Autumn Lake Healthcare At Bradford Oaks

Based on record review and interviews it was determined that the facility failed to have a process in place that ensured a Resident's medication irregularity reports were reviewed by the primary care physician and the actions taken based on the recommendations were being documented. This was found evident of 1 (Resident #13) of 5 Residents reviewed for medication regimen review.The findings include:Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative.On 4/7/26 at 8:59 AM, the surveyor reviewed Resident #13's MMR's along with Resident #13's medication orders. 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.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that the facility failed to ensure that each resident's medication regimen was free from unnecessary medications. This was evident for 1 (Resident #4) of 5 residents reviewed for unnecessary medication during the annual survey.The findings include:On 4/7/26 at 11:47 AM, Review of Resident #4's medication orders reveal that resident has two medications that were ordered for pain management. The first order was for Tylenol to be given when the pain level is at 1-5. The second order is for Oxycodone HCl Oral Tablet 20 MG (Oxycodone HCl) Give 1 tablet by mouth every 8 hours as needed for Pain 6-10 Further review of the March 2026 medication administration records (MAR) revealed that on 3/6, 3/7, 3/28 and 3/29, Resident #4 was given oxycodone a narcotic medication use to control high level pain when their pain levels were between 4-5.In an interview with Staff # 4, a unit manager, she was asked about pain levels and what they signify. She stated that pain levels of 1-5…

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 with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 2 of 2 random observations.The findings include:On 4/7/26 at 6:31 AM, the surveyor observed the East hallway and noted a medication cart that was unlocked and unattended next to room [ROOM NUMBER] and across from room [ROOM NUMBER]. The surveyor noted the top drawer consisted of stock medications in bottles, the 2nd drawer contained medication and vials, the 3rd drawer contained additional medication, noting Narcan, and the 4th drawer contained supplies.At 6:34 AM, the surveyor asked a staff member, who had just come out of a resident's room, who was in charge of the medication cart and was told Registered Nurse (RN) #14. The surveyor then interviewed RN #14. During the interview RN #14 stated that she had just given pain medication to a resident and must have forgotten to lock the cart. She confirmed that the medication cart was supposed to be locked…

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.

Number of residents sampled: Number of residents cited: F812, F 584 and F757F812Based on observation and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in a manner that prevents foodborne illness to the residents. This was evident during the annual survey and has the potential to affect most residents in the facility.The findings includeOn 4/6/26 at 7:53 AM an Initial tour of the kitchen was conducted accompanied by Staff #27 a temporary certified dietary manager (CDM). In the walk-in refrigerator, there were about 60 dessert bowls with no dates on them left on the roll-in refrigerator tray racks containing cinnamon apples and pears. Two cucumbers covered with white moldlike substances were in a Ziplock bag on the fridge shelf. Staff #27 stated that the desserts in the bowls should have been dated and that the cucumbers were bad. She proceeded to toss them out.Further observation of the general kitchen prep area revealed sections of white patches on the kitchen floor, the floor was not moped, areas with brown stains were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews it was determined that the facility staff failed to maintain infection prevention and control practices. This finding was found to be evident on 1 (North Nursing Unit) out of 3 nursing units reviewed for physical environment during the annual recertification survey.The findings include:The surveyor toured the North Nursing Unit at 8:05 AM on 4/6/2026.During the tour, the surveyor observed at 10:00 AM on 4/6/2026 the clean linen cart uncovered outside of room [ROOM NUMBER]. The clean linen cart had 3 shelves full of linen (bed sheets, towels, washcloths) and a blue plastic cover that was resting on top of the clean linen cart. In an interview with staff nurse #21 at 10:35 AM on 4/6/2026 the surveyor asked what the expectation was for the clean linen cart to be covered, and he/she stated that the clean linen cart should be covered with the cover. Staff nurse #21 proceeded to cover the clean linen cart with the attached blue plastic cover.The North Unit Nurse Manager was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation and staff interviews, it was determined the facility failed to provide individual closet space for a resident. This was evident for Resident # 20 during the annual re-certification survey.The findings include:On 4/6/2026 at 8:56 AM: During the initial observation of Resident #20's room, two stand-alone closets were noted on Resident #20's side of the room, positioned behind the dividing curtain. Resident #20 repeatedly attempted to close the closet door near their bed and nodded yes when asked if the open door was bothering them. Both closets contained shirts and pants. When Resident #20 was asked if the clothes were theirs, Resident #62, the roommate, stated that all the clothes in both closets belonged to them. On 4/6/2026 at 9:06 AM: Staff #17, a Licensed Practical Nurse (LPN), was questioned about the two closets on Resident #20's side of the room and whose clothes were inside, to which Staff #17 replied, I am not sure. Resident #62…

