English Oaks Convalescent & Rehabilitation Hospita

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of four sampled residents (Resident 1) when resident 1 was found in the parking lot of the apartment complex next to the facility at approximately 10:00 p.m., on 6/17/25.This failure resulted in two skin tears to Resident 1's right knee and had the potential of serious injury and harm.A review of Resident 1's clinical record, titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with diagnoses of but not limited to malignant neoplasm of unspecified kidney (a cancerous tumor that forms in the kidney), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), failure to thrive (a condition where an adult experiences unintentional weight loss, decreased appetite, and muscle wasting that can lead to health complications).A review of Resident 1's clinical record titled, SBAR Communication 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was accurately assessed for the use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and use of hearing aids. These failures resulted in staff not being aware when Resident 1 ' s partial denture and hearing aids were missing and the lack of consistent use could have contributed to Resident 1 ' s confusion and weight loss. Findings: During a review of Resident 1 ' s clinical record titled, admission RECORD (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnosis included the need for assistance with personal care. A review of Resident 1 ' s clinical record titled, NSG [nursing]: admission Data Collection and Baseline Care Plan Tool (a personalized document that identified problems, goals, and interventions), dated 1/3/25, by Licensed Nurse (LN 1), indicated Resident 1 was oriented to person, place, date, and time. The record further indicated Resident 1 ' s use of a partial denture and…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a care plan (a document that identified Resident 1 ' s problems, goals, and interventions) in place that addressed Resident 1 ' s use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and hearing aids. These failures resulted in a lack of knowledge by nursing staff of Resident 1 ' s use of a partial denture and hearing aids, lack of care of the partial denture and hearing aids, and could have contributed to Resident 1 ' s confusion and 15-pound weight loss while at the facility. Findings: During a review of Resident 1 ' s clinical record titled, admission RECORD, (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnosis included the need for assistance with personal care. A review of Resident 1 ' s clinical record titled, NSG [nursing]: admission Data Collection and Baseline Care Plan Tool (an individualized plan of care that identified Resident 1 ' s problems, goals, and…

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

Based on interview, and record review, the facility failed to provide restorative (RNA- nursing intervention to increase or maintain resident's mobility and prevent further decline in mobility) treatment and services for one of three sampled residents (Resident 2) when Resident 2 did not receive her ordered RNA therapy for the week of 9/23/24. This failure had the potential to result in a decline in physical functioning for Resident 2, resulting in a negative impact on Resident 2's health and well-being. Findings: A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility in 2024 with diagnoses that included difficulty in walking, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as stroke) affecting the left side. A review of Resident 2's Order Summary Report, (list of physician orders) dated 10/11/24, indicated RNA therapy was ordered two times a week…

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 conditions were maintained for food storage according to standards of practice and facility policy when: 1) Three serving scoops were dirty with green and brown crusted substances, and were stored with clean serving utensils in a cook's undercounter drawer; 2) Eleven cases of thawed, soft mighty healthshakes were stored in the walk-in refrigerator and two cases of them were received on 8/29/24; 3) A pipe from the dish machine did not have an air gap; and, 4) Two ice machines were not cleaned and maintained according to manufacturer's instructions. These deficient practices exposed 145 of 155 facility residents who consume food from the kitchen to potentially harmful substances which could have led to widespread foodborne illness. Findings: 1. During the initial kitchen tour on 9/17/24 at 10:19 AM, an observation and interview was conducted with the Dietary Services Manager (DSM). There were six (6) serving scoops of different sizes found with dirt and brown food debris crusted on them,…

