Lewisburg Healthcare Center

Based on Resident Council and staff interview the facility failed to provide reasonable access to mail services to residents by not delivering mail on Saturday's. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 86. Findings Include: During a meeting with Resident Council on 02/06/24 at 10:30 AM the Resident Council made a complaint that the mail is not delivered on Saturdays. An interview on 02/06/24 at 11:11 AM, with Receptionist #(4) four confirmed The mail is delivered to the mailbox at the top of the road. Sometimes the mailman will bring mail into the facility, but if not activities will go get it. I sort the mail from the weekend on Monday's and give it to the Activity department to pass out to resident's.

Based on Resident Council, observation, and staff interview the facility failed to display the most recent State inspection in a readily accessible area frequented by residents. It was discovered the State inspection was placed too high for residents in a wheelchair to reach. This had the potential to affect more than a limited number of residents. Facility census 86. Findings include: a) State inspection During the Resident Council meeting on 02/06/24 at 10:30 AM, Resident Council voiced they did not know if they had access to the State inspection or where it was located. An observation on 02/06/24 at 11:21 AM, revealed the State inspection was located in the lobby beside the receptionist office at a height too high for residents in wheelchairs to reach. During an interview on 02/06/24 at 1:26 PM the administrator stated, Someone can hand it to them, we have people here all the time. This statement confirmed residents in wheelchairs could not reach the State inspection with having to ask a staff member for help.

Based on observation and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as possible when a medication cart was left unlocked and unattended. This was a random opportunity for discovery. Facility Census: #86 Findings included: a) Medication cart 200 Hall On 02/06/24 at 8:40 AM an observation was made of the medication cart on the 200 hall cart left unattended and unlocked. There were numerous residents near the medication cart. According the the facility Policy # NS-1197-05 Medication Administration it is stated . Procedure: I. General Procedures: k. Do not leave medication cart unlocked . According to a list provided by the Director of Nursing there are six (6) residents that are at risk for elopement. This was confirmed with Licensed Practical Nurse (LPN) #7 at 8:41 AM. This was also confirmed with the Administrator on 02/06/24 at 9:28 AM.

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the reach-in freezer floor was dirty and the ice machine was not draining properly. The deficient practice had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 86. Findings included: a) Kitchen tour During the kitchen tour on 02/05/24 at 11:45 AM, it was discovered the reach-in freezer had a large amount of crusted particles on the floor and the ice machine drain line did not have the proper spacing of one (1) inch above the floor drain to prevent back flow. The Dietary Manager (DM) on 02/05/24 at 11:55 AM, verified the floor of the reach-in freezer needed to be cleaned and the ice machine was not draining properly to prevent back flow.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY , Based on record reviews and staff interviews, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for residents with a newly added psychiatric diagnosis. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the PASAAR care area. Resident identifiers: #62, #12 and #6. Facility census: 86. Findings include: a) Resident #62 During a medical record review on 02/06/24, revealed a new PASARR had not been completed when the psychiatric diagnosis of a major depressive disorder had been added to the medical diagnoses list on 11/02/22. In an interview with the Director of Nursing (DON) on 02/07/24 at 10:45 AM, they verified the new PASARR had not been completed when Resident #62 received a new diagnosis of major depressive disorder on 11/02/22. b) Resident #6 On 02/07/24, a record review of the resident's electronic medical record (EMR), the resident's Pre-admission Screening (PAS), dated 03/22/21, indicated no level II…

