Onyx Care of Winnfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to promptly obtain and notify the NP (Nurse Practitioner) of ordered lab results for 1 (Resident #58) of 42 Sampled Residents. Findings:Record Review of an undated facility policy on 01/14/2026 at 2:22 p.m. titled Laboratory Tests read in part. Lab tests are completed as ordered by the physician. The licensed nurse, or designee, will indicate when lab results are returned to the facility on the lab scheduling/tracking form. The physician or physician extender will be promptly notified of abnormal results according to facility policy. Review of Resident #58's Electronic Health Record revealed the Resident was admitted to the facility on [DATE]. Resident #58 had diagnoses that included in part. Generalized Muscle Weakness, Personal History of Pulmonary Embolism, Unspecified Sequelae of Cerebral Infarction, and Dysphagia. Review of Resident #58's admission MDS with an ARD date of 01/28/2026 revealed in part . Resident# 58 had BIMS of 06 and required…

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

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 68 residents who received meals from the kitchen. The facility failed to ensure:1. Food items in the refrigerators and freezers were labeled, dated, and stored in a sanitary manner; and 2. Dry Food items were labeled with an open date and stored in a sealed container.On 01/12/2026 at 8:55 a.m., observation of the kitchen walk-in refrigerator revealed 1 bag of green onions opened and undated, 1 bag of shredded lettuce opened and undated, and 1 Activia yogurt opened with yogurt present on the packaging. On 01/12/2026 at 08:55 a.m., S10Dietary confirmed 1 bag of green onion and 1 bag of shredded lettuce should have been sealed and labeled with an open date, but were not. S10Dietary confirmed that the 1 Activia yogurt should not have been present in the refrigerator, which was opened and should have been discarded, but was not. On 01/12/2026 at 9:03 a.m., the kitchen walk-in freezer was observed with…

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 garbage and refuse were properly disposed of. This deficient practice had the potential to affect all 71 residents at the facility.Review of facility undated policy titled Garbage and Rubbish Disposal read in part. Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen does not encourage infest or rodents. All outside dumpsters will be maintained in a clean and sanitary condition. Outdoor trash receptacles will be kept covered, and the surrounding area kept free of litter.On 01/12/2026 at 9:16 a.m., observation of the facility's outdoor dumpster area revealed a moderate amount of empty boxes outside of the dumpster area, a moderate amount of litter outside of the dumpster area, and the dumpster door was open.In an interview on 01/12/2026 at 9:16 a.m., S10Dietary confirmed that the facility dumpster area was unkempt, with a moderate amount of empty boxes and litter surrounding it, and that this should not have been. S10Dietary confirmed the dumpster door should have been closed, and it was…

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

Based on observation, record review, and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #2) out of 3 (Resident #1, Resident #2, Resident #3) sampled residents.Findings:Review of Resident #2's EMR (Electronic Medical Record) revealed an initial admission date of 12/23/2024 and diagnoses that included in part, Schizoaffective Disorder, Bipolar type, Type 2 Diabetes, Hypertensive Heart Disease without heart failure, Anxiety, History of falling, and Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 09/22/2025 indicated Resident #2 was dependent on staff for assistance with eating, mobility, transfers, and personal hygiene. Resident #2 has a BIMS (Brief Interview for Mental Status) score of 4, which indicates severe cognitive impairment.Review of Resident #2's Care Plan dated as initiated 09/19/2025 included but is not limited to, At risk for falls.resident to be up in dining room for all meals.On 12/01/2025 at 12:15 p.m., Resident #2…

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

Based on record review and interview, the facility failed to ensure a resident's discharge was documented in the resident's medical record for 2 (Resident #1, Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The facility failed to:1. Ensure documentation in the medical record included the basis for discharge for Resident #1 and Resident #R1;2. Ensure documentation in the medical record included that written discharge instructions were given to and discussed with the Resident/Responsible Party for Resident #1 and Resident #R1; and3. Ensure documentation in the medical record included discharge planning that addressed caregiver support and referrals to local contact agencies for Resident #1.Findings:On 09/03/2025, a review of the facility's policy titled Discharge Plan/Summary last revised 04/2025 revealed in part.6. If the resident is discharging to a private home, social work should meet with the person accepting responsibility for the resident. Referrals needed should be made to home health, DHS, or others based upon the needs 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.

