Oakland Nursing & Rehabilitation Center

Based on interviews, observations, and record review, it was determined that the facility failed to enter, investigate, and follow up on grievance in a timely manner. This failure was identified while performing the Resident Council task and was evident for 1 of 1 grievance reviewed in the facility's grievance log.The findings include:A grievance in a long-term care facility is a formal complaint or expression of dissatisfaction by a resident or the resident's representative regarding any aspect of care, resident rights, or the facility environment. Federal and state regulations require the facility to record all grievances, conduct a timely investigation, and provide a written decision to the complainant outlining the findings (if requested) and any corrective actions taken within required timeframes.On 12/09/25 at 3:24 PM, the surveyor interviewed Resident #37, identified as the [NAME] President of the Resident Council. When asked who oversaw grievances, the resident identified the Nursing Home Administrator (NHA). When asked how to file a grievance, the resident stated that they…

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 interview it was determined that the facility failed to ensure written transfer notice and bed hold policy information was provided to the resident and the responsible party when the resident was transferred to the hospital. This was found to be evident for two (Resident #2 and #5) of the three residents reviewed for hospitalizations.The findings include:1). On 12/11/25 review of Resident #2's medical record revealed the resident sustained a fall on 9/1/25 and was sent to the hospital. Further review of the medical record failed to reveal documentation to indicate the required written transfer notice or the bed hold policy was provided to either the resident or the resident's responsible party. On 12/11/25 at 1:41 PM Nurse #17 was interviewed in regard to the process when a resident is sent out to the hospital. Nurse #17 referenced a Continuity of Care Document (CCD); and a paper bed hold document. Nurse #17 did not mention a transfer notice and indicated he was unfamiliar with a transfer notice document. Review of the CCD document revealed it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 1 (Resident #6) out of 1 resident reviewed for position and mobility. The findings include:The MDS (Minimum Data Set) is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need.An observation of Resident #6 on 12/8/2025 at 9:30 AM revealed contractures in the left hand (fingers bent at the knuckle joints and unable to straighten). Resident #6 was unable to lift both hands. A record review for Resident #6 on 12/10/2025 at 4:20 PM included a hospital admission history and physical dated 4/29/25, which noted that the Resident had a stroke in 2022, resulting in left-sided…

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 review of medical records and interviews it was determined that the facility failed to ensure baseline care plan information was provided to the resident and or the responsible representative. This was found to be evident for 3 (Resident #3, #20 and #55) out of the 15 residents included in the survey sample.The findings include:Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.1) Review of Resident #20's medical record revealed the resident was admitted in February 2024. Further review of the medical record failed to reveal documentation to indicate the resident, or 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 observations, record reviews, and interviews, it was determined that the facility failed to ensure that residents who were dependent on staff for Activities of Daily Living (ADL) received oral care. This was evident for 1 (Resident #6) of 2 residents reviewed for ADL. The findings include: In an observation on 12/8/2025 at 9:34 AM, Resident #6 was observed lying in bed. The Resident's lips were dry and crusted.Later that day at 12:18 PM, staff #19, a licensed practical nurse, was present in Resident #6's room, confirmed that the Resident's lip was dry and crusted, and stated it needed to be cleaned with a swab.In a subsequent observation on 12/9/2025 at 8:55 AM, Resident #6's crusted areas on his/her lips remained.A record review later that day contained an MDS assessment (Minimum Data Set- a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs) dated 11/21/25 for Resident #6. The MDS documented that Resident #6 relied on staff for all self-care needs.Further review included an ADL care plan for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 1 (Resident #6) out of 3 residents reviewed for activities.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care.An interview with Resident #6's representative on 12/8/2025 at 11:49 AM showed that the resident was bed-bound and was not engaged in Activities.During multiple observations during the recertification survey, Resident #6 was observed lying in bed, yelling, and not involved in any activity.A review of Resident #6's medical record showed that the resident's diagnosis…

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

Based on observation, record review, and interviews, it was determined that the facility failed to ensure appropriate follow-up care after a hospital discharge; and failed to ensure there were orders or care plan interventions for the use and monitoring of an air mattress. This failure was evident for one (Resident #1) of two residents reviewed for catheter use; and one (Resident #53) out of one resident reviewed for skin issues.The findings include:1). On 12/08/25 at 11:39 AM, during the initial screening of residents, the surveyor observed that Resident #1 had a large amount of sediment visible within their catheter tubing. On 12/10/25 at 9:46 AM, the surveyor conducted a review of Resident #1's medical record and identified an active care plan related to indwelling catheter use with a problem start date of 06/25/25. The care plan identified that Resident #1 had a Foley catheter due to bladder neck obstruction. Long-term goal included that the resident would not develop a urinary tract infection for 90 days. A note entered into the care plan on 10/14/25 by Staff Nurse #30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services to prevent further decline in his/her range of motion. This was evident for 1 (Resident #6) out of 1 resident reviewed for position and mobility. The findings include:An observation on 12/8/2025 at 9:30 AM showed that Resident #6's left hand had contractures (fingers bent at the knuckle joints and unable to straighten), and that no device was in place. Staff #19, a licensed practical nurse, was present and reported that Resident #6 did not wear any device on the left hand. Staff #19 attempted to open the Resident's fingers but was unable to. A record review on 12/10/2025 at 4:20 PM indicated that Resident #6 was admitted to the facility with left-hand paralysis due to a stroke in 2022.The continued review included an occupational therapy (OT) evaluation dated 5/16/2025 for Resident #6. The assessment documented an impaired range…

