Oakhill Healthcare

Based on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#65), out of a total sample of 19 residents. Specifically, the facility failed to ensure the Foley catheter was positioned below the bladder draining with the flow of gravity.Findings include:Resident #65 was admitted to the facility in October 2024 with diagnoses including benign prostatic hyperplasia and malignant neoplasm of right kidney.Review of Resident #65's most recent Minimum Data Set (MDS) assessment indicated the Resident had an indwelling catheter.Review of Resident #65's current Physician's Orders indicated but was not limited to the following:Foley Cath care every shift, dated 10/25/24, indefinite. Review of Resident #65's care plan indicated the following:-The Resident has an indwelling catheter, dated 11/7/24.-The Resident will not develop any complications associated with catheter usage through the next review, revision 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 observation and interview, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in one medication cart out of three medication carts observed.Findings include: Review of the facility's policy titled Storage Medications, dated as revised 8/2024, indicated but was not limited to the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.-Certain medications or package types, ophthalmic (eye drops) require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.-When the manufacturer has specified a usable duration after opening (i.e. beyond use date), the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration.On 12/31/25 at 3:33 P.M., the surveyor observed the medication cart with Nurse #4 on Unit C Side 1 and made the following observations:Three bottles of Cosopt (used to treat increased pressure inside the eye) eye drops, for…

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

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure:1. The main kitchen floor and walk-in refrigerator shelving were maintained in a sanitary and safe condition; and2. Labeling and dating of refrigerated items in two of four kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation 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 observation, interview, and document review, 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 potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure proper hand hygiene after handling contaminated equipment and follow infection control standards while administering medications for two Residents (#15 and #44), out of five residents observed during medication administration.Findings include:Review of the facility's policy titled Administering Oral Medications, dated as revised 11/2025, indicated but was not limited to the following:-Perform hand hygiene-Select the drug from the medication cart-Perform hand hygieneReview of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised 7/2024, indicated but was not limited to the following:-This facility considers hand hygiene the primary means to prevent the spread of infections.-All staff shall follow the handwashing/hand…

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 document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Have voiced grievances investigated and addressed, for two Residents (#86 and #68), out of a sample of 18 residents; and 2. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievances, dated as revised 12/2018, indicated but was not limited to the following: - it is the policy of this facility to make information on how to file a grievance available to residents and/or resident representatives - the facility will support the right of each resident to voice grievances and to ensure that after a grievance has been received, the grievance official (administrator or designee) will work collaboratively with team members to resolve the issue and 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 document review and interview the facility failed to ensure Section C (Cognitive patterns) of the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of seven Residents (#86, #250, #60, #17, #9, #55, #40), out of a sample of 18 current residents and one discharged Resident (#97), who also had an incomplete pain section (Section J), out of a sample of three discharged records reviewed. Findings include: -Resident #86 was admitted to the facility in June 2024 with diagnoses including chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream). Review of the MDS assessment, dated 9/20/24, Section C indicated but was not limited to the following: C 0100: Should Brief Interview for Mental Status (BIMS) be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #250 was admitted to the facility in October 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 10/28/24,…

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

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 3, 2024. Findings include: Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 3, 2024 (April 1 - June 30) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -One Star Staffing Rating Triggered= Star Staffing Rating Equals 1 Excessively Low Weekend -Staffing Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's healthcare Facility Assessment (FA), revised August 2024, indicated the following: Part 1: Resident Profile 1.1 Number of residents you are licensed to provide care for - 121 -Number of licensed beds on…

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

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products, and maintain safe and clean equipment in two of three nourishment kitchenettes. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use…

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, document review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for five Residents (#9, #15, #17, #55, and #10), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #9, to obtain a matching Physician's order for advanced directives in the Resident's Electronic Medical Record (EMR) which accurately reflected his/her wishes as indicated on the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form; 2. For Resident #15, to obtain a matching Physician's order for advanced directives in the EMR which accurately reflected his/her wishes as indicated on the Resident's MOLST form; 3. For Resident #17, to ensure his/her medical records contained an active and current [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications); 4. For Resident #55, to ensure that documentation of physician visits was part of the medical…

