Oak Park Care Center

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. Review of the facility's Facility Assessment Tool, updated 1/5/23, showed: -Average daily census: 80; -Staffing type/plan: Administrator, RN, licensed practical nurses (LPNs), and certified nurse aides (CNAs); -Position: Licensed nurses providing direct care (RN or LPN): 7; -CNAs: 20; -Other nursing personnel: 3; -How did the facility assess the resident population: Point Click Care (PCC, electronic medical record), Minimum Data Set (MDS), and Quality Assurance and Performance Improvement Plan (QAPI); -Does this reflect the population observed: yes; -How did the facility determine the staffing level: Census vs acuity. Review of the staffing sheets, provided by the Assistant Director of Nursing (ADON) for staffing 12/1/22 through 12/27/22, showed: -Wednesday, 12/1/22: No RN worked any shift; -Thursday, 12/2/22: No RN worked any shift; -Friday, 12/3/22: No RN worked any shift; -Saturday, 12/5/22: No RN worked…

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 complete the controlled substance inventory sheets appropriately to maintain accurate accountability of the inventory of all controlled substances administered at all times. The facility had incomplete controlled substance sheets for three of six narcotic count sheets sampled. The sample size was 18. The census was 82. Review of the Controlled Substance Storage policy, dated 2/2020, showed: -Policy: Controlled substances are subject to special handling, storage, disposal and record keeping in the facility; -Procedures: -The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances; -Schedule II-V medications subject to abuse of diversion are stored in a permanently affixed, double locked compartment separate from all other medications; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items is…

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 monthly medication reviews (MMR) were completed timely (Residents #6, #17, #31, #44 and #47). The facility also failed to complete the physician's order to consult psychotherapy services following a gradual dose reduction (GDR) recommendation in December 2022 (Resident #47). The sample was 18. The census was 82. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/2017, showed: -Policy: The AlixaRx clinical pharmacist (ACP) performs a comprehensive review of each resident's medical record at least monthly. Irregularities, findings, and recommendations are reported at a minimum to the Director of Nursing (DON), attending physician, and the Medical Director; -Recommendations and/or MMR reports are provided to attending physicians and Medical Director within 72 hours of receipt or within three business days. 1. Review of Resident #6's electronic medical record (EMR), showed: -Diagnoses included stroke, anemia (the blood doesn't…

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 staff treated residents with dignity and in a respectful manner by leaving one resident exposed during personal hygiene after staff left the resident's room door open to the hallway and the bedroom curtains open to the parking lot (Resident #46). Staff left a resident exposed in his/her brief in the wheelchair and also spoke to him/her in a disrespectful manner when the resident notified the staff of a high blood sugar level (Resident #37) The sample size was 18. The census was 82. Review of the incontinence care policy, dated 7/21/22, showed to provide privacy, close the door and the curtains and or the blinds. 1. Review of Resident #46's quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/6/22, showed: -Severe cognitive impairment; -Total staff assistance needed with dressing, hygiene and toileting; -Always incontinent of bowel and bladder; -Diagnoses included dementia,…

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 refund resident funds within 30 days of discharge for one resident (Resident #133). The sample was 18. The census was 82. 1. Review of Resident #133's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/22, showed: -Entry date: 8/16/21; -Unplanned discharge; -Discharge assessment: return anticipated; -Discharge status: acute hospital. Review of the resident's admission/discharge/death to social security form, dated 9/20/22, showed the resident discharged on 7/9/22. Review of the resident's progress notes, showed on 8/22/22 at 5:54 P.M., call placed to hospital to get update on resident's condition. Spoke to nurse who states the resident remains in Intensive Care Unit (ICU) on ventilator and meeting has been scheduled for possible trachea placement. Review of the resident's trust account, showed: -On 8/3/22, the facility deposited the resident's August 2022 social security money in the amount of $1,346.00; -No care cost debited for August 2022; -On 8/3/22, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all physician orders were followed by not ensuring the order for a magnetic resonance imaging (MRI, procedure that make detailed pictures of areas inside the body) was completed (Resident #70), not ensuring pressure relieving boots were worn as ordered (Resident #36) and diet orders were followed as ordered (Residents #36 and #44), for three of 18 sampled residents. The census was 82. Review of the facility's physician's orders policy, dated 9/28/22, showed: -Policy: To provide guidance and ensure physician's orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Procedure: Physician orders shall be provided by licensed practitioners authorized to prescribe orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record. The required components of a complete…

