Grande Oaks

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide appropriate oral and nail care for dependent residents. This affected one (Resident #28) of three residents reviewed for activities of daily living (ADL). The facility census was 42.Findings include:Record review of Resident #28 revealed he was admitted to the facility 07/03/25 with diagnoses including respiratory failure, paraplegia, and anoxic brain damage. His care plans dated 07/21/25 noted he was totally dependent on staff for ADL, and his nails should be checked daily for length and cleanliness. His Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified he was never or rarely understood, was dependent on staff for ADL care, and his mouth could not be assessed for dental problems. He was ordered to receive oral care twice per day and had no orders indicating any treatment of thrush (an oral fungal infection commonly involving white patches on the tongue).Observation of Resident #28 on 04/21/26 at 11:10 A.M. 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 record reviews, observations, resident interviews, staff interviews and facility policy review, the facility failed to ensure resident activity preferences were honored. This affected two (Residents #1 and #26) of two residents reviewed for activities. The facility census was 42.Findings include:1. Review of the medical record for Resident #1 revealed he was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, necrotizing fasciitis and type II diabetes mellitus.Review of the care plan dated 12/31/25 revealed Resident #1 required encouragement to participate in activities of interest, was dependent on staff for activities with interventions including in-room activities if unable to attend out-of-room activities, allow to plan own leisure time activities, and respect choices in regard to limited activities. Review of the activities assessment dated [DATE] revealed Resident #1 preferred independent leisure activities, including but not limited to, a tablet and/or phone.Review…

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, observation, and interview, the facility failed to ensure that a resident with a documented Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure injury received repositioning according to their plan of care and accepted standards of practice. This affected one (Resident #28) of three residents reviewed for pressure sore care. The total census was 42.Findings include:Record review of Resident #28 revealed he was admitted to the facility 07/03/25 with diagnoses including respiratory failure, paraplegia, and anoxic brain damage. His care plans dated 07/21/25 noted he was totally dependent on staff for activities of daily living (ADL) and that he was at risk for skin breakdown and should be turned every two hours. His Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified he was never or rarely understood, was dependent on staff for bed mobility, and had pressure sores present on admission. Review of his most recent wound assessment dated [DATE] 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, observation, interview and facility policy review, the facility failed to implement therapy ordered contracture care for one (Resident #7) of one resident reviewed for range of motion and mobility. The facility census was 42.Findings include:Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included Moyamoya Disease (a progressive disorder of blocked arteries at the base of the brain), severe protein calorie malnutrition, anemia, acute kidney failure, metabolic encephalopathy (brain dysfunction), dysphagia (difficulty swallowing), cerebral infarct (tissue death), and hypertension (high blood pressure). She was admitted under hospice services on 08/20/25. The Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 0 (severe impairment), and the (Minimum Data Set) MDS 3.0 Quarterly assessment dated [DATE] and the MDS 3.0 Quarterly assessment dated [DATE], revealed the resident was dependent on staff for all…

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, resident and staff interviews, and policy review, the facility failed to provide adequate supervision and failed to ensure the safe use of assistive devices during care and transfers. This failure resulted in one resident (#18) falling from bed during single staff incontinent care despite weighing 557.8 pounds and being dependent for activities of daily living (ADL), and one resident (#32) sliding from a mechanical lift pad during transfer due to improper pad placement. This deficient practice affected two residents (#18 and #32) of three sampled residents reviewed for accidents. The facility census was 42.Findings include: 1. Review of the medical record for Resident #18 revealed she initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator and heart failure. Review of the care plan dated 04/15/22 revealed Resident #18 required assistance for activities of daily living (ADL), was at risk for falls, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #18's care was adequately supervised by a physician. Specifically, the facility failed to obtain, initiate, and implement physician orders for weight monitoring despite significant, documented changes in nutritional status and body weight. The facility also failed to notify the physician of significant weight gain requiring clinical intervention. This deficient practice resulted in Resident #18 experiencing an undocumented and unmonitored weight increase of approximately 159 pounds over a five month period, with no corresponding physician notifications, no new orders, and no comprehensive assessment or monitoring as required. This affected one (Resident (#18) of four reviewed for nutrition. The facility census was 42.Findings include:Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure,…

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, interview and facility policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (Resident #2) of five residents reviewed for unnecessary medications. The facility census was 42.Findings include:Review of the medical records for Resident #2 revealed an admission date of 10/02/24. Diagnoses included pain, type II diabetes mellitus with diabetic neuropathy, anemia, depression, post-traumatic stress disorder (PTSD), and anxiety disorder.Review of the pharmacy recommendation dated 05/05/25 regarding Diazepam (antianxiety) 2.5 milligrams (mg) twice daily (BID) for a gradual dose reduction (GDR) trial and Duloxetine (antidepressant) 30 mg daily, Sertraline (antidepressant) 100 mg daily, and Trazadone (antidepressant) 100 mg at bedtime (QHS) GDR trial.Review of the pharmacy recommendation dated 07/14/25 regarding Diazepam 2.5 mg BID. The pharmacy recommendation also noted it is time to consider a GDR trial. Please check one 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 record review, observation, review of the facility policy and interview, the facility failed to ensure the correct serving size for the mechanically altered meat was served. This affected three (Residents #6, #22, and #33) of three residents that received a mechanically altered diet. The facility census was 42.Findings include:Observation of the tray line on 04/21/26 between 12:31 P.M. and 12:49 P.M. revealed Dietary Aide (DA) #555 serving mechanically altered meals using a green-handled #12 scoop, providing only one scoop of mechanically altered meat per meal. At 12:49 P.M., staff were observed pushing the last meal cart to the final unit.Review of the diet extension sheet showed that the mechanically altered meat (beef stroganoff) was to be served using a #6 scoop.During an interview on 04/21/26 at 12:50 P.M., DA #555 and Regional Dietary Manager (RDM) #900 confirmed that the green-handled scoop used was a #12 scoop. RDM #900 stated that, when using a #12 scoop, DA #555 should have provided two scoops to meet the required portion size. DA #555 verified she had provided…