Based on record review and interview, the facility failed to have a discharge summary that included the required information for 2 (Resident #1 and Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The discharge summaries for Resident #1 and Resident #R1 failed to include:1. A recapitulation of the residents' stay that included diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results;2. A final summary of the residents' status at the time of the discharge; and3. Reconciliation of all pre-discharge medications with the residents' post-discharge medications (both prescribed and over-the-counter).Findings:On 09/03/2025, a review of the facility's policy titled, Discharge Plan/Summary last revised 04/2025 revealed in part.12. The Discharge Summary form should be completed with care needs identified and documented as appropriate.14. Guidelines for completion of the Discharge Summary: Nursing: Identifies continuing nursing needs. Specifies level of nursing care needed. Verifies…

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 provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents sampled with behavioral health diagnoses by failing to: 1. Develop and implement a person-centered plan of care that addressed Resident #1's history of Substance Use/Abuse; 2. Ensure concerns identified in the provider's progress notes regarding drug diversion were addressed; and 3. Perform monthly UDS as ordered. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses…

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 admission and Quarterly MDS assessments accurately reflected a resident's status for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled MDS Assessment, revised 06/2023, revealed, in part .these assessments provide information on the resident's condition and facilitate development of an individualized plan of care. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with admission diagnoses which included, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's Quarterly MDS with ARD of 04/22/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Further review of the MDS revealed Resident #1's history of suicidal behaviors, suicidal ideations, and substance use/abuse were not listed. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in…

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

Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met professional standards of quality care for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .a baseline care plan is the initial plan of care to be used upon admission, until the comprehensive care plan is completed. The baseline care plan is to be developed within 48 hours. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's medical record revealed Resident #1 did not have a baseline care plan. Interview with S2DON…

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's comprehensive care planned revealed Resident #1 was not care-planned for Suicidal Ideations, History of Suicidal Behavior, PTSD, or Substance Use/Abuse. Interview with S1ADM on 06/12/2025 at 12:50 p.m. confirmed Resident #1 was not care-planned for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide mental health services as dictated by accepted standards of quality for a resident admitted with multiple mental health diagnoses for 1 (Resident #1) of 5 sampled residents. The facility failed to: 1. Provide a timely referral for mental health services, and 2. Ensure mental health services were provided on a continual basis. Findings: Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score 0f 15, which indicated intact cognition. Resident #1 was taking antipsychotic and antidepressant medications on a routine basis. Review of Resident #1's Urine Drug Screen dated 01/22/2025 at 5:00 p.m. revealed Resident #1 was positive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse, for 1 (#3) of 3 (#2, #3, and #5) residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse by Resident #5. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's undated policy on 02/05/2025, titled Abuse Prevention, read in part . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consults, volunteers, staff from other agencies, family members, legal guardian, or any other individual. Resident #3 Review of Resident #3's medical record revealed an admit date of 01/05/2024, with diagnoses that included: Schizoaffective Disorder Bipolar type, Anxiety Disorder, Major Depressive Disorder, Depression, Glaucoma, Legal…

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

Based on observation and interview the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure the nutritional adequacy of the meal for all residents who received a regular diet prepared by the facility kitchen. Findings: Review of Production Sheet Main Menu S/S 2024 provided by the facility revealed Baked Chicken portion size was 3 oz. Observation of lunch preparation on 09/30/2024 at 11:40 a.m. revealed improper serving sizes for six residents. Plates were served to 5 residents on a regular diet with one small chicken leg and two small chicken legs served as a double portion for 1 resident. Interview with S3 Dietary Manager and S4 Regional Director of Nutritional Services on 09/30/2024 at 12:43 p.m. confirmed one chicken leg without the bone was only approximately 2 oz. and that residents should have been served two chicken legs to meet the 3 oz. portion size on the menu and that two small chicken legs were not considered a double portion.

Based on observation and interview the facility failed to store food in accordance with Professional standards for food safety. The facility failed to properly store dry food items in the kitchen as evidenced by one loaf of bread with mold present; two packages of hot dog buns that expired on 08/19/2024; one opened box of cornstarch that was undated and one used pad of butter in the refrigerator, unsealed and undated. This deficient practice had the potential to affect any resident who consumed meals served from the facility's kitchen. Findings: Kitchen observation of the dry food storage area with S3 Dietary Manager on 09/30/2024 at 09:04 a.m. revealed one loaf of bread with mold present; two packages of hot dog buns that expired on 08/19/2024 and one box of cornstarch opened and undated. Observation of the walk-in refrigerator with the S3 Dietary Manager revealed one used pad of butter, unsealed and undated.

