White Oak Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide drinks consistent with resident preferences for 1 (#R7) of 1 resident observed for drinking preferences. The facility failed to provide Resident #R7 coffee when he requested it. Findings: Review of Resident #R7's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #R7's Quarterly MDS with an ARD of 02/20/2026 revealed a BIMS of 8, which indicated he was moderately cognitively impaired. On 05/05/2026 at 12:25 p.m., an observation was made of Resident #R7 self-propelling himself out of his room in his wheelchair, holding a drinking tumbler. He waved his drinking tumbler in the air. When asked if he wanted coffee, he shook his head yes. At that time, S4LPN was observed down the hall. S4LPN was notified Resident #R7 wanted coffee. S4LPN shook her head and stated no. On 05/05/2026 at 12:28 p.m., an observation and interview was conducted with S15OT walking toward Resident #R7. S15OT told Resident #R7 he could not…

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

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care for 2 (#5 & R1) of 4 residents reviewed for infection control.Review of the facility's titled Enhanced Barrier Precautions dated January 2025 revealed the following, in part: It is the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: (i.e. Wounds and / or indwelling medical devices (e.g.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident's MDS Assessment accurately reflected their status for 5 (#4, #7, #13, #21, and #43) of 19 residents in the sample. The facility failed to ensure: 1. Resident #7 was coded correctly for antipsychotics; 2. Resident #43 was coded correctly for insulin; 3. Resident #13 was coded correctly for their Level II PASRR status; and 4. Resident #4 and #21 were coded correctly for restraint status. This deficient practice had the potential to affect a current census of 92 residents. 1. Review of Resident #7's Clinical Record revealed an admission date of 02/20/2024 with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Schizophrenia, Delusional Disorders, and Unspecified Dementia. Review of Resident #7's Quarterly MDS with an Assessment Reference Date (ARD) of 10/02/2025 revealed, in part, the following: Section N. Medications N0415. High-Risk Drug Classes: Use and Indication A. Antipsychotic: Yes Review of Resident #7's…

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

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly labeled, dated, and sealed. This had the potential to affect 92 residents who were served from the kitchen.Findings:On 12/01/2025 at 8:28 a.m., an initial tour of the kitchen was conducted with S5DM. The observations were made of the following items available for consumption:Main kitchen area:1 clear bag of Grits (1/2 bag) opened, undated, and not sealed.2 clear bags of cornbread mix opened and undated.5 clear bags of seasoning mixes opened and undated.1 box of powdered sugar opened, undated, and not sealed.Walk-In Cooler: 1 Large, plastic bag of cheddar cheese opened and undated.1 Large, plastic bag of parmesan cheese opened and undated.1 tray of liquid-filled drinking cups (10 cups) undated and unlabeled.8 bowls of fruit cocktail undated, and unlabeled. On 12/01/2025 at 8:45 a.m., an interview was conducted with S5DM. He confirmed the above items were not dated 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, interviews, and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 (#10, #79, and #95) of 19 sampled residents. The facility failed to ensure:1. Medication administration was accurately documented on the MAR for Residents #10 and #95; and2. Colostomy changes were documented for Resident #79.1. Review of the facility's undated policy titled, Medication-Documentation of Administration revealed the following, in part: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). Resident #10 Review of Resident #10's Clinical Record revealed an admission date of 02/05/2025 and diagnoses, which included Hypertensive Heart Disease and Peripheral Vascular Disease. Review of 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 reviews and interview, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate PASRR Level II determinations and recommendations into a resident's transitions of care for 1 (#98) of 4 (#3, #13, #66, and #98) residents reviewed for PASRR.Findings: Review of the facility's undated policy titled Resident Assessment-Coordination with PASRR Program revealed the following, in part: Policy Explanation and Compliance Guidelines:7. Recommendations, such as any specialized services, from a PASRR Level II Determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of Resident #98's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Unspecified Psychosis. Review of Resident #98's Form 142 revealed he was approved for admission by Level II authority for 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 observations, interviews, and record review, the facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality by nursing staff failing to observe and ensure a resident consumed medication for 1 (#10) of 7 residents reviewed for medication administration.Findings: Review of Resident #10's Clinical Record revealed an admission date of 02/05/2025 and diagnoses, which included Hypertensive Heart Disease and Peripheral Vascular Disease. Review of Resident #10's Quarterly MDS with an ARD of 11/12/2025 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #10's current Physician Orders revealed the following, in part: Lasix oral tablet 40 mg by mouth twice daily at 5:00 a.m. and 12:00 p.m. Review of Resident #10's MAR dated 12/01/2025 revealed the following, in part:Lasix 40 mg by mouth at 12:00 p.m. with a check mark and initials indicating S7LPN administered Resident #10's Lasix at 12:00 p.m. An observation was made of Resident #10 on 12/01/2025 at 3:55 p.m. She had a white tablet in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to obtain informed consent prior to the installation of bed rails/grab bars for 1 (#13) of 19 residents in the sample. This deficient practice had the potential to affect a current census of 92 residents. Findings: Review of Resident #13's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses including severe morbid obesity. Review of Resident #13's quarterly MDS Assessment with an ARD of 09/18/2025, revealed she was assessed to have a BIMs score of 15, indicating she was cognitively intact. Review of Resident #13's Physician Orders, dated 10/01/2024 through 12/01/2025, revealed, in part, the following: 04/01/2025 - Grab bars x2 to assist with bed mobility.Review of Resident #13's current Care Plan, revealed, in part, the following: Problem: Resident uses bed rails/grab bars x2 for bed mobility and repositioning. Intervention: Ensure valid consent on chart prior to initiating.Review of Resident #13's Physical Restraint /…

