Pataskala Oaks Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and policy review, the facility failed to provide proper cleaning/disinfection of equipment between resident use. This affected two (Resident #32 and #12) of eight residents (Resident #5, Resident #9, Resident #12, Resident #27, Resident #32, Resident #34, Resident #45, and Resident #61) identified on Middle Hall as requiring blood pressures prior to medication administration and one (Resident #19) of one reviewed for glucometer use. The facility census was 50. Findings Include: 1. On 08/20/2025 at 8:16 A.M., observation revealed Registered Nurse (RN) #33 took Resident #32's blood pressure using an electronic blood pressure monitor. She did not sanitize the blood pressure cuff at that time. RN #33 then completed the medication administration of this resident. On 08/20/2025 at 8:39 A.M., observation revealed RN #33 take Resident #12's blood pressure with an electronic wrist blood pressure monitor. This was the same cuff used on Resident #32 and was not cleaned 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 record review, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program by not ensuring a resident was not started on an antibiotic for a suspected urinary tract infection until a urinalysis culture result was received to identify best course of treatment. This affected one (Resident #8) of four residents reviewed for urinary tract infections. The facility census was 50. Findings include: Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, psychotic disorder with delusions, dementia, and the need for assistance with personal care. Review of Resident #8's nurses' progress notes revealed a nurse's note dated 06/04/25 at 3:13 P.M. that indicated the resident was seen by the nurse practitioner that day for increased confusion and weakness. She was previously ordered to have laboratory test performed to included a complete blood count and a complete metabolic panel, but had…

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

Based on observation, interview, review of manufacturer guidelines, and facility policy review, the facility failed to date a multi-dose vial of Tubersol tuberculin solution when opened for use. This deficient practice had the potential to affect 12 residents who were newly admitted after the tuberculin solution was received from the pharmacy. The facility census was 50. Findings Include: An observation on 04/23/24 at 7:43 A.M. revealed an in use opened multi-dose vial of Tubersol tuberculin solution in the medication refrigerator located in the facility medication room. There was a yellow sticker on the bottom of the vial with the word date written on it. There was no opened date written on the sticker, on the vial or on the box were the vial was stored. The storage box had a label from the pharmacy with a delivery date to the facility of 03/07/24. Interview on 04/23/24 at 7:50 A.M. with Licensed Practical Nurse (LPN) Unit Manager #400 confirmed the opened multi-dose vial Tubersol tuberculin solution did not have an opened date on the yellow sticker, the vial or the box where 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, interview, and review of facility policy the facility failed to ensure five residents (#11, #27, #28, #37, and #49) on a mechanically altered diet were served food at an appropriate texture. This affected five residents (#11, #27, #28, #37, and #49) of 15 residents on a mechanically altered or soft diet. The facility census was 50. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 07/08/17 with diagnoses including Alzheimer's disease, dysphagia, hypertension, and cognitive communication deficit. Review of Resident #27's diet order dated 09/29/23 revealed an order for a soft texture diet. 2. Review of the medical record for Resident #37 revealed an admission date of 02/10/23 with diagnoses including cerebral infarction, respiratory disorders, depression, and diabetes mellitus. Review of Resident #37's diet order dated 09/09/23 revealed she was to receive a mechanically altered diet. 3. Review of the medical record for Resident #11 revealed an admission date of 04/21/23 with diagnoses including dysphagia, cerebral…

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 use appropriate hand hygiene during meal service. This had the potential to affect 46 of 46 residents who consumed food from the kitchen. The facility identified four residents (#25, #42, #46, #51) who were unable to eat by mouth. The facility census is 50. Findings include: Observation on 04/24/24 from 10:45 A.M. to 12:19 P.M. of the kitchen revealed Dietary Staff #466 doing a variety of tasks including the following: preparing puree food, putting gloved and ungloved hands into oven mitts to pull food out of the oven, setting up the steamtable, obtaining food temperatures, going in and out of the walk-in refrigerator, and serving food. Meal service included a bacon,lettuce,tomato (BLT) sandwich, Dietary Staff #466 was observed touching the bread for the BLT and the bread for grilled cheese sandwiches. During the entire observation Dietary Staff #466 was observed changing her gloves multiple times, however, she was not observed washing her hands during the entire observation. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to complete a bed hold notice within 24 hours of a resident's discharge to the hospital. This affected one resident (Resident #55) out of four residents reviewed for hospitalization. The facility census was 50. Findings Include: Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE] and was sent to the hospital on [DATE] for evaluation of altered mental status and was discharged from the facility on 02/05/24. Review of Resident #55's medical record revealed Resident #55 primary payer was Ohio Medicaid which requires notification to resident's representative the option to hold the resident's bed at the facility following a discharge to the hospital. There was no bed hold notice found in Resident #55's medical record. Interview on 04/23/24 at 10:02 A.M. with the Business Office Manager (BOM) # 472 confirmed Resident #55 did not have a bed hold notification sent to the 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 observation, record review, interviews, and facility policy review the facility failed to apply and document the use of a left elbow brace to decrease the decline of contracture. This affected one resident (Resident #5) out of two residents reviewed for position and mobility. The facility census was 50. Findings Include: Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses including Cerebral Palsy, high blood pressure, and type two diabetes mellitus. Resident #5 required assistance from staff to complete personal care tasks, transfers, and bathing. Resident #5 had mild cognitive impairment and used a wheelchair for mobility. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section O - Special Treatments, Procedures, and Programs splint or brace assistance was not marked. Review of Resident #5's signed physician orders for 04/2024 revealed an order dated 02/02/24 for Resident #5 to wear a left elbow extension…

