Oxford Rehabilitation & Health Care Center

Based on observation, record review and interviews, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified and ensured continuous evaluation of care delivery systems and to prevent continued concerns that affect the quality of life of the residents on all resident care units. Specifically, the facility failed to ensure a Quality Assurance Improvement plan was established when sources of concern were reported related to the residents being cold. Findings include: Findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) dated April 2015 indicated the (Organizations) Health Care Systems facilities will have effective Quality Assurance Performance Improvement programs to improve the quality of life, and quality of care and services delivered in facilities.During the survey conducted on 2/10/26 through 2/12/26 multiple residents residing in the facility on both floors said they have been reporting that they are cold most of the winter until 2/12/26, when they reported feeling more heat.…

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 and interviews, the facility failed to 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 on one unit ([NAME]), out of four units and for one Resident (#109) residing on the [NAME] Unit.Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on the [NAME] Unit:For Resident #109, the facility staff failed to wear Personal Protective Equipment (PPE) while providing high contact care for the Resident on EBP with a feeding tube.Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP), revised 7/2022, indicated the following:-It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or tarted multi-resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistant to all or most…

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 provide a homelike environment during dining on 4 of 4 units. Specifically, the facility failed to ensure resident meals were served on standard dining ware and cutlery and instead were served Styrofoam boxes and plastic cutlery due to the dish machine being broken for approximately the last three months. Findings include: During breakfast and lunch meals of the entire survey period from 2/24/25 through 2/27/25, residents were observed eating their meals out of Styrofoam take-out containers and with plastic cutlery. During the resident screening process on 2/24/25, multiple residents from the first-floor units reported that all their meals have been served in Styrofoam containers and with plastic cutlery for months. One resident reported it is difficult to eat from plastic fork because the food will not stay on the utensils. Another resident on the first-floor reported that his/her food is always cold when delivered and it is likely from being in a Styrofoam box. During the resident screening process on 2/24/25, multiple…

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 maintain kitchen equipment in safe operating condition. Specifically, the facility failed to ensure the dish machine was functioning properly and replace it with a new, functional dish machine. Findings include: During breakfast and lunch meals of the entire survey period from 2/24/25 through 2/27/25, residents were observed eating their meals out of Styrofoam take-out containers and with plastic cutlery. During the resident screening process on 2/24/25, multiple residents from the first-floor and second-floor units reported that all of their meals have been served in Styrofoam containers and with plastic cutlery for months. During the kitchen walk-through on 2/25/25 at 11:14 A.M., the Foodservice Director (FSD) said the dish machine has been broken and not functional for at least one month. The FSD then said there is a brand-new dishwasher in the hallway and we are waiting for it to get installed, the FSD continued to say it has been in the hallway for a lot longer than one month. The FSD then said since the dish machine…

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 for two Residents, (#50 and #16), out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. When one out of two nurses observed made three errors out of 28 opportunities resulting in a medication error rate of 10.71%. Specifically: 1.) For Resident #50, Nurse #1 administered Linzess (oral medication for constipation) after a meal when the medication was ordered to be administered 30 minutes before a meal. 2.) For Resident #16, Nurse #1 administered the incorrect dose (two sprays instead of one) of a nasal spray (Azelastine HCL, used for allergies) and Nurse #1 failed to administer the correct fiber medication (psyllium husk instead of calcium polycarbophil). Findings include: Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated: 1. Verify medication order of the Medication Administration Record (MAR). 6. Compare the medication label to the resident's MAR. 9. Verify the medication is being administered at 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 and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to 1. Ensure a treatment room containing resident-specific creams, lotions and other biologicals was locked while unattended on the first floor unit and 2. Ensure medication carts were locked while unattended by staff on the first and second floor units. Findings include: Review of the facility policy titled Medication Storage Room/Medication Cart Policy, dated and revised January 2025, indicated the following: - Medications are stored primary in a locked mobile medication cart which is accessible only to licensed nursing personnel. - Storage for other medications will be limited to a locked medication room. - The medication cart is to be kept locked at all times when not in use by the nurse. The medication cart is to be locked when stored in the medication room or some other location. 1. The surveyor made the following observations on the first-floor medication treatment room next to…

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

Based on observation and interview, the facility failed to ensure a dignified dining experience for one Resident, (#52), out of a total sample of 25 residents. Specifically, the facility failed to ensure the needed assistance with a meal was provided resulting in a.) the Resident resorting to feeding him/herself with his/her hands and b. served the Resident in a Styrofoam dish with plastic utensils. Findings include: Resident #52 was admitted to the facility in July 2022 and has diagnoses that include vascular dementia and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that on the Brief Interview for Mental Status exam Resident #52 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #52 required supervision or touching assistance for eating. Review of the current Activities of Daily Living (ADL) care plan for Resident #52 indicated the following intervention: -Eating: max assist, dated as revised on 2/24/25. On 2/24/25 at 8:25 A.M., 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.

