Oak Grove Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure medications and treatments were stored properly, including removal of expired medications from available supply, on 3 of 5 days of survey (3/18/25, 3/19/25, 3/20/25). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled resident (Resident #65 and #79). Findings: Review of policy Medication Self-Administration, revised 10/15/2024, states, Patients who wish to self-administer medications will be evaluated for safe and clinically appropriate capability .If it is determined that the patient is able to self-administer: A physician/advanced practice provider (APP) order is required .Self-administration and medication self-storage must be care planned .patient must be provided with a secure, locked area to maintain medications . Review of policy, Bedside Medication Storage, dated 1/2024, states, The interdisciplinary team (IDT) will review and approve resident…

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

Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 dumpsters for 1 of 4 days(3/18/24) and 1 of 3 dumpsters for 3 of 4 days of survey. (3/18/25, 3/19/25, and 3/20/25) Findings: 1. On 3/18/25 at 6:30 a.m., a surveyor observed 1 dumpster with the right-side slide door open exposing trash. Additionally, there was trash/debris on the ground. Another dumpster had a right-side top cover that was broken and open exposing trash. 2. On 3/19/25 at 8:00 a.m., a surveyor observed a dumpster had a right-side top cover that was broken and open exposing trash. 3. On 3/20/25 at 8:00 a.m., a surveyor observed a dumpster had a right-side top cover that was broken and open exposing trash. On 3/19/25 at 7:45 a.m., during an interview, the [NAME] stated the dumpsters are always supposed to be closed, but one of them has had a broken flap for a couple of weeks and she's not sure what they are doing about it. On 3/20/25 at 1:00 p.m., in an interview, the Administrator confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 7 sampled residents reviewed for respiratory (Resident #[R] R15, R20, R21, R41 and R44). Findings: 1. Review of R20's Preadmission Screening and Resident Review (PASRR) level II dated 2/25/25 revealed [he/she] has a Mental health disability and is qualified for Specialized services: You will need to be provided the following specialized services: Service or Support: Initial psychiatric evaluation to determine diagnosis and develop plan of care. Review of R20's clinical record lacked evidence this was done. Review of R20s clinical record revealed order with start date of 2/13/25 states. Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift AND as needed. Review of R20's care plan updated 2/13/25 states is at risk for complications related to the use of psychotropic drugs Medication as ordered. Resident…

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

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 2/1/24, were effective. The Federal citations F584, F625, F656, F689, F725, F842 and F880 were cited again during the annual Long Term Care Recertification Survey dated 3/24/25. Findings: During the Annual Long Term Care Survey Process for Federal Recertification dated 3/24/25, it was determined that F584, F625, F656, F689, F725, F842 and F880 would be recited for the same reasons: F584 for failure to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment; F625 failure to issue a written bed hold notice to include cost of care to the Resident and/or resident representative; F656 for failure to implement a comprehensive person-centered care plan; F689 for failure to ensure that the resident's environment was free of accident hazards relating to the storage 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 observations, interviews, clinical record review, and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Resident #33) on 1 of 3 facility units. Findings: On 3/18/25 at 1:20 p.m., a surveyor observed 2 CNAs (Certified Nursing Assistants) wearing gloves enter Resident #33's room with a mechanical hoyer lift. The resident's door was posted with a Contact Precautions sign which included a picture of a person wearing a gown, gloves, mask and face shield. The instructions stated Perform hand hygiene before and after patient contact, contact with environment and after removal of PPE (personal protective equipment). Wear N95/approved KN-95 respirator, gown, face shield and gloves upon entering this room. Change gown after EACH patient contact (written in red). Keep room door closed. Patient must wear a face mask when out of room and maintain social distancing. Perform all procedures/tests 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 record reviews and interviews, the facility failed to ensure that the resident and/or resident representative were provided with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, was completed for 2 of 22 residents reviewed for advanced directives. (Residents #27, and #79) Findings: 1. Resident #27 was admitted to the facility in 10/2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 3/19/25 at 11:56 a.m., in an interview, the Market Clinical Advisor confirmed that medical records lacked evidence that the facility offered or reviewed with the residents and/or resident representatives or that the residents and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 2. Resident #79 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 record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) Level II was implemented for 1 of 6 sampled residents reviewed for PASRR (Resident #20, (R20). Findings: 1.Review of R20's PASRR Level II, dated 2/25/25, indicated R20 was approved for specialized services to include Initial psychiatric evaluation to determine diagnosis and develop plan of care. Review of R20's care plan, updated 2/16/25 states: Resident/Patient meets PASRR II Level of care with diagnosis of Bipolar and Anxiety: Serious Mental Illness: Resident/Patient will receive appropriate specialized services as indicated on PASRR Level II thru next review date. Resident will be offered/engage with behavioral health services. Resident will engage/ be offered counseling services to develop coping skills. Review of Resident #20's current orders, dated 3/2025 lacked evidence that an order was placed for Medi tele (psyche services). 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 interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for care planning (Resident #41). Finding: Review of Resident #41's clinical record revealed a Minimum Data Set (MDS) Quarterly Assessment was completed on 1/6/25. Further review of the clinical record lacked evidence that an interdisciplinary team (IDT) meeting was held within 7 days following the assessment. During an interview on 3/24/25 at 8:37 a.m., the Director of Social Services confirmed Resident #41's last IDT meeting was held 11/13/24 and that Resident #41's clinical record lacked evidence that an IDT meeting was held within 7 days of the MDS Quarterly assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of an unlabeled medicated cream and chemicals being properly secured for 2 of 2 observations for 1 of 4 days of survey. (3/18/25) Findings: The Safety Data Sheet for Clinical Silicone Cream noted the following: 4. First Aid Measures: Eye Contact: Flush eyes with large amounts of water for at least 15 minutes. Remove contact lenses, if worn. If irritation, seek medical attention. Skin Contact: If irritation develops, wash area with water. Get medical attention if irritation persists. Inhalation: Remove victim to fresh air and keep at rest in a position comfortable for breathing. Seek medical attention if discomfort continues or if you feel unwell. Ingestion: Never give anything by mouth to an unconscious person. Consult a physician if necessary. The Safety Data Sheet for FunkAway Beads Odor Eliminator noted the following: 4.…

