Autumn Lake Healthcare At Oak Manor

Based on record review and interview, it was determined that the facility failed to review and revise the interdisciplinary care plans to reveal accurate interventions. This was evident for 1 (Resident #129) out of 2 residents reviewed for care plans during the survey process. The findings include: A care plan is a guide that addresses the unique needs of each resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assuring the resident's needs are attended to. The care plan is to be reviewed and revised at each of the resident's quarterly assessment times to ensure the interventions on the care plan are accurate and appropriate for the resident. On 3/30/26 at 11:30 AM during screening observations, the surveyor observed that Resident #129 did not have any indwelling catheters and had wounds on his feet that were covered to contain any secretions. On 4/6/26 at 9:45 AM, the surveyor reviewed the Facility policy on Enhanced barrier…

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

Based on observations, record reviews and interviews it was determined that the facility failed to maintain professional standards of practice related to oxygen orders. This was evident for 1 (Resident #49) out of 2 residents reviewed for respiratory orders. Findings include: On 03/30/2026 at 9:00 AM, an observation of Resident #49 revealed that the resident was receiving oxygen therapy. On 03/31/2026 at 9:42 AM, record review failed to reveal an active order for oxygen. On 04/01/2026 at 9:25 AM, concerns were brought up to the Director of Nursing and she indicated that she understood.

Based on observations and interviews it was determined that the facility failed to ensure that a resident had access to their call bell. This was evident for 1 (Resident #49) out of 35 observations made on call bells. The findings include: On 03/30/2026 at 8:46 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 03/31/2026 at 10:37 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 03/31/2026 at 12:18 PM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 04/01/2026 at 10:20 AM, an observation of Resident #49 revealed the call bell was on the floor and not within reach of the resident. On 04/01/2026 at 10:21 AM, an interview with Geriatric Nurse Assistant (Staff #15) revealed that the expectation regarding call bells is that it should be within reach at all times. At the same time, Staff #15 revealed that Resident #49 in particular does not have a clip on her call bell cord, making it difficult…

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, staff interviews, and record reviews, it was determined that the facility failed to ensure that residents received oxygen therapy in accordance with physician orders for 1 (Resident #45) of 2 residents reviewed for oxygen use. The facility also failed to develop a care plan to address oxygen therapy needs and failed to ensure that residents were not connected to empty oxygen tanks. The findings include:On 03/30/2026 at 11:15 AM, Surveyor observed Resident #45 on 3L of Oxygen via Nasal Cannula. On 03/30/2026 at 11:25 AM, an interview with Resident #45 was conducted. They reported that they were supposed to be on 2L of oxygen because of pneumonia. On 03/31/2026 at 10:15 AM, Surveyor observed Resident #45 on 3L of Oxygen via Nasal Cannula. On 03/31/2026 at 11:59 AM, a review of Resident #45's medical record revealed an active order to administer Oxygen via nasal cannula at 2 L/min every shift for COPD (a chronic lung disease). Additionally, review of the care plan failed to include oxygen therapy interventions. On 03/31/2026 at 12:01 PM, Surveyor observed…

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

Based on record review and interviews, it was determined that the facility 1) failed to ensure that medication was available for administration as ordered and 2) failed to administer medications on time. This was evident for 1 (Resident #31) out of 5 residents reviewed for medication administration and 1 (Resident #144) out of 3 residents reviewed for medication administration. The findings include:1) Clonazepam (brand name Klonopin) is a Schedule IV controlled substance in the United States, regulated due to risks of misuse, addiction, and physical dependence. While it has accepted medical uses for treating seizure and panic disorders, its status requires restricted, prescription-only access. On 04/02/2026 at 2:38 PM, a review of Resident #31's medical record was conducted. The review revealed an order for Clonazepam that was entered on 3/16/2026, the day the resident was admitted into the facility. The review of the Medication Administration Review (MAR) indicated that the resident was not given the medication on 3/16/20 to 3/20/2026. Review of the nurses' notes on 3/17/2026…

