Live Oak Healthcare And Rehabilitation Center

Based on record review and interview, the facility failed to ensure staff promptly reported an accident resulting in injury for physician intervention for 1 of 3 residents reviewed for falls (Resident #2). Findings include: During an interview on 8/6/2025 at 10:10 AM, Resident #2 stated that she had fallen, getting in bed and her knee got stuck, and she had to have x-rays. Review of Resident #2's nursing progress notes dated 7/10/2025 read, Note Text: This nurse entered resident's room to administer PM [afternoon] medication when resident stated that she was hurting from a fall that occurred earlier in the day. Resident stated that her right leg gave out when the CNA [Certified Nursing Assistant] was attempting to put her back in bed which resulted in her right leg twisting and going under the bed. Roommate states she witnessed said incident. This nurse palpated hip area down to her lower extremity. Resident showed signs of pain with facial grimacing and screaming for me to stop. Xray ordered for rule out. Scheduled pain medication administered at that time. Review of Resident #2'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 and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis. Findings include: During an observation upon entrance to the facility on 2/3/2025 at 9:00 AM, the nurse staffing information in the reception area was dated Friday 1/31/2025. During an interview on 2/3/2025 at 9:05 AM, the Administrator confirmed the nurse staffing data posted was for 1/31/2025 and not 2/3/2025. During an interview on 2/5/2025 at 2:00 PM, when a policy on posting of nurse staffing information was requested, the Administrator stated the facility did not have a policy and he expected it to be posted accurately daily.

Based on record review and interview, the facility failed to ensure the attending physician documented their rationale related to pharmacy recommendations and failed to ensure to implement the physician's agreed changes for 3 of 5 residents reviewed for drug regimen, Residents #23, #101, and #124. Findings include: 1) Review of the Drug Regimen Review for Resident #23 dated 3/22/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Lamotrigine (Lamictal) for Mood without recent attempt to taper. Please evaluate and consider an attempt at gradual dose reduction with eventual discontinuation or document inability to do so. Please note: abrupt cessation not recommended. Consider a slow taper over 4 weeks then discontinue. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #23 dated 4/24/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Alprazolam 0.25 mg [milligram] daily without recent attempt to taper. Please evaluate current need. Consider taper to 0.25 mg every other…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 10.81 percent. Findings include: 1) Review of Resident #11's physician order dated 10/18/2023 showed it read, Trazodone HCl Oral Tablet 150 mg [milligram] (Trazodone HCl), Give 150 mg by mouth two times a day for depression. Review of Resident #11's physician order dated 1/2/2025 showed it read, Tizanidine HCl Oral Tablet 4 mg (Tizanidine HCl), Give 2 tablet by mouth four times a day for muscle spasms. During an observation on 2/3/2025 at 11:12 AM, Staff E, Licensed Practical Nurse (LPN), began to pour Resident #11's medications into a medication cup. Staff E poured one tablet of Tizanidine 4 mg. Staff E did not pour Trazodone 150 mg (milligram). Staff E began to pour water into a medication cup and was getting ready to give the medications to Resident #11. Staff E was asked to review the medications that were in her medication cup. During an interview on 2/3/2025 at 11:15 AM, Staff E, LPN, stated, I am missing 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 record review and interview, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for blood pressure medication, residents reviewed for medication, Residents #40 and #122, 1 of 3 residents reviewed for dialysis care, Resident #80, 1 of 10 residents reviewed for advance directives, Resident #127, and 1 of 8 residents sampled for oxygen therapy, Resident #28. Findings include: 1) Review of Resident #80's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including end stage renal disease, sepsis, and anemia. Review of Resident #80's Dialysis Hand Off Communication Report dated [DATE] showed no information documented for presence of bruit/thrill, catheter dressing, signs/symptoms of infection upon his return to the facility. Review of Resident #80's Dialysis Hand Off Communication Report dated [DATE] showed no information documented for presence of bruit/thrill, catheter dressing,…

