Fairway Oaks Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure timely and accurate Pre-admission Screening and Resident Review (PASRR) for one (#73) of 23 sampled residents. Findings Included: 2. Review of the admission Record for Resident #73 showed the resident was initially admitted to the facility on [DATE] with a re-entry admission date of 03/04/2024. Admitting diagnoses included schizoaffective disorder bipolar type, major depressive disorder, dementia, mood disorder due to known physiological condition with depressive features. Review of Level I PASRR for Resident #73 dated 03/16/2022, revealed an incomplete PASRR with the qualifying diagnoses of depression, mood disorder and dementia not indicated. During an interview on 09/11/2024 at 9:45 a.m. with Staff S, Registered Nurse (RN) Minimum Data Set (MDS) Director, she said the facility's process for identifying a resident with a possible MD, ID or related condition prior to admission to the facility would start with the Admissions…

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 develop a care plan for one (#45) of six residents sampled for skin conditions and failed to develop and implement an Activities of Daily Living care plan for two ( #44 and #51) of five residents sampled. Finding Included: 1 During an observation made on 09/08/24 at 02:20 p.m., Resident # 45 was observed lying down in bed dressed in a hospital grown from the morning until late in the afternoon. The resident was trying to say something but was not able to communicate. On 09/09/2024 at 11:00 a.m., Resident # 45 was observed lying down in bed dressed in his hospital grown. Resident #45's legs was observed with scabs leaking with yellow fluid on his right and left legs. Review of an admission Record showed Resident # 45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLs) for dependent residents which included performing fingernail care and showers for two (#44 and #51) of 46 sampled residents. Findings included: 1. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44. She was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she does not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m. Resident #44 was observed in her bed, hair disheveled, her…

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 care and services according to standards of practice related to medication administration and skin care treatment for one (#45) of three residents reviewed for wound care. Finding included: During an observation made on 09/08/24 at 02:20 p.m., Resident #45 was observed lying down in bed dressed in a hospital grown from the morning until the late in the afternoon. Resident was trying to say something but was not able to communication. During an observation made on 09/09/2024 at 11:00 a.m., Resident #45 was observed lying down in bed dressed in his hospital grown. Resident #45 legs was observed with scabs leaking with yellow fluid on his right and left legs. During an interview on 09/10/2024 at 1:00 pm with Resident #45's representative, he stated [the resident] had been at the facility for a year. He was being seen by a vascular surgeon because the facility thought he could have cancer in his legs. He said the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide indwelling urinary catheter care and services to prevent leakage and breaks in tubing for two (#82 and #13) of ten sampled residents during two of two days observed (9/8/2024 and 9/9/2024). Findings included: 1. On 9/8/2024 at 10:45 a.m., Resident #82 was observed seated in her wheelchair and was slowly self propelling down the hall from her room. An attempt to interview the resident revealed she had cognition deficits and was only able to answer some simple yes and no questions. She kept saying, I just want to go back to my room, I want to go to bed. Passing staff told her, ok, in a minute, but we have lunch soon. Further observations revealed when the resident was self propelling in her wheelchair down the hallway, she was noted with an indwelling urinary catheter. The catheter bag was observed appropriately hanging under the seat of the wheelchair. However, the tubing from the bag to the resident was observed in excess slack,…

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 did not ensure trauma informed care was provided for one (#39) of one resident with post-traumatic stress disorder (PTSD). The facility did not ensure PTSD triggers were on Resident #39's care plan. The facility did not ensure staff was trained annually on trauma informed care as the facility policy indicated. Findings Included: Review of admission Record showed Resident #39 was initially admitted to the facility diagnoses which included major depressive disorder, schizoaffective disorder, unspecified psychosis, post-traumatic stress disorder, other specified persistent mood disorders, anxiety disorder, dementia. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of Resident #39's Care Plan dated revealed the following: A focus area initiated on 7/24/24 showed, the resident had experienced 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 provide residents and visitors with up to date and correct daily staffing posting information. It was determined the facility had not updated this sheet for a total of three days. Findings included: On 9/8/2024 at 8:33 a.m., an observation was made of the facility's entrance lobby. A desk in the lobby area was observed with a stand up clear plastic document holder. The holder had encased a Daily Staffing Projection sheet. The sheet had information with the date, how many nurses and how many Certified Nursing Assistants (CNAs) were working for each of the three shifts, and the resident census. The sheet showed a date of 9/5/2024, which was three days prior to the current date reviewed, 9/8/2024. The sheet had not been updated to reflect the current date, the current staffing numbers per each of the three shifts, or the current resident census. The sheet reflected a resident census of 104. An interview with the Front Desk receptionist revealed she was aware of the form because it was at her desk area. However,…