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 clinical record review and interview, the facility failed to demonstrate evidence of monitoring for mood, behavior, and side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#10). Findings: A review of Resident #10's clinical, Physician orders included the following medications: Risperidone (an antipsychotic) 2 mg (milligrams) by mouth one time a day; Lithium carbonate (used as a mood stabilizer) 300 mg by mouth twice daily; Lamotrigine (an anticonvulsant used as a mood stabilizer) 250 mg by mouth twice daily, and Trazodone (an antidepressant) 100 mg once daily to treat insomnia. Resident #10's care plan, last revised 2/6/25, identified the risk for complications related to the use of psychotherapeutic medication. Interventions included Monitor for side effects and consult physician and/or pharmacist as needed. Report the continued need of medication as related to behavior and mood. Also identified, Resident #10 exhibits or is at risk for distressed/fluctuating mood symptoms. Interventions included, Observe for signs/symptoms 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the plan of correction, and interviews, the facility's Quality Assurance Committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification on 2/1/24 was effective. The deficiencies, F689 (Free of Accident Hazards/ Supervision/Devices) was again identified during the 8/14/24 and 8/15/24 Revisit Survey. Findings: During the Annual Long Term Care Survey Process for Federal Recertification survey, dated 2/1/24, a deficiency was cited at F689 (Free of Accident Hazards/ Supervision/Devices) for failure to ensure that the residents environment was free from the potential risk of accidents relating to unsecured faux wood flooring for 1 of 3 units([NAME]) for 1 of 1 observations. The facility's Plan of Correction for F689, with a completion date of 3/13/24, indicated that an audit will be conducted for the remaining units to ensure all flooring is secured down, The floor flooring will be inspected…

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 quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meeting attendance sheets and interview, the facility failed to ensure that the Medical Director attended 3 of 4 quarterly meetings. Finding: A review of the quarterly QAPI/QAA meeting attendance sheets indicate that the Medical Director did not attend the 9/25/23, 12/20/23, and 3/14/24 quarterly meetings. A review of the facility's policy, Center Quality Assurance Performance Improvement process, with a revision date of 10/24/22, stated, Process. 2. The QAA Committee: 2.1. Functions under the authority of the Administrator and the governing Body and is composed of 2.1.1 Administrator, 2.1.2 Director of Nursing, 2.1.3 Medical Director, 2.1.4 Infection Preventionist, or designee, 2.1.5 Consultant Pharmacist (recommended), 2.1.6 Patient and/or family representatives (if appropriate), 2.1.7 Three (3) additional staff representatives, including, but not limited to department heads, certified nursing assistants, rehabilitation services, hospice, home health, etc.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to provide a safe, comfortable homelike environment on 2 of 3 units observed during complaint investigations ([NAME] and [NAME] House). Findings: Observations of [NAME] House between [DATE] at 8:21 a.m. and [DATE] at 10:26 a.m., revealed the following: On [DATE] at 8:21 a.m., during an initial tour two surveyors noted a very strong odor resembling a litter box in the hall starting at the Beauty Parlor located at the end of the main corridor and continuing onto all halls of the [NAME] and [NAME] Houses. On [DATE] at 9:45 a.m., during a facility tour Regional Ombudsman (OMB), indicated that both [NAME] and [NAME] Houses have had a very strong urine odor and [NAME] has also had a strong musty odor for quite some time At this time OMB further indicated she's asked the facility management multiple times what their plan was to fix it and never received an answer. During an interview on [DATE] at 8:17 a.m., Clinical Research Coordinator (MDS) indicated 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 record reviews and interview, the facility failed to ensure that all direct care staff received training in effective communication skills reflecting the needs of the resident population served, for 2 of 5 employee education records reviewed (#2, #5) Finding: A review of the Facility Assessment for 2024-2025, revealed the facility frequently provides care to residents with cognitive impairments, neurological and psychiatric conditions, as well as sensory impairments. The assessment stated the facility strives to provide person-centered care and psychosocial, spiritual support so that the needs of emotional and mental well-being, (and) support for helpful coping mechanisms are met. A review of staff education records for the past year lacked evidence that employees #2 and #5 had received training regarding effective communication. On 8/20/24 at 3:50 p.m., in an interview with two surveyors, the Administrator and Director of Nursing confirmed the finding.