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 residents' right to live in a manner that promoted their quality of life for 1 of 57 residents sampled, Resident #135. Findings include: Review of Resident #135's admission record showed the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, major depressive disorder, unspecified mood (affective) disorder, and acquired absence of left leg below knee. Review of Resident #135's Service Dog Card showed it read, The Americans with Disabilities Act of 1990 mandates the handler and their service dog shall have full access to all public places. It is Federal law. Handler: [Resident #135's Name], Dog Name: [Resident #135's dog's name], Breed: Mixed, ID Number: [Service Dog ID]. The card contained a photo of the service dog. Review of Resident #135's Minimum Data Set (MDS) assessment dated [DATE] under Section GG- Functional Abilities for self-care showed the resident was independent for eating, oral hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 4 residents reviewed for discharge, Resident #150. Findings include: Review of Resident #150's admission record showed the resident was admitted to the facility on [DATE]. Review of Resident #150's physician order dated 1/13/2025 showed it read, Discharge home with [Name of Home Care Provider]- SN [skilled Nursing] for wound care to left heel, scrotum, left ischium, left plantar, right elbow, right ischium, and sacrum. PT [Physical therapy] to evaluate and treat. Review of Resident #150's Discharge Return not Anticipated MDS assessment dated [DATE] showed the resident was discharged to short-term general hospital. During an interview on 2/5/2025 at 10:37 AM, the MDS Coordinator confirmed that Resident #150's discharge status was coded as short-term general hospital. The MDS Coordinator stated, It has been coded wrong. The patient was not discharged to a hospital. The patient was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 of 3 residents reviewed for behaviors, Resident #48. Findings include: Review of Resident #48's admission record showed the resident was admitted on [DATE] with diagnoses including encephalopathy, seizures, major depressive disorder, pseudobulbar affect, schizoaffective disorder and mood disorder due to known physiological condition. Review of Resident #48's physician order dated 10/11/2024 showed it read, Nuedexta Oral Capsule 20-10 mg [milligrams] (Dextromethorphan HBr-Quinidine Sulfate), Give 1 capsule via G-tube [gastric tube] two times a day for PBA [Pseudobulbar Affect: a neurological condition characterized by involuntary and uncontrollable episodes of laughing or crying, often in inappropriate situations]. Review of Resident #48's care plan did not reveal a focus for care and services related to pseudobulbar affect. During an interview on 2/6/2025 at 4:15 PM, the MDS Coordinator stated, After reviewing…

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 administered in accordance with currently accepted professional principles for 2 of 6 residents reviewed for medication administration, Residents #6 and #87. Findings include: 1) During an observation on 2/5/2025 at 9:00 AM, Resident #87 was eating breakfast in her room. There was a small plastic cup containing medications on top of her bedside. During an interview on 2/5/2025 at 9:00 AM, Resident #87 stated, I take my medication with food and not on an empty stomach. Review of Resident #87's physician orders revealed no orders for self-administering medications. During an interview on 2/6/2025 at 8:24 AM, Staff L, Registered Nurse (RN), stated, I left the medication at bedside. [Resident #87's name] likes to take her medication with food. I know this is not normal practice and is wrong. During an interview 2/6/2025 at 9:09 AM, the Director of Nursing (DON) stated, It is not protocol to leave the medication at bedside and maybe we can get the order changed for her [Resident #87], so…

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 residents who are unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal and oral hygiene for 2 of 4 residents reviewed for ADL care, Residents #88, and #131. Findings include: 1) During an observation on 2/4/2025 at 9:24 AM, Resident #88 was lying in bed. The resident's face was oily, her lips were dry and cracked with a dried crusty substance on them, and her mouth was dry when she tried to talk. During an observation on 2/4/2025 at 10:52 AM, Resident #88's lips were dry and cracked with a dried crusty substance on them, and her mouth was dry when she tried to talk. Review of Resident #88's admission record showed the resident was admitted on [DATE] with the diagnoses including encephalopathy, muscles weakness, and failure to thrive. Review of Resident #88's MDS dated [DATE] showed the resident was dependent for performing personal hygiene (oral hygiene)…

