1) Resident reviewed for respiratory care. Resident identifier: #20. Facility census: 26. Findings included: a) Resident #20 Observation at 12:18 PM on 10/30/23 revealed the resident was receiving oxygen at a flow rate of 2.5 liters via nasal cannula. Review of the current care plan found the resident was receiving oxygen related to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD.) Further review of the current physician's orders found there was no order for the resident to receive any oxygen. On 10/31/23 at 9:48 AM, Registered Nurse (RN) #26 was interviewed and asked if Resident #20 had an order for oxygen and if so, what flow rate of oxygen should the resident be receiving. RN #20 looked at the medical records of Resident #20 and said, I don't see an order, but I'll get one for 2 liters of oxygen. That's our protocol. The Director of Nursing (DON) was present and said, We should look 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, record review, and staff interview the facility failed to administer an extended-release medication within the appropriate guidelines for Resident #1. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifier: #1. Facility census: 26. Findings included: During observation of medication pass for Resident #1, Licensed Practical Nurse (LPN) #43 crushed a Metoprolol Extended Release (ER) 25mg tablet. LPN #43 placed the crushed tablet in applesauce for administration to Resident #1. The applesauce mixture also contained a crushed Norvasc 10 mg tablet, two (2) Vitamin D 3 capsules (whole not crushed) and a Neurontin 300 mg capsule (whole not opened). During an interview on 10/31/23 at 09:50 AM the Facility Pharmacist stated, The Metoprolol Extended-Release tablet can be scored and cut in half, but it is not a crushable medication. On 10/31/23 at 01:35 PM the Director of Nursing (DON) provided the Common Oral Dosage Forms That Should Not Be Crushed Do Not Crush list utilized by…

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 properly store food in a safe and sanitary manner in accordance with the professional standards for food service safety. The foods stored in the kitchen and nourishment room were not labeled correctly and foods were not discarded when expired. The failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census: 33 Findings Included: a) Kitchen An initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 04/18/22 at 11:20 AM found the following failed practices: -- Reach in Refrigerator --a pan of Lemon Jello use by date 04/08/22 --a bowl of Cream of Wheat use by date 04/14/22 --a bowl of Applesauce with no date The CDM indicated these things needed to be discarded because they were not dated when opened and/or past the use by date listed. -- Deep freeze --2 opened bags of chicken wings no open date --2 opened bags of onion rings no open date --2 opened bags of hushpuppies no open date --2 opened bags of…

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

Based on medical record review and staff interview, the facility failed to inform all residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. This was true for three (3) of three (3) residents reviewed for COVID-19 notification. Resident identifiers: #15, #19, #27. Facility census: 33. Findings included: a) Resident #15 Review of the facility's Staff Line Listing for COVID-19 Outbreak showed the facility had two (2) staff members who tested positive for COVID-19 on 01/16/22. Review of Resident #15's medical records showed the following note written on 01/18/22 at 12:24 PM, [Resident representative's name] notified that ECU [extended care unit] is in a covid outbreak status and that all residents and staff are being tested. b) Resident #19 Review of the facility's Staff Line Listing for COVID-19 Outbreak showed the facility had two (2) staff members who tested positive for COVID-19 on 01/16/22. Review of Resident #19's medical records showed the following note written on 01/18/22 at 12:03 PM,…

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

Based on medical record review and staff interview the facility failed to notify a resident representative of a change in condition. This was discovered for one (1) of four (4) residents reviewed for the care area of accidents during the Long-Term Care Survey Process. Resident # 25 had a fall on 03/18/22 and the resident representative was not contacted. Resident identifier: #25 Facility census: 33 Findings included: a) Resident #25 During a medical record review on 04/20/22 for Resident #25, it was discovered the resident had a fall on 03/23/22. The Fall Risk Assessment revealed the physician had been contacted, but there was no evidence to show the resident representative had been contacted. An interview with the Director of Nursing (DON) on 04/20/22 at 9:08 AM, verified she was unable to find any progress notes indicating the family had been contacted regarding the fall Resident #25 had on 03/23/22. .

