Oak Grove Manor

Based on observation and interviews, the facility failed to ensure residents had water at the appropriate temperature in their bathrooms. This affected three (Residents #3, #4, and #6) out of three reviewed for water temperatures. Facility census was 59. Findings include: Review of an invoice dated 10/16/24 revealed a fifty-gallon hot water tank was ordered. Review of a typed timeline provided by Maintenance Supervisor #104 revealed he was notified the hot water heater for Resident #3's room blew the seams out of the back. An order was placed for a new hot water heater. The new hot water heater was delivered late in the afternoon of 10/16/24. Maintenance Supervisor #104 installed the new hot water heater on 10/17/24. According to the timeline on 11/15/24, Maintenance Supervisor #104 was notified of the high limit switch and the breaker for the new hot water tank were tripping frequently. Maintenance Supervisor #104 replaced the upper thermostat on 11/15/24. On 11/22/24, Maintenance Supervisor #104 was notified that the water was cold again. Maintenance Supervisor #104 found 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, record review, and interview, the facility failed to ensure treatments were put in place in a timely manner. This affected three (Residents #3, #6, and #7) of three residents reviewed for wounds. Facility census was 59. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included acquired absence of bilateral legs, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic pain syndrome. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and had Moisture Associated Skin Damage (MASD). A skin condition/shower sheet dated 11/06/24 revealed Resident #3 had an open area that appeared to be an abrasion. Resident #3 requested to have an appointment made at the dermatologist. A skin monitoring/shower review sheet dated 11/12/24 revealed Resident #3 had an abrasion to buttock. Resident #3 did not want to see the facility Certified Nurse Practitioner (CNP). On 11/13/24 an…

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

Based on observation, staff interview, review of a cleaning task list, and policy review, the facility failed to store food in a safe and sanitary manner and failed to ensure food service equipment, storage areas, and kitchen floor were properly cleaned. This had the potential to affect all 67 residents. The facility census was 67. Findings included: 1. Observation of the kitchen on 10/24/24 at 9:55 A.M. with Dietary Aide #134 revealed walk-in cooler #1 was full of boxes. The boxes were stored directly on the floor inside the cooler and staff were unable to walk into the cooler due to the amount of boxes stacked four to five boxes high. Interview with Dietary Aide #134 at the time of the observation revealed the facility received the food delivery the day before and no one had time to unpack the boxes. Dietary Aide #134 verified the boxes containing food items were stored directly on the cooler floor. Review of the undated policy titled, Food Storage, revealed all refrigerated food should be stored off of the floor. 2. Observation of the kitchen on 10/29/24 at 7:50 A.M. revealed the…

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

Based on observation, staff interview, and review of a facility policy, the facility failed to maintain a pest free environment. This had the potential to affect all 67 residents. The census was 67. Findings include: 1. Observation on 10/28/24 at 10:00 A.M. revealed the dish washer room in the kitchen had, at minimum, four to five gnats and a fly. Further observation of the kitchen serving area revealed a fly was present in the area. Interview on 10/28/24 at 10:05 A.M. with Dietary Manager #119 verified the gnats and flies in the kitchen. 2. Observation on 10/29/24 at 9:30 A.M. revealed Resident #10 was sitting in a chair in his room. When Resident #10 moved, five (5) flies flew off of him. Interview on 10/29/24 at 9:32 A.M. with the Administrator verified the number of flies in Resident #10's side of the room. The Administrator removed the bag of garbage from the end of the resident's bed; however, no flies were observed near the garbage. Interview on 10/29/24 at 9:48 A.M. with Resident #23 revealed there are often flies in his room. Review of a policy titled, Pest Control Policy,…

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 family interview, staff interview, orthopedic staff interview, review of hand written statements, review of the facility incident and accident log, and policy review, the facility failed to investigate an injury of unknown origin as required. This affected one (#24) of three residents reviewed for abuse, neglect, mistreatment, exploitation, and misappropriation. The facility census was 67. Findings included: Review of Resident #24's medical record revealed an admission date of 10/17/24. Diagnoses included infection and inflammatory reaction due to an internal left knee joint prosthesis, periprosthetic fracture around internal prosthetic right hip joint, atrial fibrillation, transient ischemic attack, and muscle weakness. Review of Resident #24's clinical admission note dated 10/17/24 revealed the resident required use of a wheelchair and knee immobilizer. She had a range of motion impairment of one unspecified lower extremity. Resident #24's gait was documented as…

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 facility menu, resident interview, staff interview, observation, review of the facility food temperature logs, and review of the facility policy the facility failed to ensure food temperatures were assessed to ensure safe ranges prior to resident consumption. This had the potential to affect all 64 residents in the facility who were identified by the facility to receive food from the facility kitchen. The facility census was 64 residents. Findings include: Review of the facility lunch menu dated 07/30/24 revealed the following items were listed: chicken parmesan, spaghetti noodles, cauliflower, garlic toast. Interview on 07/30/24 at 8:26 A.M. with Resident #23 confirmed the food at the facility was fair, sometimes the hot items were not hot enough for her liking. Interview on 07/30/24 at 10:13 A.M. with Staff Member (SM) #510 confirmed she heard food concerns from residents on a daily basis, including hot food items were not hot enough, food was too tough, and residents receiving food they did not order or items they disliked. Interview on 07/30/24 at 11:01…