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

Based on observation, interview, and record review, the facility failed to protect residents from significant medication errors when 1 of 38 sampled resident's (Resident 137) Midodrine (medication used to raise blood pressure and prevent it from going too low) was not administered per physician orders. This deficient practice had the potential for Resident 137 to suffer serious consequences from blood pressure being too high if the medication was given and was not needed, or symptoms such as dizziness from not receiving the medication when it was needed. Findings: Resident 137 was admitted to the facility with diagnoses which included, Aphasia [loss of ability to understand or express speech, caused by brain damage] Following Cerebral Infarction [stroke]. A review of Resident 137's physician order's indicated, Midodrine HCI Oral Tablet 5 MG [milligrams - a unit of measure] Give 1 tablet via PEG-Tube [a feeding tube that allows you to get nutrition and medications through a tube inserted into your stomach] three times a day for Hypotension [low blood pressure] Hold for SBP [systolic…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A dishwasher (DSW) did not know how to correctly test the dish machine sanitizer or the safe temperatures and sanitizer levels for the 3-compartment sink. 2. A Diet Aide (DA) did not wash his hands after disposing the trash outside two times, and use proper food safety and sanitation practices to prevent cross-contamination. 3. Two DA's did not correctly demonstrate how to calibrate a thermometer. These failures had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. The facility census was 155. 1. During the initial kitchen tour observation, interview, and record review on 9/17/24 at 9:30 AM with DSW 1, DSW 1 tested the chemical sanitizer in the low temperature dish machine. DSW 1 took a test strip and wiped it on the counter where…

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 resident meals were served at a palatable temperature and flavor according to facility policy. This deficient practice had the potential to result in insufficient food intake, which could impair nutrition status for 145 out of 155 residents who consumed food from the kitchen. Findings: Review of the facility's Fall Menus, Week 3 Wednesday dated 9/18/24, indicated the Regular lunch meal included: Chicken cacciatore- 3 ounce (oz.) of meat, 1-2 oz. sauce, ½ cup pasta with garlic and herbs, ½ cup broccoli & cauliflower, ½ cup Italian green salad, ½ oz. dressing, Cranberry crunch square, 4-oz. cup milk. The Pureed meal included the foods listed above but used alternate measuring scoops to prepare the servings. During a kitchen observation and interview on 9/18/24 at 10:05 AM, [NAME] (CK) 1 was preparing the lunch meal items. CK 1 stated she prepared all the food items and they were in the oven or steamer until trayline started. CK 1 stated she was not sure if the regular recipe for pasta with garlic and…

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

Based on observation, interview and record review, the facility failed to ensure the dish machine was in safe operating condition according to standards of practice and facility policy when the dish machine sanitizer exceeded safe sanitizing levels for dishes. This failure had the potential to place 145 out of 155 residents who receive food from the kitchen at risk of developing food related illnesses, or adverse effects from exposure to sanitizing chemicals. Findings: During the initial kitchen tour observation, interview and record review on 9/17/24 at 9:30 AM with dishwasher (DSW) 1, there was water dripping into puddles underneath the dish machine. DSW 1 stated she didn't know about the water leak. DSW 1 demonstrated how to test the chemical sanitizer in the low temperature dish machine by taking a test strip and wiping it on the counter in the back of the dish machine where the dishes came out. The test strip turned dark purple. DSW 1 compared the test strip to the colors on the test strip container and stated, It is deep dark purple, and that's fine because it is between…

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 coordination of specialized mental health services for 1 of 38 sampled residents (Resident 1), when the facility failed to respond to the state designated authority for further PASRR (Pre-admission Screening and Resident Review-a tool used to ensure residents with certain mental illnesses receive care needed in the most appropriate setting) Level II needs. This deficient practice had the potential for Resident 1 to not receive additional care and services related to a mental disorder. Findings: A review of Resident 1's admission Record indicated she was admitted to the facility in August 2024 with diagnoses which included bipolar disorder (a mental illness that causes extreme mood swings, or shifts in energy, activity, and concentration that can make it hard to do daily tasks), and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). During a concurrent interview and record review on 9/18/24 at 11:09 a.m., with the Minimum Data Set Case Manager (MDSCM), Resident 1'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 a resident centered care plan for 2 of 38 sampled residents (Resident 76 and Resident 104) when, 1. Resident 76 required oxygen therapy via a nasal cannula (NC- tubing which delivers oxygen into your nose) but often removed the tubing, and his care plan did not include interventions which would ensure his oxygen level remained above 90%; and, 2. Resident 104's intravenous (IV, refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) therapy care plan was not specific to her midline catheter (a long, thin, flexible tube which is inserted into a large vein in the upper arm). These failures placed Resident 76 at risk of adverse effects of not enough oxygen, and placed Resident 104 at risk for harm related to inadequate care of her midline IV. Findings: 1. Review of Resident 76's admission RECORD indicated Resident 76 was admitted to the facility in the beginning of 2024 with diagnoses including hepatic encephalopathy (a brain disorder which occurs when the liver…

