Oakdale Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure one of six sampled resident (Resident 42) grooming was maintained when red patches of dried flaky skin were on top of his scalp and on the front of his shirt and pant. This failure resulted in Resident 42 having dried flaky skin on his skirt and pants which made him feel upset and embarrassed and had this had the potential to cause skin infection. Findings: During a concurrent observation and interview on 3/18/25 at 4:50 p.m. in Resident 42's room Resident 42 had patches of dry, white flakes and redness on his head. Resident 42 had the same dry white flakes on the front of his shirt and pants. Resident 42 stated he had a surgical wound treatment to the abdomen and had been not had shower because he did not want his dressing to get wet. Resident 42 gave permission for a photo of his head to be taken. Resident 42 stated he felt bad, uncomfortable and embarrassed of his head. During a concurrent observation and interview on 3/18/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 with the known behavior of wandering into other Resident rooms was left unattended on 4/10/24. This failure resulted in Resident 1 entering Resident 2's room where Resident 1 bit the hand of Resident 2. Findings: During a concurrent observation and interview on 4/23/24 at 12:57 p.m. with Resident 1, in Resident 1's room, Resident 1 was seated on her bed. Resident 1 was questioned regarding the altercation on 4/10/24, Resident 1 did not respond to the questions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 1/16/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 3 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately…

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 record reviews, review of the facility policy, and interviews, the facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for 3 (Residents #11, #31, and #89) of 5 sampled residents reviewed for advance directives. Findings included: A review of the facility policy titled, Advance Directives, reviewed in December 2020, revealed, Long Term Care Residents 1. During the admitting process the patient/family and/or surrogate decision maker will be asked if he/she has executed an Advance Healthcare Directive. This information will be recorded on the admission form and forwarded to Social Services. 1. A review of Resident #11's admission Record revealed the facility admitted to the resident on 06/15/2016. Per the admission Record, Resident #11 was their own responsible party. A review of Resident #11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was…

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

Based on interview and record review, the facility failed to provide sufficient staffing to residents when the dining room was left with insufficient staff to meet the needs of the residents requiring assistance for two of three meals on Saturday, March 23, 2019. This failure resulted in residents not having care and socialization needs met. Findings: During a resident council meeting interview, on 3/26/19, at 10:00 a.m., nine residents (Residents 8, 11, 12, 13, 14, 27, 40, 67 and 86) and two family members attended the resident council meeting and 11 out of 11 attendees at the resident council meeting expressed they were not happy with the short staffing situation in the facility dining room. During an interview with Resident 86, on 3/26/19, at 10:01 a.m., he stated staffing was an issue on holidays, weekends and flu season. He stated the facility would close the dining room prior to the weekend because of insufficient staffing. During an interview with Resident 42's wife (RW42), on 3/26/19, at 10:01 a.m., she stated the facility was understaffed and questioned why her husband only…

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

Based on observation, interview and record review, the facility failed to store and handle food safely when: 1. There were red bell peppers with a black organic substance and past their storage guidelines. 2. There was black and yellow substance inside the ice machine. 3. Trayline (meal service) food temperatures were taken in an unsanitary way. These failures resulted in unsafe food storage and handling that could lead to contamination and potentially negative outcome to all residents who consumed food from the kitchen. Findings: 1. During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/25/19, on 8:22 a.m., there was a bin of red bell pepper that had a black substance in the walk in refrigerator. DC 2 stated the date on the bin was 3/14/19 and there were 10 bell peppers inside. DC 2 stated, It is mold. During an interview with DC 3, on 3/28/19, at 8:16 a.m., she stated, Fresh bell pepper is good for 7 days. DC 3 stated it was not good to use moldy bell pepper. DC 3 stated, Sometimes it [red bell pepper] gets rotten . It has to be fresh to use for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a policy regarding the use and storage of foods brought to residents by family and visitors from outside of the facility when there were unlabeled and incorrectly labeled resident food items in the resident refrigerator. This failure had the potential of giving unlabeled or incorrectly labeled food items to the wrong resident which could result in negative outcome to the residents. Findings: During an observation and concurrent interview with Registered Nurse (RN) 1, on 3/25/19, at 4:06 p.m., in the medication room, there was a resident refrigerator with resident food items. RN 1 stated, We just put the room number on the residents' food items. There were three 12 oz. (ounce - a unit of measure) cans of beer labeled 27C, one 8 oz. can of Lime A [NAME] ([NAME] drink) labeled 6A, three unlabeled 8 oz. cans of Lime A [NAME], four 12 oz. can of Keystone Light labeled 32A and five 12 oz. cans of Michelob Ultra labeled 6A. During an…