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, record review, and review of facilities investigative report, the facility failed to ensure Resident #39 received the appropriate assistance, resulting in a fall. This affected one resident (#39) of two residents reviewed for falls. The facility census was 50. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/09/23 with diagnoses including traumatic hemorrhage of cerebrum, anxiety, depression, epilepsy, neuromuscular dysfunction of bladder, quadriplegia, anoxic brain damage, chronic obstructive pulmonary disease, and chronic respiratory failure. Review of Resident #39's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed he had moderately impaired cognition. Resident #39 was dependent on staff for all activities of daily living. Review of Resident #39's plan of care dated 10/16/23 revealed he was at risk for falls related to poor communication, impaired vision, impaired mobility, weakness, impaired cognition, anoxic brain…

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, interview, and facility policy review, the facility failed to change oxygen and nebulizer tubing as ordered. This affected one resident (Resident #14) out of two residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including asthma, high blood pressure, dementia, and weakness. Resident #14 had severe cognition impairment, required staff assistance for personal hygiene cares, transfers, and bathing. Review of Resident #14's signed physician orders revealed an order dated 01/11/23 Oxygen at 2 liters (L) as needed to maintain blood oxygen levels (SP02) greater than 90%, an ordered dated 09/29/23 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3 milligrams (mg) per 3 milliliters (ml) via nebulizer every four hours as needed for congestion, and an order dated 02/04/24 for Oxygen (02) tubing to be change every week on Sunday…

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 staff interview, review of medical records, and facility policy, the facility failed to provide non-pharmacological interventions, properly document pain location and indicators of pain, with the administration of as needed pain medication. This affected one resident (Resident #46) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of medical record for Resident #46 revealed an admission date of 01/30/24, diagnoses included ventilator dependent, pressure ulcer, chronic pain syndrome, anxiety disorder, insomnia, depression, dysphagia, chronic respiratory failure with hypoxia and hypercapnia, paraplegia, obstructive and reflex uropathy, pressure induced deep tissue damage of head, amyotrophic lateral sclerosis. Review of Resident #46's care plan dated 01/17/24, revealed Resident #46 was at risk for pain due to diagnoses of amyotrophic lateral sclerosis (ALS) and multiple pressure ulcers. Interventions included administering medications as 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 staff interview, medical record review, and review of facility policy, the facility failed to ensure an end date was documented for an as needed psychotropic drug order, document behaviors and ensure non-pharmacological interventions were attempted prior to administration of as needed psychotropic drug for Resident #46, and to complete Abnormal Involuntary Movement Scale (AIM) assessments as scheduled for two residents (#19 and #38). This affected three residents (#46, #38, #19) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: 1. Review of medical record for Resident #46 revealed an admission date of 01/30/24, diagnoses included ventilator dependent, pressure ulcer, chronic pain syndrome, anxiety disorder, insomnia, depression, dysphagia, chronic respiratory failure with hypoxia and hypercapnia, paraplegia, obstructive and reflex uropathy, pressure induced deep tissue damage of head, amyotrophic lateral sclerosis. Review of Resident #46's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of facility policy, and medical record review, the facility failed to ensure puree food was served according to the menu and at an appropriate texture. This affected one resident (#35) of one resident on a puree diet. The facility census was 50. Findings include: Review of the medical record for Resident #35 revealed an admission date of 03/24/23 with diagnoses including dementia, depression, and diabetes mellitus. Review of Resident #35's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the physician's order dated 03/21/24 revealed Resident #35 was to receive a puree texture diet. Observation on 04/24/24 from 10:45 A.M. to 12:19 P.M. revealed Dietary Staff #466 preparing puree chicken lasagna for the one resident on a puree diet. Dietary Staff #466 added one serving of chicken lasagna to the food processor and an unmeasured amount of milk from a carton. She started the blender and added three more unmeasured…

