Oak Grove Christian Retirement Village

Based on record review and interview, the facility failed to provide twice weekly showers/bathing for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 1 resident reviewed for ADLs. (Resident 3)During an interview on 9/15/25 at 10:53 a.m., Resident 3 indicated he was not receiving showers as he should. Resident 3's record was reviewed on 9/18/25 at 11:52 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (paralysis and weakness) following a stroke affecting the left non-dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. The resident required maximal assistance for showering/bathing. The Resident Preferences document, dated 5/13/25, indicated the resident preferred a shower on Monday and Thursday evenings. The previous 60 days of shower sheets were requested. There were documented showers or bed baths on 6/21, 7/3, 7/7, 7/10, 7/17, 7/21, 7/24, 7/28, 8/4, 8/18, 8/21, 8/25, and 9/4/25. There were no documented showers received after 9/4/25. During an…

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

Based on observation, record review, and interview, the facility failed to ensure signs and symptoms of constipation were addressed for 1 of 1 resident reviewed for constipation, skin treatments were completed as ordered and compression stockings were applied as ordered for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 10, 16, and 13) Findings include:1. On 9/16/25 at 9:08 a.m., Resident 10 was observed lying in bed. The resident indicated she would sometimes go for 4-5 days without having a bowel movement. Sometimes the nurses would give her a laxative, and she still would not always have a bowel movement for days. Record review for Resident 10 was completed on 9/18/25 at 10:38 a.m. Diagnoses included, but were not limited to, multiple sclerosis, anemia, hypertension, neurogenic bladder, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. The resident had an impairment on both sides of her upper and lower extremities for a functional limitation in range of motion.…

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 ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to a physician's order for wound care not followed during a wound care observation for 1 of 4 residents reviewed for pressure ulcers. (Resident 44) Finding includes: Resident 44's record was reviewed on 9/17/25 at 11:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident was cognitively intact. The resident had an unstageable wound. A Physician's Order, dated 7/19/25, indicated cleanse the right heel with wound cleanser, pat dry, apply betadine, cover with ABD (abdominal) pad, and wrap with Kerlix (bandage wrap) every evening shift. During an observation of wound care on 9/19/25 at 1:39 p.m., Agency LPN 3 was observed performing wound care to Resident 44's right heel. Agency LPN 3 performed hand hygiene and donned a gown and gloves. She removed the…

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

Based on observation, record review, and interview, the facility failed to ensure a resident who required nebulizer breathing treatments was assessed prior to, during, and/or after the treatment for effectiveness of the treatment for 1 of 1 resident reviewed for respiratory care. (Resident 14)Finding includes:On 9/16/25 at 9:16 a.m., Resident 14 was observed seated in her wheelchair in her room. The nebulizer machine was on, and she had the mouthpiece in place to her mouth. There were no staff present in the room or near the room. LPN 2 was observed at the Nurse's Station, down the hall.The resident's record was reviewed on 9/17/25 at 9:34 a.m. Diagnoses included, but were not limited to, dementia, hypertension, and osteoarthritis.The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/25, indicated the resident was cognitively intact.A Physician's Order, dated 4/1/25, indicated ipratropium-albuterol solution 0.5 mg (milligrams)-3 mg/3 ml (milliliters) two times a day. There were no orders for a pre or post nebulizer treatment assessment.There was lack of documentation any…

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 ensure residents with dementia received appropriate treatment and services related to lack of care planning with individualized interventions and activity assessments not completed for 2 of 3 residents reviewed for dementia care. (Residents 7 and 16) Findings include:1. On 9/18/25 at 11:41 a.m., Resident 7 was observed up ambulating in the hallway near the Nurse's Station. She stopped to ask LPN 2 what was for lunch. LPN 2 invited the resident to participate in the current activity that was going on, the resident agreed and went to the activity area.Resident 7's record was reviewed on 9/18/25 at 11:23 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, general anxiety disorder, and multiple sclerosis.The Annual Minimum Data Set (MDS) assessment, dated 8/30/25, indicated the resident was cognitively impaired. She had received antipsychotic and antidepressant medications.A Care Plan, updated 5/28/25, indicated the resident had impaired cognitive function or impaired thought…