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

Based on interviews and record reviews, it was determined that the facility failed to provide physical therapy services as ordered. This was evident for 1 (Resident #6) out of 6 residents reviewed for therapy services during the recertification survey. The findings include: On 03/30/2026 at 8:36 AM, an interview with Resident #6 was conducted. They reported that they were supposed to receive Physical Therapy (PT) services 3 times a week, however, this rarely happened. On 04/01/2026 at 8:25 AM, a review of physical therapy notes revealed that in February Resident #6 had 3 PT sessions (17th, 18th, and 26th) and 5 sessions in March (11th, 12th, 20th, 24th, and 26th). Review of Resident #6's care plan revealed an intervention that indicated that the resident should receive physical therapy evaluation and treatment as per orders. Further review of records revealed an active order for the resident to continue skilled Physical Therapy 3-5 times per week for 90 days for therapeutic exercises. The review of a recent PT recertification completed on 3/19/26 indicated that Resident #6 should…

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, it was determined that the facility failed to ensure that staff adhered to enhanced barrier precautions when providing care to residents. This was evident for 1 (Resident # 87) out of 6 residents reviewed for infection control practices during the recertification survey. The findings include: Enhanced Barrier Precautions (EBP) are an infection control strategy for nursing homes, requiring gowns and gloves during high-contact resident care to prevent the spread of Multidrug-Resistant Organisms (MDROs).A PICC line (peripherally inserted central catheter) is a long, thin, flexible tube inserted through a vein in the upper arm and advanced to a large vein near the heart. This tube is used to give intravenous (IV) medications to a patient. On 04/03/2026 at 08:30 AM, the surveyor observed Staff #31 give Resident #87 Fluticasone IV medication through a PICC line. Staff #31 was not wearing a gown, only gloves. Resident #87's door had a yellow sign that indicated EBP precautions to be followed when providing care or providing medications…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to address residents with significant weight loss. This was found to be evident for 1 (Resident # 122) of 3 residents reviewed for weight loss during the survey. Findings include: Resident # 122's medical record was reviewed on 12/19/25 at 10:00AM for weight loss. Upon review, it revealed the resident with an admission weight on 1/8/25 of 229.2 pounds and a weight one month later on 2/10/25 of 216.2 pounds. The resident was noted to have a significant weight loss of 13 pounds (10%) within 1 month. Review of the resident nutrition care plan on the same date at 10:25 AM reveals the care plan was initiated on 1/8/25 and one of the interventions listed was to notify the MD and dietician if resident had any significant weight changes. Review of a discharge summary note dated 2/11/25 from the residents' previous provider service indicated that the resident was morbid obese but did not address the significant weight loss of 13 pounds for one month. An interview was conducted on 2/19/25…

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 staff interviews, it was determined that the facility failed to provide a dignified dining room experience. This was evident for 1 (Resident #12) of 1 resident observed during the dinner dining observation. The findings include: On 02/18/25 at 5:05 PM, the surveyors arrived at the dining room to observe dinner at the facility. Residents were set up at tables and served by staff as they were seated. Resident # 12 was noted to be seated at a table with Resident #15. Resident #15 had a plate of food and was feeding themselves while Resident #12 was lying in a geri-chair with no plate in front of them. There were 2 cups (one of the cups contained juice) on the table in front of the Resident #12. Resident #15 spilled their juice into their plate. Staff #23 was working in the dining room and was serving other residents, and saw the resident spill the juice and remove the plate away from the resident. Before returning to assist Resident #15, Staff #23 retrieved utensils that had fallen onto the floor from another resident and discarded them, she then continued 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 observations and staff interviews, it was determined that the facility failed to maintain a sanitary environment. This was evident for 2 out 2 clean utility rooms observed during the recertification survey. The findings include: On 2/18/25 at 9:29 AM, during observation rounds with the Geriatric Nursing Assistant staff #11, the second floor, Forest View, clean utility room had two intravenous poles with a brown and gray colored particle of solid matter covering the base of the poles. The intravenous poles did not have labels on it indicating that they were clean. On 2/18/25 at 9:50 AM, during observation rounds with the Central Supply Clerk staff #12, the first floor, Chapel Valley, clean utility room had three intravenous poles, with a brown and white colored substance located at the base of the poles, and one oxygen concentrator that was covered with a gray colored particle of solid matter. Neither the intravenous poles nor the oxygen concentrator had labels on it indicating that they were clean. On 2/18/25 at 9:50 AM, the Central Supply Clerk staff #12 was interviewed.…