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 care according to professional standards of practice for 1 of 38 sampled residents (Resident 104) when a licensed nurse (LN) inserted a peripheral IV (intravenous device placed in a vein of the hand or arm and used to deliver fluids or medication) without a physician order. This failure had the potential to place Resident 104 at risk for complications related to inadequate maintenance of the peripheral IV. Findings: Review of Resident 104's admission RECORD indicated Resident 104 was admitted to the facility in mid-2024 with a diagnosis of infection and inflammatory reaction due to internal left hip prosthesis (artificial joint) and disruption of external operation (a surgical complication that occurs when a surgical incision reopens after closure). Review of Resident 104's clinical record, Progress Note, dated 8/21/24, indicated, .ceFAZolin Sodium Intravenous Solution [antibiotic used to treat infection] .Use 2 gram intravenously three times a day for left hip wound/ dehiscence [partial or total…

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 weekly showers to 1 of 38 sampled residents (Resident 48) as requested by Resident 48. This failure resulted in Resident 48 not receiving preferred bathing services (showers) and had the potential to result in decreased comfort and hygiene. Findings: A review of Resident 48's admission Record, indicated Resident 48 was admitted to the facility in March 2022 with diagnoses which included, abnormalities of gait and mobility. A review of Resident 48 's Minimum Data Set (MDS- an assessment and care screening tool) dated 7/2/24, indicated Resident 48 had the ability to understand and be understood by others with an intact memory and a Brief Interview for Mental Status (BIMS) score of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). The functional status section of the MDS indicated Resident 48 required substantial/…

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 professional standards of care were met for 1 of 38 sampled residents (Resident 37) when licensed staff were unable to contact Resident 37's orthopedist (doctor who treats disorders of bones, joints, muscles and tendons) for an order after she returned from an appointment wearing a sling (device worn to support and immobilize a limb) on her right arm and her primary medical doctor (MD) 2 was not notified. This failure led to Resident 37's sling being removed and had the potential for worsening of her condition. Findings: A review of Resident 37's admission RECORD, indicated she was readmitted to the facility in early 2024. During an interview on 9/19/24, at 11:47 AM, Resident 37 stated her right arm was extremely swollen, had limited movement, and caused her discomfort. During an interview on 9/19/24, at 12:48 PM, Licensed Nurse (LN) 5 stated Resident 37 went to an orthopedic appointment on 9/3/24 for her right shoulder. LN 5 further stated Resident 37 returned from the appointment with a sling on her…

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 implement measures to minimize accidents when: 1. One of fourteen resident's (Resident 122) wander guard to prevent elopement (a device used to alert staff if a resident leaves without their knowledge) was not being monitored; and, 2. One of three residents who smoked (Resident 296) was not assessed for the ability to smoke safely in a timely manner. These failures placed Resident 122 at an increased risk of physical harm due to his behavior of wandering in and outside the facility; and had the potential to result in Resident 296 not using her smoking device safely and could expose other residents to aerosols from an electronic cigarette device. Findings: 1. A review of Resident 122's admission Record (AR) indicated Resident 122 was admitted to the facility in 2023 with a diagnosis of Parkinson's disease (a progressive brain disorder that causes shaking, stiffness, and difficulty with balance and coordination). A review of Resident 122'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 interview and record review, the facility failed to ensure safe medication use for one of five residents (Resident 110) on antipsychotic medication, when Resident 110's antipsychotic drug, called Haldol (a drug used to treat a variety of mental and neurological disorders) was not monitored for its effectiveness. These failures placed Resident 110 at risk for inadequate symptom relief and/or adverse effects from the use of an anti-psychotic medication. Findings: A review of Resident 110 's admission Record (AR) indicated Resident 110 was admitted to the facility in August 2024 with diagnoses which included dementia (a progressive state of decline in mental abilities), and personality disorder. During a review of Resident 110's medical record titled, Minimum Data Set, (MDS- a resident assessment tool), dated 8/12/24, section I under Psychiatric/Mood disorder, indicated, Anxiety Disorder: [box checked]; Depression (other than bipolar): [ box checked] . During a review of Resident 110's Care Plan initiated on 8/19/24, the care plan indicated, . [Resident 110] receiving…