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 reviews and interviews, it was determined that the facility failed to ensure that residents' colostomy care was provided by appropriately trained, competent, skilled nursing staff. This was evident for 1 (Resident #6) of 1 resident reviewed for colostomy care. The findings include:A colostomy is an opening (stoma) on the abdomen (belly) that connects the colon (large intestine) to the outside of the body. The colostomy allows stool and gas to leave the body when it can't pass through the anus. Stool is collected in a pouch worn on the outside of the body.A record review for Resident #6 on 12/11/2025 at 6:35 AM showed that the Resident was admitted to the facility with the use of a colostomy due to ischemic bowel (lack of oxygen to the bowels) since May 2025.Continued review of Resident #6's care plan included interventions for colostomy care initiated on 6/4/25 that stated that [Resident #6] has a colostomy. Staff to care for it per facility policy. Further review of the facility's policy named ileostomy/colostomy care showed that staff had to assess peristomal skin…

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 reviews, observations, and interviews, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feedings. This was evident for 1 (Resident #6) of 1 resident reviewed for tube feeding.The findings include:A gastrostomy tube (G-tube) is a feeding tube placed into the stomach through an opening in the stomach wall. If one cannot consume sufficient nutrients, formula, liquids, and medications are administered via a G-tube. The formula containers and delivery systems are changed frequently (daily or every few feedings) to prevent bacterial issues.A record review on 12/8/25 indicated that Resident #6 had been at the facility since May 2025 and required tube feeding for nutritional support.The continued review included a provider's orders for tube feeding for Resident #6. The order specified that the resident was to receive Osmolite 1.5 via the G-Tube pump at 65 mL/hr (milliliters) for 24 hours daily. The order further stated, under special instructions, to Date and label tubing with each change.An observation 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 observations, record reviews, and interviews, it was determined that the facility failed to follow an attending physician's order to administer oxygen to a resident. This was evident for 1 (Resident #49) of 2 residents reviewed for Respiratory Care. The findings include: During an observation on 12/8/2025 at 8:50 AM, Resident #49 was observed lying in bed and receiving oxygen via a nasal cannula connected to an oxygen concentrator set to 1 L (Liter).During a later observation, staff #19, a licensed practical nurse, was present with the surveyor at Resident #49's bedside. Staff #19 confirmed that Resident #49's oxygen was set to 1 L and stated that it should be set to 2 L. Staff #19 then checked the filter on the back of the oxygen concentrator and said, This is probably why it's on 1 L; the filter is dirty and needs to be changed.A record review for Resident #49 included an attending physician's order, initiated on 3/3/25, for O2 (oxygen) at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (lung disease). However, an earlier observation showed…

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, observations, and record review, it was determined that the facility failed to manage Residents' pain. This was evident for 2 (Residents #6, #59) of 2 residents reviewed for pain management.The findings include: The PAINAD (Pain Assessment in Advanced Dementia) Scale is a tool that assesses pain levels in patients with cognitive impairments, such as delirium or dementia, by observing the patient for five minutes and then scoring behaviors such as breathing, independent of vocalization, negative vocalization (like occasional moaning or groaning, or repeated troubled calling out), facial expression, body language, and consolability.Proper use of the PAINAD Scale, as part of a comprehensive pain management plan, can help reduce the likelihood of a patient experiencing unrecognized and untreated pain. The total score ranges from 0 to 10. A possible interpretation of the scores is: 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain.1) During an interview on 12/8/2025 at 11:47 AM, Resident #6's representative reported that Resident #6's leg pain was poorly…

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 interview it was determined that the facility failed to ensure the resident was seen by the primary care provider every 30 days for the first 90 days of admission. This was found to be evident for one (Resident #3) out of three resident reviewed for nutrition.The findings include:On 12/10/25 review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis that included, but not limited to, dementia, heart disease and lung disease. The Primary Care Physician (PCP) #18 completed the Admitting History and Physical on 8/3/25, this was more than 5 weeks after the resident's admission to the facility. The note for this initial visit was recorded on 9/20/25. Further review of the medical record revealed the resident's weight on 6/24/25 was 144 lbs. On 7/21/25 and 8/1/25 the resident's weight was recorded as 135.7 lbs. This 8.3 lbs weight loss represents a significant weight loss of 5% in one month. The 8/3/25 PCP note failed to…

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

Based on observation and interview it was determined that the facility failed to have separately locked, permanently affixed compartments for the storage of controlled drugs that required refrigeration. This was found to evident in two out of the two medication storage rooms in the facility. The findings include: On 12/9/25 at 2:52 PM observation of Unit 2's medication storage room, with Nurse #19, revealed the medication refrigerator contained a locked box. Nurse #19 reported this box was used for the storage of Ativan when there is a resident who requires this medication. The refrigerator door did not have a locking mechanism, and the box was not permanently affixed in the refrigerator. The key to this narcotic box was observed to be kept inside the unlocked refrigerator, attached to the shelf on the door. Nurse #19 was observed removing the box from the fridge and unlocking it with the key stored in the refrigerator.On 12/9/25 at 3:00 PM observation of the Unit 4 medication room with Nurse #13 revealed a locked narcotic storage box in the unlocked refrigerator. Nurse #13…

