Oaks Of West Kettering The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff and resident interviews, observations, and policy reviews, the facility failed to follow infection control procedures during wound and incontinence cares. This affected two (#08 and #62) out of three residents observed for infection control procedures. The facility census was 95. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 06/21/24 with medical diagnoses of chronic respiratory failure with hypoxia, chronic viral Hepatitis C, neuromuscular dysfunction of bladder, anemia, paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/14/25, indicated Resident #62 was cognitively intact, was dependent upon staff for all activities of daily living and had an indwelling catheter. Review of the medical record revealed a care plan, dated 11/20/24, which stated Resident #62 had a urinary catheter related to neurogenic bladder with an intervention to perform catheter care every shift. Review of physician orders…

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

Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure resident room was free from flies. This affected one (#11) out of three residents reviewed for pests/insects in rooms. The facility census was 95. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/26/25 with medical diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 08/02/25, revealed Resident #11 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene and substantial/maximum assistance for bathing, transfers, and bed mobility. Observation with interview on 08/18/25 at 11:28 A.M. of Resident #11's room revealed six flies either flying in the room or sitting on Resident #11's bedsheets. Resident #11 stated he has had issues with flies in his room since he arrived at the facility. Interview on 08/18/25 at 11:33 A.M. with Licensed Practical Nurse (LPN) #256 confirmed…

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 staff interview, the facility failed to ensure a floating porcelain sink was maintained in a safe manner. This affected one (#66) resident of three residents reviewed for physical environment. The facility census was 101. Findings included: Review of the medical record for Resident #66, revealed an admission date of 11/11/24. Diagnoses included toxic encephalopathy, schizophrenia, chronic viral hepatitis-C, visual hallucinations, auditory hallucinations, alcohol abuse, drug induced akathisia, muscle weakness and dysphagia. Review of the admission Minimum Data Set (MDS) assessment for Resident #66 dated 11/18/24, revealed Resident #66 had moderate cognitive impairment and the resident required moderate assistance with transfers and sitting to standing. Review of an incident report titled Skin Tear dated 12/15/24 at 11:23 A.M. and authored by Licensed Practical Nurse (LPN) #233, revealed a Certified Nursing Assistant (CNA) reported Resident #66 was bleeding. There was blood noted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, observation, and review of facility policy, the facility failed to ensure a resident's representative was notified when a resident had a change in condition by sustaining a laceration which required sutures and continued wound care. This affected one (#66) of three residents reviewed for notification of change in condition. The facility census was 101. Findings included: Review of the medical record for Resident #66, revealed an admission date of 11/11/24. Diagnoses included toxic encephalopathy, schizophrenia, chronic viral hepatitis-C, visual hallucinations, auditory hallucinations, alcohol abuse, drug induced akathisia, muscle weakness and dysphagia. Review of the admission Minimum Data Set (MDS) assessment for Resident #66 dated 11/18/24, revealed Resident #66 had moderate cognitive impairment and the resident required moderate assistance with transfers and sitting to standing. Review of an incident report titled Skin Tear dated 12/15/24 at 11:23 A.M. and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure the facility's East Unit crash cart included an assembled suction machine with canister, and a backboard. This affected 49 residents (#26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73 and #74) who resided on the East Unit out of the 112 residents at the facility. The facility census was 112. Finding include: Observation of the East Unit crash cart on [DATE] at 7:45 A.M. with Registered Nurse (RN) #56, revealed there was a suction machine sitting on top of the crash cart; however, there was no suction collection canister in place or located in the crash cart. There was also no backboard on the crash cart. Review of the Emergency Crash Cart Checklist for [DATE] at the same time, revealed all dates were blank, indicating the crash cart had not…