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 ensure infection control guidelines were in place and implemented related to lack of hand hygiene with glove changes during wound care and improper personal protective equipment (PPE) worn in an Enhanced Barrier Precaution (EBP) room while accessing a peripheral intravenous central catheter (PICC) line. (Residents 44 and 1) Findings include: 1. During an observation of wound care on 9/19/25 at 1:39 p.m., Agency LPN 3 was observed performing wound care to Resident 44's right heel. Agency LPN 3 performed hand hygiene and donned a gown and gloves. She removed the old dressing, performed hand hygiene, and donned clean gloves. She cleansed the area with wound cleanser and gauze, removed her gloves, and then donned new gloves without performing hand hygiene. She continued to pat the area dry with clean gauze and then applied the ABD pad and wrapped with Kerlix. During an interview on 9/19/25 at 1:48 p.m., Agency LPN 3 indicated she should have performed hand hygiene with every glove change. During an interview on…

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

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to antibiotics started without indication for use for 2 of 2 residents reviewed for urinary tract infections. (Resident 44 and 3) Findings include: 1. Resident 44's record was reviewed on 9/17/25 at 11:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident was cognitively intact. A Progress Note, dated 9/4/25 at 1:33 p.m., indicated the nurse practitioner was notified of the resident's high blood sugar and new orders were received for a urinalysis (urine test) with culture and sensitivity. A urinalysis result, dated 9/5/25 at 4:05 p.m. and reported on 9/8/25 at 7:01 a.m., indicated the resident's urine was positive for enterococcus faecium (bacteria) vancomycin-resistant strain (VRE) 50-100,000 colonies per milliliter. The bacteria had resistance to…

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 medications were administered as ordered for 1 of 3 residents reviewed for medication administration. (Resident C) Finding includes: Resident C's record was reviewed on 8/13/25 at 9:04 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, and hypertensive chronic kidney disease. The Annual Minimum Data Set assessment, dated 7/18/25, indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 3/31/25, indicated the resident had an altered cardiovascular status related to congestive heart failure, hypertension (high blood pressure), and hyperlipidemia (high levels of fat/lipids in the blood). Interventions included, but were not limited to, administer medications as ordered. A Physician's Order, dated 4/1/25, indicated metoprolol tartrate (blood pressure medication) 25 milligrams, 1 tablet by mouth twice a day. Check blood pressure (bp) prior to administering the medication. Hold the medication if bp is less than 100/50 or heart rate is less than 60. The…

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

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration, lack of respiratory assessments, and oxygen saturation monitoring for 2 of 4 residents reviewed for respiratory care. (Residents B and D)Findings include:1. Record review for Resident B was completed on 8/12/25 at 1:39 p.m. Diagnoses included, but were not limited to, heart failure, chronic pulmonary edema (excess fluid in the lungs), and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident was moderately cognitively impaired. The resident required partial moderate assistance with bed mobility and dressing. The resident received oxygen therapy. A Care Plan, dated 7/3/25, indicated the resident required oxygen therapy related to ineffective gas exchange. An intervention included to check the oxygen tank every 4 hours to make sure the resident had sufficient supply. The August 2025 Physician’s Order Summary (POS) indicated an order for oxygen at 4 liters per nasal cannula…

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 maintain clinical records that were complete and accurately documented related to documentation of medications and oxygen administered for 2 of 4 residents reviewed for medications and oxygen. (Residents B and C) Findings include:1. Record review for Resident B was completed on 8/12/25 at 1:39 p.m. Diagnoses included, but were not limited to, heart failure, chronic pulmonary edema (excess fluid in the lungs), and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident was moderately cognitively impaired. The resident required partial moderate assistance with bed mobility and dressing. The resident received oxygen therapy. A Care Plan, dated 7/3/25, indicated the resident required oxygen therapy related to ineffective gas exchange. An intervention included the resident required the oxygen continuous at all times. A Care Plan, dated 7/25/25, indicated the resident had an order for BiPAP (bilevel positive airway pressure machine to assist with breathing) therapy to be worn at…

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 a resident who received new diagnoses of a fractured right tibia and multiple fractured ribs from a facility incident was assessed thoroughly and frequently upon returning from the emergency room for 1 of 3 residents reviewed for quality of care. (Resident B) Finding includes: Resident B's record was reviewed on 5/6/25 at 10:26 a.m. The diagnoses included, but were not limited to, a spiral fracture of the right tibia, peripheral vascular disease, history of traumatic brain injury, and cognitive deficit. Cross reference F689. A Nurse's Progress Note, dated 3/10/25 at 10:29 p.m., indicated the resident returned to the facility per ambulance. She was assisted to bed by two staff. There was an immobilizer on the right lower leg. She complained of pain to the area. A Nurse's Progress Note, dated 3/11/25 at 1:37 a.m., indicated the immobilizer on the right leg was in place. There was no assessment of the right leg or the status of the resident. There were no assessments completed by the nurses on 3/12/25. A Nurse…