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 develop a comprehensive person-centered care plan for bladder incontinence and dehydration. Resident Identifiers: #86 and #111. Facility Census: 86 Findings Include: a) Resident #86 On 02/05/24 at 2:00 PM during an interview with the resident, she discussed her needs for bladder incontinence. On 02/06/24 at 01:57 PM a record review found documentation of 73 urinary episodes, she was incontinent 67 of the 73 episodes. Further review of the record found there was no comprehensive care plan in place for bladder incontinence. This was confirmed with the Director of Nursing on 02/06/24 at 2:20 PM. b) Resident #11 An observation on 02/05/24 at 3:19 PM revealed, Resident #11 had an IV in his hand. A record review of Resident #11's order on 02/05/24 at 3:30 PM revealed Resident # 11 was receiving Sodium Chloride Intrevenous Solution for dehydration. Further review of the medical record showed no care plan was developed for Dehydration. During and Interview on 02/06/24 at 9:30 AM with the Director of Nursing it was confirmed 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 revise a person-centered care plan for a change in a resident's condition. This was true for one (1) of 23 care plans reviewed during the Long Term Care Survey Process. Resident #27 had a change in nutritional status which was not revised on the person centered care plan. Resident identifiers: #27. Facility census: 86. Findings include: a) Resident #27 During a medical record review on 02/07/24, the care plan had an intervention to educate and limit resident's salt intake. There was an order on 01/20/24 for sodium chloride tablet one (1) gram four (4) times a day as a supplement. Her diet orders were a regular diet, mechanical texture and regular consistency with a start date of 01/12/24. An interview with the Director of Nursing (DON) on 02/06/24 at 3:05 PM, verified the care plan had not been revised to remove the intervention for limiting salt intake.

Based on observation, record review, resident, staff interview the facility failed to assist a dependent Resident with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of two (2) residents reviewed for ADL care. Resident Identifier: #240. Facility census: 86. Findings Include: a) Resident #240 showers On 02/05/24 at 12:12 PM, Resident #240 stated he hasn't received or been offered a shower or bath since his admission. A review of Resident #240's ADL documentation found; no showers documented. During an Interview on 02/06/24 at 11:09 AM the Director of Nursing (DON) verified there was no documentation that Resident #240 received showers. She stated, he should have been put on the shower list and been offered a shower before 02/05/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect three (3) of 23 residents reviewed in the long-term care survey sample. The facility failed to follow physician's orders for Resident #12 and Resident #90. The facility also failed to complete neurological evaluations after an unwitnessed fall for Resident #240. Resident Identifiers: #12, #240, #90. Facility census: 23. Findings included: a) Resident #12 Review of Resident #12's medical records showed a physician's order written on 03/16/22 for no water pitcher at bedside. Further review of Resident #12's medical records showed the resident had a diagnosis of hyponatremia, or low sodium in the blood. During an observation on 02/06/24 at 10:30 AM, Resident #12's room was noted to have a large plastic glass, or pitcher, on the overbed table. The large plastic pitcher had some water 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.

Based on observation, record review, and staff interview, the facility failed to ensure care of a resident with a tracheostomy within professional standards of care. The facility failed to follow the physician's order to always have a smaller size of trach tube at the bedside. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tracheostomy. Resident Identifier: #68. Facility census: 86. Findings included: a) Resident #68 Review of Resident #68's physician's orders showed an order written on 01/11/24 which stated, Trach-Type: cuffed size: Shiley 6XLT. Another physician's order also written on 01/11/24 stated, Have same size trach and one smaller at bedside at all times. A smaller tracheostomy tube may be needed in case of emergencies. An observation of the emergency equipment at Resident #68's bedside was made on 02/07/24 at 10:23 AM. Shiley size 6XLT tracheostomy tubes were located at the bedside. However, no smaller size tracheostomy tube could be found at the bedside. On 02/07/24 at 10:27 AM, Registered Nurse (RN) #64…

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 document specific behaviors to monitor the efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #12. Facility census: 86. Findings included: a) Resident #12 Review of Resident #12's physician's orders showed the resident was receiving the following psychotropic medications: - Ativan (lorazepam) for anxiety - Risperdal (risperidone) for schizoaffective disorder, bipolar type - Cymbalta (duloxetine) for depression - Depakote (divalproex sodium) for schizoaffective disorder, bipolar type Further review of Resident #12's physician's orders showed an order written on 12/21/22 to monitor behaviors every shift. The behaviors to be monitored were as follows: - Cursing, physical aggression, hitting - Yelling - Suicidal ideation Non-pharmacological Interventions to be implemented were as follows: - If resident is able to physically able, involve in activity such as walking or some other…