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 resident record review and staff interviews, the facility failed to ensure the accuracy and consistency of the medical record when resident documentation contained conflicting information, including two different mattress orders that were both documented as being in place for the same dates. This affected one (Residents #17) of 22 residents sampled during the survey. The facility census was 42.Findings include:Review of Resident #17's medical record revealed an admission date 12/19/25 with diagnoses of bilateral primary osteoarthritis of hip, morbid obesity, and type II diabetes mellitus with hyperglycemia.Record review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was cognitively intact and was at risk for developing pressure ulcers.During an interview on 04/19/26 at 10:12 A.M., Resident #17 reported he had not had an air mattress since the end of March 2026. However, physician orders dated 04/16/26 and the April 2026 Treatment Administration Record (TAR) showed 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 resident record review, resident interview, staff interviews, review of the hospice contract and facility policy review, the facility failed to ensure requests for hospice services were honored for Resident #18 and failed to ensure a hospice care plans were updated for Resident #7. This affected two (Residents #7 and #18) of two residents reviewed for hospice services. The facility census was 42.Findings include:1. Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, dependence on respirator (ventilator status), and heart failure. Review of the care plan dated [DATE] revealed Resident #18 required assistance for activities of daily living (ADL), was at risk for falls, and had a high body mass index (BMI) related to obesity, with interventions that included observing, monitoring and reporting changes, assisting with ADL, following physician orders and monitoring weights. Review of the care plan 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 observation, record review, and interview, the facility failed to ensure call lights were left in reach of residents. This affected one (Resident #41) of four residents reviewed for environmental concerns. The facility census was 42.Findings include:Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she needed substantial assistance from staff for bed mobility.Observation of Resident #41 on 04/19/26 at 10:08 A.M. revealed her call light was hanging from the bed rail outside of her reach on the right side. The right side had three pillows stacked preventing her from reaching the cord to pull the call light up into reach.Interview with Registered Nurse (RN) #518 on 04/19/26 at 10:38 A.M. confirmed the above observation. Following surveyor intervention, she placed the call light within resident reach.This deficiency represents non-compliance…

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

Based on observations, interviews and facility policy review, the facility failed to ensure a clean, safe and homelike environment. This affected three (Residents #8, #29, and #36) of four residents reviewed for physical environment. The facility census was 42.Findings include:1. During an observation on 04/19/26 at 10:14 A.M., Resident #8's room had a large hole in the wall behind the head of the bed with multiple scrapes, scratches, and areas of missing paint. Walls, floors, and the nightstand surrounding the resident's room contained large brown- and yellow-colored dried splatter stains of unknown origin. The floor was visibly dirty and covered with food particles and debris. Interview on 04/19/26 at 10:20 A.M. with Registered Nurse (RN) #518 observed and verified the condition of Resident #8's room. 2. On 04/22/26 at 9:23 A.M., observation of Resident #29's room revealed the air conditioner unit's front cover was hanging off, and the vent cover was detached and lying on the floor. The floor had dirt marks and debris. A long curved gouge was present in the floor by the entrance…

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, interviews and review of the facility policy, the facility failed to ensure hand hygiene practices were being performed consistently with accepted standards of practices to prevent the transmission of communicable diseases and infections. This had the potential to affect12 (Residents #15, #23, #24, #25, #27, #28, #29, #37, #39, #41, #44, and #46) on the south hallway who did not have functioning soap dispensers in their rooms of 48 residents reviewed for infection control. The facility census was 48. Findings include:Observation during facility tour on 10/20/25 at 10:50 A.M. with the Administrator and Director of Nursing (DON) revealed multiple resident rooms which did not have functioning soap dispensers to use for hand hygiene. These included rooms of Residents #23, #25, #27, #28, #29, #37, #39, #41, #44, and #46. In the room of Resident #15, the soap dispenser was observed to be missing off the wall. Interview with the Director of Nursing (DON) and Administrator on 10/20/25 at 10:50 A.M. confirmed the non-functional soap dispensers in resident's bathrooms.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the facility policy, the facility failed to ensure room and hall soap and sanitizer dispensers were functioning properly as required and failed to ensure the wall in Resident #14's room was in good repair. This affected 14 (Residents #2, #9, #11, #14, #15, #23, #25, #27, #28, #30, #37, #39, #41, and #46) of 48 residents reviewed for a safe and sanitary environment. The facility census was 48. Findings include:Observation during facility tour on 10/20/25 at 10:50 A.M. with the Administrator and Director of Nursing (DON) revealed multiple resident rooms which did not have functioning soap dispensers to use for hand hygiene. These included rooms of Residents #23, #25, #27, #28, #30, #37, #39, #41, #44, and #46. In the room of Resident #15, the soap dispenser was observed to be missing off the wall. Observation of the north hallway alcohol sanitization dispensers outside of Resident #2's room, the dispenser outside of Residents #9 and #11's rooms and the dispenser…

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, observation, interviews and review of facility policy, the facility failed to ensure resident preferences were honored as requested. This affected one (Resident #19) of three reviewed for resident preferences. The facility census was 48. Findings include:1. Review of the medical record for Resident #19 revealed an admission date of 06/07/24. Diagnoses included but were not limited to interstitial pulmonary disease, dependence on respirator, chronic respiratory failure, supraventricular tachycardia, neuropathy, chronic obstructive pulmonary disease, disorders of diaphragm, obstructive sleep apnea, and chronic respiratory failure with hypoxia, obesity and anxiety disorder. Review of Resident #19's care plan revealed the resident required assistance with activities of daily living (ADL) related to spinal stenosis, peripheral neuropathy, and chronic obstructive pulmonary disease (COPD). An intervention dated 07/09/25 was listed as a soft touch pad call light is to be clipped to resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, interviews and facility policy review, the facility failed to ensure documentation of ongoing monitoring and evaluations for the continued use of a restraint and the usage of other interventions for reducing or discontinuing the use of the restraint. This affected one (Resident #50) out of six medical records which were reviewed. The facility census was 48. Findings include:Closed record review for Resident #50 revealed the resident was admitted to the facility on [DATE] and expired on [DATE] with the following diagnoses: acute respiratory failure, chronic obstructive pulmonary disease (COPD), encephalopathy, dependence on ventilator, gastrostomy, cerebral infarction, tracheostomy, mood disorders, atrial fibrillation, anxiety, hypertension, diabetes. This resident had no known allergies and was a full code. Review of the provider orders for Resident #50 dated [DATE] revealed an order for mitt restraints to assist with safety, check skin with donning and doffing every shift. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure all ordered treatments/medications were provided to residents as ordered. This affected one (Resident #19) out of four residents who were interviewed for ordered treatments/medications. The facility census was 48. Findings include:Review of the medical record for Resident #19 revealed an admission date of 06/07/24. Diagnoses included but were not limited to interstitial pulmonary disease, dependence on respirator, chronic respiratory failure, supraventricular tachycardia, neuropathy, chronic obstructive pulmonary disease, disorders of diaphragm, obstructive sleep apnea, and chronic respiratory failure with hypoxia, obesity and anxiety disorder. Review of Resident #19's care plan revealed the resident required assistance with activities of daily living (ADL) related to spinal stenosis, peripheral neuropathy, and chronic obstructive pulmonary disease (COPD). An intervention dated 07/09/25 was listed as a soft touch pad call…

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, observation, interview and facility policy review, the facility failed to ensure physician orders were followed related to obtaining weights for two (Residents #11 and #19) of three residents reviewed for weight monitoring. The facility census was 48. Findings include:1. Review of the medical record for Resident #11 revealed an admission date of 04/14/22. Diagnoses included but were not limited to chronic respiratory failure, tracheostomy, dependence upon respirator, type II diabetes with hyperglycemia, and morbid obesity. The last weight recorded was on 07/02/25. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. Review of activities of daily living (ADL) revealed Resident #11 was dependent upon staff for ADL. Review of Resident #11's care plan last reviewed on 09/04/25 revealed increased risk for malnutrition as evidenced by morbid obesity,…