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

Based on observation and staff interview it was determined that the facility failed to have call light cords accessible for Residents and failed to ensure that the resident's call system was functioning properly. This finding was found to be evident in 2 (Resident #68 and #76) out of 28 Residents reviewed call light accessibility and 1 (Resident #7) of 1 call light reviewed for call light functionality.The findings include:Resident Call System is a mandatory communication network in healthcare facilities, allowing Residents to alert staff from their bedside or bathrooms. These systems, ranging from traditional wired pull cords to advanced wireless pendants with fall detection and real time location systems, improve safety and care coordination. Every Resident must have a way of calling for assistance from their bedside and in their bathrooms. 1.On 4/6/2026 at 8:05 AM the surveyor toured the North Nursing Unit. The surveyor observed at 9:05 AM on 4/6/2026 that Residents #68 and #76 did not have an accessible call light in the Resident room. Both Residents were alert, ambulatory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, it was determined that the facility failed to ensure an effective pest control program. This was evident for 1 (Resident #168) out of 1 residents reviewed for pests during the recertification survey. The findings include: On 04/06/26 at 10:00 AM, the surveyor observed a rodent bait box and hole that was sealed with a yellow substance in the resident's room during the initial tour. On 04/06/26 at 1:30 PM, the surveyor interviewed the resident's surrogate. The surrogate stated that he/she had concerns about rodent activity in the resident's room due to two known sightings in the facility that the hospice staff documented during their visits. The surrogate provided the surveyor with documentation which consisted of a medical social services clinical note, a hospice aide visit note, a hospice nursing clinical note and a copy of an email that he/she sent to the ombudsman regarding pests. On 01/20/26, the medical social services clinical note stated that a large fat…

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, it was determined the facility staff failed to notify the Responsible Party when a resident (Resident #2) Pressure Ulcer worsened. This was evident for 1 of 5 residents reviewed during the complaint survey.The findings include:Resident #2 was admitted to the facility with diagnoses which included Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Pressure Ulcer of Sacral Region, Pressure-Induced Deep Tissue Damage of Right Heel and Pressure-Induced Deep Tissue Damage of other site. The resident expired in [DATE].On [DATE] at 7:45 AM a review of Resident #2's clinical record revealed that the resident was admitted to the facility from the hospital on [DATE] with several injuries to the skin including an Unstageable Pressure Ulcer of Sacral Region.On [DATE] the facility's Wound Consultant assessed Resident #2's skin injuries and treatment recommendations were implemented. The consultant conducted weekly evaluations of the wounds.Further review of the clinical…

