3 Reports
Inspection Report — Dec 18, 2024
Routine CMS
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, medical record documentation, infection prevention and control, and adherence to physician orders at the nursing facility.
Findings
The facility failed to correctly implement physician's orders for medication administration for one resident, maintain complete and accurate medical records for catheter care and medication side effect monitoring, and follow infection prevention protocols including Enhanced Barrier Precautions and hand hygiene for catheter care.
Deficiencies (3)
F 0658: The facility failed to follow physician's orders for Resident #3 by administering Amlodipine Besylate medication despite blood pressure readings below the prescribed threshold of 140/90 mmHg.
F 0842: The facility failed to maintain complete medical records for Resident #7 by omitting documentation of suprapubic catheter care and intake and output, and failed to document side effects monitoring for antidepressant, antianxiety, and anticoagulation medications for Resident #3.
F 0880: The facility failed to implement infection prevention protocols by not following Enhanced Barrier Precautions and proper hand hygiene during suprapubic catheter care for Resident #7.
Report Facts
Residents sampled for medication administration: 16
Residents reviewed for catheter care: 1
Residents reviewed for unnecessary medication and medication regimen: 5
Residents observed for Enhanced Barrier Precautions: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Licensed Practical Nurse | Administered Amlodipine Besylate medication to Resident #3 against physician's orders and confirmed lack of awareness of blood pressure parameters. |
| S1DON | Director of Nursing | Reviewed medication administration and documentation deficiencies and confirmed expectations for compliance. |
| S3LPN | Licensed Practical Nurse | Failed to document suprapubic catheter care and intake/output for Resident #7 and did not follow Enhanced Barrier Precautions during catheter care. |
| S4LPN | Licensed Practical Nurse | Forgot to document intake and output for Resident #7 on 12/11/2024 day shift. |
| S5LPN | Licensed Practical Nurse | Forgot to document intake and output for Resident #7 on 12/04/2024 night shift. |
Inspection Report — Dec 20, 2023
CMS
Date: Dec 20, 2023
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations and to evaluate residents' understanding of binding arbitration agreements included in admission agreements.
Findings
The facility failed to ensure medications requiring refrigeration were properly stored, specifically Lorazepam Concentrate was found at room temperature instead of refrigerated. Additionally, the facility failed to educate residents and their representatives about the binding arbitration agreements they signed upon admission.
Deficiencies (2)
F 0761: The facility failed to ensure medications requiring refrigeration were properly stored. Lorazepam Concentrate for Resident #79 was found at room temperature instead of in the medication room refrigerator.
F 0847: The facility failed to ensure residents or their representatives understood the binding arbitration agreement signed on admission for 3 residents (#21, #77, and #177). All 24 current residents had signed binding arbitration agreements without education on their meaning.
Report Facts
Residents affected: 1
Residents affected: 3
Residents currently residing: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Confirmed improper medication storage of Lorazepam Concentrate | |
| S2DON | Confirmed medication storage requirements and temperature guidelines | |
| S3AC | Reviewed admission agreements and confirmed presence of arbitration agreements | |
| S1ADM | Confirmed lack of education on arbitration agreements for residents | |
| Pharmacist | Confirmed proper storage requirements for Lorazepam Concentrate |
Inspection Report — Jan 19, 2023
CMS
Date: Jan 19, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the nursing home Christwood, related to a regulatory survey completed on 01/19/2023.
Findings
No health deficiencies were found during the survey.
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