Ravenswood Village

Based on policy review, record review, and staff interview, the facility failed to make prompt efforts to resolve a grievance/concern and to keep the resident's representative notified of progress toward resolution. This was true for one (1) of three (3) grievances reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #4. Facility census: 60. Findings Included: a) Policy Review of the facility's Grievance/Concern policy, with a review date of 06/01/22, directs the facility will: -Contact the person filing the grievance/concern to acknowledge receipt -Investigate the grievance/concern -Take corrective actions, if needed -Notify the person filing the grievance of resolution within 72 hours b) Resident #4 During an interview on 03/13/23 at 11:11 AM, Resident #4 stated she was not able to hear very well without her hearing aid. Resident #4's family member was at resident's bedside and reported the hearing aid was lost approximately a week or so ago but had not been found. Mom barely hears anything without it. Review of the Grievance/Concern log, on 03/14/23 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 policy review, record review, and staff interview, the facility failed to ensure an allegation of neglect and a serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of three (3) sampled residents with neglect concerns reviewed under reportables during the Long-Term Care Survey Process. Resident identifiers: #27 and #19. Facility census: 60. Findings included: a) Policy Review of the facility's Abuse Prohibition policy, with a review date of 10/24/22, states immediately upon receiving information concerning a report of suspected or alleged neglect the facility will report allegations to the appropriate state and local authorities within 24 hours. Additionally, the policy states the facility will report within two (2) hours any event which results in serious bodily injury. b) Resident # 27 A review of reportables from October 2022 - March 2023, completed on 03/14/23 at 11:30 AM, revealed the facility had three (3) reportables related to allegations of neglect. An allegation 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 and staff interview the facility failed to ensure resident Minimum data sets were completed and accurately reflected the residents status. Resident #35 had three (3) MDS assessments which were in accurate under section (N) medications. Also for Resident #35 the nutritional Care Area Assessment (CAA) for nutritional status was not fully complete. For Resident #54 the facility failed to complete an accurate MDS in regards to the residents hospice status. This was true for two (2) of 19 sampled residents reviewed during the Long Term Care Survey Process. Resident Identifiers: #35 and #54. Facility Census: 60. Findings Included: A) Resident #35 1) Medications A review of Resident #35's medical record at 7:30 am on 03/15/23 found three (3) MDS with the following assessment reference dates 10/03/22, 01/03/23, and 03/03/23. Review of all three (3) assessments found the following answers to Section N0450. Antipsychotic Medication Review: . B. Has a gradual dose reduction (GDR) been attempted?…

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 Resident #19's care plan was implemented in the area of falls. This was true for one (1) of 19 sampled residents. Resident Identifiers: #19. Facility Census: 60. Findings included: a) Resident #19 A review of Resident #19's medical record at 8:00 am on 03/15/23 found the following care plan focus statement: (First name of Resident #19) is at risk for falls and actual falls related to cognitive loss, lack of safety awareness, muscle weakness, and unsteadiness on feet The goal associated with this focus statement read as follows: (First name of Resident #19) will have no falls with no major injury through next review. The care plan contained the following intervention: Yellow tape to call light along with yellow laminated sign Please use call bell and wait for help placed in room to assist with visual cuing and promote safety awareness Observation of Resident #19's room with the Director of Nursing (DON) on 03/15/23 at 11:30 am found there was no a yellow laminated sign reading, please use call bell…

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 ensure Resident #31's neurological assessments were completed when there was bruise discovered to her right outer eye. In addition Resident #38 had a recommendation from a medical specialist which was not addressed with the attending physician and was not completed prior to surveyor intervention. This was true for two (2) for 19 sampled residents reviewed during the long term care survey process. Resident Identifiers: #31 and #38. Facility census: 60. Findings included: a) Resident #31 An observation at Resident #31 on 03/13/23 at 2:53 PM found the resident had a bruise to the outside of her right eye. A review of her medical record found a change in condition dated 03/12/23 at 6:30 PM. The change in condition form indicated that neurological checks would be initiated. Further review of the record found no indication the neurological assessments were completed. An interview with Director of Nursing (DON) at 12:21 PM on 03/14/23, confirmed the neurological assessments were not completed. b) Resident…