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 review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure Insulin pens were labeled with an opened date on 2 (MCa and MCb) of 2 medication carts reviewed. This deficient practice had the potential to affect all residents who received insulin in the facility.Findings:On 12/01/2025 at 2:55 p.m., an observation was made of MCa with S6LPN, which revealed Resident #92's Lantus Subcutaneous Solution Pen-Injector was opened and was not labeled with an opened date. On 12/01/2025 at 2:58 p.m., an interview was conducted with S6LPN. S6LPN confirmed Resident #92's Lantus Subcutaneous Solution Pen-Injector was not labeled with an opened date. She stated she did not know when the pen was opened.On 12/01/2025 at 3:25 p.m., an observation was made of MCb with S7LPN, which revealed Resident #80's Lantus Subcutaneous Solution Pen-Injector was opened and was not labeled with an opened date.On 12/01/2025 at 3:27 p.m., an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for pressure ulcers. The facility failed to ensure nursing staff accurately documented Resident #2's pressure ulcer interventions. Findings: Review of the facility's undated policy titled, Documentation revealed the following, in part: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment . for continuity of care, treatment decisions . Procedure: 3. Be concise, accurate, and complete . 12. Personnel will be expected to document timely, accurately, and completely. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Stage 3 Pressure Ulcer Of Sacral Region, Stage 4 Pressure Ulcer Of Left Heel, and Stage 3 Pressure Ulcer Of Other Site. Review of Resident #2's admission Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure medications were administered safely and timely by leaving medications at bed side for 1 (#3) of 3(#1, #2, and #3) residents observed during the survey. Findings: Review of the facility's undated policy titled, Medications- Administration, revealed the following, in part: Policy Statement: Residents may self-administer medications only if attending physician, in conjunction with Interdisciplinary Care Planning Team, has determined that they have the decision making capacity to do so safely. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/10/2025 revealed she had a BIMS of 15, indicating she was cognitively intact. Review of Resident #3's Current Physician's Orders included, in part:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure nursing staff notified the NP of a residents fall outside, which required a care plan update, for 1 (#5) of 3(#3, #4 and #5) residents reviewed for falls. Findings: Review of the facility's undated Policy Titled, Falls- Resident, revealed the following, in part: Actual Falls 1. When a resident falls, the charge nurse will access . and notify the physician for the appropriate orders. Review of the facility's undated Policy Titled, Change in a Resident's Condition or Status revealed the following: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: a. An accident or incident involving the resident. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included History of Falling. Review of Resident #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/06/2024 revealed Resident #5 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 reviews and interviews, the facility failed to ensure that each resident's comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 1 (R1) of 8 (#1, #2, #3, #4, #5, #6, #7 and R1) resident records reviewed for comprehensive assessments. The facility failed to ensure that the resident admission assessment was completed within the 14-day requirement. Findings: R1 Review of R1's admission MDS assessment with an Assessment Reference Date (ARD) of 02/12/2025, revealed an admit date of 01/31/2025. Further review of the Admit MDS revealed the MDS had a status of in progress. On 02/25/2025 at 1:34 p.m., an interview was conducted with S2MDS. She reviewed R1's admission MDS and confirmed R1 was admitted to the facility on [DATE]. She further confirmed R1's admission MDS was still in progress, and was not completed in the required timeframe. On 02/25/2025 at 1:50 p.m., an interview was conducted with S1DON. He reviewed R1's admission MDS and confirmed R1 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1 (#3) of 3 (#3, #5, and #7) residents reviewed for falls. Findings: Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed the resident had diagnoses which included Paraplegia and Unspecified Injury at T7-T10 Level of Thoracic Spinal Cord. Review of Resident #3's Quarterly MDS with an ARD of 11/20/2024 revealed a BIMS of 14, which indicated he was cognitively intact. Review of Resident #3's current Care Plan revealed the following: Problem: The resident is at risk for falls. Intervention: 11/16/2024-Fall mat. On 02/24/2025 at 9:00 a.m., an observation was made of Resident #3 in his room. No fall mat was observed at bedside. On 02/25/2025 at 8:42 a.m., an observation was made of Resident #3 in his room. No fall mat was observed at bedside. On 02/24/2025 at 2:58 p.m., an interview was conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident's comprehensive plan of care was developed within 7 days after completion of the comprehensive assessment for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6, #7) residents reviewed for care plans. Findings: Review of the facility's undated policy titled Care Plans-Comprehensive, revealed the following, in part: Policy It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 7. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #1's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure census checks were accurately documented for 2 (#5 and #6) of 3 (#5, #6, and #7) residents reviewed for elopement and wandering. Findings: Resident #5 Review of Resident #5's clinical record revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: Cerebral Infarction, Hemiplegia and Hemiparesis. Review of Resident #5's MDS with an ARD of 12/06/2024 revealed a BIMS of 3, which indicated severe cognitive impairment. Review of Resident #5's physician's orders revealed the following, in part: 02/13/2025-Q 30 minute checks due to falls and census checks related to elopement risk. Review of Resident #5's Task log, dated 02/13/2025 to 02/15/2025, revealed no documentation of census checks every 30 minutes. On 02/26/2025 at 12:28 p.m., an interview was conducted with S8ADON. She stated if a resident had orders for census checks, it would appear in the CNA Task log and prompt documentation. On 02/25/2025 at 1:50…

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 interviews, the facility failed to have sufficient certified nursing assistant staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. The deficiency had the potential to affect the facility's total census of 76 residents. Findings: Review of the facility's policy titled Sufficient Staff, undated, revealed the following: 37. The facility will supply services by sufficient number of each of the following personnel types on a 24 hour basis to provide nursing care to all resident in accordance with resident care plans; CNAs and LPNs. On 01/16/2025 at 3:30 p.m., an interview was conducted with S1ADM. He stated the facility required the following staffing ratio; 8 CNAs on the day shift, 8 CNAs on the evening shift and 4 CNAs on the night shift. Review of the facility's Staffing Pattern revealed on 12/22/2024, 12/29/2024, 01/11/2025, and 01/12/2025, the night shift had 3 CNAs providing direct care. On 01/15/2024 at 10:30 a.m., an interview…

