Broward Oaks Nursing And Rehabilitation

Based on observations, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet observed during 1 of 2 visits to the main kitchen. This has the potential to affect the 20 out of 98 residents on a Pureed diet. The findings included: The International Dysphagia Diet Standardization Initiative, dated January 2019, showed the following: Pureed food should have a smooth texture with no lumps, and it should not be formed or sticky. In an observation conducted on 5/5/25 at 7:55 AM in the central kitchen during the breakfast tray line, the following was noted: A half-size 6-inch deep stainless steel steam table container with pureed pancakes. Staff G, Cook, was getting ready to start the tray line for the breakfast meal. Closer observation showed that the pureed pancakes did not have a smooth consistency and were noted to be lumpy and grainy. This Surveyor tested the pureed food consistency using a spoon, which showed that it was firm and sticky on the spoon. In an interview conducted on 5/5/25 at 8:00 AM with Staff G, 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 observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 visits to the main kitchen. The findings included: In an observation conducted on 5/5/25 at 7:30 AM during the initial tour of the main kitchen, the following were noted: The Dietary Service Manager was noted to have no facial hairnet protection while walking around the food production area. Staff F, Diet Aide, was noted to have no facial hairnet protection while walking around the food production area. Three rolls of raw ground beef, 5 pounds each, were noted inside the sink with no running water flow. In this observation, Staff G [NAME] stated that the raw ground beef was thawing for lunch today. The reach-in refrigerator was noted to have a metal container of cooked vegetables that was partially opened and exposed. A dirty, used rag was noted in a red bucket with no sanitizing solution. Empty food boxes and dirty used gloves were noted on top 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review for Resident #93 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Muscle Weakness (Generalized), Dysphagia, Expressive Language Disorder, and Adult Failure to Thrive. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. On 05/05/25 at 10:10 AM observation of Resident #93 receiving tube feeding. There was no Enhanced Barrier Precaution (EBP) sign posted in room or on door. During an interview conducted on 05/05/25 at 10:34 AM with Staff A, Registered Nurse (RN), who stated he has worked at the facility for just over 1 year. When asked about Enhanced Barrier Precautions (EBP) he said he does not have any residents on EBP on his assignment today. When asked what the criteria for someone to have EBP is he said he would have to check on that. The RN never got back to the surveyor.…

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, observations and interviews, the facility failed to ensure residents Do Not Resuscitate (DNR) directives were signed by the resident's Power of Attorney (POA) agent for 1 of 27 sampled residents reviewed for Advances Directives, Resident #67. The findings included: Review of the facility's policy, titled, Resident Rights Regarding Treatment and Advance Directives implemented on 11/28/17, provided by the administrator, did not address the DNR (Do Not Resuscitate) for procedure. Review of Resident #67's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Adult Failure to Thrive Alzheimer's Disease and Vascular Dementia. Review of Resident #67's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status was not conducted due to the resident is rarely / never understood. The resident had severe cognition impairment and was totally dependent on the staff to complete the activities of daily living…

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, record and policy review, the facility failed to develop care plans for 2 of 3 sampled residents reviewed for Peripherally Inserted Central Catheter (PICC) lines, Resident #89 and Resident #557; and failed to develop care plans for residents with a Left Ventricular Assist Device (LVAD) for 1 of 1 sampled resident reviewed for a LVAD, Resident #87. The findings included: The facility's policy, titled, Comprehensive Care Plans, implemented 11/28/17, revealed, in part, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Record review revealed Resident #89 was admitted to the facility on [DATE]. The resident was readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis, with other diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) 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 record review and interviews, the facility failure to administer antibiotic therapy in a timely manner for 1 of 1 sampled resident, Resident #505, as evidenced by not administering the antibiotic on 09/16/23 for two consecutive doses as ordered; and failed to ensure physician orders were followed for residents with a Left Ventricular Assistive Device (LVAD), as evidenced by lack of accurate monitoring, calulating and documentation of mean arterial pressure (MAP) for 1 of 1 sampled residents, Resident #87. The findings included: 1. Review of Resident #505's clinical record documented an admission on [DATE] with a discharge on [DATE]. The resident's diagnoses included Cellulitis of Left Lower Limb, Fracture of Left Patella with subsequent encounter for Closed Fracture with Routine Healing, and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of Resident #505's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental…

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 provide nutritional interventions and assessments in a timely manner for 2 of 5 sampled residents reviewed for nutrition, Resident #15 and Resident #70. The findings included: Review of the facility's policy, titled, Weight Height Monitoring Policy, with a reviewed date of 11/28/23, included: In accordance with the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition suggests otherwise or not aligned with the resident preferences. The facility will obtain heights and measure/monitor weights upon admission, on Day 3 post admission by Restorative, weekly and monthly to assure communication and timely interventions to support or reverse weight gained or lost. Weight can be a useful indicator of nutritional status. Significant unintended…

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, record and policy review, the facility failed to maintain Peripherally Inserted Central Catheter (PICC) lines in a sanitary manner for 3 of 3 sampled residents reviewed for PICC lines, Residents' #67, #89, and #557. The findings included: The facility's policy, titled, PICC/Midline/CVAD Dressing Change implemented 11/28/17, revealed It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. 1. Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis. Other documented diagnoses included Chronic Obstructive Pulmonary Disease and Pressure Ulcer of sacral region. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental…