Based on record review and interview, the facility failed to ensure staff received mandatory training on it's Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 2 of 5 employee files reviewed (#2, #5). Finding: Review of the facility's Center Quality Assurance Performance Improvement Process policy, with a revision date of 10/24/22, stated Process. 2.11 The QAA (Quality Assurance and Assessment) Committee promotes full employee participation in identifying and improving key processes. 2.11.1 Ensures education for all staff to facilitate understanding of QAPI program and processes, and systems to engage staff in participation in identifying improvement opportunities and participating in PI (Performance Improvement) teams. 2.11.2 Assures QAPI program and processes are presented at staff orientation and at annual mandatory inservice programs. A review of employee education files lacked evidence that employees #2 and #5 received annual mandatory training regarding the facility's QAPI program. On 8/21/24…

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

Based on record reviews and interview, the facility failed to ensure it's standards, policies and procedures for it's Compliance and Ethics program were communicated to all staff, for 2 of 5 employee files reviewed (#2, #4). Finding: A review of employee education files lacked evidence that employees #2 and #4 received annual mandatory training regarding the facility's Compliance and Ethics program. On 8/21/24 at 3:50 p.m., in an interview with two surveyors, the Administrator and Director of Nursing confirmed the finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect and promote a resident's dignity for 1 of 4 resident sampled for hygiene (Resident #1). Findings: Resident #1 was admitted to facility on 9/6/22 with diagnoses to include Alzheimer's disease. Review of Resident #1 Minimum Data Set (MDS) dated [DATE] revealed Resident had a Brief Interview for Mental Status (BIMS) of 8 of 15 indicating he/she had moderate cognitive impairment. Further review of MDS revealed Resident was dependent of staff for her activities of daily living (ADL's). Review of Resident#1's care plan initiated 9/6/22 revealed [Resident #1] is at risk for decreased ability to perform ADL(s) in grooming, personal hygiene, requires 1 person extensive assist with bathing, and grooming . During observation of breakfast meal on [NAME] House on 5/28/24 at 8:20 a m., Resident #1 was observed sitting at dining room table with a significant amount of facial hair that appeared to be approximatley 1/2 inch in length. During an interview 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 interviews and observations, the facility failed to ensure that accommodations were made for residents that included call bell and telephone being within reach for a resident that is capable of using a call bell and telephone for 1 of 1 resident observed for accommodations (Resident #2). Findings: Observations of Resident #2 between 5/28/24 at 8:10 a.m., through 5/29/24 at 7:35 a.m., revealed the following: -On 5/28/24 at 8:10 a.m., Resident #2 was observed in bed with with his/her side table positioned over the bed. A piece of paper was noted with large print indicating names and phone numbers. Residents #2's telephone was noted lying on a wheelchair cushion located to left of resident and not in reach. Call bell was observed to be dangling from Resident #2's right bedside rail, not in reach. -On 5/28/24 at 10:02 a.m., Resident #2 was observed in bed with with his/her side table positioned over the bed. A piece of paper was noted with large print indicating names and phone numbers. Residents #2's telephone was noted lying on a wheelchair cushion located to left of 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 record review, and interview, the facility failed to ensure provider documentation of resident needs that cannot be met and facility attempts to meet those needs during a facility initiated discharge for 1 of 2 residents reviewed for discharge (Resident #4). Finding: On 5/10/24 the Department of Licensing & Certification received a complaint indicating on 5/9/24 Resident #4 was transferred to an acute care hospital and the facility refused to take [him/her] return, because they are unable to provide the appropriate level of care for this resident. Review of Resident #4's medical record reveals he/she was admitted to the facility on [DATE] with diagnoses including dementia and encephalopathy. Review of intake Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating Resident #4 was significantly impaired. Review of Resident #4's clinical record revealed progress note dated 5/9/24 stating: ''It was brought to my attention from upper management that I…