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, observation and interview it was determined that the facility failed to ensure the medical record accurately reflected the resident's need for and use of supplemental oxygen. This was found to be evident for one (Resident #3) out of two residents reviewed for respiratory care.The findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis that included, but not limited to, dementia, heart disease and lung disease. On 12/8/25 at 9:45 AM Resident #3 was observed in bed, an oxygen concentrator was observed next to the resident's bed but it was not on and the resident was not receiving oxygen at the time of the observation.On 12/9/25 at 9:03 AM the resident was observed asleep in a geri-chair located next to the nursing station. No oxygen was observed being administered at this time. Review of the physician orders revealed an order, in effect since 6/24/25 for oxygen at 2 liters per minute via nasal cannula…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and policy review, the facility failed to check the automated external defibrillator (AED) daily for 157 days out of 421 days (37%). Findings included:Review of the manufacturer's Periodic Maintenance insert, undated, revealed the AED should be checked to ensure the Rescue [NAME] indicator is green, the battery had charge, the prompts were working on the LED (light emitting diode), the display was readable, the pads were ready for use, all buttons were working, and the case was intact. Review of the AED checks from 06/2024 until 07/25/2025 revealed 157 days out of 421 days went unchecked. During a phone interview on 07/26/2025 at 1:58 PM, Licensed Practical Nurse #18 stated her normally scheduled shift was 6:30 AM and it was the responsibility of the nurse working on Level 1 to do the crash cart on that level and the crash cart and AED on Level 3/2 when coming in for their shift. During a phone interview on 07/28/2025 at 4:07 PM, Registered Nurse (RN) #21 stated 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 record review, observation, interview, facility document review, and facility policy, the facility failed to protect residents from verbal and physical abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect, Exploitation, or mistreatment, dated 10/23/2019, indicated, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. 1. A Face Sheet revealed the facility admitted Resident #5 on 08/23/2024. According to the Face Sheet, the resident had a medical history that included an injury to the lumbar spine, anemia, insomnia, and coronary artery disease. A quarterly Minimum Data…

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 facility document review, staff interview, and facility policy review, the facility failed to submit an initial allegation of a bruise of unknown origin and failed to submit a five-day follow-up report of verbal abuse timely for Resident #5. Additionally, the facility failed to submit a five-day follow-up report of misappropriation of property timely for Resident #6. These failures affected 2 (Resident #5 and Resident #6) of 7 residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect, Exploitation, or mistreatment, dated 10/23/2019, indicated, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. Component V:…

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 a review of staffing sheets and interview, it was determined that the facility failed to ensure that a registered nurse was onsite at the facility at least 8 consecutive hours a day, 7 days a week. This practice has the potential to affect the health and safety of all residents. The findings include: On 6/7/23 at 8:44 AM, a review of the facility's actual working staffing sheets for April 2023 and May 2023 was conducted. Review of the staffing sheets for April 1 to 30, 2023 failed to reveal documentation to indicate that an RN (registered nurse) worked for 8 consecutive hours a days on 6 of 30 days in April 2023. There was no documentation to indicate that an RN worked or was present in the facility during the 6:30 AM to 6:30 PM shift, or the 6:30 PM to 6:30 AM shift on 4/1, 4/2, 4/14, 4/15, 4/29 and 4/30/23. Review of the staffing sheets for May 1 to 31, 2023 failed to reveal documentation to indicate an RN (registered nurse) worked for 8 consecutive hours a days on 6 of 31 days in May 2023. There was no documentation to indicate that an RN worked or was present in 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 of the kitchen and staff interview, it was determined that the facility failed to follow professional standards for food service safety. This deficient practice has the potential to affect all residents. The findings include: 1) On 5/22/23 at 10:57 am, during a tour of the facility ' s kitchen prep area revealed that the pipe plate under the prep sink was coming away from the wall, and the hole around the pipe was exposed. A freezer in the prep area had boxes of single-serving chocolate and strawberry ice cream that had been opened but not labeled with the date opened. A refrigerator that was located in a separate room behind the kitchen prep area was observed and found to have a carton of heavy whipping cream that was opened and dated 4/27/23. Per the label, it was to be discarded within seven days of opening, which would have been 5/3/23. A second refrigerator in that area, labeled as a produce refrigerator, was observed and revealed a tray of rice crispy treats that was partially…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, facility staff failed to treat residents with respect and dignity during meal time. This was evident for 2 (# 31 and #10) of 9 residents observed in Unit 1 Dining Room. The findings include: On 5/23/23 at 08:39 AM, an observation was made oof the 1st-floor Unit's dining room with 9 residents seated there. The DON was observed feeding Resident # 31 breakfast while other residents fed themselves. She left the room without finishing feeding Resident #31. Resident # 10 ( who required assistance with feeding) was observed sitting in a Geri chair, facing the other residents who were eating, and did not have a meal tray. At 8:44 AM on 5/23/23, the Assistant Director of Nursing (ADON) entered the dining room to finish feeding Resident #31 (approximately 5 minutes after the DON had left). At that time, Staff # 11(GNA, Geriatric Nurse Assistant) entered the dining room with Resident # 10's meal tray and sat down to feed them. On 6/06/23 at 03:48 PM, a record review 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 Based on interviews, record reviews, and observations, it was determined that the facility failed to honor a resident's bathing preference. This was evident for 1 resident (Resident #24) out of 1 resident reviewed for choices during an annual survey. The findings include: Resident #24 was admitted to the facility for long-term care. During an interview on 05/22/23 at 3:42 PM, the resident reported that she would have liked to have received more showers during her stay at the facility. On 06/1/23 at 11:28 AM, a review of the Resident's #24 quarterly minimum data set (MDS) dated [DATE], section F, revealed that the resident expressed that it was very important to him/her to choose between a tub, shower bed bath, or sponge bath. During an interview with the Activities Director on 6/1/23 2:18 PM, s/he reported that s/he asked the resident which type of bathing they would prefer. S/he reported that, at the time Resident #24 was admitted , s/he documented the resident's preference on a handwritten document titled…

