Grand Oaks Care

Based on interview and record review, the facility failed to notify the physician of one of three sampled resident ' s change of condition when Resident 1 ' s blood sugar/glucose levels were above 200 (normal is 70 - 99 mg [milligrams]/dL [deciliter]) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being sent to the acute hospital and being admitted for dehydration (too little fluid in the body [can occur when the kidneys try to excrete sugar, in response to high blood sugar levels, thru urination leading to dehydration]), hyperglycemia (elevated blood sugar), and hypernatremia (elevated sodium level in the blood [can occur when there is an increase in urination related to high blood sugar and the kidneys lose more water than they retain]). Findings: During a review of the Physician Orders (PO), the PO indicated, Accu-check (device used to check a blood sugar) BID (twice a day) without coverage notify MD (Doctor of Medicine) if BS (blood sugar) less than 60 (mg/dL) or greater than 200 (mg/dL) .start date 4/21/25. During a review of 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 ensure one of five sampled residents (Resident 1) care plan was implemented when Resident 1 did not have a staff member with him at all times. This failure had the potential for Resident 1 to exhibit aggressive behaviors towards other residents. Findings: During a review of Resident 1's Care Plan (CP), dated 12/16/24, the CP indicated, (Resident 1) was physically aggressive striking out at others 1/5/25.Interventions.(Resident 1) to be 1:1 supervision at all times. During an observation on 1/29/25 at 1:40 p.m. in Resident 1's room, Resident 1 was standing up on the side of the bed. Resident 1 was alone in his room. During a concurrent observation and interview on 1/29/25 at 1:42 p.m. with Director of Nursing (DON), in Resident 1's room, Resident 1 was observed alone in his room. DON stated Resident 1 was supposed to have a 1:1 staff with him always. During an interview on 1/29/25 at 2:14 p.m. with Nursing Assistant (NA), NA stated she was the assigned 1:1 for Resident 1. NA stated when she went to break, she…

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 follow their policy and procedure (P&P) on Quality Assurance and Performance Improvement (QAPI - data-driven, proactive approach to improving the quality of care and services in the facility). This failure had the potential for the facility to not recognize, identify, address and correct resident safety, care and outcomes for 37 of 37 sampled residents. Findings: During a concurrent interview and record review on 10/10/24 at 2:35 p.m. with Administrator, the facility's QAPI dated 2024 was reviewed. The last QAPI meeting was 9/2024. During the 1/2024 QAPI meeting completing nursing staff competencies, quality of care, incomplete employee files and nursing documentation audits were identified. Administrator stated there was no measurable data discussed for completing the nursing staff competencies. The QAPI plan was not effective. The Administrator stated the analytical data was not available to put in the Process Improvement Projects (PIPs).The QAPI reports indicated no measurable data that were being monitored and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure five of 18 sampled residents (Resident 33, Resident 50, Resident 64, Resident 67, and Resident 63) call lights were within reach. This failure had the potential for residents unable to call for assistance and potential for delaying care. Findings: During a concurrent observation and interview on 10/7/24 at 10:03 a.m. with Certified Nursing Assistant (CNA) 3, in Resident 33's room, Resident 33's call light was on the floor out of Resident 33's reach. CNA 3 stated the call light must have fallen on the floor, the call light should have been clipped to Resident 33's blanket and within Resident 33's reach. During a review of Resident 33's Minimum Data Set (MDS - an assessment tool), dated 8/9/24, the MDS indicated, Brief Interview for Mental Status (BIMS-cognition screening) score was 4 (score of 0-7 indicates severe cognitive impairment). The MDS indicated, under Functional Abilities and Goals, Resident 33 required maximal assistance…

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 an Advance Directive (AD-health care preferences, including decisions for end-of-life care) acknowledgement form was completed for ten of 20 sampled residents (Resident 443, Resident 40, Resident 20, Resident 6, Resident 37, Resident 51, Resident 18, Resident 43, Resident 54, and Resident 87). This failure had the potential to result in the residents' wishes or health choices not being honored. Findings: During a concurrent interview and record review on 10/10/24 at 8:42 a.m. with admission Coordinator (AC), Resident 443's Advanced Directive Acknowledgement (ADA), dated 9/25/24 was reviewed. The ADA indicated, Resident 443 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 443 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:44 a.m. with AC, Resident 40's ADA, dated 7/17/24 was reviewed. The ADA indicated, Resident 40 had not completed an AD. AC stated 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 interview and record review, the facility failed to ensure: 1) A Licensed Nurse did not share her Electronic Protected health information (EPHI-resident clinical record) access code) and leave Graduate Vocational Nurse (GVN, unlicensed nursing staff) 1 unsupervised while administering narcotics (addictive pain medications) for three of three sampled residents (Resident 51, Resident 63, and Resident 18). This failure resulted in unauthorized access to residents' protected health information, falsification of residents' medical record and the potential for medication errors. 2) Physician Orders were followed when licensed nurse did not document wound care treatment for three of three residents (Resident 51, Resident 63, and Resident 18). This failure had the potential for worsening of Resident 51, Resident 63 and Resident 18's wounds. Findings: 1. During an observation on 10/7/2024 at 11:38 a.m. in the 400 hallway, GVN 1 was administering medications to residents without licensed nurse supervision. During a concurrent interview and record review on 10/10/24 at 11:53 a.m. with…