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 a discharge planning process was in place which addressed discharge goals and needs, including caregiver support, referrals to local contact agencies as appropriate and involvement with the resident for one of two residents sampled for discharge planning (Resident #70). The census was 82. Review of the facility's discharge plan/summary policy, reviewed 10/7/21, showed: -Policy: An interdisciplinary summary is competed on a resident upon discharge to assure the continuum care needs of the resident are met; -A physician order must be obtained; -Upon notification of impending discharge, the interdisciplinary team should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process; -If the resident is discharging to a private home, social work should meet with the person accepting responsibility for the resident. Referrals needed should be made to home health, or…

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

Based on observation, interview, and record review, the facility failed to obtain perimeters for a blood sugar over 350 for one sampled resident (Resident #37) and failed to update the resident's care plan. In addition, the facility failed to ensure the Glucagon (medication to treat low blood sugar levels) kit was assessable to all nursing staff. The resident sample was 18. The census was 82. During an interview on 1/23/23 at 12:15 P.M., Corporate Nurse A said the facility did not have a policy for insulin administration. Review of Resident #37's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/22, showed: -Cognitively intact; -Diagnoses included diabetes, hyponatremia (low sodium in the blood), and hyperlipidemia (high level of lipids in the blood); -Insulin injections administered in the last seven days. Review of the resident's blood sugar results, for November 2022, showed: -On 11/3/22 at 6:40 A.M., a blood sugar of 400 (normal 90-130); -On 11/15/22 at 8:51 A.M., a blood sugar of 561; -At 4:15 P.M., a blood…

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 a resident received appropriate treatment and services to maintain or improve mobility when staff did not provide range of motion for one resident or a restorative therapy (RT) program for a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) prevention and treatment (Resident #60). The facility census was 82. Review of the undated referral to the restorative program policy, showed: -Policy: The restorative team promotes the highest level of functioning in areas of self-care, cognition, communication and mobility; -Procedure: Nursing rehabilitation or other staff may provide restorative referrals for the restorative program when: -A decline in function of a resident is noted, per nursing documentation; -The restorative referral should be made to the Restorative Nurse, per facility protocol. The Restorative Nurse is then responsible for development of the restorative program and communicating the interventions 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 observation, interview and record review, the facility failed to maintain proper positioning of the resident's indwelling catheter (a thin tube inserted through the urethra into the bladder to drain urine) tubing and catheter drainage bag for one resident (Resident #18). The facility failed to ensure there were current physician orders for the indwelling urinary catheter. Facility staff also failed to address the catheter use on the resident's care plan. The facility identified one resident with an indwelling urinary catheter (Resident #18). The census was 82. Review of the facility's catheter care policy, dated 7/13/22, showed the facility will maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/22, showed: -Severe cognitive impairment; -Required extensive assistance with bed mobility, transfers, dressing, toileting and…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration dates and that medications for residents who were no longer in the facility were removed from the active medication supply for one of one medication room. The facility identified having one medication room, four medication carts and one treatment cart. The census was 82. Review of the facility's Medication Storage in the Facility policy, revised 11/2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Observation on 1/24/23 at 9:41 A.M., of the medication storage room, showed: -A pack of intravenous (injection of a…

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

Based on observation, interview and record review, the facility failed to offer special dietary equipment per the resident's plan of care to assist each resident to maintain their highest level of function and independence, for one resident (Resident #36). The sample was 18. The census was 82. Review of Resident #36 Care Plan, in use at the time of survey, showed: -Problem: Resident needs help with activities of daily living (ADLs) due to a stroke; -Outcome: Resident's needs will be met with assist of staff; -Interventions: Resident will have built up dietary utensils at meals. Divided plate at meals. Lid cup with straw. Review of the Resident's Meal ticket, showed: -Breakfast: Regular diet, thin liquids, dislikes milk; -Adaptive equipment: built-up utensil handles, divided plate, lidded cup with straw; -Standing order: double eggs; -Lunch: Regular diet, thin liquids, dislikes milk; -Adaptive equipment: built-up utensil handles, divided plate, lidded cup with straw; -Standing order: double protein; -Dinner: Regular diet, thin liquids, dislikes milk; -Adaptive equipment: built-up…

