Ayden Healthcare Of Oregon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of drug manufacturer instructions for use, the facility failed to ensure a resident was encouraged to use and offered an oral rinse after administration of an orally inhaled medication containing a steroid. This affected one (#263) of three residents reviewed for medication administration. The facility census was 90.Findings include:Review of the medical record for Resident #263 revealed he was admitted on [DATE] with diagnoses including emphysema, hypertension, viral hepatitis C, alcohol dependence, cocaine use, and toxic encephalopathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #263 was cognitively impaired and did not exhibit behaviors at the time of the assessment. Resident #263 utilized a walker and a wheelchair and required moderate assistance with activities of daily living, personal hygiene, bed mobility, and transfers.Review of physician orders for Resident #263 revealed the resident 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 personnel record review, staff interview, review of policy, and review of the facility's Tuberculin (TB) Risk Assessment, the facility failed to ensure all new hire employees had current TB testing results in their employee files. This had the potential to affect all 80 residents. The facility census was 80. Findings include: Review of the facility's TB Risk assessment dated [DATE] revealed the facility had a TB screening program for all employees that required a baseline skin test with a two-step skin test for all healthcare workers. 1. Review of the personnel file for Licensed Practical Nurse (LPN) #460 revealed a hire date of 02/05/25. Further review of the personnel file for LPN #460 revealed no TB skin test results in the file. Interview on 09/09/25 at 4:50 P.M. ,with Human Resource Director (HRD) #410 verified there were no TB skin test results in the personnel file for LPN #460. 2. Review of the personnel file for Housekeeper #400 revealed a hire date of 09/11/24. Further review of the personnel…

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

Based on observation, staff interview, resident interview and review of facility policy, the facility failed to ensure treatments for pressure wounds were completed as physician ordered. This affected one (#52) of three residents reviewed for wound care. The facility census was 74. Findings include: Review of medical record for Resident #52 revealed admission date of 11/10/23. Diagnoses included quadriplegia, pressure ulcer of the left heel, stage four pressure ulcer of the sacral and pressure induced deep tissue damage of right the buttocks. Review of the Minimum Data Set (MDS) assessment, dated 01/31/25, revealed Resident #52 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed Resident #52 had bilateral impairment to the upper and lower extremities and was staff dependent on all activities of daily living (ADLs). Additionally, Resident #52 had two stage three pressure ulcers and five stage four pressure ulcers. Review of Resident #52's care plan, dated 01/27/25, revealed the resident had 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 observation, staff interview, and policy review, the facility failed to maintain the North and South shower rooms in a clean and sanitary manner. This had the potential to affect all residents except 24 (#3, #8, #9, #10, #15, #17, #18, #19, #20, #26, #27, #31, #33, #44, #47, #51, #52, #55, #56, #57, #58, #59, #62, and #70) residents identified as not using the shower rooms. The facility census was 70. Findings include: Observation on 07/10/24 beginning at 9:07 A.M., revealed there was a debris and a buildup of a dark colored substance around the perimeter of the shower floor tiles in both the North and South shower rooms. Interview on 07/10/24 at 9:11 A.M., with Housekeeping and Laundry Supervisor (HLS) #250 verified the dark colored substance on the floor tiles in both the North and South shower rooms. Review of the policy titled, Floors, last revised 2009, revealed floors would be maintained in a clean, safe, and sanitary manner. Review of the policy titled, Quality of Life-Homelike Environment, last revised 05/2017, revealed the facility would maintain a clean, sanitary…

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, review of controlled substance records, review of pharmacy receipts, resident and staff interview, and policy review, the facility failed to timely obtain pharmacy services when resident medication was needed for administration. This affected one (#73) of three residents review for medications. The facility census was 70. Findings include: Review of the medical record for Resident #73 revealed an admission date of 06/13/24 and a discharge date of 07/08/24. Diagnoses included type two diabetes mellitus, osteoarthritis of the knee, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition. Review of the hospital discharge medication orders revealed Resident #73 was ordered the narcotic pain medication oxycodone-acetaminophen 5-325 milligrams (mg) per tablet with instructions to take one tablet by mouth every eight hours as needed for pain for two days. Review of a pharmacy receipt…