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

Based on interview and record review, the facility failed to use staff development resources effectively and efficiently to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual training when 57 of 59 Certified Nursing Assistants (CNAs) did not complete one or more of the annual five required dementia training in-services. This failure had the potential for the residents to be cared for by CNA's inadequately trained. Findings: During a concurrent interview and record review with Director of Staff Development (DSD 2), on 3/28/19 at 11:30 a.m., DSD 2 stated the dementia in-service training sign-in sheets indicated there were missing CNA signatures on all five dementia training in-services. DSD 2 stated the following CNA's did not complete one or more of the required five dementia training modules, CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65. During a concurrent interview…

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 interviews and record review, the facility failed to assess the demographic composition of its resident population and location as part of the required facility assessment when there was no water management program for the facility. This failure resulted in the facility not having a water management program which could potentially expose the residents to Legionella in an event of an outbreak. Findings: During an interview with Maintenance Engineer (ME), on 3/27/19, at 10:52 a.m., ME stated he was aware of the All Facilities Letter 18-39 that was issued on September 17, 2018 requiring facilities to develop and implement a water management program. ME stated, We do not test for Legionella. ME stated he had not tested for Legionella and the facility did not have any water testing results. ME stated he did not have a map of the water system and do not have a policy regarding testing the water for Legionella or a water management plan. During an interview with Administrator (ADM), on 3/27/19, at 10:55 a.m., ADM stated he had just become aware of the All Facilities Letter 18-39…

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 effectively implement and maintain an infection prevention and control program for 11 of 59 sampled residents (Resident 46, 63, 39, 11, 238, 63, 32, 36, 43, 14 and 18) when: 1. Registered nurse (RN) 5 and RN 1 failed to perform hand hygiene prior to placing on gloves when care was delivered to residents during a physical assessment and a finger stick procedure to test blood for blood sugar levels for (Resident 46, 63, and 39). 2. Licensed vocational nurse (LVN) 4 and RN 1 used a contaminated pair of gloves in the performance of the finger stick procedure on three residents (Resident 11, 238, and 63), and touched objects in the resident room without changing the gloves LVN 4 wore to perform the finger stick procedure. 3. RN 5 used a contaminated pair of gloves in the provision of care to Resident 43. 4. Resident 14's nasal (nose) cannula (a plastic tubing used for the delivery of oxygen through the nose) was exposed and left hanging low draped over the regulator dial of the oxygen concentrator. 5. The facility…

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 equipment in safe operating condition when: 1. There was ice build-up on the door frame and on a copper pipe inside the walk-in freezer. 2. There was black and yellow substance in the ice machine at the bottom part of the evaporator. These failures had the potential for the residents to use ice and food that was unsafe for consumption that could lead to negative outcome. Findings: 1. During an observation on 3/25/19, at 8:24 a.m., in the kitchen, there was ice build-up on the top frame of the freezer door and copper pipe by the top, right corner toward the back of the walk-in freezer. During a concurrent observation and interview with the Dietary Aide (DA), on 3/28/19, at 8:09 a.m., in the kitchen, the freezer door was not fully closed. Inside the freezer, there were water drops along a strip of plastic by the side of the freezer door. The DA stated he had noticed the ice buildup in the freezer. The DA stated it water drips happened when the freezer door was not fully closed or left open for a while.…

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 staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual mandated training to keep competencies in the delivery of care when: 1. Three of 21 CNAs (CNA 1, 2 and 3) completed less than 12 hours of mandatory training per year. 2. 57 of 59 CNAs (CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65) did not complete the five dementia training modules offered by the facility. This failure resulted in CNA's insufficient training which placed the resident at risk to not have quality of care needs met. Findings: 1. During employee records review with the director of staff development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19 at 2:50 p.m., stated from 3/16/18 to 3/24/19: 1. CNA 1 was provided in-service training's for five of 12 hours. 2. CNA 2 was provided in-service…

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 safe and homelike environment for residents when: loud alarms and overhead paging was frequently used in the facility and Resident 4's restroom floor was in disrepair. These failures created an environment that was not homelike for residents. Findings: During an observation on 3/25/19, at 8:50 a.m., in the kitchen, the Dietary [NAME] (DC) 2 overhead paged the Maintenance Engineer (ME). During a concurrent observation and interview with Assistant Director of Nursing (ADON), on 3/26/19, at 9:32 a.m., at the nurses' station, a very loud alarm turned on with a light by a wall at the nurses' station. The alarm was heard in the whole facility. The ADON stated, [The alarm turns on] when the residents push on the exit doors [when they are] trying to go out. The ADON stated some residents with wander guard wrist bands (a system to alert staff when a resident is exit seeking or exits a building) triggered alarms to alert staff when they got close to exit doors. During an observation on 3/26/19, at 10:17 a.m.,…

