Oak Glen Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman) for one of three sampled residents (Resident 1). This failure has the potential for the Ombudsman not to be able to advocate for the resident in protecting his rights from inappropriate transfer and discharge. Findings: On September 4, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles). A review of Resident 1 ' s History and Physical, dated April 4, 2024, indicated Resident 1 can make decisions. A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated June 27, 2024, indicated, Resident 1 had Brief Interview of Mental Status (BIMS-a tool to measure cognitive function in older adults), score of 14 (cognitively intact). A review of Resident 1 ' s SNF/NF…

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 a comfortable environment for the residents, when the temperature level for one of the four residents' rooms and in the facility hallway was above 81 degrees Fahrenheit (°F -temperature scale). This failure had the potential to cause discomfort, irritability, sleep disruption, and could lead to health problems. Findings: On July 9, 2024, at 4:15 p.m., an unannounced visit to the facility was conducted to investigate a physical environment issue. On July 9, 2024, at 4:20 p.m., the Resident Representative (RR) was interviewed. The RR stated, on July 6, 2024, the air conditioning was not functioning and the staff had indicated it would be fixed. The RR, who visits the facility daily, stated, facility was hot. The RR stated, last night Resident A woke up soaking wet. The RR stated, the facility air conditioning unit was in poor condition. On July 9, 2024, at 4:30 p.m., the Maintenance Director (MD) was interviewed. The MD stated he was unaware that the air conditioning was not working last Saturday (July…

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 food items were stored, prepared, and served under sanitary conditions when: 1. The fifteen pounds of bacon were thawed and were refrozen; and 2. There was no thawing log available for review in accordance to the facility's policy and procedure. These failures had the potential to result in food borne illnesses (illness that comes from eating contaminated food) to 56 medically vulnerable residents. Findings: 1. On April 8, 2024 at 9:08 a.m., during initial tour of the kitchen with the Food and Nutrition Service Director (FNSD), inside the freezer, four-one-gallon plastic bags containing bacon were observed not frozen solid. A concurrent interview was conducted with the FNSD, FNSD stated the bags of bacon were not in their original container. The FNSD further stated the bacon should be frozen solid, when stored in the freezer. On April 10, 2024, at 8:06 a.m., during an interview with the FNSD, the FNSD stated, the fifteen pound bacon in original container was thawed and placed in the walk-in…

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

Based on observation, interview, and record review, the facility failed to ensure the dietary staff performed testing of the sanitizing solution according to manufacturer's instructions. This failure had the potential to cause foodborne illness (illness that comes from eating contaminated food) among the 56 vulnerable residents in the facility. Findings: During a concurrent observation, interview, and review of the manufacturer's instruction for testing QUAT concentration, on April 10, 2024, at 8:26 a.m., the [NAME] was observed to had dipped the strip into sanitizing solution for five seconds, then compare the strip to a color scale found on the strip container. The [NAME] stated according to the manufacturer's instruction, dip the test strip for 1-2 seconds, and then compare within 10 seconds the strip with the color scale. The [NAME] stated he dipped the strip for five seconds and did not follow the manufacturer's instruction. The [NAME] further stated he should have followed the manufacturer's instruction. The [NAME] stated, otherwise it would not reveal an accurate result 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for one of 16 sampled residents (Resident 54), the call light was within the resident's reach. This failure had the potential to result in Resident 54 not being able to call for staff assistance when needed. Findings: On April 9, 2024, at 8:01 a.m., Resident 54 was lying in bed. The call light was observed not within reach by Resident 54, it was on his right side hanging in between the floor and the bed. Resident 54 stated he could not call for assistance. Resident 54 stated, the call light was not by his side. On April 9, 2024, at 8:33 a.m., during a concurrent interview and observation in Resident 54's room with CNA 1, CNA 1 stated, Resident 54's call light was not within reach. CNA 1 further stated, the call light should be placed within easy reach of the resident. A review of Resident 54's admission Record, dated April 10, 2024, indicated the resident was admitted to the facility on [DATE], with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record readily accessible to the staff, for one of three residents reviewed for AD (Resident 49). This failure had the potential for Resident 49's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment. Findings: On April 10, 2024, Resident 49's record was reviewed. Resident 49 was admitted to the facility on [DATE]. A review of Resident 49's Minimum Data Set (an assessment tool), dated March 14, 2024, indicated Resident 49 had severe cognitive impairment. A review of Resident 49's Advance Directive Acknowledgement, dated January 22, 2024, indicated Resident 49 had executed an Advance Directive. There was no documented evidence a copy of the AD was provided in Residents 49's medical…