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, staff interviews, and review of the facility policies, the facility failed to ensure safe food handling occurred during meal service, failed to ensure the thermometer used to check food temperatures was sanitized between food items, and failed to ensure the high-temperature dishwasher washed and/or rinsed at the proper temperatures. This affected two residents (#9 and #70) who received a cheeseburger and the potential to affect all 82 residents residing in the facility. The facility identified all 82 residents in the facility received food from the kitchen. Findings include: 1. Observation prior to meal service on 04/30/24 at approximately 11:20 A.M. revealed [NAME] #553 was preparing to take food temperatures. [NAME] #553 removed a cloth soaking in a red sanitizer bucket and wrung it out and placed it on the counter near the steam table. [NAME] #553 then used the cloth to wipe the thermometer, placed the cloth back on the counter, and tested the temperature of mashed potatoes. [NAME] #553 then picked up the cloth and wiped off the thermometer and placed the…

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

Based on observation, staff interview, and review of the menu portion spreadsheet, the facility failed to provide adequate protein portions for residents on a mechanical soft diet. This affected five (#15, #16, #22, #33, and #40) of six residents identified on a mechanical soft diet. The facility census was 82. Findings include: Review of the dietary menu spreadsheet for lunch on 04/30/24 revealed the portion for mechanical soft pork chop should have been six ounces. Observation during meal service on 04/30/24 beginning at 11:30 A.M. revealed [NAME] #553 used a size 20 scoop (equivalent to 1.52 ounces) to serve mechanical soft pork chops. Interview on 04/30/24 at 12:30 P.M. with [NAME] #553 confirmed some mechanical soft pork chop was leftover. [NAME] #553 stated it was because some residents on a mechanical soft diet chose the alternative menu option. [NAME] #553 confirmed he used the 20 scoop to serve mechanical soft pork to the residents on a mechanical soft diet. Interview and observation on 05/01/24 at 10:00 A.M. with Dietary Manager (DM) #569 confirmed the size 20 scoop held 1…

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

Based on observations, staff interviews, and review of the facility policy, the facility failed to provide clean resident rooms. This affected four (#21, #27, #55, and #59) of four residents reviewed for environment. The facility census was 82. Findings include: 1. Observation on 04/30/24 at 8:51 A.M. revealed Resident #27 sitting in their room wearing a shirt with food on it and the floor of room was dirty and sticky and an area of dry yellowish fluid was noted under Resident #27's bed. Interview on 04/30/24 at 8:55 A.M. with Occupational Therapy Assistant (OTA) #564 verified Resident #27 was sitting in their room wearing a shirt with food on it and the floor of the room was dirty and sticky and a dried yellowish fluid was noted under Resident #27's bed. 2. Observation on 04/30/24 at 9:26 A.M. revealed the floor of the resident room, shared by Residents #55 and #59, was dirty and sticky. Subsequent observation on 04/30/24 at 2:44 P.M. revealed the floor of the resident room, shared by Residents #55 and #59, continued to be dirty and sticky. Interview on 04/30/24 at 4:05 P.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, and facility policy review, the facility failed to ensure residents had access to their call lights and their bed mobility equipment. This affected three (#12, #48, and #67) of three residents reviewed for accommodation of needs. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included early-onset cerebellar ataxia, type two diabetes mellitus without complications, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 03/09/24, revealed Resident #12 was cognitively intact. Resident #12 was dependent on staff for shower/bathing, lower body extremity, personal hygiene, and always incontinent of bowel and bladder. Observation on 04/29/24 at 2:05 P.M. revealed Resident #12 was sitting in a wheelchair next to the bedside. Resident #12 reported she wanted to go back to bed. Resident #12's call light was observed to be under…