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 accurately document a physician order by signing that an order had been completed when the order had not been completed by not changing oxygen and nebulizer tubing as documented. This affected one resident (Resident #14) out of two residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including asthma, high blood pressure, dementia, and weakness. Resident #14 had severe cognition impairment, required staff assistance for personal hygiene cares, transfers, and bathing. Review of Resident #14's signed physician orders revealed an order dated 01/11/23 Oxygen at 2 liters (L) as needed to maintain blood oxygen levels (SP02) greater than 90%, an ordered dated 09/29/23 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3 milligrams (mg) per 3 milliliters (ml) via nebulizer every four hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to perform hand hygiene during wound care. This affected one resident (Resident #34) out of four residents reviewed for pressure ulcer/injury. The facility census was 50. Findings Include: Review of Resident #34's medical record revealed Resident #34 was admitted to the facility on [DATE] and re-admitted from a hospital stay on 04/19/24 with diagnoses including pressure injury to sacrum, bacteremia (blood infection), high blood pressure, depression, and bilateral above the knee amputations. Resident #34 had minimal cognitive impairment and required assistance from staff for Activities of Daily Living (ADL) tasks, transfers, and medical treatments. Review of Resident #34's signed physician orders revealed an order dated 04/20/24 for sacrum pressure injury treatment of packing wound with half strength Dakins solution soaked kerlix gauze and secure with a foam dressing. Change daily and as needed when soiled, an order…

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, policy review, and interview, the facility failed to provide a safe and comfortable environment for residents when the front hallway and back hallway were cluttered providing an increased risk of falls or accidents for residents. This affected 12 residents (#3, #5, #11, #17, #19, #22, #25, #33, #44, #57, #87, and #89) of 52 residents in the facility. Findings included: Observation on 01/30/24 at 9:08 A.M. during a tour of the facility revealed in the back hallway by the vending machines and therapy gym there were four bedside tables, one bed frame, one shower chair, 12 boxes, a walker, a geri-chair, and a wheelchair all to the right side of the hallway. Additionally, there were three mechanical lifts, two over the bed tables, four nursing carts, and 13 wheelchairs to the right side of the hallway on the front hall. On one nursing treatment cart, the sharps container was approximately one and a half inches over the fill line and on one nursing medication cart, the sharps container was approximately half an inch over the fill line. Interview on 01/30/24 at 9:26…

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

Based on observation, interview and policy review, the facility failed to store cold sandwiches and milk at the appropriate temperatures to prevent potential for food borne illness. This had the potential to affect 46 of 52 residents who consume food and beverages provided by the facility. The facility census was 52. Findings included: Observation on 01/31/24 at 11:14 A.M. revealed [NAME] #214 taking temperatures of lunch items available to residents. For an alternate option to the meal being served, a cold ham and turkey sandwich was provided from the walk-in refrigerator and [NAME] #214 took the temperature of the sandwich which was 45.9 degrees Fahrenheit. Additionally, [NAME] #214 checked the temperature of a carton of milk from the walk-in refrigerator which had a temperature of 48 degrees Fahrenheit. [NAME] #214 did use two separate thermometers to check temperatures and recalibrated both thermometers to ensure accuracy with the same results. Interview on 01/31/24 at 11:18 A.M. with [NAME] #214 confirmed the sandwich and milk should have been 41 degrees or less. [NAME] #214…