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.

Review of medical records, and staff interview, it was determined that the facility failed to obtain a GI (gastrointestinal) consultation as requested by the physicians for resident # 60. This was evident for 1 of 9 residents reviewed during the survey. The findings include: Review of Resident #60's medical record on 2/18/25 at 1:55pm revealed a physician ordered to obtain a GI (gastrointestinal) consultation for poor po (by mouth) intake and weight loss. Further review of the medical record on 2/18/25 at 3pm failed to reveal if a GI consultation was done or scheduled. During an interview with the Director of Nursing on 2/18/25 at 3:30pm pm she stated the consultation should have been scheduled and she would investigate it. After surveyor intervention the GI consultation was scheduled on 2/19/25 for March of 2025.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, and interviews, it was determined that facility staff failed to address the nutritional needs of a resident who had a known significant weight loss. This deficient practice was evident for 1 (#89) of 1 resident reviewed during the survey. The findings include: On 02/13/25 at 7:53 AM, the surveyor observed Resident #89 awake in bed watching television. The resident appeared frail. During a follow-up interview on 02/13/25 at 12:53 PM, the resident reported difficulty with food, explaining that they are unable to keep food down and experience large bowel movements immediately after eating. On 02/14/25 at 9:34 AM, review of Resident #89's medical record revealed a medical diagnosis of diverticulitis (a condition where small pouches in the wall of the large intestine becomes inflamed or infected. This can cause nausea, vomiting, constipation, and diarrhea). Further review of medical records revealed an admission weight of 167.9lbs on 09/13/24. Resident was discharged 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 medical record reviews, observation, and interviews it was determined that the facility failed to ensure that the physician documented the medical history and treatment plan related to residents with significant weight loss. This was evident to be true for 2 (#48, #89) of 6 residents reviewed for excessive weight loss during the survey. The findings include: 1.) On 02/18/25 10:08 AM the surveyor observed the resident in bed covered with blankets and apparently sleeping. The resident's husband sat at the foot of the bed in a wheelchair with a mask in place. The resident's spouse stated that he/she came in this morning in order to ensure the resident ate his/her breakfast. The spouse stated the Resident #48 had a poor appetite and needs encouragement to consume her/his meals. On 02.18.2025 at 11:12 AM the surveyor reviewed the electronic medical record related to Resident # 48. This resident experienced the following weight losses and gains during a three month period: Weight Trends: 12.18.24: 163.9 lbs. 12.25.24: 160.4lbs. 01.14.25: 150.8lbs 02.04.25: 145.6 lbs Total weight…