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

Based on record review and interview, the facility failed to ensure residents received blood pressure medications following parameters for 1 of 6 residents reviewed for medication administration, Resident #136. Findings include: Review of Resident #136's physician order dated 6/8/2024 showed it read, Amlodipine Besylate Oral Tablet 5 mg [milligram] (Amlodipine Besylate), Give 1 tablet by mouth one time a day for hypertension, Hold for systolic less than 110 or pulse less than 60. Review of Resident #136's Medication Administration Record (MAR) for January 2025 showed the resident received Amlodipine 5 mg on 1/2/2025 at 9:00 AM when systolic blood pressure was 102 and pulse was 59 and on 1/12/2025 at 9:00 AM when pulse was 58. Review of Resident #136's physician order dated 6/8/2024 showed it read, Losartan Potassium Oral Tablet 100 mg (Losartan Potassium), Give 1 tablet by mouth one time a day for hypertension, Hold for systolic less than 110 or pulse less than 60. Review of Resident #136 MAR for January 2025 showed the resident received Losartan Potassium 100 mg on 1/2/2025 at 9:00…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received oxygen as prescribed by physician for 1 of 8 residents sampled for oxygen therapy, Resident #28. Findings include: During an observation on 2/3/2025 at 9:47 AM, Resident #28 was in bed. The resident was not receiving oxygen. The oxygen tubing was no dated. During an observation on 2/4/2025 at 10:34 AM, Resident #28 was lying in bed with eyes closed and glasses on. Resident #28 was receiving oxygen via nasal cannula at 3.5 liters per minute. There was no date on the canula or humidification bottle. During an observation on 2/5/2025 at 12:18 PM, Resident #28 was receiving oxygen via nasal cannula at 4.5 liters per minute. Review of Resident #28's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure with hypercapnia (abnormally elevated carbon dioxide levels in the blood),…

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 food items were labeled in 1 of 3 nourishment rooms. Findings include: During an observation on 2/3/2025 at 9:25 AM while conducting a tour of the nourishment rooms with the Certified Dietary Manager (CDM), there were one unlabeled and undated grocery bag containing Chicken BLT salad bowl, one unlabeled and undated Chef salad bowl, and one unlabeled and undated clear plastic container of blackberries on the bottom shelf of the refrigerator in Nutrition room [ROOM NUMBER] located on the 300 hallway. During an interview on 2/3/2025 at 9:30 AM, the CDM stated, All foods brought in must be labeled with the residents' name, when it was brought in, and the expiration date of 7 days after it was brought in. Review of the facility policy and procedure titled Food: Safe Handling for Foods from Visitors with the last review date of 1/13/2025 showed it read, Procedures . 4. When food items are intended for later consumption, the responsible…

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 infection control standards were followed for catheter care to prevent the possible spread of infection and communicable diseases for 1 of 3 residents reviewed for indwelling urinary catheters, Resident #136. Findings include: During an observation on 2/3/2025 at 10:58 AM, Resident #136's catheter bag was lying on the floor. During an interview on 2/3/2025 at 11:05 AM, Staff C, Licensed Practical Nurse (LPN), stated, That bag should absolutely not be lying on the floor. During an interview on 2/4/2025 at 11:30 AM, the Director of Nursing stated that it was her expectation for the nurses on the floor to check the catheter bags during medication pass. Review of the facility policy and procedure titled Nursing- Catheter Care- Urinary with the last review date of 1/13/2025 showed it read, General Guidelines . Infection Control: 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag . b.…

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

Based on record review and interview, the facility failed to ensure pain medications were administered as ordered for 1 of 3 residents reviewed for accuracy of medication administration, Resident #2. Findings include: Review of Resident #2's physician order dated 10/30/2024 read, Oxycodone HCl Oral Tablet 5 MG [milligrams] (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #2's physician order dated 11/12/2024 read, Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 4 hours as needed for Non Acute Pain. Review of Resident #2's progress note dated 11/12/2024 at 3:03 PM read, Spoke with family regarding Residents [Sic.] POC [Plan of Care]. Requesting [Local hospice's name] Consult. Email sent to Social Services. Family requesting pain med [medication] increase. Notified NP [Nurse Practitioner] with new orders initiated. No further questions or concerns at this time. Review of Resident #2's progress note dated 11/12/2024 at 4:51 PM read, Resident told 7-3 CNA [Certified Nursing…