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

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 47, Resident 48, and Resident 51), had Restorative Nurse Assistant (RNA - therapy for residents with limited mobility) program orders. This failure had the potential for Resident 47, Resident 48, and Resident 51 to have an avoidable reduction in range of motion. Findings: During a concurrent observation and interview on 10/7/24 at 10:12 a.m. in Resident 47's room, Resident 47 stated he gets changed in his bed. During an observation on 10/7/24 at 10:22 am in Resident 48's room, Resident 48 was watching tv. Resident 48 was non-verbal. During a concurrent interview and record review on 10/9/24 at 11:52 a.m. with the Director of Rehabilitation (DOR), Resident 47 and Resident 48's Order Summary Report (OSR), dated October 2024 was reviewed. DOR stated neither Resident 47 nor Resident 48 had orders for RNA program. During a concurrent interview and record review on 10/9/24 at 3:24 p.m. with Assistant Director of Nursing (ADON), Resident 47 and Resident 48's OSR,…

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 complete performance evaluations for three of eight sampled employees (Certified Nursing Assistant [CNA] 3, CNA 5 and Licensed Vocational Nurse [LVN] 1. This failure had the potential for employees not meeting performance standards providing care for residents. Findings: During a concurrent interview and record review on 10/9/24 at 11:53 a.m. with Director of Staff Development (DSD), CNA 3's employee personnel record (EPR), undated was reviewed. The EPR indicated, CNA 3's date of hire was on 8/1/24. DSD stated she was unable to find CNA 3's competency checklist. DSD stated CNA 3 should have had a competency checklist completed prior to working on the floor alone. During a concurrent interview and record review on 10/9/24 at 12:06 p.m. with DSD, CNA 5's EPR, undated was reviewed. The EPR indicated, CNA 5's most recent competency checklist was completed on 7/7/23. DSD stated, Yes [CNA 5] is due and should have had her annual review and competency checklist completed last July. During a concurrent Interview and record review…

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

Based on interview and record review, the facility failed to ensure social services assessments (SSA) were completed quarterly (every three months) for nine of 19 sampled residents (Resident 51, Resident 63, Resident 71, Resident 44, Resident 27, Resident 6, Resident 54, Resident 47, and Resident 48). This failure had the potential for the delay in providing medically related social services for the residents affecting their psychosocial needs. Findings: During a concurrent interview and record review on 10/9/24 at 9:41 a.m. with Social Services Supervisor (SSS), Resident 51, Resident 63, Resident 71, Resident 44, Resident 27, Resident 6, Resident 54, Resident 47, and Resident 48's SSAs were reviewed. The SSAs indicated they were not completed every three months for the following residents: a. Resident 51's last SSA was completed on 8/11/23 (11 months overdue). b. Resident 63's last SSA was completed on 4/20/23 (15 months overdue). c. Resident 71's last SSA was completed on 8/25/23 (11months overdue). d. Resident 44's last SSA was completed on 6/2/23 (13 months overdue). e. 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.

Based on interview and record review, the facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for the month of July 2024. This failure had the potential for residents' adverse health outcomes due to physician was not notified of the pharmacy recommendations. Findings: During a review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident (PSHUR), dated 7/1/24 until 7/28/24, the PSHUR indicated, there were 99 pharmacy recommendations the facility did not act on. There were no documentation of notification of the physician. During an interview on 10/9/24 at 11:13 a.m. with Director of Nursing (DON), DON stated the July 2024 pharmacy recommendations were not acted upon. DON stated she did not check if the pharmacy recommendations in July 2024 were completed. During a review of the facility's Consultant Pharmacist's Medication Regimen Review…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure two opened medication bottles in the medication storage room were labeled with an opened date. This failure had the potential for contamination of medications. 2. Dispose of three bottles of medications for Resident 79 in a plastic bag in Medication Cart 2 bottom drawer. This failure had the potential for discontinued or outdated medication to be administered. 3. Ensure approximately 50 Over-The-Counter (OTC) medication bottles were safely and securely stored from unauthorized personnel. This failure had the potential for medication to be accessed by unauthorized staff and patients. 4. Ensure medications Resident 54's medications were safely and securely stored from unauthorized personnel and other residents. This failure had the potential for medication to be accessed by unauthorized staff and residents. Findings: 1. During a concurrent observation and interview on 10/8/24 at 1:18 p.m. with Assistant Director of Nursing (ADON) in the medication storage room, there were opened bottles of Glucosamine…