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 address residents' pain in a timely manner for 1 of 1 sampled resident reviewed for Pain, Resident #70. The findings included: Review of the facility's policy, titled, Pain Management, implemented on 11/28/2017, showed the following: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. To help a resident attain or maintain their highest practicable level of well-being and to prevent or manage pain, the facility should recognize when the resident is experiencing pain. Record review showed that Resident #70 was admitted to the facility on [DATE] with diagnoses to include Protein-Calorie Malnutrition, Colon Cancer, and Lung Cancer. Review of the Physicians' orders revealed the following: -On 12/01/23, an order for Morphine Sulfate (pain medication), 15…

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 ensure that dialysis services were consistent with professional standards of practice for 1 of 1 sampled resident reviewed for dialysis (Resident #62), as evidenced by inproper hand hygiene during observation of dialysis services and not providing the correct fluid restriction as per physician orders. The findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses that included End-Stage Renal Disease, Type 2 Diabetes, and dependence on renal dialysis. Review of the physician's orders revealed a diet for regular texture and regular/thin consistency with 1200 fluid restriction diet. Dietary: 240 milliliters (8 ounces) with breakfast, 120 milliliters (4 ounces) with lunch, and 300 milliliters (10 ounces) with dinner. In-house hemodialysis every Monday, Wednesday, and Friday. In an observation conducted on 02/05/24 at 12:30 PM, Resident #62 was in his room with the lunch tray. Closer…

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 review, the facility failed to ensure physician visits were performed as required for 1 of 1 sampled resident reviewed for physician visits, Resident #76. The findings included: Review of the facility's policy, titled, Physician Visits and Physician Delegation, with a reviewed / revised date of 11/28/23, included the following: It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The Medical Record personnel to track due dated of physician visits. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate as appropriate by law. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting…

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, record and policy reviews, the facility failed to initiate care plans with interventions regarding the diagnosis of Trauma/Post Traumatic Stress Disorder (PTSD) in a timely manner for 1 of 1 sampled resident reviewed for Trauma, Resident #86. The findings included: A review of the facility policy, titled, Trauma Informed Care, dated 11/28/2017, revealed that the facility would ensure residents who are trauma survivors receive culturally competent trauma-informed care in accordance with professional standards of practice. Record review revealed Resident #86 was admitted on [DATE] with diagnoses of Trauma/Post Traumatic Stress Disorder (PTSD) and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #86 has a Brief Interview of Mental Status (BIMS) score of 11, indicating intact cognition. In an interview conducted on 02/07/24 at 10:46 AM, Resident #86 stated that someone came to his house in [another country] and shot his wife to death in front of him. He was then…

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 medication error rate was not 5 percent or greater. The medication error rate was 12% percent, 3 medication errors were identified while observing a total of 25 opportunities, affecting Residents #70 and #77. The findings included: Review of the facility's policy, titled, Medication Administration, with a reviewed date of 11/28/23, included: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by physician. Administer medication as ordered in accordance with manufacturer specifications. Review of the Drug label Information at the following website provided by the Consulting Pharmacist: DailyMed - BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE…

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, observations and interviews, the facility failed to remove expired over-the-counter (OTC) medications from the Central Supply cabinet; failed to remove expired over-the-counter medications from 1 of 3 medication carts observed (medication cart #2-West Wing); failed to secure medications at the beside for Resident #94; and failed to ensure that 1 of 2 treatment cart was locked when unattended (West Wing treatment cart). The findings included: Review of the facility's policy, titled, Medication Storage, implemented on 11/28/17, documented, in part: it is the policy of this facility to ensure all medications housed on our premises will be stored .medication rooms .and to ensure proper .seclusion and safekeeping .all drugs and biologicals will be stored in locked compartments (i.e. medication crats, cabinets, drawers, medication rooms) unused medications: .all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated .medications . 1. On 02/07/24 at 4:01…

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 provide an arbitration agreement that explicitly grants the resident or their representative the right to rescind the contract within 30 calendar days of signing it for 2 of 3 sampled residents reviewed for arbitration, Residents #76 and #3. The findings included: 1. Record review showed Resident #76 was initially admitted to the facility on [DATE]. He was later discharged on 04/21/22 and readmitted again on 05/25/22. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #76 has a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Continued record review showed Resident #76 signed an arbitration agreement on 09/14/21, after September 16, 2019. The arbitration agreement signed by Resident #76 did not show they had the right to rescind the contract within 30 calendar days of signing it. An interview was conducted on 02/08/24 at 8:35 AM with Resident #76, who stated he did 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 review, the facility failed to maintain communication with hospice, as it relates to the resident's coordinated plan of care and services, to ensure each entity is aware of their responsibilities for 1 of 1 resident reviewed for hospice (Resident #70); and failed to accurately identify a resident's services for 1 of 1 sampled resident reviewed for Hospice services, Resident #76. The findings included: 1. Review of the facility's policy, titled, Coordination of Hospice Services and End of Life Care, implemented on 11/28/2017, revealed the following: The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. The facility and hospice provider will coordinate a care plan and implement interventions per the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide influenza and pneumococcal immunizations as required for 5 of 5 sampled residents, reviewed for immunizations, Residents #89, #87 #76, #94, and #557. The findings included: Review of the facility's policy, titled, Influenza Vaccination, with a reviewed date of 10/15/23, included: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. Review of the facility's policy, titled, Pneumococcal Vaccine Series, with a reviewed date of 10/15/23, included: It is our policy to offer our residents, staff, and volunteer workers immunization…