Based on interviews and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for one Resident, (#55), out of a total sample of 25 residents. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation dated February 2023, indicated but was not limited to the following: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation's Abuse also includes the deprivation 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 interviews and records reviewed, the facility failed to report an allegation of abuse to the State Agency for one Resident (#55) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation dated 2/2023, indicated but was not limited to the following: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation's Abuse also includes the deprivation of any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being instances of abuse of all residents irrespective of any mental or physical…

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 implement the care plan for one Resident (#6) out of a total sample of 20 residents. Specifically, the facility failed to ensure that the call light was within reach of Resident #6 while he/she was in bed. Findings include: The facility policy titled Call Light, Use of, dated April 2015, indicated the following: -All residents/patients will have a call light or alternative communication device within his/her reach when unattended. Resident #6 was admitted to the facility in January 2011 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side (stroke). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/20/25, indicated that on the Brief Interview for Mental Status exam Resident #6 scored a 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #6 requires substantial to maximal assistance with bed mobility. Review of the current Functional mobility…

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, and interviews, the facility failed to ensure residents on the first-floor unit were provided with care in accordance with professional standards of practice. Specifically, two different surveyors at two different times observed Nurse #1 prepare and administer medications without referencing the medication administration record in the electronic health record. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols,…

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 provide assistance with Activities of Daily Living (ADL) for one Resident, (#52), out of a total sample of 25 residents. Specifically, for Resident #52 the facility failed to provide assistance with feeding. Findings include: Review of the facility policy titled Activities of Daily Living, dated as April 2015, indicated: -A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. Resident #52 was admitted to the facility in July 2022 and has diagnoses that include vascular dementia and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that on the Brief Interview for Mental Status exam Resident #52 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #52 required supervision or touching assistance for eating. Review of Resident #52's care card, dated as revised on 12/2024, indicated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure interventions related to pressure injury healing were implemented for two Residents, (#5 and #39), out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Resident #5 and Resident #39's air mattresses was on the correct setting. Findings include: Review of the facility policy titled Support Surface' undated, indicated the following but not limited to: -A physician's order is required for the use of a specialty support surface. The order shall include the type of mattress, the mode (alternating or static), and setting. -Specialty support surfaces will be checked each shift for proper functioning and or inflation. 1. Resident #5 was admitted to the facility in July 2023 with diagnoses including traumatic brain injury and hemiplegia and hemiparesis. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #5 is moderately cognitively impaired evidenced by a score of 11 out of 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 observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident, (#39), out of a total sample of 25 residents. Specifically, the facility failed to ensure oxygen was administered at the correct setting. Findings include: Review of facility policy titled Oxygen Administration Nasal Cannula dated November 2020, indicated the following but not limited to: -To deliver low oxygen flow per physician's order (generally 1-6 LPM (liters per minute) and 24% -45% concentration) via nasal cannula. -Set the oxygen liter flow to the prescribed liters flow per minute. Resident #39 was admitted to the facility in November 2024 with diagnoses including chronic respiratory failure with hypercapnia, interstitial pulmonary disease. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for 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.

Based on record review and interview, the facility failed to maintain accurate medical records for one Resident, (#86), out of 25 sampled residents. Specifically, for Resident #86 the facility failed to maintain accurate neurological flow sheets after two unwitnessed falls. Findings include: Review of the facility policy titled, Neurological Signs, dated August 2015, indicated the following: Any resident who sustains a head injury or when a head injury is questioned or suspected will have neurological signs monitored as follows: - Every fifteen (15) minutes for one (1) hour - Every thirty (30) minutes for one (1) hour - Every hour for four (4) hours - Every four (4) hours for sixteen (16) hours - Every eight (8) hours for forty eight (48) hours Neurological signs to be evaluated are inclusive of: - Pupils reaction to light (PEARL) - Level of Consciousness - Change in mental status - Change in speech - Change in strength in extremities - Vital Signs - Blood Pressure, Pulse, Respirations - Head pain - Nausea/vomiting The findings of each evaluation is compared, analyzed and documented…

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.