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 infection prevention and control practices when: 1. One of three sampled clean linen cart covers were not fully covered during transport. 2. Four of ten sampled staff (Certified Nursing Assistant-CNA 3, CNA 4, Hospice CNA, and Nursing Consultant [NC]} did not follow enhanced droplet (used to prevent spread of airborne infectious agents) and contact precautions (used to prevent the spread of infectious agents through direct or indirect contact). 3. One of one sampled Resident's (Resident 77) room was not deep cleaned prior to moving another Resident (Resident 87) into room. 4. One of ten sampled staff (Licensed Vocation Nurse [LVN] 1) did not perform appropriate hand hygiene. These failures had the potential to transmit infectious diseases to Residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 10/8/24 at 1:41 p.m. with Laundry Personnel (LP) in the hallway outside laundry area, a linen cart cover which contained clean linens was opened approximately…

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 and interview, the facility failed to store chemical containers off the ground. This failure had the potential for the chemical containers to be knocked over and result in a toxic spill which would put staff and Resident's health and safety at risk. Findings: During a concurrent observation and interview on 10/8/24 at 1:14 p.m. with Laundry Personnel (LP) in the laundry room, on the right side of the washing machine, there were five chemical containers and one bleach bottle on the ground. LP stated the containers are filled with chemicals and should be stored above ground. During an interview on 10/8/24 at 1:58 p.m. with Administrator, Administrator stated there should not be anything on the ground in the laundry room, everything should be four inches off the ground. Facility's policy and procedure on chemical storage was requested on 10/9/24 and 10/10/24 and was not provided.

Based on observation, interview, and record review the facility failed to ensure one of 37 sampled residents' (Resident 87) room was maintained with a homelike environment. This failure resulted in Resident 87 feeling uncomfortable and not able to use his personal belongings. Findings: During a concurrent observation and interview on 10/7/24 at 10:30 a.m. with Resident 87, in Resident 87's room, a breathing excercise device, hung on the wall. The breathing exercise device was labeled with another resident's (Resident 87) initials. Resident 87 stated there were items in his room that did not belong to him. Resident 87 stated he was not sure who the items belonged to. During an interview on 10/7/24 at 2:31 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated when a resident moved or discharged , Social Services would tell staff to pack up the residents' belongings and where to move them. CNA 8 stated she worked last Thursday and Resident 77 had already moved to a different room. CNA 8 stated the belongings in Resident 87's room belonged to Resident 77. During a review of the…

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

Based on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) was notified of transfer and discharge for two of three sampled residents (Resident 89 and Resident 90). This failure had the potential for unsafe resident transfer and discharge. Findings: During a review of Resident 89's Transfer or Discharge Fax Cover Sheet Ombudsman Program (TDFCSO), dated 8/2/24, the TDFCSO indicated Resident 89 was discharged on 8/1/24. The TDFCSO indicated, Faxed 8/2/24 at 9 a.m. There was no fax confirmation the ombudsman received the notice. During an interview on 10/9/24 at 2:40 p.m. with Social Services Supervisor (SSS), SSS stated she was not sure if ombudsman received the notification of Resident 89's discharge. SSS stated, There was no fax confirmation. During a review of Resident 90's TDFCSO, dated 9/2/24, the TDFCSO indicated Resident 90 was discharged on 7/31/24. There was no fax confirmation the ombudsman…

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 interventions to prevent skin breakdown were implemented for one of one sampled residents (Resident 51). This failure had the potential for Resident 51 to develop skin breakdown and worsening skin injury. Findings: During a concurrent observation and interview on 10/9/24 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 4 in Resident 51's room, Resident 51's heels were not elevated and were touching the bed. Resident 51 had non blanchable redness (discoloration of the skin that does not turn white when pressed which can indicate a pressure ulcer) on her left heel. LVN 4 stated Resident 51's heels were supposed to be elevated to prevent skin breakdown. During a review of Resident 51's Order Summary Report (OSR), dated 10/8/24, the OSR indicated, Heels up device, monitor for proper placement every shift for hx [history] of blanchable redness. During a review of Resident 51's Braden Scale for Predicting Pressure Sore Risk (BSP), dated 9/26/24, the BSP indicated, Resident 51 had a score of 12 (high risk…

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 follow their policy and procedures titled Medication Reordering and Unavailable Medications when Licensed Nurse did not reorder medications timely, notify physician of unavailable medication and obtain alternate orders for one of one sampled residents (Resident 54). This failure resulted in .Resident 54 not receiving physician ordered diabetic medications (to manage blood sugar level) and had the potential to result in adverse health outcomes. Findings: During a review of Resident 54's Order Summary Report (OSR), dated 10/9/24, the OSR indicated the following orders: Admelog Injection Solution [rapid acting insulin, medication to manage blood sugar level] 100 UNIT/ML (milliliter) Inject 15 unit subcutaneously before meals for DM (diabetes mellitus) hold for BS (blood sugar) < (less than) 100, Jardiance oral tablet (medication to manage blood sugar level) 25 mg [milligrams] Give 1 tablet by mouth one time a day for Diabetes Mellitus, Lasix oral tablet [medication to remove excess water in the body] 40 mg Give 1 tablet by mouth…

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 order for one of three sampled residents (Resident 47) for nectar thick consistency beverage. This failure had the potential for Resident 47 to have a choking incident. Findings: During a concurrent observation and interview on 10/9/24 at 3:56 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 47's room, Resident 47 had unthickened (thin) juice on his bedside table. CNA 1 stated Resident 47 drinks thin liquids. CNA 1 stated Resident 47 did not like the thick consistency. During a concurrent observation and interview on 10/9/24 at 4:14 p.m. with Certified Dietary Manager (CDM) in Resident 47's room, Resident 47 had cans of soda on his bedside table. CDM stated he was not aware if the soda was getting thickened for Resident 47. During a review of Resident 47's Order Summary Report (OSR), dated October 2024 was reviewed. The OSR indicated, Resident 47's diet order was Regular Diet Puree texture, Nectar Thick Consistency. During an interview on 10/10/24 at 12:15 p.m. with Director 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.