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, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Residents #39) of three residents reviewed for medication administration. The facility census was 64 residents. Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/11/17 with diagnoses including parkinsonism, bipolar disorder, osteoarthritis, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 07/08/24 revealed the resident was cognitively intact. Review of the physician's orders for Resident #39 revealed an order dated 09/15/23 for Gabapentin (an anti-seizure medication) 600 milligram (mg) tablets three times daily. The order included entries indicating the medication was reordered on 07/23/24 and 07/24/24. Review of the Medication Administration Record (MAR) for Resident #39 dated July 2024 revealed the resident did not receive Gabapentin on 07/23/24 and 07/24/24. Review of 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to serve residents with orders for mechanically altered diets the proper textured diet as ordered by the physician. This affected three (Residents #11, #16, and #18) of 14 residents on a mechanically altered diets. The facility census was 64 residents. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 08/23/19 with diagnoses including Alzheimer's disease, oral phase dysphagia, muscle weakness, and a complete loss of teeth. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 07/12/24 revealed the resident had severely impaired cognition, required a mechanically altered diet and received set up assistance with eating. Review of the care plan for Resident #11 dated 07/16/24 revealed the resident had the potential for oral/dental health problems related to being edentulous (no natural tooth or tooth fragments present) and was at risk for malnutrition and dehydration. Interventions included to consult with…

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, staff interview, resident interview, and review of the facility policy, the facility failed to serve resident meals which honored the resident's preferences and accommodated resident allergies. This affected three (Residents #11, #16, and #18) of 14 residents on a mechanically altered diets. The facility census was 64 residents. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 08/23/19 with diagnoses including Alzheimer's disease, oral phase dysphagia, muscle weakness, and a complete loss of teeth. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 07/12/24 revealed the resident had severely impaired cognition, required a mechanically altered diet and received set up assistance with eating. Review of the care plan for Resident #11 dated 07/16/24 revealed the resident had the potential for oral/dental health problems related to being edentulous (no natural tooth or tooth fragments present) and was at risk for malnutrition and dehydration. Interventions included to consult…

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

Based on resident interview and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected nine (#3, #7, #17, #27, #33, #41, #52, #53, and #56) of nine residents interviewed regarding mail delivery and had the potential to affect all 70 residents residing in the facility. The census was 70. Findings include: Interview on 05/15/24 at approximately 10:00 A.M. with nine (#3, #7, #17, #27, #33, #41, #52, #53, and #56) residents during a Resident Council meeting revealed multiple concerns were expressed that residents were not receiving mail on Saturdays. The residents reported mail was delivered to the business office, sorted, and then distributed to residents by the activities department. The residents reported the business office was typically open Monday through Friday, so mail that was delivered to the facility on Saturday was never distributed to residents within 24 hours of delivery. During an interview on 05/15/24 at 10:40 A.M., Activities Assistant #41 reported the activities department staff were in charge of distributing mail to…

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

Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 70 residents residing in the facility. The census was 70. Findings include: During an observation on 05/13/24 at approximately 8:10 A.M., with Dietary Supervisor #55, two exterior facility dumpsters were observed with trash laying on the ground around the dumpsters. The trash included a potato bag, a chip bag, an empty applesauce container, a disposable glove, soup cans, bread wrappers, jelly packet wrappers, water and pop bottles, cookie wrappers, a used brief, a disposable plastic cup, sandwich wrappers, and a chicken nugget carton from a local fast-food chain. Further observation revealed unidentified animal track marks could be seen throughout the mud located near the dumpsters. During an interview at the time of the observation on 05/13/24, Dietary Supervisor #55 verified the debris on the ground around the dumpster and stated the facility had issues with raccoons.

Based on observation, resident and staff interviews, and review of a concern log, the facility failed to maintain comfortable sounds levels in the facility. This has the potential to affect nine (#3, #7, #17, #27, #33, #41, #52, #53, and #56) of nine residents who voiced concerns regarding the sound levels in the facility. The facility census was 70. Findings include: Observation at the nursing station, which was located in the center of the four units in the facility was completed on 05/15/24 at 7:10 A.M. The observation identified there was a very loud alarm that sounded anytime the door to the patio where residents who smoke go outside was opened. The alarm and panel was located at the front of the nursing station and was very loud. The alarm was heard going off multiple times on 05/15/24 including at 7:14 A.M., 7:18 A.M., and 7:20 A.M. The observation identified there are currently four unidentified residents who are not interviewable located at the nursing station and appeared annoyed at the ongoing sound. Interview with Resident #3 was completed on 05/15/24 at 1:57 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident representative interview, staff interview, and review of scheduled activities, the facility failed to ensure residents were offered or assisted in attending activities and failed to provide activities as scheduled. This affected six (#3, #17, #27, #41, #46, and #53) of nine residents reviewed for participation in activities. The facility census was 70. Findings include: 1. Review of the activity calendar for May 2024 revealed on 05/15/24 the facility would provide a detective activity at 2:00 P.M. and a daily walk outside at 3:00 P.M. Observation on 05/15/24 from 1:57 P.M. to approximately 2:30 P.M. revealed five (#3, #17, #27, #41, and #53) residents were sitting in the dining area where scheduled activities in the facility were planned to take place. Further observation revealed there were no staff in the area and no organized activities were taking place. Interviews at the time of observation revealed numerous random residents reported they were unsure if…