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 ensure a sanitary kitchen related to dishwasher temperatures not reaching the required temperature and lack of temperature monitoring for a high temperature dish machine. This had the potential to affect all 52 residents who received meals from the Main Kitchen. Finding includes: The initial kitchen tour was completed on 10/15/24 at 9:00 a.m. with the Dietary Manager (DM). The DM indicated the dishwasher was a high temperature dish machine. A wash cycle was observed and the wash temperature was 105 degrees (Fahrenheit) and the rinse was 191 degrees. The DM indicated the wash cycle should be 180 degrees and he was unsure about the rinse cycle. The Dish Machine Temperature Log for October 2024 was reviewed. The log indicated, High Temperature Machine Wash 160 degrees, Rinse 180 degrees. Report any variations to the Food Service Supervisor or Administrator. Breakfast wash/rinse temperatures were recorded as follows: 10/2- 128/185 10/4- 130/187 10/9- 127/187 10/10-129/134 10/11- 138/187 10/14- 156/176 Lunch…

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 establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to inaccurate documentation of narcotic medications for 1 of 3 residents reviewed for narcotics. (Resident 211) This had the potential to affect all residents who received narcotic medications. The deficient practice was corrected by 9/26/24, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the narcotic documentation irregularities and possible staff involvement, notified the appropriate entities, re-educated current staff on misappropriation and narcotic documentation, and implemented audits for narcotic documentation accuracy. Finding includes: The record for Resident 211 was reviewed on 10/18/24 at 9:16 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, heart failure, Alzheimer's disease, and absence of right leg above knee. The Quarterly Minimum Data Set assessment indicated the…

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

Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 15) Finding includes: Resident 15's record was reviewed on 10/17/24 at 9:50 a.m. Diagnoses included, but were not limited to, heart failure, diabetes mellitus and fluid overload. The Quarterly Minimum Data Set assessment, dated 7/27/24, indicated the resident was significantly impaired for daily decision making. Progress Notes indicated the resident was sent to the hospital on 8/24/24 and returned to the facility on 8/29/24. There was no documentation to indicate the State approved transfer form was completed and sent with the resident. There was no documentation to indicate the resident's Responsible Party had received written notification of the resident's transfer to the hospital. During an interview on 10/17/24 at 9:20 a.m., RN 4 indicated when residents were sent out to the hospital they were sent with a face sheet, a copy of the DNR, bed hold…

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 a resident and/or their Responsible Party were sent the facility's bed hold and reserve bed payment policy before and upon transfer to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 15) Finding includes: Resident 15's record was reviewed on 10/17/24 at 9:50 a.m. Diagnoses included, but were not limited to, heart failure, diabetes mellitus and fluid overload. The Quarterly Minimum Data Set assessment, dated 7/27/24, indicated the resident was significantly impaired for daily decision making. Progress Notes indicated the resident was sent to the hospital on 8/24/24 and returned to the facility on 8/29/24. There was no documentation to indicate the facility's bed hold policy was completed and sent with the resident. There was no documentation to indicate the resident's Responsible Party had received written notification of the facility's bed hold policy. During an interview on 10/17/24 at 9:20 a.m., RN 4 indicated when residents were sent out to the hospital they were sent with a face sheet,…

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 ensure care plans were reviewed and revised to include changes related to IV (intravenous) fluids for 1 of 22 resident care plans reviewed. (Resident D) Finding includes: Resident D was observed in bed on 10/15/24 at 9:44 a.m. There were no IV supplies or equipment in her room. The resident indicated she had not had an IV since returning to the facility from the hospital on 9/14/24. Resident D's record was reviewed on 10/17/24 at 1:44 p.m. Diagnoses included, but were not limited to, malignant neoplasm of kidney, urinary tract infection, pathological fracture, bone cancer, paraplegia, and neuromuscular dysfunction of the bladder. The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident was cognitively intact. A Care Plan, dated 9/14/24, indicated the resident needed IV fluids for dehydration. Interventions included, but were not limited to, administer IV fluids, monitor IV site and arm every shift, and complete flushes per orders. There were no Physician's Orders for IV fluids.…