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

Based on medical record review and staff interview, the facility failed to consistently implement the bowel movement plan to administer medications as physician ordered for a resident not having a bowel movement for several days. This affected one (#7) of two residents reviewed for bowel incontinence. The facility census was 82. Findings include: Review of Resident #7's medical record revealed an admission date 10/03/23. Diagnoses included methicillin resistant staphylococcus aureus (MRSA) infection, viral infection of urogenital system, and constipation. Review of the Minimum Data Set (MDS) assessment, dated 04/10/24, revealed Resident #7 had mild cognitive impairment and was always incontinent of bowel and bladder. Review of Resident #7's plan of care dated 10/05/23 revealed Resident #7 was at risk for alteration in elimination to rule out incontinent of bowel and bladder. Interventions included administer medications as ordered. Review of Resident #7's Bowel and Bladder Elimination Record for April 2024 revealed no documented bowel movements for eight days from 04/02/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility urinary continence and incontinence assessment and management policy, the facility failed to ensure a resident received timely incontinence care and services. This affected one (#67) of seven residents reviewed for bowel and bladder incontinence in a facility census of 82. Findings include: Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, gastrointestinal hemorrhage, anemia, coronary artery disease, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #67 had severe cognitive impairment, dependent on staff with activities of daily living, required partial to moderate assistance from staff with transferring and repositioning, utilized a wheelchair with partial to moderate assistance for mobility, and always incontinent of bowel and bladder. Review of the nursing plan of care dated 03/26/24 revealed…

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

Based on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to manage the resident's pain and administer pain medications as physician ordered. This affected one (Resident #287) of two residents reviewed for pain management. The facility census was 82. Findings include: Review of the medical record revealed Resident #287 had an admission date of 04/24/24 with diagnosis of polyneuropathy (peripheral nerve pain). Review of the care plan initiated on 04/24/24 revealed Resident #287 was care planned for pain management with interventions of medications as ordered. Review of Resident #287's physician orders for 04/24/24 revealed an order for gabapentin (treats nerve pain) 300 milligrams (mg) three times daily. Review of the physician progress note dated 04/30/24 for Resident #287 revealed a medication adjustment for the gabapentin (used for nerve pain) to change the dose from original dose of 100 mg three times daily to 300 mg three times daily. Observation on 05/01/24 at 7:50 A.M. of Licensed Practical Nurse (LPN) #610…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for a resident. This affected one (Resident #287) of one resident reviewed for dialysis. The facility census was 82. Findings include: Review of the medical record for Resident #287 revealed an admission date of 04/24/24 with diagnoses of end-stage renal disease (ESRD) and dependence on dialysis. Review of the admission assessment dated [DATE] for Resident #287 revealed he was alert and oriented to person, place, time, and situation indicating he was cognitively intact. Review of the baseline care plan initiated on 04/24/24 for Resident #287 revealed he was care planned for dialysis. Review of the medical record for Resident #287 from 04/24/24 to 05/01/24 revealed there was no dialysis communication documentation. Interview on 05/01/24 at 4:43 P.M. with Registered Nurse (RN) #636 revealed the facility does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the provider responded in a timely manner to pharmacy recommendations of an as needed psychotropic medications. This affected one (#7) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 04/10/24, revealed Resident #7 was cognitively intact. Review of Medication Regimen Review, dated 02/19/24, revealed the pharmacy review identified a psychotropic as needed (PRN) medication and identified the need for anticipated duration and continued use rationale. Resident #7 was prescribed Clonazepam tablet 0.5 milligram (mg) with instructions to take one tablet by mouth every twelve hours as needed. There was no physician response. Review of Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, resulting in a medication error rate above five percent (%). A total of six medications errors were observed out of 40 opportunities for a medication administration error rate of 15.00%. This affected one (#4) of seven residents observed during medication administration. The facility census was 82. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, anxiety, chronic obstructive pulmonary disease (COPD), chronic kidney disease, gastric esophageal reflux disease (GERD), and peripheral vascular disease (PVD). Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #4 had intact cognition and received antianxiety, antidepressant, anticoagulant, diuretic,…