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/family interview, record review, and staff interview, the facility failed to assist a resident/resident representative in locating resources, as well as in making appointments, and arranging for transportation to replace a lost hearing aid. This was true for one (1) out of three (3) residents reviewed for grievances. Resident identifier #4. Facility census: 60. Findings included: a) Resident #4 During an interview on 03/13/23 at 11:11 AM, Resident #4 stated she was not able to hear very well without her hearing aid. Resident #4's family member was at resident's bedside and reported the hearing aid was lost approximately a week or so ago but had not been found. Mom barely hears anything without it. Review of the Grievance/Concern log, on 03/14/23 at 1:37 PM, revealed the following details: -A Grievance/Concern was completed on 03/07/23 at 12:38 PM, stating, resident's left hearing aid is missing. -Staff who were aware of the Grievance/Concern were listed as Social Worker #12, the Director of Nursing, and the Administrator. During an interview on 03/14/23 at 2:33 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 observation, record review and staff interview the facility failed to ensure Resident #19's fall interventions were implemented; therefore, her environment was not as free from accident hazards as possible. This was true for one (1) of two (2) residents reviewed for the care area of accidents during the long term care survey. Resident Identifiers: #19. Facility Census: 60. Findings included: a) Resident #19 A review of Resident #19's medical record at 8:00 am on 03/15/23 found the following care plan focus statement: (First name of Resident #19) is at risk for falls and actual falls related to cognitive loss, lack of safety awareness, muscle weakness, and unsteadiness on feet The goal associated with this focus statement read as follows: (First name of Resident #19) will have no falls with no major injury through next review. The care plan contained the following intervention: Yellow tape to call light along with yellow laminated sign Please use call bell and wait for help placed in room to assist with visual cuing and promote safety awareness Observation of Resident #19'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.

Based on record review and staff interview the facility failed to ensure Resident #35 maintained acceptable parameters of nutrition. Resident #35 had abnormal lab values. In response to the lab values the physician ordered a low potassium diet. This order was never implemented by facility staff. This was true for one (1) of five (5) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #35. Facility Census: 60. Findings Included: a) Resident #35 A review of Resident #35's medical record found a Comprehensive Metabolic Panel (CMP) dated 06/07/22 which indicated the residents potassium level was high at 4.7. A further review of the record found a nurses note dated 06/08/22 written at 12:04 PM which read as follows: Physician Notified (list name,date,time of notification): (Name of attending physician) 6/8/2022 Labs Reviewed (list labs): CMP Physician Response/Other Action Taken/Resident Representative notified if applicable: low potassium diet. Further review of the record found no indication the low potassium diet recommended…

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 post the nurse staffing data on a daily basis at the beginning of each shift. This was a random opportunity for discovery and had the potential to affect a limited number of residents and visitors wishing to view the information. Facility census: 60. Findings included: a) Staff posting Review of the facility's staff posting on 03/14/23 at 7:40 AM, found the previous day's nurse staffing on display. Receptionist #3 confirmed the nurse staff posting for 03/14/23 was not posted upon Surveyor entrance to the building. During an interview, on 03/14/23 at 9:40 PM, the Administrator acknowledged the facility's failure to have the current nurse staffing posted at the beginning of the morning shift. .

Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 19 sampled residents reviewed in the Long-Term Care Survey process. The facility failed to update a resident Physician Orders for Scope of Treatment (POST) form to reflect the name and contact number of the Hospice agency providing services to resident. Resident identifier: #54. Facility census: 60. Findings included: a) Resident #54 A brief record review, completed on 03/13/23 at 1:49 PM, identified the following details: -Resident #54 had a Physician Orders for Scope of Treatment (POST) form on file. The facility had obtained consent from Resident #54's Health Care Surrogate (HCS) on 12/05/22. Social Worker #12 assisted with the completion of the form. -Resident #54 began to receive hospice services on 12/11/22. -A care plan conference was held on 12/15/22. The POST form was not updated at that time to reflect Resident #54 was receiving Hospice services or the name and contact number of the Hospice agency. The 2021 POST Form Guidance instructs, this form 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 observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A nurse failed to use a barrier during medication pass and staff failed to change their gloves and sanitize their hands after incontinence care. This was a random opportunity for discovery and has the potential to affect a limited number of residents. Resident identifier: 16 and 55. Facility census: 60. Findings include: a) Medication administration During an observation of medication administration on 03/14/23 at 8:16 AM, Licensed Practical Nurse (LPN) #17 placed three eye drop containers in the original boxes on Resident (R) #55's bedside table without a barrier. R#55 picked up one bottle at a time, removed the bottle from the box and placed the cap on the bedside table while administering each eye drop. R#55 replaced the cap and put each bottle back into it's box after each administration. LPN…