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 facility policy review, the facility failed to ensure the high temperature dishwashing machine sanitized at the proper temperature. This failure had the potential to affect 85 of 88 residents who received food from the kitchen. Findings included: During an interview on 07/08/24 at 8:48 A.M., the Dietary Director (DD) stated the dishwashing machine rinse temperature should be 180 degrees Fahrenheit (F). The DD stated she thought the thermostat was broken. During an interview on 07/09/24 at 8:12 A.M., Dietary Aide (DA) #15 stated she had checked the dishwashing machine temperature on the morning of 07/08/24, and the temperature reached 190 degrees F. DA #15 stated, as far as she knew, the dishwashing machine thermostat worked correctly. During an interview on 07/09/24 at 10:04 A.M., the Service Technician, from the dishwashing machine company, indicated there were two thermostats on the dishwashing machine. He stated one thermostat indicated the rinse tank temperature and another thermostat that was toward the back left of the dishwashing machine…

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, record review, and facility policy review, the facility failed to establish and maintain an infection control program to prevent the transmission/development of infection for three (Resident #139, Resident #37, and Resident #5) of seven residents reviewed for infection control. Specifically, the facility failed to ensure that staff implemented Enhanced Barrier Precautions (EBP) for Resident #37 and #139 and failed to appropriately handle dirty linens and store respiratory equipment properly for Resident #5. Findings include: 1. Medical record review indicated the facility admitted Resident #139 on 06/21/24. According to the admission Record, the resident had a medical history that included diagnoses of sepsis, chronic kidney disease, and neuromuscular dysfunction of the bladder. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 06/28/24, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident #37) of six residents who required tube feedings received enteral nutrition in a manner that minimized the risk of complications. Specifically, the facility failed to ensure that Resident #37's enteral nutrition (tube feeding) formula was labeled with the date and time the infusion began. Findings included: Medical record review revealed the facility admitted Resident #37 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of persistent vegetative state, anoxic brain damage, gastro-esophageal reflux disease, and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #37 was in a persistent vegetative state with no discernable consciousness. The MDS indicated Resident #37 had a feeding tube for nutrition and received 51 percent (%) or more of their calories through tube…

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, record review, and facility document review, the facility failed to obtain laboratory services ordered by the physician for one (Resident #74) of five residents reviewed for urinary catheter/urinary tract infection. Findings include: Medical record review revealed the facility admitted Resident #74 on 03/22/24. According to the admission Record, Resident #74 had a medical history that included diagnoses of person injured in a traffic collision, fracture of the left femur, fracture of the right femur, multiple fractures of ribs, contusion of the lungs bilaterally, urge incontinence, and a closed fracture of the right lower leg. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/24, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #74 required set up or clean-up assistance from staff with eating. According to the MDS, Resident #74 had an indwelling urinary catheter. The MDS revealed the resident had no active…

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, facility document review, and facility policy review, the facility failed to follow the planned menu for the pureed diet for one (Resident #54) of seven residents who received pureed diets. Findings include: Medical record review indicated the facility admitted Resident #54 on 05/17/24. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #54's Order Summary Report, with active orders as of 07/11/24, revealed an order with a start date of 07/06/24 for a regular diet pureed texture. Review of the Puree diet Week at a glance document revealed the facility lunch menu for 07/09/24 that indicated a planned menu for the pureed diet included Pureed 2-#8 [two four ounce or two 1/2 cups] scoop [NAME] Marzetti [a baked pasta, meat, and cheese casserole dish] (1 Cup). An observation of the lunch meal service on 07/09/24 at 11:07 A.M., revealed Resident #54, who was on a pureed diet, was served one #8 scoop of pureed [NAME] Marzetti or one half of the required serving. 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 record review, interview, review of facility documentation, and review of facility policy, the facility failed to report an allegation of sexual abuse to the state agency. This affected one (Resident #137) of three residents reviewed for abuse. Findings include: Medical record review revealed the facility admitted Resident #137 on 07/01/22. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), schizoaffective disorder bipolar type, tobacco use, depression, generalized anxiety disorder, hemiplegia (paralysis or weakness) affecting the left nondominant side, need for assistance with personal care, and unsteadiness on feet. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/24, revealed Resident #137 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. A police report dated 04/09/24 revealed at approximately 1:03 P.M. on 04/09/24, a police officer was dispatched to the facility in response to a Morals/Sex Offenses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, a review of a police report, review of facility documentation, and policy review, the facility failed to have evidence that an allegation of abuse was thoroughly investigated for one (Resident #137) of three residents reviewed for abuse. Specifically, Resident #137 alleged Family Member (FM) #16 sexually abused the resident on 04/09/24. The facility failed to have documented evidence they reviewed facility video [NAME] footage from the time of the incident; failed to have documented evidence they interviewed/obtained statements from the resident, the alleged perpetrator, witnesses, and staff who worked closely with Resident #137; and failed to determine whether abuse was substantiated. Findings included: Medical record review revealed the facility admitted Resident #137 on 07/01/22. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), schizoaffective disorder bipolar type, tobacco use,…