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 notify the Ombudsman of facility-initiated resident transfers for 2 (#5 and #6) of 3 (#4, #5, and #6) residents reviewed for emergency transfers. This deficient practice had the potential to affect a current census of 76 residents. Findings: Review of the facility's undated policy titled, Transfer and Discharge, revealed, in part, the following: Definitions: Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all…

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, observation, and interviews the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 3 (#3, #4 and #5) of 5 (#3, #4, #5, #6 and #8) residents reviewed. The facility failed to: 1. Ensure Resident #3's PT evaluation was completed as ordered; and 2. Ensure Resident #4's care plan was comprehensive and individualized for wandering behaviors; and 3. Ensure Resident # 5's every 30 minute checks were completed as ordered. This deficient practice had the potential to affect a current census of 76 residents. Findings: 1. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, Hemiplegia and Hemiparesis following Cerebrovascular Disease and Unspecific Dementia. Review of Resident #3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/29/2024, indicated resident was assessed by the facility to have a Brief Interview of Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 (RR1) of 4 (#1, #8, #9 and RR1) residents reviewed for ADL care. Findings: Review of the facility policy titled, Activities of Daily Living (ADLs), undated revealed the following: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain . personal and oral hygiene. Review of the clinical record for Random Resident 1 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Morbid Obesity and Functional Quadriplegia. Review of Random Resident 1's most recent MDS with an ARD of 10/23/2024 revealed the resident was assessed to have a BIMS of 15. Further review revealed she was always incontinent and required extensive assistance for ADL care. Review of the care plan for Random Resident 1 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure Activities of Daily Living (ADL) care was accurately documented for 2 (#8 and #9) of 3 (#1, #8 and #9) Residents reviewed for ADL care. Findings Review of the facility policy titled, Documentation, revealed the following, in part: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., for continuity of care, treatment decision and to support services provided for payment. 2. A legal record that protects the resident, physician, nurse and the facility that may be traditional paper record, electronic record or combination of both. Review of Resident #8's clinical record revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: Unspecified Injury At unspecified level of Thoracic Spinal Cord and Acute Pain due to Trauma. Review of Resident #8's quarterly Minimum Data Set (MDS) with an Assessment Reference…

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 and interviews, the facility failed to provide pharmaceutical services to meet the needs of 1 (#1) of 3 (#1, #2, and #4) sampled residents reviewed for behavioral health services. The facility failed to ensure S2RN administered Resident #1's Ativan per the Physician's Order. Findings: Review of the facility's undated policy titled Medications-Administering, revealed in part, the following: Policy Interpretation and Implementation: 3. Medication must be administered in accordance with the orders. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder. Review of Resident #1's Physician's Orders revealed the following: A handwritten telephone order for Ativan 1 mg IM x 1 dose for agitation and aggression, written by S2RN ordered on 10/13/2024 at 4:29 p.m. Review of Resident #1's MAR for October 2024 revealed no documentation Ativan had been administered as ordered on 10/13/2024. On 11/13/2024 at 12:22 p.m., 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 observations and interviews, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 9 of 9 (Room A, Room B, Room C, Room D, Hall E, Hall F, Room G, Room H, and Room I) areas observed for environmental concerns. This deficient practice had the potential to affect a census of 88 residents currently residing in the facility. Findings: Room A An observation was conducted on 09/18/2024 at 12:12 p.m. of Room A. One fluorescent light fixture was observed with no cover in place. One fluorescent light fixture was observed to be broken with dead bugs inside and paint marks on the sides. Two fluorescent light fixtures were observed with dead bugs inside the covers. All four walls were observed with scuff marks, indentations and missing paint. The baseboards were observed to be scuffed, missing paint and had a blackish brown substance beneath them. The floor tiles had stains throughout. The blinds for the window were missing. A stainless steel serving cart had dust visible on all surfaces. The 4 air conditioner vents were covered in rust.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 4 (#13, #18, #26, and #46) of 6 (#13, #18, #26, #38, #46, and #48) sampled resident records reviewed for PASRR. Findings: Resident #13 Review of the Clinical Record revealed Resident #13 was admitted to the facility on [DATE] with the following mental health diagnoses: Anxiety Disorder and Schizophrenia (onset date of 11/12/2021). Further review revealed no Resident Review Form for a PASRR Level II determination. Resident #18 Review of the Clinical Record revealed Resident #18 was admitted to the facility on [DATE] with the following mental health diagnoses: Depression and Schizophrenia (onset date of 03/31/2023). Further review revealed no Resident Review Form for a PASRR Level II determination. Resident #26 Review of the Clinical Record revealed Resident #26 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to provide the ordered therapeutic diet for 1 (#21) of 4 (#21, #22, #42, and #66) residents reviewed for nutrition. Findings: Review of the facility's undated policy titled Nutrition Services, revealed the following, in part: Policy Interpretation and Implementation 2. Nursing personnel will ensure that residents are served the correct food tray. Review of Resident #21's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included End Stage Renal Disease. Review of Resident #21's MDS with an ARD of 07/02/2024, revealed a BIMS of 15, which indicated intact cognition. Review of Resident #21's current Physician Orders revealed the following, in part: Start date 04/25/2024- Diet: liberal renal; 1000 ml fluid restriction Start date 06/25/2024-No soups/broth Review of Resident #21's Nutrition Assessment Notes, dated 06/24/2024, revealed the…

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

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Medication carts were free of loose pills for 2 (Med Cart A and Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts reviewed. 2. Medication carts were free of expired drugs or biologicals for 1 (Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts reviewed. 3. Medications were stored at proper temperatures in 1 (Med Frig D) of 1 (Med Frig D) medication refrigerators reviewed. Findings: Review of the facility's policy titled, Medications Storage, revealed, the following, in part: Policy Interpretation and Implementation 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 1. On 09/18/2024 at 8:30 a.m., an observation was made of Med Cart A with S10LPN, which…