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 prevent the possible spread of infection during hygiene care for 1 of 3 residents, Resident #2. Findings include: During an observation of Resident #2's peri-care, on 11/4/2024 at 1:30 PM, Staff B, CNA (Certified Nursing Assistant), and Staff C, CNA were observed preforming hand hygiene and donning gloves prior to initiating care. Staff C, CNA did not prevent the possible transfer of bacteria when cleansing the outside of the resident's left groin then cleansing the inside labial/vaginal area of the resident's left groin, then cleansing the outside of the resident's right groin area to the inside labial/vaginal area, and then rinsing the resident's groin area from the outside to the inside. Staff C, CNA did not remove her gloves and did not perform hand hygiene. Staff C, CNA picked up a tube of barrier cream and applied it to Resident #2's groin and vaginal areas. Staff C, CNA did not remove her gloves and did not perform hand hygiene. Staff C, CNA cleansed Resident #2's perineal area (the region of skin…

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

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 3 of 3 shower rooms and 2 of 2 resident rooms, Residents #411 and #24 (Photographic evidence obtained). Findings include: 1. During the facility tour on 10/10/2023 at 12:20 PM with the Maintenance Director and the Regional Maintenance Director, the shower rooms were toured. The East Unit shower room had multiple personal items in the room. There was a black discoloration in the shower stall along the grout line of the floor tile and the wall tile and along the grout lines between the wall joints. There was a brown discoloration on the tiles of one shower stall and a gray discoloration on the floor tiles of the second shower stall. There was a Hoyer lift sling attachment apparatus with buildup residue on it. The tiles just above the baseboard in the dressing area were displaced and the baseboard and tile above it next to the toilet in the east shower room were also displaced. The [NAME] Unit shower room had unsecured disposable razors laying on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 5 of 6 medication carts and failed to ensure the medications were secured in 1 of 3 wings (Photographic evidence obtained). Findings include: During an observation of Medication Cart [NAME] Run 1 on 10/8/2023 at 9:43 AM with Staff K, License Practical Nurse (LPN), there were one medication cup with 3 circular pills and 18 loose pills inside the medication drawer, one opened Levemir vial with no opened or expiration dates, one opened Basaglar Kwikpen with no legible opened date, one opened bottle of Loteprednol [NAME] 0.5% eye drops with no opened or expiration dates, one opened Breo Ellipta Inhaler with no opened or expiration dates, one opened Fluoromethol [NAME] 0.1% with no opened or expiration dates, one opened Timolol Mal Sol 0.5% with no opened and expiration dates, two opened Latanoprost Sol…

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 food was stored in a safe and sanitary manner in 3 of 3 nourishment rooms. Findings include: During a tour of the facility nourishment rooms on 10/8/2023 at 9:55 AM with Staff A, Dietary Aide, During an observation on 10/8/2023 at 9:57 AM in the [NAME] Unit nourishment room with Staff A, Dietary Aide, there were three grocery store food bags containing an unlabeled and undated fruit bowl, an unlabeled and undated sub sandwich, and one container of unidentifiable food substance on the middle shelf of the refrigerator. There was a red sticky substance splattered on the interior base of the freezer. During an interview on 10/8/2023 at 9:57 AM, Staff A, Dietary Aide, stated, Those should be labeled with the residents' name, room number, and when it was brought in. Staff A acknowledged the red substance on the interior base of the freezer and stated she did not know whose responsibility it was to clean the freezer. During an observation on 10/8/2023 at 10:05 AM in the East Unit nourishment room Staff 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 promptly act on the concerns voiced during a Resident Council Meeting. Finding include: During the facility tour on 10/10/2023 at 12:20 PM with the Maintenance Director and the Regional Maintenance Director, the shower rooms were toured. The East Unit shower room had multiple personal items in the room. There was a black discoloration in the shower stall along the grout line of the floor tile and the wall tile and along the grout lines between the wall joints. There was a brown discoloration on the tiles of one shower stall and a gray discoloration on the floor tiles of the second shower stall. There was a Hoyer lift sling attachment apparatus with buildup residue on it. The tiles just above the baseboard in the dressing area were displaced and the baseboard and tile above it next to the toilet in the east shower room were also displaced. The [NAME] Unit shower room had unsecured disposable razors laying on the bar soap holder and next to the drain on the floor in the dressing area. There was a brown…

