Oak Haven Rehab And Nursing Center

Based on record review and staff interviews, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate for two residents (# 7, #19) of 25 residents sampled. Findings included: 1. Review of Resident #19's admission Record revealed an admission date of 05/24/2023 with diagnoses to include Anxiety Disorder and Major Depressive Disorder. Review of the Level I PASRR, dated 08/24/2023, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) the diagnosis of Depressive Disorder was not marked. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 2. Review of Resident #7's admission Record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the Resident Assessment Instrument (RAI), the facility failed to ensure one resident (#106) of five residents reviewed for unnecessary medications had the care plan revised after a medication was discontinued. Findings included: Review of the Admissions Record showed Resident #106 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified convulsions, muscle weakness, and cognitive communication deficit. Review of the Medication Review Report showed Resident #106 had no antipsychotic drug regimen. Review of the Discontinued Physician Orders revealed Olanzapine Tablet 5 [milligrams] MG- Give 0.5 tablet by mouth two times a day for psychotic disorder. with discontinued date 06/12/24. Review of Care Plan showed the following care area: Focus- The resident uses antipsychotic medications r/t Behavior management Date Initiated: 05/31/2024. Goal- The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Plan of Care was followed for 1 of 39 sampled residents (#267) related to an order for a medication, documentation of administering the medication and follow-up documentation. Findings included: During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated that on Saturday at 3 p.m., they told the aide he was in pain due to constipation. They requested a suppository. They stated the nurse came in an hour later and stated she would come back…

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 medications were stored properly for 2 (#272 and #19) out of 6 medication administration observations. Findings included: On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, Licensed Practical Nurse (LPN). Staff J was observed entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart and went into the bathroom to wash her hands. The LPN was unable to visualize the unattended medication while she was in the bathroom. On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. The LPN placed the insulin bottle on the computer keyboard on the medication cart, entered the resident's room and injected the insulin. The LPN was unable to visualize the unattended medication while in the resident's room. During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration observation. The DON the expectations were…

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, record review and review of the facility's policy Menu and Meals Service: Nourishment/Snacks, the facility failed to ensure one resident (#73) of one resident reviewed was provided a snack when requested. Findings included: During an interview on 07/15/24 at 10:56 a.m., Resident #73 stated, I am still hungry, I got two eggs but I still would like a snack. During an interview on 07/15/24 at 11:00 a.m., Staff C, Certified Nursing Assistant (CNA) was notified of Resident #73's snack request. Staff C, CNA stated, I am not his CNA but he gets double portions for his meals. An observation on 07/15/24 at 11:19 a.m., revealed Resident #73 continued to sit beside his bed in wheelchair with no snack visible on the bedside table. During an interview on 07/15/24 at 11:20 a.m., Resident #73 stated, No one ever brought me that snack. During an interview on 07/15/24 at 11:22 a.m., Staff D, Registered Nurse (RN) Nurse stated, I will go get him a snack and the CNA should have provided it when requested. During an interview on 07/15/24 at 11:36 a.m., Staff C, CNA…

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 medical record was accurate and complete related to to documentation of Skilled Nursing Documentation Notes for 3 (#8, #19, #267) of 39 sampled residents. Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. No odors were noted. No skin impairments were observed. Her personal items were noted. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Chronic Respiratory Failure with hypoxia, diabetes, Chronic Obstructive Pulmonary Disease (COPD),…

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 Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to 1.) failing to ensure proper storage of medication and biologicals, for 3 of 4 treatment carts, on 1 of 2 hallways (F761) and 2.) failing to maintain an effective infection control and prevention program to prevent the spread of infection by failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one (Resident #3) of 2 residents under transmission based precautions (F880) during the revisit survey conducted on 09/11/2024. Findings included: 1.) An observation on 09/11/2024 at 0917 AM revealed 3 treatment carts unlocked and unsecured across from the nurse's station. There were no staff near the carts, and the carts contained prescription…

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 observations, interviews and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen related to not labeling or dating foods, not maintaining refrigerator and freezer temperature logs, not implementing cleaning schedules and not utilizing sanitizing buckets for three days (5/23/22, 5/24/22 and 5/25/22) of four days observed. Findings included: On 05/23/2022 at 9:26 a.m., the initial kitchen tour was conducted with Staff J, [NAME] Manager. An observation of the walk-in cooler revealed no thermometer found inside the cooler. Also observed were food items not properly labeled and or dated to include: two opened containers of cottage cheese, white sliced cheese wrapped in clear plastic, an opened package of sliced turkey, a container of fruit (pale yellow in color and appeared to be diced) and a partially used pan of red gelatin with no date. Staff J, [NAME] Manager stated (red gelatin) was used as a dessert and was not sure exactly when, but it was for a supper…