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, resident and staff interview, review of the facility policy, and review of the manufacturer guidelines of insulin administration, the facility failed to ensure medications were administered to the residents without a significant medication error. This affected one (Resident #287) of seven residents reviewed for medication administration. The facility census was 82. Findings include: Review of the medical record for Resident #287 revealed an admission date of 04/24/24 with diagnoses of diabetes mellitus and long term insulin use. Review of the admission assessment dated [DATE] for Resident #287 revealed he was alert and oriented to person, place, time, and situation indicating he was cognitively intact. Review of the care plan initiated 04/25/24 revealed Resident #287 was care planned for diabetes with intervention to check blood sugar as ordered, resident has a dexcom continuous glucose monitoring (CGM) system. Review of the current physician orders from 04/2024 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medication entries were accurately documented and contained in the medical record. This affected two of seven residents (#4 and #287) reviewed for medication administration. The facility census was 82. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, anxiety, chronic obstructive pulmonary disease (COPD), chronic kidney disease, gastric esophageal reflux disease (GERD), and peripheral vascular disease (PVD). Review of Resident #4's physician's orders revealed the medications had the prescribed timeframes: 05/21/23 Cilostazol 100 milligrams (mg) given twice daily for intermittent claudication between 7:00 A.M. - 10:00 A.M. (rising) and 7:00 P.M.-10:00 P.M. (HS range), 05/21/23 Budesonide 0.5 mg per(/)2.0 milliliters (ml) inhalation vial given twice daily for COPD between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, police interview, review of Resident Council meeting minutes, and review of policies, the facility failed to ensure residents were treated in a dignified manner. This affected one (#61) of three residents reviewed resident rights. The facility census was 76. Findings include: Review of the medical record for Resident #61 revealed an admission date of 02/05/24, diagnoses included major depressive disorder, post-traumatic stress disorder, erectile dysfunction, paraplegia, type II diabetes mellitus, chronic kidney disease, and autonomic dysreflexia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had moderate cognitive impairment, required moderate assistance for toilet hygiene, showering, dressing and personal hygiene and maximal assistance for transfers. Resident #61 planned to return home upon discharge. A Medicare 5-day MDS assessment dated [DATE] revealed Resident #61 was independent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of policy for incontinence, and review of staff correction form, the facility failed to ensure a resident who was dependent on staff for care, was provided incontinence care in a timely manner. This affected one (#10) of four residents reviewed for incontinence care. The census was 82. Findings included: Review of medical record for Resident #10 revealed admission date of 08/25/20, with a readmission date of 02/17/22. The resident was admitted with diagnoses including schizoaffective disorder, bipolar disorder, muscle weakness, cognitive communication deficit and unsteady feet. Review of the minimum data set (MDS) assessment dated [DATE], revealed the resident was moderately cognitively impaired. The resident was assessed as the need for toileting as being dependent and for chair to bed or bed to chair transfer as dependent. Review of the care plan relative to the risk in decline for activity of daily living (ADL) function revealed interventions which included the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, policy review, and hospital documentation review, the facility failed to notify the physician to obtain orders and instructions to maintain and assess a resident chest tube drainage system. This affected one (#2) of one resident reviewed for chest tube care and treatment. The facility census was 79. Findings include: Review of Resident #2's medical record revealed an admission date of 08/25/23, with diagnoses including: malignant pleural effusion, right lung small cell carcinoma, sick sinus syndrome, morbid obesity, cardiomyopathies, pneumonia, abnormal coagulation profile, acute kidney failure, congestive heart failure, cutaneous abscess of abdominal wall, type 2 Diabetes Mellitus, chronic obstructive pulmonary disease, atrial fibrillation, cardiac defibrillator, and prosthetic heart valve. Review of the hospital discharge documentation dated 08/25/23, lacked instructions or care related to the chest tube drainage system and chest tube dressing treatments. 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 medical record review, staff interview, policy review, and hospital documentation review, the facility failed to maintain and assess a resident chest tube drainage system. This affected one (#2) of one resident reviewed for chest tube care and treatment. The facility census was 79. Findings include: Review of Resident #2's medical record revealed an admission date of 08/25/23, with diagnoses including: malignant pleural effusion, right lung small cell carcinoma, sick sinus syndrome, morbid obesity, cardiomyopathies, pneumonia, abnormal coagulation profile, acute kidney failure, congestive heart failure, cutaneous abscess of abdominal wall, type 2 Diabetes Mellitus, chronic obstructive pulmonary disease, atrial fibrillation, cardiac defibrillator, and prosthetic heart valve. Review of the hospital discharge documentation dated 08/25/23, lacked instructions or care related to the chest tube drainage system and chest tube dressing treatments. Review of the nursing admission assessment dated [DATE] between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as indicated. This affected one (#3) of four sampled residents reviewed for fall prevention and safety interventions. The facility census was 79. Findings include: Review of Resident #3's medical record revealed an admission date of 12/12/06, with diagnoses including: dementia, major depression, psychosis, abnormal posture, coronary artery disease, repeated falls, hypertension, atrial fibrillation, chronic kidney disease, anemia, anoxic brain damage, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. According to the most current minimum data set assessment dated [DATE], revealed Resident #3 was assessed with moderate cognitive impairment, ability to communicate clearly, dependent on staff for the completion of activities of daily living including bed mobility, utilized a wheelchair for mobility, incontinent of bowel and bladder with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and review of the facility policies, the facility failed to ensure medications were properly stored and not left at the resident bedside. This affected four (#4, #37, #40, and #278) of four residents reviewed for medication storage. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #37 had an admission date of 06/17/23. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus and glaucoma. There was no physician order that Resident #37 could self administer medications. Observation during medication administration on 07/19/23 at 8:42 A.M. revealed Resident #37 had an Incruse Ellipta inhaler (treats COPD), brimonidine tartrate ophthalmic solution 0.15% eye drops (treats glaucoma), Latanoprost ophthalmic emulsion 0.005% eye drops (treats glaucoma) and albuterol sulfate 0.083% inhalation solution (treats COPD) in the unlocked top drawer of Resident #37's bedside storage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and resident interview, and review of the facility policy, the facility failed to ensure a resident was treated with dignity. This affected one (Resident #12) of two residents reviewed for dignity. The facility census was 74. Findings include: Review of the medical record for Resident #12 revealed an admission date of 10/05/22. Diagnoses included obstructive uropathy and pressure ulcers to the sacral region, left hip, left buttock, and the left heel. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and required the extensive assistance of two staff for personal hygiene and toilet use, had a suprapubic catheter. Review of the care plan revealed Resident #12 was at risk for alteration in elimination due to suprapubic catheter. Interventions included to keep the urinary drainage bag below the level of the bladder, empty the urinary drainage bag each shift and as needed, and maintain dignity cover over…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, and review of the facility policy, the facility failed to ensure call lights were within the resident's reach. This affected two (#19 and #20) of two residents reviewed for accommodation of needs. The facility census was 74. Findings include: 1. Review of Resident #20's medical record revealed Resident #20 had an admission date of 02/17/22. Diagnoses included schizoaffective disorder, dementia with mood disturbance, anxiety, major depressive disorder, obsessive compulsive disorder, convulsion, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had impaired cognition and required the extensive assistance of two staff for bed mobility, transfers, and toileting. Observation on 07/17/23 at 9:17 A.M. revealed Resident #20 was sitting up in bed and her call light paddle was clipped above her head on the top of the bed. The call light was not within reach for Resident #20. Interview on 07/17/23…