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

Based on record review and interview, the facility failed to notify the physician of significant change in condition for 2 of 2 residents reviewed for significan change in condition (Residents #2 and #3). Findings: 1.On 2/20/24 at 9:08 a.m., the Department of Licensing received a complaint indicating Resident #2 had been complaining about abdominal pain all day. After family intervention Resident #2 was transferred to an acute care hospital and underwent surgery for a perforated bowel and splenectomy. Resident #2 was admitted to facility on 3/13/23 with diagnoses to include morbid severe obesity, constipation, and history of small bowel obstruction with resection in 2011. Review of Resident #2's clinical record revealed Nursing Documentation dated 1/27/24 at 4:45 p.m., stating Patient complaining of abdominal pain in the morning. Patient received [Malox] and had a large BM. Patient still complaining of pain. Given tums. Patient did not eat lunch. VSS. [Borborgamy] [ rumbling sounds] in all four quadrants. Daughter and daughter in law came in and requested patient go to ED 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 reviews, interviews the facility failed to update/implement a care plan in the area of constipation for 1 of 1 care plan reviewed (Resident #2). Findings: Resident #2 was admitted to facility on 3/13/23 with diagnoses to include severe morbid obesity, constipation, and history of small bowel obstruction with restriction in 2011. Review of Residents 2's care plan initiated 3/5/23 lacked evidence that goals and interventions were put in place for constipation. During an interview 5/29/24 at 12:32 p.m., Marketing Clinical Advisor and a surveyor reviewed Resident #2's care plan and confirmed no goals /interventions were put in place for constipation.

Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 5 residents reviewed for documentation (Resident's #1 and #2, #3 & #5). Findings: Review of facility policy titled Activities of Daily Living (ADL's) dated 5/1/23 states Documentation of ADL care is recording in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real time . ADL care is documented every shift by the nursing assistant. 1. Review of Resident #1's clinical record Tasks dated May 2024 lacked evidence that Resident #1 received assistance with toileting during the day shift on 5/6/24, 5/11/24 or 5/28/24,during the evening shift on 5/10/24 and 5/28/24 or during the night shift on 5/1/24, 5/5/24, 5/10/24 5/18/24 or 5/24/24. Further review of Resident #1's Task dated May 2024 lacked evidence that Resident #1 received hygiene assistance during the day shift on 5/6/24, 5/11/24, or 5/28/24. During the evening shift on 10/10/24, or during the night shift 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 interview, the facility failed to demonstrate a good faith effort to secure a written transfer agreement with a local hospital to ensure the safe and orderly transfer of residents for care and treatment. Finding: On 8/20/24 at 1:50 p.m., in an interview with a surveyor, the Administrator stated she was unable to locate a written transfer agreement with the local hospital which was approved for participation in the Medicare and Medicaid programs. The Administrator stated she had contacted the office of the hospital's President and was told there was no written transfer agreement and that it was not needed by the hospital. The Administrator confirmed that she was told there had only been a verbal agreement between the facility and the hospital for the transfer of residents. The local hospital was noted to be 1.2 miles from the facility. The Administrator provided a copy of the transfer agreement with the next closest hospital, 17 miles away from the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a sanitary environment related to the storage of personal toiletries, and urine collection devices for 1 of 3 units observed ([NAME] House). Findings: On 5/28/24 at 8:20 a.m., 11:12 a.m. and 5/29/24 at 7:15 a.m., observervations of room [ROOM NUMBER] shared bathroom belonging to Resident's #3 and #8 revealed a wooden shelf containing an unlabeled and unbagged bedpan, 1 opened and unlabeled bottle of body lotion,1 unlabeled bottle of men's 3 in 1 wash, and 1 opened and unlabeled bottle of mouthwash available for use. On 5/28/24 at 11:43 a.m., and 5/29/24 at 7:16 a.m., shared bathroom belonging to Rooms 45/46: contained unlabeled, unbagged bed pan on floor behind toilet, visible debris around toilet base, 8 oz bottle of cleansing spray, and 2.5 oz bottle of hand cream observed on shelf, available for use. During an interview on 5/28/24 at 11:45 a.m., Registered Nurse (RN)1 indicated that resident personal belongings should be labeled and stored…

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

Based on record review and interview, the facility failed to ensure that 1 of 5 employee files reviewed (#2) contained evidence of training to meet the residents' behavioral health care needs. Finding: A review of the Facility Assessment for 2024-2025, noted its population profile includes a high frequency of residents admitted with neurological, cognitive, and psychiatric/mood conditions. Functional care requirements for mental health states manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. A review of the facility's policy, Behaviors: Management of Symptoms, with a revision date of 7/1/24, stated Center staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting behavioral health needs…

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, observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related linen handling, urinary collection devices and sharps/needle safety for 1 of 1 days of survey on 1 of 3 units ([NAME] House). Findings: On 2/27/24 at 8:43 a.m., during observation of [NAME] House, the following was observed: 1. Observation of a Laundry Aid delivering linens to the [NAME] house dining room using an uncovered wire cart. She removed the tablecloths and placed them into the [NAME] in the dining room. At this time, she confirmed she was delivering clean tablecloths stating, now that I'm thinking about it, I should've covered it with a sheet. Review of the facility policy, Linen Handling, revised 5/1/23 states, All linen will be handled, stored, transported, and processed to contain and minimize exposure to waste products. Instructions to: Keep clean linen…

