Good Shepherd Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to update the PASARR for Resident #19, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of four (4) residents reviewed for PASARR during the survey process. Resident Identifier: 19. Facility census: 181. a) Resident #19On 08/21/25, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 08/31/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated Other developmental disabilities.A continued record also revealed Resident#19 received a diagnosis of Paranoid Schizophrenia on the diagnosis listed after admission on [DATE] but did not receive a new PAS to address whether specialized services were needed. On 08/21/25 at 11:06 AM, an interview with the Director of Nursing confirmed the PAS presented to the surveyor did not indicate Paranoid Schizophrenia and was never updated.

Based on record review and interview, the facility failed to ensure the clarification of a resident's medication order for a drug that was required to be taken with food h. This was a random opportunity for discovery. Resident Identifier #40. Facility Census: 181.Findings Include: a) Resident #40 Record review on 08/20/25 at 8:59 AM revealed that Resident #40 had the following order dated 05/01/25, prescribed by her physician:Sensipar Oral Tablet 30 MG (Cinacalcet HCl)Give 1 tablet by mouth one time a day for elevated calciumThe United States Food and Drug Administration (FDA) guidelines state the following for administration of Cinacalcet (Sensipar):For all indications, Cinacalcet (Sensipar) should be taken with food or shortly after a meal and should always be taken whole and not divided. Sensipar lowers serum calcium and, therefore, patients should be carefully monitored for the occurrence of hypocalcemia. Potential manifestations of hypocalcemia include paresthesia's, myalgias, muscle cramping, tetany, and convulsions. Serum calcium should be measured within 1 week after…

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 reviews and interviews, the facility failed to follow weight policy and ensure resident weight was accurate and if needed a re weight preformed. Resident #51's weights were not rechecked per policy. This was a random discovery during the survey process and had the potential to effect more then a limited number of residents. Resident identifier: #51. Facility census: 181 a) Resident #51Resident #51 had five weights entered into the charting that should have triggered a re-weigh on that same day, as well as notification to the Medical Doctor. The facility failed to preform the re-weigh or notify the MD per facility policy. Record review on 08/21/25 at 9:55 AM revealed the following:Five weight events of 5% loss / gains from 01/01/25 - 08/12/25 01/01/25 145.8 pounds ( 5.5% (7.6 pounds) from previous weight01/01/25 145.8 lbs, 5.5% / 7.6 lbs from previous weight used by system01/04/25 145.8 lbs, 5.5% / 7.6 lbs from previous weight used by system. 07/01/25 143 lbs, 7% / 10 lbs from previous weight used by system08/04/25 133 lbs, 7% /10 lbs from previous weight used 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 record review and interview, the facility failed to ensure that the recommendations by the pharmacist were reviewed, addressed, and responded to, by the physician. This effected 2 out of 4 residents sampled. Resident Identifier 23 and 1. Census:181 The facility FAILED TO MEET STANDARD as evidenced by:The facility failed to ensure the pharmacist recommendations where address by the physician to ensure medication need or adjustment for residents #1 and #23. There were no copies of the recommendations in the electronic charts, the hard copies had the recommendations in them, but were unsigned by MD for the last two months. Resident (1) Record Review: 08/20/2025 MRR - was not signed into the resident's chart. There was not an electronic or hard copyMissing signature of MD on last two MRR's dated 7/31/25 & 6/30/25 Had sign here tags in place for MDInterview: 8/20/2025Pharmacist stated that they place a copy in the hard chart for the MD to review and sign.Resident (23) Record Review :08/20/2025 MRR - was not signed into the residents chart. MRR - was not signed into 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 medical record review, policy review, resident interview and staff interview, the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for four (4) of 36 reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: Resident #6, Resident #158, Resident #116 and Resident #43. Facility census: 118. Findings included: A review of the facility policy titled Care Planning-Interdisciplinary Team with a revision date of 04/13/23 read as follows: .3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan a) Resident #6 During an interview on 06/26/23 at 3:06 PM Resident #6 stated that I have never attended a care meeting or been invited. During an interview on 06/26/23 at 2:48 PM Social Services (SS) #155 stated the care plan meetings are held two (2) weeks after the Minimum Data Set…

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, policy review, medical record review, resident interview 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 for four (4) of four (4) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident identifiers: #6, #36, #1 and #72. Facility census: 181. Findings included: A review of the facility policy titled Activity Policy with a revision date of 04/13/23 read as follows: .Individualized and group activities are provided that reflect the schedules, choices and rights of the residents. They are offered at hours convenient to the resident, including evenings, holidays and weekends. They reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Activities appeal to men and women as well as those of various age groups…