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 interview, it was determined that the facility failed to ensure that significant weight losses were reported to the physician, registered dietitian and family in a timely manner. This was found to be evident for 2 (Resident #23, #39) out of 5 residents reviewed for nutrition. The findings include: A resident is considered to have a significant weight loss if they lose 5% in one month, 7.5% in 3 months or 10% in 6 months. 1) Review of Resident #23's medical record on 6/5/23 revealed that the resident had resided at the facility for several years and whose diagnoses included, but were not limited to, dementia and depression. Review of the 3/13/23 Minimum Data Set assessment noted the resident had severe cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of 0/15. Review of the resident's weight record revealed that, on 2/2/23, the resident weighed 121 lbs. On 3/3/23, the resident weighed 114 lbs. This 7 lbs weight loss in one month indicated a significant weight loss of 5.7% in one month. Review of a progress 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined that the facility failed to provide a home-like environment to residents. This was evident for 2 of 2 nursing units reviewed for environment. The findings include: On 5/22/23 at 3:14 PM, an observation was made of room [ROOM NUMBER]. It had three holes in the wall to the left of the window; each hole measured about a third of an inch, and two of the holes had drywall anchors inserted. Also, the room had four holes about the size of a nickel above the dresser with tape attached and drywall anchors inserted. Further observation revealed drywall cracks on both sides of the heating and cooling unit that extended from corner to corner. Also, another crack about the size of a half-moon was noted on the left side of the window. Multiple scrapes in the paint on the bathroom doorframe exposed the metal. The light on the ceiling outside the bathroom door had one bulb burned out, and the light over the sink was not working. The sink piping into the wall had a gap, 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 record review and interview, it was determined the facility failed to develop and implement abuse policies and procedures. This was evident for 1 of 1 abuse policies reviewed. The findings include: A review of the facility's policy for subject, Abuse, Neglect, Exploitation, or Mistreatment on 5/30/23 at 1:56 PM was conducted during the investigation of MD00181095 and revealed no date of implementation and showed that the last revision date was 10/1/20. In the section titled, Component VI: Investigation Number 4, read that, if an employee was accused of abuse/neglect, that they would be suspended during the investigation process. However, the facility failed to implement this policy by failing to suspend Staff #32 (Geriatric Nursing Assistant) when she had been accused of neglect for Resident #250 on 1/14/22. Number 5 of the same section was titled, Guidelines for Investigation. Letter section A. read to immediately assess the resident/patient at the time of discovery of the alleged abuse. However, a medical record review for Resident #250 revealed that, after an allegation…

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 that facility staff failed to conduct a thorough investigation of an allegation of abuse and failed to further protect the residents until the investigation had been completed. This was evident for 1( Resident #250) of 5 residents reviewed for neglect. The findings include: On 5/30/23 at 2:15 pm, a review of the facility's investigation file for MD#00181095 revealed that facility staff reported, on 1/14/22 at approximately 8:30 PM, Resident #250's family memberb alleged that Staff #32 (Geriatric Nursing Assistant) had neglected the resident by telling him/her to just lay in their wet bed. The family member had met with a previous Director of Nursing to discuss the concerns. However, the previous Director of Nursing failed to write a statement about the conversation. The facility indicated on the self-report form that an investigation had been started. Further review of the file revealed that the facility failed to interview Resident #250, other staff who…

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 staff interview, it was determined that the facility failed to: 1) notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#42) of 4 residents reviewed for hospitalization. The findings include: 1) On 5/24/23 at 11:09 AM, a review of Resident #42's medical record revealed that the resident was transferred to the hospital on 4/13/23 following an acute change in condition. On 4/13/23 at 5:41 PM, in a progress note, the nurse indicated that the bed hold and discharge policy was sent with the resident to the hospital. Further review of the medical record failed to reveal documentation that a copy of the bed hold and discharge policy were provided to the resident upon transfer to the hospital. In addition, there was no documentation found in the medical record to indicate the resident's representative was notified in writing of the resident's transfer along with the reason why the resident was transferred to the hospital. On 5/24/23 at 4:39 PM, during an…

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

Based on record review, and interview, it was determined that the facility failed to provide a resident's representative with a written bed hold policy when the resident was transferred to the hospital. This was evident for 1 resident (Resident # 9) out of 4 residents reviewed for hospitalizations during an annual survey. The finding include: Review of resident records on 5/24/23 at 3:19 PM revealed that Resident # 9 was a long-term resident of the facility and was transferred to the hospital on 4/21/23 at 11:00 PM. On 05/24/23 at 3:19 PM, review of a nursing progress note, dated 4/21/23 at 11:28 PM, revealed that Resident # 9's power of attorney (POA) was notified that Resident #9 was transferred to the hospital on 4/21/23. Further review of the progress notes from 4/21/23 through 4/24/23 failed to reveal that Resident # 9's POA was notified of the bed hold policy. On 5/25/23 at 2:25 PM, the Director of Nursing (DON) was interviewed. During the interview, the DON reported that she had no further documentation that a bed hold policy was provided to the Resident #9's POA. The DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that facility staff failed to code the Minimum Data Set (MDS) assessments accurately. This was evident for 1(# 36) of 4 residents reviewed for limited range of motion and 1 (#39) of 5 residents reviewed for unnecessary medications. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument, federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) During an observation of Resident #36 on 6/01/23 at 10:44 AM, the resident was asked to lift both arms, and s/he could not raise the left arm all the way up (full range of motion). On 5/23/23 at 10:44 AM, a record review for Resident # 36…