Based on observation, interview, and record review, the facility failed to honor one of one sampled residents' (Resident 37) food preferences. This failure had the potential for Resident 37 to have unmet nutritional needs. Findings: During a concurrent observation and interview on 10/07/24 at 12:27 p.m. with Resident 37 in Resident's 37 room, Resident 37 was laying in his bed with a food tray in front of him. Resident 37's lunch plate had brussels sprouts, mashed potatoes and gravy, and pot roast. Resident 37 had facial grimace and stated, I don't ever eat brussels sprouts and once they are on my plate I will not eat it. Resident 37 stated he does not remember what he asked for, but he stated he knew he did not order the brussels sprouts. During a review of Resident 37's Minimum Data Set (MDS- assessment tool), dated 8/23/24, the MDS indicated, Resident 37 had a Brief Interview for Mental Status (BIMS, cognition assessment tool, 15-point scale: 0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact) score of 13 (score of 13-15 means cognitively intact). 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.

Based on observation, interview, and record review, the facility failed to ensure the food was served at the proper temperature for two of three sampled residents (Resident 6 and Resident 7). This failure resulted in Resident 6 and Resident 7 being served food at an unappetizing temperature. Findings: During a concurrent observation and interview on 6/20/24 at 7:16 a.m. with Resident 5 in Resident 5's room, Resident 5 had a waffle, a slice of toast, a sausage patty, milk, and juice on his breakfast tray. Resident 5 stated the waffle, toast and sausage patty were lukewarm and not hot. During a concurrent observation and interview, on 6/20/24 at 7:20 a.m. with Resident 6, in Resident 6's room, Resident 6 had a slice of French toast, oatmeal and sausage on her breakfast tray. Resident 6 stated the breakfast was cold, and the oatmeal was always cold. Resident 6 stated she would prefer the food to be hotter. During a concurrent observation and interview on 6/20/24 at 7:38 a.m. with Dietary Supervisor (DS), in the hallway. A breakfast tray was taken off the meal cart and the temperature…

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 four of five sampled staff (Certified Nursing Assistant - CNA 1, CNA 3, CNA 4, and CNA 5) were wearing name tags. This failure resulted in residents and visitors being unaware of who was providing care. Findings: During an interview on 6/5/24 at 9:03 a.m. with Family Member 1 (FM 1), FM 1 stated she was unable to identify the staff because they usually do not have name tags on. During an interview on 6/5/24 at 11:02 a.m. with Resident 1, Resident 1 stated she was unable to identify staff because they do not wear name tags. During a concurrent observation and interview on 6/5/24 at 1:37 p.m. with CNA 1, CNA 1 was observed going in and out of residents' rooms assisting residents. CNA 1 was not wearing a name tag. CNA 1 stated she did not have a name tag on because she misplaced it and had not requested a new one. CNA 1 stated she should have a name tag on. During an interview on 6/5/24 at 1:02 p.m. with Director of Staff Development (DSD), DSD stated all staff were expected to wear a name tag. 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.

Based on interview and record review, the facility failed to ensure the abuse policy was implemented for two of five sampled residents (Resident 4 and Resident 5) when an abuse allegation was not reported to the management by a staff member (Licensed Vocational Nurse - LVN 1). This failure had the potential for delayed investigation and place other residents at risk for abuse. Findings: During an interview on 6/5/24 at 12:14 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 5/30/24, Resident 1 reported (to LVN 1) Resident 4 and Resident 5 were afraid of Certified Nursing Assistant (CNA) 2 because she (CNA 2) had hit or yelled at Resident 4, and she was loud or mean to Resident 5. LVN 1 stated when Resident 1 reported the allegations she did not report it to the management because Resident 1 stated she already reported the allegations to the Director of Nursing (DON). LVN 1 stated she would talk to the DON about the allegations when she returned to work on 6/5/24 (6 days later). LVN 1 stated she should have reported the allegations to the management. During an interview 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 interview and record review, the facility failed to ensure the Physician and Responsible Party (RP) was notified of an injury for one of three sampled residents (Resident 1). This failure resulted in the Physician and RP being unaware of the injury. Findings: During a review of the S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR) dated 4/20/24 at 9:50 p.m., the SBAR indicated, The change in condition, symptoms, or signs observed and evaluated is/are: Falls. During a review of Resident 1's Progress Notes (PN) dated 4/21/24 at 6:32 a.m., the PN indicated, Resident returned from ER (Emergency Room) at approx.(approximately) 0620 (6:20 a.m.).Resident has abrasion to bilateral shins with discoloration. During a concurrent interview and record review on 5/8/24 at 3:10 p.m. with Director of Nursing (DON), DON reviewed Resident 1's PN's and was unable to provide evidence of the Physician and RP being notified of the abrasions to bilateral shins. DON stated the RP reported the abrasions to her when Resident 1 was still at the hospital after the fall. DON…

