Auburn Oaks Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe discharge home for one of four sampled residents (Resident 1), when Resident 1 was discharged home with another resident's (Resident 2) medications. This failure had the potential for Resident 1 to take the wrong medications causing adverse effects. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including orthopedic aftercare for fusion of spine (surgery to connect two or more bones in the sine) and spinal stenosis (narrowing of the spaces in the spinal canal). A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- blood flow to the brain is blocked). A review of Resident 1's Minimum Data Set (MDS- 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 interview and record review, the facility failed to complete annual performance evaluations (PEs) for three of five sampled certified nursing assistants (CNAs; CNA 3, CNA 4, and CNA 5), for a census of 95. This failure increased the risk of residents receiving poor-quality care from the CNAs. Findings: During a concurrent interview and record review on 10/2/24 at 2:48 p.m. with the Director of Staffing Development (DSD) and the Consultant of Director of Staffing Development/Infection preventionist (CDSD/IP), the DSD and CDSD/IP reviewed CNA 3, CNA 4, and CNA 5's employee's files and found the following: CNA 3 was hired on 7/30/19, CNA 4 was hired on 12/26/20, and CNA 5 was hired on 8/31/09. All the CNAs files reviewed had no documented evidence the annual PEs were done. The DSD stated, I have not completed any employee's performance evaluations PEs in 2023 to 2024 . During a concurrent interview and record review, on 10/3/24 at 9:15 a.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON stated, The PEs are completed by the DSD and are used to identify…

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, interview, and record review, the facility failed to ensure care and services in accordance with acceptable professional standards of quality were provided for four of 25 sampled residents (Resident 143, Resident 144, Resident 36, and Resident 85), when: 1. Medication and ointments were left at the nightstand of Resident 143; 2. Medication, hazardous liquids and ointments were left at the bedside of Resident 144; 3. A medication was not administered completely and left at the bedside, and oxygen tank was empty while in use for Resident 36; and 4. The oxygen (O2) saturation levels were not monitored for Resident 85. These failures had the potential risks to negatively affect the residents' health status. Findings: 1. Resident 143 was admitted in late 2024 with diagnoses which included peripheral vascular disease [decreased blood flow to the arms and legs], communication deficit, difficulty walking, and lack of coordination. During a review of Resident 143's Baseline Care Plan (BCP), 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 observation, interview and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for four of five randomly selected residents (Residents 3, 22, 75 and 78); and 2. An antibiotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after being opened and medications were removed. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 3 had a physician's order dated 9/16/24, for hydrocodone/acetaminophen (a medication to treat pain)…

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 interview and record review, the facility failed to develop and implement a process to ensure clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for one of 25 sampled residents (Resident 83). This failure had the potential to result in medication-related problems, errors, or irregularities identified and reported by the PC, and the potential for unnecessary medications (such as prolonged use, excessive dose, unmonitored use, duplication, etc.) for the resident. Findings: A review of Resident 83's medical record indicated she was admitted to the facility on [DATE] with multiple diagnosis including Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), anxiety, insomnia, dementia, high blood pressure, depression, and repeated falls. A review of the Resident 83's medical record indicated she had physician's orders 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.

Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for resident use, medications with shorter expiration dates after use were labeled with an open date, single-use medications were discarded after use, medications were labeled with a pharmacy label, and medications in medication carts were stored in a clean, safe and orderly manner in accordance with the facility's policy and procedure (P&P). These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being safely stored. Findings: During an inspection on 9/30/24 at approximately 11 a.m. of the Central Supply, alongside Assistant Director of Nursing (ADON), three tubes Skintegrity Hydrogel (a topical used for wound care) expired 2/2024 and two vials EvenCare G3 blood glucose test strips (used to test blood sugar) expired 6/2024 were identified. ADON confirmed the finding and stated expired items were to be removed…

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, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 95 residents who received facility prepared foods, when: 1. Proper food labeling was not followed; 2. Expired foods were not discarded; 3. Undated box of loose bananas with dark brown to black discoloration and leaking fluids were stored in the walk-in refrigerator; and 4. Several wet steam table pans were found stacked at the clean and ready-to-use storage areas. These failures had the potential to cause food-borne illnesses. Findings: 1. During the initial kitchen tour on 9/30/24 beginning at 8:40 a.m. the following items were observed not having proper labeling: Inside the dry storage: Unlabeled and opened clear plastic bag of coconut flakes with no opened or used date. Inside the walk-in refrigerator: Opened resealable plastic bag of diced onion with no opened or used by date; and Unlabeled and opened clear plastic bag of cut celery sticks with no opened or used by date. During a concurrent…

