Royal Oaks Manor-Bradbury Oaks

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY B. During a review of Resident 23's AR, the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and fever, unspecified. During a review of Resident 23's H&P, dated 9/11/2024, the H&P indicated, Resident 23 had the capacity to understand and/or sign any form. During a review of Resident 23's MDS, dated [DATE], the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 did not receive the influenza vaccine in the facility. During a concurrent review of the activities CP with the Activities Staff (AS) on 11/14/2024 at 2:46 PM, the AS stated there was no activities CP developed for Resident 23. The AS stated the activities CP would guide the AS on what activities should be provided to Resident 23. During a review of 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 observation, interview, and record review, the facility failed to use appropriate alternatives prior to the use of bedrails for two of two sampled residents (Resident 12 and Resident 23.) This deficient practice had the potential to result in accidents for Resident 12 and Resident 23 due to the use of bedrails. Findings: A. During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 on 5/10/2024, with diagnoses that included dementia (a progressive state of decline in mental abilities,) muscle weakness, and difficulty with walking. During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 3 was unable to express ideas and wants and was unable to understand verbal content. During an observation on 11/12/2024 at 10:35 AM, Resident 12 was asleep in bed, lying on her back. A quarter siderails was up on both sides of the bed. B. During a review of Resident 23's AR, the AR…

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 accuracy of medical records for one of one sampled resident (Resident 23) by failing to: A. Ensure Resident 23's Medication Administration Record (MAR, a log initialed and/or signed by the nurse with the date and time each time a medication is administered to a resident) was complete when on 9/21/2024, 9/25/2024, and 9/28/2024, the facility's Controlled Drug Record for Hydrocodone-Acetaminophen (pain medication used to relieve moderate to severe pain, works in the brain to change how your body feels and responds to pain) 5-325 mg (milligram, unit of measurement) indicated Hydrocodone-Acetaminophen 5-325 mg was removed and Resident 23's MAR did not reflect administration of Hydrocodone-Acetaminophen 5-325 mg. B. Ensure Resident 23's change of condition for the development of a skin rash was documented in Resident 23's medical record. These deficient practices resulted in an inaccurate MAR and had the potential to result in a medication error for…

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 its infection prevention and control program for four of seven sampled residents (Resident 2, 26, 41, and 40) by failing to: A. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and hand hygiene was performed when entering and exiting Room A. B. Ensure the toilet seat was clean in the shared restroom of Resident 2 and Resident 26. C. Ensure an open and unlabeled personal toiletry was not stored inside the shared restroom of Residents 41 and 40 D. Ensure the clean linen was handled properly in the laundry room. These deficient practices had the potential to result in transmission of infectious microorganisms (an organism that can be seen only through a microscope) and cross contamination (process by which bacteria can be transferred from one…

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 B. During a review of Resident 39's AR, the AR indicated, Resident 39 was originally admitted to the facility on [DATE] with multiple diagnoses including anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), encounter for attention to gastrostomy (a surgical procedure used to insert a tube often referred to as a G-tube through the abdomen and into the stomach for feeding and medications) and need for assistance with personal care. During a review of Resident 39's History and Physical, dated 10/16/2024, the H&P indicated, Resident 39 was in NAD (no acute distress) and was awake, alert, and oriented x 3 (to person, place, and time). During a review of Resident 39's MDS, dated [DATE], the MDS indicated, Resident 39's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 39 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or…

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 grooming was provided to one of two sampled resident (Resident 18) who had dark brown substance under three fingernails of the left hand. This deficient practice had the potential to affect Resident 18's wellbeing and the potential to contaminate Resident 18's environment. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2021, with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil,) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage.) During a review of Resident 18's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 18's cognitive (ability to understand and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 18 sometimes understood verbal content and rarely was able to express ideas and wants. The MDS 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 activities were provided to one of three residents (Resident 23). This deficient practice had the potential to affect Resident 23's emotional and psychosocial wellbeing. Findings: During a review of Resident 23's admission Record (AR), the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact with reality is lost). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23…

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 one sampled resident (Resident 6) received treatment and care in accordance with the physician's order by failing to ensure Resident 6's edema (swelling caused by too much fluid trapped in the body's tissues) was cared for adequately. This deficient practice had the potential to result in Resident 6's edema not improving and had the potential to cause pain and further complications to Resident 6. Cross Reference F656 Findings: During a review of Resident 6's admission Record (AR), the AR indicated, Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including displaced intertrochanteric fracture of left femur (a type of broken hip in the [femur] thigh bone), subsequent encounter for closed fracture with routine healing, essential primary hypertension (high blood pressure) and pain, unspecified. During a review of Resident 6's History and Physical (H&P), dated 9/25/2024, the H&P indicated, Resident 6 had…