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

Based on personnel file review, staff interview, and review of a job description, the facility failed to ensure the activities program was directed by a qualified individual as required. This had the potential to affect all residents who resided in the facility with the exception of two (#32 and #60) residents who the facility identified as not participating in activities. The facility census was 70. Findings include: Interview on 05/16/24 at 11:23 A.M., with Activities Director (AD) #51 confirmed the staff member did not have the certification, experience, or education required to be the director of the facility's activities program. AD #51 also verified they were not licensed or registered. AD #51 stated the facility would be providing the training for AD #51 to become a certified activities program director. Review of the personnel record for AD #51 revealed AD #51 did not have a certification to be an activities director or the appropriate training and/or education to hold the position of activities director. During an interview on 05/16/24 at 12:22 P.M., the Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interviews, the facility failed to provide one (#71) of 17 sampled residents reasonable accommodations of needs and preferences to enhance the ability to perform self-mobility. The facility census was 70. Findings include: Review of Resident #71's medical record identified admission to the facility occurred on 04/08/24 with medical diagnoses including morbid obesity, congestive heart failure, high blood pressure, diabetes, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 was cognitively intact and required partial/moderate assistance with rolling. Review of Resident #71's physician orders dated 04/13/24 revealed an order for bilateral bed mobility bars to facilitate independence with bed mobility. Observation and interview with Resident #71 occurred in the resident's while the resident was in bed on 05/15/24 at 2:12 P.M. Resident #71's bed was observed without assist bars…

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 and staff interview, the facility failed to ensure one (#38) of five residents reviewed for advanced directives were consistent throughout the medical record. The facility census was 70. Findings include: Review of Resident #38's medical record identified admission to the facility occurred on 09/18/20 with medical diagnoses including congestive heart failure (CHF), edema, pain, morbid obesity, and diabetes. Review of Resident #38's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition. Review of Resident #38's physician orders dated 03/25/24 revealed an order for the resident to be a Full Code (full life-saving measures in the event of cardiac or respiratory arrest) status for advanced directive. Review of Resident #38's current plan of care revealed the resident wished to have a Do Not Resuscitate - Comfort Care (DNR-CC; only comfort measures to be administered in the event of cardiac or…

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

Based on medical record review, resident and staff interview, review of self-reported incidents (SRIs), and policy review, the facility failed to ensure alleged perpetrators were identified in reports of abuse allegations submitted to the State Survey Agency. This affected one (#30) of two residents reviewed for abuse. The facility census was 70. Findings include: Review of Resident #30's medical record identified admission to the facility occurred on 08/08/22 with medical diagnoses including non-stemi myocardial infarction, anemia, hypertension, generalized weakness, depression, obesity, and hypokalemia. Interview with Resident #30 on 05/13/24 at 8:26 A.M. stated Stated Tested Nurse Aide (STNA) #92 was rough with her care and she reported it to the facility. Resident #30 stated the facility did an investigation and asked her questions regarding the incident. Review of the facility's SRI submitted to the State Survey Agency on 04/09/24 identified an allegation of abuse was made by Resident #30. The facility reported the incident as required; however, the facility omitted STNA #92 as…

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, review of emergency medication availability lists, and review of an emergency medication policy, the facility failed to provide an as needed medication from the emergency supply for one (#3) of five residents reviewed for medications. The facility census was 70. Findings include: Review of Resident #3's medical record identified admission occurred on 10/19/17 with medical diagnoses including asthma and bipolar disorder. Review the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was assessed with no cognitive impairment. Review of Resident #3's nursing progress notes identified at 6:43 P.M. on 05/14/24 the resident requested a respiratory assessment be completed. The assessment completed at that time identified no concerns. Further review of the progress notes revealed a note dated 05/15/24 at 3:14 P.M. identified a nurse called the pharmacy and requested a refill of Resident #3's inhaled bronchodilator medication Ventolin inhaler…

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

Based on medical record review and resident and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#59) of five residents reviewed for medications. The facility census was 70. Findings include: Review of the medical record for Resident #59 revealed an admission date of 08/03/23. Diagnoses included absence of right below the knee amputation status post gangrene, type two diabetes with hyperglycemia, chronic obstructive pulmonary disease with acute exacerbation, major depressive disorder, unspecified dementia with mood disturbances, anemia, delirium due to psychosis. Review of the medical record and physician's order for Resident #59 revealed and order dated 04/22/24, that identified a change in dosage of the antipsychotic Abilify from two (2) milligrams (mg) to five (5) mg. The order was received and acknowledged by Licensed Practical Nurse (LPN) #82. The order transcribed by LPN #82 on 04/22/24 was inadvertently discontinued. Review of Resident #59's medication administration records (MARs) for April and May 2024…

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

Based on medical record review and staff interview, the facility failed to ensure accurate documentation in the medical record when wound care treatments, prevention devices, and supplement orders were administered. This affected one (#66) of two residents reviewed for wounds. The facility census was 70. Findings include: Review of the medical record for Resident #66 revealed an admission date of 02/23/24 with diagnoses including displaced fracture of the left femur, diabetes mellitus, and anxiety. Review of the physician's orders for Resident #66 revealed an order dated 03/02/24 to cleanse the surgical site, staples, and sutures on the left hip with normal saline, pat dry, and leave open to air every night shift. Further review revealed an order dated 03/26/24 for the resident to have podus boots (boots used for heel pressure injuries) on when in bed as tolerated every shift for prevention, and an order dated 05/04/24 for house liquid protein twice a day for wound healing in the morning and at bedtime. Review of the medication administration record (MAR) and treatment…

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

Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 74. Findings include: Review of the facility's sign-in sheet for the QA meeting minutes for the meetings held in September 2023 and November 2023 revealed no evidence the medical director attended the meetings. Interview with the Administrator on 01/29/24 at 3:17 P.M. verified the medical director did not attend the QA meetings as required. The Administrator stated that the last QA meeting that Medical Director (MD) #391 attended was February 2023. A phone interview on 01/29/24 at 3:49 P.M. with Medical Director (MD) #391 revealed that he attended the QA meeting in February and that he runs a full-time clinic. MD #391 stated that since the meetings are in the middle of the day, he can't make it.