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

Based on staff interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was for 17 of 21 Certified Nursing Assistants (CNAs). These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews. Findings: During employee records review with the Director of Staff Development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19, at 2:50 p.m., the following CAN records indicated: 1. CNA 31 with a hire date (HD) of 3/22/17, was evaluated on 11/19/18, eight months and 18 days late. 2. CNA 32 with a hire date of 7/1/13, was evaluated on 11/20/18, four months and 19 days late. 3. CNA 62 with a hire date of 2/21/17, was evaluated on 3/7/18, 14 days late. 4. CNA 65 with a hire date of 1/26/17, was not evaluated on 1/2018 and 1/2019. 5. CNA 2 with a hire date of 5/26/16, was evaluated on 11/21/18, seven months and 21 days late. 6. CNA 28 with a hire date of 3/28/16 was evaluated on 5/17/18, two…

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 menu was followed when incorrect portions of beef stew were served to 21 of 22 residents receiving small portion diets. This failure resulted in residents receiving incorrect servings and amount of nutrients in their meals which could potentially result to negative outcome to the residents. Findings: During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/26/19, at 11:38 a.m., in the kitchen, trayline [meal service on trays] was started. There was a pan of regular beef stew with red and blue ladle. A pan of mechanical beef stew had red and blue ladle. A pan of pureed beef stew had red and blue ladle. DC 2 stated, The blue ladle is 6 oz. [ounce - unit of measure] and red ladle is 8 oz. During an interview with DC 4, on 3/26/19, at 1145 a.m., she stated the regular and mechanical beef stew pan both had blue and red ladles. DC 4 stated, They are 8 oz. [red] and 6 oz. [blue]. During an interview with DC 3, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of 28 sampled residents (Resident 57, 71 and 83) were treated with dignity and respect when the three residents sat together for lunch and were served at different times. This practice failed to promote the right to a dignified dining experience for Resident 57, 71 and 83. Findings: During an observation on 3/25/19, at 11:45 a.m., in the dining room, four residents shared the same dining room table. Resident 64's lunch meal was served by Certified Nursing Assistant (CNA 1) first. Resident 64 began to eat while Residents 57, 71, and 83 waited to be served. Resident 83 requested to be served lunch and asked CNA 1 about the whereabouts of her lunch. During an observation on 3/25/29, at 11:52 a.m., in the dining room, Resident 83 stated, I am getting hungry. Resident 71's lunch tray was served and waited for a CNA to provide assistance with feeding. Resident 57 was served next and began to eat while Resident 83 continued to wait…

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 residents right to privacy during care for two of two sampled residents (Resident 39 and 65) when: Resident 39 and 65 were provided with care by two Registered Nurses (RN 1 and RN 5) without privacy. This practice violated Resident 39's and 65's right to privacy during the delivery of care. Findings: During a medication administration observation on 3/26/19, at 7:35 a.m., RN 5 entered Resident 65's room and took the resident's blood pressure (measures how hard the blood is pushing against the walls of the arteries) while the maintenance man worked on Resident 65's neighbors bed. RN 5 did not pull the privacy curtain to offer Resident 5 privacy and allowed the maintenance man to see. During an interview with RN 5, on 3/26/19, at 8:15 a.m., she stated she should have pulled the privacy curtain around Resident 65's bed to ensure her privacy was protected from others not involved in her care. During a medication administration observation on 3/26/17, at 12:03 p.m., RN 1 entered Resident 39's room to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review the facility failed to ensure services provided meet professional standard of quality for 18 of 18 sampled residents (Resident 17, 25, 42, 64 ,74, 89, 90, 1, 7, 10, 20, 31, 41, 76, 74, 5, 89 and 64) when: 1. Registered nurse (RN) 5 did not follow the manufacturer's specifications on an inhaler (inhalers - a portable device for administering a drug which is to be breathed in) inhalation administration use for one of 18 sampled residents (Resident 17). This failure had the potential to place Resident 17's at risk for developing infections in her mouth. 2. RN 2 signed the medication administration record (MAR) prior to the administration of medications to one of 18 sampled residents (Resident 25). This failure had the potential to place Resident 25 at risk for medication errors. 3. The facility failed to follow the physician ordered diet for one of 28 sampled residents in the dining room when Resident 5 was served a regular diet instead of a clear liquids diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident who were unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition for two of 28 sampled residents (Residents 83 and 71) when Residents 83 and 71 did not have assistance with their meals. This failure resulted in Residents 83 and 71 having to wait for 10 minutes to receive assistance with their meals which could have the potential to cause unplanned weight loss. Findings: During an observation in the dining room, on 3/25/19, at 11:45 a.m., four residents were seated at the same table. Resident 64 was served her lunch meal by Certified Nursing Assistant (CNA) 1. CNA 1 left and did not serve Resident 71, 83 and 57 their lunch meal. During an observation in the dining room, on 3/25/29, at 11:52 a.m., Resident 71 was served her lunch but did not start eating. Resident 71 waited for assistance. Resident 57 was served her lunch and started eating. At 11:55 a.m., Resident 83…