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

Based on review of the staff vaccination matrix, staff interview, and facility policy review, the facility failed to ensure all staff were vaccinated against the COVID-19 virus or had a valid exemption on file prior to working in the facility. This had the potential to affect all 59 residents who resided in the facility. Findings Include: Review of the Staff Vaccination Matrix dated 03/15/23 revealed Dietary #180 was listed as unvaccinated. The facility had a total of 84 staff and 83 staff were either vaccinated or had a religious exemption on file. Interview on 03/14/23 at 1:34 P.M. with the Director of Nursing (DON) revealed the facility had a total of 84 staff; 19 staff had religious exemptions on file. One staff, Dietary #180 was unvaccinated. Dietary #180 was contacted on 03/13/23 and should be attending a vaccine clinic on 03/16/23. Interviews on 03/15/23 at 3:48 P.M. and 5:30 P.M. with the DON confirmed Dietary #180's hire date was 02/15/23. Dietary #180's first day of work was 02/18/23. Dietary #180 had worked a total of 19 shifts since her hire date unvaccinated against…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) for individuals with mental disorders was accurate. This affected four (Resident #14, #16, #19 and #42) of four residents reviewed for preadmission screening. The census was 59. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Record review revealed Resident #16 is non-verbal, answers with shaking head yes/no, however at times doesn't reply with non-verbal gesture - he will just stare with no response. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy and procedure review, revealed the facility failed to ensure monthly pharmacy reviews are completed. This affected six residents (#16, #25, #28, #30, #42, and #258) of 11 residents reviewed for unnecessary medications. The census was 59. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual minimum data set (MDS) dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. There was no evidence of monthly pharmacy review for January 2023. 2. Review of Resident #28's medical record review revealed he was admitted to the facility on [DATE]. Diagnoses included…

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 4. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual MDS dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Review of the Pharmacy recommendation for 02/25/23 revealed Resident #16 has been taking Latuda 40 mg daily for bipolar disorder since March 2022. Please evaluate the potential for a dose reduction at this time to determine the lowest, effective dose. If contraindicated please provide a brief note. 5. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #19) of one resident reviewed for advanced directives. The facility census was 59. Findings Include: Record review for Resident # 19 revealed the resident was admitted on [DATE] with medical diagnoses of Alzheimer's disease, post- traumatic stress disorder, dysphagia, dementia, depression, [NAME] insufficiency, polyosteoarthritis, peripheral vascular disease, apraxia, anxiety disorder. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident did not answer or did not cooperate with many sections of the assessment. Review of the physicians' orders for Resident #19 revealed an ordered dated [DATE] for full resuscitation code status signifying that cardiopulmonary resuscitative measures CPR is to be conducted in case of cardiac or respiratory arrest. The electronic medical record resident banner…

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 facility policy review, the facility failed to notify one resident's (Resident #30) nephrologist of laboratory test results as ordered by the physician. This affected one (Resident #30) of one reviewed for notification of change. The facility census was 59. Findings Include: Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), hyperkalemia, Type II Diabetes Mellitus, and hypertensive chronic kidney disease with end stage renal disease. Review of lab orders revealed Resident #30 had the following lab orders: Complete Blood Count (CBC), Ferritin, Iron Pan, Protein total random urine with creatinine, urinalysis with microscopic, Vitamin D, renal function panel, Parathyroid Hormone (PTH), Folate, and Vitamin B12 dated 11/18/22 with instructions to fax results to nephrologist and CBC, Ferritin, Iron Panel, PTH, protein…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and staff interview, the facility failed to ensure treatment orders were completed for residents with cardiac and blood pressure medical conditions. This affected two residents (#30 and #42) of five residents reviewed for unnecessary medications. The census was 59. Findings include: 1. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression, diabetes, and congestive heart failure (CHF). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was mildly impaired. He required extensive assistance of two plus staff members physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the physician orders revealed an order dated 03/08/22 for daily weight, one time a day related to congestive heat failure (CHF). 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, and observation revealed the facility failed to ensure pressure ulcer treatment and interventions were in place for two residents (#17 and #28) of four residents reviewed for pressure ulcers. The census was 59. Findings included: 1. Review of Resident #28's medical record review revealed he was admitted to the facility on [DATE]. Diagnoses included psychosis, post traumatic stress disorder (PTSD), major depression, anxiety, anorexia, cerebral vascular accident with left sided hemiplegia and peripheral vascular disease. Review of Resident #28's significant change minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required total dependence of two or more staff members physical assistance for bed mobility, transfers, and toilet use. He required extensive assistance of one staff member physical assistance for personal hygiene and dressing. Review of Resident #28's pressure ulcer risk assessment dated [DATE] revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure respiratory equipment was stored appropriately to prevent infection. This affected one resident (#17) of two residents reviewed for respiratory care. The census was 59. Findings include: Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fracture of the left femur, high blood pressure, rheumatoid arthritis, dementia, anxiety and protein calorie malnutrition. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assistance of two or more staff members for bed mobility, transfers, and extensive assistance of one staff member physical assistance for dressing and personal hygiene. She required total dependence of two or more staff members for toilet use. Review of the physicians orders dated 01/26/23 revealed an order 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.