Based on observations and interviews, the facility failed to ensure the facility provided a sanitary environment. This affected seven residents (Resident #3, #9, #43, #46, #54, #69 and #80) and had the potential to affect all residents residing in the facility. The facility census was 74. Findings include: Observation of the shower rooms on 01/22/24 at 6:43 A.M. with Assistant Director of Nursing (ADON) #336 revealed the shower room on 200-Hall had dirty linens all over the floor and the trash was overflowing. The shower room on the 400-Hall had mold in the corner of the shower and on the shower chair. The toilet had brown paper towels in it and did not have a flushing handle. ADON #336 stated that that toilet is not in use, and the water is not turned on but there shouldn't be dirty paper towels in it. ADON #336 verified the findings at the time of the observations and verified that the shower rooms are both still being used by residents for their showers. Observation of the physical environment on 01/22/24 at 6:45 A.M. with the Administrator revealed the floor around Resident #3'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 observations, interview and record review, the facility failed to ensure the physician was notified when residents had a change of condition. This affected three residents (Resident #14, #49 and #69) out of three reviewed for change of condition. The facility census was 74. Findings include: 1. Review of the open medical record for Resident #69 revealed an admission on [DATE]. Diagnoses included multiple sclerosis, chronic pain syndrome and neuromuscular dysfunction of bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on toileting and needed assistance with repositioning. The assessment indicated Resident #69 had four stage 3 pressure ulcers (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on admission. Review of the admission nursing assessment dated [DATE] revealed a pressure ulcer to the right gluteal fold (right buttock) that measured 7 centimeters (cm) by…

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 its smoking policy was followed as written. This affected three (#2, #45, and #56) of three residents interviewed for smoking. The facility identified 14 residents who were smokers. The facility census was 74. Findings include: Interview on 01/22/24 at 7:05 A.M. with Resident #45 revealed that smoke breaks are always late, especially in the morning. Interview on 01/22/24 at 7:10 A.M. with Resident #56 revealed that smoke breaks are always late especially in the morning. Interview on 01/22/24 at 9:30 A.M. with Resident #2 revealed that smoke breaks are always late especially in the morning. Observations on 01/25/24 at 7:00 A.M. revealed Residents #2, #16, #45, and #56 were waiting near the designated smoking area to be taken outside for a supervised smoke break. Observation and interview on 01/25/24 at 7:28 A.M. with State Tested Nursing Assistant (STNA) #400 verified that she came to take the smokers outside to the designated smoking area at 7:28 A.M. and that the smoking time was 7:00 A.M. STNA #400…

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, staff interview, and record review, the facility failed to maintain a system to preventing the spread of infections and communicable diseases for nine residents (Resident #5, #6, #12, #27, #59, #60, #67, #70 and #74) identifed as being on isolation precautions. This has the potential to affect all residents. The facility census was 74. Findings include: Observations of the physical environment on 01/22/24 at 5:05 A.M. revealed isolation carts outside of nine resident rooms (Resident #5, #6, #12, #27, #59, #60, #67, #70 and #74). There were no gowns in any of the isolation carts. Additionally, two residents (Resident #59 and #74) did not have a sign posted on the door indicating vistors should see the nurse before entering. Interview on 01/22/24 at 5:40 A.M. with State Tested Nursing Assistant (STNA) #352 stated there was not enough personal protective equipment (PPE) available. She stated she had gloves and masks, but had to go into isolation rooms without a gown because there were not enough available on her shift. Interview on 01/22/24 at 5:31 A.M. with…

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, resident and staff interview, record review, and policy review, the facility failed to provide routine bathing and grooming services for Resident #65 and routine bathing services for Resident #63. This affected two residents (#65 and #63) of three residents reviewed for provision of Activities of Daily Living (ADLs). The facility census was 74. Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 11/03/23. Medical diagnoses included wedge compression fracture of the vertebrae, muscle weakness, chronic pain, and a myocardial infarction (heart attack). Resident #65's listed shower days were on Mondays and Fridays. Review of Resident #65's admission Minimum Data Set (MDS) assessment, dated 11/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Resident #65 was identified to be hard of hearing but did not use a hearing aide. Resident #65 required substantial/maximum assistance with toileting, showering/bathing, and dressing. Resident #65 was dependent for personal…

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

Based on medical record review and staff interview, the facility failed to ensure a comprehensive plan of care was developed to address a resident's communication barriers. This affected one (#15) of three residents reviewed for communication. The facility census was 73. Findings include: Review of Resident #15's medical record revealed an admission date of 09/15/23. Diagnoses included cerebral infarction (stroke) and bilateral hearing loss. Review of the admission Nursing Observation assessment, dated 09/15/23, revealed Resident #15 was alert to person, place and situation. She was observed to be verbally incomprehensible. There was no indication Resident #15 was deaf. Review of the baseline care plan, dated 09/15/23, revealed Resident #15 was deaf and had a hearing aid. No interventions for effective communication with the resident were identified. Review of the admission Minimum Data Set (MDS) assessment, dated 09/22/23, revealed Resident #15 had highly impaired hearing, had a hearing aid, sometimes understood staff and sometimes was understood by staff. Review of the care plan,…

