Oasis Pavilion Nursing & Rehabilitation Center

Based on observations, staff interviews, and facility policy and procedure reviews, the facility failed to meet professional standards of quality care by failing to ensure resident information and a list of resident names to unauthorized personnel were not exposed when the electronic record screen was unlocked and unattended. This failure to meet these professional standards can result in the potential for resident personal information available to be seen by unauthorized individuals. Findings include: During an observation of the medication cart conducted on March 6, 2024 at 7:50 a.m., there was an uncapped syringe and pill cup filled with an assortment of pills that were left unattended on a cart. The electronic health record (EHR) was open and uncovered, displaying a resident's picture and list of medications. The registered nurse (RN/staff #161) who was responsible for the medication cart and the EHR was found in alcove with another patient; and the pill cup, syringe, and EHR screen were out of the line of sight of the nurse. In another medication administration with the RN…

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 clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the residents' (#1 and #63) rights to be free from abuse of another resident (#149 and #15). The deficient practice could result in further abuse of residents and appropriate action not take. Findings include: Regarding resident #1 and resident #149 -Resident #1 (alleged victim) was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, Parkinson's disease with dyskinesia, major depressive disorder, chronic obstructive pulmonary disease, and rheumatoid arthritis. The activities of daily living (ADL) care plan initiated on November 28, 2022 included that the resident required assistance due to weakness, congestive heart failure, Parkinson's disease, and restless leg syndrome. Interventions included assist with ADLs as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS)…

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 clinical record review, staff interviews and policy review, the facility failed to ensure that care plan was updated and revised as needed for one resident (#15). The deficient practice could result in resident not receiving appropriate treatment/services to meet their needs. Findings include: Resident #15 was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, and multiple sclerosis. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating that the resident was cognitively intact. The MDS also included that the time of the assessment the resident was negative for psychosis, behavioral symptoms, wandering, and rejection of care. A nursing note dated July 26, 2023 revealed that the roommate (resident #63) reported that resident #15 had been mean, bumped into the roommate with the motorized scooter and told the roommate that she controlled the room. Per the documentation, the roommate…

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 and staff interviews, clinical record review and facility policy and procedures, the facility failed to ensure care and services related to an indwelling urinary catheter was provided to one resident (#47). The census was 96. The deficient practice could result in residents being at risk for urinary catheter complications and urinary tract infections. Findings include: Resident #47 was admitted on [DATE] with diagnosis of urinary tract infection (UTI), sepsis, unspecified organism and type 2 diabetes mellitus (DM) without complications. The care plan dated January 25, 2024 revealed the resident had altered elimination as exhibited by bowel incontinence and indwelling Foley catheter. The goal was that the resident will not develop a urinary tract infection related to Foley catheter use. Interventions included barrier cream incontinent care to prevent skin breakdown; catheter care per facility policy; assistance to the commode/toilet with morning care, before and after meals, 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.

Based on observations, staff interviews and review of the facility policies/procedures, the facility failed failed to keep two of the four medication carts locked and under the direct supervision of authorized staff; and, failed to ensure that medications were not left unattended on the medication cart. The facility also failed to keep two of the four medication carts locked and under the direct supervision of authorized staff in an area where residents could access them. Findings include: During an observation of the medication cart conducted on March 6, 2024 at 7:50 a.m., there was an uncapped syringe and pill cup filled with an assortment of pills that were left unattended on a cart. During an observation of the medication storage areas with a Licensed Practice Nurse (LPN/staff #161) conducted on March 6, 2024, at 1:50 p.m., two unlocked and unsupervised medication carts were in an unlit alcove of Hall B of the facility. These carts had over-the-counter medications easily accessible in the top drawer of both carts. In an interview with the LPN (staff #161) immediately 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 observation, staff interviews, and review of facility policy and procedure, the facility failed to implement infection control practices for resident care when preparing insulin for medication administration; and, failed to clean single-resident insulin pens prior to administration. The deficient practice could result in resident to developing infection and complication. Findings include: During a medication administration observation with license practical nurse (LPN/staff #123) conducted on March 6, 2024 at 10:44 a.m., the LPN was preparing insulin medication for one resident and the LPN did not wipe the single-resident use needle insertion site with an alcohol swab on before placing the needle for administration. In an interview with the assistant of director of nursing (ADON/staff # 72) conducted on March 7, 2024 at 2:06 p.m., the ADON stated that nurses were expected to follow the 5 rights of medication administration, lock their computer screens and medication carts when stepping away. The ADON stated that it was expected for nurses to check blood sugars and insulin…