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 acceptable standards of practice for infection control during personal care for two residents (Resident #46 and Resident #83). Staff failed to change their gloves or sanitize their hands after touching soiled surfaces, prior to touching the resident and his/her personal items. Staff also placed soiled linens directly onto the resident's floor. The sample was 18. The census was 82. Review of the Facility's Incontinent Care policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care; -Procedure: Explain procedure to the resident. Perform hand hygiene and apply gloves. Removed soiled brief. Cleanse the perineal area (the surface area between the thighs, extending from the pubic bone to the tail bone); -Use a clean surface area for the cloth for each wipe and use multiple cloths if necessary to maintain infection control; -Remove soiled gloves, perform hand hygiene and apply clean gloves; -Apply clean brief and clothing. 1. Review of Resident #46'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 observation, interview and record review, the facility failed to ensure the residents' call light system was working properly and ensure that the call light was in reach for two of 18 sampled residents (Residents #31 and #37). The census was 82. Review of the facility's Resident Call System Policy, dated 10/20/22, showed the following: -Policy: The facility call system relays calls directly to a centralized work area from the resident's bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines; -Responsibility: Nursing, Interdisciplinary Team (IDT) Members, Maintenance Director, and Licensed Nursing Home Administrator (LNHA); -Procedure: -Upon admission nursing will orientate resident to accessing the resident call system; -During rounds nursing and IDT team members will ensure resident call system is within reach of the resident; -In the event resident call system is down; call bells will be utilized until power is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a corridor in one hall was completely equipped with handrails. This practice potentially affected any residents who reside in or use this area in the facility. The census was 82. Observation on 1/22/23 at 9:15 A.M., showed the handrail in between the men's shower and room [ROOM NUMBER], a whole piece of handrail was missing. The three braces and screws, where the handrail was supposed to be hung, were still attached to the wall. During an interview on 1/22/23 at 10:01 A.M., Certified Nurse Assistant (CNA) Q said the handrail by room [ROOM NUMBER] has been missing for months. He/She said there was no handrail in that area when he/she was employed in September 2022. He/She said the maintenance staff were aware of the issue. During an interview on 1/27/23 at 8:35 A.M., the Maintenance Supervisor said he was made aware of the missing handrail a couple of weeks ago. He said a replacement has been ordered and was waiting for the delivery. 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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for the controlled substances on one of four medication carts. The facility census was 87. 1. Review of the Certified Medication Technician's (CMT)'s narcotic count sheet, dated 6/1 through 7/18/19, for the 100 and 200 Halls, showed the following: -No signature by the on-coming staff, a total of 26 shifts; -No signature by the off-going staff, a total of 33 shifts; -Narcotic count not recorded or signed by the on-coming or off-going staff, a total of 13 shifts. 2. During an interview on 7/18/19 at 1:54 P.M., CMT E said the on-coming and off-going CMTs and nurses are supposed to count the controlled substance cards and the number of pills per card at the beginning and end of every shift and sign the ledger after doing so. The controlled substance report showed 14 cards in the medication cart. CMT E counted the cards…

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 dignity to residents by not providing dining assistance to one visually impaired resident (Resident #40), failed to assist a resident with wet soiled clothing (Resident #8), failing to treat a wound and allowing the drainage from that wound to remain visible on the wall (Resident #14) and by placing a resident who could not eat among a group of others who were enjoying an ice cream treat (Resident #69). The sample size was 18. The census was 87. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/19, showed the following: -Severe cognitive impairment; -Unable to ambulate; -Extensive assistance to total dependence on staff for all mobility and personal care; -Supervision with eating; -Severely impaired vision; -Diagnoses included diabetes, dementia, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels…

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 complete a facility code status (full code-if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed) form for one resident (Resident #77), failed to obtain a physician's order for code status for one resident (Resident #6) and failed to perform a yearly review to verify the code status for two residents (Residents #10 and #14). These practices affected four out of 18 sampled residents. The census was 87. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease and malnutrition. Review of the medical record, showed the following: -A physician's order, dated 11/1/18, for full code; -An 8 by 10 inch form in the front of the chart that read FULL CODE; -No signed…