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 follow up Level II Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) evaluation from the appropriate State-Designated Authority (SDA) upon admission, for two of four residents (Residents 42 and 44). This failure had the potential for Residents 42 and 44 not to receive the services required in an appropriate setting as determined by the SDA. Findings: 1. On April 10, 2024, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder and mild neuro cognitive disorder (types of mental disorders). A review of Resident 42's PASARR Level 1 Screening document dated March 21, 2024, indicated, .Level 1 - Positive .Result: Positive for suspected MI (sic) (Mental Illness) .Level II Mental…

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 for one of 16 residents reviewed for quality of care (Resident 10) to ensure resident was monitored for signs and symptoms of bleeding or bruising (discoloration and tenderness of the skin resulting from pooling of blood beneath the skin) and the physician was notified. This failure had the potential for delayed treatment and management. Findings: On April 9, 2024, at 8:51 a.m., a concurrent observation and interview with Resident 10, in his room, was conducted. Resident 10 was observed with skin discoloration (bruising) approximately three centimeters (cm) by 0.5 cm. on the right upper arm. Resident 10 stated she could not remember when she got it. Resident 10 stated she could have gotten it from wheeling her wheelchair. A review of Resident 10's admission Record, indicated , she was admitted to the facility on [DATE], with diagnoses which included cerebro-vascular accident (stroke- a result of disrupted blood flow to the brain). 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.

Based on observation, interview, and record review, the facility failed to follow the menu for a Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) NAS (no added salt) Mechanical Soft with chopped meat- diet, for one of 16 residents (Resident 33). This failure had the potential to not meet the resident's nutritional needs. Findings: On April 10, 2024, at 11:54 a.m., the FNSD was interviewed. The FNSD stated for fortified diet, the [NAME] should add extra gravy to make it fortified. A review of Resident 33's meal tray card, for lunch, indicated Mechanical Soft/chopped meats, Fortified NAS. During a concurrent observation and interview, on April 10, 2024, at 12:14 p.m., during lunch tray line in the kitchen with the Cook, the [NAME] was observed not adding extra gravy to Resident 33's lunch meal tray. The [NAME] placed Resident 33's lunch meal tray onto the meal delivery cart, ready to serve. The [NAME] was asked about Resident 33's lunch meal tray, the [NAME] stated he did not add another scoop of gravy to Resident 33's meal…

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 for one of seven residents (Resident 159), to accommodate Resident 159's food preference for no fish, when Resident 159 was served fish. This failure resulted in Resident 159's food preference not being honored, potentially leading to the resident not consuming the food served and having the potential for weight loss. Findings: A review of the facility document titled, Cooks Spreadsheet, for Week 3 Wednesday, indicated, .SPRING MENUS .Garden Fresh Meatloaf . A review of the facility document titled, Good For Your Health Menus, for April 8-14, 2024, indicated, .Wednesday April 10 .Garden Fresh Meatloaf . During tray line observation in the kitchen on April 10, 2024, at 12:45 p.m., the ktichen was observed to run out of meatloaf while serving meal trays. The [NAME] was observed preparing chicken and fish replacing meatloaf. Seven residents were not served meatloaf. In a concurrent interview with the Cook, the [NAME] stated, the facility ran out of meat loaf. The [NAME] stated, seven residents were not served…

