Osage Healthcare & Wellness Centre

Based on observation, interview, and record review, the facility failed to: 1. Ensure two of three residents' (Resident 2 and Resident 22) oxygen concentrator (machine that converts normal air to a more concentrated oxygen) was turned off when not in use. This failure had the potential to create an oxygen enriched environment, increased risk of fire hazards, equipment malfunction, and compromised resident safety.Findings:During a review of Resident 2's admission Record (Face Sheet). The Face Sheet indicated the facility admitted Resident 2 on 11/14/2019 with diagnoses including heart failure (a disorder which causes the heart to not pump the blood efficiently), history of cerebral infarction (stroke - loss of blood flow to a part of the brain due to blockage), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's History and Physical (H&P) dated 9/18/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment 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: 1. ensure employee performance, competency validation, initial orientation validation, and orientation activities checklist were completed for 3 of 6 employees, RN1, LVN 2, and CNA 2. This failure had the potential to result in residents not receiving the required care based on the employee performance competency, orientation validation, and orientation activities provided for the proper care of the residents. Findings: During a review of the employee file of RN 1, the 2024 Annual Evaluation (yearly performance review) was not in the employee's file. During a review of the employee file for LVN 2, the Licensed Nurse Onboarding Activities Checklist (structured steps, training, and social interactions that integrate a new employee into an organization), dated 12/24/24, were missing validation of the following care requirements: Resident's Rights, admission Procedures, Discharge/Transfers, Psychotropics (medications to alter brain function, mood,…

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: 1. Ensure one of one resident's (Resident 49) mouth was rinsed after administration of prescribed inhaler Breo Ellipta [an inhaler used as a maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and fill with mucus)].This failure had the potential to result in Resident 49 developing irritation of the mouth, discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the mouth after inhaler use.Findings:During a review of Resident 49's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 49 on 10/9/2025 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), mild intermittent asthma with acute exacerbation (a sudden or worsening of shortness of breath, wheezing, cough, chest tightness leading to a decline in 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 observation, interview and record review, the facility failed to: 1. Ensure medication error rate was less than five percent (%). Two errors out of 34 total opportunities contributed to an overall medication error rate of 5.88% for one of five residents (Resident 49) observed during medication administration (med pass).Resident 49's cholecalciferol (Vitamin D) 400 units [(IU - international units) a unit of measurement] tablet and fluticasone propionate suspension 50 mcg/act (micrograms per actuation- a unit of measurement) nasal spray were administered per physician's order. This failure had the potential to result in impaired bone health, increased fracture risk, respiratory complications, worsening allergy symptoms, nasal congestion and decreased comfort.Findings:During a review of Resident 49's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 49 on 10/9/2025 and was readmitted on [DATE] with diagnoses including fracture (broken bone) of left femur (the longest,…