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 clinical record review, facility documents, resident and staff interviews, and policy reviews, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents, which included resident #235. Failure to provide sufficient staffing could result in resident care oversights. Findings include: Observations were done for call light response time in hall E, D and C and revealed the following: Hall E: Call light observed on 11/15/22 at 11:30 AM, answered at 11:49 AM Call light observed on 11/15/22 at 1:23 PM, answered at 1:54 PM Hall C: Call light observed on 11/16/22 at 10:01 AM, answered at 10:10 AM Hall D: Call light observed on 11/16/22 at 12:56 PM, answered at 1:16 PM An interview was conducted with a Certified Nursing Assistant (CNA/staff #43) on 11/16/22 at 1:48 PM. Staff #43 stated that call lights should be answered in no more than 10 minutes, or in less than 20 minutes if they are with another resident. She added that if a CNA has too many call lights, they have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure medications were not left in the room of one resident (#239). The deficient practice could negatively impact residents' care, and result in residents not receiving medications as ordered by the physician. The sample was 18 residents. Findings include: Resident #239 was admitted on [DATE] with diagnoses that included surgical aftercare, type 2 diabetes, polyneuropathy, non-pressure chronic ulcer of right heel, presence of aortocoronary bypass graft, PVD with angioplasty with implants and grafts and peripheral vascular disease. Review of a care plan initiated on November 10, 2022 revealed no evidence of a care plan for medication self-administration. Review of the clinical record revealed no evidence of a medication self-administration assessment. Review of physician orders revealed: -Lactulose Solution 20 GM/30 ML, Give 10 ml (milliliter) by mouth two times a day for bowel care dated…

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 clinical record reviews, staff interviews, and facility policies, the facility failed to ensure the resident's responsible party was notified when two residents (#134 and #45) had a change of condition. The sample size was 3. The deficient practice could result in other residents' responsible parties not being notified. Findings include: Resident #134 was admitted [DATE] with diagnoses that included pneumonia, bipolar disorder, depression and sepsis. Review of a nurses' note dated 2/3/2022 at 22:30 revealed the nurse found the resident on the floor on their knees by the bedside in a large amount of stool feces. The resident was unable to tell the nurse what happened. Some confusion was noted and there was no evidence of the resident hitting their head. The resident denied pain or discomfort at the time. The resident was assessed for injuries, no injuries were noted. No evidence of pain or discomfort. The resident was taken to the shower to be cleaned and dried and returned to bed. The physician and 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 closed clinical record review, staff interviews, and policy review, the facility failed to implement their policy regarding an allegation of abuse involving one resident (#284). The sample size was 2. The deficient practice could result in further incidents of alleged abuse not being reported and investigated. Findings include: Resident #284 was admitted to the facility on [DATE], with diagnoses that included difficulty walking, other abnormalities of gait and mobility and type 2 diabetes. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating the resident had intact cognition. An interview was conducted on November 17, 2022 at 12:41 p.m. with the Assistant Director of Nursing (ADON/staff #19) regarding an allegation of abuse involving resident #284. Staff #19 stated she knew resident #284 fell on a Sunday (December 19, 2021). Staff #19 stated that when she came back to work on a Monday (December 20, 2021), she saw…