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, it was determined that the facility failed to develop a baseline care plan within 48 hours. This was evident for 1 (Resident #5) of 5 residents reviewed during the complaint survey.The findings include:The baseline care plan is a document that outlines how to provide care for a new nursing home resident. It's created within 48 hours of admission. The plan's purpose is to reduce the risk of adverse events and ensure the resident receives quality care.On 1/8/26 at 11:30 AM, a review of Resident #5's medical record showed an admission date of 10/13/25. However, the baseline care plan was not completed and signed until 10/28/2025, exceeding the 48-hour requirement. This was confirmed by the Resident Representative.On 1/8/25 at 12:23 PM, during an Interview with the Director of Nursing (DON), she confirmed that baseline care plans must be completed and signed within 48 hours of admission, with a copy provided to the resident or their Representative. The DON was informed of this concern and acknowledged the finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaints, interviews and record reviews, it was determined that the facility failed to 1) hold a care plan meeting of the Interdisciplinary Team for a resident at the time of the quarterly revision of their care plans and 2) review and revise the care plan to meet resident's needs. This was evident for 2 (Resident #2 and #5) of 2 resident reviewed for care planning during complaint survey. The findings include: 1) Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Resident #2 was admitted to the facility in [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Pressure Ulcer of Sacral Region, Pressure-Induced Deep Tissue Damage of Right Heel and Pressure-Induced Deep Tissue Damage of other site. 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 review of a complaint, record review, and interview, it was determined that the facility failed to write a physician's order for a warm compress. This was evident for 1 (Resident #4) of 5 residents reviewed during the complaint survey.The findings include:On 1/5/26 at 1:20 PM, a review of complaint #2662431 indicated that Resident #4 was reported with a swollen lip on 11/5/25. A care plan meeting note dated 11/6/25 suggested, Resident #4 was reassessed and noted that he/she may have bitten his/her left lip due to jarred teeth or potentially due to mouth care.On 1/6/26 at 7:45 AM, a review of the progress notes identified the following entries that stated that the Physician was notified and a new order was received to apply warm compress:1. 11/5/25 at 10:29 PM, Change in condition: Resident was noted with left lip swollen with the skin intact, on assessment resident was not notice to be in pain, and no new wound noted. Resident was noted with left lip swelling. MD (Doctor of Medicine) notified, new order to apply warm compress.2. 11/6/25 11:01 AM, General Nurses Note:…

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 resident interviews, observations, medical record review and interviews with facility staff it was determined the facility failed to adhere to professional standards of practice when administering medications to residents. This was found to be evident for 2 (Resident # 7 and # 5) of 2 residents reviewed for medications, and 1(Resident # 13) of 3 residents reviewed during a medication administration observation conducted during a complaint survey.The findings include: 1) An interview was conducted with Resident #7 on 10/15/25 at 3:45 PM and the resident was asked if s/he had any concerns regarding care. The resident acknowledged that s/he submitted concerns to the state agency but as of current, the concerns regarding care have improved, with one exception: medications are still being given late. On the same date at 4:00PM, Resident # 7 medical record was reviewed and the medication administration audit report for October 1, 2025, revealed the resident received scheduled physician ordered medications late. The following concerns were identified: 1.Metoprolol Tartrate 100…