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 residents (Resident 1) call light was in working order. This failure had the potential for staff to be unaware of Resident 1 needing assistance. Findings: During an observation on 4/24/24 at 1:43 p.m. in Resident 1's room, Resident 1's call light button was pressed. When the call light button was pressed the call light did not turn on outside of the room or in the hallway. During a concurrent observation and interview on 4/24/24 at 1:55 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 pressed the call button, and the call light did not light up outside of the room or in the hallway. CNA 1 stated Resident 1 used the call light to ask for assistance and she was going to notify maintenance that the call light was not working. During a concurrent observation and interview on 4/24/24 at 2:03 p.m. with Maintenance Director (MD), in Resident 1's room, MD inspected the call light and stated the call button was pushed all the way in and the call light was not working.…

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 and monitoring and wound care were completed as ordered by the physician for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to result in worsening of the residents' wounds. Findings: a. During a review of Resident 1's Order Summary Report (OSR), dated 3/31/24, the OSR indicated, Monitor reddened open area to right heel for s/s [signs and symptoms] of worsening or infection. Notify MD [Doctor of Medicine] of any changes every shift for 21 days.Start date 3/25/24.End date 4/15/24. During a concurrent interview and record review on 4/19/24 at 1:37 p.m., with Treatment Nurse (TN), Resident 1's Treatment Administration Record (TAR) dated 3/2024 and 4/2024 were reviewed. The TAR indicated, monitoring was not documented on 3/28, 4/2, and 4/5. TN stated when the monitoring was done it should have been documented on the TAR. TN stated when the documentation was not on the TAR, the monitoring was not done. b. During a review of Resident 2's OSR dated 4/16/24, the OSR indicated,…

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

Based on interview and record review, the facility failed to administer medication and check the blood sugar for one of two sampled residents (Resident 1) as per physician order. This failure had the potential to affect Resident 1's medical condition. Findings: During a review of Resident 1 ' s Order Summary Report (OSR), dated 12/31/23, the OSR indicated Resident 1 was to be given Protonix 40 (stomach medication) mg (milligram) daily at 6 a.m. and blood sugar check two times a day at 6 a.m. and 8 p.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 12/1/23 thru 12/31/23, the MAR had no signatures on 12/1/23 for the medication Protonix and the 6 a.m. blood sugar check. During a concurrent interview and record review on 1/30/24 at 11:53 a.m. with Director of Nurses (DON), Resident 1 ' s MAR dated 12/1/23 thru 12/31/23 was reviewed. DON confirmed Protonix was not given on 12/1/23 at 6 a.m. and Resident 1 ' s blood sugar was not checked on 12/1/23 at 6 a.m. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration,…

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 physician was notified for one of three sampled residents (Resident 1) when Resident 1 was not administered prescribed medications. This failure had the potential for Resident 1 to have health complications. Findings: During a review of Resident 1 ' s Medication Administration Record (MAR), dated December 2023, the MAR indicated, Bumetanide (removes excess fluid from your body).give 1 tablet by mouth two times a day for CHF [congestive heart failure-when the heart cant pump enough blood to provide body with the blood and oxygen it needs]. Bumetanide was not administered on 12/3, 12/4, and 12/5. There was no documentation the physician was notified of the medication not being administered. During a review of Resident 1 ' s Progress Notes (PN), the PN ' s indicated, E-MAR-Administrations Note.12/3/2023 at 8:18 a.m., Bumetanide.awaiting pharmacy refill. E-MAR-Administrations Note 12/4/23 at 6:34 p.m., Bumetanide.awaiting pharmacy refill. E-MAR-Administrations Note.12/5/23 at 8:03 a.m., Bumetanide. pending delivery…