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: 1. Ensure a resident who had a diagnosis of dementia (a progressive state of decline in mental abilities) and legally blind (severe vision loss) understands the legal documents (documents affecting the legal rights of any person) including Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all of certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not, the decision is final and can be enforced by a court, and can only be appealed on very narrow grounds) she signed during admission to the facility for one of three sampled residents (Resident 39). This deficient practice resulted for Resident 39 signing a facility contractual agreement without her full understanding.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted 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 observation, interview, and record review the facility failed to: 1. Ensure staff wore Personal Protective Equipment (PPE) when handling one of five resident's (Resident 21) gastrostomy tube (gtube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) who was on enhance barrier precautions (EBP - is an approach of targeted gown and glove use during high contact resident care activities).This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.Findings:During a review of Resident 21's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 21 on 7/2/2022 with diagnoses including hemiplegia (a medical condition characterized by paralysis or severe weakness on one entire side of the body) and hemiparesis (weakness on one entire side 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: 1. ensure that one of five residents, Resident 49, was provided COVID-19 and Influenza vaccines. This failure had the potential to place Resident 49 at risk of being infected with COVID-19 and Influenza viruses.Findings:During a review of Resident 49's admission Record, dated 1/28/2026, the admission Record indicated Resident 49 has Chronic Obstructive Pulmonary disease (a lung disease that makes it difficult to breathe) , mild intermittent asthma (a low-severity, lung condition characterized by infrequent coughing, wheezing, chest tightness) , and cognitive communication deficit (difficulty communicating due to underlying thinking disruptions rather than just language or speech problems). During a review of Resident 49's History & Physical, dated 1/29/2026, the History & Physical indicated Resident 49 does not have the capacity to understand and make decisions and Resident 49's potential for rehabilitation is fair to poor. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's hearing aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty of hearing) was encoded and assess her hearing ability properly. This deficient practice had the potential to negatively affect the plan of care and delivery of care services for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). 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 develop a person-centered care plan for one of one sampled resident (Resident 1) by failing to: 1. Develop a comprehensive care plan addressing Resident 1's missing right hearing aid. This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). During a review of Resident 1's History and Physical (H&P), dated 11/17/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure audiology (branch of science and healthcare focused on the study, diagnosis, treatment, and prevention of hearing, balance, and related auditory disorders in patients of all ages) consultation appointment was provided in a timely manner for one of one sampled resident (Resident 1). This deficient practice had the potential for Resident 1's deterioration of hearing that could negatively affect her quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). During a review of Resident 1's History and Physical (H&P), 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: 1. Ensure an inventory of personal belongings was signed by resident or resident representative and facility staff and copy was provided for one of one sampled resident (Resident 1). This deficient practice had the potential for not having proper accountability of Resident 1's personal belongings.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). During a review of Resident 1's History and Physical (H&P), dated 11/17/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review 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 interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 4) was transferred from chair to bed using an appropriate technique.This deficient practice resulted in Resident 4 feeling discomfort when being transferred.Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 4's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 4 was able to make needs known, but could not make medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 8/18/2025, the MDS indicated Resident 4 had the ability to make himself understood and ability to understand others. Resident 4…

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: 1. Ensure one of four sampled employees (Certified Nursing Assistant 2) had an annual skills competency completed.This deficient practice had the potential to result in residents receiving a decreased quality of care.Findings:During a concurrent interview and record review on 8/27/2025 at 2:30 p.m. with the Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 2's employee file was reviewed. The DSD stated CNA 2's new hire competency was completed on 2/21/2024. CNA 2 should have had an annual competency completed in February of 2025. The DSD stated the annual competency was not completed because she forgot. The annual competency is needed to ensure staff have up to date skills and check if retraining is needed. If staff don't know what they are doing it will affect the quality of the care the resident receives. During a review of the facility's policy and procedure (P&P), titled Staff Competency Validation, dated June 2024, the P&P indicated competency validation is completed to evaluate an individual'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a sandwich for one of five sampled resident (Resident 40) was identified with a label and date. This deficient practice placed Resident 40 at risk for foodborne illness (any illness resulting from eating contaminated/spoiled foods). Findings: During review of Resident 40's admission Record (front page of the chart that contains a summary of basic information about the resident), Resident 40 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and muscle weakness (loss of muscle strength) During a review of Resident 40's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/18/2024, the MDS indicated Resident 40's cognitive (the ability to think and process information)…

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 out of three sampled residents, (Resident 26) call light was within reach. This deficient practice placed Resident 26 at risk for accidents and had the potential to delay in meeting Resident 26 physical and emotional needs. Findings: During an observation on 10/30/2024 at 10:29 a.m. Resident 26's call light was hanging on the side of the bed and not within reach. During a review of Resident 26's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (a chronic metabolic disease that causes high blood glucose levels), and gastro-esophageal reflux disease ([GERD] is a condition in which the stomach contents leak…

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: 1.Inform the physician one of one sampled resident (Resident 38) refused to take trazodone (medication to treat depression). This deficient practice placed Resident 38 at risk for worsening of depression and withdrawal effect that could cause medical complications. Findings: During a review of Resident 38's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 38 was admitted to the facility on [DATE]. Resident 38's admission diagnoses included major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 38's History and Physical (H&P), dated 4/10/2024, the H&P indicated, Resident 38 had the capacity to understand and make decisions. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1.Ensure an accurate Minimum Data Set ([MDS] - a federally mandated resident assessment tool), was completed accurately for one of 13 sampled residents (Resident 9). This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Cervices (CMS) and had the potential for a poor care planning which could affect the health and safety of Resident 9. Findings: During a review of Resident 9's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), muscle weakness congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 9's History and Physical (H&P), dated 12/11/2023, the 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 interview and record review the facility failed to ensure one out of three sampled residents, (Resident 26) had a care plan to: 1. Monitor the frequency of outside food being brought in by family. 2. Monitor Resident 26's ability to tolerate regular textured (consists of normal, everyday foods textures that including hard, chewy, dry, and crunch foods) food brought in by family. These deficient practices resulted in failure to monitor Resident 26's prescribed pureed textured diet (a texture-modified diet that consists of foods that are ground, pressed, or strained until they have a smooth, soft consistency, like pudding) and had the potential to place Resident 26 at risk for choking. Findings: During an observation on 10/29/2024 at 10:15 a.m. in Resident 26's room, there was an empty box of a burger, large bag of potato chips, crackers, and cans of soda on the bedside table. During a review of Resident 26's admission Record ([Face Sheet] front page of the chart that contains a summary of basic…