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 parameters were in place for Physician notification related to weight monitoring for a resident with three times a week weights for 1 of 1 resident reviewed for edema. (Resident 15) Finding includes: Resident 15's record was reviewed on 10/17/24 at 9:50 a.m. Diagnoses included, but were not limited to, heart failure, diabetes mellitus and fluid overload. The Quarterly Minimum Data Set assessment, dated 7/27/24, indicated the resident was significantly impaired for daily decision making. A Physician's Order, dated 4/22/24, indicated to weigh the resident every Monday, Wednesday and Friday related to congestive heart failure. There were no parameters in place for when to notify the Physician of a change in weight. The current Fluid Maintenance Care Plan indicated the resident was at risk for fluid volume overload due to congestive heart failure. Interventions included, but were not limited to, monitor electrolytes, assess for presence of edema, follow fluid volume restriction orders and monitor input and output.…

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 ensure a resident with pressure ulcers received the treatment and services necessary to promote healing related to updating and following Physician's Orders for wound care for 1 of 3 residents reviewed for pressure ulcers (Resident 20). Finding includes: During an observation of Resident 20's wound care on 10/21/24 at 10:54 a.m., the Wound Care Nurse was observed changing the dressings on the right heel, right ankle, and right lower leg. She entered the room, washed her hands with soap and water, and donned a gown and gloves. She removed the old dressings from the right lower leg, right ankle, and right heel, each dated 10/19/24. She removed her gloves and donned new gloves, without performing hand hygiene between glove use. She sprayed wound cleanser to gauze and cleaned the right lower leg and then threw away the gauze. She removed more gauze, sprayed it with wound cleanser and cleaned the right ankle. She removed more gauze, sprayed it with wound cleanser and cleaned the right heel. She opened a foam…

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 ensure an indwelling Foley (urinary) catheter collection bag for a resident with a history of infection was covered and not hanging off the top of a garbage can for 1 of 1 residents reviewed for urinary catheters. (Resident C) Finding includes: On 10/16/24 at 10:37 a.m., Resident C was observed sitting in a recliner in her room. The resident's urinary catheter bag was uncovered and hanging off the top of a garbage can sitting next to her. The uncovered bag was touching the top and the side of the garbage can. The garbage can was observed with trash in the can. On 10/16/24 at 3:15 p.m., the Assistant Director of Nursing (ADON) was asked to observe the resident's catheter bag. Resident C was observed sitting in a recliner in her room. The resident's urinary catheter bag was uncovered and hanging off the top of a garbage can sitting next to her. The uncovered bag was touching the top and the side of the garbage can. The garbage can was observed with trash in the can. Record review for Resident C was completed on…

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

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to respiratory equipment not changed as ordered and incorrect flow rate of oxygen (O2) administered for 3 of 4 residents reviewed for respiratory care. (Residents B, C, and D) Findings include: 1. On 10/15/24 at 10:16 a.m., Resident B was observed sitting in a wheelchair in her room. An oxygen concentrator was next to the resident. The water humidification bottle on the concentrator was dated, 10/6/24. The resident's night stand drawer was open and a nebulizer treatment mask was observed, dated 10/6/24. Record review for Resident B was completed on 10/16/24 at 3:02 p.m. Diagnoses included, but were not limited to, heart failure, respiratory failure, and COPD (chronic obstructive pulmonary disease). The Quarterly Minimum Data Set (MDS) assessment, dated 8/19/24, indicated the resident was moderately cognitively impaired. The resident required oxygen therapy. A Care Plan, dated 11/19/23, indicated the resident had a diagnosis of COPD and 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 ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to lack of non-pharmacological interventions used prior to giving anti-anxiety medication and lack of monitoring for side effects of an antidepressant for 2 of 5 residents reviewed for unnecessary medications. (Residents 37 and 48) Findings include: 1. Resident 37's record was reviewed on 10/18/24 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, depression and asthma. The Quarterly Minimum Data Set (MDS) assessment, dated 7/19/24, indicated the resident had significant cognitive impairment and received anti-anxiety medications. A Physician's Order, dated 6/24/24, indicated to give alprazolam (anti-anxiety medication), 0.25 milligrams (mg) every six hours as needed for as needed for anxiety. A Physician's Order, dated 6/21/24, was for an anxiety…