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, interview, review of videos provided by Resident #19's daughter and facility policy review, the facility failed to ensure external door ventilator alarms were monitoring and functioning appropriately for the safety for two (Residents #11 and #19). The facility also failed to ensure physician orders were followed related to nasal cannula being on for Resident #19 as ordered. This affected one (Resident #19) who used an Average Volume-Assured Pressure Support (AVAPS) and one resident (Resident #11) who used an Assist Control Volume Control (ACVC) ventilator of three residents reviewed for ventilator care and had the potential to affect eight additional (Residents #1, #5, #9, #10, #17, #18, and #49) identified by the facility as using AVAPS or ACVC ventilators. The facility census was 48. Findings include:1. Review of the medical record for Resident #19 revealed an admission date of 06/07/24. Diagnoses included but were not limited to interstitial pulmonary disease, dependence on respirator,…

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, record review, resident interview, staff interview, and review of facility policies the facility failed to ensure medications were secured properly. This affected one (Resident #10) of four residents observed for medication administration. Findings include: Review of medical record noted Resident #10 had an admission date of 10/02/24. Diagnoses included chronic obstructive pulmonary disease, unspecified, pain unspecified, post-traumatic stress disorder, depression, type two diabetes mellitus with diabetic neuropathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment 03/25/25 noted Resident #10 had intact cognition. Review of the medical record revealed Resident #10 had no assessment for the self-administration of medication. Observation on 03/24/25 at 9:49 A.M. noted Resident #10 lying in bed with a cup of medications at bedside. Resident #10 verified the cup of medications at bedside and stated staff left the medications for her to take when she was ready. Interview 03/24/25 at 9:52 A.M., Licensed Practical Nurse (LPN) #501 stated…

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, observation and interview, the facility failed to properly disinfect a glucometer after checking blood sugars. This affected one (Resident #13) of one resident observed for blood sugar monitoring and had the potential to affect 17 residents who required blood sugar monitoring residing on the 100 hall. Findings include: Review of medical record for Resident #13 noted an admission date of 06/26/24. Diagnosis included type two diabetes mellitus with diabetic neuropathy, unspecified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #13 had intact cognition. Review of plan of care dated 06/26/24 noted Resident #13 was at risk for hyper/hypoglycemia related to diabetes. Interventions included to obtain blood sugars as ordered. Review of physician order dated 07/19/24 noted staff were to obtain blood sugars twice a day related to diabetes. Observations on 03/24/25 at 4:11 P.M., Licensed Practical Nurse (LPN) #501 obtained a blood sugar for Resident #13. LPN…

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

Based on record review and interview, the facility failed to use 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 49 residents residing in the facility. Findings include: Review of the facility staffing schedules and the staff punch details dated from 10/01/24 through 10/31/24, revealed there was no RN coverage for 10/27/24. Interview on 11/21/24 at 11:58 A.M. with Human Resources Director #287 verified there was no RN coverage on 10/27/24. This deficiency represents non-compliance investigated under Complaint Number OH00159004.

Based on observation, interview and review of facility policy, the facility failed to serve meals at a palatable temperature. This had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49. Findings include: Review of the facility posted meal times revealed breakfast is served at 8:30 A.M., lunch is served at 12:30 P.M. and dinner is served at 5:00 P.M. Observation on 11/12/24 at 10:00 A.M. with Dietary Manager (DM) #266 revealed there were no lunch temperatures for 10/18/24 no lunch and dinner temperatures taken on 11/07/24, no dinner temperatures for 10/2/24, 10/03/24, 10/05/24, 10/06/24, 10/07/24, 10/11/24, 10/12/24, 10/15/24, 10/17/24, 10/18/24, 10/23/24, 10/24/24, 10/30/24 and 10/31/24, 11/02/24, 11/03/24, 11/06/24, 11/08/24, 11/10/24 and no evidence of temperatures taken for breakfast, lunch or dinner on 10/28/24, 10/29/24 and 11/11/24. Observation of lunch tray line temperatures on 11/12/24 at 12:18…

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.

Based on observation, staff and resident interviews, and review of facility mealtimes and policy, the facility failed to ensure meals were provided at posted time and residents were offered a snack as required when there was greater than 14 hours between dinner and breakfast. This had the potential to affect all 41 residents receiving meals from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49. Findings include: 1. Observation of lunch tray line temperatures on 11/12/24 at 12:18 P.M. with [NAME] #253 revealed tray line started at 12:20 P.M. which ran until 12:40 P.M. for the adjacent facility which had a separate license. Tray line for Grande Oaks started at 12:40 P.M. Tray line stopped at 1:14 P.M due to running out of the white and wild rice. Five trays (Resident #147, #148, #149, #150 and #151) were left to finish. [NAME] # 253 confirmed due to running out of rice, the last five trays were delayed while more rice was made. Observation on 11/12/24 at 1:23…

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 consistently ensure food was stored and served under sanitary conditions. This had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49. Findings include: Observation during the initial kitchen tour conducted on 11/12/24 at 9:27 A.M. with [NAME] #253 revealed the low temperature dish machine reached the appropriate temperature of 125.6 Fahrenheit (F), but the chlorine chemical test strip did not change color and remained white and unchanged from when put in the dish machine prior to start of the cycle. [NAME] #253 confirmed and stated disposable dishes would be used until the dish machine was fixed. Observation on 11/12/24 at 10:00 A.M. with Dietary Manager (DM) #266 confirmed the temperature logs for the dish machine were not completed since 11/06/24, confirmed there were no cleaning logs for September, October or 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, interviews and facility policy review, the facility failed to ensure safe handling of resident food brought in from outside the facility. This has the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49. Findings include: Observation on 11/12/24 at 10:20 A.M. with Dietary Manager (DM) #266 revealed on the south resident hall the resident refrigerator at the nurse's station revealed three unlabeled, undated meat sandwiches, no evidence of temperature monitoring logs for the refrigerator and the unit microwave had dried food particles stuck to the ceiling and the sides of the microwave. No temperature logs were located on or near the refrigerator. DM #266 confirmed the above findings at the time of the observation. Observation on 11/12/24 at 10:25 A.M. with DM #266 revealed the resident refrigerator on the skilled…

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

Based on record review and interviews, the facility failed to ensure accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 49 residents residing in the facility. Findings include: Review of the punch details dated from 10/14/24 through 10/18/24 revealed Nurse Practitioner #330 was listed at eight hours each day under nursing, Registered Nurse (RN) and RN wages. Interview on 11/21/24 at 11:58 A.M. with Human Resources Director #287 revealed Nurse Practitioner #330 was not on the staffing schedule, however, she had listed her on the punch details as an RN. She was not aware what her actual role at the facility was but knew that she did come in and work at the facility. After obtaining the answer of where Nurse Practitioner #330 worked in the building, she returned and stated she was actually working as the nurse practitioner at the facility. She stated she had been entering Nurse Practitioner #330's hours in the payroll-based journal (PBJ) as she believed she could still utilize her hours…