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 staff interview, it was determined that the facility failed to maintain a safe and sanitary environment for residents, visitors, and staff. This was evident for the parking lot and the East hallway during the survey. The findings include: On 2/4/25, at 9:45 AM upon entry to the parking lot area in front of the facility's front doors, there were masks, gloves, and various paper packaging littering the ground. The same observations were made on 2/5/25 at 8:50 AM, 2/5/25 at 3:00 PM, 2/7/25 at 7:00 AM, 2/7/25 at 1:00 PM, 2/10/25 at 8:00 AM, 2/10/25 at 4:10 PM, 2/11/25 at 8:30 AM. On 2/11/25 at 1:00 PM, a pile of nonsterile clear gloves was found in a parking spot, as well as the other trash noted previously. On 2/13/25 at 9:30 AM, there was a piece of cardboard laying in a parking spot, dirty masks, gloves, a paper cup with trash in it. At the doorway was a plastic bag used for produce at a grocery store, that looked like it had been ran over. An interview with the Maintenance Director 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 record review and interview, it was determined that the facility failed to have a process in place to ensure that allegations of abuse, were reported to the state agency (SA) and within the required timeframe. This was evident for 1 (R40) of 32 residents reviewed for abuse. The findings include: A review of the facility's investigation file for the facility reported incident MD00207668 on 2/11/25 at 2:34 PM revealed a statement written by LPN 5. According to his statement he became aware of R40's allegation of abuse against Geriatric Nursing Assistant (GNA)12 on 7/13/24 at 3:20 PM. On the incident report LPN5 reported that he reported it to Registered Nurse (RN)6. Further review revealed the initial report form, and the facility documented they became aware of the abuse allegation on 7/14/24 at 12N and reported to SA 7/14/24 at 1:30 PM. No confirmation email included. On 2/13/25 at 2:58 PM a review of the email confirmation for sending the initial report confirmed it was sent to the SA on 7/14/24 at 1:27 PM. An interview with LPN5 on 2/13/25 at 3:44 PM confirmed that he 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 record review and interview, it was determined facility staff failed to ensure that an alleged perpetrator had no further access to vulnerable residents during an investigation and to conduct a thorough investigation of the allegation. This was evident for 1 (R40) of 32 residents reviewed for abuse. The findings include: On 2/5/25 at 10:30 AM a review of the facility's policy titled Abuse, Neglect, and Exploitation with no implementation date but was reviewed on 11/13/23. In the section for definitions, Misappropriation of resident property is included as abuse. In section IV B the facility identifies Resident reports of theft of property, or missing property is an indicator of possible abuse. In section V the facility states that identifying and interviewing all involved people including witnesses as part of a thorough investigation and to focus the investigation on determining if abuse has occurred and to what extent. In section VI the facility's expectation for protecting the residents includes room or staffing changes. In section VII, the Administrator is responsible…

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 it was determined that the facility failed to provide a baseline care plan to the resident's representative. This was evident for 1 (#12) of 9 residents reviewed for care to prevent pressure ulcers. The findings include: Baseline care plan - must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. During a review of a complaint regarding Resident (R)12 on 2/5/25 at 9:55 AM, it was revealed that the complainant reported they were not given a copy of the resident's baseline care plan or made aware of the medications the resident was taking. On 2/18/25 at 1:03 PM, a review of the closed record for R12 revealed no evidence that the baseline care plan or list of medications were given to the resident or resident representative. 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, interview, and policy review, the facility failed to ensure that food items in the dry storage area were discarded upon the use by date printed on the carton. This failed practice had the potential to affect the six residents that received nectar thickened liquids and the nine residents that received med pass 2.0 supplement from the kitchen. Findings include: On 02/04/25 at 5:54 AM during the initial tour of the dry storage area, there were two cases of 22 one-quart cartons of Med Plus 2.0 vanilla nutritional that displayed a use by date of 11/17/24. Additionally, there was one case of nine one-quart cartons of Thickened Dairy Drink that displayed a use by date of 01/01/25. The Dietary Manager (DM) stated she would remove those items and dispose of them. During an interview on 02/07/25 at 3:46 PM, the DM stated that items were not in rotation, it could possibly make residents that receive those products sick. Everyone should be checking the date on food items when new products are brought in. Review of the facility's policy titled, Food Safety Requirements,…