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 safe medication storage practices in three of nine medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when, 1. An expired multi-dose prescription medication was stored and available for use. 2. An undated multidose prescription medication was stored and available for use. 3. An expired single-dose prescription medication was stored and available for use. These failed practices could contribute to unsafe medication storage and administration of outdated and ineffective medications. Findings: 1. During a concurrent observation and interview on [DATE] at 4:16 p.m., License Nurse (LN) 15 removed a multi-dose inhaler, Wilexa Inhub (fluticasone propionate and salmeterol inhalation powder) 250/50 (a device used to administer medication to treat lung diseases), for Resident 26 from the Med Cart on North Med 3. The multi-dose inhaler had a date written on the date opened label of [DATE]. The manufacture…

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 food brought in from the outside for 1 of 38 sampled residents (Resident 85), was stored and reheated according to regulatory standards and facility policy. This failure affected the temperature and palatability of Resident 85's meal, and had the potential to alter nutrition status. Findings: A review of Resident 85's admission Record dated September 20, 2024, indicated the resident was admitted on [DATE] with diagnoses which included congestive heart failure (condition that occurs when the heart cannot pump enough blood to meet the body's needs), type 2 diabetes (uncontrolled blood sugar), iron deficiency anemia (low levels of iron in the blood), and vitamin D deficiency (low levels of vitamin D in the blood). A review of Resident 85's Minimum Data Set (MDS- an assessment and care screening tool) on 9/18/24 indicated she had a BIMS (brief interview of medical status) of 15, whereby a score of 13-15 meant cognition was intact.…

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 maintain infection prevention and control practices for 2 of 38 sampled residents (Resident 56 and Resident 246) when: 1. The licensed nurse (LN) did not change gloves or perform hand hygiene during wound care for Resident 56; and, 2. Resident 246's urinal was not labeled with name or room number. These failures placed Resident 56 at increased risk of healthcare associated infections, and increased the risk Resident 246's urinal could be used by another resident. Findings: 1. A review of Resident 56's admission RECORD, indicated he was readmitted to the facility in mid-2024 with diagnoses which included a history of methicillin resistant staphylococcus aureus (MRSA) infection (a germ that is resistant to many antibiotics) and gastrostomy (a tube inserted through the abdomen and into the stomach to provide nutrition). A review of Resident 56's Treatment Administration Record (TAR), dated September 2024, indicated, .Cleanse tube Stoma [opening in the abdomen for the gastrostomy tube] Site with Theraworx Spray…

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 medical record accurately reflected a fall incident for one of four residents (Resident 3) when, a. Licensed staff failed to document whether Resident 3's fall mat (placed on the floor at bedside to prevent injury in the event of a fall) was present on 9/8/23, when Resident 3 fell out of bed; and b. The interdisciplinary team (IDT-members include professionals from varied disciplines to provide collaboration) recommended use of a fall mat (to prevent injury in the event of a fall) for Resident 3, but Resident 3's care plan and other records indicated this intervention was in place. This failure had the potential to cause miscommunication of information and confusion among healthcare providers regarding Resident 3's fall, which could contribute to the development of inadequate fall prevention measures for Resident 3. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in 2021 with diagnoses including congestive heart failure (when the heart muscle is weakened),…

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 adequate pain management for one of seven sampled Residents (Resident 1) when Resident 1's pain medication was not ordered in a timely manner. This failure led to Resident 1 experiencing unnecessary pain which had the potential to affect her physical and psychosocial well-being. Findings: A review of Resident 1's admission RECORD, indicated she was admitted to the facility in May of 2024, with diagnoses which included osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of Resident 1's clinical record, Progress Notes, dated 5/18/24, at 2:20 PM, indicated, .Pt [patient] is requesting an order for Norco [narcotic pain-relieving medication] 5/325 mg [milligrams- unit of measure] for pain as Tylenol [non-narcotic pain-relieving medication] does not help with pain. Communication placed in . [physician medical group communication binder] . A review of Resident 1's clinical record, Progress…