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

Based on medical record review, review of facility investigation, review of Self-Reported Incident (SRI), review of police report, staff interview, review of personnel files, and policy review, the facility failed to ensure residents were free from misappropriation of property. This affected one (#41) out of three residents reviewed for misappropriation. The facility census was 89. Findings include: Review of the medical record for Resident #41 revealed an admission date of 04/17/24. Diagnoses included aphasia following cerebral infarction, ischemic cardiomyopathy, peripheral vascular disease, and chronic kidney disease stage three. Review of the admission Minimum Data Set (MDS) assessment, dated 04/24/24, revealed Resident #41 had moderately impaired cognition. Review of the SRI dated 04/29/24 revealed Resident #41's family reported to the facility that Resident #41's debit card was missing. Resident #41's family provided the facility with bank statements, which showed several transactions that were not made by Resident #41. The SRI indicated the facility's investigation revealed…

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

Based on observation and staff interview, the facility failed to maintain the ice machine in a manner to protect against the spread of food borne illness. This had the potential to affect all 90 residents in the facility. The facility census was 90. Findings include: Observation on 07/26/21 at 8:50 A.M., revealed the ice machine in the kitchen with a plastic bag loosely covering the opening. Ice was observed through the loosely covered opening. The lid to the ice machine was observed on the floor beside the ice machine. There was a cart containing dirty dishes approximately 2 feet away from the ice machine. Interview on 07/26/21 at 8:50 A.M., with the Dietary Manager (DM) #17 stated the lid had been in need of repair since the week prior and verified the opening to the ice machine was not secure, ice was visible through the sides of the plastic bag, and the cart containing dirty dishes in close range of the ice machine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident, visitor and staff interviews, review of facility policy, and review on online resources per the Center for Medicare and Medicaid Services (CMS) nursing home memos, the facility failed to permit resident visitation at the time of their choosing and provide privacy for visits. This affected four(#54, #68, #79 and #31) of four residents reviewed for visitation practices. The census was 90. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 08/22/17, with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 07/21/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the care plan for Resident #54 dated 03/13/20 revealed the resident was at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19 precautions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff interviews the facility failed to ensure care plans were updated or revised for residents residing on the secured unit. This affected six (#8, #22, #50, #54, #68 and #85) of 37 sampled residents. The facility identified thirty residents who reside on the secured unit. The facility census was 90. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 12/09/20, with diagnoses including Alzheimer's disease, dementia with behavioral disturbance. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and requires supervision with locomotion on unit. Further review of the medical record revealed a Wander Risk assessment dated [DATE], that revealed the resident was at moderate risk for wandering/elopement. Review of the resident's medical record failed to provide a plan of care addressing the resident's need to be placed on the secured unit…