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, it was determined that facility staff failed to ensure the resident's medical records were complete and accurate. This was evident for 2 (R630 and R12) of 92 residents reviewed during the survey. Findings include: 1) During a review of a complaint regarding Resident (R)12 on 2/5/25 at 9:55 AM, it was revealed that the complainant reported concerns that staff were not turning and repositioning the resident to prevent skin breakdown. On 2/20/25 at 8:41 AM a review of geriatric nursing assistance (GNA) documentation for turning and repositioning of the resident for the dates of 10/20/21 - 11/17/21 revealed the resident was dependent on staff for turning and repositioning. However, staff documented that they had not turned and repositioned the resident on the following dates: 10/21/21, 10/22/21, 10/24/21, 10/25/21, 10/26/21, 10/28/21, 10/30/21, and 10/31/21. The findings were reviewed with the Regional Director of Nursing (DON) and she stated she would review the medical record. The Regional DON reported on 12/20/25 at 12:10 PM that she found 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 observation, interview, record review, and facility policy review, the facility failed to follow infection control procedures related to droplet precautions for one of one resident (R 44) reviewed for isolation precautions out of a total sample of 39. This had the potential to cause cross-contamination with other residents and staff. Findings include: Review of R44's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R44 was admitted to the facility on [DATE] with the diagnoses of heart disease, end stage renal disease, and type II diabetes. Review of R44's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/01/24 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R44 was dependent for eating, dressing, bed mobility, toileting, showering/bathing and transfers. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R44 was cognitively intact. Record review 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 review of medical records, observation of patient care, and interview with facility staff, it was determined that the facility failed to ensure that residents' assessments of bed mobility accurately reflected residents' ability to maneuver themselves in bed. This was evident for 3 (Residents #1, #2, #3) of 9 residents identified by the facility's lift assessments as requiring the assistance of two staff to reposition in bed. The findings include: A review was performed on 2/6/20 at 10:15 AM of education given to staff regarding bed mobility following the annual survey with end date 12/11/2019. During the review, it was found that staff were educated to rely on a label outside of resident rooms to determine how many staff were required to assist the resident with positioning in bed. If a resident required 2 staff members to reposition in bed, the label outside the resident's room would end with a 2. Otherwise, the resident required only 1 staff member's assistance to reposition in bed. During an interview with Geriatric Nursing Assistant (GNA) #3 that took place on 2/6/20 at…

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, the facility staff failed to ensure that Resident # 22 and Resident #160 's nails were clean. This was evident for 2 out of 6 residents investigated for Activities of Daily Living (ADL) during the survey process. The findings include: On 12/3/19 around 11:18 AM during resident observations it was noted that Resident #22 fingernails on both hands were caked with dirt. It was shown to staff #8. Per the Minimum Data Set (MDS), the resident is an extensive assist for personal hygiene. On 12/04/19 around 08:44 AM while interviewing Resident #160 it was noted that the nails on both hands were dirty. The facility failed to maintain adequate grooming

Based on observation and staff interviews the facility staff failed to ensure that Resident #64's tracheostomy was setup to the doctor's orders. This was evident for 1 out of 1 resident investigated for a tracheostomy during the survey process. The findings include: On 12/10/19 while reviewing the records for Resident #64's tracheostomy care and set up, the order revealed that the trach tubing is to be changed monthly. Also, the oxygen level is to be set on 2 liters/min. While assessing the resident, it was noted that there was no date on the tubing, therefore the writer could not determine the age of the tubing. Staff #13 was shown the tubing and stated that the tubing will be changed. In addition, the 02 concentrator was set at 5 liters/min as opposed to the 2L noted in the resident's orders. The Eastside Unit Manager, Staff #10, was informed and verified the 02 level at 5 liters. Facility staff did not follow the physician orders.

Based on meal service observations and staff interviews it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to Demonstrate appropriate hand hygiene to prevent the spread of infection during lunch meal service involving resident's (R#61). This was evident during dining observation. The findings include: On 12/02/19 at 12:30 PM during lunch meal observation in the facilities main dining room, Geriatric Nursing Assistant (GNA) #9 was observed repositioning Resident #61 who was being wheeled into the main dining room by another staff member. GNA #9 was observed touching with his/she hands to reposition Resident #61's right lower leg and foot placing it back in the wheelchair. GNA #9 was, also, observed retuning to the food tray table and touching and serving another lunch plate without washing hands or sanitizing hands before touching and serving a lunch food plate to another resident in the dining room. On 12/02/19 at 12:35 PM Surveyor # 39709 conducted a staff interview…

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