Armour Oaks Senior Living Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that hot water temperatures from faucets throughout the facility, were consistently between 105 ºF (degrees Fahrenheit) and 120 ºF. Resident rooms [ROOM NUMBER]) on the South east side of the facility, had water temperatures between 94 ºF and 99 ºF. Resident rooms 14, 21, 22, and 12 on the north side of the facility had temperatures that were 120.2- 121.4 ºF; and Resident rooms [ROOM NUMBERS] had water temperatures between 76.1 ºF and 92.3 ºF .The facility also failed to ensure that staff who are checking temperatures allowed to flow for at least 2 minutes before measuring the water temperatures. This practice potentially affected all residents. The facility census was 35 residents. Review of the facility's policy entitled Safe water Temperatures and dated 3/23, showed: It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Explanation and Compliance Guidelines: 1. Direct care…

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

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to safeguard against mold possibly getting into food and/or beverages; failed to change the deep fryer oil in a timely manner; failed to consistently document hot food temperatures at the steam table to ensure they were suitably cooked to lessen the chance of bacterial contamination; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 34 residents with a licensed capacity for 38 residents at the time of the survey. 1.…

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

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 34 residents with a licensed capacity for 38 residents at the time of the survey. 1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a handwashing sink, and an ice machine. Observation on 1/11/23 between 12:47 P.M. and 1:48 P.M. during the facility LSC room-by-room inspections with the Assistant Operations Director (AOD) showed the following: -There was a facility-wide fire sprinkler system. -There was a boiler…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for three sampled residents (Residents #19, #31 and #3) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's MDS 3.0 completion policy dated 2022 showed the facility would conduct an accurate assessment of the resident. 1. Review of Resident #19's care plan dated 3/1/23 showed: -The resident had a regular diet with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods are finely chopped, blended, or ground to make them smaller, softer, and easier to chew) and regular, thin liquids. -The resident admitted to hospice services (end of life care) on 5/19/23. -An update on 8/5/23 showed the resident had weight loss over the last four months. -No interventions of receiving tube feeding (a medical device used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility reported an allegation of abuse immediately to the Administration when on 1/1/24 Certified Medication Technician (CMT) B attempted to get Resident #30's vital signs (temperature, pulse and respirations) which resulted in the resident becoming agitated, yelling and remaining upset after the alleged incident out of 12 sampled residents. The facility started their investigation on 1/8/24 seven days after the alleged incident. The facility census was 34 residents. Review of the facility's Abuse, Neglect and Exploitation policy dated 10/2022 showed: -It was the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -The facility will develop and implement written policies and procedures that prohibit and prevent abuse,…

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 and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of transfer from the facility for two sampled residents (Residents #17, and #32) out of 12 sampled residents. The facility census was 34 residents. The facility did not have a policy for Ombudsman notification. 1. Review of Resident #17's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Acute (severe and sudden onset) respiratory failure (a condition where there is not enough oxygen in body tissues) with hypoxia (insufficient oxygen in the blood). -Pneumonia (an infection that affects one or both lungs). Review of the resident's hospital record showed he/she admitted to hospital on [DATE] and discharged back to the facility on 8/21/23 for Acute Respiratory failure with Hypoxia. Review of the facility Ombudsman notification dated August…