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, interviews, and record reviews, it was determined that the facility failed to provide the necessary care to ensure that a resident was kept well-groomed with clean hair. This was evident for 1 resident (Resident #24) out of 1 resident reviewed for choices. The findings include: An observation on 5/22/23 at 1:10 PM in Residents 24's room revealed Resident #24 lying supine in bed. The resident's hair was noted to be matted and disheveled. On 6/2/23 at 10:40 AM, Geriatric Nursing Assistant (GNA ) #40 was interviewed. During the interview, GNA #40 reported that, after bathing a resident, she would document that either a partial bed bath or complete bed bath was provided to the resident. GNA #40 reported that the main difference between a partial bath and a complete bed bath was that the resident's hair was washed during a complete bed bath. On 6/2/23 at 10:52 AM, during an interview with GNA #11, they confirmed GNA #40'S statement that residents' hair was washed only during a complete bed bath or a shower. On 6/2/23, review of point of care notes (GNA…

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, it was determined the facility 1) failed to ensure that a newly admitted resident was provided the appropriate medications upon admission to the facility. This was evident for 1 (# 257) of 1 resident reviewed for general concerns. This was evident for 1 (#246) of 8 residents reviewed for complaints. The findings include: 1) Review of records on 5/31/23 at 4:30 PM, under History and Physical written by Physician #30, dated 5/24/23, revealed that Resident # 257 was admitted to the facility for rehabilitation following a hospitalization. Further review revealed that the resident had medical diagnoses that included, but were not limited to, hypothyroidism. On 5/31/23 at 3:56 PM, a review of Resident #257's hospital Discharge summary, dated [DATE], revealed the hospital's medication recommendations included Levothyroxine,(Thyroid medication) and melatonin (sleep aid). On 5/31/23 at 04:14 PM, a review of physician orders failed to reveal an order for Levothyroxine. In addition,…

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 records reviews, observations, and interviews, the facility failed to establish a process to safely monitor residents in the dining room without staff supervision nor were residents in the dining room provided with a means to communicate with the staff in case of an emergency and or routine requests. This was evident for two out two observations made during the investigation phase of the annual survey. The findings include: On 06/01/23 at 10:20 AM, the surveyor observed six residents in the second-floor dining room/lounge on level two. The surveyor also observed that there were two residents in recliners with the inability to reach a call bell or to get out of the recliner without assistance, four residents in wheelchairs, in the dining room between 10:20 AM and 10:45 AM. There were no tap call bells on the dining room tables. The surveyor asked both GNA #11and GNA #12 if there was a process for monitoring residents in the dining room. Both stated that they and the assigned LPN took turns checking in on the residents located in the dining room but there was no set…

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 interview, it was determined that the facility failed to evaluate and implement measures to address the resident's nutritional needs as evidenced by 1) failing to ensure resident weights were obtained timely following readmission to the facility and weights were obtained as recommended by the dietician, 2) failing to ensure that a resident's significant weight loss was confirmed and reported to the dietician and physician so it could be addressed in a timely manner, 3) failing to ensure the physician addressed a resident's significant weight loss, 4) failing to ensure the dietician recommendations were implemented, and 4) failing to ensure the resident's representative was notified when the resident had a significant weight loss. This was evident for 3 (#246, #23, #24) of 5 residents reviewed for nutrition. The findings include: A resident is considered to have a significant weight loss if the lose 5 % in one month, 7.5 % in 3 months or 10% in 6 months. 1) On 6/2/23 at 3:00 PM,…

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, it was determined that the physician failed to address a residents' recent significant weight loss in the progress notes. This was found to be evident for 1 (Resident #23) out of 5 residents reviewed for nutrition. The findings include: A resident is considered to have a significant weight loss if they lose 5% in one month, 7.5% in 3 months or 10% in 6 months. 1) Review of Resident #23's medical record on 6/5/23 revealed the resident had resided at the facility for several years and whose diagnoses included, but were not limited to, dementia and depression. Review of the resident's weight record revealed that, on 2/2/23 the resident weighed 121 lbs. On 3/3/23, the resident weighed 114 lbs. This 7 lbs weight loss represents a significant weight loss of 5.7% in one month. Review of the 3/10/23 primary care physician (Staff #30) note revealed documentation that the physician Reviewed falls care plan vitals weights, the physician also documented under chief complaint: no falls, infections, weight problems and no wounds, stable at this time. Further review…

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

Based on medical record review and staff interview, it was determined the physician failed to see residents every 60 days at a minimum. This was evident for 1 (#246) of 5 residents reviewed for nutrition. The findings include: On 6/6/23 at 8:30 AM, a review of Resident #246's medical record revealed that there had been an 85 day lapse between visits by the resident's attending physician. In the medical record, there was a physician visit note dated 5/10/22, which indicated Resident #246 was seen by the physician on that date. The next visit note by the resident's attending physician on dated 8/4/22 which was a lapse of 85 days between visits. On 6/6/23 at 11:30 AM, the Director of Nurses (DON) was made aware of the concern and a request was made for any physician visit notes to indicate that Resident #246 was seen by the physician between 5/10/22 and 8/4/22. No other physician visit notes for Resident #246 were provided by the end of the survey. The DON, the NHA and the Corporate Clinical Service Director were made aware of the finding on 6/7/23 at 5:18 PM.