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 and staff interview, the facility failed to maintain the walls in the residents' rooms. This was a random opportunity for discovery. Rooms identifiers: 301, 302, and 307. Facility census: 60. Findings include: a) On 03/13/23, observations on the first day of the survey revealed the following concerns in residents' rooms. --301 multiple areas where paint was off the wall and dry wall was exposed. Trim broken, cracked and hanging off the edge of the wallboard at the head of the bed. --302 several holes in the drywall, trim ripped above resident's bed and hanging outward --307 paint missing off the wall and trim cracked and hanging out over the first resident's head of bed On 03/15/23 at 8:36 AM, a tour with the Maintenance Director confirmed the drywall was exposed where the paint was missing in all three rooms, the holes in the walls and the trim above the headboards needed repaired. .

Based on a random opportunity for discovery, through observation and interview, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records. Electronic medical records were left open and visible to those passing by in the hallway of the facility. This random opportunity for discovery. Resident identifiers: Residents #17, #6 and #33. Census: 56. Findings included: a.) Policy Review A review of Policy OPS209 Privacy Rights: Patient, with a revision date of 11/28/16, notes the patient has a right to personal privacy and confidentiality of his/her personal and medical records. b.) Resident #17 An observation , on 01/25/22 at 08:32 AM, revealed the medication cart on A Hall with the Electronic Medication Administration Record (EMAR) visible as one walked down the hallway. No nurse was present at the medication cart. Information visible pertained to Resident #17 and included the following: name, allergies, code status, vital sign results and special instructions for medication administration. An interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, staff and resident interview, the facility failed to provide resident-centered care and services, in accordance with preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs. This was true for five (5) of eighteen (18) residents reviewed during the Long-term Survey Process Survey (LTCS). For Resident #32, the facility failed to complete an accurate readmission assessment when resident was readmitted , this was true for areas of vital signs including weights and failure to assess and identify pressure ulcers, For Resident #22, the facility failed to follow physician orders for antiseizure medications and Resident #6 the orders for supervision while eating and the special utensils. and for Resident #51 medications were not given as ordered and for Resident #30's orders for feeding tube flushes were not followed. Resident identifiers: #32, #22, #6, #51, and #30. Facility census: 56. Findings include: 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 facility was free from accident hazards over which it had control. The A-Hall medication cart was left unlocked and unattended on two (2) occasions, allowing access to medications by residents and unauthorized persons. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 56. Findings included: a) Unlocked Medication Cart on the A-Hall on 01/24/22 at 11:45 AM. Observation on 01/24/22 at 11:45 AM, found the medication (med) cart on the A-Hall was left unlocked and unattended. Certified Nursing Aide (CNA) #29 confirmed the med cart was unlocked and unattended, allowing access to medications by residents and unauthorized personnel. CNA #29 then stated she would find a nurse to address the concern. On 01/24/22 at 11:51 AM, the Assistant Director of Nursing (ADON) joined Surveyor on the A-Hall by the med cart. The ADON also confirmed the nurse assigned to the A-Hall med cart had left it unlocked and unattended. He confirmed it was 