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 a fall investigation, staff interview, and review of facility policy, the facility failed to implement fall interventions for a resident identified at risk for falls. This affected one (#74) of three residents reviewed for falls. The facility census was 73. Findings include: Review of Resident #74's medical record revealed an admission date of 10/21/23 and a discharge date of 10/31/23. Diagnoses included Congestive Heart Failure (CHF), legal blindness, chronic pain syndrome, and repeated falls. Review of Resident #74's baseline care plan, dated 10/21/23, revealed the fall section was not initiated and no interventions were implemented. Review of the fall risk assessment, dated 10/22/23, revealed Resident #74 was at risk for falls as he was legally blind, had balance problems while standing and walking, had decreased muscular coordination, was jerking or unstable when making turns and required the use of assistive devices. The assessment was silent for clinical suggestions for interventions. Review of the Medicare Five-Day Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure a resident was placed on contact isolation and contact isolation precautions were followed when the resident tested positive for a drug resistant organism. This affected one (#8) of three residents reviewed for infection control. The facility census was 71. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/15/22 with diagnoses including dementia and Methicillin-Resistant Staphylococcus Aureus (MRSA) (diagnosed on [DATE]). Review of the nursing progress note dated 07/07/23 at 6:23 P.M. revealed Resident #8 had tested positive for MRSA. There were no orders noted for contact isolation. The nursing progress note dated 07/09/23 at 11:20 P.M. stated Resident #8 continued on an antibiotic for MRSA in the nares (nostrils). Review of the medical record including care plan, physician's orders, Medication…

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, resident and staff interview the facility failed to ensure residents dependent on staff was provided showers/ bathing on regular basis. This affected three (#10, #20 and #40) of three residents reviewed for receiving routine bathing services. The total facility census was 62. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE], with most recent readmission on [DATE]. Diagnoses for Resident #10 included non-pressure chronic ulcer of the left heel and mid foot, cirrhosis of the liver, hepatic encephalopathy, depression, type two diabetes, gout, and severe septic shock. Review of the 06/12/23 quarterly minimum data set (MDS) assessment revealed the resident is cognitively intact, had physical behaviors one to three days of the review period and required extensive assist from staff for personal hygiene. Review of the bathing documentation provided for Resident #10 for the last 30 days revealed the resident had documented bed baths 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, record review, and facility staff interview, the facility failed to ensure a resident at risk for pressure development had physician ordered pressure reducing interventions implemented per the order. This affected one (#10) of two residents reviewed. The facility census was 62. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE], with most recent readmission on [DATE]. Diagnoses for Resident #10 included non-pressure chronic ulcer of the left heel and mid foot, cirrhosis of the liver, hepatic encephalopathy, depression, type two diabetes, gout, and severe septic shock. Review of the 06/12/23 quarterly minimum data set (MDS) assessment revealed the resident is cognitively intact, had physical behaviors one to three days of the review period and required extensive assist from staff for personal hygiene. The resident was coded as having a risk for pressure ulcers but not currently having any pressure ulcers. Review of Resident #10's 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.

Based on review of staffing schedules, review of Benefits Improvement and Protection Act (BIPA) daily staff postings, and staff interview, the facility failed to maintain the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 61 residents currently residing in the facility. Findings include: Review of facility staffing schedules and daily BIPA staffing postings dated between 10/01/22 and 11/08/22, revealed an RN was not present and working in the facility for eight consecutive hours on 10/02/22, 10/03/22, 10/08/22, 10/09/22, 10/10/22, 10/15/22, 10/27/22, 11/05/22, 11/06/22, or 11/07/22 (10 days). Interview on 11/09/22 at 9:54 A.M. with the Director of Nursing verified the facility did not have RNs on duty in the facility for eight consecutive hours on the aforementioned dates. This deficiency represents non-compliance investigated under Complaint Master Number OH00137389 and Complaint Number OH00136346.

Based on observation, staff interview, and policy review, the facility failed to ensure expired refrigerated medications were discarded, monitor temperatures in the medication refrigerators, and ensure foods and drinks were not stored in the medication refrigerator. This had the potential to affect all 61 residents receiving medications stored in the medication refrigerator. The facility census was 61. Findings include: Observation and interview on 11/07/22 at 1:04 P.M. with the Director of Nursing (DON) revealed the facility had one medication storage room. Observation of the refrigerator used for storing medications in the medication storage room revealed a refrigerator temperature log posted on the refrigerator. The refrigerator temperature log was dated July 2022 and had four temperatures logged for the month of July 2022. The DON verified the temperatures of the refrigerator should be monitored daily to assure the temperature ranged from 34 to 41 degrees. The DON verified the refrigerator temperature had not been monitored since July 2022. Observation on 11/07/22 at 1:05 P.M.…