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 surveyor observation it was determined the facility failed to provide palatable food at an appetizing temperature. This was evident for 3 out of 3 hot food items checked on the test tray. This failure had the potential to affect all residents receiving meals. The findings include: On 02/18/25 at 01:01 PM, a test tray was requested at the end of food service in the Chapel Way dining area. The food temperature was checked using the facility's thermometer by Staff #16. The potatoes were 119.8 degrees Fahrenheit. The spinach was 109.2 degrees Fahrenheit. The meat (veal) was 123.1 degrees Fahrenheit. The internal temperature for hot food should be over 135 degrees Fahrenheit. During an interview with the Regional Dietary Manager on 02/28/25 at 1:06 PM, she verified the temperature. She stated that she and the Dietary Manager would be doing inservices on making sure foods are property temped.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, interviews, and observations, the facility failed to honor the residents' food preferences. This was evident to be true for 3 ( #13, #17, and #92) out of 10 residents observed dining during the survey. These findings include: On 02.19.25 at 08:16 AM the surveyor entered the multipurpose room [ROOM NUMBER] on the 2nd floor and there was only one resident present. Resident #92 stated that he/she had a lot of concerns regarding the facility and including the food service. Resident #92 stated that the facility often did not serve what was listed on the menu and often he/she was served food items that were not his/her preference. The surveyor observed that the kitchen staff had the tops off the food serving containers and were not currently serving food to any residents. The surveyor asked the dietary aides if they make an effort to keep the food warm for the residents. The dietary aides responded yes and then proceeded to cover the food serving containers. On 02.19.25 at 08:22 AM 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 and staff interview, it was determined the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, and maintain a clean working environment, during the survey The findings include the following: On 2/13/25 at 08:25 AM, An initial tour of the facility Kitchen was completed with the Regional Dietary manager and the following was found: 1.Seven repoured unlabeled apple sauce containers were observed sitting on the dirty utility table. 2. A large white laundry basket with several soiled white linens was observed in the dry storage room. 3. Food and a liquid substance were noted on the kitchen floor near the walk in the freezer. 4. A red substance was noted to have spilled all over metal shelves in the facility's walk- in refrigerator. 5. The surveyor observed that the area designated for rinsing dirty dishes was found unkempt with food particles left in the strainer. During the interview on 2/13/25 at 09:30 AM with the Dietary Manager and the Regional Dietary Manager present he stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with facility staff it was determined the facility failed to document if interventions were put in place to address a resident with a significant weight loss, document a significant change in the resident's medical condition, failed to notify the physician, and interdisciplinary team. This was found to be evident for 2 (Resident # 122, #89) of 5 residents reviewed for weight loss during the survey. Findings include: 1.) Resident # 122's medical record was reviewed on 12/19/25 at 10:00AM for weight loss. Upon review, it revealed the resident with an admission weight on 1/8/25 of 229.2 pounds and a weight one month later of 2/10/25 of 216.2 pounds. The resident was noted to have a significant weight loss of 13 pounds (10%) within 1 month. Review of the resident nutrition care plan on the same date at 10:25 AM reveals the care plan was initiated on 1/8/25 and one of the interventions listed is to notify the MD and dietician if resident has any significant weight changes.…

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 staff interviews, it was determined that the facility staff failed to adhere to infection control practices. This was evident for 1 (Resident #15) of 1 resident observed during the dinner dining observation. The findings include: On 02/18/25 at 5:05 PM, the surveyors arrived at the dining room to observe dinner at the facility. Residents were set up at tables and served by staff as they were seated. Resident #15 had a plate of food and was feeding themselves. Resident #15 spilled their juice into their plate. Staff #23 was working in the dining room and was serving other residents, and saw the resident spill the juice and remove the plate away from the resident. Before returning to assist Resident #15, Staff #23 retrieved utensils that had fallen onto the floor from another resident and discarded them, she then continued to assist Resident #15 with feeding and did not sanitize her hands. The surveyors interviewed Staff #23 and made her aware of the concern about picking up the utensils and not performing good hand hygiene when providing service to 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 medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #9). This was evident for 1 of 37 residents reviewed during an annual survey. The findings include: On 11/14/24, review of Resident #9's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of the medical record revealed that, on 2/24/2023, the Resident was assessed by facility staff to be at a low risk for elopement. The facility reported to OHCQ (Office of Health Care Quality) on 7/7/24 at 1 PM the Resident was found outside the facility at a local church approximately 2:30 PM by the Police. The Resident was brought back to the facility and assessed at that time and found to have no injuries. On 11/14/24 at 9:30 AM, an interview with Resident #9 revealed that she was going to the church service in the facility, and she was unaware of the cancellation. Resident stated she wanted to worship God, so she…