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 follow its policy and procedure when medications were not documented when administered for one of three sampled residents (Resident 1). This failure resulted in an inaccurate medication administration record (MAR). Findings: During a review of Resident 1 ' s Medication Administration Record (MAR), dated December 2023, the MAR indicated, Amiodarone (used to treat irregular heart rate) give 1 tablet by mouth one time a day.Aspirin 81 (helps to prevent heart attack or stroke) tablet.give 1 tablet by mouth one time a day for CAD (coronary artery disease-reduction of blood flow caused by plaque in the arteries).Bumetanide (removes excess fluid from your body).give 1 tablet by mouth two times a day for CHF [congestive heart failure-when the heart cant pump enough blood to provide body with the blood and oxygen it needs].Carvedilol (used to treat high blood pressure) give 1 tablet by mouth two times a day for HTN (hypertension).Omeprazole (used to treat gastroesophageal reflux disease [GERD]).give 1 tablet by mouth two times 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 interview and record review the facility failed to develop a base line care plan for one of three sampled residents (Resident 1) partial thickness (damage to skin) wound to coccyx area (tailbone area). This failure has the potential for staff to be unaware of how to care for Resident 1's wound. During a review of Resident 1's Progress Notes (PN), dated 10/4/23, the PN indicated Resident 1 was admitted to the facility with partial thickness wound to coccyx area. During a concurrent interview and record review on 11/20/23 at 2:41 p.m. with Director of Nurses (DON), Resident 1's care plan was reviewed. DON was unable to find documented evidence a base line care plan was developed for Resident 1's partial thickness wound to coccyx. DON stated a base line care plan should have been developed. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline dated, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview, and record review, the facility failed to ensure wound care was provided according to physician order for one of three sampled residents (Resident 1) . This failure has the potential to result in worsening of Resident 1's wounds. Findings: During a review of Resident 1's Active Orders (AO), dated 10/23/23, the AO indicated Resident 1's had partial thickness to coccyx (tail bone area) to be cleansed with a wound cleanser, apply medi honey (wound gel), and cover with a border gauze daily. During a review of Resident 1's Treatment Administration Record (TAR), dated 10/4/23 thru 10/31/23, the TAR had no signature on 10/22/23, 10/23/23 and 10/27/23. During a concurrent interview and record review on 11/20/23 at 2:41 p.m. with Director of Nurses (DON), Resident 1' s TAR dated 10/4/23 thru 10/31/23 was reviewed. DON confirmed wound care /treatment was not provided for Resident 1 on 10/22/23, 10/23/23, and 10/27/23. During a review of the facility's policy and procedure (P&P) titled, Wound Treatment Management, dated 5/22, the P&P indicated, 1. Wound treatments will 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 interview and record review, the facility failed to ensure the Nurses Dialysis Commmunication [sic] Record (NDCR) between the facility and the dialysis center was completed for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the facility to be unaware of the needs and services the residents required. Findings: a. During a review of Resident 1's NDCR, dated 8/30/23, the NDCR indicated, Resident 1's dialysis center did not complete the NDCR. During a review of Resident 1's NDCR, dated 8/25/23, 9/1/23, 8/30/23, 9/8/23, 9/11/23, 9/13/23, 9/18/23, the NDCR indicated, Post – Dialysis Monitoring. the section was blank indicating it was not completed by the facility when Resident 1 returned from dialysis. b. During a review of Resident 2's NDCR dated 9/6/23, the NDCR indicated, the facility did not complete the pre-dialysis section prior to Resident 2 going to dialysis. During a review of Resident 2's NDCR, dated 8/18/23, 8/21/23, 8/23/23, 8/25/23, 8/28/23, 8/30/23, 9/1/23, 9/8/23 and 9/20/23, the NDCR indicated, Post –…

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 follow its policy and procedure on Storage of Medication when medications were left at the bedside for one of three sampled residents (Resident 1). This failure had the potential for residents to be at risk for unsafe administration of medications. Findings: During an interview on 9/21/23, at 2:04 p.m. with Family Member (FM) 1, FM 1 stated there was medication left at Resident 1's bedside on 9/21/23 for approximately three hours. During an interview on 9/22/23, at 6:12 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 does not administer her own medications and medications should not be stored at bedside. During an interview on 9/22/23, at 6:23 a.m. with LVN 3, LVN 3 stated she was assigned to Resident 1 on 9/21/23. LVN 3 stated during the morning medication administration, LVN 4 was assisting with administering medication. LVN 3 stated LVN 4 left Resident 1's medication at bedside after realizing Resident 1 had already been administered the medication. LVN 3 stated Resident 1 does not administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was re-evaluated for elopement risk (ER) and a care plan (CP) was developed when Resident 1 was found off facility grounds. This failure resulted in staff being unaware of Resident 1 leaving the facility unsupervised for a second time and the potential for injury. Findings: During a review of Resident 1's admission Record (AR), dated 9/11/23, the AR indicated, Resident 1 was admitted [DATE] and diagnoses included unspecified dementia (impairment of memory). During a review of Resident 1's Progress Notes (PN), dated 8/23/23 (18 days prior to the second elopement on 9/11/23), the PN indicated, Has [sic] an episode of wandering. DON [Director of Nursing] notified writer that resident was found in the corner between [street name] and [street name]. CNA [Certified Nursing Assistant] notified to keep an eye on resident. During a review of Resident 1's Elopement- Exit-Seeking Profile (EESP), undated, the EESP…