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 clinical records were complete and accurately documented related to the lack of a resident's name on a self-medication administration assessment for 1 of 5 residents reviewed for unnecessary medications. (Resident 23) Finding includes: The record for Resident 23 was reviewed on 10/16/24 at 2:46 p.m. Diagnoses included, but were not limited to, repeated falls, hemiplegia (paralysis on one side of the body) due to a stroke, aphasia (loss of language use), hypertension, and right foot drop. The Quarterly Minimum Data Set (MDS) assessment, dated 8/6/24, indicated the resident had moderate cognitive impairment, and required set up assistance for most activities of daily living. A Physician's Order, dated 8/2/24, indicated the resident could self-administer Econazole nitrate powder (an antifungal medication) topically, twice daily to the groin and scrotum. A Self-Administration of Medication Evaluation, dated 8/2/24 and received from the Assistant Director of Nursing (ADON), failed to document a resident's name. During an…

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

Based on observation and interview, the facility failed to ensure infection control guidelines were in place and implemented related to hand hygiene and glove use during a wound treatment for 1 of 1 treatments observed. (Wound Care Nurse and Resident 20) Finding includes: During an observation of Resident 20's wound care on 10/21/24 at 10:54 a.m., the Wound Care Nurse was observed changing the dressings on the right heel, right ankle, and right lower leg. She entered the room, washed her hands with soap and water, and donned a gown and gloves. She removed the old dressings from the right lower leg, right ankle, and right heel, each dated 10/19/24. She removed her gloves and donned new gloves, without performing hand hygiene between glove use. She sprayed wound cleanser to gauze and cleaned the right lower leg and then threw away the gauze. She removed more gauze, sprayed it with wound cleanser and cleaned the right ankle. She removed more gauze, sprayed it with wound cleanser and cleaned the right heel. She did not perform hand hygiene or change gloves between caring for each wound.…

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 medical records were complete and accurately documented, related to oxygen administration and saturation levels, for 2 of 3 residents reviewed for oxygen. (Residents B and C). Findings include: 1. A record review for Resident B was completed on 7/24/24 at 10:41 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 4/22/24, indicated the resident was cognitively impaired. The resident received oxygen therapy. A Care Plan, dated 5/4/24, indicated the resident had chronic respiratory failure, COPD, and used oxygen. An intervention included to check oxygen saturation every shift. A Resident Experience Form, dated 7/15/24, indicated the resident's daughter had a concern with the resident's portable oxygen tank not being turned on. The summary of the investigation indicated the portable oxygen tank was full but not turned on. The facility spoke with the Nurse Practitioner who then gave an order to…

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 report an allegation of abuse/neglect to the Administrator of the facility, for 1 of 1 resident with an allegation of abuse/neglect voiced by a family member. (Resident B) Finding includes: Resident C's record was reviewed on 5/13/24 at 8:09 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 2/17/24, indicated the resident had a moderately impaired cognitive status, had no behaviors, and was dependent for eating. A Care Plan, dated 7/21/23, indicated a risk for falls. An intervention, dated 7/21/23, indicated no hot drinks were to be served in the room or with meals. A Nurse's Progress Note, dated 5/8/24 at 4:29 a.m., indicated Agency LPN 1 was summoned to the resident's room by a CNA and observed the resident in bed with reddened skin to the upper abdomen and underneath the left breast. The areas were tender to touch and the resident grimaced and winced when the area was touched. Resident B had indicated she had spilled…

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 adequate supervision was provided and care plan interventions were followed to prevent a fall (Resident D) and spillage of hot coffee on the skin (Resident C), for 2 of 3 residents reviewed for accidents and supervision. Findings include: 1. Resident D's record was reviewed on 5/14/24 at 8:58 a.m. The diagnoses included, but were not limited to, dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 4/22/24, indicated the resident had a severely impaired cognitive status, no behaviors, no impairments of the upper and lower extremities, was dependent for toileting, and required maximum assistance for bed mobility and transfers. She was independent with wheelchair mobility and had no falls since the last review. During an interview on 5/14/24 at 10:04 a.m., The RN MDS Nurse indicated the MDS assessment was incorrect and the resident had a fall on 2/29/24 and the MDS would be modified. A revised Care Plan, dated 5/4/24, indicated a risk for injuries related to falls and falls had occurred on 12/15/23, 1/29/24,…