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, staff interview and record review, the facility failed to implement an ongoing resident centered activities program to support the resident/family's choice of activities to maintaining and/or improve resident's physical, mental and psychological wellbeing for one of four sampled residents (Resident 43). This failure resulted in the activity needs of Resident 43 going unmet. Findings: During a telephone interview with a family member (FM) 1, on 3/25/19, at 9:27 a.m., she stated Resident 43 loves music, like western and pop music and enjoyed being around people. FM 1 stated she had provided the resident with a radio and wanted the radio to be on music for the resident to make sure Resident 43 wound not feel alone. FM 1 stated the last time she was at the facility, she noticed the television owned by another resident was not on. FM 1 stated she was informed the television set was broken. FM 12 stated she recently bought a new television set for Resident 43's visual stimulation. FM 1 stated she asked some of the CNAs (certified nursing assistant) who 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 residents environment remained free of accident hazards for one of 59 sampled residents (Resident 4) when the linoleum (hard, washable floor covering) flooring by the door to Resident 4's bathroom was lifted and peeling off the floor base. This failure resulted in a hazardous environment for Resident 4 that could lead to falls. Findings: During a concurrent observation and interview with Resident 4, on 3/28/19, at 11:23 a.m., she stated, In July of last year, I fell going in the bathroom . There is a lip [peeling linoleum] on the floor. My feet get caught on it . See how you get your toes under there? There was peeling of the linoleum flooring going to the bathroom. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 3/28/19, at 1:56 p.m., in Resident 4's room. LVN 3 felt the floor by the bathroom door with her foot. LVN 3 stated, It [peeling linoleum flooring] catches my foot. It is a fall risk. The floor shouldn't be like that. LVN 3 stated the floor was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles and ensure all drugs and biologicals were securely stored and permit only authorized personnel to have access to these medications when: 1. An insulin medication vial was not labeled with a change of direction sticker for one of 12 sampled residents (Resident 63). 2. Registered nurse (RN) 5 left an inhaler on top of the med cart unattended. 3. RN 2 left the medication cart unlocked and unattended. These failures placed all residents' health and safety at risk when drugs were inappropriately labels and drugs were left unattended and accessible to unauthorized individuals. Findings: 1. During a concurrent medication administration observation and interview Registered Nurse (RN) 1, on 3/26/19 at 12 p.m., RN 1, held the bottle of the insulin and read the pharmacy label, Humalog [insulin - medication to treat diabetes (a…

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

Based on observation, interview and record review, the facility failed to follow the physician ordered diet for one of 28 residents (Resident 5) in the dining room when Resident 5 was served a regular meal instead of a clear liquid. This failure resulted in Resident 5 being given the wrong diet which had the potential to compromise his scheduled medical procedure. Findings: During an observation on 3/25/19, at 11:48 a.m., in the dining room, Resident 5 was given his lunch tray. On Resident 5's tray was roast turkey with alfredo sauce, pasta and green beans. Resident 5 stated he was on a clear liquid diet. During an interview with Registered Nurse (RN) 1, on 3/25/19, at 12:05 p.m., he stated, For Resident 5, clear liquids was ordered for today. He is scheduled for a procedure . All meals ordered today is clear liquids. RN 1 stated Resident 5's lunch should have been clear liquids. During an interview with RN 1, on 3/26/19, at 4:11 p.m., he stated the physician ordered diet was not followed for Resident 5's lunch on 3/25/19. RN 1 stated, Doctor's orders should be followed. During an…

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