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, interview, and record review, the facility failed to maintain an infection prevention and control program for four of 25 sampled residents (Resident 148, Resident 36, Resident 1 and Resident 3), when: 1. A hand held nebulizer (HHN, breathing treatment device) and a nasal cannula (tubing that delivers oxygen) were unlabeled and undated for Resident 148; 2. A nasal cannula and HHN with expired dates were found at the nightstand of Resident 36; 3. Resident 1's oxygen (O2) tubing and face mask was not labeled or dated; and 4. Resident 3 O2 tubing and face masks were not labeled or dated and the antimicrobial bag was labeled with an expired date. These failures increased the potential risk for respiratory infection. Findings: 1. Resident 148 was admitted in late 2024 with diagnoses which included pulmonary edema (fluid in the lung causing cough with extreme difficulty of breathing), muscle weakness and swallowing difficulty. During a concurrent observation and interview on [DATE] at 10:23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 25 sampled residents (Resident 92), when the discharge MDS indicated the resident was discharged to an acute hospital. This failure resulted in Resident 92's MDS inaccurate assessment data submitted to CMS (Centers for Medicare-Medicaid Services). Findings: Resident 92 was admitted to the facility in the middle 2024 with multiple diagnoses which included heart failure and difficulty in walking. During a review of Resident 92's Physician Orders (PO), dated 8/20/24, the PO indicated, Discharge to home with medications . During a review of Resident 92's Nurse's Note (NN), dated 8/21/24 at 10:17 a.m., the NN indicated, Pt [patient] is discharging to home today . During a review of Resident 92's Nurse Practitioner Note (NPN), dated 8/21/24 at 3:04 p.m., the NPN indicated, .resident noted to be discharging to go home today . During 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 interview and record review, the facility failed to ensure comprehensive care plans were developed or implemented for three out of 25 sampled residents (Resident 36, Resident 148, and Resident 85), when: 1. Resident 148 had no care plan for a newly ordered respiratory treatment; 2. Resident 36's respiratory treatment and oxygen (O2) therapy care plan was not implemented; and 3. Resident 85's O2 therapy care plan was not implemented. These failures increased the potential risk to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 148 was admitted in late 2024 with diagnoses which included pulmonary edema (fluid in the lungs causing cough with extreme difficulty of breathing), muscle weakness and swallowing difficulty. During a review of Resident 148's Physician Orders (PO), dated [DATE], the PO indicated, Ipratropium-Albuterol Solution [combination medication used to treat obstructive lung disease] .3 ml [milliliter, volume…

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 2. Resident 29 was admitted to the facility in early 2024 with diagnoses which included spinal stenosis (narrowing of the spinal canal in the lower part of the back), dysphagia (difficulty swallowing foods or liquids), and unspecified dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 29's MDS, dated [DATE], indicated Resident 29's cognition as moderately impaired. The MDS reflected that Resident 29 required supervision, verbal cues, and touching/steadying assistance when eating. During a review of Resident 29's care plan (CP), dated 8/5/24, the CP indicated Resident 29 was on, 1:1 assist and needs encouragement and sometimes feeding assist .Eats in dining room for most meals. During a dinning observation on 9/30/24 at 12:50 p.m. Resident 29 did not receive 1:1 assistance after the staff placed her meal in front of her. During a review of Resident 29's meal ticket, dated 9/30/24, the meal ticket indicated Resident 29's assist instruction which included…

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, interview and record review, the facility failed to ensure physician's orders were followed in accordance with professional standards for two of 25 sampled residents (Resident 85 and Resident 71), when: 1. Resident 85's oxygen (O2) was not administered as ordered and O2 saturation level was not monitored; and 2. Resident 71's insulin medication was administered outside of physician ordered parameters. These failures increased the potential risk for the decline in the residents' health status and well-being. Findings: 1. Resident 85 was admitted in the middle of 2024 with diagnoses which included lung cancer, pulmonary fibrosis (scarred lung tissue over time causing shortness of breath), and chronic obstructive pulmonary disease (COPD). During a review of Resident 85's Care Plan (CP), dated 8/21/24, the CP indicated, [Resident 85] has pulmonary fibrosis .oxygen therapy as ordered. During a review of Resident 85's Minimum Data Sets (MDS, an assessment tool), dated 8/27/24, the MDS indicated Resident 85 had no memory impairment and needed O2 therapy. During an…