NOT CORRECTED Based on observations and interview, the facility failed to adhere to infection control practices and standards, increasing the risk of contamination and spread of infection for residents in the facility. Specifically, two different surveyors at different times during the day shift observed Nurse #1 touch pills directly with her ungloved hands during the medication pass. Findings include: Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated: 3. Perform hand hygiene. 14. Do not touch the medication when opening the bottle or unit dose packaging. 1. On 3/19/25 between 7:16 A.M., through 7:24 A.M., the surveyor made a continuous observation of Nurse #1 going between two medication carts on the first-floor unit. The surveyor observed Nurse #1 preparing medications from several different prescription medication cards, over the counter bottles, and narcotics, Nurse #1 was placing medications directly into her ungloved hands. Nurse #1 placed the medications into medication cups, and Nurse #1 administered medications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations and a review of invoices, the facility failed to ensure a homelike environment for two of two resident occupied floors. Specifically, the facility failed to ensure bedroom ceilings, walls, furniture, bathrooms and floors were undamaged and clean. Findings include: 1. On 3/28/24 at 12:34 P.M. the surveyor started an observation of the second floor rooms room [ROOM NUMBER] - The bathroom ceiling was stained brown. room [ROOM NUMBER]- The bathroom ceiling was stained brown, behind bed A and B, the walls were scuffed and patched, without paint. room [ROOM NUMBER] - The bathroom ceiling was stained brown. room [ROOM NUMBER] - A hole in the wall behind bed B. room [ROOM NUMBER] - Mouse droppings under the radiator and the bathroom ceiling was stained brown. room [ROOM NUMBER] -The bathroom ceiling was stained brown and the bathroom heat vent was coming off the wall. room [ROOM NUMBER] - Holes in the wall behind bed B, the bed B head board was broken, there were mouse droppings in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to: 1. Ensure its roof did not leak, which caused chronic widespread damage to bedroom and hallway ceiling tiles in resident care areas and 2. Ensure it had an effective pest control program. Findings include: 1. On 5/6/24 throughout the morning, the surveyors observed the first and second floor resident bedrooms and common areas. First floor: room [ROOM NUMBER] - Two ceiling tiles had brown stains. One ceiling tile had a stain approximately a foot in diameter and the other ceiling tile had two splotches of brown stains. room [ROOM NUMBER] - Two bedroom ceiling tiles by entrance door are bulging and have brown stains measuring approximately 24 inches x 30 inches. Two bathroom ceiling tiles above the toilet have dark brown…

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, observations and review of Pest Control Logs and the Pest Control contract, the facility failed to ensure an effective pest control program on two of two resident occupied floors. Findings include: Review of the Pest Control Services Agreement dated 8/8/2018, indicated a technician will inspect and treat for pests, including rodents, on a monthly basis. The agreement indicated that the resident bedroom will be treated upon request. Review of the Pest Control invoices indicated that from September 2023 through February 2024, technicians inspected and treated the building. Review of the Pest Control log, kept on the first and second floor nursing stations, indicated the Pest Control company had not inspected or treated resident bedrooms during November and December 2023, and as of 3/29/24 had not inspected or treated for pests, including rodents, during March 2024. Review of the Pest Control logs indicated 24 entries in which resident and staff reported mice in different locations, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure for five Residents (#7, #17, #23, #36 and #62) that care plans were implemented, out of a total sample of 36 residents. Specifically: 1. For Residents #7, #17, #23 and #62, the facility failed to provide supervision with meals, per the plan of care. 2. For Resident #36, the facility failed to ensure his/her heels were offloaded. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) dated April 2015 indicated the following: A program of assistance and instruction in ADL skills is developed and implemented based on individual evaluation to encourage the highest level of functioning. 1. Resident #7 was admitted to the facility in January 2011 with diagnoses including bipolar disorder, depression and anxiety, stoke and dysphagia (difficulty eating). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #7 scored a 14 out of 15 on the Brief Interview for Mental Status exam…

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 ensure one Resident's (#105) grievance regarding missing personal items was addressed, out of a sample of 36 residents. Findings include: Review of the undated facility policy, titled Grievance Policy, indicated, but was not limited to, the following: - The facility will appoint a grievance officer who will be responsible for overseeing the grievance process including: - Receiving and tracking grievances - Conducting any necessary investigations; - Maintaining the confidentiality of information associated with a grievance (e.g. identity of a resident who makes an anonymous complaint); - Issuing written grievance decisions to the resident if requested; and - Coordinating with the state and federal agencies if necessary. - Upon receipt of the grievance, the staff person receiving the grievance shall immediately notify the grievance officer. - The grievance officer shall begin the grievance process by logging a summary of the grievance (if oral), the date the grievance was received and by initiating an investigation. - Review…