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 policy review, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all residents who resided in the facility and received meals from the facility kitchen. The facility identified no residents who did not eat from the facility kitchen. The facility census was 61. Findings include: Observation on 11/07/22 at 8:15 A.M. revealed the kitchen oven with large amounts of dark, sticky grease buildup on the outside and the inside. The inside oven windows were coated in grease and unable to see through the glass. The bottom of the oven had thick dark grease and the grates were coated in grease buildup. There were crumbs and cobwebs on the bottom shelf of the oven. The steam table revealed sticky dark grease dripping down the front of the steam table by the controls. A stand-up fan located by the doors of the kitchen blowing towards the steam table had dust coating the blades and the safety screen. The dishwashing room revealed six rubber mats that were sticky and had crumbs stuck to them. The floor of 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 review of the facility provided Quality Assessment and Assurance (QAA) quarterly meeting attendance sheets and staff interview, the facility failed to ensure the Infection Preventionist attended QAA meetings at least quarterly. This had the potential to affect all 61 residents residing in the facility. Findings include: Review of the QAA attendance sheets dated 05/20/22, 06/15/22, 07/20/22, 08/19/22, 09/29/22, and 10/27/22 revealed there was no Infection Preventionist documented as attending any of the meetings. Interview on 11/09/22 at 2:18 P.M., the Administrator verified the Infection Preventionist was not present at the QAA meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, policy review, and review of the Centers for Disease Control and Prevention guidance, the facility failed to ensure infection control measures were followed related to hand hygiene and personal protective equipment (PPE). This had the potential to affect all residents residing in the facility. The facility census was 61. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, heart disease, anemia, and hypertension. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired and required setup assistance for meals. Review of Resident #15's physician orders identified an order dated 10/28/22 for contact/droplet precautions for exposure to Covid-19. Interview on 11/07/22 at 9:28 A.M., with Resident #04 revealed staff often wore their masks down below their nose 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 3. Review of Resident #54's medical record revealed an admission date of 09/16/22 and discharged on 09/18/22. Diagnoses included COVID-19, atrial fibrillation, vascular dementia, epileptic seizures, wedge compression fracture of thoracic vertebra, and intracerebral hemorrhage. Record review of the nursing progress note dated 09/18/22 at 2:26 P.M., revealed Resident #54 was having seizures. Resident #54's physician was made aware and gave orders to send Resident #54 to the hospital. Resident #54 was transported to the emergency room. Interview on 11/08/22 at 5:01 P.M.,with Business office Manager (BOM) #302 confirmed Resident #54 nor her Representative received a written notice of discharge. Interview on 11/09/22 at 10:19 A.M., with Social Services Designee (SSD) #353 confirmed Resident #54 nor her Representative or the Ombudsman received a written notice of discharge for Resident #54. Based on medical record reviews and staff interviews, the facility failed to provide written notification for the reason 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 medical record review, observations, resident interview, and staff interview, the facility failed to ensure residents who were required staff assistance with activities of daily living were provided assistance with grooming. This affected one (Resident #45) out of four residents reviewed for activities of daily living. Additionally, the facility failed to ensure residents received showers as scheduled. This affected five (Residents #9, #18, #28, #44, and #49) out of five residents reviewed for showers. The census was 61 residents. Findings include: 1. Review of Resident #45's medical record revealed the resident was admitted on [DATE] with diagnoses which included chronic respiratory failure, dependence on supplemental oxygen, heart failure, macular degeneration, and long-term use of anticoagulants. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/07/22, revealed Resident #45 had moderate cognitive impairment and required one person assistance for bathing as well as limited assistance…

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 5. Review of the medical record for Resident #312 revealed Resident #312 was admitted to the facility on [DATE] with diagnoses which included heart failure, hypertension, long-term use of anticoagulants, anxiety disorder, neuropathy, peripheral vascular disease, open wound of right foot and left elbow, and muscle weakness. Review of Resident #312's MDS 5-day assessment, dated 10/05/22, revealed the resident had mild cognitive impairment. Review of the pharmacy Medication Regimen Review (MRR) for Resident #312, dated 10/08/22, revealed a pharmacy recommendation regarding a contraindication in administration of the resident's prescribed Plavix and Omeprazole medications. The MRR described an inefficacy of Plavix when co-administered with Omeprazole, listed alternatives to Omeprazole, and noted per the manufacturer there was an increased risk of bleeding with the co-administration of these two medications. Review of prescribed medications in the medical record for Resident #312 revealed there were no changes to 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 reviews, pharmacy regiment reviews, policy review, family and staff interviews, the facility failed to ensure residents were free from unnecessary psychotropic medications . This affected four (#04, #9, #11, and #18) of four residents reviewed for psychotropic medications. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #04 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, depression, psychosis, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was cognitively intact and was independent for activities of daily living. Review of Resident #04's prescribed medications list dated November 2022 revealed the resident was ordered to receive Wellbutrin (Bupropion) 150 milligram (mg), once per day; Sertraline 100 mg, once per day; Risperidone 0.5 mg; twice per day, and Lamotrigine 200 mg, once per day. Review of pharmaceutical recommendations made to…

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

Based on observation, staff, physician and pharmacy interview, and medical record review, the facility failed to ensure a medication error rate of less than 5 percent. There were four observed errors out of 31 opportunities this resulted in a medication error rate of 12.9 percent. This affected two resident's (#01 and #310) out of three residents observed for medication administration. The facility census was 61. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 03/15/06. Diagnosis included constipation. Review of the physician order for Resident #01 dated 06/04/22 revealed an order for senna tablet 8.6 milligrams (mg) give one tablet by mouth in the morning for constipation. Observation of the medication administration on 11/08/22 at 07:29 A.M. revealed Licensed Practical Nurse (LPN) # 403 did not have Resident #01's medication senna tablet 8.6 mg available for administration. LPN #403 verified the medication was not available and revealed she would check later to see if the medication may be located in the stock medication room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and staff interviews, the facility failed to provide bed hold notification, at the time of transfer. This affected two (#21 and #54) of five residents reviewed for bed hold notice. The facility census was 61. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 09/08/22. Resident #21 was paying privately for their stay at the facility. The record revealed Resident #21 was hospitalized from [DATE] through 11/03/22. The record provided no evidence of written notification of the facility's bed hold notification. Resident #21 was readmitted to the facility on [DATE]. Interview on 11/08/22 at 12:36 P.M., with Business office Manager (BOM) #302, confirmed she is responsible for providing resident/families bed hold notifications when they are transferred to the hospital. The interview confirmed she only sends these notification to residents whom are Medicaid payer source. The interview confirmed upon admission to the facility each resident 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.