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 and record review, the facility failed to submit a resident's discharge assessment for one supplemental resident (Resident #28) out of four residents who triggered for assessment concerns. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #28's discharge assessment dated [DATE] showed it was not submitted to Centers for Medicare & Medicaid Services (CMS) and was marked do not submit to CMS on 9/8/23. Review of the Resident Assessment Instrument (RAI) Manual dated October 2023 showed the following on page 1 of chapter 5: -Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS a federally mandated assess tool completed by facility staff for care planning) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. During an interview on 1/11/24 at 7:59 A.M., the MDS Coordinator said he/she did not submit private pay resident's assessments to CMS. During…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan that included one high risk medication for one sampled resident (Resident #31) out of five residents sampled for medication review. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's care plan dated 12/28/23 showed no care plan for the use of anticoagulant medication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed the resident was on an anticoagulant (medication used to slow down the blood clotting process) medication. Review of the resident's Physician's Order Sheet (POS) and Medication Administration Record (MAR)'s dated January 2024 showed a physician's order dated 12/22/23 for Eliquis (an anticoagulant) 5 milligrams (mg), one tablet by mouth two times a day related to heart disease. During an interview on 1/16/24 at 9:06 A.M., the MDS Coordinator said he/she did not usually care plan for anticoagulant medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered safely and were not left at bedside for one sampled resident (Resident #25) and to prime a insulin pen prior to administration for one sampled (Resident #23) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Resident Self-Administration of Medication Policy dated November 2017 showed: -A Resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. -All Nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. 1. Review of Resident #25's quarterly Minimum Data 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 observation, interview and record review, the facility failed to put adequate supervision measures in place to prevent a newly admitted resident, who was assessed to be an elopement risk and showed signs of confusion and exit seeking behaviors, from leaving the facility unannounced for one sampled resident (Resident #335) and to complete an Annual or quarterly Safe Smoking Assessment to assess the resident's ability to safely smoke electronic cigarette with or without supervision for one sampled resident (Resident #20) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Elopement and Wandering Resident policy/procedure, dated 2022, showed: -Residents would be assessed for their risk of elopement and unsafe wandering upon admission and throughout their stay. -The interdisciplinary team would evaluate the unique factors contributing to the elopement risk in order to develop a person-centered care plan. -Interventions to increase staff awareness of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respond to the pharmacist's recommendations for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Medication Regimen Review (MRR) policy dated October 2022 showed: -The pharmacist shall document the findings for each MRR. -The pharmacist shall communicate any irregularities verbally to the physician, Director of Nursing (DON) and/or staff of any urgent needs. -The pharmacist shall communicate any irregularities in written communication to the attending physician, the facility's medical director and the DON. -Facility staff shall act upon all recommendations according to procedures. 1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE]. Review of the resident's pharmacist's note dated 12/26/23 showed: -The resident was newly admitted to the facility. -Instructions to ensure target behaviors and side effects…

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 and record review, the facility failed to ensure medications were ordered with adequate monitoring for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE]. Review of the resident's care plan dated 12/28/23 showed: -The resident had a diagnosis of high blood pressure. -There was no care plan for anticoagulant (medication used to slow down the blood clotting process) medication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed: -Some of the resident's diagnoses included heart disease and high blood pressure. -The resident received anticoagulant medications. Review of the resident's Medication Administration Record (MAR) dated December 2023 showed: -A physician's order 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 interview and record review, the facility failed to ensure target behaviors and side effects were being monitored for psychotropic medications (any medications that affect brain activities associated with mental processes and behavior) for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's care plan dated 12/28/23 showed the resident used an antidepressant (medications used to treat depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and an antianxiety (used to treat anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) medication with instructions to monitor and document side effects and effectiveness every shift. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed: -Some of the resident's diagnoses…

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 have a Registered Nurse (RN) on duty eight hours a day, seven days a week. This deficient practice had the potential to negativly affect all residents residing at the facility.The facility's census was 37 residents. Record review of the facility's undated Registered Nurse Staffing Policy, showed: -The facility interpreted state and federal guidelines to say the facility must use the services of a RN for at least eight consecutive hours a day, seven days a week. -The Director of Nursing (DON) or designated staffing coordinator scheduled at least one eight-hour shift each day on the nursing schedule. -The eight hour shift will be suffice by the RN each day the DON is on site for at least eight consecutive hours. -When the DON is not on site for eight consecutive hours, the designated staffing coordinator will schedule an RN to be the charge nurse for the day shift (7:00 A.M. to 3:00 P.M.). -If an RN is not available for the 7:00 A.M. to 3:00 P.M., the DON or designated Staffing Coordinator will schedule an RN as either:…

