Oasis Center For Rehabilitation And Healing

Based on observation, interview, and review of the Hydrion Test Strip instructions the facility failed to maintain a sanitary kitchen to prepare food in a manner to prevent contamination and food borne illness. This had the potential to affect all residents (#15, #16, #18, #28 and #31) who received nothing by mouth. The facility census was 92. Findings include: Observation on 04/11/24 at 10:05 A.M. during a tour of the kitchen revealed a puree prep station with a buildup of grease and dirt on the bottom shelf. The top shelf of the puree prep station had a buildup of dirt on it. The white tiles around the walls in the kitchen had a buildup of black dirt on them. The microwave was dirty with dried food splatter in it. The three-sink sanitation station had a container of Hydrion strips (test strips to test the chemical levels for proper sanitization) expired 03/15/22. The findings were verified by the Dietary Manager (DM) #675 at the time of the tour. On 04/11/24 an interview with DM #675 during the tour of the kitchen revealed food preparation stations were to be cleaned after each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary environment. This had the potential to affect all 92 residents in the facility. Findings include: Observation on 04/11/24 at 9:35 A.M. during a tour of the facility revealed the shower room on 300-hall had broken tile around shower drain. The handwashing sink was visibly dirty. The supply cart for shower items had visible dirt on it. The paper towel dispenser had visible dirt on top of it. Hair and dirt were noted on baseboard heating unit. The tub had dirt around the drain (dirty buildup of soap scum), and the area around the tub ledge had a buildup of dirt on it. The floor was dirty. The toilet was full of a bowel movement. There were two broken tiles noted at the bottom of the doorway to that hall. The activity lounge on the 400-hall had visible dirt on the walls and chair rail. The base board heating unit had a buildup of dust on it. The windowsill had a buildup of dust and dirt. All observations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure restorative range of motion (ROM) exercises were completed as ordered by the physician. This finding affected two residents (#8 and #76) of three residents reviewed for restorative ROM exercises. Findings include: 1. Review of Resident #76's medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including anoxic brain damage, muscle weakness, and tracheostomy status. Review of Resident #76's physician orders revealed an order dated 03/29/23 for restorative passive ROM exercises to all extremities for at least fifteen minutes a day every shift. Review of Resident #76's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive two staff assist for bed mobility, dressing, and personal hygiene as well as total dependence of two staff assist for transfers, eating, and toilet use.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the accuracy of Resident #76's medical record. This finding affected one resident (#76) of three residents reviewed for the accuracy of the medical records. Findings include: Review of Resident #76's medical record revealed he was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including anoxic brain damage, muscle weakness, and tracheostomy status. Review of Resident #76's physician orders revealed an order dated 03/08/23 to shower/bed bath the resident per the resident's father's preference every Monday, Wednesday, and Friday; an order dated 03/29/23 for restorative bilateral hand/wrist splint on for six hours and assess skin prior to application, apply at 12:00 A.M. and remove at 6:00 A.M.; an order dated 06/21/23 to cleanse the percutaneous endoscopic gastrostomy tube (PEG or G tube which was a thin, flexible tube inserted into the stomach wall for nutrition or fluids) with normal saline,…

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

Based on observation, record review and interview, the facility failed to ensure the menu was followed as written. This had the potential to affect all residents, with the exception of seven residents (#10, #11, #12, #14, #16, #27 and #73) who received no food by mouth. The facility census was 88. Findings include: Review of the menu for breakfast on 08/01/23 revealed a menu of oatmeal or cold cereal, ham, egg, and cheese breakfast omelet muffin and toast. Observation of breakfast on 08/01/23 at 8:40 A.M. revealed scrambled eggs and toast were served. Observation on 08/01/23 at 8:45 A.M. of the menu substitution log revealed no evidence of a substitution to the breakfast meal. Interview on 08/01/223 at 8:48 A.M. with Certified Dietary Manager (CDM) #204 confirmed no substitutions were made to the meal for breakfast on 08/01/23. He confirmed he was not aware scrambled eggs were served in place of the ham, egg, and cheese breakfast omelet. This deficiency represents non-compliance investigated under Complaint Number OH00144779.