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, staff interview, and review of facility policy the facility failed to ensure expired house stock insulin was discarded. The facility failed to ensure topical medication was stored separately from oral inhalers. This had the potential to affect seven (#5, #19, #33, #35, #64, #80, #339) insulin-dependent residents on the Central Unit. This affected one (#9) of one resident receiving topical ointments. The census was 90. Findings include: 1. Observation on [DATE] at 1:15 P.M., of the Central Unit medication room,with Registered Nurse (RN) #27 revealed there was a house stock vial of insulin unopened with an expiration date of [DATE] being stored with the house stock medications. Interview on [DATE] at 1:15 P.M., with RN #27 confirmed the house stock insulin was expired and should have been discarded. Review of the facility list of residents on the central unit revealed seven (#5, #19, #33, #35, #64, #80, #339) insulin dependent residents. Review of the facility policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to have the required information on discharged notices. This affected two (#1 and #19) of four reviewed for hospitalizations. The census was 90. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 10/17/19. Diagnoses listed included major depressive disorder, osteogenesis imperfecta, cerebral infarction, hypertension, sickle-cell disease, anxiety disorder, and hyperlipidemia. Further review of the medical record revealed Resident #1 was discharged to a local hospital on [DATE] for chest and lung pain. Review of a facility document titled Notice of Hospital Transfer or Therapeutic Leave dated 05/26/21, revealed the form did not contain the reason for discharge, a state of the resident's rights to appeal, or the Office of the State Long Term Ombudsman information. 2. Review of the medical record of Resident #19 revealed an admission date of 08/16/19 and readmitted to the facility on [DATE]. 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 medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure dependent residents were provided with adequate nail care. This affected one (#68) of three residents reviewed for activities of daily living (ADLs). The facility identified 62 residents dependent on staff assistance with ADLs. The census was 90. Findings include: Review of the medical record for Resident #68 revealed an admission date of 02/27/21, with a diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #68 dated 06/18/21 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the care plan for Resident #68 dated 02/27/21 revealed the resident had impaired ADL function related to impaired memory, confusion, impaired mobility/balance, potential to be in pain, and current health status. Goal of care plan was for resident to have ADL needs met with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interview, the facility failed to ensure wounds were provided treatments as ordered and regularly assessed. This affected one (#78) of four residents reviewed for wound care. The facility census was 90. Findings included: Review of the medical record for Resident #78 revealed an admission date of 06/18/21 and a diagnosis of peripheral vascular disease (PVD). Review of admission nurses note for Resident #78 dated 06/18/21 revealed resident was admitted to the facility from the hospital with multiple wounds to bilateral lower extremities. Review of admission nursing assessment for Resident #78 dated 06/18/21 revealed resident had multiple gangrenous areas to bilateral lower extremities and a stage four pressure area to his sacrum. Review of the assessment revealed there was no further description of resident's wounds. Review of the Minimum Data Set (MDS) for Resident #78 dated 07/04/21 revealed resident was cognitively impaired and required extensive…

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, staff interview, and review of facility policy the facility failed to regularly assess pressure sores, obtain physician orders for new developed pressure sores and apply pressure relieving devices This affected three (#78, #68 and #41) of four residents reviewed for wound care. The census was 90. Findings include: 1. Review of the medical record for Resident #78 revealed an admission date of 06/18/21 and a diagnosis of peripheral vascular disease (PVD). Review of the Minimum Data Set (MDS) for Resident #78 dated 07/04/21 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs). Review of admission nurses note for Resident #78 dated 06/18/21 revealed resident was admitted to the facility from the hospital with a stage four pressure ulcer to the sacrum. Review of admission nursing assessment for Resident #78 dated 06/18/21 revealed resident had multiple gangrenous areas to bilateral lower extremities and a stage…

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, medical record review, and staff interviews, the facility failed to provide treatment of physician ordered splint devices to maintain range of motion and prevent contractures. This affected one (#41) of three residents reviewed for limited range of motion. The facility identified 26 residents residing in the facility with contractures. The facility census was 90. Findings include: Review of the medical record of Resident #41 revealed an admission date of 01/08/15. Diagnoses included malignant neuroleptic syndrome, cerebral infarction, ST Elevation (SEMI) myocardial infarction, essential hypertension, gastro-esophageal reflux, COVID-19, persistent vegetative state, tracheostomy status, gastrostomy status, anoxic brain damage, anxiety disorder, and severe hypoxic ischemic encephalopathy. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required total dependence of two staff for bed mobility, transfers,…