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

Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage room, and walk-in refrigerator and walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; to follow correct hair hygiene practices; and to separate damaged foodstuffs. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 37 residents with a licensed capacity for 38 residents. 1. Observations during the initial kitchen inspection on 7/13/22 between 8:52 A.M. and 12:15 P.M. showed the following: -In the basement Dry Storage room there was no thermometer in a freezer to confirm correct temperatures. -In the basement walk-in refrigerator there was a package of mint leaves, a partial package of cheese…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The facility also failed to ensure two sampled residents (Resident #14 and #26) were tested/screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function). The facility census was 37 residents. Record review of the facility's undated water-borne pathogen prevention program entitled Facility Legionella Policy and Procedure, printed out and provided by the Administrator, showed a mostly educational, 15-page document that failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by failing to document personal belongings upon admission and to follow-up timely as part of the grievance process when clothes were reported missing for three sampled residents (Resident #14, Resident #25, and Resident #33) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -The facility must take appropriate steps to prevent misappropriation of resident property. -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. -Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative (if applicable) with a written summary of the baseline care plan for three sampled residents (Residents #26, #14 and #22) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated Base Line Care Plans policy showed: -Every resident had an interdisciplinary care plan initiated within 24 hours of admission. -The care plan identified priority problems and needs to be addressed by the interdisciplinary team (IDT). -The resident and/or the family member was involved in the care planning. -The facility developed and implemented a base line care plan for each resident that included effective and person-centered care of the resident that met professional standards of quality of care. -The baseline care plan was developed within 48 hours of the resident's admission. -The facility may develop a comprehensive care plan in place of the baseline care plan if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide daily oral care to include brushing of teeth to one sampled resident (Resident #20); and to provide fresh water daily to two sampled residents (Resident #20 and #33) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated policy titled Nutrition/Hydration Status Maintenance showed based on a resident's comprehensive assessment, the facility will ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health. Record review of the facility's undated policy titled Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) showed: -It is the policy of the facility to sustain an environment that humanizes and individualizes each resident's quality of life. -The care and services provided are person-centered, and honor and support each resident's preferences. -The facility will provide care and services for the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Seizures (a sudden uncontrolled electrical disturbance in the brain). -Anemia (a condition in which the blood doesn't have enough healthy red blood cells). -Urine retention (a condition in which your bladder doesn't empty completely each time you urinate). -Edema (swelling caused by excess fluid trapped in your body's tissues). -Open angle glaucoma (a condition that causes nerve damage to nerve at the back of the eye). Record review of the resident's care plan dated 11/27/18 showed: -The resident was able to complete bed mobility, transfers and ambulation independently. -The resident was at risk for falls due to unsteady gait at times and shuffling gait dated 5/3/18. -Staff was to complete the fall risk assessment quarterly and PRN (as needed) dated 5/3/18. -Ensure floors were free from spills or clutter related to a fall dated 6/21/22. -The resident had a diagnosis of seizure disorder…

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

Based on observation, interview, and record review, the facility failed to ensure residents' prescription medications that had been opened had the date the medication was opened written on the container; to ensure medication containers were clean, and to ensure residents personal belongings were not mixed in with medications. The facility census was 37 residents. Record review of the facility's policy, Medication Storage in the Facility, dated 10/4/18 showed: -Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were to be immediately removed from stock, disposed of according to procedures for medication disposal. -Medication storage areas were kept clean, well-lit, and free of clutter. -Medication storage conditions were monitored on a monthly basis and corrective action was taken if problems were identified. 1. Observation on 7/15/22 at 6:20 A.M. of the Nurses' treatment cart with Licensed Practical Nurse (LPN) B showed: -A resident's prescribed medication, Opium tin (a narcotic pain reliever) 10…

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 and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #25) out of 12 sampled residents when the resident's debit card was used for $303.69 in unauthorized purchases. The facility's census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -The facility took appropriate steps to prevent misappropriation of resident property. -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. -Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law. -Immediately was defined as as soon as possible: -Any allegation of abuse, neglect, mistreatment,…

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 and record review, the facility failed to report to the State and the local Police within 24 hours, when a resident reported fraudulently charges on his/her credit card. This deficient practice negatively affected one sampled resident (Resident #25) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. -Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law. -Immediately was defined as as soon as possible: -Any allegation of abuse, neglect, mistreatment, exploitation or injures of unknown source resulting in serious…

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

Based on observation, interview, and record review, the facility failed to follow the facility policy to have a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) mask stored in a bag when not in use for one sampled resident (Resident #14) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated Oxygen and Nebulizer guidelines showed all nebulizer tubing must be kept in a bag when not in use. 1. Record review of Resident #14's record summary showed: -The resident moved into the facility on 5/17/22. -Some of the resident's diagnoses included: --Chronic obstructive pulmonary disease (COPD). --Hypoxemia (low oxygen levels in the blood). --Chronic respiratory failure (when the respiratory system fails in one or both of its gas exchange functions of oxygenation and carbon dioxide elimination) with hypoxia (low oxygen in the body tissues). Record review of the resident's care plan dated 5/17/22 showed: -The resident was at risk for respiratory distress related to COPD. -Instructions 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.