Based on medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for Resident #25 in the area of restraints and alarms. This was found for one (1) of fourteen MDS assessments reviewed during the Long-Term Care Survey Process. Resident identifier: #25 Facility census: 33. Findings included: a) Resident #25 During a medical record review on 04/18/22 for Resident #25, it was discovered the quarterly MDS assessment completed on 03/18/22 had not been coded to reflect chair and bed tab alarms were being used daily by the resident. An interview with the Director of Nursing (DON) on 04/20/22 at 9:08 AM, verified the MDS had not been coded correctly for the daily use of a chair and bed tab alarm for Resident #25. .

Based on medical record review and staff interview the facility failed to develop an accurate comprehensive person-centered care plan for a resident receiving respiratory services. This was discovered for one (1) of fourteen care plans reviewed during the Long-Term Care Survey Process. The intervention for respiratory care for Resident #9 did not have the correct liters per minute of oxygen to be administered via a nasal canula. Resident identifier: # 9 Facility census: 33 Findings included: a) Resident #9 During a medical record review on 04/19/22, it was discovered the care plan interventions for oxygen therapy did not include the correct two (2) liters of per minute of oxygen to be received via a nasal canula for Resident #9. In an interview with the Director of Nursing (DON) on 04/19/22 at 11:36 AM, verified the interventions for oxygen therapy had three (3) liters of oxygen instead of the correct two (2) liters of oxygen to be received by Resident #9. .

Based on medical record review and staff interview the facility failed to revise a care plan in the area of fall risk. This was discovered for one (1) of fourteen care plans reviewed during the Long-Term Care Survey Process. The care plan for Resident #9 had not been revised to indicate chair and bed alarms were being used daily. Resident identifier: #9 Facility census: 33 Findings included: a) Resident #9 During the medical record review on 04/19/22 for Resident #9, the care plan indicated resident was to be evaluated for chair and bed tab alarms. The care plan had not been revised on 04/14/22 to reveal the resident had been using a chair and bed tab alarm daily since 01/26/22. An interview with the Director of Nursing (DON) on 04/19/22 at 11:36 AM, verified the interventions to evaluate the need for a bed and chair alarm had not been revised to indicate Resident #9 was using the chair and bed tab alarms daily. .

Based on medical record review and staff interview, the facility failed to ensure the resident's environment was as free from accident hazards as possible. The medication cart was observed to be unlocked and unattended in the hallway. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 33. Findings included: a) Medication Cart On 04/20/22 at 10:04 AM, the medication cart was noted to be placed in the hallway, in front of a storage room. A resident room was located next to the storage room. No staff member was in attendance. On 04/20/22 at 10:05 AM, the Director of Nursing (DON) was notified the medication cart was unlocked with no staff in attendance. The DON locked the medication cart. On 04/20/22 at 10:06 AM, Registered Nurse (RN) #19 returned to the medication cart. RN #19 stated the medication cart key was jamming and she was afraid the cart wouldn't unlock if she had locked it. No further information was provided through the completion of the survey. .

Based on observation and staff interview, the facility failed to ensure oxygen therapy was administered in accordance with professional standards of practice. Resident #134's oxygen tubing and humidification bottle were not dated when changed. This was a random opportunity for discovery. Resident identifier: #134. Facility census: 33. Findings included: a) Resident #134 On 04/18/22 at 12:01 PM, Resident #134 was noted to be wearing supplemental oxygen via nasal cannula. The oxygen tubing and humidification bottle were not dated to indicate when they had been last changed. On 04/18/22 at 12:03 PM, the Director of Nursing confirmed Resident #134's oxygen tubing and humidification bottle were not dated to indicate when they were changed. Resident #134 stated it hadn't been very long since they were changed. No further information was provided through the completion of the survey. .

Based on medical record review and staff interview, the facility failed to ensure residents were assessed for pneumococcal vaccination status and offered vaccination if appropriate. This was true for one (1) of five (5) residents reviewed for influenza and pneumonia vaccinations. Resident identifier #25. Facility census: 33. Findings included: a) Resident #25 Record review of the facility's policy titled LTC Influenza and Pneumococcal Vaccination with effective date April 2003 and revision date March 2018 showed the following procedures to be performed: - Nursing staff were to assess the pneumococcal vaccination status of all residents and identify unvaccinated residents who are at risk for pneumococcal disease. - If the resident was a candidate for the vaccination, the physician would be notified, and consent obtained from resident and/or responsible person to proceed with vaccination. Review of Resident #25's medical records showed no documentation that the resident was assessed for pneumococcal vaccination status and had received a pneumococcal vaccination if appropriate. During…

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.