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (#30) of 1 (#30) resident reviewed for environment. The facility failed to ensure Resident #30 had a call light in reach in order to call for assistance. The total sample size was 23. Findings: Review of Resident #30's medical record revealed an admit date of 01/05/2024 with diagnoses that included: Legal Blindness, Major Depressive Disorder, Schizoaffective Disorder, Major Depressive disorder, and Cognitive Communication Deficit. Review of Resident #30's Minimum Data Set (MDS) with an ARD of 08/15/2024 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of Resident #30's Care Plan with review date of 04/25/2024 revealed in part . Sensory/Perception Altered: Vision related to legal blindness. Resident #30 is at risk for falls and injuries. Keep call light within reach while in room. Interview on 09/30/2024 at 10:50 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (#76) of 2 ( #68 and #76) residents reviewed for abuse. The facility failed to ensure Resident #76 was not physically abused by Resident #68. Findings: Review of the facility's policy titled Abuse Prevention, on 10/02/2024, with a review date of 10/2022, revealed in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Abuse defined: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. Physical Abuse: This includes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigation of an incident of abuse for 1 (#76) of 2 (Resident #68 and Resident #76) residents sampled for abuse in a total sample of 23. Findings: Review of the facility's policy dated 10/2022, and titled Abuse Prevention on 10/02/2024, read in part . Investigation: The facility will initiate at the time of any finding of potential abuse or neglect, an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. Review of a facility's Incident Report documented by S1 Administrator, revealed on 08/11/2024 at 5:00 p.m., S9 CNA reported that while she was passing out snacks in the special care unit's common area, Resident #76 tapped Resident #68 on the shoulder. Resident #68 became frightened and made physical contact with Resident #76 by grabbing her hair. S9 CNA reported while on the way to separate the residents, Resident #76 fell onto the…

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

Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, by failing to implement appropriate interventions for weight loss for 1 (#56) of 2 (#32 & #56) residents reviewed for nutrition. The facility failed to: 1. Ensure Resident #56's meal intake was documented for each meal, as care planned, and 2. Provide one on one assistance to Resident #56 with all meals, as care planned. Findings: Review of Resident #56's medical record revealed an admit date of 03/31/2021 with diagnoses that included in part .Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension. Review of Resident #56's Quarterly MDS with an ARD of 09/19/2024 revealed a BIMS could not be completed because the resident was rarely or never understood. Review of the MDS revealed Resident #56 required supervision or touching assistance with eating and was independent with sit to stand and chair/bed to chair transfers. Review of Resident #56's Care Plan with…

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 ensure that each resident was treated with respect and dignity and cared for in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#2) of 3 (#1, #2, & #3) sampled residents by failing to ensure she was free of facial hair. Findings: Review of Resident #2's medical record revealed an admit date of 03/15/2024 with diagnoses that included in part .Pneumonia, Urinary Tract Infection, Major Depressive Disorder, Dementia, Down's Syndrome, Type 2 Diabetes Mellitus, and Moderate Intellectual Disabilities. Review of Resident #2's MDS with an ARD of 05/07/2024 revealed a BIMS was not conducted the resident was rarely or never understood. Review of the MDS revealed the resident required set up or clean up assistance with eating, substantial or maximal assistance with toileting hygiene and showering or bathing self, and partial to moderate assistance with personal hygiene. Review of Resident #2's current care plan revealed the resident was at risk for decline in ADLs 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 to implement the plan of care to meet the needs of 2 (#1 & #2) of 3 (#1, #2, & #3) sampled residents. The facility failed to monitor and record food intake at each meal as directed in the residents' care plans. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 03/05/2024 with diagnoses that included in part .Unspecified Dementia, Major Depressive Disorder, History of falling, Anxiety Disorder, and Insomnia. Review of Resident #1's Quarterly MDS with an ARD of 04/24/2024 revealed a BIMS score of 4 indicating severe cognitive impairment. Review of the MDS revealed Resident #1 required supervision or touching assistance with eating. Review of Resident #1's current care plan revealed a potential for weight loss with a problem onset of 03/05/2024. Interventions in the care plan included in part .Dietician to evaluate and follow up as needed, determine food preferences, downgrade diet to mechanical soft with chopped meats, house supplement 8 ounces twice daily between meals, monitor food intake…

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 maintain patient care equipment in safe operating condition for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #3's clinical record revealed an admit date of 07/07/2022 with diagnoses which included: Hypertension, Unspecified sequelae of other Cerebrovascular Disease, Type 2 Diabetes Mellitus, and Insomnia. Review of Resident #3's Quarterly MDS with an ARD of 12/28/2023 revealed a BIMS score of 11, indicating moderate cognitive impairment. Review of the MDS revealed Resident #3 had impairments to both sides of his lower extremities, and was dependent with chair/bed to chair transfers and independent with wheeling a manual wheelchair. Review of Resident #3's Care Plan with a Target of 04/2024 revealed a problem of impaired mobility and at risk for decline in ADLs related to diagnoses of: CVA, Depression, and Bilateral AKAs. Interventions included: A self-release belt while up in wheelchair due to poor safety awareness due to bilateral AKAs…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored under proper temperature controls for 2 (Hall A medication refrigerator and Hall B medication refrigerator) of 2 medication refrigerators. Findings: Review of the facility's policy titled Medication Storage revealed in part . All drugs, treatments, and biologicals must be stored securely, and following the manufacturer's labeled recommendations. Review of the facility's procedure titled Medication Storage revealed in part . Medications requiring refrigeration must be stored between 36 degrees F and 46 degrees F in a refrigerator. A thermometer must be used for frequent monitoring. Medications that require storing in a cool place are to be refrigerated unless otherwise labeled. Review of the Hall B Medication Storage Refrigerator/ Equipment Temperature Log on 09/06/2023 at 11:50 a.m. with S4 LPN, revealed the refrigerator temperatures were not checked daily. Interview with S4 LPN revealed the medication refrigerator should be checked daily by the night shift nurses. S4 LPN…