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 record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that the consulting pharmacist's identified irregularities were reviewed and what, if any, action had been taken to address it. This was true for three (3) out of six (6) residents reviewed for unnecessary medications. Resident identifiers: #51, #34, and #19. Facility census: 56. Findings Included: a) Resident #51 A medical record review, completed on 01/25/22 at 1:45 PM, revealed the consulting pharmacist had completed a medication regimen review (MRR) on 03/05/21. The MRR outlined the following recommendation: -Recommendation: No indication requiring Protonix twice daily, please change to once daily. There was no evidence the attending physician had reviewed the pharmacist's consultation report. There was no physician response documented. There was no physician signature. On 01/26/22 at 11:00 AM, the Director of Nursing (DON) confirmed the facility failed to ensure the attending physician reviewed the irregularity and it was not documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of communicable diseases and infections including COVID - 19. This was based on improper hand hygiene, wound care and catheter care. A Resident not being placed in transmission based precautions (TBP) per Center for Disease Control and Prevention (CDC) guidelines and visitation being denied. Facility Census 56. Resident Identifies # 30, #53, #32, #46 Findings Included: a) Medication pass On 01/25/22 at 9:24 AM, During medication pass this surveyor observed RN #51 use ABHR (Alcohol- based hand rub) over gloved hands to sanitize used gloves. RN # 51 then attempted to continue with medication pass but was stopped by this surveyor before touching medications. RN # 51 was guided to use centers for disease control and prevention (CDC) guidelines for hand hygiene. RN# 51 then took off 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, facility policy review and staff interview the facility failed to maintain the Resident #53's dignity by not pulling the curtain during a dressing change. This was a random opportunity for discovery . Resident Identifier # 53 Facility Census: 56. Findings Included: a) Resident #53 A review of the the Facility Policy titled: Wound Dressings: Aseptic No Touch with an effective date of 06/01/96 with a review date: 12/01/21, and a revision date: 12/01/21 found the following: . 7 explain the procedure and provide privacy. On 01/26/22 at 10:35 AM , the Assistant Director of Nursing (ADON) was observed providing wound care to Resident #53's wound on his buttocks. The ADON proceeded to address Resident #53 and explained the procedure. The ADON at this time undressed Resident #53 leaving the curtain open and Resident #53 vulnerable to the view of anyone entering the room. As the ADON removed Resident #53's brief he stated Resident must have lost old dressing in brief, as there was not a dressing covering the wound. On 01/26/22 at 11:26 AM, The DON acknowledged that 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 ensure three (3) of 18 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed 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: #19, #50, and #51. Facility Census: 56. Findings included: a) Resident #19 A medical record review, completed on 01/24/22 at 2:00 PM, found there was a signed POST form on file. The POST form was signed and dated by Resident #19 on 09/16/20. Section E of Resident #19's POST form did not list the telephone number of Resident #19's Medical Power of Attorney (MPOA). The guidance for completing the POST form, compiled by the [NAME] Virginia Center for End-of-Life, states the name, address, and phone number of the person legally authorized to make healthcare decisions [should the resident be incapacitated] are to be listed on the lines marked Name/Address/Phone. A Physician Determination of Capacity,…