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 a resident received the necessary treatment and services related to the lack of a thorough and timely assessment completed after a resident had fallen for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: Resident B's record was reviewed on 4/16/24 at 10:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, fracture around the internal prostheses of the left knee, and pathological fracture of the right ankle. A Nurse's Progress Note, dated 3/29/24 at 7:44 p.m., indicated the resident was being assisted with transferring by Agency CNA 1 and was lowered to floor in the bathroom. There were no injuries observed. The family, Nurse Practitioner, and the Director of Nursing (DON) were notified. The vital signs were within normal limits. The after-fall assessment on 3/29/24 at 7:44 p.m., was not thorough and had not included the presence or absence of significant findings, nor the actual vital signs. There were no other assessments completed after the fall on 3/29/24 at 7:44 p.m.,…

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 a sanitary kitchen related to built up burnt food debris and grease in 2 ovens for 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect 54 residents who received food from the kitchen. Finding includes: The initial kitchen tour was completed on 11/13/23 at 9:07 a.m. The inside of 2 ovens had an accumulation of built up burnt food debris and grease. Interview with [NAME] 1 on 11/13/23 at 9:18 a.m., indicated the ovens were supposed to be cleaned weekly and dig not appear to be cleaned for awhile. Interview with the Dietary Manager on 11/17/23 at 11:09 a.m., indicated the ovens should be cleaned at least weekly. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag for 1 of 1 residents reviewed for dignity. (Resident 21) Finding includes: On 11/13/23 at 10:24 a.m. and again on 11/14/23 at 11:42 a.m., Resident 21 was observed lying in bed. A urinary catheter bag was hanging on the side of the bed with visible urine in the bag. There was not a covering over the bag. The bag was visible from the doorway. Record review for Resident 21 was completed on 11/14/23 at 11:45 a.m. Diagnoses included, but were not limited to, stroke, neurogenic bladder, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 9/18/23, indicated the resident was cognitively moderately impaired. The resident had an indwelling urinary catheter. Interview with RN 1 on 11/14/23 at 11:47 a.m., indicated the resident's catheter bag should have been covered with a dignity bag. 3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure a resident's preference was honored related to not receiving a beverage of choice per her request for 1 of 2 residents reviewed for choices. (Resident 1) Finding includes: On 11/15/23 at 9:23 a.m., Resident 1 was sitting at a table by the nurse's station. The resident asked LPN 1 if she could have some hot chocolate. LPN 1 indicated she would have to ask the resident's nurse. LPN 1 was observed asking RN 1 if the resident could have some hot chocolate. RN 1 indicated the resident would have to wait until the resident's daughter arrived to the facility to assist her with the hot chocolate. The resident would spill it on herself without assistance. LPN 1 then went back and told the resident she would have to wait until her daughter got there to assist her with the hot chocolate. Record review for Resident 1 was completed on 11/15/23 at 9:21 a.m. Diagnoses included, but were not limited to tardive dyskinesia (movement disorder that causes involuntary facial tics), heart failure, hypertension, 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 record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 2 of 3 residents reviewed for hospitalization. (Residents 48 and 55) Findings include: 1. Resident 48's record was reviewed on 11/14/23 at 11:56 a.m. Diagnoses included, but were not limited to, dementia, anxiety and depression. The resident resided on the memory care unit. The Quarterly Minimum Data Set assessment, dated 9/5/23, indicated the resident required limited staff assistance for bed mobility, transfers and eating, and extensive staff assist for toileting. Progress Notes dated 8/5/23, indicated the resident was sent to the hospital for evaluation following a fall. The resident returned later that day. On 8/6/23, the resident was sent back to the hospital for additional evaluation after complaining of pain to her hip from the fall. There was a lack of documentation any hospital transfer form had been completed or the State transfer form had been provided in writing to the resident or his 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for 1 of 18 residents reviewed for care plans. (Resident 48) Finding includes: Resident 48's record was reviewed on 11/14/23 at 11:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, anxiety and depression. The resident resided on the memory care unit. The Quarterly Minimum Data Set assessment, dated 9/5/23, indicated the resident required limited staff assistance for bed mobility, transfers, and eating, and extensive staff assist for toileting. The admission Care Plan was initiated on 7/15/23. There were no care plans prior to that date, including a baseline care plan within 48 hours of admission. Interview with the Medical Records Coordinator, on 11/15/23 at 11:15 a.m., indicated there was no baseline care plan completed for the resident.