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

Based on observation, interview and record review, the facility failed to ensure 5 out of 5 dietary staff hired were trained on how to test the chemical dishwasher for chlorine. Findings: On 09/18/2024 at 1:41p.m., an observation was made of S14CHD placing the following items through a low temperature dishwasher: 1. 1 full rack of black serving trays 2. 1 full rack of cups 3. 1 full rack of bowls No testing of chlorine was observed. On 09/18/2024 at 1:43 p.m., an interview was conducted with S14CHD. He stated he washes dishes on the day shift. He confirmed he did not test the low temperature dishwasher for chlorine. He was not able to demonstrate how to test the low temperature dishwasher for chlorine. He confirmed he was not trained on how to test the low temperature dishwasher for chlorine. On 09/18/2024 at 1:45 p.m., an interview was conducted with S7DEM. He confirmed all kitchen staff should be using the chemical rinse method to sanitize dishes. He further stated there were 5 dietary staff hired to operate the low temperature dishwasher. He was unable to provide…

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

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 81 residents who were served from the kitchen. Findings: Review of the facility's policy, titled Food Safety Guidelines for Dry Storage to Know, dated 05/05/2024, revealed, in part: Label and Date- Labeling and dating aren't just for food you keep in cold storage. Always label any food not in its original container. An initial tour of the kitchen was conducted on 09/17/2024 at 8:34 a.m. with S7DEM. Observations were made of the following items: 11oz. container of opened parsley flakes without a label indicating an open date or expiration date. 6 lb. container of opened onion powder without a label indicating an open date or expiration date. 6 lb container of opened garlic powder without a label indicating an open date or expiration date. 11 oz. container of opened ground garlic and ginger mix without a label indicating an open date or expiration date. On 09/17/24 at 8:58 a.m., a tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents understood the binding arbitration signed on admission for 2 (#143 and #192) of 3 (#44, #143, and #192) residents reviewed for arbitration. Findings: Review of the facility's Optional Binding Arbitration, page 2 of 3, dated 09/16/2019, revealed, in part: Section G. Other Provisions: Opportunity to Read: the resident or legal representative acknowledges that he/she has received a copy of this agreement and has had ample opportunity to read it before accepting it. Resident #143 Review of Resident #143's clinical record revealed he was admitted on [DATE]. Review of Resident #143's clinical record revealed a form titled, Optional Binding Arbitration. The arbitration form was dated and signed on 09/05/2024 by Resident #143 and S6CAC. On 09/17/2024 at 3:58 p.m., an interview was conducted with Resident #143. He stated he was admitted to the facility from the hospital. He stated he did not know what an arbitration agreement was. He stated…

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

Based on observations, interviews and record reviews, the facility failed to develop and implement appropriate plans of action to correct and ensure ongoing compliance with identified quality deficiencies. This deficient practice had the potential to affect a census of 88 residents currently residing in the facility. Cross Reference: F558, F609, F656, F677, F689, F802, F812, F835, and F880, Findings: Review of the facility's most recent Quality Assurance and Performance Improvement (QAPI) Team Meeting Notes, held 08/28/2024 at 10:00 a.m., revealed in part, the following: 1. Dietary Management Review: Review of ServSafe Protocols, Diets, Customer Service and Quality of Meals and Beverages continues in daily QAPI; and 2. Monitoring and audits for all Complaint Surveys dated 06/10/2024 through 08/23/2024 showing continued compliance in all areas previously cited including, in part: therapeutic diets, food storage, abuse reporting and enhanced barrier precautions. Monitoring and audits of these areas through the end of September 2024. Review of the facility's Areas of Deficiency cited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to implement an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. Proper Personal Protective Equipment (PPE) was worn by staff for 2 (#5 and #49) of 2 residents on Enhanced Barrier Precautions (EBP); and 2. Urine soiled laundry was removed from a resident's room for 1 (#87) of 27 (#4, #8, #13, #16, #18, #21, #22, #25, #26, #27, #32, #38, #42, #43, #46, #48, #49, #53, #54, #56, #58, #64, #65, #66, #85, #87, #192) residents observed during initial pool. Findings: 1. Resident #5 A review of the facility's policy titled, Enhanced Barrier Precautions, dated 05/2023 revealed, in part: Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities. 48. High-contact care activities include: c. transferring, g. device care or use: feeding tubes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences by failing to respond to call lights in an appropriate time frame for 1(#192) of 5 (#27, #53, #54, #66 and #192) residents reviewed for call light response. Findings: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, undated revealed the following: 20. Ensure the call light system alerts staff members directly or goes to a centralized staff work area. 21. All staff members who see or hear an activated call light are responsible for responding. If the staff cannot provide what the resident desires, the appropriate personnel should be notified. Review of Resident #192's clinical record revealed the resident was admitted to the facility on [DATE]. On 09/17/2024 at 8:59 a.m., an interview was conducted with Resident #192. Resident #192 stated she was wet and needed to be changed. Resident #192…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure allegations of physical abuse and misappropriation of resident property were reported to the facility administrator and the state survey agency timely for 1 (#54) of 27 residents reviewed for abuse in the initial pool. Findings: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation revealed the following, in part: Definitions: Abuse means the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish . Review of the facility's policy titled, Abuse Investigation and Reporting with a revision date of October 2019 revealed the following, in part: Policy Statement: All reports of resident abuse, exploitation, misappropriation of resident property, mistreatment shall be promptly reported to local, state and federal agencies (as defined by current regulations) . Reporting: 1. All alleged violations involving abuse, exploitation, or mistreatment, including misappropriation…