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 surveyor review of the clinical record, surveyor observations and interviews with facility staff, it was determined that the facility failed to develop a comprehensive plan of care for residents. This finding was evident for 2 of 27 residents reviewed during the survey (Resident #44 and #64). The findings include: 1. On 10-13-2020 at 3:42 PM surveyor observation of Resident #44 revealed that the resident was yelling out constantly for staff for assistance. Further observation on 10-15-2020 at 12:26 PM revealed that the resident was yelling out again for staff response. Surveyor asked the resident why the resident was yelling out and the resident stated he/she wasn't sure. On 10-15-2020 surveyor review of the clinical record revealed in August 2020 the resident was ordered medication for delusional behavior and psychosis after an initial assessment visit by the facility's consultant psychiatrist. Further review revealed on 10-13-2020 that another visit was made by the consultant psychiatrist to address the resident's agitated behavior and increased the dose 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 surveyor review of the clinical record, surveyor observations and interviews with facility staff, it was determined that the facility failed to ensure consistent behavior monitoring of residents' use of psychotropic medications. This finding was evident for 3 of 6 residents selected during the Unnecessary Medication Review and Mood/ Behavior Reviews (Resident #44, #4, #64). The findings include: 1. On 10-15-2020 surveyor review of the clinical record for resident #44 revealed nursing documentation on 08-03-2020 at 6:53 AM that the resident's family had reported to staff that the resident had contacted them talking about driving on the highway, running out of gas , not having any money and saying that the family needed to come and pick up the resident. Family requested that the resident be assessed by the physician or a psychiatrist. Further review revealed nursing documentation on 08-03-2020 at 4:27 PM that the resident was told the assigned physical therapist about seeing kids in the resident's room. The consultant psychiatrist was notified by staff and was scheduled 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 surveyor review clinical record, observation, and interviews with facility staff, it was determined that the facility failed to provide an environment that promotes resident respect and dignity. This finding was evident in 1 of 27 residents (Resident #1) selected for this survey. The findings include: On 10-13-2020 at 8:30 AM, 3:16 PM and at 5:15 PM, surveyor observation of Resident #1 revealed a Foley catheter drainage bag (a Foley catheter is flexible tube which passes through the urethra and into the bladder to drain urine) hanging from the right side of the bed with no dignity bag (a bag which covers the Foley catheter's urine collection bag from plain sight) present. On 10-13-2020 at 5:20 PM, surveyor brought the Unit Manager into the room and asked her to identify the condition of the catheter collection bag. The Unit Manager acknowledged that there was no dignity bag over the collection bag. On 10-13-2020 at 5:24 PM, surveyor interview with the facility's Administrator provided no additional information.

Based on surveyor review of the clinical record and interviews with facility staff, it was determined that the facility staff failed to notify Resident #47's responsible party of the resident's weight loss. This finding was evident for 1 of 27 residents reviewed during the survey. The findings include: On 10-15-2020 surveyor review of the clinical record for Resident #47 revealed 09-03-2020 documentation by dietician #2 that noted after a review of the resident's weights, there was a 7% weight loss x 30 days. At that time, based on the dietician's recommendations, orders were obtained for a speech therapy screen, monitor of weekly weights and the addition of the dietary supplement, Boost Plus to be given twice daily. Further review revealed a speech therapy screen was completed for Resident #47 on 09-03-2020 with the implementation of Dysphagia (difficulty in swallowing ) Therapy three (3) to five (5) times a week for four weeks. However, there was no documented evidence in the clinical record that Resident #47's responsible party was notified of the 09-03-2020 significant weight…