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 observations, staff interview, resident interview, and review of facility policy, the facility failed to ensure residents were provided a clean homelike environment. This affected two resident (#12 and #17) of seven residents reviewed for a clean homelike environment. The facility census was 74. Findings include: 1. Observation and interview on 07/17/23 at 12:56 P.M. revealed Resident #12's tiled floor was sticky to the point shoes stuck to the floor. Resident #12 stated she was tired of the sticky floor and stated everyone talks about the floor being sticky but no one does anything about it. Interview on 07/18/23 at 2:16 P.M. with Housekeeping Supervisor #400 stated resident rooms were cleaned daily, including floors mopped. Upon entering Resident #12's room, Housekeeping Supervisor #400 verified the floor was sticky and contained several items of debris under the bed, over bed table and in the corner behind the room door. Review of the facility policy titled Cleaning and Disinfecting Residents' Rooms, dated August 2013, revealed housekeeping surfaces identified as floors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review, the facility failed to ensure a resident who required extensive assistance from staff with personal hygiene was provided adequate nail care to ensure the nails remained trimmed and clean. This affected one (#23) of three residents reviewed for activities of daily living. The facility census was 74. Findings include: Review of the medical record revealed Resident #23 had an admission date of 08/20/12. Diagnoses included type two diabetes mellitus, peripheral vascular disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 required the extensive assistance of one staff for personal hygiene. Review of the nursing notes dated 07/01/23 through 07/19/23 revealed Resident #23 had not refused nail care. Observation and interview on 07/17/23 at 10:23 A.M. revealed Resident #23 had long fingernails. There was debris underneath 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, staff interview, resident interview, observation, and review of the facility policies, the facility failed to provide the treatments for surgical wounds as ordered by the physician and recommendations from the hospital. This affected one (Resident #179) of one resident reviewed for wounds. The facility census was 74. Findings include: Review of the medical record for Resident #179 revealed an admission date of 07/14/23. Diagnoses included surgical repair of abdominal aortic aneurysm without rupture on 07/11/23. Review of the admission nursing assessment dated [DATE] revealed Resident #179 had been admitted from hospital and had a surgical incision midline above umbilicus, and bilateral groin surgical incisions. Review of the hospital's continuation of care discharge document dated 07/14/23 revealed orders for Resident #179's abdominal surgical site to be cleansed with normal saline, pat dry, apply collagen, and cover with foam or dry dressing every three days. The bilateral groin surgical…