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was found to be evident for all of the GNA's working in the facility. Based on review of employee files and staff interview, it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) were evaluated annually and provided appropriate re-education based on the outcome of these evaluations. This was found to be evident for 3 of 3 GNA (#14, #20, #23) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility. The findings include: On 6/7/23 at 2:00 PM, a review of employee files revealed that annual evaluations for GNA's with over one year of service had not been completed. Review of Staff #20's employee file revealed no annual evaluation since 2017. A yearly performance review was not found in Staff #14's employee file. A yearly performance review was not found in the…

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

Based on record review, and interviews, it was determined that the facility 1) failed to ensure a resident had a continuous supply of their prescribed medications. This was evident for 1 (Resident # 25) out of 5 residents reviewed for unnecessary medications, and 2) failed to ensure staff followed porcedures related to the accounting of controlled substances. This was found to be evident on 2 of 2 nursing unit. The findings include: 1) On 5/31/23 at 10:30 AM, Resident #25's records were reviewed revealing the resident had resided at the facility for more than 2 years. On 5/31/23 at 8:56 AM, a review of Resident #25 medication administration record (MAR) between March 26th - April 30th, 2023, revealed multiple dates that prescribed medication was not administered with the corresponding documentation indicating that it was not administered because it was unavailable or awaiting delivery. The medications not administered included: Paxlovid ( oral treatment for COVID)was not available for a twice-a-day administration on 4/1/23 & 4/2/23, artificial eye lubricant was not available 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 medical record review and interview, it was determined that the pharmacist failed to identify an order that was over the maximum recommended dose of a medication. This was found to be evident for 1 (Resident #39) out of 5 residents reviewed for unnecessary medications during the survey. The findings include: Review of Resident #39's medical record on 6/1/23 revealed the resident was admitted to the facility in March 2023 after a hospitalization, with diagnoses that included, but were not limited to type 2 diabetes and dementia. Since 3/30/23, the resident had an order for metformin 1000 mg to be given twice a day, and another order for metformin 500 mg to be given twice a day. Each of these two orders indicated they should be given together, that the resident was to receive 1500 mg of metformin twice a day. Review of the medication administration record revealed documentation that the resident was receiving the 1500 mg of metformin twice a day as ordered, except on some occasions when the resident refused the medication. When administered as ordered, 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 medical record review and interview, it was determined that the facility failed to ensure a resident was free from excessive dose of a medication. This was found to be evident for 1 (Resident #39) out of 5 residents reviewed for unnecessary medications during the survey. The findings include: Review of Resident #39's medical record on 6/1/23 revealed the resident was admitted to the facility in March 2023 after a hospitalization, with diagnoses that included but were not limited to, type 2 diabetes and dementia. Since 3/30/23, the resident had an order for metformin 1000 mg to be given twice a day, and another order for metformin 500 mg to be given twice a day. Each of these two orders indicated they should be given together, that the resident was to receive 1500 mg of metformin twice a day. Review of the medication administration record revealed documentation that the resident was receiving the 1500 mg of metformin twice a day as ordered, except on some occassions when the resident refused the medication. Metformin is a medication used to help control high blood sugar in…

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

Based on observation, review of pertinent documentation and interviews it was determined that the facility failed to ensure medications were stored according to accepted professional standards. This was found to be evident for two out of two nursing units. The findings include: 1. Failed to ensure medication refrigerator was maintained at acceptable temperature for the storage of insulin. On 5/24/23 at approximately 3:15 PM observation of the medication refrigerator in the first floor medication room revealed the temperature was 34 degrees. This observation was confirmed by the nurse (Staff #15) who acknowledged that the temperature was too low and reported it needed to be adjusted. Insulin was observed being stored in this refrigerator. Insulin should be stored between 36 - 46 degrees Fahrenheit. On 6/06/23 at 3:40 PM observation of the medication refrigerator in the first floor medication room revealed a temperature of 32 degrees. This observation was confirmed by the nurse (Staff #26). Insulin was observed in this refrigerator. Surveyor reviewed the concern with the nurse that…

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 interview, observation, and staff interview, it was determined that the facility failed to serve residents a meal that was appetizing in appearance and at the appropriate temperature. This was evident for 1 (#35) of 1 resident reviewed for food concerns. The findings include: On 5/22/23 at 2:56 PM, during an interview with Resident #35, s/he reported that the food was served cold. An observation of the kitchen on 5/26/23 at 7:05 AM revealed Staff #36 (Cook) and Staff #35 (Cook) was preparing food for breakfast and lunch. An observation of the steam table revealed they had begun to add items before the surveyors arrived. The eggs, grits, cream of wheat, and sausage gravy were on the steam table. During the observation, the bacon and sausage were added. At 7:28 AM, they started to prepare the residents' trays for breakfast. Prior to preparing the trays, Staff #36 failed to obtain the temperature of the food items on the steam table when they had been on the stream table for up to 23 minutes. After he prepared the first tray, the surveyor requested temperatures 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 record review and staff interview, it was determined that the facility failed to maintain complete medical records for residents. This was evident for 1 (#35) of 3 residents reviewed for hospitalization and 1 (#36) of 9 residents reviewed for abuse. The findings include: 1) On 5/26/23 at 11:01 AM, a record review for Resident #35 revealed that the attending physician completed a Physician Certification Related to Medical Condition, Substitute Decision Making, and Treatment Limitations form on 2/1/23 that documented the Resident was capable of making medical decisions. Further review revealed that Staff # 28 (Registered Nurse) completed a Situation, Background, Assessment, and Recommendation (SBAR) form (SBAR is a written communication tool that nurses use to help provide essential and concise information when calling the doctor about patient care) on 02/16/23. The document read that Resident #35, who had a history of congestive heart failure (a long-term condition when the heart muscle doesn't pump blood like it should and blood often backs up and fluid can build up in 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, and interview, it was determined that the facility failed to ensure that appropriate hand hygiene was maintained during wound care. This was evident for 1 resident (Resident #25) reviewed for pressure injury during an annual survey. The findings include: On 5/26/23, 2023 at 1:30 PM, wound care observations were conducted for resident #24 in room [ROOM NUMBER]. LPN staff #15 and the Director of Nursing (DON) participated in the wound care treatment. The observation included 3 separate wound sites. Continued wound observation on 5/26/23 at 1:38 PM, revealed that staff #15 cleaned scissors with an alcohol wipe and removed gloves and immediately donned new gloves. The observation failed to reveal that the nurse sanitized his hands after removing his gloves. Observation at 1:41 PM, revealed that staff #15 removed the soiled dressing from wound site #1. Staff # 15 then cleaned the wound. Staff #15 then immediately proceeded to apply a clean dressing on the wound. Observation failed to reveal that…