Based on observation, record review, interview, and facility policy review the facility failed to ensure a variety of foods were offered and failed to honor resident preferences for meals. This affected five residents (#22, #5, #61, #62, and #78) and had the potential to affect all residents, except for seven residents (#10, #11, #12, #14, #16, #27 and #73) who received no food by mouth. The facility census was 88. Findings include: Review of the medical record for Resident #22 revealed an admission date of 12/18/22. Diagnoses included sepsis, diabetes, malnutrition, and kidney failure. Review of the diet orders and preferences provided by the facility revealed Resident #22 requested meat with her meal each morning. Review of the menu for the month of July 2023 revealed scrambled eggs were served 15 of 30 days. Interviews on 07/31/23 at 7:16 A.M. with Residents #5, #61, #62, and #78 revealed the same food was always served, especially eggs at breakfast. They didn't eat when they got tired of the same thing being served. Interview and observation on 07/31/23 at 9:16 A.M. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure residents who required assistance with showers received them based on their preference. This affected two residents (#72 and #78) of three residents reviewed for activities of daily living (ADL). The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 01/08/21. Diagnoses included Multiple Sclerosis, morbid obesity, gastro-esophageal reflux disease (GERD), and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. She required total assistance of two people for transfers and toilet use, extensive assistance of two people for bed mobility and dressing and extensive assistance of one person for hygiene. It was very important for her to choose between a bed bath, tub bath, and shower. Review of the physician's orders for July 2023 revealed Resident #72 was to receive a shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy the facility failed to ensure Resident #78's medical record was updated to reflect his most current care needs. This affected one resident (#78) of three residents reviewed for general care and services. The facility census was 88. Findings include: Review of the medical record for Resident #78 revealed an admission date of 12/18/21. Diagnoses included pulmonary embolism, pulmonary fibrosis, respiratory failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was severely cognitively impaired. He required extensive assistance of one person for toilet use, limited assistance of one person for transfers, dressing, and hygiene, and supervision of one person for bed mobility. Review of the physician's orders for July 2023 revealed Resident #78 required the use of a Hoyer (mechanical) lift with the assistance of two people for transfers. Interview on 07/31/23 at 9:16 A.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Hoyer (mechanical) lifts were functioning appropriately. This affected two residents (#72 and #90) of three residents reviewed for accidents and had the potential to affect 23 additional residents (#8, #11, #13, #15, #16, #20, #21, #25, #26, #27, #30, #39, #41, #50, #54, #60, #63, #64, #65, #66, #68, #78, and #80) identified by the facility as requiring the use of a Hoyer lift for transfers. The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 01/08/21. Diagnoses included Multiple Sclerosis, morbid obesity, gastro-esophageal reflux disease (GERD), and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. She required total assistance of two people for transfers and toilet use, extensive assistance of two people for bed mobility and dressing, and extensive assistance of one…

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

Based on observations, interviews and record reviews, the facility failed to ensure the kitchen was staffed with sufficient, competent support personnel to safely and effectively carry out the functions of the food and nutrition services for resident food production and service. This had the potential to affect all residents receiving meals from the kitchen except four residents (Resident #22, #73, #79 and Resident #80) who did not receive nutrition by mouth. The census was 94 residents. Findings include: Observations on 06/06/23 at 11:53 A.M. of the facility kitchen and puree food process revealed [NAME] #618 pureeing meatloaf and green beans. [NAME] #618 placed two large chunks of meatloaf into the food processor, then added approximately eight ounces of beef broth which [NAME] #618 did not measure prior to adding it to the meat. Observations of the pureed meatloaf at the end of the puree process revealed the meatloaf was watery and looked unpalatable. [NAME] #618 began adding an unmeasured amount of thickening powder three different times to thicken puree. Cook #618 moved on to…

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

Based on observations and interview, the facility failed to dispose of garbage/refuse appropriately. This had the potential to affect all 94 residents residing in the facility at the time of survey. Findings include: Observation was conducted on 06/05/23 at 9:08 A.M. with the Dietary Director (DD) of the kitchen's outside dumpster. Surrounding the dumpster was debris including dirty latex gloves, plastic bottles and bags and cardboard boxes. Interview during the observations, the Dietary Director verified the observations and stated he was still educating the staff on proper disposal of garbage.