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

Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status. The facility failed to ensure: 1. A resident's annual Minimum Data Set (MDS) assessment was accurately coded in regards to PASRR Level II for 1 (#48) of 6 (#13, #18, #26, #38, #46, and #48) residents reviewed for PASRR; and 2. A resident's quarterly MDS assessment was accurately coded in regards to hospice status for 1 (#4) of 28 residents reviewed in the final sample. Findings: Review of the facility's policy titled MDS - Conducting an Accurate Resident Assessment, with no effective date, revealed, in part, the following: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment of relevant care areas. 1. Accurate assessments addressing each resident's status, needs, strengths, and areas of decline must be conducted by qualified staff that are knowledgeable about the resident and correctly documented in the medical record. 1. Review of Resident #48's Clinical Record revealed an admission date of 06/22/2020…

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, observations, and interviews, the facility failed to develop and/or implement a comprehensive person-centered care plan for 5 (#4, #14 #32, #54 and #75) of 28 residents reviewed in the sample. The facility failed to ensure: 1. Resident #4's hospice status was reflected in the care plan; 2. Resident #14's ostomy care was provided per physician's orders; 3. Resident #32 attended her scheduled physician's appointment as per physician's orders; 4. Resident #54's transfer status was reflected in the care plan; and 5. Resident #75's smoking status was reflected in the care plan. Findings: 1. Resident #4 Review of Resident #4's Clinical Record revealed an admission date of 01/25/2024 with diagnoses, which included Chronic Diastolic Congestive Heart Failure and the Presence of Cardiac Pacemaker. Further review revealed resident was admitted to a local hospice agency on 07/09/2024. Review of Resident #4's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2024,…

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

Based on interviews and record reviews the facility failed to ensure that a resident who was unable to carry out Activities of Daily Living (ADL's) without assistance received the necessary services to maintain good grooming and personal hygiene for 1 (#32) of 3 (#16, #87, and #32) reviewed for ADL's. Findings: A review of the Bath, Bed Policy and Procedure with no effective date revealed: Policy: Residents will be assisted with bathing as needed. Resident baths will be scheduled per resident preference as possible or at least 3 times weekly. It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues A review of the Quarterly Minimum Data Set (MDS) with an ARD of 08/08/2024 revealed Resident #32 had an admit date of 09/09/2017 and a Brief Interview for Mental Status (BIMS) Score of 15, indicating the resident was cognitively intact. A review of the Clinical Record revealed Resident #32 had the following diagnoses: Type 2 DM with foot ulcer. Review of September 2024 Progress notes revealed the following in part:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 of 1 (#43) residents reviewed for tube feeding. Findings: Review of Resident #43's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Vascular Infarction, Aphasia, and Dysphagia. Review of Resident #43's Quarterly MDS with an ARD of 08/09/2024 revealed the provider assessed the resident as having a BIMS of 0, indicating the resident was rarely/never understood. Further review revealed, Resident #43 had a feeding tube. Review of Resident #43's current Physician Orders revealed the following, in part: 10/12/2023 - Enteral feeding; Glucerna 1.2 at 70ml/hour continuous for 22 hours daily, feeding held for up to 2 hours to provide daily routine care 11/23/2021 - Diet Type: NPO (Enteral Feedings Only) An observation was made of Resident #43 on 09/17/2024 at 8:45 a.m. Resident #43's feeding tube was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection 2 (#2 and #R1) of 5 (#1, #2, #3, #R1, and #R4) residents reviewed for repositioning. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment while providing care to Resident #2 and #R1, residents on Enhanced Barrier Precautions; 2. Staff did not hang a urinary drainage bag above the level of Resident #2's bladder during a transfer; and 3. Staff performed proper hand hygiene during the care of Resident #R1. Findings: Review of the facility policy titled Enhanced Barrier Precautions with no date, revealed the following, in part: Enhanced barrier precautions refer to the use of gowns and gloves for use during high contact resident care activities for residents known to be colonized and infected with a MDRO as well as those at increased risk of MDRO…

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 a resident received services in the facility with reasonable accommodation of needs for 1 (#3) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure Resident #3's request to get out of bed was honored in a timely fashion. Findings: Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction and Primary Disorders of Muscles. Review of Resident #3's admission MDS with an Assessment Reference Date of 06/12/2024 revealed the resident had a BIMS score of 15, which indicated intact cognition. Further review revealed Resident #3 was dependent on transfers. Review of Resident #3's current Care Plan revealed the following, in part: Problem: ADLs: Requires assistance with ADL's related to Impaired Mobility Interventions: Transfers: Requires a mechanical lift On 07/17/2024 at 9:36 a.m., an interview was conducted with Resident #3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 1 (#3) of 3 (#1, #2, and #3) sampled residents reviewed for ADLs. The facility failed to ensure Resident #3 received incontinence care timely. Findings: Review of the undated facility policy titled, Incontinence Programs revealed the following, in part: (3) Check and Change Staff Involvement: Monitor for incontinent episodes and provide incontinence care Suggested Interventions: 1. Provide Incontinence care on a predetermined schedule and as needed. Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction and Primary Disorders of Muscles. Review of Resident #3's admission MDS with an Assessment Reference Date of 06/12/2024 revealed the resident had a BIMS score of 15, which indicated intact cognition. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#R3) of 3 (#3, #R2, and #R3) residents reviewed for diabetes. Findings: Review of Resident #R3's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Diabetes. Review of Resident #R3's Yearly Minimum Data Set with an Assessment Reference Date of 07/01/2024 revealed he had a BIMS of 10, which indicated he was moderately cognitively impaired. Review of Resident #R3's current Physician Orders revealed the following, in part: Humalog 100 Unit/Ml Kwikpen Blood Glucose AC and HS If FSBS 0-199=0Units, 200-250=2Units SQ, 251-300= 4Units SQ, 301-350= 6Units SQ, 351-400= 8Units SQ, greater than 400, administer 12 units and notify MD. Start date 05/04/2024. Review of Resident #R3's July 2024 Medication Administration Record (MAR) revealed the following, in part: July 5th-7:00 a.m.-BG 150, box checked that insulin 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 interviews and record review, the facility failed to ensure the administrator reported to and was accountable to the governing body. S1ADM failed to ensure the facility's QAPI program was maintained. This deficient practice had the potential to affect a census of 87 residents. Findings: A review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI), as of 06/10/2024, revealed, in part, the following: 11. Governance and leadership: a. The governing body and/or executive leadership is responsible and accountable for the QAPI program. b. Governing oversight responsibilities include, but are not limited to the following: ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities. iii. Ensuring the program is sustained during transitions in leadership and staffing. c. The QA Committee shall communicate its activities and the progress of its subcommittee PIPs to the governing body at least quarterly. A review of the facility's QAPI Committee Members revealed, in part, the following: Medical Director;…