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 and staff interview, the facility failed to serve a balanced meal. A resident was not served all items listed on the tray ticket. This was true for one (1) of two (2) residents reviewed for food. Resident identifier: #10. Facility census: 86. Findings Included: a) Resident #10 Review of the Menu for the lunch meal on 02/07/24 was homestyle meatloaf, au gratin potatoes, seasoned green peas, dinner roll, caramel apple upside down cake. An observation on 02/07/24 at 1:00 PM of lunch meal pass found Resident #10 was served meatloaf, peas, and caramel apple upside down cake. A review of Resident #10's tray ticket found dislikes: scalloped potatoes. During an interview with the Dietary Manager (DM) on 02/07/24 at 1:07 PM verified Resident #10 was only served meatloaf, peas, and caramel apple upside down cake. She stated that she should have had a roll and a substitute of mashed potatoes. The DM continued to say that she has a new employee working the tray line.

Based on observation, record review, and staff interview, the facility failed to provide an assistive device to help a resident receive hydration. Resident #15 did not have a Kennedy cup as ordered. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #15. Facility census: 86. Findings included: a) Resident #15 Review of Resident #15's physician's records showed an order written on 01/24/24 for a Kennedy cup with meals and at bedside. A Kennedy cup is a small lightweight cup with a handle and a lid, which allows residents with disabilities to independently take fluids better. Review of Resident #15's medical records showed the resident had diagnoses of unspecified lack of coordination and generalized muscle weakness. On 02/06/24 at 11:05 AM, Resident #15 was noted to be in bed. A large plastic water pitcher with a handle and lid with a straw was noted on the overbed table. The resident did not have a Kennedy cup at the bedside. On 02/06/24 at 3:10 PM, Resident #15 was noted to be in bed. 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, staff interview, the facility also failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering an Enhanced Barrier room. These failed practices had the potential to affect every resident currently residing in the facility. Resident Identifier: #5. Facility census: 86. Findings included: a) Resident #5 An observation on 02/05/24 at 1:50 PM found Nurse Aide (NA) #5 and NA #63 in Resident #5s room. The signage on Resident #5s door showed the room was on Enhanced Barrier. The TBP sign stated, Providers and Staff Must: put on gloves and gown before room entry. Both NA #5 and NA #63 was observed in Resident #5's room without gowns providing care. A medical record review for Resident #5 revealed, an active Physician orders: -- Enhanced barrier precautions related to: MDRO When dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. Start date 12/26/23. During an interview on 02/05/24 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 record review and staff interview the facility failed to maintain accurate documentation for administration and dispensing of narcotic medication for three (3) of three (3) medication carts reviewed. This failed practice had the potential to affect more than a limited number of residents. Facility census: 85. Findings include: a) Medication Controlled Drugs Policy Record review of the facility's undated policy titled, Medication Controlled Drugs and Security, found: Controlled drugs as well as controlled drug count sheets and cards are counted every shift change by the nurse reporting on duty with the nurse reporting off duty. The inventory of the controlled drugs, count sheets, and number of cards must be recorded on the narcotic records and signed for correctness of count. The controlled drug record must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct after the count has been completed. b) Shift Change Controlled Substance Inventory Tracker Record review showed the facility used a logbook with forms…

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, family interview and staff interview, the facility failed to maintain an accurate medical record. This is true for two (2) of three (3) residents reviewed for the Respiratory Syncytial Virus (RSV) Consent during the complaint survey. Resident Identifiers: #32 and #80. Facility census: 85. Findings included: a) Resident #32 During a record review on 01/17/24 at 11:15 AM, Resident #32's medical record revealed a immunization record of RSV vaccine received on 12/29/23 in the left deltoid. Further record review revealed a verbal consent was obtained from the resident's representative, consent was witnessed by two (2) staff members, and contained no date. During an interview on 01/18/24 at 3:34 PM, Resident #32's representative stated They call me about everything. They called me today for consent for the RSV Vaccine. I told them I thought he already had it a few weeks ago, but they never responded. I went ahead and gave my consent for the vaccine again. During an interview on 01/22/24 at 12:08 PM the Director of Nursing acknowledged the RSV Consent forms did not…