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

Based on medical record review, observations, resident interview, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place and environmental hazards were not present in a room for a resident assessed at risk for falls. This affected two (#68 and #8) of seven residents reviewed for accidents and hazards. The census was 90. Findings include: 1. Review of the medical record for Resident #68 revealed an admission date of 02/27/21, with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #68 dated 06/18/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the fall risk assessment for Resident #68 dated 06/30/21 revealed the resident was at risk for falls. Review of the care plan for Resident #68 dated 10/09/19 revealed the resident was at risk for falls and fall related injury related to impaired mobility/balance, incontinence, potential to be in pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to provide timely incontinence care for a resident and ensure a resident with a nephrostomy tube was provided care and treatment per physician orders. This affected two (#15 and #19) of three reviewed for care and treatment of bladder and bowel. The census was 90. Findings include: Review of Resident #15's medical record revealed an admission date of 11/07/16. Diagnoses listed included peripheral vascular disease, major depressive disorder, disorder of thyroid, atrial flutter, hyperlipidemia, anxiety disorder, chronic pain syndrome, diabetic polyneuropathy, and type II diabetes mellitus. Resident #15 was assessed as being cognitively intact, requiring extensive assistance of one for activities of daily living (ADLs) in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Review of Resident #15's care plan revealed she has an alteration in bladder elimination/incontinence. Resident #15 wears…

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 the medical record review and staff interview, the facility failed to ensure medications were administered per physician orders. This affected two (#15 and #20) of six resident medical records reviewed for pharmacy. The facility census was 90. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 11/07/16. Diagnoses listed included peripheral vascular disease, major depressive disorder, disorder of thyroid, atrial flutter, hyperlipidemia, anxiety disorder, chronic pain syndrome, diabetic polyneuropathy, and type II diabetes mellitus. Resident #15 was assessed as being cognitively intact, requiring extensive assistance of one for activities of daily living (ADLs) in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Further review revealed physician orders: dated 03/31/18 for aspirin enteric coated 81 milligrams (mg) one tablet (PO) by mouth daily, an order dated 07/16/18 for atorvastin calcium 10 mg PO daily, and an order dated 03/03/20 Celexa 10 mg PO…

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. Review of the medical record of Resident #05 revealed an admission date of 10/17/20. Diagnoses included muscle weakness, type 2 Diabetes Mellitus with diabetic neuropathy, morbid obesity, essential hypertension, paroxysmal atrial fibrillation, major depressive disorder, COVID-19, polyneuropathy, gastroesophageal reflux, and sleep apnea. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician's orders revealed an order dated 06/11/21 for hydroxyzine hcl tablet 25 milligrams (mg) as needed (PRN) every 8 hours for anxiety. Review of the pharmacy medical record review dated 06/24/21 revealed a notification of the order for hydroxyzine PRN required a 14-day stop with an in-person physician evaluation prior to re-ordering the medication. Recommendations were made to review the PRN order and indicate the length of therapy for the order. Below the pharmacy recommendations, the box indicating disagreement was checked and was signed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interview, the facility failed to ensure gradual dosage reductions were attempted for residents receiving psychotropic medications and failed to ensure antipsychotic medications were given for an appropriate indication. This affected three (#54, #68 and #15) of six residents reviewed for unnecessary medications. The facility identified 23 residents with orders for antipsychotic medications. The facility census was 90. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 08/22/17 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #54 dated 07/12/21 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the care plan for Resident #54 dated 06/16/19 revealed the resident had a behavior problem including wandering and an instance of physical aggression on 06/16/19.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policies, the facility failed to ensure staff practiced appropriate hand hygiene during medication administration. This affected one (#31) of five residents observed for medication administration. The census was 90. Findings include: Review of the medical record revealed Resident #31 was admitted on [DATE], with a diagnosis of chronic kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #31 date 05/21/21 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of the July 2021 physician orders for Resident #31 revealed an order dated 07/24/20 for potassium chloride tablets by mouth every morning. Observation on 07/28/21 at 9:03 A.M., revealed Licensed Practical Nurse (LPN) #30 broke potassium chloride tablets with her bare hands and placed them in a cup with applesauce for administration. Interview on 07/28/21 at 9:03 A.M. with LPN #30 confirmed…