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 complete a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. This deficient practice had the potential to affect a census of 87 residents. Findings: Review of the facility's CMS 672, dated 06/10/2024, revealed, in part, the following: Total Residents (F78): 87 A. Bladder Status Indwelling or external catheter: 10 Occasionally or frequently incontinent of bladder: 45 Occasionally or frequently incontinent of bowel: 39 B. Mobility Ambulation with assistance or assistive device: 4 C. Mental Status Documented signs and symptoms of depression: 6 Documented psychiatric diagnosis: 26 Dementia or Alzheimer's disease: 5 Behavioral healthcare needs: 15 D. Skin Integrity Pressure ulcers: 14 Receiving preventative skin care: 83 E. Special Care Hospice Care: 4 Chemotherapy: 1 Dialysis: 7 IV therapy: 5 Respiratory treatment: 4 Ostomy care: 7 Injections: 21 Tube feedings: 3 Mechanically altered diets: 17 Rehabilitative services: 62…

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 develop, implement and maintain an effective, comprehensive, data-driven QAPI (Quality Assurance and Performance Improvement) program focused on indicators of the outcomes of care and quality of life. This deficient practice had the potential to affect a census of 84 residents. Findings: A review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI), as of 06/10/2024, revealed, in part, the following: Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2. The QA Committee shall be interdisciplinary and shall: b. Meet at least quarterly and as needed . 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. 5. The plan and supporting documentation will be presented to the State Survey Agency . upon request. A review of the facility's QAPI Committee Members…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure it was free of significant medication errors for 1 (#1) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for medications. The deficient practice had the potential to effect the 84 residents residing in the facility receiving medications. Findings: Review of the facility's undated policy titled Medications-Administering revealed the following, in part: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required time frame. Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Unspecified Convulsions and Traumatic Brain Injury. Review of Resident #1's Discharge MDS with an ARD of 05/12/2024 revealed the resident was unable to complete the BIMS interview. Review of Resident #1's Physician Orders dated…

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 an observation, interviews and record review, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines by failing to: 1) Follow the approved menu in regard to meals served; 2) Record and archive deviations/substitutions of menu. This deficient practice had the potential to affect the 77 Residents who receive meals prepared by the facility kitchen. Findings: Review of the facility's undated titled, Menu Substitution, revealed in part, the following: Policy: To provide a substitute when an uncontrolled situation has temporarily made an item unavailable, decisions on menu substitutions will be made after discussion with the dietary professional whenever possible. 2. All changes to the menu will be recorded on the Menu Extension Sheets and the Substitution Sheet. The date, menu item, substitution and reason for the substitution will be recorded on the Menu Substitution Sheet. 3. Menu changes should be evaluated monthly by the dietary professional and an appropriate plan of action made to prevent further changes. 4.…

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, observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 77 residents who were served meals from the kitchen. Findings: Review of the facility's undated policy titled, Storage: Dry Food revealed in part, the following: Dry food storage pertains to those foods not likely to support bacterial growth in their normal state. These foods include: d. Dried beans Procedure: 1. Store dry foods in a cool dry place . 2. Dry foods can be contaminated, even if they don't need refrigeration. On 06/06/2024 at 9:30 a.m., a tour of the kitchen was made with S22DM. During the tour, an observation was made of sprouted red beans with a large amount of mold in a 5 gallon clear plastic container. Through interview, S22DM stated the red beans must have gotten wet. S22DM confirmed the above observation and stated the red beans should have been discarded.

Based on record review and interviews, the facility failed to ensure effective communication was performed as mandatory training for all direct care staff for 3 (S7CNA, S8CNA, S9CNA) of 5 (S5LPN, S6LPN, S7CNA, S8CNA, S9CNA) personnel files reviewed. Findings: Review of the facility's Facility Assessment Tool, as of 06/06/2024, revealed, in part, the following: Date of Assessment or Update: 05/14/2024 3.4 Staff Training, Education and Competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Communication - All staff members are expected to be effective at communicating with each other, with residents, with family members and with other visitors to the facility. Review of the facility's policy titled In-service Training, undated, revealed, in part, the following: Policy Interpretation and Implementation: 1. All personnel will receive ongoing education as required by federal and state laws. 6. The director of nursing will maintain a planned annual schedule of…

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 resident elopement was reported to the State Survey Agency as required within the specified timeframes for 1 (#7) of 2 (#7 and #8) residents reviewed for elopement. Findings: A review of the clinical record for Resident #7 revealed he was admitted to the facility on [DATE] and had diagnoses, which included Other Neurological Conditions, Aphasia, Cerebral Vascular Accident, Encephalopathy, Alcohol Use, Muscle Wasting and Atrophy to the Left Lower Leg, Lack of Coordination, Unsteadiness on Feet, and Muscle Weakness. A review of the admission MDS with an ARD of 02/27/2024 revealed Resident #7 had a BIMS of 4, which indicated he was severely cognitively impaired. A review of the Nurse's Notes for Resident #7 revealed the following: 05/20/2024 at 9:45 a.m.- Visitor came into the facility and spoke with S17UC. He asked if the facility had a resident by the name of Resident #7. Visitor stated there was a man at a fast food chain who identified…