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 one of three sampled residents (Resident 2) received care to prevent pressure ulcers, when Resident 2 was not repositioned every two hours. This failure had the potential to result in Resident 2 developing pressure ulcers related to prolonged time spent on his back. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility with diagnoses which included weakness. A review of Resident 2's clinical record, Braden Scale For Predicting Pressure Sore Risk dated 9/28/23, indicated Resident 2 scored 15, which indicated he was at risk for developing a pressure ulcer. A review of Resident 2's Minimum Data Set (MDS - contains clinical and demographic information) dated 10/12/23, indicated, .Bed mobility - how resident .turns side to side, and positions body while in bed .Self Performance .Extensive assistance .Support .Two+ persons physical assist . A review of Resident 2's Care Plan, undated, indicated, .Impaired bed mobility and transfers related to: weakness…

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 maintain its infection prevention program when: 1. Licensed nurse (LN) 4 failed to perform hand hygiene consistently while performing wound care for Resident 5. 2. Certified nursing assistant (CNA) 5 did not don (put on) the appropriate personal protective equipment (PPE) when providing care for residents on Enhanced Standard Precautions (an approach of targeted gown and glove use during high-contact resident care activities, designed to reduce transmission of drug resistant organisms). These failures had the potential to result in infection in residents receiving care in the facility. Findings: 1. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility with diagnoses which included, VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) [a condition in which veins have problems moving blood back to the heart]. During a concurrent observation and interview on 11/16/23, at 12:20 PM, in Resident 5's room, Resident 5 was observed to be in bed with his lower extremities uncovered and the…

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

Based on observation, interview, and record review, the facility failed to ensure effective pain management for one of five sampled residents (Resident 5), when Resident 5 complained of pain and was not assessed or given pain medication for approximately 2 hours. This failure resulted in Resident 5 waiting an extended time for pain medication and had the potential for Resident 5 to experience emotional distress from inadequate pain relief. Findings: A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility with diagnoses which included a history of falls and dorsalgia (back pain). During a medication administration observation, with licensed nurse (LN) 1, on 10/13/23, at 9:34 AM, certified nursing assistant (CNA) 1 approached and informed LN 1 Resident 5 requested pain medication. LN 1 stated she had already given Resident 5 her pain medication and did not go and assess Resident 5. During a concurrent observation and interview with Resident 5 in Resident 5's room, on 10/13/23, at 10:57 AM, Resident 5 was tearful. Resident 5 stated she had been…

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 professional standards of practice were implemented during medication administration for one of four sampled residents (Resident 4) when gastrostomy (G-Tube-a tube directly into the stomach for nutrition, hydration, and medications) tube medications were crushed together and administered at once. This failure had the potential to result in a clogged gastrostomy tube and unknown effects of medications interacting with each other. Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility with diagnoses which included gastrostomy tube and dysphagia (difficulty swallowing). During an observation in Resident 4's room, with licensed nurse (LN) 1, on 10/13/23, at 8:36 AM, LN 1 had two small plastic pouches of crushed medications. LN 1 poured the crushed medications into two 30 ml (milliliter-a measure of volume) medication cups, added approximately 15 mls of water, stirred, opened the G-tube line, flushed with 30mls water, poured in the first mixture of medications,…