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, interview, and record review, the facility failed to provide the residents with a safe and comfortable environment free of accident hazards when four out of ten residents' bathroom faucets had water temperatures above 120 degrees Fahrenheit (F, scale for measuring temperature). This failure could potentially place residents at risk of accidental scalds or burns from hot water. Findings: During a concurrent observation and interview on 9/30/24 at 8:56 a.m. with Certified Nurse Assistant (CNA) 6 in Resident 1's bathroom, CNA 6 confirmed the faucet water temperature to be 120.2 F. Resident 1 stated, The water is always very hot, and at times I am scared the water might burn or scald me . During a concurrent observation and interview on 9/30/24 at 11:02 a.m. with Housekeeper (HK) 1 in Resident 22 and 7's bathroom, HK 1 confirmed the faucet temperature to be 122.2 F. HK 1 stated that the water was very hot and could burn or scald the resident's skin since they were fragile. During a concurrent observation and interview on 9/30/24 at 11:11 a.m. with CNA 7 in Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident food preferences were accommodated for four of 25 sampled residents (Resident 51, Resident 60, Resident 82, and Resident 20), when the residents' meal choices were not served. This failure increased the potential risk for the residents not attaining their highest practicable mental, physical and psychosocial well-being. Findings: 1. Resident 51 was admitted in late 2020 and readmitted in the middle of 2021 with diagnoses which included malnutrition, adult failure to thrive (condition where the individual's organs specifically the digestive tract are not absorbing required nutrients), and swallowing difficulty. During a review of Resident 51's care plan (CP), dated 9/2/24, the CP indicated, At risk for Altered Nutritional Status, Malnutrition - 9/2/22, revised 7/4/24 - Food preferences to be honored; Baseline food preferences - 10/26/22, revised 7/7/24 - Food preferences to be honored at time of service. During a review 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 observation, interview, and record review, the facility failed to ensure the antibiotic stewardship guidelines were followed for one of 25 sampled residents (Resident 12), when Resident 12 received an antibiotic with no end date. This failure resulted in inappropriate or unnecessary use of antibiotic treatment for the resident. Findings: Resident 12 was admitted to the facility in the Spring of 2012 with a diagnosis that included diabetes (abnormal blood sugar levels), kidney disease, and urinary tract infection (UTI). During a review of Resident 12's Physician Orders (PO), dated 12/11/22, the PO indicated, [Brand Name] Capsule 250 MG (Cephalexin) Give 250 mg [milligram, unit of weight] by mouth one time a day for UTI .CEPHALEXIN 250 MG CAPSULE - TAKE 1 CAPSULE BY MOUTH ONCE DAILY (NO STOP DATE .INDEFINITE). There was no documented evidence an order of monitoring for signs and symptoms of UTI. During a review of Resident 12's Minimum Data Set (MDS, an assessment tool), dated 8/14/24, the MDS indicated Resident 12 had no memory impairment. During an interview on 10/1/24 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 observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from verbal abuse when a Certified Nursing Assistant (CNA 1) used profanity while Resident 1 asked for assistance. This failure resulted in Resident 1 feeling intimidated and verbally abused at the facility. Findings: A review of Resident 1's admission Record indicated he was admitted to the facility in early 2023 with multiple diagnoses including depression, cerebral infarction (also known as a stroke - damage to tissues in the brain due to a loss of oxygen to the area), benign prostatic hyperplasia (also known as enlarged prostate) with lower urinary tract, complications of amputation of the left leg above the knee, difficulty walking, muscle weakness, lack of coordination, contracture of left hand, and abnormal posture. A review of Resident 1's Minimum Data Set (MDS-an assessment tool) Cognitive Patterns, dated 6/20/24, indicated he had a Brief Interview for Mental Status Score (BIMS-a tool to assess cognition) of 15 out of 15, which indicated he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1's) rights were exercised safely when the resident self-administered medications without being evaluated or monitored by the health professionals. This failure resulted in Resident 1 taking multiple non-prescription supplements and vitamins, taking duplicate medications and increased the potential for adverse effects, medication errors, and ineffective medication therapy. Findings: Review of Resident 1's clinical record, admission Record, indicated the resident was a long term resident in the facility with diagnoses that included chronic inflammation disorder affecting nerves (disorder that leads to loss of strength or sensation), diabetes (a serious condition where your blood sugar level is too high), pain and hallucinations. In a concurrent observation and interview on 6/20/24 starting at 11:19 a.m. in Resident 1's room, with Licensed Nurse (LN 1) present, multiple bottles of vitamins and…