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, resident and staff interview, and review of the facility policy, the facility failed to timely assist a resident with dental care needs who had a physician order to be seen by the dentist and was having signs and symptoms of dental pain and discomfort. This affected one (Resident #17) of two residents reviewed for dental. The facility census was 74. Findings include: Review of the medical record for Resident #17 revealed an admission date of 09/03/21. Diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, sleep apnea, and major depressive disorder. Review of the care plan dated 09/17/21 with a revision date of 01/22/23 revealed Resident #17 had oral dental health problems related to missing and broken teeth. Interventions included diet as ordered, apply lip balm as needed, consult dietician if chewing swallowing problems are noted, coordinate arrangements for dental care, encourage the resident to wear dentures, 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, staff interview, and facility policy review, the facility failed to ensure dietary staff serving food change gloves between tasks when plating meals. This had the potential to affect all 67 residents who receive food from the kitchen. The facility identified all residents, with the exception of Resident #13 and #271, to receive food from the kitchen. The facility census was 69. Findings include: Observation on 03/04/20 at 4:56 P.M. revealed [NAME] #430 wore disposable gloves while serving the dinner meal. [NAME] #430 placed the gloved right hand into an oven mitt, took food out of the oven, removed oven mitt with right hand, and kept the disposable gloves on. [NAME] #430 picked up a hamburger bun with the gloved right hand. [NAME] #430 touched the drawer handle to get a spatula and immediately afterwards picked up two cheese slices with the gloved hand. At no time during this observation did [NAME] #430 wash hands and put on new gloves. Interview on 03/04/20 at 5:01 P.M. with [NAME] #430 verified he/she did not hand wash or changed disposable gloves between…

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, review of the dietary spreadsheet, and staff interview, the facility failed to provide proper food portions for mechanically altered diets. This affected eight residents (#12, #18, #36, #37, #48, #60, 362, #369) who receive a mechanical soft diet. The facility census was 69. Findings include: Review of the dietary spreadsheet for dinner on 03/04/20 or the mechanical soft diets revealed the protein to be offered was three ounces of corned beef. Observation on 03/04/20 at 4:57 P.M. revealed dietary staff to be using a size 16 scoop, or two ounce portion, for the mechanical soft corned beef. Interview on 03/04/20 at 5:00 P.M. with Kitchen Manager #450 verified a two ounce scoop size was used for the mechanical soft corned beef. The facility identified eight residents (#12, #18, #36, #37, #48, #60, 362, and #369) who receive a mechanical soft diet.

Based on medical record review, observation, and staff interview, the facility failed to follow physician ordered isolation precautions for one (#16) of two residents reviewed for transmission-based precautions. The facility identified two residents with orders for transmission-based precaution. In addition, the facility failed to properly store a urine collection device in the bathroom shared by four residents (#5, #22, #36, #47). The facility census was 69. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/03/09. Diagnoses included major depressive disorder; chronic obstructive pulmonary disease (COPD); benign prostatic hyperplasia without lower urinary tract symptoms; rheumatoid arthritis; obstructive and reflux uropathy, unspecified; and atherosclerotic heart disease. Review of a lab report dated 02/17/20 for Resident #16 revealed a white blood cell count (WBC) of 1.8. The lab report indicated a normal reference range for WBC to be between 4.00 to 11.00. Review of physician orders dated 02/18/20 for Resident #16 revealed…