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 properly maintain a clean and sanitary kitchen, and storage area when: 1. Kitchen appliances (microwave, toaster, stove top, and oven) were covered with grease, grime, and cooked on food debris. 2. Kitchen floors and walls were covered with dust, dirt, debris, and grime. 3. Food tray carts had food debris inside of carts with clean trays. 4. Storage shelf with cleaned pots and pans had grease and food debris. 5. Storage bins noted with grease and food stains on inside and outside of bins. 6. Dietary [NAME] (DC) 2 did not perform hand hygiene when preparing food. These failures had the potential to spread food borne illnesses to residents. Findings: 1. During a concurrent observation and interview on 10/10/22, at 9:50 AM, with Dietary Service Supervisor (DSS), in the kitchen, the inside of the microwave was observed with multiple spots of dark brown substance on the top and sides. On top and sides of the toaster had a build up layer of grease, and the toaster crumb tray was covered with black crumbs. On 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 ensure call lights were answered promptly for three of 63 sampled residents (Resident 72, Resident 56, and Resident 40 ). This failure had the potential for not meeting residents' care needs, having psychosocial distress, and potential for adverse health outcomes. Findings: During an interview on 10/10/22, at 9 AM, with Resident 72, Resident 72 stated, staff does not answer call lights timely. Resident 72 stated, Sometimes I have to wait for a long time to be changed. During a review of Resident 72's Minimum Data Set (MDS-an assessment tool), dated 8/30/22, the MDS indicated, Resident 72 had a Brief Interview for Mental Status (BIMS) score of 13 (score of 13-15 means cognitively intact) and Resident 72's Functional Status indicated, Resident 72 required extensive assistance (staff provide weight-bearing support) and one person physical assist with toilet use. During an interview on 10/11/22, at 7:54 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ongoing activity programs for five of 63 sampled residents (Resident 72, Resident 13, Resident 8, Resident 22, and Resident 11). This failure had the potential for residents not being recognized of their interests, experiencing feelings of social isolation, and sadness, affecting their quality of life. Findings: During a concurrent observation and interview on 10/10/22, at 9 AM, with Resident 72, in Resident 72's room, Resident 72 was in bed awake and was looking at the doorway. Resident 72 stated, No activity for today. When asked if staff comes and visits her, she stated, No, they do not provide me with anything to do. During a review of Resident 72's Activity Participation (AP) dated 9/2022, the AP indicated, there were no activities provided on the dates 9/15/22, 9/17/22, 9/20/22, 9/21/22, 9/22/22, 9/24/22, 9/25/22, 9/26/22, 9/27/22, 9/28/22, 9/30/22, and 10/1/22. During a review of Resident 72's Minimum Data Set (MDS-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 ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) pre (before) and post (after) assessments were completed for three of five sampled dialysis residents (Resident 35, Resident 33, and Resident 36). This failure had the potential for residents who were undergoing dialysis treatment not being assessed and monitored, and potential for experiencing adverse health outcomes. Findings: During a concurrent interview and record review on 10/11/22, at 8:30 AM, with Assistant Director of Nursing (ADON), Resident 35's Nurses Dialysis Communication Record (NDCR), dated 8/9/22, was reviewed. The NDCR indicated, the pulse rate, respiratory rate, temperature, pain assessment, and dialysis access site assessment were not completed. There were no nurses signature on the pre dialysis treatment. Resident 35's NDCR dated 9/29/22 indicated, the blood pressure, pulse rate, and respiratory rate on the pre and post dialysis treatment were not completed. ADON stated, 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 interview, and record review, the facility failed to ensure narcotics (highly regulated, highly addictive drugs) were reconciled (inventoried) each shift for one of three medication carts (Hall 200 cart). This failure had the potential to result in an inaccurate account of the narcotic inventory and drug diversion. Findings: During a concurrent interview and record review, on 10/12/22, at 9:50 AM, with Assistant Director of Nursing (ADON), the SHIFT VERIFICATION OF CONTROLLED DRUG COUNT and Narcotic Card Count Sheet, both dated 10/12/22, for Hall 200 medication cart were reviewed. The above documents indicated, there were no licensed nurse signature for the AM shift on 10/12/22. ADON confirmed the above documents had no licensed nurse signatures. During an interview on 10/12/22, at 10:51 AM, with ADON, ADON stated the expectation is for narcotics to be counted each shift to ensure there are no discrepancies. During a review of the facility's policy and procedure (P&P) titled Controlled Substance Administration & Accountability, dated 6/1/22, the P&P indicated, The entire…

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 its policy and procedure in serving food and drink in an appropriate temperature for 7 of 63 sampled residents (Resident 1a, Resident 1b, Resident 1c, Resident 1d, Resident 1e, Resident 1f, and Resident 58). This failure had the potential for unmet nutritional needs of the residents. Findings: During an interview on 10/11/22 at 10:26 AM, with Confidential Resident Council Members (CRCM), (Resident 1a, Resident 1b, Resident 1c, Resident 1d, Resident 1e, Resident 1f), all CRCMs stated, food is served cold at meals. During an interview on 10/11/22 at 10:45 AM, with Resident 58, Resident 58 stated, food is served cold. During a concurrent observation and interview on 10/11/22, at 11:50 AM, with Dietary Service Supervisor (DSS), in the kitchen, the dietary aide placed the refrigerated items (milk, jello, salad) on the resident trays to be served for lunch. DSS checked the temperature of the milk with a thermometer, and stated, the milk temperature was 44 degrees (°) Fahrenheit (F-unit of measure). The milk…