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 observations, interviews, and record review the facility failed to maintain and promote a resident's dignity related to personal hygiene for one resident (#368) of three sampled residents. Findings included: During an interview with Resident #368 on 05/23/22 at 10:28 a.m., Resident #368 revealed he spoke to a staff member an hour ago, as they were making his bed, and told them he was wet. He stated the staff member told him she would return in twenty to thirty minutes to help. Resident #368 revealed he was still wet and this situation happens frequently. An observation made from the hall on 05/24/22 at 8:39 a.m. revealed Resident #368 sitting in his wheelchair in a hospital gown on leaving his back open and exposed. Resident #368 stated he needs to be dressed and has been sitting in his gown since 5:30 a.m. Resident #368 revealed he was not sure if anybody was going to help change him. An observation on 05/24/22 at 8:47 a.m. revealed Resident #368 was still not dressed, and his back was exposed to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to develop and implement a care plan with goals and interventions related to dentures for one resident (#14) of forty-seven residents. Findings included: During observed times on 5/23/2022 at 12:20 p.m.; 5/24/2022 at 8:10 a.m. and 12:00 p.m.; 5/25/2022 at 7:50 a.m. and 12:30 p.m.; and on 5/26/2022 at 7:30 a.m., Resident #14 was observed either being assisted with eating from staff or was lying in bed with her eyes closed and with her mouth open. Resident #14 was observed with no upper or lower dentures or natural teeth. Observations during the breakfast and lunch meal service on 5/23/2022, 5/24/2022, 5/25/2022, and 5/26/2022 revealed Resident #14 was not wearing any dentures while being assisted from staff with eating. Resident #14 was unable to speak related to her medical care and services during an attempted interview in relation to her mouth care and if she had dentures. Resident #14 could not remember if she had dentures or not.…

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 observations, medical record review and interviews, the facility failed to provide treatment and services related to not assisting one resident (#72) with donning of a palm guard of a total of 21 residents with contractures. Findings included: Resident #72 on 05/23/22 at 9:59 a.m. was observed with a left-hand contracture. The resident stated she did not know where to get a splint but would like one. An observation was made on 05/24/22 at 8:30 a.m. of Resident #72. Resident #72 was without a splint/palm protector on the left hand. Review of Resident #72's admission Record indicated an admission date of 04/04/22 with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left-dominant side; hypo-osmolality and hyponatremia. Review of the Minimum Data Set (MDS) assessment, dated 04/10/22, revealed in Section G (Functional Status) Resident #72 needed extensive assistance with bed mobility, transfer, dressing, and toilet use. Resident #72 had an impairment to one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure one (#115) out of five residents sampled for unnecessary medications received medications according to physician orders regarding a duplication of insulin orders and administration of anti-hypertensive medication outside of parameters. Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified type 2 Diabetes Mellitus with diabetic neuropathy, atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm, and hypertensive heart disease with heart failure. A review of Resident #115's May 2022 Medication Administration Record (MAR) identified the following orders: - Admelog SoloStar 100 unit/milliliter (u/mL) Solution pen-injector. Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus. The order started on 4/16/22 and was discontinued on 5/24/22. - Humalog…

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, record review, and interviews the facility failed to ensure one (#115) out of five residents sampled for the administration of unnecessary medications was monitored for behaviors and side effects related to the use of psychotropic medications. Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to generalized anxiety disorder and primary insomnia. The April 2022 Medication Administration Record (MAR) indicated Resident #115 received the psychotropic medication Buspirone twice daily and Alprazolam three times a day for anxiety, both of which began on 4/15/22. A review of the April MAR and Treatment Administration Record (TAR) did not indicate staff were monitoring the resident for exhibited behaviors or side effects related to the administration of the psychotropic medications. The May 2022 MAR and TAR identified Resident #115 was administered 30 milligrams (mg) of Buspirone twice daily and 0.25…