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 surveyor review of the clinical record, review of the Beneficiary Protection Notifications and interview with facility staff, it was determined that the facility failed to provide residents with the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). This finding was evident for 2 of 3 residents selected for the Beneficiary Protection Notification review (Residents #8 and #15). The findings include: A Medicare health provider must give an advance NOMNC to enrollees receiving skilled nursing, home health (including psychiatric home health), or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services. The SNFABN provides information to the beneficiary in order to decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. 1. On 10-15-2020 surveyor review of the clinical and administrative record for Resident #8 revealed 07-31-2020 would be the resident's last day of Medicare coverage for skilled…

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 surveyor review of the clinical record, surveyor observation and interview with resident #31 and facility staff, it was determined that the facility staff failed to revise the comprehensive plan of care for Resident #31. This finding was evident for 1 of 27 residents reviewed during the survey. The findings include: On 10-15-2020 at 1:04 PM surveyor observation and interview with Resident #31 revealed that the resident had obtained a hearing aid for severe hearing loss of the left ear. The resident stated that its stored in the resident's top drawer of the bedside table when not wearing it . Further observation on 10-19-2020 at 8:54 AM, during a medication pass to Resident #31, revealed Licensed Practical Nurse (LPN) #3 and the Chapel Way unit manager were observed attempting to communicate to the resident about the medications and neither asked the resident whether the hearing aid was in place or its location until surveyor intervention. Record review revealed on 09-30-2020 Resident #31 had been fitted for and had received a left hearing aid. Staff added the hearing aid 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 surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice. This finding was evident in 2 of 27 residents reviewed during the survey(Resident #64 and #28). The findings include: 1. On 10-14-20 at 10:20 AM, surveyor review of the clinical record for Resident #64 revealed a physician order written on 08-28-20 to check the resident blood sugar before each meal and notify the physician if the sugar level was less than 70 or above 300 per ML. Further record review revealed that on 09-10-20 the physician gave another order to discontinue the order that specified calling the physician when the sugar/glucose level was less than 70 and more than 300. The physician replaced the order with a sliding scale indicating insulin to be administered based on the resident blood glucose level. However, the facility nursing staff continued both orders and did not discontinue the previous order as indicated by the primary…

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 surveyor observation, record review, and staff interview, it was determined that the facility staff failed to follow physician's orders. This finding was evident in 1 of 27 residents reviewed for quality of care during the survey (Resident #22). The findings include: On 10-13-2020 at 9:31 AM, surveyor observed Resident #22 had a left arm contracture. However, the resident did not have any splint on. On 10-13-2020 at 9:35 AM, medical record review of Resident #22 revealed the resident had a physician's order to don left elbow splint after AM care and doff after dinner. On 10-13-2020 at 12:22 PM and at 3:09 PM, surveyor observed Resident #22 without the left elbow splint. However, review of the resident's treatment administration record for October 2020 revealed LPN Staff #3 documented that the resident had the splint on at 9:00 AM on 10-13-2020. On 10-15-2020 at 11:12 AM, a telephonic interview with LPN Staff #3 revealed her documentation that she applied the splint on Resident #22 at 9:00 AM on 10-13-2020 was an error. On 10-14-2020 at 10:17 AM and 11:52 AM, surveyor…

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 surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility failed to ensure infection control practices to prevent development and transmission of communicable disease and infections. This finding was identified during the observation of 3 of 3 resident during glucose testing (Resident #4, #64, and #188). The findings include: On 10-14-2020 at 7:10 AM, Surveyor review of the clinical records for Residents #4, #64 and #188 revealed a medical condition in which their body doesn't use insulin properly resulting in unusual blood sugar levels. Additional review revealed a physician order that stated check blood sugar before each meal. Give insulin per sliding scale. On 10-14-2020 at 7:30 AM, surveyor observed Staff #4 checking resident blood sugar prior to breakfast. Staff # 4 removed the glucometer (medical device for determining the approximate concentration of glucose in the blood) from a hand held basket to check…

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.