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, repair invoice, and cleaning checklists, the facility failed ensure wheelchairs were being cleaned as required, failed to ensure shower rooms and equipment was maintained in a sanitary manner, and failed to ensure facility phones were in working order. This had the potential to affect all 49 residents residing at the facility. Findings include: 1. Observation on 11/12/24 at 3:38 P.M. with the Administrator revealed the following concerns: - The power wheelchair for Resident #137 was heavily soiled and a used disposable glove was found behind the seat. -The power wheelchair for Resident #135 had a visible dried spill on the seat, food crumbs on the seat and a dried spill that was on the seat which ran over the back and down the seat cushion -The power wheelchair for Resident #101 had dried soil on the front side of the upper back cushion and footrest had multiple visible dried spills. Following the above observations, the Administrator confirmed the above findings and stated…

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, policy review and staff interview, the facility failed to implement care planned interventions were followed to complete quarterly smoking safety assessments to ensure safe smoking practices. This affected two (#150, #153) of three residents reviewed for smoking. The facility identified fourteen current residents (#100, #105, #114, #123, #127, #128, #129, #10, #140, #141, #143, #148, #149 and #150) as smokers. The facility census was 49. Findings include: 1. Review of the medical record for Resident #150 revealed and admission date of 05/30/18. Diagnoses included but were not limited to spastic hemiplegia affecting left nondominant side, epilepsy, and schizoaffective disorder. Review of the 09/08/24 quarterly Minimum Data Set (MDS) for Resident #150 revealed he was cognitively intact and was independent for activities of daily living (ADLs). Review of the smoking assessment task in the electronic medical record for Resident #150 revealed the last smoking assessment prior to survey entrance was last completed on 02/20/24 which indicated he had loss of upper…

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, psychological evaluation, interview and policy review, the facility failed to ensure Resident #153's mental impairment and resident representative concerns were addressed to ensure a safe discharge for one resident (Resident #153) of three reviewed for discharge. The facility census was 49. Findings include: Review of the closed medical record for Resident #153 revealed an admission date of 09/06/23 and a discharge date of 09/25/24. Diagnoses included but were not limited to type II diabetes mellitus, opioid dependence, and bipolar disorder. Resident #153 was noted to be independent for Activities of Daily Living (ADLs). Review of the 03/17/23 Durable Power of Attorney for Healthcare for Resident #153 revealed she listed three power of attorneys (POAs) in order of preference and succession to serve as her agent to make health and personal care decisions. Resident #153's daughter was listed as number one and her son was listed as number three. This document gives the person you…

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, interviews and policy review, the facility failed to ensure bathing was provided as scheduled for three (Residents #121, #122 and #155) of three residents reviewed for showers. The facility census was 49. Findings include: 1. Review of the medical record for Resident #121 revealed an admission date of 06/07/24. Diagnoses included but were not limited to chronic respiratory failure, congestive heart failure, dependence upon a respirator, vascular dementia, and obesity. Review of 09/14/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #121 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #121 was dependent for bathing and transfers. Review of physician orders for Resident #121 revealed an 11/06/24 order for showers every Wednesday and Saturday day shift and to complete a progress notes for all refusals. Review of Resident #121's care plan revealed it was last reviewed on 09/13/24 and indicated bathing assistance was required. Review of the shower…

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, interviews and policy review, the facility failed to ensure weights were completed per physician ordered related to Resident #121's congestive heart failure. This affected one resident (Resident #121) of three residents reviewed for weight monitoring. The facility census was 49. Findings include: Review of the medical record for Resident #121 revealed an admission date of 06/07/24. Diagnoses included but were not limited to chronic respiratory failure, congestive heart failure, dependence upon a respirator, vascular dementia, and obesity. Review of 09/14/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #121 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #121 was dependent for transfers. Review of physician orders for Resident #121 revealed a 07/03/24 order for daily weights in the morning related to congestive heart failure. Review of Resident #121's care plan revealed Resident #121 was noted to be at risk for alteration in nutrition and/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, interview and facility policy the facility failed to ensure physician visits were completed as required. This affected three of three residents (Residents #122, #153 and #154) reviewed for physician services. This had the potential to affect all 49 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #122 revealed an admission date of 03/21/23. Diagnoses included but were not limited to acute postprocedural respiratory failure, hemiplegia, dependence on respirator, type II diabetes mellitus, and moderate protein calorie malnutrition. Review of 10/02/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #122 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition and dependence upon staff for activities of daily living (ADLs). Review of the physician visits for Resident #122 revealed no physician or nurse practitioner visits since 09/05/24. Physician visits listed within the past year were 11/07/23, 08/16/24 and 09/05/24. No nurse practitioner notes were listed 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 record review and interviews, the facility failed to ensure Resident #155 was free of significant medication errors. This affected one (Resident #155) of six residents reviewed for medication errors. The facility census was 49. Findings include: Review of the closed medical record for Resident #155 revealed an admission date of 03/28/24 with diagnoses including chronic kidney disease, heart failure and sepsis. He was discharged to the hospital on [DATE] for gastrointestinal bleeding. Review of Resident #155's census at the facility revealed he was active in the facility from 10/07/24 through 10/28/24. Review of the physician's orders for Resident #155 revealed he was on antibiotics for an urinary tract infection and wound infection. His orders included: -Ceftriaxone Sodium Intravenous Solution 2 grams (antibiotic) at lunch dated 10/08/24 and discontinued 10/09/24. -Ceftriaxone Sodium Intravenous Solution 2 grams at lunch dated 10/09/24 and discontinued 10/14/24. -Ceftriaxone Sodium Intravenous Solution…

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, observation and policy review the facility failed to ensure physician ordered diet modified texture was followed as required. This affected one (Resident #122) of three reviewed for diet texture. The facility census was 49. Findings include: Review of the medical record for Resident #122 revealed an admission date of 03/21/23. Diagnoses included but are not limited to acute postprocedural respiratory failure, hemiplegia, dependence on respirator, type II diabetes mellitus, and moderate protein calorie malnutrition. Review of 10/02/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #122 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed resident received a mechanically altered diet and required set up for eating meals. Review of the care plan for Resident #122 which was last reviewed on 10/19/24 revealed risk for dental or chewing problems related to missing or broken teeth. Interventions was diet as ordered by the physician. Review of the physician orders dated…

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 review of facility policy the facility failed to ensure adequate hydration was provided between meals as required. This affected four residents (Resident #121, #122, #125, and #137) and had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. Findings include: 1. Review of the medical record for Resident #121 revealed an admission date of 06/07/24. Diagnoses included but were not limited to chronic respiratory failure, dependence upon a respirator, vascular dementia, and obesity. Review of 09/14/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #121 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated resident was cognitively intact. Review of activities of daily living (ADLs) revealed resident requires supervision with eating and drinking. Review of Resident #121's care plan which was last reviewed on 09/13/24 revealed she was at risk for alteration in nutrition…