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 a resident's comprehensive plan of care was implemented for 1(#4) of 8( #1, #2, #3, #4, #5, #6, #7 and #8) residents reviewed in the sample. The facility failed to ensure Resident #4 received the correct diet as ordered by the physician. Findings: Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia, Unspecified Severity, with Behavioral Disturbances and Age-Related Cognitive Decline. Review of the Physician Orders for Resident #4 revealed the following: 05/19/2024- Honey Thick liquid; No straw. Review of the Care Plan for Resident #4 revealed the following, in part: 05/15/2024- Resident is on Honey Thick liquids. Goal: Ensure resident is on Honey Thick liquid. Intervention: Resident should not use straw, No water pitcher at bedside; provide resident with Honey Thick liquids. On 06/10/2024 at 9:30 a.m., an observation was made of Resident #4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#2 and #5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for unnecessary psychotropic medications. Findings: Resident #2 Review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #2's June 2024 Physician's Orders revealed an order written on 05/17/2024 for Risperdal 2 mg tablet , one tablet by mouth every twelve hours as needed (PRN) for agitation. Further review revealed the PRN medication had no stop or duration date. Review of Resident #2's June 2024 Medication Administration Record (MAR) revealed Risperdal 2 mg tablet by mouth every twelve hours as needed was started on 05/17/2024. Further review revealed the PRN medication had no stop or duration date. Resident #5 Review of Resident #5's clinical record revealed the resident was admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for wound care. Findings: Review of the facility's policy titled, Charting and Documentation, dated 07/2017, revealed the following, in part: Policy Statement: All services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: c. Treatments or services performed. 3. Documentation in the medical record will be objective, complete, and accurate. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cellulitis to the Right Lower Limb, Stage 3 Pressure Ulcer to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed in final sample. The facility failed to ensure Resident #1's care plan reflected his frequent bath refusals. Findings: Review of the 12/2016 dated facility's policy titled, Care Plans, Comprehensive Person-Centered reviewed on 04/16/2024, revealed the following, in part: A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included End Stage Renal Disease, Cellulitis to Right Lower Limb, and Pressure Ulcer Stage 3 Sacral Area.…

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment while providing care for 1 (#2) of 2 (#2 and #3) sampled residents who were on Enhanced Barrier Precautions. Findings: Review of the facility's policy, titled Enhanced Barrier Precautions, reviewed on 04/16/2024, dated 04/2024, revealed the following, in part: Policy Statement: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms. 2a. Applicable conditions and devices: i. Wounds and/or indwelling medical devices (hemodialysis catheters) even if the resident is not known to be infected or colonized. 3a. Gowns and gloves. 4. High-contact resident care activities include: d. Providing hygiene. f. Changing…

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 reviews and interviews, the facility failed to protect the resident's right to be free from physical abuse by Resident #2 for 1 (#1) of 6 (#1, #2, #3, #4, #5 and #6) residents reviewed for abuse. Findings: Review of the facility's policy, Recognizing Signs and Symptoms of Abuse and Neglect revealed the following, in part: Policy Statement: Our facility will not condone any form of resident abuse. Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of injury, intimidation resulting in physical harm, pain or mental anguish. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Anoxic Brain Damage, Traumatic Brain Injury, Cognitive Communication Deficit and Functional Quadriplegia. Review of Resident #1's Nurse's Notes dated December 2023 revealed the following, in part: 12/01/2023 at 8:02 p.m., S5LPN noted other residents reported Resident #1 was burned on his arm with 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 record review and interview, the facility failed provide, at minimum, abuse, neglect and exploitation training for 1 (S6CNA) of 6 (S2CNA, S3CNA, S4LPN, S5CNA, S6CNA and S7CNA) personnel records reviewed for the completion of abuse, neglect, and exploitation training. Findings: Review of the facility policy Staffing Training stated in part: Policy Statement: All staff will receive the appropriate training through HR Orientation, Facility Orientation. Orientation will occur within seven days of hire and include the following: Procedures and requirements for reporting Abuse, Neglect, and Exploitation. Review of S6CNA personnel record revealed a rehire date of 10/02/2023. Further review of the personnel record revealed no documented evidence S6CNA completed abuse, neglect, and exploitation training after rehire. On 11/29/2023 at 2:45 p.m., an interview was conducted with S1HR. She confirmed S6CNA was rehired on 10/02/2023. She confirmed there was no documented evidence S6CNA completed the required abuse, neglect, and exploitation training and should have.

Based on observation, interviews, and record reviews, the facility failed to have sufficient licensed nursing staff and certified nursing assistant staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficiency had the potential to affect the facility's total census of 78 residents. Findings: Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form, dated 07/09/2023 through 07/22/2023, revealed, in part, the following: 07/09/2023 NF Residents: 73 Hours Provided: 146.5 Hours Required: 171.5 Hours +/-: -25.05 Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form, dated 07/23/2023 through 08/05/2023, revealed, in part, the following: 07/23/2023 NF Residents: 76 Hours Provided: 179.75 Hours Required: 201.6 Hours +/-: -21.85 07/29/2023 NF Residents: 75 Hours Provided: 154.25 Hours Required: 176.25 Hours +/-: -22 07/30/2023 NF Residents: 75 Hours Provided: 164.75 Hours Required: 176.25 Hours +/-: -11.5 Review of the PBJ Staffing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure medications were available for administration as ordered by the physician for 4 (#3, #4, #10, and #32) of 6 (#3, #4, #10, #20, #32 and #48) residents reviewed for medication administration in the final sample. Findings: Review of the facility's policy titled Pharmacy Services Overview revealed, in part, the following: Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Policy Interpretation and Implementation: 1. Pharmaceutical services consists of: a. The processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding (e.g., intravenous antibiotics), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications,…