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 leftover food brought by visitors or family members was stored properly when the temperature of the refrigerator was at 44 degree F (Farenheit - unit of measurement). In addition, food found inside the refrigerator at the nurses' station was not labeled. This failure had the potential for residents to be exposed to foodborne illness. Findings: On April 10, 2024, at 8:50 a.m., during a concurrent observation of the resident's refrigerator at nurses' station 2 and an interview with the Food and Nutrition Service Director (FNSD), it was observed that the residents' refrigerator was 44°F (degrees fahrenheit - a scale for measuring temperature). Inside the refrigerator, a cup of soup was observed, which was not labeled with a name or date. The FNSD stated, the food should be labeled with the resident's name and a use- by date. The FNSD stated, the refrigerator temperature should be below 41°F. The facility document policy and procedure titled, Foods Brought by Family/Visitor, dated October 2017,…

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 two staff reviewed was offered the COVID-19 (a respiratory infection caused by a virus) vaccination and provided education regarding the benefits and risks of the COVID-19 vaccine. This failure had the potential for the staff not to have guidance and information regarding the COVID-19 vaccine. Findings: On April 11, 2024, at 2:45 p.m., during a concurrent interview and review of CNA 2's Employee Onboarding File, with the Director of Staff Development (DSD), the DSD stated, CNA 2 was hired on March 19, 2024. The DSD stated, CNA 2's COVID-19 vaccination was on February 10, 2022 (2 years ago). The DSD stated, she should have offered COVID-19 vaccine to CNA 2 upon hire. On April 11, 2024, at 3:09 p.m., during a concurrent interview and review of CNA 2's Employee Onboarding File, with the Infection Preventionist (IP), the IP stated, CNA 2 was not offered the COVID-19 vaccine and was not educated on COVID-19 immunization upon hire. The IP further stated, she is responsible for offering the COVID-19 vaccination to…

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 infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented, for one of six employees reviewed, when: 1. For Certified Nurse Aide (CNA) 1, the Employee's Screening Sheet (a log that employees fill out to self-report temperature, hand hygiene, fever or chills, cough, short of breath/difficulty breathing, fatigue, muscle or body aches, head ache, sore throat, new loss of taste/smell, congestion/runny nose, nausea/vomiting, diarrhea, pink eye, not feeling well) was accurately completed. 2. The Dietary Supervisor (DS) was sent home when she had signs and symptoms of respiratory illness (body aches, headache, sore throat, cough, and runny nose) on January 9, 2024, and January 10, 2024; These failures had the potential to increase staff and resident exposure and transmission of Covid-19 and/or other respiratory illnesses. Findings: 1. On January 17, 2024, the Employee's Screening Sheet, dated January 10, 2024, was reviewed. CNA 1, who worked the night…

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 store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. There was no thawing and handling system for frozen nutritional supplement drinks (health shake); 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance, and 3. The foodservice department had no system for ambient food (food that can be safely stored at room temperature in a sealed container, for example, canned tuna fish) cooling down process. These failures had potential to cause foodborne illness in a highly susceptible population of 50 out of total census of 50 residents who received food from the kitchen of the facility. Findings: 1. During an observation in the walk-in refrigerator on November 7, 2022, at 9:35 a.m., there was a box of nutritional supplement drinks (health shakes, the drinks that provide additional nutrients and are perishable) did not indicated any date of pulled from 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 provide a clean environment for the residents and visitors. One out of two garbage disposal bins located outside by the kitchen had trash inside and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour observation on November 7, 2022, at 10:09 a.m., one out of two dumpsters located outside nearby facility kitchen had trash inside and not securely closed by the dumpster lid. A concurrent interview with the Food Service Manager (FSM), she confirmed the dumpster was not securely closed with the lid. She agreed it was not acceptable and stated the dumpster lid should be closed tightly all the time. During an interview with the Registered Dietitian (RD) on November 10, 2022, at 9:35 a.m., she stated the dumpsters should be closed at the time to prevent pest and rodent infestation. A review of undated facility policy 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 ensure infection control practices were implemented when: 1. A staff member did not perform handwashing according to facility protocol; 2. The facility did not implement Legionella (a bacteria that can cause legionnaire's disease [a type of pneumonia]) water management program policy and procedure; and 3. A licensed nurse did not sanitize blood pressure equipment in between use. These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population. Findings: 1. On November 9, 2022, at 9:41 a.m., Certified Nursing Assistant (CNA) 3 was observed performing handwashing at the nurses' Station 1. CNA 3 completed her handwashing in less than 20 seconds. In a concurrent interview with CNA 3, CNA 3 stated the duration of handwashing should be one minute. She stated she did not perform handwashing properly. On November 10, 2022, at 12:43 p.m., the Infection Preventionist (IP) was interviewed. She stated handwashing surveillance was performed randomly by her. The IP…