Based on record review, observations, and interviews, the facility failed to ensure Resident #30, #35, #237 and #440 were treated in a dignified and respectful manner including covering their indwelling catheter drainage bags. This affected four residents (Resident #30, #35, 237, and Resident #440) of seven residents reviewed for indwelling catheters. The facility census was 94. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 12/05/22. Diagnoses included encounter for surgical aftercare following surgery on the genitourinary system, neuromuscular dysfunction of the bladder system, and retention of the urine. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/11/23, revealed the resident had impaired cognition. Resident #30 required an indwelling catheter. Review of physician order dated 06/02/23 revealed staff were to maintain indwelling catheter until follow up with urology to remove catheter in office. Observation on 06/05/23 at 1:51 P.M., Resident #30 was observed sitting in the hallways with other residents.…

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 policy review, observation, and staff interviews, the facility failed to maintain all resident rooms in a clean and comfortable manner. This affected six residents (Resident #12, #21, #187, #27, 50, and Resident #10) of 24 residents reviewed for physical environment. The facility census was 94. Findings included: On 06/06/23 at 11:33 A.M. observations revealed discolored and dirty flooring in Residents #12 and #21's room, black marks on the room baseboards, water marks from a dark liquid, and orange food particles on the floor. On 06/06/23 at 11:37 A.M. observations revealed discolored and dirty flooring in Residents #187 and #27's room, black marks on the room baseboards, water marks, and a spilled plastic cup with red liquid in it spilling out onto the floor. On 06/06/23 at 11:40 A.M., observations revealed discolored and dirty flooring in Residents #50 and #10's room, black marks on the room baseboards, and scraps of paper on the floor. Observation of the 400 unit on 06/07/23 at 10:50 A.M. revealed all the same observations in the rooms belonging to Resident #10, #12,…

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

Based on record review and interview, the facility failed to complete resident assessments within the required times frame for Resident #439. This affected one resident (#439) of 24 residents reviewed for comprehensive assessments. The facility census was 94. Findings include: Review of the medical record for Resident #439 revealed an admission date of 05/13/23. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, malignant neoplasm of the esophagus, and hypertension. Review of Resident #439's Minimum Data Set (MDS) 3.0 assessments revealed admission and Medicare five-day assessments were initiated with assessment reference dates (ARD) of 05/20/23 but were not completed as required. Further review of Resident #439's admission MDS revealed sections not completed included sections A, B, G, GG, H, I, J, L, M, N, O, P, S and V. Sections of Resident #439's Medicare five-day assessment that were not completed included sections A, B, G, GG, H, I, J, L, M, N, O, P and S. Interview with Licensed Practical Nurse (LPN) #643 on 06/08/23 at 8:26 P.M.…

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

Based on record review, observation and interview, the facility failed to complete in a timely manner a comprehensive, person-centered care plan for Resident #82. This affected one resident (#82) of 24 residents reviewed for comprehensive care plans. The facility census was 94. Findings include: Review of the medical record for Resident #82 revealed an admission date of 03/14/23. Diagnoses included acute embolism and thrombosis of deep veins of right distal lower extremity, acute embolism and thrombosis of right tibial vein, hypertension, and bipolar disorder. Further review of medical record for Resident #82 revealed a smoking risk form was completed on 03/14/23 and identified Resident #82 to be independent with smoking. Review of Resident #82's care plan dated 03/15/23 revealed Resident #82 actively smoked and use of cigarettes since admission was not added to the comprehensive care plan until 06/05/23. Observation on 06/05/23 at 1:17 P.M. revealed Resident #82 had a box of cigarettes on the bed side table. Interview on 06/05/23 at 1:20 P.M. with Licensed Practical Nurse (LPN)…

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

Based on observation, interview, and record review, the facility failed to provide appropriate and physician ordered care and services to promote wound healing for Resident #57. This affected one resident (Resident #57) of two residents reviewed for wound care. The facility census was 94. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/30/22 with diagnoses including idiopathic peripheral autonomic neuropathy, type two diabetes mellitus, severe morbid obesity, chronic obstructive pulmonary disease, spinal stenosis, depression, hypothyroidism, hypertension, atrial fibrillation, neuromuscular dysfunction of the bladder, and stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to penis/scrotum. Resident #57 had a indwelling urinary catheter due to a neurogenic bladder. Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment, dated for 04/16/23, revealed the resident had intact cognition, was independent with eating, required physical extensive…

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

Based on record review, observation and interview, the facility failed to ensure oxygen was administered as ordered for Resident #19. This affected one resident (#19) of three residents reviewed for oxygen therapy. The facility census was 94. Findings include: Review of Resident #19's medical record revealed an admission date of 05/05/23. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, severe persistent asthma and shortness of breath. Review of Resident #19's physician orders for June 2023 revealed an order for continuous oxygen administration at four liters per minute (LPM). Observation on 06/05/23 at 12:00 P.M. revealed Resident #19 was receiving oxygen continuously at three and a half LPM. Interview on 06/05/23 at 12:01 P.M. with Licensed Practical Nurse (LPN) #658 confirmed Resident #19 was receiving oxygen continuous at three and a half LPM. Observation on 06/06/23 at 3:07 P.M. revealed Resident #19 was receiving oxygen continuously at three and a half LPM. Interview on 06/06/23 at 3:07 P.M. with the Director of Nursing (DON)…