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, interview, and record review, the facility failed to provide adequate monitoring and supervision for one of three sampled residents (Resident 3), when Resident 3 eloped (leaving unsupervised and undetected) from the facility. This failure had the potential to cause harm to Resident 3. Findings: Resident 3 was admitted in the Fall of 2023 with diagnoses which included Metabolic encephalopathy (a chemical imbalance caused by an illness that damages the brain), alcohol abuse with withdrawal delirium (a serious change in mental abilities), hypertension (high blood pressure), homelessness, and muscle weakness. During a review of Resident 3's Face Sheet (identification sheet), the Face Sheet indicated Resident 3's family member was the responsible party (RP, person responsible for the patient). During a review of Resident 3's Progress Notes Nurses Notes (PN), dated 10/28/23, at 11:02 a.m., the PN indicated, [Nurse] from [Name of Hospital] called stating pt [patient] was brought in by ER [Emergency room] staff stating pt fell off his bike. She is calling to clarify…

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, interview, and record review, the facility failed to ensure safety measures were in place for one out of five sampled residents (Resident 4), who was at risk for falling. This failure had the potential to cause physical injury. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in October 2018 with diagnoses including frequent falls and unspecified dementia (loss of cognitive functioning - thinking, remembering, and reasoning) and difficultly walking. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/2/23, indicated Resident 4 required one-person physical assistance from staff for transfers between surfaces (e.g. moving from the bed to a wheelchair or from the bed to a chair). The MDS further indicated Resident 4 used a wheelchair in the facility. During a concurrent observation and interview on 10/3/23 at 12:49 p.m. in Resident 4's room, Resident 4 was seen with Licensed Nurse (LN 1). Resident 4 was observed leaning on her right side facing her transfer pole…

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 interview and record review the facility failed to medicate Resident 5 with her scheduled fentanyl (opioid pain medication) patch. This failure had the potential to increase pain during end-of-life care. A review of a facility document titled, admission RECORD, indicated Resident 5 was admitted on [DATE], with diagnoses that included Alzheimer's (problems with memory, thinking and behavior). Resident had a hospice (agency that assists with end-of-life care) provider. During a telephone interview on 10/3/23 at 9:38 a.m. with Resident 5's Responsible Party (RP), RP stated she went to visit Resident 5 around 9/22 and noticed the resident was grabbing her stomach and was moving around in bed. RP stated Resident 5 appeared in pain. A review of a facility document titled, Medication Administration Record, indicated on 9/19/23 and 9/22/23, the scheduled dose of fentanyl 72 hour, 25mcg (mcg= microgram, unit of measurement) patch was not given. A review of a facility document titled, Medication Administration…

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, interview and record review, the facility failed to ensure the resident call light system was accessible for two out of five residents (Resident 1 and Resident 3). This failure increased the risk of residents being unable to obtain assistance when needed. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted in December 2021 with diagnoses that included dementia (inability to think or do daily tasks) and muscle weakness. A review of Reident 3's admission RECORD, indicated Resident 3 was admitted in October 2022 with diagnoses that included dementia and muscle wasting. In a concurrent observation and interview, on 10/3/23 at 11:46 a.m., Resident 1 was sitting in a wheelchair on the left side of his bed with a beside table in front of him. Certified Nurse Assistant 1 (CNA 1) stated Resident 1's call device was not in reach of the Resident and was on the opposite of the bed where Resident 1 was sitting. In a concurrent observation and interview, on 10/3/2023 at 11:50 a.m., Resident 3 was observed laying in bed. CNA 1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 1) of a census of 97 was free from abuse, when Resident 2 intentionally grabbed Resident 1's shirt. This failure increased the potential to negatively impact Resident 1's highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 2's progress note, dated 8/7/23, indicated around 10:30 in the morning, Resident 2 was observed by staff rolling down the hallway beside the nursing station in his wheelchair. Resident 1 was seated when Resident 2 made a stop and grabbed him by the front of his shirt. Resident 2 verbalized he was tired of Resident 1 and his behaviors. Resident 2 could not sleep because Resident 1 kept coughing all night and his television (TV) volume was up until midnight. Resident 2 felt his personal space wasn't being respected because Reisdent 1 would bring his stuff into his side of the room. A review of an admission record indicated Resident 1 was admitted to 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, interview and record review, the facility failed to ensure records of disposition and effective storage of destroyed controlled medications (regulated substances or drugs) were maintained when: 1. Random controlled medication audits did not reconcile for two out of five residents (Resident 3 and Resident 27); and 2. Multiple vials containing crushed and partially crushed medications, including narcotics, were found to be retrievable in four medications carts. These failures resulted in the facility not having accurate accountability of controlled substances and increased the potential for drug diversion and accidental exposure to destroyed medications. Findings: 1a. Resident 3 was admitted in early 2021 with diagnoses which included chronic pancreatitis (inflammation of pancreas) and chronic pain syndrome. During a review of Resident 3's Order Summary Report (OSR), dated 8/23/22, the OSR indicated, [Brand name, (hydrocodone-acetaminophen, controlled pain medication)] 10-325 milligram [mg, a unit of measure] 1 tablet by mouth every 6 hours as needed for moderate…