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

Based on observation and staff interview, the facility failed to provide and maintain infection prevention and control programs designed to provide a safe sanitary environment to help prevent the development and transmission of communicable diseases and infections in the facility. This facility failed to provide medication barriers during medication administration for one (1) resident. Resident identifiers: #26. Facility Census: 85. Findings included: a) Resident #26 During a tour of the facility, on 01/18/24 at 9:20 AM, Licensed Practical Nurse (LPN) #75 was administering medication to Resident #26. LPN #75 did not place a barrier on the over the bed table prior to placing the following medications directly on the over the bed table: -Refresh Tear Solution -Trelegy Inhaler -Ipratropium Bromide Nasal Solution During an immediate interview, LPN #75 stated, I used the activity sheet for the barrier, I should have used the wax paper barrier that is on my medication cart. During a record review, on 01/18/24 at 10:00 AM, Resident #26's medical records revealed the following physician…

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

Based on record review, staff interview and family interview the facility failed to notify Resident #46's representative in advance of care. The facility did not notify the Medical Power of Attorney (MPOA) prior to administering vaccinations and for resident's change of condition and treatment of the shingles. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #46. Facility census: 85. Findings include: a) Resident #46 A record review of a physician's determination of capacity showed Resident #46 demonstrated incapacity to make medical decisions as of 4/15/23. Resident #46's record also contained a Resident RSV (Respiratory Syncytial Virus Infections) Consent and Screen form completed on 12/01/23. The form was used to obtain verbal consent from Resident #46's Medical Power of Attorney (MPOA) for of the RSV vaccination. The consent was signed by two (2) nurses and indicated the Resident's Representative was contacted via phone on 12/01/23 and gave permission for the RSV vaccine to be…

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

Based on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner. This failed practice had the potential to affect more than a limited number of residents who currently resided in the facility. Facility census 90. Findings included: a) RSV immunization Review of the facility documents regarding immunization, found zero (0) out of 90 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination. On 11/28/23 at 3:45 PM the Infection Preventionist (IP) stated she had not had time to start giving the information or offer the RSV vaccine to anyone, yet IP went on to say she did not know when she would have time to do it. b) The Centers for Disease Control and Prevention (CDC) Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe…

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 maintain an appropriate infection control and surveillance program to prevent the development and transmission of Covid-19 during an active Covid-19 outbreak. This failed practice was a random opportunity for discovery and had the potential to affect more than an isolated number of residents currently residing in the facility. Resident identifiers: #84, #7, #73. Facility census: 90. Findings included: a) Covid-19 Visitor and Vendor Notification Record review of the facility's policy titled Criteria for Covid-19 Requirements revised on 05/11/23, showed under the surveillance topic for employees, contractors, vendors, and visitors, The facility needs to ensure all who enter the facility are aware of recommended IPC practices in the facility. Post signs and visuals at the entrance, lobby, elevators, break rooms, therapy, activity room, and on the units that include instructions about current infection prevention and control recommendations. The signage should contain the source control necessary according…

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 offer immunization to all residents when a COVID-19 vaccine/booster was available. This was true for five (5) out of five (5) reviewed for immunization. Resident identifiers: #76, #8, #89, #35, and #26. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 90. Findings included: a) Resident #76 A review of the medical records for Resident #76 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. b) Resident #8 A review of the medical records for Resident #8 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. c) Resident #89 A review of the medical records for Resident #89 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. d) Resident #35 A review of the medical records for Resident #35 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. e) Resident #26 A review…

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 two (2) of three (3) discharged residents reviewed were care planned for their discharges to home. In addition the facility failed to ensure Resident #36 was care planned for a significant weight loss. Resident identifiers: #36, #92 and #93. Facility census: 89. Findings included: a) Resident #92 The Resident was admitted to the facility on [DATE] and was discharged to home on [DATE]. The Resident's admission Minimum Data Set (MDS) with assessment reference date (ARD) of 07/19/23 found she participated in her assessment and expected to be discharged to home. An interview with Social Worker #110 at 9:01 AM on 09/26/23 confirmed the resident was not care planned to return home. b) Resident #93 The Resident was admitted to the facility on [DATE] and discharged to home on [DATE]. The admission MDS with ARD of 05/03/23 noted the resident participated in her assessment and expected to be discharged to the community. Social Worker #110 confirmed…