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 facilities water management program, observations, staff interview, and policy review, the facility failed to properly sanitize the blood glucose monitoring system between resident use. This affected one (#282) of two resident using the glucometer during medication administration. The facility identified ten resident who use the glucometer from the west medication cart. Additionally, the facility failed to implement a water management program for the prevention and spread of Legionella. This had the potential to affect all 86 resident who reside at the facility. The census was 86. Findings include: 1. Observation on 04/01/19 at 5:30 P.M. of licensed practical nurse (LPN) #353 revealed the LPN used the blood glucose meter to check the blood glucose level for Resident #22. After completing the check for Resident #22, LPN #353 returned to the medication cart and cleansed the glucose meter with an alcohol prep pad. LPN #353 then picked up the glucometer, walked to the room of Resident #282, and used the glucose meter to assess Resident #282's blood glucose level.…

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 medication storage area observation and staff interviews, the facility failed to properly label and store medications. Additionally, the facility failed to adequately secure narcotic medication. This affected one (#26) resident medication that was expired, one medications with no residents identification information or prescription label, and one multi-use vial of medication that was opened and undated located in two (central one medication cart and east one medication cart) of five medication storage areas observed. The census was 86. Findings include: 1. Observation on 04/04/19 at 1:19 P.M. of the central one medication cart revealed basaglar insulin pen 100 units/milliliter prescribed to Resident #26 was opened on 03/06/19. Review of the insulin pen package revealed the medication expired 28 days after opening. Interview on 04/04/19 at 1:20 P.M. with licensed practical nurse (LPN) #335 verified the basaglar insulin pen prescribed to Resident #26 and located in the central one medication cart was expired. 2. Observation and interview on 04/04/19 at 1:36 P.M. of the east…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure advanced directives being stored in the hard chart and electronic health record (EHR) were consistent. This affected one (#32) of 24 residents reviewed for consistency of advanced directives. The census was 86. Findings include: Review of the medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dysphagia, dementia with behavioral disturbances, hypertension, neoplasm of digestive system, major depressive disorder, vascular dementia, diabetes mellitus type two, chronic pain syndrome, affective mood disorder, chronic kidney disease, osteoarthritis, psychosis, weakness, edema, and left upper extremity flexion contractures in the elbow, wrist and hand. Review of the Resident #32's care plan dated 11/16/16, revealed the resident had advanced directives in place which included do not resuscitate comfort care (DNRCC). Interventions included the doctor, physician assistant or nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family, nurse practitioner and staff interview, and review of facility policy, the facility failed to notify resident representatives and/or the provider of a change in a resident's status or refusals of care. This affected three Residents (#36, #51, and #77) of three residents reviewed for notification of changes. The facility census was 86. Findings include: 1. Review of Resident #77's medical record revealed an admission date of 03/30/17 with diagnoses that included dementia with behavioral disturbance, insomnia, osteoarthritis, malignant neoplasm of breast, anemia, and mood disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated revealed Resident #77 had severe cognitive impairment. Review of physician orders dated 04/17/18 revealed Seroquel (antipsychotic) was ordered 50 milligrams (mg) by mouth every 12 hours. Review of physician orders dated 04/13/18 revealed Seroquel 25 mg by mouth at bedtime was discontinued for gradual dose reduction. Review of physician…