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

Based on observations, interviews, the facility's Dish Machine Logs, Food Storage-Cold Goods Policy and Procedure last revised 4/2018, Food Storage-Dry Goods Policy and Procedure last revised 9/2017, and Refrigerated/Frozen Storage Policy and Procedure last revised 6/15/18, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for air conditioning units, vents, a mixer, the ice machine, shelving, a reach-in freezer, a walk-in refrigerator and dry storage for 1 of 1 kitchen tour. In addition, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. This has the potential to effect all residents. Findings: The facility's Dish Machine Logs state at the bottom under Standards: high temp: wash: 150 to 160°F, rinse: 180°F. If temperature or chemical concentration does not meet parameters, stop washing and alert a manager or designee. The facility's Food Storage: cold foods revised 4/2018 states under Procedures: 5. All foods will be stored wrapped in or covered containers, labeled…

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 interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 Units ([NAME] House, [NAME] House & [NAME] House) and the Laundry Findings: On 2/1/24, from 2:10 p.m. to 3:00 p.m., a surveyor did an environmental tour with the Interim Administrator, the Regional Maintenance Director, and the Housekeeper Supervisor in which the following findings were was observed: [NAME] House > The resident Hoyer lift had chipped/missing paint on the legs creating uncleanable surfaces. > The resident sit-to-stand lift has dried food and dirt/debris in the foot base. >Resident room [ROOM NUMBER] - The cove base was dirty and marred with black marks. The closet door, to the left and right of the sink was marred with black marks. The heater was marred with black marks. The floor around the base of the toilet was dirty. There was a commode bucket on the bathroom floor. > Resident room [ROOM…

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's and record review's, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 39 sampled residents (#22, #52). Findings: 1. Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's clinical record included a diagnoses of congestive heart failure, cardiomyopathy, diabetes, chronic kidney disease, prostate cancer with urinary retention which required an indwelling urinary catheter. Resident #22's baseline care plan, initiated 12/29/23 only addressed the resident's need for assistance with mobility. The interventions specified the need for the head of bed to be elevated, and physical and occupational therapy screens. No other information was provided. On 1/3/24 and 1/4/24, the care plan was updated to address Resident #22's needs regarding activities of daily living, risk for cardiovascular complications, indwelling…

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

Based on interviews and record review, the facility failed to provide residents with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities. Findings: On 2/1/24 at 11:30 a.m., in an interview with a surveyor, Activities Staff stated no scheduled activities were provided on weekends since September/October of 2023, when the weekend activities staff position was eliminated. Staff stated if there is a special occasion, they will flex their weekday hours and work 1-2 hours on a weekend day for a special event. Otherwise, no group activities, including church services, are held on weekends. The Activities Staff stated they set up recreation carts with self-directed activities available in the dining room of each unit. Staff stated there are no activities, other than tv, for residents who cannot participate independently. A review of the February 2024 Activities Calendar revealed the only weekend activity scheduled was a 2-hour Superbowl social on 2/11/24. On 2/1/24 at 11:45 a.m., the finding…

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, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on 3 of 3 units. (#3, #7, #14, #27, #29, #52, #55, #69, #79 & #291) Findings: 1. On 1/29/24 at approximately 12:15 p.m., in an interview with a surveyor Resident #3 indicated that he/she does not receive his/her showers as requested for Fridays. A review of the shower schedule showed that Resident #3 was scheduled for showers or whirlpool baths on Fridays. A review of CNA documentation for October 2023 - January 2023 indicated that he/she only received a shower on Saturday 11/18/23, Tuesday, 11/28/23, and Saturday 1/20/24. 2. On 1/29/24 at 11:31 a.m., during an interview with Resident #7. Surveyor asked do you get the help you need without waiting a long time? Resident #7 stated No, there's not enough staff. I've been going without baths and can't recall the last time I had a shower. A review of ADL documentation indicates 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 performance evaluations and interview, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA #1, CNA #3, and CNA #5). Findings: 1. CNA #1 was hired on 12/20/21. CNA #1's last performance evaluation was completed in 2022. The facility was unable to provide evidence of a completed annual performance evaluation for 2023. 2. CNA #3 was hired on 6/29/21. CNA #3's last performance evaluation was completed in 2022. The facility was unable to provide evidence of a completed annual performance evaluation for 2023. 3. CNA #5 was hired on 4/4/16. CNA #5's last performance evaluation was completed in 2022. The facility was unable to provide evidence of a completed annual performance evaluation for 2023. On 2/01/24 at 8:25 a.m., in an interview, the Interim Administrator confirmed that the facility lacked documentation of 2023 yearly performance evaluations for CNAs #1, #3 and #5.

Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 12 of 39 residents reviewed for activities of daily living (#7, #14, #22, #27, #28, #29, #30, #32, #43, #52 & #69), and for 2 of 39 residents reviewed for medication and treatment administration (#14, #22). Findings: 1. A review of Resident #7's Certified Nursing Assistant (CNA) documentation of activities of daily living (ADLs) for October 2023 - January 2024, revealed multiple days lacking documentation on multiple shifts as follows: October 2023 Bed Mobility: 11 out of 31 days Eating: 11 out of 31 days Bathing: 11 out of 31 days November 2023 Bathing: 20 out of 30 days December 2023 Bathing: 24 out of 31 days Eating: 21 out of 31 days January 2024 Bathing: 16 out of 29 days 2. Resident #14's clinical record revealed an admission date of 12/6/23. A review of Resident #14's CNA documentation of ADL's for December 2023 and January 2024, revealed multiple days lacking documentation on multiple shifts as follows: December 2023 Bathing - 21 out…

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

Based on observations, interviews and record reviews, the facility failed to implement appropriate infection control standards for residents requiring transmission-based precautions (TBPs) for 3 of 3 residents reviewed (#31, #35, #198), and failed to ensure staff received appropriate education regarding TBPs. 1. 0n 1/30/24, a review of the clinical record revealed Resident #31 had a current physician order that noted: contact precautions for urine only. staff should wear gloves with attends changes and goggles should splash from a bed pan or commode be possible. ESBL[Extended Spectrum Beta-Lactamase] in urine. Other Active 10/30/2023 0n 1/30/24 at 2:00 p.m., a surveyor observed Resident #31's room and there was no personal protective equipment (PPE) station and no sign informing those entering the room that enhanced barrier precautions were required. 0n 1/30/24 at 2:30 p.m., in an interview, the Director of Nursing and the Marketing Clinical Advisor confirmed that Resident #31 had ESBL and there should be an enhanced barrier precaution sign on the door and PPE available for staff…

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

Based on observations, interviews and he facility's Dish Machine Logs, the facility failed to ensure that the kitchen high temperature dish washing machine was maintained in good repair and in safe operating condition for 1 of 1 kitchen tours (1/29/24). From October 2023 to February 2024, the kitchen high temperature dish washing machine was no consistently reaching proper wash and rinse/sanitizing temperatures. Findings: The facility's Dish Machine Logs state at the bottom under Standards: high temp: wash: 150 to 160°F, rinse: 180°F. If temperature or chemical concentration does not meet parameters, stop washing and alert a manager or designee. 0n 1/29/24 between 9:15 a.m. to 9:40 a.m., during an initial kitchen tour, a surveyor asked dietary aides #1 and #2 please run the dish machine 3 times in a row. The first wash was 140 degrees Fahrenheit(F.) and the rinse was 160 degrees F. The second wash was 144 degrees F. and the rinse was 162 degrees F. The third wash was 144 degrees F. and the rinse was 160 degrees F. The surveyor asked dietary aide #1 and dietary aide #2 if they knew…

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 and interviews, the facility failed to develop or implement the care plan interventions for the residents' current needs for residents requiring transmission-based precautions (TBPs) for 1 of 3 residents reviewed (#31). Finding: 0n 1/30/24, a review of the clinical record revealed Resident #31 had a current physician order that noted: contact precautions for urine only. staff should wear gloves with attends changes and goggles should splash from a bed pan or commode be possible. ESBL[Extended Spectrum Beta-Lactamase] in urine. Other Active 10/30/2023 0n 1/30/24 at 2:00 p.m., a surveyor observed Resident #31's room and there was no personal protective equipment (PPE) station and no sign informing those entering the room that enhanced barrier precautions were required. A review of Resident #31's current care plan did not include enhanced barrier precautions for Extended Spectrum Beta-Lactamase(ESBL). 0n 1/30/24 at 2:30 p.m., in an interview, the Director of Nursing and the Marketing Clinical Advisor confirmed that Resident #31 had ESBL and there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that the residents environment was free from the potential risk of accidents relating to faux wood flooring for 1 of 3 units([NAME]) for 1 of 1 observations. Findings: On 1/30/24 at 8:15 a.m., on the [NAME] Unit, a surveyor observed the faux wood flooring moving and coming up when carts were pushed down the hallway and staff were walking down the hallway. On 1/30/24 at 8:30 a.m., observations were made on the [NAME] Unit by a surveyor, the Interim Administrator and the Regional Maintenance Director to observe the flooring. The Administrator confirmed that there were ambulating residents on the unit and that the loose and moving sections of flooring were not secured to the floor, were definitely an accident hazard for residents and staff. Both the Interim Administrator and the Regional Maintenance Director were able to pick different sections of the flooring up which were loose and not secured down. Further observation of the [NAME] Unit by 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 record review and interview, the facility failed to recognize and address a potential significant weight change for 1 of 8 sampled residents reviewed for nutritional status (#52). Finding: A review of the facility's policy for Weights and Heights, stated Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Hospital weight will not serve as admission or re-admission weight. A review of Resident #52's electronic clinical record indicated an admission date of 12/6/23. Resident #52's weight on 12/6/23 was recorded as 254 pounds. On 12/25/23, nineteen days later, Resident #52's weight was recorded as 224 pounds, revealing a potential 30-pound weight loss. Further review of Resident #52's clinical record lacked evidence of weekly weight monitoring for 12/13/23 and 12/20/23. There was no evidence staff followed up on Resident #52's potential 30-pound weight loss. On 1/31/24 at 10:24 a.m., in an interview with a surveyor, the Marketing Clinical Advisor confirmed that staff did not follow the facility's policy by using 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 interview and record review, the facility failed to ensure that a resident who requires dialysis receive such services, consistent with the professional standards of practice in the area of monitoring a dialysis catheter site from 10/4/2023 to 2/1/24, for 1 of 1 resident receiving dialysis (#69). Finding: On 2/1/24 at 11:15 a.m., during an interview with a surveyor, Resident #69 stated that he/she goes to dialysis on Monday, Wednesday, and Friday. The surveyor observed Resident #69 with a dressing to the left chest. Resident #69 stated that is what they use for dialysis right now but he/she will be getting a fistula soon. A review of Resident #69's clinical record revealed diagnoses which included, Congestive Heart Failure, Diabetes Mellitis, and Chronic Kidney Disease, Stage 5. Documentation on Resident #69's hospital Discharge Documentation dated 10/2/23, indicated that on 9/28/23, Resident #69 had a placement of a tunneled dialysis catheter. A review of Resident #69's current care plan was completed. There is no mention that the resident has a tunneled dialysis catheter.…