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 menu was being followed for the therapeutic diet and portion sizes for lunch on November 7, 2022, and lunch on November 8, 2022, when: 1. Resident 30 was on CCHO (consistent carbohydrate, a diet treatment for diabetes), NAS (no added salt), Renal (a diet treatment for chronic kidney disease or end stage kidney disease) with finger food (food items that are in bite size and can pick up by fingers to consume) did not receive a wheat roll as indicated on the menu; 2. Three residents (Resident 8, 22, and 304) received incorrect portion sizes, when: a. Resident 8 was on regular diet with mechanical soft texture (a diet with food texture modified into a soft, chopped, or ground consistency for person who has chewing or swallowing difficulties) and dislike spinach who received three ounces (oz.) of corn (substitute of spinach) instead of four oz.; b. Resident 22 was on regular diet with mechanical soft texture and large portion who received three oz. of broccoli and three oz. of pasta instead of four oz…

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 for two of 50 residents reviewed for resident rights (Residents 34 and 43), during dining observation: 1.For Resident 34, the staff member was not positioned according to facility standards; and 2.For Resident 43, the resident was not positioned according to facility standards. These failures had the potential for Resident 34 and 43, to not attain their highest practicable mental, physical, and psychosocial well-being. Findings: 1. Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnosis which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anemia (low red blood cells). A review of Resident 34's Minimum Data Set (an assessment tool) dated September 27, 2022, indicated, Resident 34 required extensive assistance (staff provided weight bearing-support) with eating. On November 7, 2022, at 12:51 p.m., the during dining observation,…

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 provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility) for one of three residents reviewed for SNF ABN (Resident 39). This failure had the potential to result in the resident to not be informed about the potential liability for payment in non-covered Medicare Part A services in writing. Findings: Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE] with a diagnosis which included hemiplegia and hemiparesis (weakness on one side of the body). Resident 39's Medicare Part A started on September 13, 2022, & ended October 20, 2022. The resident continued to stay in the facility for long term care. There was no documented evidence the resident/beneficiary received a written SNF ABN. On November 10, 2022, at 2: 50…

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 Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was updated for one of four residents reviewed for PASARR (Resident 25). Resident 25 had developed a new diagnosis and was provided antipsychotic (a class of psychotropic [drugs that affecta person's mental state]) medication on September 14, 2021. This failure had the potential for the resident to be inapproriately placed in the facility, and not receive the treatment and services to meet the resident's needs. Findings: A review of Resident 25's record indicated, Resident 25 was admitted to the facility on [DATE], with diagnosis which included dementia (memory loss) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 25's PASARR dated June 9, 2021, indicated, .Initial Preadmission Screening .Level 1 -…

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 for two of 15 residents reviewed for care planning (Residents 25 and 36), when: 1. For Resident 25, the care plan was initiated for wandering and elopement; and 2. For Resident 36, the care plan intervention for Lance Adam's Syndrome (generalized muscle jerks) was implemented. This failure had the potential to result in injury when resident experienced uncontrollable movements. Findings: 1. A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 25's physician order dated November 6, 2022, indicated the following: - Monitor resident for episodes of elopement and encourage in group activities to stay in the dining room and participate . - Monitor for episodes of wandering and encourage in group activities to stay in the dining room and participate or activity of choice . There was no care plan initiated for elopement and wandering. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for one of 50 residents (Resident 17), care and services were provided according to accepted standards of clinical practice when the resident was allowed to self-administer her medications. This failure had the potential to result in unsafe adminstration of medication. Findings: On November 7, 2022, at 9:45 a.m., during a concurrent observation and interview with Resident 17, a green tablet was observed inside the medication cup, on the overbed table. Resident 17 stated the nurse gave her two tablets this morning after breakfast for her upset stomach. Resident 17 stated she took one tablet, and she told the nurse she would take the other tablet later. Resident 17 stated the nurse left the other tablet for her to take later. On November 7, 2022, at 10:31 a.m., during a concurrent observation and interview with Resident 17 and Licensed Vocational Nurse (LVN) 2, LVN 2 stated he did not see the medication at bedside. Resident 17 stated…