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 manage pain in accordance with professional standards of practice for one (1) of six (6) residents reviewed for the care area of pain. Resident identifier: #51. Facility census: 181. Findings included: a) Resident #51 Review of Resident #51's medical records showed an order written on 05/30/23 for hydrocodone-acetaminophen every four (4) hours as needed for severe pain [rated] 6-10. The resident had no other pain medication ordered. On the following dates, at the following times, hydrocodone-acetaminophen was given even though the Resident reported her pain level was less than six (6): - 05/31/23 at 6:04 AM, pain level was rated five (5). - 06/04/23 at 3:50 AM, pain level was rated one (1). - 06/08/23 at 6:07 AM, pain level was rated four (4). - 06/13/23 at 2:49 PM, pain level was rated four (4). During an interview on 06/28/23 at 2:22 PM, the Director of Nursing (DON) confirmed Resident #51 had received hydrocodone-acetaminophen when her pain level was less than the physician-ordered pain level parameters for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge/transfer. This was true for one (1) of one (1) residents reviewed for hospitalization. Resident identifier #178. Facility census 181. Findings included: a) Resident #178 Record review on 06/28/23 at 10:27 AM, revealed Resident #178 was discharged to the hospital on [DATE]. Subsequent review of the Resident #178's medical record showed it did not contain evidence the Notice of Transfer or Discharge was provided to the Ombudsman upon discharge on [DATE]. On 06/28/22 at 10:04 AM during an interview the Director of Nursing (DON) confirmed the Ombudsmen was not notified of the discharge on [DATE].

Based on record review and staff interview, the facility failed to ensure the residents Preadmission Screening and Resident Review (PASRR) reflected the admission diagnosis. This was true for three (3) of five (5) reviewed for the PASRR care area during the Long-Term Care Survey. Resident identifiers: Resident #30, Resident #76, Resident #8. Facility census: 181. Findings included: a) Resident #30 During a record review on 06/27/23 at 10:37 AM, Resident #30's medical record revealed admitting diagnoses of anxiety disorder and bipolar disorder. Further review of the medical record revealed a PASRR dated 09/15/22, Section 30 Current Diagnosis, was coded None. During an interview on 06/27/23 at 2:48 PM with Social Services #155 stated I do not complete the PASRR, I just send it to the state for approval. The physician and a nurse complete them. During an interview on 06/27/23 at 3:09 PM, the DON acknowledged the PASRR was not completed with the diagnosis of bipolar disorder. b) Resident #76 A medical record review on 06/27/23, of the list of admission diagnoses for Resident #76…

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

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to comply with physician's orders. This deficient practice had the potential to affect three (3) of 36 residents reviewed in the long-term care survey sample. Resident identifiers: #60, #43, and #158. Facility census: 181. Findings included: a) Resident #60 Review of Resident #60's physician's orders showed an order written on 07/10/22 for the following laboratory testing every January and July: complete blood count, comprehensive metabolic panel, ferritin, iron, and lipid panel. Review of Resident #60's laboratory results for January 2023 showed results for the complete blood count and comprehensive metabolic panel. No results for the ferritin, iron, and lipid panel were in the resident's medical file. During an interview on 06/27/23 at 4:04 PM, Registered Nurse (RN) #8 confirmed the ferritin, iron, and lipid panel laboratory testing had not been performed in January 2023 as ordered by the physician. b)…

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 ensure wander guard devices were properly maintained to prevent elopement hazards. This failed practice was true for one (1) of two (2) Residents reviewed for elopement. Resident identifier: #151. Facility census: 181. Findings included: a) Resident #151 On 06/26/23 at 11:37 AM Resident #151 was observed ambulating throughout the hallway, near the 3 central elevator on 3rd floor. Resident #151 was noted to have a wander guard bracelet in place on the left lower extremity. Record review showed an order dated 02/11/23 to apply accutech [wander guard] bracelet for safety and check every shift for safety. Record review of the facility's policy titled, Safety/Accident Prevention, Accu Check System, not dated, showed that functioning of the transmitters was to be checked weekly. The policy's use statement showed wander guards were to be used to guarantee that residents with cognitive impairment were safe from exiting the building while…