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 staff interview, the facility failed to provide written transfer notification to one (#84) resident when they were hospitalized and failed to notify the Ombudsman of the transfer. This affected one (#84) of one residents reviewed for hospitalization and had the potential to affect all residents. The facility census was 86. Findings include: Review of Resident #84's medical record indicated an admission date of 12/27/18. Diagnoses included gastrointestinal hemorrhage, unsteadiness on feet, type two diabetes mellitus, hypertension, hyperlipidemia, convulsions, anemia, anxiety disorder and major depressive disorder. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #84 had severely impaired cognitive skills for daily decision making and required extensive assist of two for bed mobility, transfers, toileting, dressing and personal hygiene. The medical record indicated Resident #84 was transferred and admitted to the hospital on [DATE] after a fall. 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 medical record review, policy review and staff interview, the facility failed to issue written notice of the bed hold policy when a resident was transferred to the hospital. This affected one (#84) of one residents reviewed for hospitalizations. The total facility census was 86. Findings include: Review of Resident #84's medical record indicated an admission date of 12/27/18. Diagnoses included gastrointestinal hemorrhage, unsteadiness on feet, type two diabetes mellitus, hypertension, hyperlipidemia, convulsions, anemia, anxiety disorder and major depressive disorder. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #84 had severely impaired cognitive skills for daily decision making and required extensive assist of two for bed mobility, transfers, toileting, dressing and personal hygiene. The medical record indicated Resident # 84 was transferred and admitted to the hospital on [DATE] after a fall. The record revealed the record had no evidence the resident 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 medical record review and staff interview, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected one (#32) of 20 resident reviewed for accuracy of the MDS assessment. The census was 86. Findings include: Review of the medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dysphagia, dementia with behavioral disturbances, hypertension, neoplasm of digestive system, major depressive disorder, vascular dementia, diabetes mellitus type two, chronic pain syndrome, affective mood disorder, chronic kidney disease, osteoarthritis, psychosis, weakness, edema, and left upper extremity flexion contractures in the elbow, wrist and hand. Review of occupational therapy progress notes certification period 10/21/18 through 01/09/19, revealed Resident #32 was assessed to have left elbow, hand, and wrist contractures. Documentation revealed Resident #32 had limited range of motion to the left upper extremity. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and review of policy and procedures, the facility failed to ensure 48 hours baseline care plan were completed and failed to ensure a copy was provide to the resident/resident representative as required. This affected three Residents (#4, #59 and #60) out of nine residents in the investigative sample. The facility census was 86. Findings include: 1. Review of medical record for Resident #60 revealed an admission date of 02/21/19 with diagnosis including muscle weakness, type two diabetes, chronic obstructive pulmonary disease, low back pain, congestive heart failure and hypertension. Review of nursing evaluation completed 02/21/19 lacked any documentation of a baseline care plan. Review of comprehensive care plan documented On 02/25/19 was the date of the Resident #60 care plan development was initiated for a nutritional risk. Further review lacked any documentation of the formulation of a 48 hour baseline care plan. Review of care conference summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and nurse practitioner interview and policy review, the facility failed to obtain blood work as ordered for one resident which resulted in a delay in treatment. This affected one (#51) of five residents reviewed for medications. The census was 86. Findings include: Review of Resident # 51's medical record revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included peripheral vascular disease, major depressive disorder, thyroid disorder, atrial flutter, hyperlipidemia, right below the knee amputation, chronic obstructive pulmonary disease, hypothyroidism, and type two diabetes mellitus with diabetic polyneuropathy. The resident's annual minimum data set (MDS) assessment dated [DATE] indicated the resident had mild or no cognitive impairment and required extensive assistance with activities of daily including bed mobility, dressing, toileting and hygiene. The physician orders included a comprehensive metabolic panel (CMP) monthly. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff interview, the facility failed to ensure a physician ordered splint device was available for resident use. This affected one (#32) of one resident reviewed for limited range of motion. The census was 86. Findings include: Review of the medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dysphagia, dementia with behavioral disturbances, hypertension, neoplasm of digestive system, major depressive disorder, vascular dementia, diabetes mellitus type two, chronic pain syndrome, affective mood disorder, chronic kidney disease, osteoarthritis, psychosis, weakness, edema, and left upper extremity flexion contractures in the elbow, wrist and hand. Review of the care plan dated initiated 05/31/17, revealed Resident #32 required a restorative program for splinting. The intervention included apply splint to left elbow as tolerated. Review of occupational therapy progress notes certification period 10/21/18…