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, interview, and record review, the facility failed ensure the medication error rate of 5 percent or below was maintained for a census of 93, when two medication errors were observed during medication pass. This failure resulted in medication error rate of 5.41%. Findings: 1. During a medication pass observation on 1/30/23, at 8:09 a.m., with Licensed Nurse 1 (LN 1), LN 1 was observed preparing 8 medications for Resident 66. During a review of Resident 66's Order Summary Report (OSR), dated 12/20/22, the OSR indicated, [Brand Name, diltiazem, blood pressure medication] Extended Release 24 Hour 180 milligram (mg, a unit of measurement) 1 tablet by mouth one time a day at 0800 [8 a.m.] .Hold if SBP (Systolic Blood Pressure, a measurement that indicates how much pressure blood is exerting against artery walls when the heart beats) is below 160. During a review of Resident 66's Medication Administration Record (MAR) for January 2023, the MAR indicated, LN 1 administered [diltiazem] to Resident 66 on 1/30/23, with a documented SBP of 130. During an interview on…

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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 66) was free of a significant medication error, when the resident received a blood pressure medication twenty-nine times, below the hold parameter as ordered. This failure had the potential risk for harm to Resident 66. Findings: Resident 66 was admitted in late 2022 with diagnoses which included high blood pressure. During a review of Resident 66's Order Summary Report (OSR), dated 12/20/22, for [Brand Name, diltiazem (blood pressure medication)] 180 milligram (mg, a unit of measurement) 1 tablet by mouth one time a day at 0800 (8 a.m.) .Hold if SBP (Systolic Blood Pressure, a measurement that indicates how much pressure blood is exerting against artery walls when the heart beats) is below 160. During a review of Resident 66's Medication Administration Record (MAR) for the months of December 2022 and January 2023, the MAR indicated nursing staff administered [diltiazem] with a SBPs below the hold parameter of 160, on the following dates: 12/21/22, 12/24/22, 12/25/22,…

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, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with current guidelines and principles in a census of 93, when: 1. Two bottles of expired medications were available for resident use; and 2. Ten opened inhalers were not labeled with an open and discard date. These failures had a potential for residents to receive unsafe medications. Findings: 1. During an observation on 1/30/23, at 11:05 a.m., in the central supply medication room, with the Director of Central Supply (DSC), the DSC identified two bottles of simethicone (a medication to relieve gas), dated 12/2022. The DSC verified both bottles were expired and indicated the bottles should have been removed from the facility's drug supply. During an interview on 1/30/23, at 11:04 a.m., with the Director of Nursing (DON), the DON confirmed the expired simethicone should have been pulled out from the inventory. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, revised 10/22, the P&P indicated,…

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, interview and record review, the facility failed to ensure a baseline care plan (BCP), for two of 25 sampled residents (Resident 185 and Resident 187), was completed and provided to the resident or the resident's responsible party (RP). This failure had the potential to leave the residents and the responsible parties without information summarizing the goals, medications, treatments, diet, and discharge plans. Findings: 1. Resident 185 was admitted on [DATE] with diagnoses which included a neck fracture. During a review of Resident 185's electronic medical record on 1/30/23, the medical record indicated the BCP was not completed and was in progress. During a review of Resident 185's Order Summary Report (OSR), dated 1/30/23, the OSR indicated, [Neck] Collar on at all times every shift. During a concurrent observation and interview on 1/30/23, at 9:12 a.m., Resident 185 was laying in bed, awake and alert and verbally responsive, with a neck collar in place. Resident 185 stated, I hurt my…