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

Based on record review and staff interview, the facility failed to maintain an accurate and correct medical record. This was discovered for one (1) of 36 residents reviewed for the area of advance directives. Resident #175 did not have an order for hospice services and the Do Not Resuscitate (DNR) order was incomplete. Resident identifier: #175 Facility census: 181. Findings included: a) Resident #175 a1) During a medical record review on 06/28/23, revealed no diagnosis for hospice services on the current physician's orders. Further review indicated the care plan had been updated on 06/26/23 for hospice services. In an interview with Registered Nurse (RN) #164 on 06/28/23 at 12:16 PM, the RN verified there were no current orders for hospice services for Resident #175. a2) A review of the DNR order was found to be incomplete. There was no physician's signature and date, and the Medical Power Attorney (MPOA) signature was not dated. In an interview with Registered Nurse (RN) #100 on 06/27/23 at 8:22 AM, the RN verified the DNR order did not have a physician's signature and there were…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Appropriate hand hygiene was not performed during the pressure ulcer dressing change for one (1) of one (1) pressure ulcer dressing change observations. Resident identifier: #60. Facility census: 181. Findings included: a) Resident #60 Review of the facility's policy statement titled Wound Care indicated the facility's policy for removing the soiled dressing before wound treatment was as follows: - Put on exam glove. Loosen tape and remove dressing. Place dressing in plastic bag. Pull glove over dressing from one hand and then the other. - Remove gloves and place in plastic bag. The policy did not identify that hand hygiene must be performed between removing the soiled gloves and applying clean gloves and before proceeding with the wound treatment. On 06/28/23 at 10:07 AM, observation of Resident #60's left Achilles heel pressure ulcer…

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 that vaccination education was provided to residents receiving influenza vaccination. This failed practice had the potential to affect three (3) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #60, #97, and #30. Facility census: 181. Findings included: a) Policy Review Review of the facility's policy titled Prevention and Control of Influenza with a review date of March 2023 stated that residents with capacity or their Medical Power of Attorneys would be given information regarding the benefits and potential side-effects of the immunization. No policy implementation date was given. The policy contained no guidance regarding documentation of that information was provided to the resident. b) Resident #30 Review of Resident #30's progress note showed a note written by Social Worker (SW) #155 on 09/09/22 that stated, 9/7/22. Spoke with [resident's first name]. She would like to receive the flu vaccine. The resident's medical records contained no evidence was found that…

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

Based on observation and staff interview, the facility failed to display the staffing posting in a prominent place readily accessible to residents and visitors. This was a random opportunity for discovery. Facility census: 178. Findings included: a) Staff Posting On 03/30/22 at 8:37 AM, an observation found no staff postings on the second or third floor of the facility. Review of the facility found there are three (3) floors with seven (7) units where resident reside. The staff posting is unavailable for residents and visitors to readily view on six (6) of seven (7) units. During an interview on 03/30/22 at 8:47 AM, the Human Resources Director #268 revealed the staff posting could only be seen at the main entrance of the building and on One South. On 03/30/22 at 9:38 AM during an interview with the Regulatory Compliance Officer, she verified the staff postings are only located at the main entrance of the building and on One South. .

Based on observation of medication administration, staff interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent. Facility staff failed to administer medications according to professional standards for two (2) residents during medication administration contributing to a 10.53 % medication error rate. This deficient practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident # 123 and #89 Census: 178 Findings included: a) Policy review On 03/29/22 the facility policy, titled, Drug Therapy Oral Administration of Medication, no revision date, was reviewed. Under Key Procedural Points, the policy addressed under item 3: Not all tablets or capsules can be crushed. Crushing enteric-coated tablets of time- release capsules destroy their intended effect. If resident has problems swallowing whole tablets or capsules, obtain an order for medications to be given in immediate release liquid or form, if available. Under Section 3 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 policy review, observation, medical record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 and influenza in regard to precaution signage at resident doors, medication pass, and dietary services. These practices had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident identifiers: #128, #105, #35 and #84. Room identifier: #224. Facility census: 178. Findings included: Record review of the facility's policy titled, Infection Control, with a revision date of June 2021, showed that signs will be placed on the door to indicate precautions needed prior to entering a residents room. a) Resident #128 An observation on 03/28/22 at 11:14 AM found no signage on Resident #128's door to indicate precautions. On 03/28/22 at 11:14 AM completed the initial tour and 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 and staff interview, the facility failed to revise a care plan when the resident required increased assistance with meals. Resident identifier: #21. Facility census: 178. Findings included: a) Resident #21 On 03/28/22 at 1:20 PM, observation of resident #21 who did not have a lunch tray. On 03/28/22 at 1:25 PM, interview with Nurse Aide #83 when resident #21 would receive lunch tray and Nurse Aide #83 replied, in a few minutes she requires assistance with meals. On 03/29/22 at 1:00 PM, review of Resident #21 care plan showed resident was able to feed self once the tray was set up. On 03/29/22 at 2:04 PM interview with Administrative Nurse #3 to show Resident # 21 [NAME] to this surveyor and resident # 21 is to have a one (1) person assist for all meals. Resident #21 care plan states Resident #21 is to feed her self once tray is set up. No revision occurred with Care Plan. Administrative Nurse #3 agreed the Care Plan was not updated. On 03/29/22 at 4:20 PM, interview with Director of…