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 policy review, medical record review and staff interview, the facility failed to investigate one resident's fall with injury to identify contributing factors to possible prevent future falls. This affected one (#36) of two residents review for accidents. The census was 86. Findings include: Review of Resident #36's medical record review indicated the resident was admitted on [DATE]. Diagnosis included Alzheimer's disease, cerebral arthrosclerosis, major depression, type two diabetes mellitus, hypertension, hyperlipidemia, anxiety and schizoaffective disorder. The resident's minimum data set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment and required limited assistance with activities of daily including ambulation, locomotion and extensive assistance with transfers, dressing, eating, toileting and hygiene. The resident's care plan dated 05/23/18 indicated the resident was at risk for falls and fall related injury. Review of Resident #36's progress notes indicated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and resident and staff interview, the facility failed to implement a fluid restriction as recommended for a dialysis resident. This affected one (#182) out one resident review for dialysis care. The facility identified two residents currently residing in the facility who receive dialysis treatments. The census was 86. Findings include: Review of medical record for Resident #182 revealed an admission date of 03/28/19 with diagnosis including hypertension, type two diabetes, hyperparathyroidism, anemia related to chronic kidney disease, Rheumatic mitral stenosis insufficiency and end stage renal disease. Review of hospital documentation dated 03/11/19 documented a Registered Dietician assessed Resident #182 and his current diet order consisted of mechanical altered diet with thins liquids and a 1,500 milliliters (ml) fluid restriction Review of the facility's hospital discharge report sheet dated 03/28/19 documented Resident #182 was identified as a dialysis 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 medical record review, staff interview, and policy review, the facility failed to ensure a resident was free from unnecessary medications regarding prescribing antibiotics for the appropriate signs and symptoms of infection. This affected one (#48) of five resident reviewed for unnecessary medication. The census was 86. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbances, hypothyroidism, hypertension, insomnia, diabetes mellitus, psychosis, and Alzheimer's disease. Review of a progress note dated 03/26/19 at 9:11 A.M. revealed Resident #48 was assessed by the nurse practitioner and noted to have a hard raised area on the left forearm. Documentation revealed an order was given for antibiotic therapy for three days. Continued review of the medical record for Resident #48 revealed no other assessment information to describe symptoms related to the hard raised area 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 medical record review and staff interview, the facility failed to ensure physician ordered laboratory tests were completed. This affected one (#48) of five resident reviewed for unnecessary medication. The census was 86. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbances, hypothyroidism, hypertension, insomnia, diabetes mellitus, psychosis, and Alzheimer's disease. Review of a physician order dated 01/09/19 revealed Resident #48 was ordered the laboratory tests complete blood count (CBC), basic metabolic panel (BMP), hemoglobin A1c (HgbA1c) and thyroid-stimulating hormone (TSH) to be completed every six months starting on the fifteenth for hypothyroid, anemia, and diabetes mellitus type two. Review of Resident #48's medical record revealed no evidence the laboratory tests CBC, BMP, HgbA1c and TSH were completed during the months of 01/19, 02/19, 03/19, or 04/19. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident representative and staff interview, the facility failed to provide routine dental services. This affected one (#35) of one resident reviewed for dental services. The census was 86. Findings include: Review of the medical record for Resident #35 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral disturbances, hypothyroidism, anxiety, hypertension, diabetes mellitus type two, amnesia, and heart failure. Review of the care plan dated 03/24/19 revealed Resident #35 had dentures. The resident required assistance with oral care and wore full upper and lower dentures. Resident #35 was to consult with a dentist for assessment and treatment of oral health. Review of the medical record for Resident #35 revealed no evidence of routine dental services offered to the resident. There was no documentation of consent or refusal for dentistry services. Interview on 04/01/19 at 6:15 P.M. with Resident #35's representative revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed implement their antibiotic stewardship protocols to ensure appropriate antibiotic use. This affected one (#48) of three resident's reviewed for antibiotic use. The census was 86. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbances, hypothyroidism, hypertension, insomnia, diabetes mellitus, psychosis, and Alzheimer's disease. Review of a progress note dated 03/2619 at 9:11 A.M. revealed Resident #48 was assessed by the nurse practitioner and noted to have a hard raised area on the left forearm. Documentation revealed an order was given for antibiotic therapy for three days. Continued review of the medical record for Resident #48 revealed no other assessment information to describe symptoms related to the hard raised area on the resident's left forearm. Review of the physician's orders dated 03/26/18…

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.