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 all staff were trained on infection prevention and control. This failure had the potential for staff to be unaware of infection control practices and spread infectious diseases to residents and visitors. 2. Implement infection control practices when Certified Nursing Assistant (CNA) 8 did not perform hand hygiene. This failure had the potential to spread infectious diseases, including the highly contagious Covid 19 virus to other residents, staff, and visitors. Findings: 1. During an interview on 10/12/22, at 9:50 AM, with Infection Control Preventionist (ICP), ICP stated, the DSD (Director of Staff Development) does all the staff in services. ICP stated, facility staff are educated on donning (putting on) and doffing (taking off) PPE (Personal Protective Equipment-a specialized clothing or equipment worn for protection against infectious materials-gowns, gloves, masks, face shields) in the facility. During an interview 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 interview and record review, the facility failed to ensure a copy of an Advanced Directive (AD-a legal document that explains how medical decisions are made for a resident if they become too ill to make decisions), or a Physician Order for Life Sustaining Treatment (POLST) was placed in the medical record/chart for one of 63 sampled residents' (Resident 239). This failure had the potential for licensed staff to be unaware of Resident 239's desired medical treatment in the event of an emergency. Findings: During a concurrent interview and record review, on 10/11/22, at 9:40 AM, with Licensed Vocational Nurse (LVN) 6, Resident 239's medical record/chart was reviewed. It was noted there was no Advance Directive or Physician's Order for Life Sustaining Treatment in Resident 239's medical record/chart. LVN 6 confirmed the finding and stated, there is no AD or POLST documents in Resident 239's medical record/chart. During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advanced Directives, dated 6/1/22, the P&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.

Based on interview and record review, the facility failed to develop a person-centered care plan for one of 63 sampled Residents (Resident 80) with Dementia (a group of thinking and social symptoms that interferes with daily functioning). This failure had the potential for not providing the appropriate care to Resident 80 who has diagnosis of Dementia. Findings: During a review of Resident 80's admission RECORD (AR), dated 9/2/22, the AR indicated Resident 80 was admitted with the diagnosis of UNSPECIFIED DEMENTIA. During a concurrent interview and record review, on 10/13/22, at 10:16 AM, with Director of Nursing (DON), Resident 80's Care Plan (CP), dated 10/13/22 was reviewed. It was noted Resident 80 had no CP for Dementia care. DON confirmed the finding and stated, the CP for a resident with Dementia should include a cognition (thought process) care plan. During a concurrent interview and record review, on 10/13/22, at 10:21 AM, with DON, Resident 80's Minimum Data Set (MDS-an assessment tool), dated 9/6/22 was reviewed. Resident 80's MDS Section C (evaluates the resident'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 appropriate services to maintain hygiene for one of 63 sampled residents (Resident 58) when showers were not given as scheduled. This failure had the potential to result in skin breakdown, infection, loss of dignity, and psychosocial distress. Findings: During a concurrent observation and interview on 10/10/22, at 11 AM, with Resident 58, outside Residents 58's room, Resident 58 was sitting in her wheelchair, alert and oriented, being attended by a certified nursing assistant (CNA). Resident 58 stated, she was shocked she was able to get a shower today as its been three weeks since she has been offered a shower. During a review of Resident 58's Minimum Data Set (MDS-assessment tool), dated 8/30/22, the MDS indicated, Resident 68 had a Brief Interview for Mental Status (BIMS) score of 15 (score of 13-15 indicated cognitively intact). During an interview on 10/12/22, at 9:10 AM, with CNA 4, CNA 4 stated, there is a log which identifies who is scheduled for a shower for either the AM or PM shifts. She…

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. Provide restorative nursing (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) for one of 63 sampled residents (Resident 72) when Resident 72 was not assisted to get up from bed according to physician's order. This failure had the potential for Resident 72 to experience a decrease in range in motion and quality of life. 2. Provide palm guard splint (used as a barrier between fingers and palms to prevent injury to the palm from severe finger flexion contracture) for two of 63 sampled residents (Resident 72 and Resident 13) according to the physician's order. This failure had the potential for Resident 72 and Resident 13 to worsen their contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decrease mobility. Findings: 1. During a concurrent observation and interview on 10/10/22, at 9 AM, with Resident 72,…

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 tray card (tray diet order preference card) was followed for two of 63 sampled residents (Resident 77 and Resident 72). This failure had the potential for the resident to not receive adequate nutrition. Findings: 1. During a concurrent observation and interview, on 10/10/22, at 12:19 PM, with Resident 77, in the dining room, Resident 77 was eating her lunch. Resident 77 stated, her tray card was not followed again. She stated, she complains all the time and it does not change. Resident 77 stated, she had lost weight, and she needed to watch her nutrition. She stated, her tray card stated plastic utensils and they gave me metal utensils. Resident 77 stated, her teeth are bad and these metal utensils hurt her teeth and she then cannot eat her food. Resident 77 stated, they are also suppose to give me extra gravy which again they did not give me. During an interview on 10/10/22, at 12:20 PM, with Restorative Nursing Assistant (RNA) 1, RNA 1 stated, she would bring her (Resident 77) some plastic utensils…

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.