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 did not ensure the medication error rate was less than 5% for three (#14, #93, #498) of four sampled residents who were administered medications. This resulted in seven errors from 35 medication administration opportunities for a medication error rate of 20.00%. Findings included: 1. On 09/10/2024 at 9:55 a.m., Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications were in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for…

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 1. the medical record contained accurate and complete documentation for three (#498, #93, #14) of 46 sampled residents related to bathing and for one (#51) of four sampled residents related to medication administration. Findings included: 1. On 09/10/2024 at 9:55 a.m. ,Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for…

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 provide Abuse/Neglect training to one (Staff X) of 10 employees reviewed. Findings Included: During an interview on 09/10/2024 4:30 p.m. the Director of Nursing (DON) stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's Resident Representative (RR) was reporting an allegation of neglect. The DON stated he went to Resident #100's room to speak with the family. He stated the family reported to him when they came in to visit Resident #100 on 03/13/2024 during the night, they found the resident in two briefs, the resident had a hospital gown on top of her clothes and was tucked in underneath her, the resident's hands were bound behind her, and that the resident's TV was not working. The DON stated once he spoke with the family, he went and notified the Nursing Home Administrator (NHA) and their regional. He stated when…

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 all alleged violations of abuse to include physical restraints were reported to the State Survey Agency for 1 (#100) out of 23 residents sampled. Findings included: Review of Resident #100's admission Record revealed she was originally admitted to the facility in 2020 with medical diagnoses of Alzheimer's disease, diabetes mellitus, non-Alzheimer's dementia, delusional disorders, chronic kidney disease, peripheral vascular disease, and depressive episodes. Review of Resident #100's Quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 showing Resident #100 was cognitively impaired. Functional Abilities and Goals, Section GG revealed Resident #100 required Partial/moderate assistance for Toileting hygiene, and Shower/bathe care, personal hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. According to the Self-Care…

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 a review of the Food Committee meeting minutes and the facility policy on Grievances/Complaints, Filing; interview with the Dietary Manager, and interview and observation of eight residents (#157, #160, #159, #158, #38, #15, #30, #72) at meals, the facility failed to resolve a concern related to receiving condiments at meals voiced at the Food Committee meeting. Findings included: An interview was conducted with Resident #157 on 08/29/2022 beginning at 10:30 a.m. He reported that the breakfast meal was always great with the lunch and dinner meal so-so. He said he was never given salt and pepper and was told he had to ask the aides for it when they brought his tray. He said he sometimes would remember to ask before they brought the tray, but if he forgot they often forgot also. He said he liked sandwiches at lunch, not the hot meal, but usually it didn't come with mayonnaise or mustard. He said sometimes he waited for someone to being him the condiment and sometimes he went without. A second visit with Resident #157 on 08/30/2022 at 12:30 p.m., during lunch, confirmed that…

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, observation, and interview, the facility failed to implement their Weight Assessment and Intervention Policy by developing a care plan relevant to weight loss and failed to implement the care plan that had been developed on 02/19/2021 and revised on 04/09/2021 and 03/14/2022, for one (Resident #20 ) of 48 sampled residents related to weight loss. Findings included: Resident #20 was re-admitted to the facility on [DATE] with multiple diagnoses that included Multiple Sclerosis, heart disease, and depression. A review of the resident's monthly weights revealed weight loss from 179 lbs (pounds) on 01/06/2022 to 159 lbs on 08/03/2022. In six months, from 02/02/2022 when the resident was weighed at 175.5 lbs, until 08/03/2022, the resident sustained a weight loss of 16.5 lbs or 9%. Resident #20 weighed 173 lbs on 06/07/2022, 168 lbs on 07/04/2022, and 159 lbs on 08/03/2022. Weight loss for this resident was continuing without changes to the care plan or to the resident's diet order. The change…