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

Based on observations and staff interview, the facility failed to meet professional standards of quality when a non-crushable medication was crushed and administered to Resident #142. In addition, the facility failed to ensure Resident #89 had been assessed and approved by the physician to self administer two (2) inhalers. This was a random opportunity for discovery. Resident identifiers: #89 and #142. Facility census: 178. Findings included: a) Resident #89 During an observation of a medication pass for Resident #89 on 03/29/22 at 9:18 AM with Licensed Nurse (LPN) #47 found the two (2) inhalers were placed on the overbed table. This resident removed the inhaler (Combivent a bronchodilator), from the box, shook the inhaler and proceeded to self-administer one (1) puff. Resident #89 wiped out the mouth piece with a tissue and put the inhaler back in the box. Resident #89 then removed the second inhaler (Symbicort a steroid) and proceeded to self-administer two (2) puffs. Again, this resident wiped the mouth piece with a tissue and put the inhaler back in the box. LPN #89 took both…

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 one (1) of 35 sampled residents reviewed, received treatment and care in accordance with physician's orders. The facility failed to ensure physician's orders were implemented for Resident # 217. Resident identifier: Resident #217. Facility census: 178. Findings included: a) Resident #217 A review of the electronic medical record, on 03/28/22 showed a current physician's order, with a start date of 03/09/22, for Resident #217 to have heels floated at all times when in bed every shift. An observation on 03/29/22, at 8:00 AM, with Licensed Practical Nurse #44 (LPN #44), Resident #217 was lying in bed and had her heels directly on the bed and had not been floated. An interview on 03/29/22 at 8:00 AM, with LPN #44, verified Resident #217 did not have her heels floated as required by the physician's order. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, staff interview, and record review, the facility failed to provide necessary treatment and services to promote healing of pressure ulcers. This was true for one (1) of six (6) residents reviewed for pressure ulcers. Resident identifier: #103. Facility census 178. Findings included: a) Resident #103 An observation on 03/30/22 at 9:30 AM of dressing changes to Resident #103 right and left heel found there was no dressing on the left heel when Registered Nurse (RN) #32 removed the resident's sock to perform the dressing change. A review of the medical record found Resident #103 had a Physician's order dated 03/16/22 {typed as written} Collagenase Ointment 250 unit/gram Apply to left heel topically every day shift for wound Cover with dry dressing. The treatment administration record (TAR) showed the treatment order date (03/16/22) there was no documentation the dressing was changed on 03/25/22 or 03/26/22 per physician order. A dressing change was documented on 03/29/22, but there was no…

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

Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not stored safely or properly for residents reviewed during the Long-Term Care Survey Process (LTCSP). This was a random opportunity for discovery. Resident identifier: #376. Facility census: 178. Findings included: a) Resident #376 An observation of Resident #376 at 1:00 PM on 03/28/22 found a nebulizer machine on a stand beside the resident. Resident #376 was not using the nebulizer and the tubing and mouthpiece were sitting uncovered on the stand. Another observation on 03/29/2022 at 8:30 AM found Resident #376's a nebulizer mouthpiece and tubing were laying uncovered on top of the nebulizer machine. Licensed Practical Nurse (LPN) #47 was in Resident #376's room. In an interview on 03/29/22 at 8:30 AM, LPN #47 verified the nebulizer mouthpiece and tubing were sitting on the stand and should be placed in a bag to be stored when not in use. In an interview on 03/30/22 at 11:00 AM the Director of…

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

Based on record review, staff interview, and policy review, the pharmacist failed to identify irregularities for medications in excessive doses related to Acetaminophen (Tylenol). This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #16. Facility census: 178. Findings included: a) Resident #16 A medical record review for Resident #16 found, physician orders as follows for Resident #16: --Tylenol Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 4 hours as needed for pain with a start date of 12/19/21. --Acetaminophen Elixir Give 10 cc by mouth every 4 hours as needed for general discomfort with a start date of 12/21/21. It's possible for Resident #16 to receive 5850 milligrams of Acetaminophen in one day. On 03/30/22 at 9:58 AM an interview with the Director of Nursing (DON) verified there was a potential for Resident #16 to receive an excessive dose of Acetaminophen. She stated that they changed the Acetaminophen order to liquid and didn't discontinue the pill form. .