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 treatment and care were provided in accordance with professional standards of practice, for two of 15 residents residents reviewed for quality of care (Residents 25 and 32) when: 1. For Resident 25, the blood work was completed according to the physician order on September 2022; and 2. For Resident 32, the physician order was followed for administration of Resource 2.0 (a nourishment to increase caloric intake). These failures had the potential for Resident's orders to not be followed resulting in a delay of care and physical well being. Findings: 1. A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 25's physician order dated April 11, 2021, indicated Resident 25 was to have routine blood work (Complete blood Count and Comprehensive Metabolic Panel) every three months on March, June, September, and December 2022.…

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 for one of seven residents reviewed for unnecessary medications (Resident 34) to ensure that the pharmacy recommendation for September 23, 2022, regarding the use of Atarax (hydroxyzine-is used to relieve itching caused by allergic skin reactions) was acted upon promptly. This failure had the potential for Resident 34 to experience the adverse side effect such as sedation. Findings: A review of Resident 34's record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) A review of Resident 34's record titled, Consultant Pharmacist's Medication Regimen Review, dated September 23, 2022, indicated the resident is currently on Morphine pm (narcotic analgesics -pain medicines), Depakene (valproic acid- antiepileptic used to treat various types of seizure disorders, Pamelor (Nortriptyline- used to treat the symptoms 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 interview and record review, the facility failed to ensure one of seven residents (Resident 25), was assessed by the physician for the use of antipsychotic medication. This failure had the potential to result in unnecessary use of antipsychotic medication for Resident 25. Findings: A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of the document titled, INITIAL HISTORY and PHYSICAL, dated July 22, 2022, indicated Resident 25 had a diagnosis of dementia. There was no indication in the physician progress notes Resident 25 had a diagnosis of Schizophrenia. There was no documentation the physician assessed Resident 25's behaviors. A review of the document titled, Order Summary Report, for the month of November 2022, indicated, .SEROquel Tablet (QUEItapine Fumarate) Give 75 mg (milligram) by mouth two times a day for schizophrenia . On November 9, 2022, at 9:30 a.m., Registered Nurse Supervisor (RNS)…

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 the licensed nurse administered medications according to the physician's order when two medications were not administered for one of four residents observed during medication pass (Resident 5). These failures resulted in a medication error rate of 7.69 percent and increased the potential of harm to residents due to medications not being administered as prescribed by the physician. Findings: On November 9, 2022, at 8:23 a.m., during medication pass observation with Licensed Vocational Nurse ( LVN) 3, the following medications were administered: 1. Lovaza (omega 3- supplement for managing high triglycerides [a type of body fat in the blood]) one gram (gm) two capsules by mouth; 2. Spirinolactone (used to treat high blood pressure) 25 mg (milligram) one tablet by mouth; 3. Gabapentin (nerve oain medication) 100 mg one tablet by mouth; 4. Escitalopram (used to treat depression [persistent feeling of sadness and loss of interest] 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 interview and record review, the facility failed to ensure for one of 50 residents (Resident 22), an identified concern regarding missing personal belongings was tracked, reviewed, and followed by the committee. This failure resulted in an unsettled resolution to the identified concern affecting the quality of care, quality of life, and resident safety. Findings: On November 7, 2022, at 3:06 p.m., Resident 25 was observed in the room holding a stuffed toy. The name identified on the label of the stuffed toy did not match the resident in possession of the toy. On November 9, 2022, at 3:36 p.m., in a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, he stated he recognized the stuffed toy in Resident 25's room. CNA 1 stated the stuffed toy belonged to Resident 22. CNA 1 reviewed Resident 22's personal belongings list and stated Resident 22 had eight toys and only one stuffed toy was in Resident 22's room. CNA 1 stated it could be that during room change, the resident's personal belongings were lost during the transfer. CNA 1 stated he was not…

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