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 observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty medication administration opportunities were observed and five errors were identified for four residents (#42, #268, #17, and #49) of seven residents observed. These errors constituted a 12.5% medication error rate. Findings included: 1. On 5/24/22 at 4:29 p.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #42. The staff member dispensed the following medications: - Humalog Kwikpen 4 units - Humulin N 37 units - Carvedilol 6.25 milligram (mg) tablet - Acetaminophen 325 mg - 2 tablets. Staff P, LPN primed the Humalog pen appropriately then primed the Humulin N insulin pen while holding the pen with the needle pointing downwards. Staff P injected the Humulin and she was taking the pen away the insulin squirted in an arc out of the tip. Staff P identified that had never happened before. According to the manufacturer (https://uspl.lilly.com/humulinn/humulinn.html#ppi), users…

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 observations, record reviews, and interviews the facility failed to 1. ensure one medication cart (400-hall) out of four medication carts and two out of two treatment carts (Station One carts) were locked while unattended, 2. opened insulin vials/pens (9) were dated to ensure the medication was discarded when expired, and 3. ensure one insulin vial (Lispro) was refrigerated when unopened. Findings included: 1. An observation was made, on [DATE] at 10:31 a.m. of two unlocked treatment carts parked across from Station One nursing station. (Photograph Evidence Obtained) The Director of Nursing (DON) was standing at the nursing station with her back to the carts. Staff M, Unit Manager (UM), confirmed the carts should have been locked and they (facility) were possibly doing treatments and did not lock the carts. On [DATE] at 11:12 a.m., an observation was made of an unlocked medication cart outside of room [ROOM NUMBER]. The observation indicated a person could move in between the cart and the doorway 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 observations, facility record review and staff interviews, the facility failed to ensure one courtyard, where residents frequent during the day to engage in smoking activities, was maintained and cleaned related to multiple used cigarette butts found on sidewalks, grass, dry landscaping and tabletops for three days (5/23/2022, 5/24/2022 and 5/25/2022) of four days observed. Findings included: During tours of the facility's outdoor courtyard on 5/23/2022 at 11:30 a.m. and 1:45 p.m.; 5/24/2022 at 9:08 a.m. and 11:10 a.m.; 5/25/2022 at 10:00 a.m. and 11:40 a.m.; and on 5/26/2022 at 7:55 a.m., the outside courtyard area where residents frequented daily either to get fresh air or to participate in group smoking activities, was observed with multiple used cigarette butts flicked and strewn on the various grassed and landscaped areas as well as on concrete walking surfaces and table tops. (Photographic Evidence Obtained) During various times of each of the days observed, there were approximately ten to fifteen residents who came out during scheduled smoking times (8:00 a.m., 11:00…

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 observations, facility record review and staff and resident interviews, the facility failed to ensure implementation of an effective pest control program for four of four days observed to include 5/23/2022, 5/24/2022, 5/25/2022 and 5/26/2022. It was determined there were wasp/hornet like flying insects and several wasp/hornet like nests and mud dauber (type of wasp) nests in the facility courtyard where residents frequent most of the day. Findings included: During brief tours of the facility courtyard frequented by residents daily, on 5/23/2022 at 11:30 a.m., 5/24/2022 at 9:08 a.m. and 1:20 p.m., 5/25/2022 at 10:00 a.m. and on 5/26/2022 at 8:00 a.m., many wasp/hornet like nests were observed attached to the inside door wall light housings and stuck on various areas under roof overhangs. (Photographic Evidence Obtained) While residents were outside and spread throughout the courtyard, the outside doors leading into the facility's 200 and 400 unit television lounges, were observed with five flying wasp like/hornet like insects. Further observations revealed wasp/hornet like…

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, resident interviews and policy review the facility failed to honor resident rights in holding group resident council meetings as desired by 6 of 6 residents present in the resident group council meeting. Findings included: On 9/22/2021 at 10:30 a.m., a resident council meeting was held by the surveyor with six residents in the main dining room with ample space for social distancing. During the meeting, the residents revealed that they had not had group resident council meetings for several months. The residents reported that they were told that some staff members had tested positive for COVID-19 and this was why they could not meet. A review of the resident council minutes revealed no group meetings had occurred since June 2, 2021. According to the residents, the Nursing Home Administrator (NHA) had informed them in August 2021 that there would be no group meetings until further notice. The residents stated that there was no reason not to have group meetings and activities since most residents had their vaccines and wore their masks in the common areas. 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 resident record review, staff interview, telephone interview with the Ombudsman and review of facility policies and procedures, the facility failed to ensure notification of transfers was made to the Office of the State Long-Term Care Ombudsman for one (#79) of three residents reviewed for transfer and discharge rights. Findings included: Review of Resident #79's admission Record revealed she was originally admitted to the facility in June of 2021, re-admitted on [DATE], and discharged to a local hospital on 9/1/2021. A review of a nursing progress note dated 9/1/2021 noted: Resident discharged to hospital via Emergency Medical Services due to respiratory distress. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120) revealed no indication that the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer. On 9/22/21 at 10:59 AM, the local Long-Term Care Ombudsman Council (LTCOC) was contacted via telephone. The ombudsman stated that they had not…