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, resident and staff interview, the facility failed to ensure one (1) of eighteen (18) sampled residents had Minimum Data Sets (MDS) which were not completed and/or inaccurately coded. The MDS for Resident #22, failed to reflect his cognitive patterns (section C), mood (section D), behaviors (Section E) and medication (Section N) these sections were incomplete and/or inaccurate. Resident identifier: #22. Facility census: 56. Findings include: a) Resident #22 Review of resident #22's medical records, revealed the resident was admitted to the facility on [DATE]. diagnosis included anoxic brain damage, quadriplegic, communication deficient, cerebral infarction due to overdose of illegal substance, tracheostomy, gastrostomy, hepatic failure, and seizures. He was unable to communicate on admission. A significant change MDS with an assessment reference date (ARD) of 12/09/21 was completed. At that time the resident was coded as speech clear, and resident understands, and he is understood, this…

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

Based on record review and staff interview the facility failed to implement a comprehensive care plan for the care area of nutrition. Resident #30's fluid output was not monitored as directed in the care plan. This was true for one (1) of 18 residents reviewed for care plan implementation. Resident Identifier # 30. Facility Census: 56 Findings Included: a) Resident # 30 A review of Resident #30's care plan with an initiated date of 01/03/22 reveals the following: A care plan focus that reads: Resident requires indwelling foley catheter 16fr (french) with 10 ml (milliliters) balloon The care plan interventions included: Monitor output for odor, color, consistency, and amount. On 01/25/22 at 2:25 PM, the DON acknowledged the care plan intervention stated the facility would document the amount of urine produced by Resident #30. The DON stated they do not have an order for strict I&O so they are not recording urine outputs. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to revise the Resident #30's care plan in a timely manner regarding his wishes for end of life care. This was true for one (1) of 18 residents reviewed for care plan implementation. Resident Identifier # 30. Facility Census: 56. Findings Included: a) Resident # 30 A review of the [NAME] Virginia Orders for Scope of Treatment (POST) form dated [DATE] on file in Resident #30's medical record found the following: Section A is selected No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation. Further review of the medical record revealed a physician order dated [DATE] at 12:38 PM, which read do not resuscitate (DNR). A Physician Determination of Capacity dated [DATE] states Resident #30 lacks sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. Expected duration of incapacity is long term. This form is signed by MPOA and Facility Physician. A review of the medical records revealed a care…

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

Based on observation, resident interview, policy review, and staff interview, the facility failed to provide respiratory care and services consistent with professional standards of practice. The facility failed to change humidifier bottles every seven (7) days. The failed practice was true for two (2) of two (2) residents reviewed for respiratory care. Resident identifiers #34 and #19. Facility census: 56. Findings included: a) Resident #34 Review of the facility policy entitled Respiratory Equipment / Supply Cleaning / Disinfecting, with a revision date of 06/01/21, revealed oxygen humidifiers were to be changed every seven (7) days. An observation, on 01/24/22 at 11:57 AM, revealed Resident #34 was receiving oxygen through a nasal cannula at the rate of two (2) liters per minute. Resident #34 reported, I think the water bottle has been completely empty for a while now. Surveyor observed no water in the humidifier bottle which was dated 01/13/22. During an interview, on 01/24/22 at 12:02 PM, the Director of Nursing (DON) confirmed there was no water in the humidifier bottle and it…

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 each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of six (6) residents reviewed for unnecessary drugs. Resident Identifier: #51. Facility census: 56. Findings included: a) Resident #51 A medical record review, completed on 01/25/21 at 1:45 PM, revealed the consulting pharmacist had completed a medication regimen review (MRR) on 03/05/21. The MRR outlined the following recommendation: -Recommendation: No indication requiring Protonix twice daily, please change to once daily. There was no evidence the attending physician had reviewed the pharmacist's consultation report. There was no physician response documented. There was no physician signature. On 01/26/22 at 11:00 AM, the DON confirmed the facility failed to ensure the attending physician reviewed the irregularity and it was not documented what, if any, action had been taken to address it. The DON then stated she would need to follow-up with the physician to determine how to proceed. .

Based on observation and interview, the facility failed to ensure the residents were free from significant medication errors. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census: 56. Resident identifier: Resident #6. Findings included: a) Resident #6 An observation made during the medication administration pass, on 01/25/22, at 08:40 AM, revealed Registered Nurse (RN) #50 pulled Toprol XL Tablet Extended Release 24-hour 50 MG for Resident #6. RN #50 proceeded to crush the Toprol XL Extended-Release tablet with other medications and placed them in pudding in preparation to administer to Resident #6. At this time, the surveyor questioned the crushing of an extended-release medication and Nurse #50 stated she was aware Toprol XL was an extended-release medication but stated the medications had to be crushed for Resident #6 before administering. RN #50 verified there was no specific order allowing for the extended release medication to be crushed. After surveyor stopped Nurse #50 from administering the crushed…

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 food was stored in a safe and sanitary manner to prevent the spread of Food Borne illness. This failed practice had the potential to affect an isolated number of residents currently residing in the facility. The facility had outdated items stored in the facility's nutritional pantry. In addition the Refrigerator Temperature Log in the nutritional pantry was incomplete. Facility Census: 56. Findings Included: a) Initial Tour of the nutritional pantry During an initial tour of the nutritional pantry beginning at 11:43 am on 01/24/22 with the Certified Dietary Manager (CDM) the following issues were identified: -- One Gallon of Sweet Tea with the name of Resident #15 on it. The manufactured stamped expiration date was 11/12/21 and the tea was opened and a portion of the tea was gone. The tea was in a cabinet and not refrigerated. The container of tea also indicated the tea was to be Refrigerated. -- A Salad with the last name of Resident #48 written on it. The salad was not dated as to when it was made and placed in…

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.