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

Based on record review, observation and interview, the facility failed to provide showers for Resident #5 who was dependent on staff for showers and grooming. This affected one resident (Resident #5) out of three residents reviewed for activity of daily living needs. The facility census was 44. Findings include: Review of medical record for Resident #5 revealed an admission date of 03/24/23. Diagnoses included acute respiratory failure with hypoxia (low levels of oxygen), chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, mixed receptive -expressive language disorder, dependence on respirator, encounter for attention to tracheostomy, and metabolic encephalopathy. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/24, revealed Resident #5 was severely impaired cognitively, had no rejection of care during the assessment reference period, and was dependent on staff for all activities of daily living and for mobility. Resident #5 was on oxygen therapy, required suctioning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a medication error rate was less than five percent. Two errors occurred within 22 opportunities for error resulting in a medication error rate of nine percent. This affected two residents (#32 and #40) out of three residents observed for medications administration. The facility census was 44. Findings include: An observation on 09/18/24 between 11:00 A.M. and 3:00 P.M. of three Licensed Practical Nurses (LPN #355, LPN #361, LPN #358) administer medications to three residents (Resident #12, Resident #32, Resident #40) with 22 opportunities for error revealed two medication errors were observed as follows (The medication error rate was 9 percent): 1. Resident #32 was admitted on [DATE] with diagnoses including chronic respiratory, kidney and heart failure with heart arrhythmia, ileus, high cholesterol, obstructive sleep apnea, prostate cancer, spinal stenosis, hypothyroidism, hyponatremia, atherosclerotic heart disease and diabetes mellitus. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #41 received his anticoagulant medication (apixaban) in a timely manner. This affected one resident (#41) out of three residents reviewed for medication administration. The facility census was 44. Findings include: Resident #41 was admitted on [DATE] with diagnoses including interstitial pulmonary disease, chronic respiratory and heart failure, cardiac arrhythmia, vascular dementia, high blood pressure, spinal stenosis, obesity, depression, glaucoma, anxiety, obstructive sleep apnea, idiopathic neuropathy, and anemia. A review of Resident #41's Medication Administration Record (MAR) dated 09/01/24 to 09/30/24 indicated to administer apixaban 5 milligrams (mg) orally two times a day. The apixaban medications was scheduled to be administered at lunch time and nighttime at 7:00 P.M. Resident #41's MAR indicated documentation that the scheduled lunch time dose of apixaban 5 mg was administered orally on 09/15/24 at 5:50 P.M. The next dose…

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, observation and interview the facility failed to date vials of insulin medication after opening. This affected one resident (#32) out of three residents observed for medication administration and had the potential to affect 12 residents (#1, #6, #13, #14, #18, #19, #27, #28, #32, #35, #43, #44). who the facility identified as receiving insulin injections in the facility. The facility census was 44. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses including chronic respiratory, kidney and heart failure with heart arrhythmia, ileus, high cholesterol, obstructive sleep apnea, prostate cancer, spinal stenosis, hypothyroidism, hyponatremia, atherosclerotic heart disease and diabetes mellitus. Resident #32's physician order dated 07/19/24 indicated to administer Lispro insulin solution 100 units per milliliter per sliding scale. If the blood glucose level was: 111 milligrams per diluent (mg/dL) to 150 mg/dL administer 0 units, 151 mg/dL…

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 The facility failed to ensure Resident #40's medications were documented at the time the medications were administered. This affected one resident (#40) out of four residents reviewed for medication administration records. The facility census was 44. Findings include: Resident #40 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including sepsis, hypotension, asthma, dysphagia, rheumatoid arthritis, venous insufficiency, respiratory/heart failure, quadriplegia, anemia, vitamin D deficiency, gastroesophageal reflux disease, depression, neuromuscular bladder, osteoporosis, and systemic lupus erythematosus. A review of Resident #40's Medication Administration Record (MAR) dated 09/01/24 to 09/30/24 indicated no documentation on 09/16/24 of the medications scheduled as upon rising were administered. The following medications were were scheduled to be administered upon rising: MS Contin 30 milligrams (mg) orally, ProHeal 30 cubic centimeters (cc) orally, Saccharomyces boulardil one capsule orally 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,observation and interview the facility failed to perform proper hand hygiene during medication administration and/or when using the glucometer for Resident #28, #32 and #41 and when providing incontinence care for Resident #41. This affected three residents (#28, #32 and #41) of five residents reviewed for infection control. The facility census was 44. Findings include: 1. Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses including chronic respiratory, kidney and heart failure with heart arrhythmia, ileus, high cholesterol, obstructive sleep apnea, prostate cancer, spinal stenosis, hypothyroidism, hyponatremia, atherosclerotic heart disease and diabetes mellitus. An observation on 09/18/24 at 11:11 A.M. of Licensed Practical Nurse (LPN) #355 revealed she had just obtained a resident's blood sugar reading using a glucometer. LPN #355 placed the glucometer in the top drawer of the medication cart and did not disinfect the glucometer. LPN #355 proceeded…

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, medical record review, and review of facility policy, the facility failed to ensure appropriate measures were taken which identified Resident #7 as requiring isolation-based precautions for COVID-19 and staff donned appropriate personal protective equipment (PPE) when entering Resident #7's room. This affected 25 residents who resided on the South unit where Resident #7 resided (Residents #2, #9, #10, #12, #15, #16, #18, #19, #20, #21, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #41). Facility census was 43. Findings include: Review of the medical record for Resident #7 revealed an admission date of 04/27/23 with diagnoses including acute respiratory failure, dysphagia, right rib fracture, anemia, anxiety, and encounter for surgical aftercare. Further review of the diagnoses revealed a newly added diagnosis of COVID-19 on 09/04/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 06/28/24 revealed Resident #7 had intact cognition, and a primary medical condition listed as debility and…

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

Based on observation, interview, and review of the facility maintenance documents, the facility failed to ensure the building was maintained in a clean, home-like, leak-free environment, or that the building did not have exterior precautions that would prevent insects from coming into the building. This had the potential to affect all 46 residents residing in the facility. Findings include: Observation on 07/10/24 from 3:20 P.M. to 3:40 P.M. of the main dining hall revealed the following: A missing piece of tile just in front of the lip near the exit from the dining hall to the patio. A bucket in the main dining/activity hall one-third full of water collecting drips from the ceiling. The ceiling above the bucket was covered with peeling paint, wet plaster, and wood beams were exposed underneath. Missing ceiling paint/plaster at least a foot in diameter on the vaulted ceiling with exposed wood and a rust-colored water stain running from the exposed area down to the lower beam which contained loose, bubbling paint. Multiple rust-colored stains around the vent grates. Visible cracks in…