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 document review, the facility failed to explain binding arbitration agreements and provide the Residents or their responsible party with the right to fully review the agreement for two of two Residents (#60 and #92) that had signed Arbitration agreements in the facility. Findings include: During an interview on 11/3/24 at 9:34 A.M., the Administrator said the facility offered arbitration agreements, he was responsible for overseeing the arbitration agreement process and there were no residents currently residing in the facility that had ever signed an arbitration agreement. Review of the medical records for Resident #60 and Resident #92 on 11/4/24 indicated both Residents had a signed arbitration agreement in their records. During a follow up interview on 11/5/24 at 9:38 A.M., the Administrator said he is responsible for having the residents or their responsible party review and potentially sign the arbitration agreements in the facility at this time. He said there are not currently any resident in the facility who have a signed arbitration. He was made aware…

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 document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director failed to attend the last two quarterly QAPI meetings and the laboratory and pharmacy providers had not attended any of the four quarterly QAPI meetings throughout the year 2024. Findings include: Review of the facility provided QAPI Program Resource Guide, dated as revised 6/2019, indicated but was not limited to the following: - facility develops QAPI plans that are comprehensive, including all departments and all services offered by the facility - Leadership is accountable for fully engaging all members Review of the facility's QAPI calendar, last revised 6/2019, indicated the following people were expected to be in attendance quarterly: Medical Director, Administrator, Director of Nurses, Lab provider, MDS Nurse, Business office manager, Pharmacy provider, Medical records, Unit managers (if applicable) Review of the facility's QAPI Attendee…

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 document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed: 1. For Residents #17 and #52, to ensure staff used appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) when providing care; and 2. To have a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Findings include: 1. Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce…

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, for one Resident (#5), from a total sample of 18 residents, the facility failed to ensure staff documented pertinent information in the medical record including the discharge/transfer destination, reason for the discharge/transfer, a summary of the resident's current medical status and failed to ensure that necessary information was communicated to the receiving health care institution to ensure a safe and effective transition of care. Findings include: Resident #5 was admitted to the facility in July 2024 and had diagnoses including a history of urinary tract infections and chronic obstructive pulmonary disease. Review of the medical record indicated medication administration notes, dated: 7/27/24, 7/28/24, 7/29/24, 7/31/24, 8/1/24, 8/2/24, 8/3/24. 8/5/24 and 8/6/24 with only the acronym MLOA (Medical Leave of Absence). Further review of the medical record failed to indicate any documentation of the reason for the transfer to the hospital, which hospital the Resident 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 document review and interview, the facility failed to ensure two Residents (#250 and #60) were offered or provided a summary of their baseline care plans, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, dated as revised 11/2017, indicated but was not limited to the following: - the resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident, a summary of medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility. 1. Resident #60 was admitted to the facility in October of 2024 with diagnoses including unspecified dementia, diabetes mellitus and hypertension. Review of the Brief Interview for Mental Status (BIMS), dated 10/23/24, indicated the Resident suffered from severe cognitive impairment with a score of 3 out of 15. Further review of the medical record indicated the Resident's healthcare proxy (HCP) was activated 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, interview, and document review, the facility failed to review and revise the care plan for one Resident (#22), out of a total sample of 18 residents. Specifically, the facility failed to ensure the care plan was updated with current Health Care Proxy (HCP) status. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised 1/2024, indicated but was not limited to: - Policy: a comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs is developed for each resident. - the resident comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. Review of the facility's policy titled Advanced Directives, last revised 1/2024, indicated but was not limited to: - Policy: Advanced Directives will be respected in accordance with state law and facility policy - Guidelines: The plan of care for each…

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 care and services consistent with professional standards of practice for three Residents (#95, #33, and #22), out of a total sample of 18 residents and three closed records. Specifically, the facility failed to ensure: 1. For Resident #95, that the Registered Nurse (RN), who made a pronouncement of death, documented the assessment in the medical record as required; 2. For Resident #33, that all components of wound care recommendations were implemented timely and air mattress settings were in accordance with physician's orders; and 3. For Resident #22, that a physician's order was in place to transfer the Resident to the hospital. Findings include: 1. Review of the facility's policy titled RN Pronouncement, last revised 11/2017, indicated but was not limited to: -Documentation in Nurses Notes by the Registered Nurse (RN) making the pronouncement should include: -Absence of respirations, apical pulse, and blood pressure -Time 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 observation, interview, and record review, the facility failed to ensure the environment was free from accident hazards for one Resident (#85), out of a total sample of 18 residents. Specifically, the facility failed to implement interventions on the comprehensive care plan to ensure safety precautions were taken for resident safety as related to smoking and complete an accurate initial and quarterly smoking evaluation. Findings include: Review of the facility's policy titled Smoking Policy - Residents, dated last revised 3/2024, indicated but was not limited to the following: - This facility shall establish and maintain safe resident smoking practices. - Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas and smoking times. - A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. - The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine the resident's ability to smoke…