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 closed clinical record review, staff interviews, and policy review, the facility failed to report an allegation of abuse involving one resident (#284). The sample size was 2. The deficient practice could result in further incidents of alleged abuse not being reported. Findings include: Resident #284 was admitted to the facility on [DATE], with diagnoses that included difficulty walking, other abnormalities of gait and mobility and type 2 diabetes. An interview was conducted on November 17, 2022 at 12:41 p.m. with the Assistant Director of Nursing (ADON/staff #19) regarding an allegation of abuse involving resident #284. Staff #19 stated she knew resident #284 fell on a Sunday (December 19, 2021). Staff #19 stated when she came back to work on a Monday (December 20, 2021), she saw the resident's eyes were blackened like a racoon. Staff #17 stated approximately two days later on Tuesday (December 21, 2021), a detective from the police department came to the facility. Staff #17 stated she was with 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 closed clinical record review, staff interviews, and policy review, the facility failed to implement their policy regarding an allegation of abuse involving one resident (#284). The sample size was 2. The deficient practice could result in further incidents of alleged abuse not being investigated. Findings include: Resident #284 was admitted to the facility on [DATE], with diagnoses that included difficulty walking, other abnormalities of gait and mobility and type 2 diabetes. An interview was conducted on November 17, 2022 at 12:41 p.m. with the Assistant Director of Nursing (ADON/staff #19) regarding an allegation of abuse involving resident #284. Staff #19 stated she knew resident #284 fell on a Sunday (December 19, 2021). Staff #19 stated when she came back to work on a Monday (December 20, 2021), she saw the resident's eyes were blackened like a racoon. Staff #17 stated approximately two days later on Tuesday (December 21, 2021), a detective from the police department came to the facility. Staff…

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 clinical record review, staff interviews, and policies and procedures, the facility failed to notify one resident (#80) and/or the resident's representatives in writing of a transfer/discharge and failed to send a copy of the notice to the Ombudsman. The sample was 2. The deficient practice could result in receiving residents/representatives and the Ombudsman not receiving written notices of transfers/discharges. Findings include: Resident #80 was admitted on [DATE] with diagnoses that included herpes zoster eye disease, anemia, dementia, heart failure, cerebral infarction, cerebral atherosclerosis, dysphagia, peripheral vascular disease, pneumonitis, chronic respiratory failure, and fracture of left femur. The clinical record indicated the resident had a family member as an emergency contact. Review of the admission Minimum Data Set (MDS) assessments dated September 8, 2022, revealed a Brief Interview of Mental Status score of 11, which indicated the resident had moderate cognitive impairment. 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 clinical record review, staff interviews, and policies and procedures, the facility failed to ensure one resident (#80) and/or the resident's representatives was provided written information regarding the facility's bed hold policy before transfer to the hospital. The sample was 2. The deficient practice could result in the resident not being informed of the facility's bed hold policy. Findings include: Resident #80 was admitted on [DATE] with diagnoses that included herpes zoster eye disease, anemia, dementia, heart failure, cerebral infarction, cerebral atherosclerosis, dysphagia, peripheral vascular disease, pneumonitis, chronic respiratory failure, and fracture of left femur. The clinical record indicated that the resident was their own responsible party, and included a family member as an emergency contact. Review of the clinical record revealed a discharge Minimum Data Set assessment dated [DATE] which indicated the resident was discharged to an acute care hospital. Review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, the RAI (Resident Assessment Instrument) Manual and policy review, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#53) within the required timeframe. The sample size was 18. The deficient practice could result in the resident not having continuity of care. Findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, and hypertensive heart disease without heart failure. The admission Data Collection dated 10/11/22 revealed the resident's skin was good/without areas of concern. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. The resident required limited to extensive 1 to 2 persons physical assistance for most activities of daily living (ADLs) and had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policies, the facility failed to ensure one resident (#81) received treatment and care that was in accordance with professional standards of practice. The sample size was 18. The deficient practice may result in residents not receiving needed care and services. Findings include: Resident #81 was admitted to the facility on [DATE] with diagnoses that included laceration of the stomach, subsequent encounters, dysphagia, and acute post hemorrhagic anemia. A communication deficit care plan initiated 08/31/22 related to a non-verbal status had a goal to be able to communicate wants and needs. Interventions stated to anticipate and provide basic needs such as pain control and to ask questions requiring simple yes or no answers. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have severely impaired cognition, and He required extensive 1-person physical assistance for most activities of daily living. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that 2 residents (#53 and #233) received pressure ulcer treatment and care in accordance with professional standards of practice. The sample size was 8. The deficient practice increases the risk for pain, infection and rehospitalization. Findings include: -Resident #53 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, and hypertensive heart disease without heart failure. The admission Data Collection dated 10/11/22 revealed skin good/without areas of concern. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. The resident required limited to extensive 1 to 2 persons physical assistance for most activities of daily living (ADLs) and had no pressure ulcers/pressure injuries. A Braden Scale dated…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that RNA (Restorative Nurse Assistant) services were consistently provided for two sampled residents (#27 and #32) with limited mobility. The deficient practice could result in residents experiencing decrease in mobility. Findings: -Resident #27 was admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the care plan initiated on 10/23/20 revealed the resident required assistance with Activities of Daily Living related to cerebrovascular accident with right sided weakness. The goal was that the resident would achieve maximum functional mobility. Interventions stated consult PT (physical therapy)/OT (occupational therapy)/ST (speech therapy)/RNA as needed, use bilateral assistance bars for mobility, and consult PT/OT as needed for education of appropriate use of bed mobility assistance bars. Review of the rehabilitation…