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

Based on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene during medication administration and wound care for residents #57, #64, and #443, and failed to ensure a urinary catheter drainage bag was off the floor for Resident #440. This affected four residents (#57, #64, #443, and #440) of 24 residents reviewed for infection control. The facility census was 94. Findings include: 1. During an observation of medication administration on 06/06/23 at 7:44 A.M., Licensed Practical Nurse (LPN) #614 without performing hand hygiene prepared medications for Resident #443. Following preparation of medications, LPN #614 entered the room without performing hand hygiene. LPN #614 handed Resident #443 the medication cup filled with prepared medications. Resident #443 took all medications and LPN #614 threw the empty medication cup in the trash can and walked out of the room without performing hand hygiene. Interview on 06/06/23 at 7:55 A.M. with LPN #614 confirmed no hand hygiene was performed before or after medication administration…

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, observations, and interview the facility failed to maintain appropriate pest control to prevent infestation. This affected two (Resident #30, #52) of 24 residents reviewed for physical environment. The facility census was 94. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 12/05/22. Diagnoses included encounter for surgical aftercare following surgery on the genitourinary system, neuromuscular dysfunction of the bladder system, and retention of the urine. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/11/23, revealed the resident had impaired cognition. 2. Review of the medical record for Resident #52 revealed an admission date of 08/02/19. Diagnoses included schizoaffective disorder, paranoid personality disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/22/23, revealed the resident had impaired cognition. Observations on 06/05/23 at 2:35 P.M. revealed Residents #30 and #52 were lying in their beds. Observations 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 and interview, the facility failed to ensure Dietary Manager #553 met the minimum qualifications to serve as the director of food and nutrition services. This had the potential to affect all 87 residents who received food prepared at facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents. Findings include: A review of Dietary Manager (DM) #553 personal file revealed a hire date of 6/24/19. There was no evidence DM #553 was a Certified Dietary Manager. Interview on 05/04/21 at 9:18 A.M. with DM #553 revealed he had worked at the facility for about 2 years. DM #553 had started Dietary Manager training but did not take all the module tests or the final test to become certified. Dietary Manager was not a certified dietary manager and did not have an associate degree or higher in food service management. There was also no evidence that he had any certification related to food service management. On 05/04/21 at 12:15 P.M. interview with Registered Dietitian (RD) #604 revealed she was not full time at the facility, and was…

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

Based on observation, interview, and record review, the facility failed to ensure sufficient kitchen staff were available to prepare resident meals and snacks, serve resident meals, and maintain a clean and sanitary environment in the kitchen. This affected all 87 residents who received meals prepared in the facility kitchen (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents. Findings include: 1. Initial tour of the kitchen on 05/03/21 from 9:18 A.M. to 9:39 A.M. revealed the following observations, which were confirmed by Dietary Manager (DM) #553 during the initial tour. : • The refrigerator floor was dirty and needed to be swept and mopped. • The freezer had ice buildup going into freezer and there were bags of ice were place directly on the floor. • The shelf above the stove had accumulated grease and dust. • The stovetop needed to be scrubbed. The oven was dirty, and the oven knobs needed to be cleaned. • There was a soiled serving spoon in the utensil drawer. • The can opener had an accumulation of dried food. • The floors and the lower…

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, resident interview, and staff interview, the facility failed to ensure the menu and food choice alternates were available for residents to review in order to meet the resident's needs and food preferences. This affected one (Resident #194) of one resident reviewed for food choices and meal service, and had the potential to affect all 87 residents (Residents #31 and #58 received nothing by mouth) who received meals prepared at the facility. The facility census was 89 residents. Findings include: Resident #194 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, colostomy status, and malignant neoplasm of the rectum. The Medicare 5-day Minimum Data Set assessment, dated 04/08/21, revealed Resident #194 had intact cognition. The resident was independent for eating, bed mobility, transfers, walking, locomotion, and personal hygiene. The resident was on a Regular diet with no restrictions. Interview on 05/04/21 at 12:02 P.M. with Resident #194…