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 provide activities of daily living (ADL) care for dependent residents to maintain personal hygiene. Resident identifier: #36. Facility census: 89. Findings included: a) Resident #36 Review of the bathing activity with the Director Of Nursing (DON) at 1:25 PM on 09/26/23, found the Resident had not received a shower in the past 30 days. At 2:49 PM on 09/26/23, the DON verified the resident should receive two (2) showers a week on Wednesdays' and Saturdays'. During the month of September 2023, the resident received 1 bed bath on 09/09/23. Review of August 2023, bathing schedule found the resident refused bathing activity on 08/12/23. The resident received two (2) bed baths in August 2023, one (1) on 08/05/23 and one (1) on 08/23/23. Review of the current care plan with the DON found no information indicating the resident refuses showers. The DON did not know why showers were not provided as directed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review, and staff interview, the facility failed to ensure pain management was provided to Resident #8 and failed to ensure residents #85 and #39 were properly evaluated for pain. This was found for three (3) of three (3) resident's reviewed for the care area of pain. Resident identifiers #8 and #85 and #39. Facility census:89. a) Resident #8 Resident #8 admitted to the facility on [DATE] after a car wreck which resulted in broken ribs and a fractured tibia. According to the medical record, the resident is alert and oriented and has capacity to make her own medical decisions. The resident was ordered Morphine Sulfate, oral tablet, 15 mg. give 1 tablet every 4 hours as needed (PRN) for pain. At 4:30 PM on 09/26/23, the resident stated her pain medicine did not come in from the pharmacy about 2 weeks ago. There was some kind of a mix up at the pharmacy. My nurse talked to me about it and called the doctor. The doctor ordered Oxycodone 10 mg. When the nurse went to get the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, policy review, record review and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for five (5) of five (5) Residents reviewed during the complaint survey process. Resident Identifiers: resident #28, Resident #53, Resident #70, Resident #11 and Resident #78. Facility Census: 90. Findings Included: a) Activity Calendars During the initial tour of the facility on 09/18/23 at 10:00 AM the Daily Activity Sheet posted outside the Main Dining Room (MDR) read as follows: -10:30 AM SFL(Strength for Life) exercise -2:00 PM Outdoor Social During an observation on 09/18/23 at 10:57 AM in the 400 Hall Lounge, where the group activities was to be held. The Residents in attendance were four (4) ladies which had just finished getting their fingernails painted by the Activity staff. An immediate…

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 family interview the facility failed to maintain an appropriate infection control program in order to maintain a safe and sanitary environment to help prevent the development and transmission Covid-19 during an active Covid-19 outbreak. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Resident identifiers: #85, 58, #86, #13, #80. Facility census: 90. Findings included: a) Covid-19 Visitor Notification On 09/18/23 at 9:30 AM when surveyors entered the building, the main entrance to the facility for visitors was open and easily accessed without any code required to enter the building. No signage was posted on the door to alert visitors that the facility was in an active Covid-19 outbreak. No one was present at the front desk in the lobby. Some staff were observed wearing face masks throughout the facility. Surveyor was greeted by the Director of Nursing (DON) asked asked if the facility was in an active outbreak. The DON replied, Yes we have been for a while. The DON verified 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 and staff interview the facility failed to provide a safe, clean and home like environment. The facility failed to maintain clean and sanitary wheelchair for Resident #89. The facility also failed to keep the residents' wheelchairs in good repair to maintain clean and sanitary equipment. Resident Identifiers: Resident #89, Resident #85, Resident #7 and Resident #11. Facility Census:90. Findings Included: a) Resident #89 During the initial tour of the facility on 09/18/23 at 9:56 AM Resident #89's wheelchair has a large amount of food built up on the seat, the wheels and on the foot rests. The left armrest missing material exposing the mesh lining. The arm rest could not be cleaned and sanitized. A review of the facility wheelchair cleaning schedule Resident # 89 wheelchair was scheduled to be cleaned on Fridays (09/15/23). No other documentation was provided. During an interview on 09/19/23 at 12:31 PM the Director of Plant Maintenance acknowledged Resident #89's left wheelchair armrest needed to be replaced. b) Resident #85 During an observation on 09/18/23 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, policy review and staff interview the facility failed to ensure Resident #41 was provided care in a manner which preserved her dignity. Resident #41 was receiving medication in the facility hallway. This was a random opportunity for discovery. Resident Identifiers:Resident #41. Facility Census: 90. Findings Included: a) Resident #41 A review of an undated facility policy titled Medication Administration read as follows. .II. Preparation .e. Provide for privacy/dignity . During a tour of the facility on 09/18/23 at 12:04 PM Resident # 41 was sitting in a gerichair on 500 hall. Licensed Practical Nurse (LPN) #47 was assisting Resident #41 with her ice cream, when LPN #47 saw this surveyor, she began feeding her very fast and spilling the ice cream down Resident #41's chin and on her shirt. LPN #47 was asked Was there medication in the ice cream LPN #47 stated Yes, they were taking her to the dining room so I needed to give it to her. It was her Lortab and was due at noon. LPN #47 acknowledged she should not have gave resident #41 medication in the hallway.