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 clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#235) was provided pain management in accordance with professional standards of practice. The sample size was 2. The deficient practice could result in unrelieved pain and additional complications. Findings include: Resident #235 was admitted on [DATE] with diagnoses that included abnormality of gait and mobility, difficulty walking, nondisplaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, and generalized muscle weakness. Review of the admission assessment dated [DATE] revealed the resident was alert, oriented to person, place, date/time, purpose, and was anxious. An admission Note dated August 10, 2021 at 7:00 PM revealed the resident was agitated and did not want to be at the facility and would be leaving in the morning. The note also revealed they would continue to monitor to ensure safety and comfort. Review of the pain management tool…

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 clinical record review, staff interview, and policy review, the facility failed to ensure target behavior monitoring was conducted for one resident (#17) who was receiving psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #17 was admitted on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance and anxiety, bipolar disorder, schizophrenia, unspecified, and major depressive disorder. Review of the physician orders revealed an order for Olanzapine 15 milligrams for bipolar disorder dated December 4, 2021, Clonazepam tablet 0.5 milligrams for restlessness dated January 13, 2022, and Cymbalta 60 milligrams for depression as evidenced by crying dated February 9, 2022 Review of the care plan with a revision date of July 15, 2022 revealed the resident takes the psychotropic medication (Olanzapine) related to bipolar, unspecified…

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, resident and staff interviews, and review of policy and procedures, the facility failed to ensure menus were consistently followed. The deficient practice could place residents at risk of nutritional problems and dissatisfaction with their meals. Findings include: The following deviations from the posted menu were identified: -On 11/15/22 the lunch menu included shrimp scampi over rice and zucchini. Noodles were served in lieu of rice and no zucchini was provided. -On 11/16/22 the menu called for navy bean soup. Split pea with ham soup was delivered. An interview was conducted on 11/14/22 at 10:52 a.m. with a resident. She stated that 9 times out of 10 she will fill out her menu slip and they will bring her something else. The resident stated that she has been told that the kitchen was short of food. An interview was conducted on 11/17/22 at 9:18 a.m. with a Certified Nursing Assistant (CNA/staff #32). She stated that replacement food items are often provided instead of what the residents ordered. She stated that she thinks dietary does not always read 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 concerns identified during the survey, the Facility Assessment, staff interviews, and policy review, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure a plan of action was developed and implemented that corrected identified quality care concerns related to skin breakdown not being corrected. The deficient practice could result in other quality concerns not being corrected. Findings include: During the annual survey conducted 11/14/22 through 11/17/22, concerns were identified regarding delayed identification and assessment of new and existing skin wounds, delays in obtaining and/or providing wound treatments and in wound treatments not consistently being provided. Review of the Facility Assessment, reviewed 03/24/22, revealed the purpose of the assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment stated the type of care provided by the facility included pressure…

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 observations, staff interviews, and policies and procedures, the facility failed to ensure that infection control standards were followed by failing to perform hand hygiene during wound care for one resident (#53). The deficient practice could result in the spread of infection. Findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of head of right radius, subsequent encounter for closed fracture with routine healing, unspecified fall, and unspecified fracture of the right femur. An admission data collection dated October 11, 2022 revealed skin was good without areas of concern. Review of admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 12 indicating the resident had moderately impaired cognition. The assessment stated resident #53 required extensive assistance of 1-2 persons with ADLs (Activity of Daily Living). Review of nurses' notes dated October 27, 2022 at 11:39 a.m.,…

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.