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 provide activities of daily living (ADL) tasks for residents who required assistance to address soiled fingernails for one (Resident #207) of three residents sampled for ADL care. Findings included: Review of Resident #207's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated severe cognitive impairment. Review of the admission readmission Nursing Packet dated 08/12/2022, revealed under the ADL Evaluation section the resident was coded as X 1 Staff Total Dependence (Resident Does Not Participate In Activity At All) regarding how much assistance the resident required with personal hygiene. Review of the resident's care plan dated 8/12/22 with a revision on 8/29/22 related to OT (Occupational Therapy) evaluation complete. Resident requires assistance with ADL functions. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to assess scratches on a resident's shins for one (Resident #9) of two residents sampled for skin conditions. Findings included: Review of Resident #9's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. An observation of Resident #9 on 08/29/22 at 9:54 a.m., revealed the resident's bilateral shins were noted with scratches that were dry and red in color. An observation on 08/31/22 at 3:36 p.m., revealed Resident #9 sitting in her wheelchair in her room. The resident was noted to have scratches that were red in color on her bilateral shins. An interview with the resident at that time revealed she did not know how she got the scratches and thought she scratched herself. In an interview on 09/01/22 at 11:01 a.m., the Director of Nursing (DON) said she was not aware the resident had…

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 did not identify the specific behaviors to monitor related to the administration of psychotropic medications for two (Residents #1 and #9) of six residents sampled for unnecessary medications. Findings included: 1. A review of Resident #9's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #9 had diagnoses that included Major Depressive Disorder, Mood Disorder, and Anxiety Disorder, according to her face sheet. A review of the resident's physician orders revealed current orders for the use of Depakote Tablet Delayed Release 125 MG give 125 mg by mouth in the evening related to UNSPECIFIED MOOD (AFFECTIVE) DISORDER; Escitalopram Oxalate Tablet Give 10 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED; Lorazepam Tablet 0.5 MG Give 0.5 mg by…

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 did not ensure the medication error rate was below 5 % for three (Residents #35, #257, and #96) of four sampled residents who were observed during medication administration. This resulted in 8 errors from 31 medication administration opportunities for a medication error rate of 25.81%. Findings Included: 1. On 08/31/2022 at 8:47 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #35. Staff D prepared and administered the following medications: Brimonidine Tartrate 0.2% solution one drop in both eyes, multivitamin with mineral one tablet, Plavix 75 mg one tablet, Lisinopril 40 mg tablet, Duloxetine HCL capsule delayed release 60 mg, Spironolactone 25 mg one tablet, Timolol maleate solution 0.5% one drop into each eye, and Lasix 40 mg tablet one tablet. Staff D stated the resident had an ordered dose of Amitiza capsule 8 mcg give 1 capsule by mouth every 12 hours for constipation dated 07/01/2022, but it was not in the medication cart. The nurse further…