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 record review and interview the facility failed to: 1. Revise one of three sampled residents Resident 26) interventions identified by the multidisciplinary care team ([IDT] group of healthcare professionals from different disciplines) who was at risk of aspirating (inhalation of food or liquid into the lungs). The deficient practice had the potential for repeat occurrence. Findings: During a review of Resident 26's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM] a chronic metabolic disease that causes high blood glucose levels), and gastro-esophageal reflux disease ([GERD] a condition in which the stomach contents leak backward from the stomach into the esophagus).…

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; 1. Ensure one of one sampled resident (Resident 16) who had a stage 4 pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was turned and reposition every two hours. This deficient practice had the potential to worsen and delay wound healing. Findings: During review of Resident 16's admission Record (front page of the chart that contains a summary of basic information about the resident), Resident 16's was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), muscle weakness (loss of muscle strength), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (a mental illness that…

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: 1. Ensure resident with long thick elongated (nail plate grows linger than the nail bed) toenails received podiatry (profession dealing with the specialized care of the feet) care services for one of one sampled resident (Resident 36). This deficient practice had the potential to result in discomfort and decline in physical mobility for Resident 36. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record, indicated Resident 36 was admitted to the facility on [DATE]. Resident 36's diagnoses included muscle weakness, iron deficiency anemia (a condition when your body does not have enough iron), and protein calorie malnutrition (a condition that occurs when someone doesn't consume enough protein, calories, and other nutrients). During a review of Resident 36's History and Physical (H&P), dated 10/6/2024, the H&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: 1. Ensure one of three sampled residents (Resident 26) bed was placed in the lowest position to prevent injuries during a fall. This deficient practice had the potential in the resident falling from the bed and sustaining an injury. Findings: During a review of Resident 26's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 26 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 26's diagnoses included chronic obstructive pulmonary (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (a chronic metabolic disease that causes high blood glucose levels), and gastro-esophageal reflux disease ([GERD] is a condition in which the stomach contents leak backward from the stomach into the esophagus). During a review of Resident 26's History and Physical (H&P), dated 7/7/2024, 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 interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 146) was provided with a scheduled toileting plan, per bowel and bladder assessment. This deficient practice had the potential for decline in bladder and bowel function for Resident 146. Finding: During a review of Resident 146's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 146 was admitted to the facility on [DATE]. Resident 136's diagnoses included muscle weakness, nondisplaced fracture of greater trochanter of left femur (a break in the top of the thigh bone near the hip), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing. During a review of Resident 146's History and Physical (H&P), dated 10/23/2024, the H&P indicated, Resident 146 did not have the capacity to understand and make decisions. During a review of Resident 146's Minimum Data Set…

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: 1. Ensure one of one sampled residents received hemodialysis ([HD] a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 9) by failing to communicate to Resident 9's physician regarding Registered Dietitian ([RD] a health professional in nutrition) recommendation to provide Nova source ( a high calorie, nutritional supplement designed for those on dialysis) supplement. This deficient practice had the potential to result in weight loss and malnutrition that can lead to worsened health complication for Resident 9. Findings: During a review of Resident 9's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included End…