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

Based on record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, resident rights and dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant's (CNA) employed, completed the required annual training (CNA #1). Findings: On 1/31/24, during a review of employee personnel records, the following was noted: 1. CNA #1's employee personnel record lacks evidence of mandatory abuse, resident rights and dementia training within the last twelve months. On 1/31/24 at 1:15 p.m., during an interview with a surveyor, the Marketing Clinical Advisor confirmed that there was no facility documentation to show that CNA #1 received the mandatory abuse, resident rights and dementia training within the last twelve months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 3 of 3 Units ([NAME], [NAME] and [NAME]) and in the laundry room, for 1 of 1 environmental tour. Findings: On 3/17/22 from 8:20 a.m. to 8:50 a.m., an Environmental Tour was done with the Interim Center Executive Director, the Maintenance Director, the Director of Senior Maintenance of Health Care Service Group(HCSG) and the Maintenance Assistant in which the following were observed: [NAME] Unit: > The hallway ceiling, outside the nurse's station, had a large patch on it with a hole directly next to the patch. There was also a hole in the ceiling about 1 foot from the patch. [NAME] Unit: > The whirlpool room, across from the clean linen closet, had a dirty/dusty ceiling exhaust vent and had a dirty floor around the base of the toilet. > The whirlpool room near room [ROOM NUMBER] had a dirty/dusty ceiling exhaust vent…

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, the facility failed to implement Infection Control Contact Precautions for a resident diagnosed with an antibiotic resistant bacteria for 1 of 3 sampled resident receiving an antibiotic. Finding: On 3/15/22, a review of documentation in Resident #120's clinical record, in the nurse's note section, stated the resident had an indwelling Foley catheter. On a Physician progress note, dated 3/10/22, the Physician stated the resident had hematuria (blood in the urine) and was treated with the antibiotic-Augmentin. The facility was waiting for a culture and sensitivity of the urine. A review of the nurse's note, dated 3/11/22 at noon, stated Resident #120's urine culture results showed Extended Spectrum Beta-Lactamase (ESBL), a germ that produces an enzyme that makes it harder to treat with antibiotics. The Physician Assistant was contacted for new orders. Documentation on the nurse's note, dated 3/11/22 at 1:00 p.m., the Augmentin was discontinued and Resident #120 was started on a new medication, Cipro 500 milligrams (mg) give one tablet by mouth…

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 policy review, personnel files review, and interviews, the facility failed to follow its own policies to ensure a Maine background check was completed for new employees before they are permitted to work for 1 of 6 sampled employees (Employee #1). Findings: The facility's 2.0 Abuse Prohibition Policy, revised 8/1/16 states that, The Facility shall screen potential employees for a history of abuse, neglect, exploitation or mistreating residents . On 3/16/22, a surveyor requested and received 6 randomly sampled employee personnel files to review from the Center Nurse Executive. On 3/16/22, Employee #1's personnel record was reviewed by a surveyor. The personnel record lacked evidence that a Maine background check was completed. Employee #1's date of hire is 2/28/22. On 3/16/22 at 2:45 p.m., a surveyor confirmed with the Workforce Manager that a Maine background check was not completed for Employee #1 until 3/16/22, 16 days after hire date. The Workforce Manager stated, a Maine background check is done prior to being hired and, this was a transfer from another…