Based on record review and staff interview, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for a resident. This affected two (#49 and #54) of 17 residents reviewed for baseline care plans. The facility census was 61. Findings include: 1. Review of Resident #49's medical record revealed an admisssion date of 08/08/22. Diagnoses included: discitis, hyperlipidemia, chronic pain syndrome, cocaine abuse, alcohol abuse, dementia, psychotic disturbance, encephalopathy, malnutrition, lymphoma, and arthritis. Review of Resident #49's electronic and paper medical record revealed no evidence of a baseline care plan being developed. Interview on 11/09/22 at 9:54 A.M., with the Director of Nursing verified there was no baseline care plan developed within 48 hours of Resident #49's admission. 2. Review of Resident #54's medical record revealed an admission date of 09/16/22. Diagnosis included: COVID-19, atrial fibrillation, vascular dementia, epileptic seizures, wedge compression fracture of thoracic vertebra, 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 record review, resident and staff interview, the facility failed to complete a comprehensive care plan and include residents in care planning process. This affected two (#34 and #36) of 20 residents reviewed. The facility census was 61. Findings include: 1. Record review revealed Resident #34 was admitted to the facility on [DATE]. Diagnosis included hypertension, muscle weakness, abnormal posture, dysphagia, disorders of bladder, glaucoma, anxiety disorder, major depressive disorder, and obesity. Record review of the Minimum Data Set Assessment (MDS) assessment dated [DATE], revealed Resident #34 had a Brief Interview of Mental Status (BIMS) score of 15 of 15 (cognitively intact). Resident #34 required extensive assistance of two for bed mobility, total dependence of two for transfers, toileting, dressing, and supervision for eating. Record review of Resident #34's medical records revealed there was no documentation of a comprehensive care plan being completed within seven days of admission to include…

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, resident and staff interviews, the facility failed to ensure discharge planning for a resident was initiated. This affected one (#110) of two residents reviewed for discharge. The facility census was 61. Findings include: Review of Resident #110's medical record revealed an admission dated of 10/13/22, with medical diagnoses including: stroke, failure to thrive, hypertension, COVID-19 and pain. Review of Resident #110's written plan of care identified no plan was in place for discharge planning. Review of Resident #110's admission Minimum Data Set (MDS) assessment (MDS) identified in section Q: identified Resident #110 is an active discharge plan occurring for the resident to return to the community. The MDS identified a plan was occurring. Resident #110's record identified no plan could be located. Interview on 11/07/22 at 10:55 A.M., with Resident #110 confirmed she lived in her home in the community prior to admission with the assistance of her brother. The interview confirmed this is where she plans on returning to, but has not heard anything from…

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

Based on record review and staff interview, the facility failed to ensure physician ordered skin assessments were completed. This affected on (#49) of one residents sampled for skin integrity. The census was 61 residents. Findings included: Review of Resident #49's medical record revealed an admission date of 08/08/22, with diagnoses included: discitis, hyperlipidemia, chronic pain syndrome, cocaine abuse, alcohol abuse, dementia, psychotic disturbance, encephalopathy, malnutrition, lymphoma, and arthritis. Review of Resident #49's admission Minimum Data Set (MDS) assessment, dated 08/15/22, revealed the resident was cognitively impaired and required extensive assistance of two staff for bed mobility. Review of Resident #49's physician orders identified an order dated 08/09/22 for weekly skin review every dayshift every Tuesday for monitoring. Review of Resident #49's plan of care, dated 08/26/22, revealed the resident was at risk of impaired skin integrity related to loss of skin integrity, edema, and nutrition. Interventions included evaluate skin integrity, and monitor 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, medical record review, resident and staff interview, the facility failed to assess a resident after an accident, complete fall risk assessments after falls and ensure physician orders for were followed to not provide straws to a resident at risk for aspiration. This affected three (#18, #45, and #49) of four residents reviewed for accidents/ hazards. The facility census was 61. Findings include: 1. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypotension, muscle weakness, abnormal posture, other abnormalities of gait and mobility, and rheumatoid arthritis. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment, dated 07/21/22, revealed the resident was cognitively intact and required the extensive assistance of one staff for transfers. Review of Resident #18's plan of care, dated 06/15/22, revealed the resident was at risk for falls related to unsteadiness on feet, and rheumatoid arthritis.…

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

Based on medical record review and staff interview, the facility failed to ensure resident meal intakes were consistently recorded/monitored. This affected three (#9, #30, and #38) out of 20 residents reviewed. The census was 61. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/09/21. Diagnoses included protein calorie malnutrition, dementia, altered mental status, and nutritional deficiency. Resident #9 had a physician's order, dated 11/23/21, for a regular diet with mechanical soft textures. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/30/22, revealed Resident #9 required supervision after set up for meals. Review of the care plan, revised 11/06/22, revealed Resident #9 was at risk for malnutrition. Interventions included to provide diet and supplements as ordered, monitor nutritional health state, monitor percent of meals consumed and record, and provide assistance to resident as needed. Review of the electronic medical record (EMR) meal intake documentation from October 2022 to November 2022 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 medical record review, observation, staff interview, and facility policy review, the facility failed to ensure oxygen tubing and humidification was changed in accordance with the physician order. This affected one (Resident #36) of six residents reviewed for oxygen services. The facility census was 61. Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 09/05/22 with medical diagnoses including acute and chronic respiratory failure, congestive heart failure, depression, anemia, morbid obesity, diabetes, high blood pressure, and pain. Review of Resident #36's physician order, dated 10/08/22, revealed an order to change pre-filled water bottles on oxygen concentrator and humidification weekly and as needed. Observation of Resident #36's oxygen concentrator and humidification on 11/07/22 at 10:29 A.M. revealed the date written on the bottle was 10/08/22. The oxygen tubing attached to the oxygen concentrator was undated. Review of Resident #36's Treatment Administration Record (TAR) for November 2022 revealed a nurse had…