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 resident monitoring and the services provided met professional standards of quality for three of 32 sampled residents, (Resident 547, Resident 56, and Resident 548) when: 1. Resident 547 and Resident 56 were not monitored for adverse effects of blood thinner medication use in the setting of high-risk status; and, 2. Resident 547's skin issues identified upon admission were not monitored, and weekly summaries (a head-to-toe assessment report that provides information progress or decline in a resident's health status on a weekly basis) and weekly skin assessments were not completed for Resident 547 and Resident 548 These failures could contribute to unsafe medication monitoring with adverse consequences for Resident 547, and Resident 56, and could contribute to decline in health condition of Resident 547 and Resident 548. Findings: 1a. During a review of Resident 547's medical record, titled Medication Administration Record (or MAR where key information about the Resident's medications including 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 respiratory care provided was consistent with professional standards of practice for 3 of 32 sampled residents (Resident 547, Resident 131, and Resident 95) when: 1. Resident 547 had duplicate oxygen orders and did not receive oxygen at the prescribed flow rate; 2. The oxygen flow rate was not followed per physician order for Resident 131; 3. Oxygen therapy was provided without a physician order for Resident 95; and, 4. Resident 95's oxygen tubing and the oxygen humidifier bottle were not dated when changed. These failures placed Resident 547, Resident 131, and Resident 95 at risk for respiratory distress and inadequate treatment. Findings: 1. Review of the admission Record indicated Resident 547 was admitted to the facility in February 2023 with multiple diagnoses including pulmonary embolism (blood clot in the lungs), Chronic obstructive pulmonary disease (COPD: a lung disease that cause airflow blockage and breathing-related…

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, observation, and record review the facility failed to ensure safe medication storage practices in three out of three medications rooms (a locked room that stored medication) and four out of eight medications/treatment carts (a locked mobile cart that stored medication and treatment drugs) when: 1. Treatment cart in the South station (a unit within the facility) contained unlabeled medications. 2. Medication room in the South station contained large quantities of un-used or discontinued medications and the multi-dose (means the bottle or container could be used multiple times) medication containesr were opened and undated. 3. Medication cart #C in the South station stored opened test strips bottle (strips used to measure blood sugar using a device) without an open date (when a fresh new container is opened, they mark the date it was opened) markings and the medication disposal bottle (also called RX Destroyer, a liquid container used to deactivate unused or refused medications) had brownish sticky spillage on the body of the container and on the storage floor. 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 observation, interview, and record review, the facility failed to ensure resident's rights to be treated with dignity were honored for one of 32 sampled residents (Resident 7) when staff stood at Resident 7's bedside while assisting Resident 7 to eat the lunch meal in bed. This failure had the potential to negatively impact Resident 7's psychosocial well-being. Findings: During a concurrent observation and interview on 2/15/23, at 12:48 p.m., Certified Nurse Assistant (CNA) 1 confirmed she stood at Resident 7's bedside to assist Resident 7 to eat the lunch meal on 2/15/23. CNA 1 stated she typically sat down while helping a resident to eat their meal, but she was tired of sitting and wanted to stand up. CNA 1 stated there was a potential to make the resident feel uncomfortable when standing to help them eat their meal. Review of Resident 7's ADL (Activities of Daily Living) care plan, initiated 6/6/19, indicated, .The resident requires Extensive assistance by 1 staff to eat . During an interview on 2/17/23, at 1:10 p.m., the Director of Nursing (DON) stated staff should be…

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

Based on observation, interview, and record review, the facility failed to develop and/or implement a person-centered care plan for one of thirty-five sampled residents (Resident 7) when fall risk care plan interventions (call light within reach and non-skid footwear) were not implemented for Resident 7. This failure had the potential to result in a fall with the potential for injury for Resident 7. Findings: During a concurrent observation and interview on 2/14/23, at 4:25 p.m., Licensed Nurse (LN) 2 confirmed Resident 7 was sitting in a chair next to the bed. LN 2 confirmed Resident 7 was wearing regular socks and the call light was on the bed and located out of Resident 7's reach. LN 2 stated Resident 7 was at risk for falls. LN 2 stated that Resident 7 needed to wear non-skid socks and that any patient who was a fall risk needed to have non-skid socks on. LN 2 stated Resident 7 could be more at risk for falling without non-skid socks on. LN 2 stated the risk to a resident not having the call light within reach could result in their needs not being met and Resident 7 could fall…

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 1c. Review of Resident 77's admission RECORD indicated Resident 77 was admitted to the facility with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During an interview on 2/16/23, at 10:10 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 77 did not refuse care. CNA 1 stated sometimes Resident 77 could be resistive to a shower so then a bed-bath would be provided. CNA 1 stated if a resident refused to shower, then staff would document in the resident record that the resident refused. CNA 1 stated that they still followed the weekly shower schedule and provided showers to the residents even if they were on hospice care (for people who are nearing the end of life to provide services to maximize comfort for a person who is terminally ill by reducing pain and addressing…