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 the necessary respiratory care and services for one Resident (#22), out of a total sample of 18 residents. Specifically, the facility failed to ensure oxygen (O2) equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection. Findings include: Review of the User's Technical Manual, dated January 2019, for Resident #22's oxygen concentrator indicated but was not limited to: - Description of operations: - Air is drawn into the Oxygen Concentrator through an external air intake gross particulate filter. -Routine Maintenance - To ensure accurate output and efficient operation of the unit, the user must perform simple routine maintenance tasks: -Clean the air intake gross particle filter Review of the World Health Organization: Care, Cleaning and Disinfection of Oxygen Concentrators Checklist (2022) indicated: -Inspect and clean air intake filter (1-2 times per week) 1. Pull the filter…

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 a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#39, #22) with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated last revised 10/2019, included but was not limited to: - Policy: to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. - Staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. - Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. - Trauma informed care is culturally sensitive and person-centered. - As part of the comprehensive assessment, identify history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences…

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 records reviewed and interviews, for one Resident (#55), out of 18 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Findings include: Review of the facility's policy titled Physician Services, last revised February 2020, indicated but was not limited to: - Policy: The medical care of each resident is under the supervision of a Licensed Physician. Policy Interpretation and Implementation: - The physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. - Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current regulations and facility policy. Resident #55 was admitted to the facility in January 2024 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 document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) for two Residents (#10 and #40), out of a total sample of 18 residents, were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Pharmacist and that recommendations for Resident #40 were acted upon in a timely manner. Findings include: 1. Resident #10 was admitted to the facility in August 2024 with diagnoses including sepsis (a severe whole-body infection), diabetes mellitus, and depression. Review of the medical record for Resident #10 indicated the Pharmacist had completed a MRR and indicated but was not limited to the following: 8/11/24: see report for recommendations 9/5/24: see report for recommendations 10/6/24: see report for recommendations 11/5/24: no irregularities or recommendations at this time During an interview on 11/6/24 at 9:29 A.M., Nurse #4 reviewed the medical record and said she could not locate any of the MRR pharmacy recommendation forms or reports indicating what…

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 one Resident's (#40) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 18 residents. Specifically, the facility failed to ensure as needed antianxiety medications were limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. Findings include: Review of the facility's policy titled Psychotropic Medication, dated last revised 7/2023, indicated but was not limited to the following: - Psychoactive medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed. - A physician's order and an appropriate diagnosis is required for psychotropic medications. - Residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition or diagnosis that is documented in the clinical record. - The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rational…

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 all medications used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Provide a permanently affixed compartment and separate from all other medications for the storage of one schedule IV (low potential for misuse and dependence) and one schedule III (moderate to low potential for physical and psychological dependence) controlled substance in one of three medication room refrigerators reviewed; and 2. Ensure medications were not left unsecured when not in direct supervision of the licensed nurse. Findings include: 1. Review of the facility's policy titled Storage of Controlled Substances, revised August 2020, indicated but was not limited to the following: -Schedule II through V medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications or in accordance with state regulations. On 11/5/24 at 9:37 A.M., the surveyor reviewed the B Unit medication…

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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a court appointed Legal Guardian in place to make his/her health care decisions, the Facility failed to ensure his/her Guardian was promptly notified of changes in his/her medication administration and discontinuation of medications. Findings include: Review of the Facility's Policy titled, Change in a Resident's Condition or Status, dated as last revised 04/04/2019, indicated that the Facility professional staff will communicate with physician, participant, and family regarding changes in condition. The Policy further indicated that regardless of the resident's current mental or physical condition a nurse or healthcare provider will inform the resident/representative of any changes in his/her medical care or nursing treatment. Resident #1 was admitted to the Facility in October 2023, diagnoses included acute right-sided cerebral vascular accident (CVA, interruption of blood flow to the brain), seizure disorder,…

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 records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document his/her skin assessment and a fall in his/her medical record. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated as last revised 10/2019, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional, or psychosocial conditions, should be documented in the resident's medical record. The Policy further indicated that the following information be documented in the resident's medical record: -objective observations; -treatments or services provided; -changes in the residents condition; and -events, incidents, or accidents involving the resident. Resident #1 was admitted to the Facility in October 2023, diagnoses included acute right-sided cerebral vascular accident (CVA, interruption of blood flow to the brain), seizure disorder, metabolic encephalopathy (a…