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

Based on observation, interview, review of the facility admission agreement, and review of the facility policy, the facility failed to ensure privacy and dignity were maintained during incontinence care for Resident #12. This affected one resident (#12) of four residents who were reviewed for incontinence care. The facility census was 46. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/15/24 with diagnoses including acute and chronic respiratory failure, anoxic brain damage, morbid obesity, dysphagia, sleep apnea, major depressive disorder, and cognitive communication deficit. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #12 had severely impaired cognition and was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #12 was dependent on staff for all activities of daily living, including bathing and toileting hygiene. Review of the care plan dated 04/15/24 revealed Resident #12 was totally dependent on staff for all aspects of activities of daily living, including bed…

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, medical record review, and facility policy review, the facility failed to ensure medications were administered per physician orders for Resident #46. This affected one resident (#46) out of four who were reviewed for medication administration. The facility census was 46. Findings include: Review of the medical record for Resident #46 revealed an admission date of 06/07/24 with diagnoses including chronic respiratory failure with hypoxia, history of urinary tract infections, spinal stenosis of the lumbar region, depression, fibromyalgia, disorders of the diaphragm, bronchiectasis, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #46 had intact cognition. Further review of the MDS revealed Resident #46 required oxygen therapy and non-invasive mechanical ventilation. Review of the care plan dated 06/08/24 revealed Resident #46 had altered respiratory status related to chronic obstructive pulmonary disease (COPD), respiratory failure, bronchiectasis, and disorders of the diaphragm. Interventions included the administration of…

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

Based on interview, record review, resident and staff statements review, the facility failed to ensure staff showing signs of potential impairment was evaluated to ensure they was competent to provide resident care following suspicions of impaired behaviors by co-workers. This had the potential to affect all residents residing at the facility. The facility census was 43. Findings include: Review of a facility investigation following suspicion of DON and Registered Nurse (RN) #267 being impaired in the facility revealed the following: Review of the witness statement dated 04/26/24 timed at 2:58 P.M. from Licensed Practical Nurse (LPN) #220 revealed on 04/26/24 at approximately 2:00 A.M. she was at the desk charting when the former DON and RN #267 came on the unit smelling of alcohol and proceeded to conduct rounds on the unit. Review of the witness statement dated 04/26/24 timed at 2:14 P.M. from State Tested Nursing Assistant (STNA) #27 revealed on 04/26/24 the former DON and another person came to the unit during the night and appeared to be drunk or high and smelled. 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 resident and staff interviews, record review and facility investigation records, the facility failed to ensure staff maintained a professional demeanor when interacting with and around residents to ensure they are treated with dignity and respect at all times. This affected two (Resident #103 and #116) of three residents reviewed for dignity and respect. The facility census was 43. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 06/11/22. Diagnoses included but were not limited to dependence on a respirator, morbid obesity, unspecified protein-calorie malnutrition, type II diabetes, anxiety disorder, schizophrenia, and epilepsy. Review of 04/10/24 annual Minimum Data Set (MDS) 3.0 for Resident #103 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #103 was cognitively intact. Review of activities of daily living (ADLs) for Resident #103 revealed he required set up for eating, oral hygiene, upper dressing, personal hygiene, chair to bed transfer, toilet transfer, required moderate assist…

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 interviews, the facility failed to ensure antibiotics were administered as ordered. This finding affected two (Residents #115 and #116) of five residents reviewed for medication administration. Findings include: 1. Review of Resident #116's medical record revealed the resident was admitted on [DATE] with diagnoses including dilated cardiomyopathy, ventricular tachycardia and tracheostomy status. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable. Review of a text message dated 04/15/24 at 3:16 P.M. provided by Licensed Practical Nurse (LPN) #202 from Nurse Practitioner (NP) #803 indicated for the nurse to administer Ertapenem one gram IM times one stat. (Ertapenem was in the starter kit.) Place an IV line and NS to be infused at 100 ml per hour for one liter. Flush the percutaneous gastrostomy (PEG) tube with 250 ml water times one stat. The text message did not identify the resident's name in the message. 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 interview and record review, the facility failed to ensure a controlled substance medication was administered per physician orders. This affected one resident (#21) out of three residents reviewed for medication administration. This had the potential to affect fifteen residents (#1, #4, #8, #10, #11, #13, #17, #21, #26, #29, #31, #33, #37, #45, and #47) who were ordered controlled substance medication. The facility census was 48. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/03/24. Diagnosis included acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, depression, history of transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, asthma, anxiety disorder, and atrial fibrillation. Review of the 5-day Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the physician orders dated February 2024 revealed an order for Alprazolam…

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, interview, and facility policy review the facility failed to ensure a controlled substance was documented after administered per physician's orders. This affected one resident (#21) out of three residents reviewed for medication administration. This had the potential to affect fifteen residents (#1, #4, #8, #10, #11, #13, #17, #21, #26, #29, #31, #33, #37, #45, and #47) who were ordered controlled substance medication. The facility census was 48. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/03/24. Diagnosis included acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, depression, history of transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, asthma, anxiety disorder, and atrial fibrillation. Review of the 5-day Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the physician orders dated February 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety and well being of Resident #51 when they did not return from a leave of absence. This affected one (Resident #51) of one resident reviewed for a leave of absence from the facility. The facility census was 49. Findings include: Review of the medical record for Resident #51 revealed an admission date of 12/13/23 with diagnoses including malignant neoplasm of the bone (cancer), multiple myeloma (cancer of the blood) and repeated falls. He was discharged from the facility on 01/14/24. Review of the Resident Sign Out form dated 01/06/24 revealed Resident #51 signed out for a leave of absence on 01/06/24 at 7:10 A.M. Review of the nursing progress note dated 01/06/24 at 6:53 A.M. revealed Director of Nursing (DON) #211 documented Resident #51 went out on leave of absence from the facility and stated he would be back later. The medical record did not contain evidence the resident returned on this date or efforts to ensure Resident #51 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the census list and staff interview, the facility failed to ensure the resident's environment was kept clean, well maintained, and homelike. This affected six (#2, #10, #12, #21, #37 and #45) residing in the affected rooms and the residents residing on the 100 hall. The census was 47. Findings include: Observation on 12/14/23 at 4:39 P.M., revealed in room [ROOM NUMBER] the bathroom floor had a thick black/brown substance on floor surrounding approximately 75% of the toilet bowl. The floor had a thick buildup of grime in each corner of the bathroom. Interview at the time of the observation, with State Tested Nursing Assistant (STNA) #300 confirmed the observation. Observation on 12/14/23 at 4:41 P.M., revealed the unoccupied room [ROOM NUMBER]'s window blinds had pieces of the blind broken of exposing the outdoors. Interview at the time of the observation, with STNA #300 confirmed the observation. Observation on 12/14/23 at 4:45 P.M., revealed in room [ROOM NUMBER] the vinyl…

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

Based on observation and interview, the facility failed to maintain the dumpster area free from debris and ensure trash was properly stored. This had to the potential to affect all residents. The facility census was 54. Findings include: Observation of the outside dumpster area on 08/29/22 at 8:18 A.M. revealed various debris, two empty boxes, a gray commode seat, and a moderate amount of bees. The side door of the dumpster on the right was open. Interview at this time with Dietary Aide (DA) #142 verified the observation.