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

Based on observation, staff interview, and facility policy review, the facility failed to treat residents in a dignified manner when assisting during meal time by standing over residents when assisting the resident to eat. This affected two (#35 and #36) out of eight residents that needed assistance with eating. The facility census was 69. Finding include: Observation on 03/02/20 at 12:27 P.M. revealed State Tested Nurse Aide (STNA) #410 assisting Resident #35 and Resident #36 eat lunch. STNA #410 alternated assisting Resident #35 and Resident #36 with eating spoonfuls of the meal, alternating between residents and standing over them. Resident #36 was sitting in a taller Broda chair and STNA #410 was nearly eye level with the resident. Resident #35 was sitting in a low wheelchair which was slightly reclined and STNA #410 was not at eye level. Observation on 03/02/20 at 12:30 P.M. revealed STNA #420 had began to assist Resident #36 with eating, offering spoonfuls of food to the resident. STNA #420 stood above the resident while assisting him with his meal. Interview on 03/02/20 at…

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 bathing record, resident interview, staff interview, and review of the facility policy, the facility failed to provide a shower or bath for one (#55) of one residents reviewed for Activities of Daily Living (ADL) care. The facility census was 69. Findings include: Review of Resident #55's medical record revealed an initial admission date of 12/09/13 and re-entry date of 12/19/18. Diagnoses included unspecified acute appendicitis, type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chest pain, hypertension, hyperlipidemia, edema, major depressive disorder, and shortness of breath. Review of the Minimum Data Set (MDS) assessment, dated 01/23/20, revealed Resident #55 was cognitively intact. The assessment revealed Resident #55 required extensive assistance of one person with personal hygiene and physical help in part of bathing with one person physical assist. Interview on 03/02/20 at 2:35 P.M. with Resident #55 revealed the resident was scheduled to receive a shower on second shift Wednesdays 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, staff interview, medical record review, and review of a facility policy, the facility failed to provide a nutritional supplement as ordered by the physician. This affected one (#51) of three residents reviewed for nutrition. The facility identified 10 residents with physician orders for nutritional supplements. The census was 69. Findings include: Review of Resident #51's medical record revealed an admission date of 07/15/19. Diagnoses included end stage renal disease, hypertension, major depression, dementia without behavioral disturbances, chronic obstructive pulmonary disease, anemia, and neuromuscular dysfunction of the bladder. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 02/14/20, revealed Resident #51 had severely impaired cognition and was prescribed a therapeutic diet with no nutritional concerns assessed. Review of a physician order dated 07/18/19 revealed Resident #51 was ordered a Magic Cup nutritional supplement to be provided daily at lunch. Review of Resident #51's weights obtained between September 2019 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure insulin was held per physician's orders. This affected one (#53) of 20 residents who receive insulin. The facility census was 69. Findings include: Review of Resident #53's medical record revealed an admission date of 11/22/13. Diagnoses included chronic obstructive pulmonary disease, difficulty walking, anxiety, edema, chronic kidney disease, depressive disorder, heart failure, hypertension, diabetes, and dementia without behavioral disturbance. Review of Resident #53's monthly physician orders dated February 2020 revealed an order for Levemir insulin 42 units subcutaneously in the morning. Hold if blood sugar is less than 110. Review of Resident #53's Medication Administration Record (MAR) dated February 2020 revealed on 02/07/20 the resident's blood sugar was 91 and insulin was administered. Again on 02/10/20 the resident's blood sugar was 78 and insulin was administered. Interview on 03/05/20 at 11:19 A.M., the Director of Nursing (DON) verified Resident #53 had received…

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, medical record review, review of a facility menu, and review of a facility policy, the facility failed to provide therapeutic diets as ordered by the physician. This affected one (#51) of three residents reviewed for nutrition. The facility identified four residents with physician orders for high protein renal diets. The census was 69. Findings include: Review of Resident #51's medical record revealed an admission date of 07/15/19. Diagnoses included end stage renal disease, hypertension, major depression, dementia without behavioral disturbances, chronic obstructive pulmonary disease, anemia, and neuromuscular dysfunction of the bladder. Review of the most recently completed Minimum Data Set (MDS) dated [DATE] revealed Resident #51 has severely impaired cognition and was prescribed a therapeutic diet with no nutritional concerns assessed. Review of a physician order dated 10/21/19 revealed Resident #51 was ordered a high protein renal diet with regular texture. Review of a…

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