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 the facility's Abuse Prohibition Policy, record review and interview, the facility failed to ensure that an alleged violation of resident abuse/neglect was reported to the state agency within 24 hours when an incident occurred for 1 of 2 residents reviewed for abuse/neglect. (#33). Findings: On 10/20/21, the facility made a report to Licensing and Certification that indicated the following: On 10/16/21 at 7:00 a.m., a Certified Nursing Assistant (CNA) reported Resident #33 was complaining of pain. The Certified Nursing Assistant (CNA) asked the Certified Nursing Assistant/Medication Technician (CNA/M) if Resident #33 could have as needed (PRN) pain medication. The CNA/M asked the charge nurse if Resident #33 could have as needed pain medication. The CNA/M and the charge nurse returned to Resident #33's room. There, the charge nurse stated that it would be best if the resident waited for his/her scheduled pain medication due at 9:00 a.m. The resident was alert and oriented at that time. The report indicated that Resident #33 appeared to be in a lot of pain at that time. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview , the facility failed to ensure that a comprehensive care plan was initiated, developed and completed based on the comprehensive assessment in the areas of Cognitive Loss/Dementia, ADL Functional/Rehab Potential, Urinary Incontinence, Psychosocial Well-Being, Falls, Nutritional Status, Dental Care, Pressure Ulcer/Injury and Psychotropic Drug Use for 1 of 13 sampled (#21). Findings: Documentation on Resident #21's Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], under Care Area Assessment Summary, noted Resident #21 would be care planned for Cognitive loss/Dementia, ADL's, Communication, Incontinence, Psychosocial Well-Being, Falls, Nutritional Status, Dental Care, Pressure ulcer and Psychotropic Drug use. As of 3/16/22, Resident #21's medical record lacked evidence of a Comprehensive Care plan being initiated, developed and completed. On 3/16/22 at 11:25 a.m., in an interview, the Center Nurse Executive(CNE) confirmed that a comprehensive care plan had not been…

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

Based on record review and interview, the facility failed to update a resident's current care plan to reflect the resident's Physician order/intervention to monitor restricted fluid intake for 1 of 2 sampled residents with fluid restriction (Resident #31). Finding: Documentation in Resident #31's clinical record, in the Physician order section, stated the resident had an order, dated 3/1/22, to Monitor Daily Fluid Restriction Total 2000 ml (must match diet order); Breakfast tray 480 ml; Free Fluids day shift 220 ml; Lunch tray 480 ml; Free Fluids Evening Shift 220 ml; Dinner tray 480 ml; Free Fluids Night Shift 120 ml. A review of Resident #31's current care plan, dated 1/9/22 was done. Under the care plan problem of Resident at risk for fluid volume excess, there was no intervention addressing the Physician's order to monitor fluid intake. On 3/16/22 at 12:45 p.m., in an interview with the Center Nurse Executive, she confirmed with the surveyor that she was unable to find evidence that monitoring of the residents fluid intake was added as an intervention on the care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to follow a Physician order for fluid intake restriction for 1 of 2 sampled residents on a fluid restriction (Resident #31) Finding: A review of Resident #31's clinical record, in the Physician order section, stated the resident had an order, dated 3/1/22, to Monitor Daily Fluid Restriction Total 2000 ml (must match diet order); Breakfast tray 480 ml; Free Fluids day shift 220 ml; Lunch tray 480 ml; Free Fluids Evening Shift 220 ml; Dinner tray 480 ml; Free Fluids Night Shift 120 ml. On 3/16/22 at 12:04 p.m., in an interview with Resident #31, he/she stated staff do not keep track of his/her fluid intake and that he/she just kind of knows how much he/she can have. On 3/16/22 at 12:20 p.m., in an interview with the [NAME] Unit Charge Nurse, she stated she was unable to find any evidence that Resident #31's fluids had been monitored. She stated there was no documentation on the Treatment Administration Record or the Medication Administration Record. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide an adaptive utensil, a small red curved spoon, for a Resident during 2 of 3 meals observed (3/14/22, and 3/16/22) (Residents #57). Findings: 1. On 3/14/22 at 12:19 p.m., Resident #57 was observed by a surveyor eating a pureed meal. The resident was using his/her knife to scoop up and eat the food. A surveyor asked Certified Nursing Assistant #1 (CNA #1) about the resident eating with a knife, and she said she would go and check on him/her. Resident #57's Nutritional assessment dated [DATE] stated, Resident #57 receiving adaptive equipment (small, curved spoon) to aid self-feeding. Resident #57's Care plan, updated on 2/22/22 stated under interventions, Provide rehab eating devices during meals. 2. On 3/16/22 at 12:22 p.m., Resident #57 was observed by a surveyor eating a pureed meal. The resident was using his/her knife to scoop up and eat the food. A surveyor asked CNA #1 where the adaptive utensil was for the resident. The CNA…

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

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall fan, an ice scoop/ice machine, air conditioners and plate covers. This was for 1 of 1 kitchen tours on 1 of 4 days of survey (3/14/22). Findings: On 3/14/22 from 11:15 a.m. to 11:45 a.m., a tour of the kitchen was conducted with the District Manager for HealthCare Services for food related services in which the following findings were observed: > The dish room wall fan by the dish washer was dusty/dirty. > The ice scoop was stored in the ice inside the ice machine bin. > The ceiling mounted air conditioner unit over the 3 bay pot sink was dusty/dirty. > The ceiling mounted air conditioner unit over a food preparation area was dusty/dirty. > There were 2 stacks of plates covers, approximately 10 in each stack, that had been wet stacked. On 3/14/22 at 11:45 a.m., in an interview, the District Manager for HealthCare Services for food related services confirmed the findings.