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: 1. Label with an open date of ketorolac (a medication used to treat swelling and redness after eye surgery) and prednisolone acetate (a medication used to treat infection before and after eye surgery) ) ophthalmic solution (liquid eye drops) for Resident 34. This deficient practice had the potential for harm to Resident 34 due to the potential loss of strength of medication. 2. Label with an open date and remove one pouch of expired ipratropium with albuterol (a combination solution use to treat and prevent shortness of breath) inhalation solution for Resident 40. This deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms for Resident 40. Findings: 1. During a review of Resident 34's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 26) nasal cannula (a medical device that provides supplemental oxygen to a patient through their nose) was dated and labeled. This deficient practice placed Resident 26 at risk for a respiratory infection (an infectious disease that affects the respiratory system, which is responsible for breathing). Findings: During an observation on 10/29/2024 at 10:15 a.m. and 10/30/2024 at 10:52 a.m. in Residents 26's room, Resident 26's nasal cannula was not dated and labeled. During a review of Resident 26's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included chronic obstructive pulmonary (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (a chronic…

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 the resident's clinical records were updated for advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (1) out of 42 sampled residents (Resident 1) by failing to maintain a current signature and adequate dates that match dates on the copy of the resident's advance directives in the resident's clinical record. Based on interview and record review, the facility failed to ensure one of 42 sampled residents advance directive was updated by failing to maintain a current signature and dates that matched the dates on the copy of the residents advance directives in the resident's clinical record. This deficient practice had the potential to result in conflict with the resident's wishes regarding health care (Resident 1). Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility with hemiplegia and hemiparesis (hemiplegia, a patient…

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 revise the care plan for one of four Residents (Resident 39). This deficient practice had the potential to result in Resident 39 to receive inappropriate interventions and treatment. Findings: During a review of Resident 39s admission record facesheet, the face sheet indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic embolism and thrombosis (is a blockage or obstruction in the pulmonary arteries in the lungs), respiratory failure (a serious condition that makes it difficult to breathe on you own), left and right hand contractures (a fixed tightening of muscle, ligaments, or skin), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 39's history and physical (H&P), dated 5/9/2023, the H&P indicated Resident 39 does not have the capacity to understand…

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 safe and sanitary food storage, food preparation practices in the kitchen by failing to: 1. Ensure one bag of breaded potato hash browns were not stored in the reach in freezer with no date and label and one large plastic wrapped bacon was open. 2. Ensure Dishwasher 1 (DW 1) knew how to use the proper sanitizer test strip for the dish machine sanitizer (competency - cross reference F802). 3. Ensure DW 1 did not take clean food trays out of the dishwasher and place them on the floor, then pick up the trays up and place the food trays that was on the floor in the rack with other clean trays. And ensure DAS did not place trays on top of clean dishes. 4. Ensure Employee's food was not stored in the resident food refrigerator without a label, date, and temperature log. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 42 out of 42 residents who received food…

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 physician orders to discontinue use of splints for one out of four Residents (Resident 39). This deficient practice had the potential to result in Resident 39 to receive the inappropriate medical treatment as ordered by the physician. Findings: During a review of Resident 39s admission record, the admission record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic embolism and thrombosis (is a blockage or obstruction in the pulmonary arteries in the lungs), respiratory failure (a serious condition that makes it difficult to breathe on you own), left and right hand contractures (a fixed tightening of muscle, ligaments, or skin), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 39's history and physical (H&P) dated 5/9/2023, the H&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 interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 treat two of five sample residents (Resident 1 and Resident 5) with dignity and respect. These deficient practices violated the resident's right to be treated with respect and dignity and had the potential to affect the self-esteem, cause emotionally distress, and psychosocial well-being of the residents. Findings: a.During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with a diagnosis that included Parkinson disease (brain disorder that causes unintended or uncontrollable movements), obstructive and reflux uropathy (disorder characterized by blockage of the normal flow of contents of the urinary tract), and other specifies disorders of bladder (medical classification of a range -Other diseases of the urine). During a review of Resident 1 ' s history and physical (H&P) dated 5/12/2023, the H&P indicated Resident 1 had 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 one of five sampled residents (Resident 2) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services as indicated in the physician orders by failing to: 1. Assess and document color and sediments (consistsof biological elements such as leukocytes, erythrocytes, epithelial cells, casts, bacteria, fungi, parasites) in Resident 2 ' s urine. 2. Notify the physician of color and sediments in Resident 2's urine output. This deficient practice resulted in delayed identification of Urinary Tract Infection [UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra)] delayed in necessary care and treatment and had the potential to lead to worsening infection. Findings: During a review of Resident 2 ' s admission record, the admission record indicated Resident 2 was admitted on [DATE] and re-admitted 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.