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 with facility staff, it was determined that the facility failed to maintain sidewalks and patios in a way that they were safe for the residents, staff, and the public to use. This was evident for 3 of 3 sidewalks and 1 of 1 patio observed during the survey. The findings include: Upon entry to the facility on 5/22/23 at 10:30 AM, surveyors observed a sidewalk extending up the side of the building from the parking lot with a sloped area outside the exit door for Unit 2 that was covered with stones. Then a connecting sidewalk that extended from the road to the patio near the front door had three areas where the concrete was separating and was uneven. The patio had two cracks; one extended vertically, that measured 10 feet, and the other, horizontally, which measured 8 feet. Both areas had wide separations and were uneven. The sidewalk that led from the patio to the front door had two cracks extending the width of the sidewalk. When leaving the facility on 5/22/23 around 4:00 PM, some of the cracks had been filled in with concrete; however, the areas…

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 the medical record, it was determined that the facility staff failed to review and revise resident's care plans after each Minimum Data Set (MDS) Assessment and as needed. This was evident for 1 (#10) of 1 resident reviewed for pressure ulcers and infections, 1 (#26) of 5 residents reviewed for unnecessary medications, 1 (#38) of 2 residents reviewed for activities of daily living, and 1 (#17) of 2 residents reviewed for care plans. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The findings include: 1) Review of Resident #10's medical record, on 3/11/19 at 3:04 PM, revealed that the resident had a pressure ulcer. A plan of care for the pressure ulcer included the goals: Ulcer will not increase in size. Ulcer will not exhibit signs of infection thru the next review. The target date for the goals was 9/16/18. The plan of care failed to reveal that the plan was evaluated on 9/16/18. A plan of care evaluation note, dated 10/5/18, stated, goals met continue…

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 with staff and review of the medical record, the facility failed to ensure that there were sufficient nursing staff to assure resident safety, to attain or maintain the highest practical well-being of each resident, and to administer medications in accordance with the standards of professional practice. This deficient practice had the potential to affect all residents. The findings include: 1) During an interview on 3/14/19 at 1:58 PM, Staff #15 was asked if there were any resident care tasks that staff were unable to complete during their shifts. S/he stated, there's lots of stuff that doesn't get done. Staff #15 indicated that ice water was not refilled as often as it should be, wheelchairs were not cleaned as scheduled, and residents were not receiving their scheduled showers/baths. Staff #15 indicated that staffing was bad and that staff were required to work 12 - 16 hour shifts. S/he indicated there were 3-4 staff who had physician notes specifying that they could not work 12 - 16 hour shifts but the rest of the staff were required to work the extended…

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 and staff interviews, it was determined that the facility failed to treat residents with dignity and respect by failing to answer call bells in a timely manner. This was evident for 1 (Resident #46) out of 16 residents interviewed the first day. The findings include: On 3/12/19 at 9:34 AM, an interview with Resident #46 revealed that s/he has turned on his/her call light for help to get on or off the bed pan and was told by staff that they start at the opposite end of the hallway for toileting and s/he would have to wait until they get to his/her room. An interview with staff #19 on 3/13/19 at 3:18 PM confirmed that the staff routinely started toileting rounds at the opposite end of the hallway. During toileting rounds no one is available to answer call lights unless the unit has been assigned a 3rd Geriatric Nursing Assistant, otherwise the residents waited until staff got to their room. Administrator, Director of Nursing (DON), and Regional Coordinator were made aware of the findings on 3/15/19 at 3:00 PM.

Based on interview with the resident and review of the medical record, it was determined that the facility staff failed to develop and implement person-centered care plans for each resident that included measurable objectives and timeframes. This was evident for 1 (Resident #10) of 1 resident reviewed for pressure ulcers and infections, 1 (Resident #26) of 5 residents reviewed for unnecessary medications, and 1 (Resident #17) of 2 residents reviewed for care plans. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) Resident #10's medical record was reviewed on 3/11/19 at 3:04 PM and revealed that the resident had a Stage 4 pressure ulcer which was present on admission. A plan of care had been developed for the pressure ulcer with the goals: Ulcer will not increase in size; Ulcer will not exhibit signs of infection thru the next review. The plan of care failed to indicate the size of the pressure ulcer to enable staff to measure resident #10's progress or…

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 staff interview, it was determined that the facility staff failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 1 (#26) of 5 residents reviewed for unnecessary medications and 1 (#38) of 2 residents reviewed for activities of daily living. The findings include: 1) On 3/13/19, a review of Resident #26's medical record revealed that physician and nurse practitioner (NP) visit progress notes for Resident #26 were not in the resident's medical record the day the resident was seen. A 12/11/18 physician progress note was attached to the electronic medical record (EMR) on 2/7/19; a 12/21/18 NP note was attached to the EMR on 1/18/19; a 1/25/19 NP note was attached to the EMR on 2/12/19, and a 2/5/19 NP note was attached to the EMR on 2/12/19. 2) A review of Resident #38's medical record revealed that physician and NP visit progress notes for Resident # 38 were not in the resident's medical record the day the resident was seen. A 2/5/19 physician progress note 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 review of facility documentation and interviews with the facility staff, it was determined that the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assurance Program revealed that effective processes had not been put in place regarding repeat deficiencies from the annual survey dated 10/19/17 related to resident record accuracy and physician visits. The Quality Assessment and Improvement program was reviewed with the Nursing Home Administrator and these concerns were discussed on 3/15/19 at 6:50 PM.