Based on observation, record review, and interview, the facility failed to develop and implement a care plan for a resident with denture problems for 1 of 20 resident care plans reviewed. (Resident 1) Finding includes: On 11/13/23 at 10:21 a.m., and 11/15/23 at 9:17 a.m., Resident 1 was observed not wearing her dentures. Record review for Resident 1 was completed on 11/15/23 at 9:21 a.m. Diagnoses included, but were not limited to tardive dyskinesia (movement disorder that causes involuntary facial tics), heart failure, hypertension, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 8/28/23, indicated the resident was cognitively moderately impaired. The resident required supervision of 1 person for eating. The assessment did not have the section checked for broken or loosely fitting dentures. The record lacked any documentation of a dental care plan. Interview with RN 1 on 11/15/23 at 9:55 a.m., indicated the resident's dentures did not fit and that was why she was not wearing them. The resident had tardive dyskinesia (movement disorder that causes involuntary…

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 ensure the necessary care and services were provided to a dependent resident related to assistance with dentures daily for 1 of 3 residents reviewed for activities of daily living. (Resident 1) Finding includes: On 11/13/23 at 10:21 a.m., Resident 1 was observed sitting in a wheelchair in her room. The resident did not have any teeth. A sign was taped on the front of her dresser that indicated to put the resident's dentures in her mouth every morning. The sign also indicated the dentures were in a yellow cup in the bathroom. The dentures were then observed to be inside a yellow cup on the bathroom sink. On 11/15/23 at 9:17 a.m., Resident 1 was observed sitting in a wheelchair by the nurses's station. The resident did not have her dentures in. At 9:19 a.m., the resident's dentures were observed in the yellow cup on top of her bathroom sink. On 11/15/23 at 10:59 a.m., Resident 1 was observed sitting in a wheelchair in her room. The resident had her dentures in her mouth. The resident was talking with 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.

Based on record review and interview, the facility failed to ensure a resident received the necessary treatment and services related to the lack of a thorough assessment completed after a fall for 1 of 1 residents reviewed for falls. (Resident 32) Finding includes: Record review for Resident 32 was completed on 11/14/23 at 2:00 p.m. Diagnoses included, but were not limited to, hemiplegia following cerebral infarct affecting left nondominant side, epilepsy, type 2 diabetes mellitus without complications, constipation, hypertension, and vitamin D deficiency. The Quarterly Minimum Data Set (MDS) assessment, dated 8/25/23, indicated bed mobility, dressing, transfers, and toileting required extensive assistance. Eating required supervision, and hygiene required limited assistance. The resident also required a wheelchair, cane, and crutches. Progress Notes, dated 10/16/23, indicated the CNA report sheet listed 1 assist, left side weakness, wheelchair bound, and bed pan at night for the resident. Interview with the DON on 11/15/23 at 2:32 p.m. indicated she was unaware of any recent fall.…

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 ensure a resident received the proper care and treatment for respiratory services related to an empty oxygen humidifier bottle and oxygen tubing not changed as ordered for 1 of 1 residents reviewed for respiratory care. (Resident 20) Finding includes: On 11/15/23 at 2:19 p.m. and 11/16/23 at 2:40 p.m., Resident 20 was observed in her bed. Her oxygen concentrator was on, the nasal cannula in place and flowing at 2 liters per minute. The nasal cannula tubing was connected to the humidifier bottle on the concentrator. The humidifier bottle was empty and the date on the tubing was 11/8. The resident's record was reviewed on 11/16/23 at 2:20 p.m. Diagnoses included, but were not limited to, dementia, heart failure and chronic obstructive pulmonary disease. She resided on the memory care unit. The Quarterly Minimum Data Set assessment, dated 10/11/23, indicated the resident was severely cognitively impaired and required extensive staff assistance for bed mobility, transfers and toileting. She used oxygen while in…