Based on observation, record review, staff interview the facility failed to ensure diabetic medication was available and administered appropriately. This failed practice was true for one (1) of two (2) residents reviewed for insulin medication regimen. Resident identifier: #21. Facility census: 90. Findings included: a) Resident diagnosis Record review showed Resident #21 had a diagnosis of Type 2 Diabetes with mild nonproliferative diabetic retinopathy without macular edema, diabetes due to underlying condition with hyperglycemia. b) April 2023 - Trulicity Insulin Administration Record review showed an order with a start date of 03/21/23 to administer Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1 application subcutaneously one time a day every Friday for diabetes. Give in addition to 1.5mg for a total dose of 3mg. EMAR (Electronic Medication Administration Record) note dated 4/21/2023 (Friday) at 3:54 PM stated Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML was not available. Pharmacy to bring. Power of attorney (POA) and doctor aware.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to provide an ongoing assessment and oversight for hemodialysis treatments, that included communication with the dialysis center for monitoring the resident's condition prior to and after treatment. This failed practice was true for three (3) of (3) residents reviewed for dialysis services with the potential to affect only a limited number of residents. Resident identifiers: #20, #48, #84. Facility census: 90. Findings included: a) Hemodialysis Policy Record review of the facility's undated policy titled, Hemodialysis Care and Monitoring, showed: Pre dialysis evaluation is to be completed within four (4) hours of transportation to dialysis to include accurate weight, vital signs, mediations administered or withheld prior to dialysis. Post dialysis a nurse to review notes from the dialysis center fir resident tolerance of treatment, medications that may have been given during dialysis, review if blood transfusion was given, check for labs hemoglobin…

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 store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to keep the outside grease trap free from debris so it could drain properly. This deficient practice has the potential to affect more than a limited number of residents. Facility Census: 84. Findings Included: A facility policy Date Marking for Food Safety with a revision date 02/01/2019 stated (typed as written) .2. The food shall be clearly marked to indicate the date by which the food shall be consumed or discarded by. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label containing the date of opening, and the date the item must be consumed or discarded. An initial tour of the kitchen with the Food Service Director (FSD) #71 beginning on 07/05/22 at 10:25 AM found the following…

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 written policies to prohibit and prevent abuse and neglect of residents. Resident #14 made an allegation of abuse which was not reported to all the required State authorities as mandated by the facility policy. This was true for one (1) of one (1) resident reviewed for the care area of abuse. Resident identifier: #14. Facility census: 83. Findings included: a) Resident #14 Review of the policy: Abuse Prohibition Policy and Procedure found: .When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the CEO (Chief Executive Officer)/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's; . Review of the medical record found the following nurses note: 06/17/2022 17:48 (5:48 PM) Nurses Note - Note Text: Resident has had increased behaviors this evening, LPN (Licensed Practical Nurse) stated her and another CNA went to shower her and resident accused her of raping her when…