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, record review, and interview, the facility failed to provide dental services to one (Resident #35) of three residents sampled for dentures. Findings Included: On 08/29/22 at 11:09 a.m., an interview was conducted with Resident #35 as she was observed edentulous when she opened her mouth. She stated, I had dentures, but it was years ago. She said when she was hospitalized about 4 or 5 years ago, I had to call an ambulance to pick me up. I wish I had taken my dentures with me. Resident #35 stated When I was in the hospital, they threw out everything in my apartment. My dentures and everything I owned. She denied having issues with chewing but if the meat, especially the pork chops, were dry it took a while to chew them. When asked, Resident #34 smiled broadly and stated, I would love dentures. She confirmed she would wear them if she had them. Resident #35 denied the facility had ever asked about obtaining dentures. She said she could not recall the last time a Dentist had performed an oral examination. Medical record review of the admission Record 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 record review and interview, the facility failed to ensure that one (Resident #21) of 40 residents sampled for PASRR (Pre-admission Screen and Resident Review) compliance was accurately completed and referred to the appropriate authority for PASRR Level II evaluation and determination. Findings included: Resident record review for Resident # 21 revealed that she was admitted to the facility on [DATE] with diagnoses that included Dementia and Psychosis. The record review revealed that the Level I PASRR was completed on 7/3/19, prior to admission. Further review revealed that the PASRR was inaccurate indicating that Resident #20 did not have a diagnosis of Dementia. The record review of the medical record for Resident #21 revealed that there was no written proof that a completed Level II PASRR had been completed. An interview was conducted with the Social Services Director on 4/14/21 at 1:58 p.m. who confirmed that the PASRR paperwork was not accurate in the chart for Resident #21 and should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure two (Residents #6 and #28) of forty sampled residents received the necessary services to provide grooming and personal hygiene related to showers, nail care, and shaves. Findings included: 1. An observation and interview was conducted on Monday, 4/12/21 at 11:53 a.m., with Resident #6. The resident appeared to have a scruffy appearance and was unshaven. When asked if he choose to be unshaven, he stated he needed to be shaved. The resident stated he would allow staff to shave him if they asked. On Tuesday, 4/13/21 at 8:50 a.m., Resident #6 was observed lying in bed, his facial hair appeared to be unshaven and unclean. On 4/14/21 at 8:47 a.m., Resident #6 was asked if he had the amount of showers he wanted, he stated, I need to have more. Resident #6 stated staff help when they were able and when asked if he wanted to be shaved, the resident nodded head and chuckled. The admission Record for Resident #6 indicated that the 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, interviews and record review, the facility failed to ensure an accident free environment for one (Resident #56) of three residents sampled for accidents. Findings included: On 4/12/21 at 12:16 p.m., Resident #56's oxygen tubing was observed on the floor and under the resident's bed. A review of the Resident #56's face sheet revealed that the resident was admitted on [DATE], readmitted on [DATE], and was his own responsible party. A review of Section E (Mood and Behaviors) of Resident #56's Minimum Data Set (MDS) completed on 3/10/21 revealed that the resident had no identified areas of concern for behaviors. Section O (Special Treatments) revealed that the resident received oxygen therapy. A review of Resident #56's event history for the last 120 days revealed an event on 2/8/21 at 3:30 p.m. that stated, [Resident #56] observed lying on the floor in his room [Resident #56] stated 'I trip [sic] on the oxygen cord and fell, I'm ok just get me up.' A review of Resident #56's care plan…

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 reviews, interviews, and observations the facility failed to assess eight (#6, #10, #11, #14, #18, #30, #45, and #73) out of forty sampled residents for the use of bed/side rails prior to their use, to obtain consent for their use from the resident or/and representative prior to their use, failed to obtain a physician order for their use, and to include the use of side rails in the resident's care plan. Findings included: The policy number ROP-44 was obtained from the Director of Nursing (DON), titled: Proper Use of Side Rails, and created 11/17, indicated the facility prohibits the use of side rails as a restraint. The Explanation and Compliance Guidelines of the policy included the following: - 2. An assessment of the resident's symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rail, and will be documented in the residents record. - 3. The physician will also review and order side rails usage as he deems…

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 implement an effective Antibiotic Stewardship program related to the monitoring of antibiotic use of one (Resident #27) of one resident sampled for Transmission-based precautions. Findings included: The Facility Matrix indicated that Resident #27 was on Transmission-based precautions. An observation on 4/13/21 at 4:03 p.m. of the area outside of Resident #27's room, did not indicate that any Personal Protective Equipment was available for staff or any signs were posted with the type of precautions to be observed while caring for the resident. On 4/13/21 at 4:04 p.m., Staff J, Registered Nurse Supervisor, stated there was not anyone on Transmission-based Precautions. When asked about Resident #27, she stated she had spoken to the physician and that the precautions were discontinued as the resident had been on an antibiotic for eight days. A review of the April Medication Administration Record (MAR) for Resident #27 indicated the resident received Linezolid 600 milligrams (mg) by mouth every 12 hours for…

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.