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

Based on observation and staff interview, the facility failed to ensure that infection control measures were implemented to promote a safe, sanitary environment and to help prevent the development and potential transmission of communicable disease and infection, regarding storage of resident medication. Specifically, 1 of 2 facility medication carts inspected was found not to be clean and sanitary. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance for Preventing Healthcare-Associated Infections (HAI): Environmental Cleaning in Global Healthcare Facilities with Limited Resources, last revised 5/4/23, indicated staff in medication preparation areas might be responsible for cleaning and disinfecting portable carts used to prepare or transport medications, and recommends the medication carts to be cleaned before and after every use. On 8/9/23 at 10:00 A.M., the surveyor inspected the Side 1 medication cart on the C Unit with Nurse #6. The surveyor observed each drawer of the medication cart to have dirt, dust, and debris on the bottom 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.

Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs of one Resident (#15), out of a total sample of 21 residents. Specifically, the facility failed to ensure Resident #15's call light was within reach. Findings include: Resident #15 was admitted to the facility in August 2018 with diagnoses which included traumatic brain injury and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/25/23, indicated Resident #15 was severely cognitively impaired, had unclear speech, was sometimes able to make self understood and had the ability to sometimes understand others. The assessment indicated Resident #15 was non-ambulatory, totally dependent for mobility and toileting and had functional limitation in range of motion with upper/lower extremity impairment on both sides. Review of the facility's policy titled Answering Call Lights, dated as last revised April 2018, indicated but was not limited to: - The purpose of the procedure is to respond to the resident's requests and needs. - When the resident…

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

Based on interview, record review, and policy review, the facility failed to provide a written summary of the baseline care plan for two Residents (#273, #323), out of 21 sampled residents. Specifically, the facility failed: 1. For Resident #273, to provide a written summary of the baseline care plan and medication review to the Resident or Resident representative; and 2. For Resident #323, to ensure that staff developed and implemented a baseline care plan or a comprehensive care plan within 48 hours as required for the Resident's cerebral infarction due to embolism of left middle cerebral artery and cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Findings include: Review of the facility's policy titled Care Plans - Baseline, established and last revised 11/2017, indicated the following: - To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident'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 observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#49), out of 21 sampled residents. Specifically, the facility failed to develop a care plan to address the Resident's diagnosis of psychosis. Findings include: Review of the facility's policy titled Comprehensive Assessments and the Care Delivery Process, last revised 8/2019, included but was not limited to: -Comprehensive assessments will be conducted to assist in developing person-centered care plans; -Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions; -Assess the individual: Gather relevant information from multiple sources, including: -observation; -physical assessment; -symptom or condition-related assessments; -resident and family interview; -hospital discharge summaries; -consultant reports; -lab and diagnostic test results; and…

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

Based on observation, interview, policy review, and record review, the facility failed to ensure staff provided the necessary respiratory care and services for one Resident (#18), out of a total sample of 21 residents. Specifically, the facility failed to ensure Oxygen was administered according to physician's orders. Findings include: Review of the facility's policy titled Oxygen Administration, last revised 11/2017, included but was not limited to: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Preparation: Verify there is a physician's order for this procedure and review the physician's orders; -Oxygen therapy is administered by way of an oxygen mask, nasal cannula (tube placed approximately one-half inch into the resident's nose), and /or nasal catheter; -Adjust the oxygen delivery device and the proper flow of oxygen is being administered; -After completing the oxygen setup, the following information should be recorded in the resident's medical record: -the rate of oxygen flow, route, and rationale. -the frequency and duration 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, policy review, and interviews, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#49) with a history of trauma, out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised October 2019, included but was not limited to: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Trauma informed care is culturally sensitive and person-centered. -Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Resident #49 was admitted to the facility in May 2021 with diagnoses including Post Traumatic Stress Disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual'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 observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#22), out of a total sample of four residents. Specifically, the facility failed to ensure the daytime dose of Divalproex Sodium (used to treat seizure disorders, certain psychiatric conditions) was given as ordered. Findings include: Review of the medical record indicated Resident #22 was admitted to the facility in May 2019 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 7/18/23, indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS further indicated the Resident was ambulatory and required supervision. The Resident required one-person physical assist going off the unit. On 8/8/23 at 8:52 A.M., during medication pass, the surveyor observed Nurse #1 from Unit B side One, preparing medications for Resident #22. Nurse #1 poured the following…

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.