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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related not following up on pharmacy recommendations in a timely manner for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Resident 48's record was reviewed on 11/14/23 at 11:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, anxiety and depression. The resident resided on the memory care unit. The Quarterly Minimum Data Set assessment, dated 9/5/23, indicated the resident required limited staff assistance for bed mobility, transfers and eating, and extensive staff assist for toileting. Current Physician's Orders included Pantoprazole (a proton pump inhibitor used to treat acid reflux) 40 milligrams (mg) daily for gastric problem and Sertraline (an antidepressant) 50 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.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to not monitoring the pulse prior to medication administration with ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 24) Finding includes: The record for Resident 24 was reviewed on 11/14/23 at 2:00 p.m. Diagnoses included, but were not limited to, hypertension, dementia, and hyperlipidemia. The admission Minimum Data Set assessment, dated 10/31/23, indicated the resident was cognitively impaired. The Physician's Order Summary, dated 11/2023, indicated an order for metoprolol succinate ER (extended release) (an antihypertensive medication) 50 mg (milligrams) daily. Hold if heart rate less than 60 or blood pressure less than 100/50. The Medication Administration Record (MAR), dated 11/2023, indicated the resident's blood pressure was documented prior to the administration of the metoprolol medication. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a staff member who worked in the facility as a Registered Nurse had an active license. This had the potential to affect all 54 residents who resided in the facility. Finding includes: The employee files were reviewed on [DATE] at 9:22 a.m. RN 2 was hired into the facility as a Registered Nurse on [DATE]. The nurse's license expired on [DATE]. Interview with the HR Director on [DATE] at 10:24 a.m., indicated the last time RN 2 worked in the facility as a Registered Nurse was [DATE]. The nurse would be taken off the schedule until her license was renewed. 3.1-14(s)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to a lancet disposed of improperly for a random observation during a blood sugar check. (Resident 107) Finding includes: On 11/16/23 at 11:21 a.m., RN 3 assessed Resident 107's blood sugar levels. RN 3 sterilized her hands and took the glucometer out of the bag. RN 3 applied gloves, cleaned the residents finger, and pricked the finger to obtain the blood sample. The resident's blood sugar was 190. The RN took off her gloves and threw them, including the lancet, into the garbage can in the resident's room. The RN proceeded to walk out of the resident's room into the hallway. Interview with the RN on 11/16/23 at 11:28 a.m., indicated she thought she put the lancet in the sharps container. The surveyor informed the RN that she put the lancet in her gloves and threw it in the trash can in the resident's room. The RN indicated she believed she did put the lancet in the garbage can inside her glove on accident, but she knew the lancet…

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 determine self-administration of medications was appropriate for residents, related to medications left with the residents for self administration and no assessment to indicate the residents were appropriate for self administration of medications, for 3 of 3 residents observed with medications left on the table and in the room for administration. (Residents F, C, and E) Findings include: 1) During an observation on 9/25/23 at 8:57 a.m., Resident F was sitting in the Dining Room at a table with three other residents. She had a medication cup sitting in front of her, which contained multiple pills. The resident then began taking the medications orally until all medications were gone. The Nurse was at the Medication Cart, located at the Nurses' Station, outside of the Dining Room. The Nurse's back was to the resident. During an interview on 9/25/23 at 9 a.m., Nurse 3 indicated she was going to come back to the Dining Room and she does not normally leave the medications with the resident. Resident F's record 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 observation, record review, and interview, the facility failed to ensure dietary preferences were followed, related to not providing items listed on the individual meal card for 1 of 3 residents reviewed for food preferences. (Resident B) Finding includes: During a supper meal observation on 9/25/23 at 5:16 p.m., Resident B was served a [NAME] sandwich, green beans, mixed melon fruit, coffee, and cranberry juice. The individual dietary menu card indicated the resident preferred hot tea and whole milk. During an breakfast meal observation on 9/26/23 at 8:31 a.m., Resident B was served an egg and sausage biscuit sandwich, a piece of wheat toast with butter, coffee, and apple juice. The individual dietary card indicated the resident preferred cranberry juice. During an interview on 9/26/23 at 8:37 a.m., Nurse 1 indicated the resident's son filled out the menu preferences at the beginning of each month. During an interview on 9/26/23 at 8:43 a.m., CNA 1 indicated the residents were to be served what 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.

Based on observation, record review, and interview, the facility failed to ensure residents were served therapeutic diets as ordered by the Physician, related to dietary and extra protein supplements, for 2 of 3 residents observed for therapeutic diets. (Residents C and D) Findings include: 1. During an observation of the dinner meal on 9/25/23 at 5:33 p.m., Resident C received her meal, which consisted of chicken corn bread bake, vegetable soup, melon mix, and cranberry juice. She had not received a health shake with her meal. After she consumed her dinner, she left the dining room at 5:58 p.m. and had not received a health shake with her dinner meal. During an observation on 9/26/23 at 8:38 a.m., Resident C received her breakfast meal, which consisted of one hard cooked egg, a piece of toast, cold cereal, and cranberry juice. The Dietary Card indicated she was to receive double protein for breakfast. During an interview with Dietary Aide 1 on 9/26/23 at 8:40 a.m., he indicated double protein would be two servings of eggs. The special instructions were on the Dietary Card and he…

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.