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 transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #80) of 1 sampled resident reviewed for resident assessments. Findings: Review of the clinical record for Resident #80, revealed an admission date of 09/06/2022, and diagnoses that included: Anxiety Disorder, Anemia, UTI, Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances, and Unspecified psychosis. Review of the facility's MDS transmission report revealed Resident #80's Quarterly MDS with an ARD (Assessment Reference Date) of 06/15/2023, was not transmitted until 07/07/2023. Interview on 09/07/2023 at 9:47 a.m. with S2 DON confirmed Resident #80's MDS assessment was completed late on 07/07/2023. S2 DON confirmed the assessment should have been transmitted timely within 14 days after completed, and was not.

Based on interview and record review, the Facility failed to have an appropriate person-centered care plan for Resident #61 by failing to have interventions care planned when Resident #61 refused ADL (Activities of Daily Living) care or refused to allow staff to change his bed linen. Total sample size was 20. Findings: Review of Resident #61's medical record revealed a date of 03/16/2023, with diagnoses which included: Major Depressive Disorder, Unspecified Dementia, Conversion Disorder with Seizure or Convulsions, and Acute Hepatitis C. Review of Resident #61's Quarterly MDS with an ARD of 06/08/2023 revealed a BIMS score of 12 (indicating mildly impaired cognition). The MDS revealed Resident #61 required supervision with set-up help only for bed mobility, dressing, eating, toilet use and personal hygiene; Resident #61 was coded as independent with transfers, and no ROM impairment to upper and lower extremities. Review of Resident #61's Care Plan with a review date of 05/22/2023 revealed he is at risk for decline in ADL's (Activities of Daily Living) related to Diagnoses of Chronic…

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 promptly notify the ordering physician of the results of a urine culture resulting in a delay of treatment for 1 (Resident #16) of 20 sampled residents. Findings: Review of the facility's policy titled Notification of a change in a resident's status read in part . Policy: The attending physician/physician extender and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Procedure: 1. Guideline for notification of physician/responsible party: f. Abnormal lab findings. 2. Document in the Interdisciplinary Team (IDT) notes: b. Physician/Physician extender notification. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part .Neuromuscular Dysfunction of the Bladder, Type 2 Diabetes Mellitus, and Urinary Tract Infection. Review of Resident #16's Quarterly MDS with ARD of 07/06/2023 revealed…

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

Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly. Findings: Observation on 09/05/2023 at 9:05 a.m. of the outside kitchen area accompanied by S5 Dietary Manager revealed 1 large blue dumpster located within a fenced in area, and 1 large black open topped roll away dumpster located outside of the fenced in area. There were multiple trash cans, and bags of trash observed spilling over the trash cans. There was a large amount of trash and debris on the ground that littered the area. Interview with S5 Dietary Manager at time of observation revealed the blue compact dumpster within the fenced in area had been broken for several weeks, and the facility brought in the roll away dumpster on yesterday 09/04/2023. S5 Dietary Manager confirmed there was a large amount of uncontained trash and debris on the ground, and there should not have been.

Based on interview and record review, the Facility failed to provide pharmaceutical services that assured the accurate reconciliation of controlled medications to meet the needs of each Resident, by failing to ensure a physical inventory of controlled medications were conducted by two licensed clinicians at each shift change. Findings: Review of the Facility's policy and procedure on controlled medications read in part . (8). At each shift change, a physical inventory of controlled medications is conducted by two licensed clinicians. By signing the Controlled Substance Tracking Form each nurse is agreeing that the number of controlled medications units (tabs, patches, etc.), and the number of Controlled Substance Records (sign-out sheet) matches the number of medication units on the Controlled Drug Record for each medication order. Review of an Incident Report dated 07/14/2023 by S1 Administrator at approximately 8:00 a.m., read in part . S3 LPN reported to S2 DON that there was an issue with the narcotic count, specifically the Fentanyl patches. S3 LPN showed S2 DON two boxes 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.