Based on record review and interview, the facility failed to ensure quality assurance (QA) meetings were held to address care issues/concerns in the facility. This affected all 54 residents who resided in the facility. Findings include: Review of the QA committee attendance records for the previous 12 months revealed the last quality assurance meeting was held on 06/30/20. Interview on 09/01/22 at 2:40 P.M. with the Administrator revealed he was unable to locate QA meeting minutes prior to his start at the facility in April of 2022.

Based on observations, interview, and record review, the facility failed to implement infection control practices to prevent the spread of infection. This had the potential to affect all residents. The facility census was 54. Findings include: 1. Observation on 08/23/22 at 5:35 A.M. revealed a call light was on outside of Resident #11 and #23's room. Precautions signs were posted along with personal protective equipment (PPE) on the outside of the door to this room. Licensed Practical Nurse (LPN) #134 was observed entering the room without donning PPE and observed to obtain Resident #11's blood sugar. LPN #134 did not complete hand hygiene upon exiting the room. Interview with LPN #134, after she exited the room, revealed she was not sure what the resident may had been on isolation for and confirmed isolation equipment was outside of the door. LPN #134 stated she should had checked prior to entering the room to see if the resident was on isolation and she should have completed hand hygiene after exiting the room. During this time, State Tested Nurse Aide (STNA) #101 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment that was also in good repair. This affected Residents #16, #39, #49, #35, #50, #105 and had the potential to affect all residents. The facility census was 54. Findings include: Observation on 08/29/22 at 9:35 A.M. of Resident #16's room revealed the floor was sticky and dirty with various stains on the floor and walls. In addition a small hole was observed in the bathroom door. Observation on 08/29/22 at 9:41 A.M. of Resident #39's room revealed the top drawer of the chest of drawers was broken and hanging off, there was debris on the floor on the side of bed near the wall, the windowsill was in disrepair, and there was small hole in wall behind the door of the room. Observations and interview during tour of the facility on 08/29/22 from 10:13 A.M. through 10:18 A.M. with Housekeeper (HSK) #138 revealed the floor in Resident #16's room was sticky and various stains were observed on the floor and walls.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely incontinence care. This affected six residents (#2, #11, #18, #20, #23 and #33) of six observed for incontinence care. The facility identified 31 incontinent residents. The facility census was 54. Findings include: 1. Observation on 08/23/22 at 5:20 A.M. revealed a strong odor of urine coming from Resident #2 and #20's room. Residents were sleeping at time of observation. Observation of incontinence care on 08/23/22 between 6:38 A.M. and 6:51 A.M. with State Tested Nursing Assistant (STNA) #101 for Resident #2 and #20 revealed both residents had been incontinent of a large amount of urine that had soaked through to their mattresses. Interview with STNA #101 after the provision of incontinence care revealed she was the only STNA on the unit and she had not had time to provide all residents with care since she started her shift at 12:00 A.M. Review of Resident #2's medical records revealed an admission date of 07/23/21.…

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 policy review, the facility failed to ensure oxygen tubing was dated to ensure timely replacement. This affected eight residents (Residents #19, #33, #1, #13, #43, #30, #38 and #22) out of 17 resident rooms checked for respiratory equipment. The facility census was 54 residents. Findings include: 1. Review of Resident #19's medical record revealed an order dated 07/09/22 for oxygen via nasal cannula at two liters per minute, titrate as tolerated to keep oxygen saturation above 90 percent. Observation on 08/22/22 starting at 9:24 A.M. with Senior Director of Nursing (SDON) #103 and Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #104 verified Resident #19's oxygen tubing was not dated. Interview with SDON #103 during the observation revealed the facility's respiratory therapy department handled oxygen tubing and verified oxygen tubing was to be changed weekly and dated at that time. Interview on 08/22/22 at 1:58 P.M. with Director of Respiratory Therapy (DRT) #110 revealed he kept track of oxygen tubing to be…

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

Based on observation and interview, the facility failed to ensure adequate staffing to meet the needs of the residents in a timely manner. This affected six of 54 facility residents (Residents #21, #22, #39, #38, #13, and #18) and had the potential to affect all residents. The census was 54. Findings include: 1. On 08/23/22 at 5:20 A.M. a strong odor of urine was detected outside of Resident #21 and #22's room. The residents were sleeping at the time of the observation. Observation of incontinence care on 08/23/22 between 6:38 A.M. and 6:51 A.M. with State tested Nurse Aide (STNA) #101 for Resident #21 and #22 revealed both residents had been incontinent of a large amount of urine that had soaked through to their mattresses. Interview with STNA #101 after incontinence care was provided revealed she was the only STNA on the unit and she had not had time to provide all residents with care since she started her shift at 12:00 A.M. 2. Observation of incontinence care on 08/23/22 at 5:35 A.M. with STNA #101 for Resident #39 revealed the resident had been incontinent of a large amount of…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen and the nursing unit refrigerators and microwave were maintained in a clean and sanitary condition and food was stored appropriately on the nursing units. This had the potential to affect all residents except nine residents (#1, #8, #18, #19, #36, #53, #204, #205, and #206) who received nothing by mouth. The facility census was 54. Findings include: Observation during a tour of the kitchen on 08/29/22 between 8:15 A.M. and 8:20 A.M. revealed a large amount of spilled grease that had various debris including cigarette butts from the trap container located outside of the kitchen. Interview at the time of observation with Dietary Aide (DA) #142 verified the observation. Observation on 08/29/22 at 11:10 A.M. of the room behind the nurses' station on the 100-hall revealed two refrigerators. One was a mini refrigerator that was black in color. Upon opening the refrigerator a strong odor was noted. Observation of the top shelf revealed a cardboard box that was discolored brown and wet; the box was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy and procedure review, the facility failed to ensure a proper discharge for Resident #55. This affected one resident (#55) of one resident reviewed for discharge to the community. The facility census was 54. Findings include: Review of the closed medical record of Resident #55 revealed an initial admission date of 04/08/22 and a discharge date of 07/14/22. Diagnoses included multiple myeloma, anemia, heart attack, and type two diabetes mellitus. Review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE] revealed the resident had an unplanned discharge to the community and cognition was intact. Review of the interdisciplinary team (IDT) discharge planning form dated 07/14/22 and completed by Licensed Practical Nurse (LPN) #131 revealed not applicable was marked to most areas on the form but Resident #55 was discharged home with no home care and medications sent home with resident. The IDT discharge planning form was electronically…