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 narcotic records, review of facility medication policies, and resident and staff interviews, the facility failed to ensure pain medications were available and administered as ordered by the physician. This affected one (Resident #36) of two residents reviewed for pain. The facility census was 61. Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 09/05/22 with medical diagnoses including acute and chronic respiratory failure, depression, morbid obesity, restless leg syndrome, pain, and diabetic neuropathy. The medical record revealed Resident #36 had a physician order for Lyrica (nerve pain medication) 100 milligram (mg) TID (three times a day), for pain and neuropathy, since admission. Interview with Resident #36 on 11/07/22 at 10:21 A.M. revealed Resident #36 stated the facility has not had her Lyrica in the facility since 11/04/22 and it still was not in the facility. Resident #36 identified this was the second time this had occurred since her admission to the facility. Review of 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 monitor a resident before and after dialysis treatments. This affected one (Resident #30) of one resident reviewed for dialysis services. The facility's census was 61. Findings include: 1. Review of the medical record for Resident #30 revealed admission date of 05/24/22. Diagnoses included end stage renal disease, with dependence on renal dialysis, diabetes mellitus, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was on dialysis treatments. Review of the care plan dated 09/02/22 revealed Resident #30 had potential for complications related to dialysis and end stage renal disease. Interventions included assess vital signs, check bruit and thrill every shift, and provide renal medications as ordered. Review of Resident #30's physician orders revealed an order dated 06/30/22 to monitor dialysis port site for infection and an order dated 07/19/22 for dialysis treatments on Tuesdays,…

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 interview, staff interviews, and review of facility policy, the facility failed to ensure medications were available for administration, leading to missed medication. This affected two (Residents #21 and #9) of five residents reviewed for medication availability. The facility's census was 61. Findings include: 1. Review of Resident #21's medical record identified admission to the facility occurred on 09/08/22 with medical diagnoses including; diabetes, left heel wound with osteomyelitis (infection), congestive heart failure, and high blood pressure. Resident #21 was hospitalized from [DATE] through 11/03/22 for a surgical intervention to the left heel wound. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was alert and oriented with no confusion noted. Review of Resident #21's re-admission physician orders revealed orders for the following medications: HumaLOG KwikPen Solution Pen-injector (insulin) 20 units in the evening with dinner,…

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 administered an unnecessary medication to a resident, This affected one (#34) of five residents reviewed for unnecessary medications. The facility census was 61. Findings include: Record review for Resident #34 revealed an admission date of 08/08/22, with diagnosis of urinary tract infection. Review of the nursing progress note dated 09/30/22, between 11:32 and 11:55 A.M., completed by Licensed Practical Nurse (LPN) #346 revealed Resident #34 was confused and disoriented. The physician was notified and ordered a urinalysis with a culture and sensitivity test. Record review of the lab results for the urinalysis test for Resident #34 ordered on 09/30/22 revealed the urinalysis was collected on 10/04/22. Review of the physician order for Resident #34 revealed an order dated 10/05/22 for Resident #34 to receive an antibiotic Cipro tablet 250 milligrams (mg) by mouth two times a day for infection for five days. Review of the medication administration record…

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, staff and resident interview, and medical record review, the facility failed to ensure residents were free from significant medication errors and insulin as well as piperacillin - tazobectam was administered without error. This affected two residents (#14 and #310) out of three residents reviewed during medication administration. The facility census was 61. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 06/28/19. Diagnosis included type two diabetes mellitus. Review of the physician orders for Resident #14 revealed an order for novolog solution (insulin aspart) inject as per sliding scale subcutaneously every shift for sliding scale for blood sugar control. If blood sugar was 150 milligram per deciliter (mg/dL) to 200 mg/dL give four units, 201 mg/dL to 250 mg/dL give six units, 251 mg/dL to 300 mg/dL give eight units, 301 mg/dL to 350 mg/dL give 10 units, 351 mg/dL to 400 mg/dL give 12 units, 401 mg/dL to 450 mg/dL give 14 units, and 451 mg/dL to 500 mg/dL give 16 units. Inject 10 units subcutaneously three…

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 medical record review, the facility failed to ensure medication therapeutic levels were monitored. This affected one resident (#09) out of 20 residents sampled. The facility census was 61. Findings include: Review of the medical record for Resident #09 revealed an admission date of 11/09/21. Diagnoses included dementia without behavioral disturbance, heart failure, cardiac arrhythmia, and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #09 had impaired cognition. Review of the care plan dated 11/30/21 revealed Resident #09 had congestive heart failure. Interventions included give cardiac medications as ordered, monitor signs and symptoms of heart failure to physician, and check for labored breathing. Review of the current physician's orders for November 2022 revealed Resident #09 had an order for 125 micrograms (mcg) Digoxin every 48 hours by mouth for heart failure. Resident #09 had an order for a Digoxin level monitoring…

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 timely notify the physician of laboratory results. This affected one resident (#34) out of five residents reviewed for physician notification. The facility census was 61. Findings include: Review of the medical record review for Resident #34 revealed an admission date of 08/08/22. Diagnosis included urinary tract infection. Review of the nursing progress note dated 09/30/22 revealed Resident #34 was confused and disoriented. The physician was notified and ordered a urinalysis with a culture and sensitivity test. Review of the laboratory results for the urinalysis test for Resident #34 ordered on 09/30/22 revealed the urinalysis was collected on 10/04/22. Review of the laboratory results for the urinalysis with the culture and sensitivity test for Resident #34 ordered on 09/30/22 revealed the culture and sensitivity resulted on 10/06/22 with greater than 100,000 Escherichia coli (E-coli). The culture and sensitivity results printed to 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.