Based on resident and staff interview and medical record review, it was determined the facility failed to include the resident and the resident's representative in the development and implementation of the resident's person-centered care plan. This was evident for 1 (#14) of 2 residents reviewed for care plans. The findings include: On 3/11/19 at 1:05 PM, during an interview, Resident #14's family member indicated that s/he visited the resident every day, that s/he was the resident's representative, and s/he was notified by the facility if there was a change in Resident #14's condition. When asked if s/he participated in the resident's care plan, Resident #14's family member stated, I have to plead ignorance on that; I haven't been to one, and stated that s/he had not received notification of Resident #14's care plan meetings. On 3/12/19, 3/13/18 and the afternoon of 3/14/19, observations were made of Resident #14's family member visiting with Resident #14 and interacting with other residents in the facility. On 3/14/19, a review of Resident #14's medical record revealed 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.

Based on observation, record review, and resident interview, it was determined that the facility failed to allow a resident to participate in choosing fall prevention measures. This was evident for 1 (#42) of 2 residents reviewed for Activities of Daily Living (ADLs). The findings include: On 3/11/19 at 12:00 PM, an observation revealed that Resident #46's walker was sitting on the opposite side of room next to the bathroom door and a tab alarm on the bed next to the resident. A tab alarm is a device that is clipped to a resident's clothing with a pull string that is magnetically attached to an alarm box. The alarm sounds when the magnetic connection is broken. An interview with the Resident on 3/11/19 at 1:00 PM revealed that s/he was not able to go to the bathroom without the walker and could not leave the bed because of the alarm. When asked about the pull alarm, the resident stated that s/he did not want that alarm because it has kept him/her awake. Review of the resident's record on 3/15/19 at 11:11 AM revealed a fall risk care plan that had an intervention of safety device,…

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 staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#26) of 5 residents reviewed for unnecessary medications. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 3/13/19, a review of Resident #26's quarterly MDS (minimal data set) with an ARD (assessment reference date) of 1/15/19 revealed that Item N0410B, 'Medications Received: Antianxiety', indicated that during the last 7 days prior to the ARD (the assessment lookback period), the resident received antianxiety medication on 3 days. Review of Resident #26's January 2019 MAR…

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 interview and record review, it was determined that facility staff failed to implement a baseline care plan to ensure that Resident #68's pain was managed. This was evident for 1 (#68) of 2 residents reviewed for pain management. The findings include: An interview with Resident #68 on 3/11/19 at 3:13 PM revealed that his/her pain scale level had been a 10/10 and that the pain was severe enough that s/he was experiencing emesis. The pain scale is a measurement of pain based on a resident's verbal report of pain from 1 to 10, 1 being the lowest level of pain and 10 being the highest level of pain. On 3/13/19, review of the resident's baseline care plan revealed a goal dated 3/20/19, Resident's immediate health and safety needs will be identified. An intervention for this goal, with a date of 2/28/19, was found that was labeled 'pain management' and specified, monitor pain in location of fractures. However, review of the MAR (Medication Administration Record) revealed that no pain management monitoring was documented. Administrator, Director of Nursing, and Regional…

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 interview with facility staff, it was determined that the facility failed to ensure physician orders for as-needed pain medication contained parameters for nursing administration of the medication. This was evident for 1 (#25) of 2 residents reviewed for pain management. The findings include: 1) Resident #25's medical record was reviewed on 3/15/19 at 12:39 PM. During the reivew, it was found that Resident #25 was prescribed two pain medications for pain relief:: oxycodone/acetaminophen 5/325 mg (Percocet) every 4 hours as needed for pain, and acetaminophen 325 mg every 4 hours as needed for pain. The Percocet order contained a special instruction to give the medication for a pain scale of 4-6. A pain scale is a measurement of pain obtained by asking a resident to verbally report their current pain from 0 to 10. Special numeric instructions like this are referred to as 'parameters.' The above Percocet order specified what pain level it should be administered for; however, the acetaminophen order did not. The Director of Nursing was interviewed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview with residents and facility staff, it was determined that the facility failed to ensure that residents received medication from competent nursing staff in a way that followed the standards of medication administration and assured resident safety. This was evident for 1 of 3 medication observations. The findings include: 1) During a medication observation of Staff #4 that took place on 3/14/19 at 9:12 AM, Staff #5 approached Staff #4 and the surveyor and offered to assist with medication pass by volunteering to run the medications to the residents to administer them so Staff #4 could continue to prepare the medications for the next resident. Staff #4 stated to Staff #5 that s/he didn't need help today because the surveyor was observing him/her. Staff #5 clarified the system nursing staff have set up to the surveyor to make it clear that, in order to be more efficient, the nurse from another unit would come over to the unit currently being observed when…

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 record and interview with facility staff, it was determined that the facility failed to ensure that resident medical records were complete and accurate. This was evident for 2 (Residents #66 & #9) of 6 residents reviewed for unnecessary medication. The findings include: 1) Resident #66's medical record was reviewed on 3/15/19 at 11:15 AM. During the review, it was found that the resident had an allergy listed for a medication that s/he was prescribed and had been receiving daily since admission. Further review of the medical record revealed that the allergy was also listed on the discharge paperwork from the resident's most recent hospitalization. The administrator was interviewed on 3/15/19 at 3:34 PM and stated that the allergy was carried over to the facility's medical record system because of the discharge paperwork from the hospital. However, s/he also stated that the resident had not had the allergy listed prior to this hospitalization and had never had a reaction to the medication. The administrator described the presence of the allergy on 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.