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

Based on interview and record review, the facility failed to report an allegation of sexual abuse to state officials for one Resident (#105) out of a total sample of 36 residents. Findings include: Review of the facility policy, titled Abuse, Neglect, and Exploitation, implemented February 2023 indicated, but was not limited to, the following: The facility will have written procedures that include: -Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable). Within specified timeframes: -Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. -The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Resident #105 was admitted to the facility in July 2023 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula) was provided according to professional standards. Specifically, the facility failed to ensure that Resident #112's enteral nutrition was administered within the physician-prescribed parameters resulting in a clinically significant and unintentional weight gain. Findings include: Review of the facility policy, titled Enteral Feeding, dated April 2015, indicated the following: -Enteral feeding provides an alternative method of nutritional support via a gastrostomy or jejunostomy tube and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally. Procedure: -Check physician order for formula, rate and water flushes Resident #112 was admitted to the facility in December 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 interview, record review and observation for one resident (Resident #63) of a total of 36 sampled residents, the facility failed to implement medication orders and treatments for peripherally inserted central catheter (PICC) line sites. Specifically: the facility failed to document administration of the antibiotic ceftriaxone and saline flushes, assess the PICC line site, change and label the dressing, change the needless connector, change the tubing, or measure the external catheter length. The facility policy Central Venous Access Device Catheter Dressing Change dated January 2022, included but was not limited to: - Refer to the IV order form [Infusion Therapy Flow Sheet] for dressing change frequency. - Dressing changes will occur according to the IV order and when the dressing is compromised (drainage, moisture observed, loose, soiled). - Assessment should occur at least every two hours during a continuous infusion, before during and after medication administration, during dressing changes, at 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 observation, interview, and record review, the facility failed to provide dental services for one Resident (#105) out of a total sample of 36 residents. Specifically, the facility failed to facilitate the replacement of Resident #105's dentures. Findings include: Review of the facility policy, titled Dental Services/Dentures, revised September 2017, indicated the following: Procedure: -Staff will assist residents in obtaining routine and emergency dental care. Services will be provided by the resident's dentist of choice, or by the facility's consulting dentist. -Staff will make transportation arrangements and/or provide transportation as necessary to the dentist's office for care, if such care is not able to be provided at the facility. -Nursing personnel will be responsible for supervision, and implementation of any prescribed changes made by the dentist and authorized by the resident's attending physician. -The appropriate health care professional will document the provision of dental services 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 interview, record review and observation for two Residents (#63, #115) out of a total of 36 sampled residents, the facility failed to document medication orders and treatments for peripherally inserted central catheter (PICC) line sites. Specifically: 1. For Resident #63, the facility failed to document administration of the antibiotic ceftriaxone and saline flushes, assess the PICC line site, change and label the dressing, change the needless connector, change the tubing, or measure the external catheter length. 2. For Resident #115, the facility failed to document PICC line site assessment, dressing changes, changing needleless connectors, and measuring external catheter length. The facility policy Central Venous Access Device Catheter Dressing Change dated January 2022, included but was not limited to: - Refer to the IV order form [Infusion Therapy Flow Sheet] for dressing change frequency. - Dressing changes will occur according to the IV order and when the dressing is compromised (drainage,…

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 policy review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after implementing actions to manage environmental concerns in the facility which included pest control management, cleanliness in the facility and managing repairs needed in the facility, the facility failed to measure the success and track the performance to ensure improvements were sustained. Findings include: A review of the facility policy titled 'Policy & Procedure Manual Quality Assurance and Performance Improvement (QAPI)' with no revision date indicated the following. -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 and addresses all the care and unique services the facility provides. -The QAPI plan will address the following elements: a. Design and scope of the facility's QAPI program and QAA Committee…

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, document review and interview, the facility failed to ensure staff adhered to infection control practices during a medication pass. Findings include: Review of the facility policy titled 'Medication Administration-Oral' dated June 2015 indicated in #14, do not touch the medication when opening the bottle or unit dose packaging. During medication pass on 3/27/24 at 7:39 A.M., the surveyor observed Nurse #1 dispense five medications by using her fingers to place the medications into a medication cup. During an interview on 3/27/24 at 7:43 A.M., Nurse #1 said that she should not have touched the medication.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the call device system was working in one bedroom located on the first floor (room [ROOM NUMBER]). Findings include: On 5/6/24 at approximately 7:52 A.M., the surveyor entered room [ROOM NUMBER], and the Resident located in Bed C asked the surveyor to jiggle the call light string to turn off the call light. The Resident said the call light apparatus was broken and if the call light string was not hung in just the right way it would activate the system for each of the three beds in the room. The surveyor observed that the call lights for all three beds were activated, even though no one had pulled their call light strings. The surveyor moved the call light string in different directions and eventually the call lights turned off. The Resident said the call light system had not been functioning properly for many weeks. The Resident said he/she had told nursing about this issue may times over the past few weeks but it was still broken. During an…

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