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 floor mats were in place for one of one sampled resident (Resident 8), who was identified as high risk for falls and as indicated in Resident 8's physician's order, Plan of Care (CP) for at risk for falls, and the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing. This deficient practice had the potential to result in falls and serious injuries leading to fractures (break in the bone) and bleeding to Resident 8. Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 3/14/2024, and re-admitted on [DATE], with diagnoses including malignant neoplasm of ascending colon (a cancerous growth in the colon [large intestine or large bowel]), difficulty walking, and muscle weakness. During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/15/2024, the MDS indicated Resident 8's cognition (ability 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 follow Pharmacist's recommendation to perform a gradual dose reduction (GDR, the stepwise tapering [to reduce dose over time] of a dose to determine if symptoms, conditions, or risks can be managed by use of a lower dose or determination of whether the dose or medication can be discontinued) for Seroquel, an antipsychotic medication (main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]), for one of one sampled resident (Resident 12). This deficient practice had the potential to result in unnecessary use of Seroquel and could potentially lead lethargy and adverse side effects (unwanted, undesired effect of a medication) to Resident 12. Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 5/10/2024, with diagnoses that included dementia (a progressive state of decline in mental abilities,) muscle weakness, and difficulty in walking.…

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 two sampled residents' (Resident 20) medication, Potassium Chloride (a mineral supplement used to treat or prevent low amounts of potassium in the blood to maintain the health of your kidneys, heart, muscles, and nervous system) ER (Extended Release, designed to release the medication at delayed or slower rates) was administered correctly as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. This failure had the potential for Resident 20 to develop gastric (of the stomach) upset and irritation and possibly lead to further harm and discomfort to Resident 20. Findings: During a review of Resident 20's admission Record (AR), the AR indicated, Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including anemia (blood disorder that occurs when your body doesn't produce enough healthy red blood cells, or when the red blood cells…

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 drugs and biologicals used in the facility were stored properly in one of two sampled medication carts (Med Cart 2). This failure had the potential to impact the effectiveness of the medications located in Med Cart 2 and decrease the efficacy (the ability to produce a desired or intended result) of the drugs. The failure had the potential to compromise the health and safety of Resident 33 and the residents who received medication from Med Cart 2 due to administration of the drugs. Findings: During a review of Resident 33's admission Record (AR), the AR indicated, Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (adult onset high blood sugar) with diabetic polyneuropathy (when multiple peripheral [relating to the edge of something] nerves become damaged), chronic obstructive pulmonary disease (COPD, a group of [long standing] lung…

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 administration of the Influenza ([flu] a common, sometimes deadly infection of the nose, throat and lungs) vaccine (are injections [shots], liquids, pills, or nasal sprays you receive to protect you against harmful diseases, before you come into contact with them) for one of five sampled residents (Resident 23), who was eligible and consented to receive the flu vaccine. This deficient practice placed Resident 23 at greater risk for acquiring, transmitting, or experiencing complications from the flu and had the potential to result in a physical decline to Resident 23. Findings: During a review of Resident 23's admission Record (AR), the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and fever, unspecified. During a review of Resident 23's…

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 pain management to one of one sampled resident (Resident 1) who was experiencing pain, in accordance with Resident 1's goals for care and preferences. This deficient practice had the potential to result in Resident 1 to continue to experience pain and affect the resident's sense of comfort and wellbeing. Findings: During a review of Resident 1's Detailed Summary, the Detailed Summary indicated the facility admitted Resident 1 on 9/9/24, with diagnoses that included displaced intertrochanteric fracture (broken bone) of the right femur (thigh bone,) dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/16/24, the MDS indicated Resident 1 had moderate cognitive impairment, the resident usually understands (comprehends most conversation) and usually makes self-understood (able to express ideas and wants if…