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 each resident received assistive devices to prevent accidents for 1 of 3 residents reviewed for accidents, Resident #128. Findings include: During an interview on 10/8/2023 at 9:50 AM, Resident #128's Mother stated, I received a phone call at 8:30 AM telling me that my son had fallen. When I got here, he had a knot on his head. During an observation on 10/8/2023 at 10:58 AM, Resident #128 was lying in bed. There were no fall mats on either side of bed and nowhere in the resident's room. During a phone interview with Staff G, Licensed Practical Nurse (LPN), on 10/9/2023 at 10:10 AM, when asked if he had knowledge of any resident on 1 on 1 or increased supervision on the [NAME] Wing, he stated, I don't remember anyone being like that. During a phone interview with Staff D, Certified Nursing Assistant (CNA), on 10/9/2023 at 10:35 AM, when asked if she remembered fall mats being in place next to the Resident #128's bed, she stated that there were no fall mats next to the resident's bed when she assisted…

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

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 1 of 10 residents receiving continuous oxygen services, Resident #104. Findings include: During an observation on 10/8/2023 at 2:30 PM, Resident #104 was lying in bed, receiving oxygen via nasal cannula. Resident #104's oxygen concentrator was set to 2 liters per minute. During an observation on 10/9/2023 at 8:45 AM, Resident #104 was lying in bed, receiving oxygen via nasal cannula. The oxygen concentrator was set to 2 liters per minute. Review of Resident #104's physician's order dated 9/12/2023, read, O2 [Oxygen] @ [at] 3 L/M [liters per minute] via N/C [nasal cannula]. Verify tubing/humidification bottle are dated per facility protocol. Order Status: Active. Review of Resident #104's care plan dated 9/6/2023 reads, [Resident 104's name] has Oxygen Therapy r/t [related to] COPD [Chronic Obstructive Pulmonary Disease]. During an interview on 10/10/2023 at 3:10 PM, Staff C, Registered Nurse (RN),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the PRN [as needed] orders for psychotropic drugs were limited to 14 days for 2 of 9 residents reviewed for behavioral monitoring, Residents #152 and #37. Findings include: 1. Review of Resident #152's admission record showed the resident was admitted to the facility on [DATE] with the diagnoses including altered mental status, unspecified psychosis not due to substance or known physiological condition, and depression. Review of Resident #152's Physician order dated 7/24/2023 reads, Xanax Oral Tablet 0.5 mg [milligrams]. Give 0.5 mg via G-tube [Gastrostomy Tube] every 12 hours as needed for agitation/anxiety. Order Status: Active. Review of Resident #152's Medication Administration Record (MAR) showed the resident received Xanax 0.5 mg tablet on 8/3/23, 8/4/23, 8/5/23, 8/7/23, 8/8/23, 8/12/23, 8/13/23, 8/21/23, 8/24/23, 8/26/23, 8/28/23, 9/2/23, 9/7/23, 9/8/23, 9/11/23 (two doses), 9/13/23, 9/14/23, 9/23/23, 9/25/23, 10/3/23, 10/5/23, and…

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

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and maintained infection control standards during enteral medication administration for 1 of 3 residents reviewed for gastrostomies, Resident #21, and during direct care for 1 of 3 residents reviewed for tracheostomies, Resident #72. Findings include: 1. During an observation on 10/10/2023 at 12:39 PM, Staff J, License Practical Nurse (LPN), performed hand hygiene with hand sanitizer and prepared Resident #21's medication. Staff J entered Resident #21's room. Staff J entered the shared bathroom and prepared water administration. Staff J washed her hands and donned gloves. Staff J placed a barrier on top of the bedside table and placed four medication cups that contained water on the barrier. Staff J stated she needed an enteral syringe in order to administer Resident #21's medication. Staff J removed her gloves and took the medication with her and walked down the hall to the nursing station. While holding the medication cup in her left hand, Staff J rested her right hand 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.