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 offer COVID-19 immunization as required for 4 of 5 sampled residents for immunizations, Residents #89, #87, #94 and #557. The findings included: Review of the facility's policy, titled, Covid-19 Vaccination, with a reviewed date of 08/04/23 included: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 (SARS-CoV-2) by education and offering our residents and staff the Covid-19 vaccine. Covid-19 vaccinations will be offered to residents and staff, when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. 1. Record review for Resident #89 revealed the resident was admitted to the facility on [DATE]. There was no documentation of the Covid vaccine being offered, accepted, or declined in the resident's medical record. 2. Record…

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

Based on interviews and records review, the facility failed to ensure residents and staff were informed of their rights to file their complaints with the Ombudsman and where to find the Ombudsman posted information, for 1 of 1 sampled resident and staff reviewed for this conncern. The findings included: During an interview with the Resident Council President on 09/14/22 at 2:18 PM, she reported that she never heard about the word Ombudsman. She also informed that she did not know where the Ombudsman information was posted. She said that they meet every month and that she has been the President of the Resident Council for nearly a year, and they never discussed how to file a complaint with the Ombudsman. Review of the Brief Interview for Mental Status (BIMS) score revealed that the Resident Council President obtained a score of 15 of 15, which is an indication of cognitive ability to provide credible information. On 09/15/22 at11:17 AM, while interviewing the Activity Director, she reported that she has been working at this facility since February 2022. She said that she was 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, interviews, and record reviews, the facility failed to develop care plans for 3 of 24 sampled residents reviewed: Resident #102 and Resident #357 related to hemodialysis and impaired vision; and Resident #33 related to revising the dialysis care plan. The findings included: Review of the facility's policy, titled, Comprehensive Care Plans, implemented on 11/28/22, documented the following: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental need that are identified in the residents' comprehensive assessment. 1. Record review for Resident #102 revealed the resident was admitted on [DATE] with diagnoses of End-Stage Renal Disease (ESRD) and Dependence on Dialysis. A review of the Physician's orders documented an order for In-House Hemodialysis with [name] dialysis centers every Monday,…

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 assure that enteral nutrition had been followed by the practitioners' orders for 3 of 4 sampled residents, Residents #14, #66, and #20, reviewed for tube feeding. The findings included: 1. A review of the facility's policy, titled, Enteral Nutrition Support Feeding Accuracy and Hydration Maintenance, revised on 09/14/22, documented the following: it is a policy of this facility to ensure accurate administration and adequate nutrition and hydration of all enteral nutrition support for all residents. Record review documented Resident #14 was readmitted to the facility on [DATE] with diagnoses that included Cerebral Ischemia, Hydrocephalus, Dementia, Gastrostomy Status, and Major Depressive Disorder. The resident had a Brief Interview Mental Status (BIMS) score that indicated the resident was severely impaired. Resident #14's care plan of 06/05/22 documented that Resident #14 is at nutritional risk as evidenced by: Enteral nutrition…

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, interviews and policy review, the facility failed to provide medication as scheduled on dialysis days for 1 of 2 sampled residents reviewed for dialysis (Resident # 33). The findings included: The facility's policy, titled, Hemodialysis, implemented 11/28/17, revealed Timely medication administration (initiated, held, or discontinued) by the nursing home and/or dialysis facility. Resident #33 was initially admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (ESRD), Dependence of Renal Dialysis and Type 2 Diabetes Mellitus (DM) without Complications. The resident's Brief Interview for Mental Status (BIMS) was 13 according to the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) 06/28/22, indicating the resident was cognitively intact. The Electronic Health Record (EHR) revealed the resident was receiving dialysis in the facility. On 09/13/22 at 10:36 AM, the Medication Administration Record (MAR) was reviewed for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food items that accommodated the preferences of 2 of 3 sampled residents during dining observations, Resident #102, and Resident #46. The findings included: 1. Record review for Resident #102 revealed an admission on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) and dependence on Dialysis. A review of the physician's orders showed an order for In-House hemodialysis with [name] dialysis centers every Monday, Wednesday, and Friday, dated 04/27/22. Review of the Minimum Data Set (MDS), dated [DATE], documented that Resident #102 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. Reivew of the physician orders documented a diet order for regular texture, thin consistency, for diet liberal renal; 1200 cc fluid restriction: 360 milliliters (ml) with breakfast, 240 ml with lunch and dinner dated 05/02/22. In an interview conducted on 09/13/22 at 8:11 AM, Resident #102 stated that 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.