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 implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility ' s COVID-19 Mitigation Plan (facility ' s plan to minimize the effect of COVID-19 and to reduce loss of life) guidelines by failing to ensure: Licensed Vocational Nurse 1 (LVN 1) wore a fitted (fit test - a test to determine how effectively a mask or respirator will protect the wearer) N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) in the facility during a COVID-19 outbreak. This deficient practice had the potential to result in the spread of COVID-19 to other residents and staff in the facility. Findings: During a concurrent observation and interview on 11/28/23 at 3:10 PM LVN 1 was observed wearing a Direct Supply 84A-7638 model (a specific model of N95 mask) N95 mask. LVN 1 stated, she had been working 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 20) were treated with dignity by failing to provide privacy during medication administration. This deficient practice resulted in exposure to Resident 1 and Resident 20's abdomens (belly) and could have resulted in a psychosocial decline to Resident 1 and Resident 20 due to feelings of humiliation, embarrassment, and being ashamed. Findings: During a review of Resident 1's Detailed Summary (DS, admission record), the DS indicated, Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial flutter (a type of abnormal heart rhythm when the heart beats faster than normal and not always in coordination), encounter for attention to gastrostomy (a surgical opening into the stomach for feeding through a tube) and dysphagia (swallowing difficulties). During a review of Resident 1's History and Physical Examination (H&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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 194 and Resident 195) had a baseline (initial) care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) developed and implemented within forty-eight hours of admission to the facility. This failure had the potential to result in lack of communication among staff members, specific care needs and current treatments not implemented, and a decline in Residents 194 and 195's physical well-being Findings: During a review of Resident 194's Detailed Summary (DS, admission record), the DS indicated, Resident 194 was admitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), elevated white blood…

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 develop and/or implement an individualized person-centered care plan for three of three sampled residents (Residents 11, 94 and145). a. For Resident 11, there was no care plan developed to address Resident 11's retention of urine. b. For Resident 145, there was no care plan developed to address Resident 145's aggressive behavior. c. For Resident 94, there was no care plan developed to address Resident 94's constipation. These deficiencies had the potential to result in inconsistent implementation of care and services and/or missed opportunities in identifying risk for Residents 11, 94 and 145. Findings: a. During a review of Resident 11's Detailed Summary (DS, admission record), the DS indicated Resident 11 was re-admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis (joint pain or stiffness) and spinal stenosis (narrowing of space within the spine). During a review of Resident 11's History and Physical (H&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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) received treatment and care in accordance with facility's Policies and Procedures (P&P) by failing to notify Resident's 27 physician regarding Resident 27's refusal to take a prescribed medication, Mucinex (helps loosen congestion [an abnormal or excessive accumulation of a body fluid] in your chest and throat, making it easier to cough out through your mouth) on October and November 2023. This deficient practice had the potential to result in the development of chest congestion and difficulty breathing for Resident 27. Findings: During a review of Resident 27's Detailed Summary (DS, admission record), the DS indicated, Resident 27 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including transient cerebral ischemic attack (TIA, a temporary blockage of blood flow to the brain), dementia (a general term for loss of memory, language, problem-solving, 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 prevent falls and ensure a safe environment for one of one sampled resident (Resident 19). Resident 19 fell on 7/2/23, 8/23/23, and on 10/29/23 and the facility failed to revise Resident 19's Fall Care Plan (CP) after every fall. This failure resulted in multiple falls and had the potential to result in major injuries, hospitalization, and a decline in Resident 19's physical well-being. Cross Reference F657 Findings: During a review of Resident 19's Detailed Summary (DS, admission record), the DS indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infections (an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]), unsteadiness of feet, hearing loss to both ears,…

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 that the residents were free from any significant medication error for one out of 16 residents (Resident 27). This failure resulted in a decreased medication efficacy (ability to produce a desired or intended result) for Resident 27 and Resident 27 may have experienced health complications related to incorrect medication administration which could have negatively impacted his health and well-being. Findings: During a review of Resident 27's admission Record indicated he was readmitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack (a stroke-like attack), diffuse large B-cell lymphoma (a type of cancer), atherosclerotic heart disease (damage or disease in the heart's major blood vessels, and gastroesophageal reflux (stomach acid or bile irritates food pipe lining. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/18/23, 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.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when, a. the liquid, in one of three red buckets (Bucket 1), used to sanitize contact surface areas in the kitchen was maintained at the correct concentration of 200-400 parts per million (ppm, unit of measurement). b. foods in one of one nourishment room refrigerator (Refrigerator 1) were not covered or labeled. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and the spread of food borne illnesses (food poisoning) amongst the residents residing at the facility. Findings: a.During an observation of the facility kitchen and interview on 10/31/23 at 10:20 a.m., with the Director of Dining Services (DDS), the sanitation (J-512 ) liquid inside three red buckets were checked for proper concentration. Bucket 1 was tested with a test strip (indicated concentration in ppm) and indicated 0 ppm and orange in color. Bucket 1's concentration was checked a second time (different test strip)…