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

Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure adequate numbers of direct care staff were present to provide quality care for resident direct care needs; 2. Ensure facility policies and procedures were developed and/or implemented for effective medication availability, storage, and administration; 3. Ensure facility policies and procedures were implemented for an effective Hospice Program; 4. Ensure facility policies and procedures were implemented for an effective Water Management Program; 5. Ensure facility policies and procedures were implemented for an effective Antibiotic Stewardship Program; 6. Ensure facility policies and procedures were implemented for an effective Kitchen and Dietary Services Program; 7. Ensure facility policies and procedures were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure: 1. Residents received scheduled medications as ordered by the physician for 2 (#4 and #10) of 29 residents reviewed in the final sample; 2. Resident #4's medications were documented in the MAR at the time of administration for 1 (#4) of 29 residents reviewed in the final sample; 3. Resident #44's Urinary Catheter was assessed daily and changed according to the hospice care plan for 1 (#44) of 5 (#19, #27, #44, #58, and #70) residents reviewed for urinary catheters; and 4. Resident #48's central venous catheter dressing was assessed and changed every 7 days for 1 (#48) of 1 (#48) residents reviewed for central venous catheter dressing. Findings: Review of the facility's policy titled Administering Medications, revealed the following, in part: Policy Statement Medications are administered in a safe and timely manner, and as prescribed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 13.04% during the medication administration observation. A total of 46 opportunities were observed, which included 6 medication errors for 3 (#4, #10 and #32) of 5 (#4, #10, #20, #32, and #48) resident's observed during medication pass. This failed practice had the potential to affect any of the 78 residents currently residing in the facility. Findings: Review of the facility's policy titled Administering Medications, revealed, in part, the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 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 observations, interviews, and record reviews, the facility failed to ensure safe and secure storage of medications in accordance with current accepted professional principles. The facility failed to ensure: 1. Schedule II-V medications, in the emergency kit box, were stored in a permanently affixed compartment; 2. Schedule II-V medications, in the emergency kit box, were stored in a single unit package drug distribution system; 3. Medication refrigerator temperature logs were maintained and documented appropriately for one refrigerator located in Med a room; and 4. Expired medications were not available for administration to residents for 1 (Cart C) of 3 carts (Cart A, Cart B, and Cart C) reviewed. Findings: Review of the facility's policy titled Storage of Medications revealed the following, in part: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 5. Discontinued, outdated, or deteriorated drugs or…

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 conduct and document an accurate facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. This deficient practice had the potential to affect a census of 78 residents. Findings: Review of the facility's CMS 672, dated 08/13/2023, revealed, in part, the following: Total Residents (F78): 75 E. Special Care Respiratory Treatment (F124): 7 Tracheostomy Care (F125): 1 Review of the facility's Facility Assessment Tool revealed, in part, the following: Facility Name (Typed): Facility Name (Typed) Persons Involved in completing the assessment: Administrator (Typed): S1ADM (Handwritten) Director of Nursing (Typed): S2DON (Handwritten) Governing Body (Typed): Facility Owners (Typed) Medical Director (Typed): Medical Director (Typed) Date of Assessment or Update (Typed): July (Typed) 2023 (Handwritten) Date Assessment Reviewed with QA/QAPI Committee (Typed): July (Typed) 2023 (Handwritten) Part 1: Our Resident Profile Numbers Indicate…

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

Based on interviews and record reviews, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for 1 (Resident #10) of 5 (#13, #10, #19, #70 and #77) residents reviewed for pain medication. Findings: Review of the facility's Notice of Disciplinary Action for S23LPN, dated 07/05/2023, revealed, in part, the following: Final Warning - narcotic logs have 'void' with no details and no witness to a waste if one was done. Narcotic signed out. Resident stated she didn't receive medication. Review of the facility's Notice of Disciplinary Action for S23LPN, dated 07/12/2023, revealed, in part, the following: S23LPN suspended on 07/12/2023 pending investigation. S23LPN shall submit to appropriate testing, if requested, based on a reasonable belief they are under the influence. Upon positive urine drug screen and no availability of corresponding prescription, S23LPN terminated effective 07/20/2023. Review of facility's Plan of Action/Continuous Quality Improvement, dated 07/12/2023, revealed, in part, the following: Problem Area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the resident was free from misappropriation of property for 1 (#10) of 6 (#10, #43, #53, #54, #65, and #68) resident's reviewed for abuse. Findings: Review of the Facility's Policy titled, Reporting Abuse to Facility Management revealed the following, in part: Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the Facility's Policy, titled, Controlled Substances revealed the following, in part: The Facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Review of Resident #10's Medical Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Pain Syndrome. Review of Resident #10's quarterly MDS with an ARD of 06/19/2023,…

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 a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 (#21) of 4 (#9,#21, #24, #53) reviewed for ADL care. Findings: Review of Facility's Policy titled Activities of Daily Living (ADLs) read in part: 2.) Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a.) hygiene (bathing, dressing, grooming, and oral care). Review of Resident #21's medical records revealed the resident was admitted to the facility on [DATE] with diagnosis which included Morbid obesity, abnormalities of gait and balance, and muscle weakness. Review of the Quarterly MDS with an ARD 7/11/2023 revealed Resident#21 had BIMs of 15, which indicated the resident was cognitively intact. 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 observations, interviews, record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were dated for 1 (#21) of 3 (#21, #44, #53) residents reviewed for respiratory care. Findings: Review of the Facility's Departmental (Respiratory Therapy) Prevention of Infection revealed in part: Infection Control Considerations Related to Oxygen Administration 6.) Change the oxygen cannula and tubing every seven (7) days, or as needed. Findings: Review of Resident #21's medical records revealed she was admitted to the facility on [DATE] with diagnosis which included COPD. Review of Resident #21's Physicians Orders: Oxygen at 2L/min continuous flow per nasal cannula. Change the Oxygen sterile water, and tubing every seven days and PRN. Record Review revealed no orders on Resident #21's MAR to change oxygen tubing. An observation was made…

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.