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, interview and record review, the facility failed to develop and implement a plan of care for two of 25 sampled residents (Resident 56 and Resident 185), when: 1. Resident 56 had no care plan developed for respiratory failure and the use of oxygen (O2); and 2. Resident 185 had no care plan developed and implemented for the use of a neck collar. These failures had the potential to result in the residents not attaining their highest practicable well-being. Findings: 1. Resident 56 was admitted in late 2022 and re-admitted in early 2023 with diagnoses which included respiratory failure. During a review of Resident 56's Order Summary Report (OSR), dated 1/17/23, the OSR indicated, Maintain O2 Sats [oxygen saturation, measure of blood oxygen content] above 90%; Oxygen - @ [at] 2 Liters/Min [minute] Via Nasal Cannula [NC] every shift. During a review of Resident 56's OSR, dated 1/26/23, the OSR indicated, Ipratropium-Albuterol Solution [medication for lung infection and asthma] .3 ml [milliliter, volume measurement] inhale orally every 6 hours as needed for SOB…

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, interview and record review, the facility failed to ensure that one of 25 sampled residents (Resident 28) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, when a fall mat was not in place as ordered by the physician. This failure increased the potential for injury. Findings: Resident 28 was admitted to the facility in the spring of 2017 with multiple diagnoses which included dementia (memory loss), muscle weakness and inability to communicate. During a review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 11/29/22, the MDS indicated Resident 28 had severely impaired memory and required total assistance from two persons for Activities of Daily Living (ADLs). During a review of Resident 28's Nursing Care Plan (NCP) titled, Fall .[Resident 28] is at risk for falls r/t [related to] weakness, Alzheimer's disease [progressive memory loss and thinking skills], HTN [hypertension, raised blood pressure] hx [history] of falls, major depressive disorder, dementia,…

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, interview and record review, the facility failed to ensure an appropriate intervention was implemented for one of 25 sampled residents (Resident 28), when Resident 28's plan of care, to turn and reposition every two hours and as needed to prevent wound progression, was not followed. This failure resulted in Resident 28's coccyx (tailbone) pressure wound progressing from Stage 2 (shallow open or break in the top two layers of the skin) to a Stage 4 (deep wound that may impact the muscle, tendons, ligaments and bone). Findings: Resident 28 was admitted in the middle of 2017 with diagnoses which included dementia (memory impairment), morbid obesity, and diabetes mellitus (abnormality of blood sugar levels). During a review of Resident 28's Nursing Care Plan, revised 5/31/17, the NCP indicated, [Resident 28] is at risk for altered skin integrity related to decreased/impaired mobility, incontinent of bowel and bladder, diabetes mellitus type 2, episodes of resistive to care, advanced age with thin and fragile skin, history of pressure injuries/skin impairment.…

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 interview and record review, the facility failed to ensure one of 25 sampled residents (Residents 27) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 27 received as-needed lorazepam (a psychotropic medication for anxiety) without prescriber-documented rationale and specified duration for extended use beyond 14 days. This failure had the potential to result in unnecessary use of medication. Findings: On 2/1/23, a review of Resident 27's medical record indicated she was admitted to the facility with diagnoses that included bipolar disorder and anxiety. Resident 27 had a physician's order, dated 1/6/23, for lorazepam 0.5 milligram (mg, a measurement), 1 tablet by mouth every 12 hours as needed for generalized anxiety disorder manifested by verbalization of anxiousness. This order exceeded 14 days. On 2/1/23, a review of Resident 27's medical record indicated there was no documented evidence to show the physician documented the rationale why the resident needed the lorazepam…

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, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and utensils in accordance with professional standards for food safety for a census of 93, when: 1. Five bags of frozen chicken breasts covered with ice crystals were found in the freezer; 2. A cutting board and can opener were found with rough surfaces which interfere with sanitization; and 3. Clean forks were touched on the eating surface by ungloved hands after being cleaned, sanitized, and dried. These failures increased the potential for food-borne illnesses. Findings: 1. During a concurrent observation and interview within the initial kitchen tour on 1/30/23, at 8:09 a.m., with the Registered Dietitian (RD), five bags of frozen chicken breast were found in the freezer covered in ice crystals. The RD stated, These should be tossed out. I don't want to compromise the health of the residents. During a review of the facility's policy and procedures (P&P), titled, Procedure for refrigerated storage, dated 2018, the P&P…

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.