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 interviews and record reviews, the facility failed to ensure accuracy of functional status in the comprehensive assessment for one (Resident #20) of 29 residents sampled. Findings included: A review of Resident #20's medical record revealed that Resident #20 was admitted to the facility on [DATE] with diagnoses to include Urinary Tract Infection, Abnormalities of Gait and Mobility, Muscle Weakness, and Need for Assistance with Personal Care. A review of Resident #20's admission Minimum Data Set (MDS) Assessment, dated 07/08/2021, revealed under Section G - Functional Status the following information related to Resident #20's self-performance: - Bed Mobility: 7 - Activity occurred only once or twice. - Transfer: 7 - Activity occurred only once or twice. - Walk in room: 7 - Activity occurred only once or twice. - Locomotion on unit: 7 - Activity occurred only once or twice. - Locomotion off unit: 7 - Activity occurred only once or twice. - Dressing: 7 - Activity occurred only once or twice. - Eating: 7 -…

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, interviews, policy review, and review of the medical record, the facility failed to ensure that a baseline care plan was developed and provided to one (#78) of 29 sampled residents. Findings included: A review of Resident #78's medical record revealed that he was admitted to the facility on [DATE]. Resident#78 was cognitively intact according to the Brief Interview of Mental Status (BIMS) score of 13 on his most recent Minimum Data Set (MDS) assessment dated [DATE]. On 09/21/21 at 11:13 AM, Resident#78 stated that he didn't recall participating in or being provided with a written copy of his baseline care plan. A review of Resident #78's medical record revealed no documentation related to a baseline care plan. On 9/21/2021 at 2:00 p.m., the Regional Nurse Consultant reviewed the electronic medical record for Resident #78 and confirmed that there was no baseline care plan. The Regional Nurse Consultant stated that the resident was scheduled to have a care plan meeting the following day,…

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 review and revise the resident centered care plan for one (#78) of 29 sampled residents related to skin issues. Findings included: On 9/21/2021 at 10:55 a.m., Resident #78 was observed with several scabs on his arms, face and shoulders. He reported that he has had them for a few weeks and that the staff were aware. The resident stated that there have been no new orders or treatment related to the scabbed areas. On 09/21/21 at 11:00 a.m., Staff E, Licensed Practical Nurse (LPN) reported that she was unaware of any skin issues for Resident #78 and no one had informed her of any skin issues. Follow-up interview with Staff E on 09/22/21 at 1:34 p.m. revealed the doctor came in to see the resident yesterday (9/21/21) and ordered Bactroban ointment to be applied on his arms, face and legs three times a day for 10 days. She stated the resident has a rash/excoriation. She reported that she wrote a change in condition report yesterday after the surveyor had notified her of the concern. She again confirmed that 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 staff interviews, medical record review, and policy review the facility failed to ensure code status was accurately reflected in the clinical record for one (#74) of two sampled residents reviewed for advance directives out of a total sample of 29 residents. Findings included: Record review of Resident #74's admission record, contained in the paper/hard chart, revealed the resident's advance directive status was recorded as FULL CODE. Additional review of the paper/hard record for Resident #74 revealed a yellow Florida Do Not Resuscitate Order signed by the resident and the attending physician on 6/22/21. A review of Resident #74's Electronic Medical Record (EMR) revealed an active physician's order with a code status of Do Not Resuscitate (DNR) dated 8/22/21. On 09/22/21 at 9:56 a.m., interview with Staff B, Licensed Practical Nurse (LPN) revealed that if there were a code, she usually checks for the resident code status in the EMR. She stated that she never checks the resident's hard chart. On 09/22/21 at 10:03 a.m., interview with Staff C, LPN revealed that if there were…

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.