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 maintain records of residents' personal possessions. Furthermore, the facility failed to address the process to maintain personal property inventory sheets in the facility's admission agreement. A review of 18 sampled residents, showed nine residents did not have documentation of their personal possessions in their medical records (Residents #39, #10, #57, #28, #14, #69, #238, #63 and #1). The census was 87. 1. Review of the facility's admission Agreement, undated, showed the facility did not address how they would document and maintain personal property inventory sheets. 2. Review of Resident #39's medical record, showed the following: -admitted to the facility on [DATE]; -A personal property inventory sheet, dated 10/24/13; -No updated personal inventory sheet. No television or radio marked on the inventory sheet. Observation of the resident's room, showed an approximately 32 inch flat screen television, and a newer radio sat on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide and ensure nail care, including cleansing and trimming had been completed and provide proper grooming for facial hair for four of 18 sampled residents (Residents #84, #21, #59 and #40). The census was 87. 1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/19, showed the following: -Moderate cognitive impairment; -Dependent on staff for personal hygiene; -Diagnoses included dementia, Parkinson's disease (a neurological condition that causes muscle rigidity, tremors, and changes in speech and gait) and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). Review of the care plan, dated 4/3/19, showed the following: -Problem: Resident has a self care performance deficit related to dementia, disease process of Parkinson's and impaired balance; -Goal: Resident will maintain current level 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 interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to obtain qualifying diagnoses for the use of antipsychotic medications for three of 18 residents sampled (Residents #77, #63 and #1). The census was 87. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed the following: -admitted to the facility on [DATE] with a readmission date of 11/16/18; -Severe cognitive impairment; -Unable to ambulate; -Extensive to total dependence on staff for all care; -Received an antipsychotic and antidepressant the last seven of seven days; -Diagnoses included Alzheimer's disease and malnutrition. Review of the physician's order sheets (POS), dated 12/1/18 through 7/31/19, showed an order, dated 1/28/19, to administer Seroquel (antipsychotic) 100 milligrams (mg) twice a day (BID) for a diagnosis of dementia with behavioral…

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 develop and implement person-centered comprehensive care plans to meet preferences and goals and address residents' medical, physical, mental and psychosocial needs, by not addressing a resident's behavioral needs (Resident #63) or address a resident's discharge goals (Resident #1). The census was 87. 1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/19, showed the following: -Moderate cognitive impairment; -No behaviors; -Extensive assistance from staff for toileting, hygiene, dressing and transfers; -Diagnoses included high blood pressure, depression, diabetes and bipolar disorder (unusual shifts in mood). Review of the resident's medical record, showed the following: -On 6/3/19 at 5:37 P.M., new orders received for the resident to be sent to the hospital after hitting another resident. When asked what happened, the resident stated that he/she wanted 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 interview and record review, the facility failed to summarize the stay for one of the two discharged residents' records reviewed (Resident #87). The staff did not write a discharge note or indicate what information they provided to the resident and to the receiving facility. The census was 87. 1. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/19, showed the following: -Moderate cognitive impairment; -Limited assistance required for personal hygiene; -Independent with all mobility; -Continent of bowel and bladder; -Diagnoses included paranoid schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves including auditory and visual delusions and hallucinations), social phobias, impulse disorder (failure to resist a temptation) and autistic disorder (characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication). Review of the physician order sheets (POS), dated 6/1/19, showed the resident's medications…

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

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident (Resident #84) by not recognizing a weight loss of 9.02% over a period of three months and not ensuring the resident received an evaluation by a registered dietician. The sample size was 18. The census was 87. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/19, showed the following: -Moderate cognitive impairment; -Extensive assistance required for all mobility, eating and toileting; -Dependent on staff for personal hygiene; -Diagnoses included dementia, Parkinson's disease (a neurological condition that causes muscle rigidity, tremors, and changes in speech and gait) and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). Review of the care plan, dated 3/29/19, showed the following: -Problem: Resident has the potential for nutritional problem related to psychosis (disruption of thoughts and…

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