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, observation and interview, the facility failed to ensure knee and arm splints were applied as ordered by physical therapy. This affected one resident, Resident #28 out of one resident reviewed for range of motion. The facility census was 54. Findings include: Medical record review revealed Resident #28 was readmitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis, type II diabetes, heart failure, hypertension, and cerebellar stroke syndrome. Review of Resident #28's physician orders dated 01/12/21 revealed the resident was to be encouraged to wear right elbow extender splint and right knee brace daily up to eight hours. Observations of Resident #28 on 08/29/22 at 11:42 A.M., 08/29/22 at 4:16 P.M., 08/30/22 at 9:10 A.M. and 11:00 A.M. revealed the resident was not wearing a right elbow extender splint or his right knee brace on. Interview with Resident #28 on 08/30/22 at 11:40 A.M. revealed staff had not applied his splint or right knee brace for quite some…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were assessed for fall risk on a routine basis to prevent the likelihood of further falls. This affected one resident (Resident #49) of three residents reviewed for falls. The facility census was 54 residents. Findings include: Review of Resident #49's medical record revealed an admission date of 12/01/13 and diagnoses including obesity, type two diabetes, depression, cardiomegaly, osteoarthritis and dementia with behavioral disturbance. Review of Resident #49's care plans dated 03/10/18 revealed she was at risk for falls due to vascular dementia, decreased physical function, bowel and bladder incontinence and history of falls. Review of Resident #49's physician's orders dated 05/09/22 revealed Resident #49 required a mechanical lift for transfers and indicated Resident #49 started on occupational therapy on 08/23/22. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure tube feedings were administered per physician orders. This affected two of two residents reviewed for tube feeding, Residents #205 and #53. The facility identified 13 residents who received tube feedings. The facility census was 54. Findings include: 1. Review of Resident #53's medical records revealed an admission date of 05/27/22. Diagnoses included gastrostomy, dysphasia (difficulty swallowing), stroke with right sided weakness. Review of the care plan dated 05/27/22 revealed Resident #53 was dependant on tube feeding for nutrition and hydration. Interventions included administer tube feeding as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was rarely understood, required extensive assistance with bed mobility, toileting and personal hygiene, and required total dependence with transfers, and eating. Review of current physician orders for August 2022 revealed Resident #53 was ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper assessment of dialysis shunt and communication with dialysis center. This affected one resident (#4) of one resident reviewed for dialysis. The facility census was 54. Findings include: Review of the medical record for Resident #4 revealed an admission date of 07/27/22. Diagnoses included end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus with diabetic nephropathy. Review of the care plan dated 07/27/22 revealed Resident #4 had potential for complications related to the diagnosis of renal failure/end stage renal disease requiring dialysis treatment. Interventions included auscultate shunt site for bruit and palpate for thrill per protocol or every shift; document presence or absence; notify the physician, dialysis center of absent thrill/bruit, and nurse to utilize dialysis communication form for pre-dialysis assessment including obtaining vital signs. Review of the admission minimum data set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #22's as needed medication was available upon request. This affected one resident (#22) of five residents (#6, #22, #37, #38, and #42) reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #22 reveled an admission date of 04/25/22. Diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure, anxiety, and history of COVID-19. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #22 had moderately impaired cognition and received antianxiety medications four days of the seven day look back period. Interview on 08/29/22 at 12:30 P.M. with Resident #22 revealed the facility ran out of her Ativan (antianxiety) recently and she did not get it for five days. Review of Resident #22's August 2022 physician orders revealed an order for Ativan tablet 0.5 milligrams (mg), give one tablet by mouth every eight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure pharmacy recommendations were reviewed by the physician and what, if any, action was taken to address the recommendations. This affected two residents (Resident #6 and Resident #22) out of five residents reviewed for unneccessary medications. The facility census was 54. Findings include: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses includng type II diabetes, major depressive disorder, cerebral infarction, history of falling and congestive heart failure. Review of Resident #6's Minimum Data Set assessment dated [DATE] revealed the resident had moderate cognitive impairment and received an antidepressant seven of seven days of the look back period. Review of Resident #6's physician orders for the month of August 2020 revealed gabapentin (used to manage behaviors) 300 mlligram (mg) twice a day, Aricept 10 mg daily, Lexapro (used to treat depression and anxiety) 20 mg daily, and mirtzapine (used…

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

Based on observation and interview, the facility failed to ensure medications stored on the 200 hall medication cart and storage room were properly labeled. This had the potential to affect Residents #1 #5, #8, #14, #15, #19, #24, #25, #33, #36, #42, #46, #51, #53, #204, #205, and #206 whose medications were stored on the 200 hall medication cart and medication room. Facility census was 54. Findings include: Observation of the medication cart on the 200 hall on 08/31/22 at 6:50 A.M. revealed a multi dose vial of tuberculin which was open and undated. The finding was verified with Licensed Practical Nurse (LPN) #119 at the time of the observation. Observation of the refrigerator in the medication storage room on the 200 hall on 09/01/22 at 7:39 A.M. revealed two bottles of Frivanq Solution 25 milligram/milliliter that were opened and undated, and a multidose tuberculin vial that was opened and undated. The finding was verified with the Director of Nursing on 09/01/22 at 7:05 A.M. Review of the tuberculin prescribing information packet insert revealed vials in use more than thirty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure collected lab specimens were sent to the lab in a timely manner. This affected two residents (#205 and #42) of two reviewed for lab services. The facility census was 54. Findings include: 1. Interview on [DATE] at 9:14 A.M. with Resident #205 revealed she had expressed concerns to the nurse regarding pain during urination. Resident #205 stated the nurse had collected a urine specimen, however it had not been sent out for testing. Resident #205 further stated she had asked the nurse the following day if the results had been reported and the nurse stated she was unsure. Interview with Licensed Practical Nurse (LPN) #118 at time of resident interview revealed LPN #118 was not aware a sample of the resident's urine had been collected or sent out for testing. Interview on [DATE] at 1:33 P.M. with LPN #118 revealed she checked on Resident #205's urine specimen and there was a urine sample labeled with Resident #205's name 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 record review and interview, the facility failed to ensure complete and accurate documentation of medical records. This affected three residents (#22, #55, and #6) of 20 whose medical records were reviewed. The facility census was 54. Findings include: 1. Review of the closed medical record of Resident #55 revealed an initial admission date of 04/08/22 and a discharge date of 07/14/22. Diagnoses included multiple myeloma, anemia, heart attack, and type two diabetes mellitus. Review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE] revealed Resident #55 had an unplanned discharge to the community and cognition was intact. Review of the interdisciplinary team (IDT) discharge planning form dated 07/14/22 and completed by Licensed Practical Nurse (LPN) #131 revealed not applicable to most areas on the form but Resident #55 was discharged home with no home care and medications sent home with resident. The IDT discharge planning form was electronically signed by LPN #131.…

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

Based on record review and interview, the facility failed to ensure influenza and pneumococcal immunizations were offered and/or provided. This affected one resident (#42) of five residents (#6, #22, #37, #38, and #42) reviewed for immunizations. The facility census was 54. Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/21/21. Diagnoses included respiratory failure, muscle weakness, and tracheostomy. Further review of the medical record revealed no evidence of the influenza and pneumococcal immunization being offered and/or provided. Interview on 08/31/22 at 2:19 P.M. with Regional Infection Control Preventionist (RICP) #114 revealed she was unable to find documentation of Resident #42 being offered and/or provided the influenza and pneumococcal immunizations including any declinations of the immunizations.