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/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for one of thirty-five sampled residents (Resident 77) when a low air loss mattress (LAL, a mattress designed to prevent and treat pressure injuries) was not implemented as indicated in Resident 77's pressure injury care plan. This failure had the potential to delay the healing of Resident 77's pressure injury. Findings: During a concurrent observation and interview on 2/15/23, at 1:01 p.m., Licensed Nurse (LN) 15 confirmed that there was not a LAL mattress on Resident 77's bed. LN 15 stated Resident 77 had pressure injuries and there was a risk for the wounds to worsen or not to heal when the pressure injury interventions were not in place. During an interview on 2/16/23, at 11:06 a.m., Hospice Nurse (HN) 1 stated he had been involved in Resident 77's hospice care for the last six months. HN 1 stated hospice provided medical equipment to the residents when needed, including…

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 a fall prevention measure was implemented for one of 32 sampled residents (Resident 82) when Resident 82's floor/landing pads (mats) were not placed on the floor on each side next to Resident 82's bed while Resident 82 was asleep. This failure placed Resident 82 at risk for injury from a fall. Findings: Review of Resident 82's clinical records titled, admission Record dated 2/16/23, indicated Resident 82 was admitted to the facility in late 2022 with diagnosis of fracture (broken bone) of the left hipbone and left pelvic bone. Resident 82's Minimum Data Set (MDS-an assessment tool) dated 1/17/23 revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 suggesting a moderately impaired mental functioning. During an initial observation in Resident 82's room on 2/14/23, at 9:41 a.m., Resident 82 was in bed asleep and there were no floor/landing pads noted on the floor on either side of the bed. During an interview with Resident 82 on 2/14/23, at 2:19 p.m., Resident 82 stated she had a fall…

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 residents receiving dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body when the kidneys stop working properly) received quality care and services consistent with professional standards of practice for one of two residents (Resident 543), when: 1. Resident 543's post-dialysis assessment was not completed on 2/14/23; and, 2. Resident 543's arteriovenous shunt (AV- connection between an artery and a vein used as an access site for dialysis) was not assessed for bruit (a sound heard through a stethoscope) and/or thrill (vibrations felt through palpation) since admitted to the facility. These failures increased the potential for delayed detection, reporting, and/or management of complications from the hemodialysis access sites for Resident 543. Findings: Review of the admission Record indicated Resident 543 was admitted to the facility in February 2023 with multiple diagnoses including end stage of renal disease (the final, permanent stage of chronic kidney…

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 one resident (Resident 64) of 32 sampled residents received a psychotropic medication (drug that effects a person's mental state) for a specific psychiatric diagnosis (mental health illness) when: Resident 64 was treated with quetiapine (also known as Seroquel, a medication used to treat mental illness) to treat symptoms including hallucinations, and potential causes of behavioral symptoms, including other medications, were not addressed as a contributing factor to Resident 64's symptoms. These failures may have contributed to unsafe medication use and adverse consequences. Findings: Review of Resident 64's medication history in the medical record indicated two medications with effects on mental status as follows: Dicyclomine Capsule 10 mg (medication for stomach and bowel disease); Give 1 capsule by mouth four times a day for treatment of . irritable bowel syndrome (or IBS, type of abdominal pain or discomfort associated with change in bowel habit) -Start Date- 09/15/22; Hydroxyzine .Tablet…

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

Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of three errors out of 34 opportunities which resulted in a facility wide medication error rate of 8.82%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The three medication errors were identified in three residents (Resident 52, Resident 64, and Resident 81) out of 12 residents observed for medication administration observation as follows: 1. Resident 52's eye drop medication administered in the wrong eye; 2. Resident 64's medications were crushed with no doctor's order; and, 3. Resident 81's medication was not administered after food consumption as ordered. These failures could contribute to unsafe medication use in the facility. Findings: 1. During a medication administration observation of Resident 52, in the facility's North unit, on 2/14/23, at 4:35 PM, Licensed Nurse 10…

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.