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 two of two sampled residents (Residents 194 and 196) were provided a sanitary environment to help prevent the development and transmission of infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms e.g., fever, redness, heat, purulent exudates, etc.) by failing to properly discard and store the resident's care items. For Residents 194 and 196, the residents shared the same restroom but nursing staff failed to discard the white top hat specimen collector after one use and failed to rinse and store the used graduated cylinder in the drawer located at the bottom of Resident 164's closet. This failure had the potential to result in cross contamination and the transfer of an infectious agent which could compromise Resident 194 and Resident 196's health. Findings: a. During a review of Resident 194's Detailed Summary (DS), the DS indicated, Resident 194 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an assessment was conducted to self-administer medications for one of one sampled resident (Resident 27). This failure had the potential to result in a decline for Resident 27's physical well-being. Cross Reference F760 Findings: During a review of Resident 27's Detail Summary (DS, admission record) indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack (a stroke-like attack), diffuse large B-cell lymphoma (a type of cancer), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), and gastroesophageal reflux (stomach acid or bile irritates food pipe lining). During a review of Resident 27's History & Physical (H&P), dated 10/13/23, the H&P indicated Resident 27 did not have the capacity to understand and/or sign any forms. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) 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 interview and record review, the facility failed to provide copies of medical records within two working days in accordance with the facility's Policy and Procedure (P&P) on Medical Records Requests for one of one sampled resident (Resident 3). This deficient practice had the potential to violate resident's right to have access to own medical records in a timely manner. Findings: During a review of Resident 3's detailed summary (admission record), the admission record indicated Resident 3 was re-admitted to the facility on [DATE] with diagnoses that included major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and hypertension (elevated blood pressure). During a review of Resident 3's History and Physical (H&P), dated 2/16/23, the H&P indicated Resident 3 had the capacity to understand and/or sign any form. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment and care-screening form), 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 interview and record review, the facility failed to accurately code fall incidents on two Minimum Data Sets (MDS, an assessment and screening tool) for one of one sampled resident (Resident 19). This failure resulted in an inaccurate assessment of Resident 94 and had the potential to affect Resident 19's physical well-being. Cross Reference F689 Findings: During a review of Resident 19's Detailed Summary (DS, admission record), the DS indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unsteadiness of feet, hearing loss to both ears, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). During a review of Resident 19's MDS, dated [DATE], indicated Resident 19 had moderate impaired cognition (ability to understand and process information) and required partial/moderate assistance with going from sitting to standing and substantial/maximum assistance when going from chair/bed to chair transfers. The MDS…

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 revise a comprehensive Care Plan (CP) for one of one sampled resident (Resident 19) following fall incidents on 7/2/23, 8/23/23, and on 10/29/23. This failure had the potential to result in major injury and a physical decline to Resident 19. Cross Reference F689 Findings: a. During a review of Resident 19's Detailed Summary (DS, admission record), the Detailed Summary indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unsteadiness of feet, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). During a review of the Risk Management Interdisciplinary (IDT) notes dated 7/2/23, 8/23/23, and 10/29/23 indicated Resident 19 was found on the floor in Resident 19's room. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening 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 interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review reported by the facility's pharmacist on the use of Remeron (a medication to treat depression [feelings of sadness and/or a loss]) were acted upon for one of five sampled residents (Resident 22) in accordance with the facility's Policy and Procedure (P&P) on Pharmacist Medication Regimen Review and Reporting. This deficient practice had the potential to result in unnecessary medication administration and potentially cause harm to Resident 22. Findings: During a review of Resident 22's Detailed Summary (admission record), the admission record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), psychotic disorder (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 22) who was on Seroquel (medication used to treat mental health condition), received a Gradual Dose Reduction (GDR- tapering a dose of medication) as indicated in the facility's Pharmacist's Recommendation and facility's Policy and Procedure (P&P) on Medication Management. This deficient practice had the potential for Resident 22 to receive unnecessary psychotropic medication (any medicine that affects behavior, mood, or thoughts) and be at risk for harm/injury. Findings: During a review of Resident 22's Detailed Summary (admission record), the admission record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), psychotic disorder (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility's medication error rate was not at five percents (%) or greater. The facility had two errors in 28 opportunities during medication pass which yielded a 7.14% medication error rate for one of three sampled residents (Resident 1). For Resident 1, two medications were crushed, combined, and administered at once via the gastrostomy feeding tube (G-tube or GT, a tube inserted through the belly that brings nutrition directly to the stomach). This failure had the potential to cause chemical incompatibility and incomplete dosage for Resident 1's medications and could cause GT complications such clogging up the tube. Findings: During a review of Resident 1's Detailed Summary (DS), the DS indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial flutter (a type of abnormal heart rhythm when the heart beats faster than normal and not always…

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.