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 allegations of abuse were reported to all required State Authorities. This was true for one (1) of one (1) resident reviewed for the care area of abuse. Resident identifier: #14. Facility census: 83. Findings included: a) Resident #14 Review of the policy: Abuse Prohibition Policy and Procedure found: .When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the CEO (Chief Executive Officer)/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's; . Review of the medical record found the following nurses note: 06/17/2022 17:48 (5:48 PM) Nurses Note - Note Text: Resident has had increased behaviors this evening, LPN (Licensed Practical Nurse) stated her and another CNA went to shower her and resident accused her of raping her when shower was complete. Resident accused staff members in shower room of stealing from her, mistreating her. Resident told staff when she was…

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

Based on medical record review and staff interviews the facility failed to timely submit a correct discharge tracking Minimum Data Set (MDS) for Resident #85. The MDS was inaccurate in the area of discharge status. This was true for one (1) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #85. Facility census: 83. Findings included: a) Resident #85 A medical record review for Resident #85 revealed a discharge MDS was coded as a acute care hospital discharge for Resident # 85, who was discharged to the community on 05/25/22. In an interview with the MDS Coordinator on 07/06/22 at 4:00 PM, she verified the discharge MDS tracking completed for Resident #85 was inaccurate in the area of discharge status. She verified the resident was discharged to the community (home) not to a acute care facility. .

Based on observation, record review, and staff interview the facility failed to implement the care plan in place for hemodialysis clamps at bedside. Resident identifier: #75 Facility Census #83 Findings Included: a) Resident #75 On 07/05/22 at 1:00 PM, during the initial interview phase of the survey it was observed that Resident #75 was a hemodialysis patient and has a right chest hemodialysis catheter. Observation found no hemodialysis catheter emergency clamps in his room. Record review of the care plan shows the Resident is to have the clamps at bedside and on the resident's person when he is self-mobile throughout the center. This was confirmed with Licensed Practical Nurse #96 on 07/05/22 at 2:50 PM. .

Based on observation and staff interview, the facility failed to ensure the Foley catheter tubing was securely anchored to prevent excessive tension on the catheter and to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. This was true for one (1) out of three (3) residents reviewed for catheter and incontinence care. Resident Identifier: #2. Facility census 83. Findings included: a) Resident # 2 During an observation on 07/06/22 at 9:23 AM, Nurse Aide (NA) #42 was observed providing catheter care. Observation revealed Resident #2 did not have an anchor to secure the Foley catheter tubing, to prevent tension and/or accidental removal causing tissue damage. On 07/06/22 at 11:00 AM, the Director of Nursing (DON) was informed of the above findings. .

Based on observation, record review and staff interview the facility failed to provide the necessary hemodialysis services consistent with professional standards of practice. This was true for one (1) of one (1) hemodialysis resident reviewed during this annual survey. Resident identifier: 75 Facility census: 83 Findings included: a) Resident #75 On 07/05/22 at 1:00 PM it was observed that Resident #75 was a hemodialysis patient and has a right chest hemodialysis catheter. Observation found no hemodialysis catheter emergency clamps in his room. Record review of current orders and the care plan shows the Resident is to have the clamps at bedside and on the resident's person when he is self-mobile throughout the center. This was confirmed with Licensed Practical Nurse #96 on 07/05/22 at 1:05 PM. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to remove expired medical supplies from the medication storage room in accordance with currently accepted professional principles. This had the potential to affect a limited number of residents. Facility census: 83. Findings included: a) Medication storage room. Upon observation on [DATE] at 10:04 AM, the following items in the medication storage room were found to be expired. This was confirmed with Register Nurse - Director of Staff Education #5. The following items were expired: --Twenty (20) blue top blood collection vacutainers expired [DATE] --Twelve (12) red top blood collection vacutainers expired [DATE] --One (1) Intravenous Venous Fluid flow controller expired [DATE] --Three (3) administrator Intravenous Venous Fluid set expired [DATE] .