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

Based on interview and record review, the facility failed to act upon resident council's concerns regarding the provision of snacks. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #81, and #83) residents who attended resident council meetings, and had the potential to affect all 87 residents who received food from the facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents. Findings include: The Resident Council minutes from 02/22/21 revealed Resident #47 had stated the only options for snacks were tea/milk/juice and chips. The resident wanted to have sandwiches and cookies available in addition to what was offered. The Plan of Correction from Dietary for this meeting did not address snacks. The Resident Council meeting minutes from 03/22/21 revealed Residents #11, #51, #79, #80, and #81 agreed the residents were not receiving snacks in the evening except maybe once a week. And when snacks were passed there was not enough to go around. When the residents asked for a snack or something extra with dinner or an…

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

Based on observation and staff interview, the facility failed to store, prepare, and distribute food under sanitary conditions to prevent contamination and potential food borne illness. This had the potential to affect all 87 residents (Residents #31 and # 58 received nothing by mouth).who were provided meals prepared in the facility kitchen. The facility census was 89 residents. Findings include: Initial tour of the kitchen on 05/03/21 from 9:18 A.M. to 9:39 A.M. revealed the following observations, which were confirmed by Dietary Manager (DM) #553 during the initial tour : • The refrigerator floor was dirty and needed to be swept and mopped. • The freezer had ice buildup going into freezer and there were bags of ice were place directly on the floor. • The shelf above the stove had accumulated grease and dust. • The stovetop needed to be scrubbed. The oven was dirty, and the oven knobs needed to be cleaned. • There was a soiled serving spoon in the utensil drawer. • The can opener had an accumulation of dried food. • The floors and the lower area of the walls were dirty. Boxes 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 record review and interviews, the facility did not ensure staff competencies necessary to provide the level and types of care needed for the resident population were included in the facility assessment. This had the potential to affect all 89 facility residents. Findings include: Record review was conducted of the Facility Assessment Tool, updated 04/06/2021, as provided by the Administrator to the survey team. The persons listed as involved in completing the assessment included the Administrator, Director of Nursing (DON), Governing Body Representative, the Medical Director, a respiratory therapist, and two licensed nurses. Within the section titled Staff training, education and competencies there were no competencies listed for each of the departments providing services to the residents. Interview was conducted on 05/11/2021 at 2:30 P.M. with the Corporate Operations Staff Person (COSP) #609 who said she could verify all the nursing services staff had not been competency trained on ventilators and there were vent dependent residents in the facility. Interview was…

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

Based on interview and record review, the facility failed to act upon resident council's concern regarding the provision of snacks. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #81, and #83) residents, and had the potential to affect all 87 residents who received food from the facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents. Findings include: The Resident Council minutes from 02/22/21 revealed Resident #47 had stated the only options for snacks were tea, milk, juice, and chips. The resident wanted to have sandwiches and cookies available in addition to what was offered. The Plan of Correction from Dietary did not address snacks. The Resident Council meeting minutes from 03/22/21 revealed Residents #11, #51, #79, #80, and #81 agreed the residents were not receiving snacks in the evening except maybe once a week; and when snacks were passed there was not enough to go around. When the residents asked for a snack or something extra with dinner or an alternate for dinner, they were told the kitchen was…

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

Based on record review, observation, and interviews, the facility did not ensure adequate cleaning of the resident rooms or common areas. The facility also failed to ensure laundry was washed and dried in a timely manner. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #82, and #83) of 24 residents reviewed for their living environment. The facility census was 89 residents. Findings include: 1. Record review of the Resident Council Minutes dated 02/22/2021, 03/22/2021, and 04/26/2021 revealed there were pervasive complaints regarding trash not being emptied sometimes for days; housekeepers not cleaning under beds and tables and not dusting nightstands or dressers; and mopping of the rooms only occurred once a week if at all. Resident #79 complained and Resident # 51 agreed the trash and linen containers were frequently full, and the lids were either off or falling off making the 400 hallway stink. An initial observation was conducted on 05/03/2021 from 9:40 A.M. to 10:11 A.M. of the 400 unit and general facility environment. The 400 unit was the largest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop care plans relative to ventilator care, dialysis care, and psychotropic drug use. This affected four (Residents #54, #59, #65, and #191) of ten residents reviewed for ventilator and dialysis care needs, and unnecessary medications. The facility census was 89 residents. Finding include: 1. Review of the medical record revealed Resident #54 was admitted on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), acute and chronic respiratory failure, colostomy status, tracheostomy status, gastrostomy status, and ventilator dependence. The Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. The resident was totally dependent on staff for bed mobility, transfers, eating, toilet use, and personal hygiene. Record review revealed no ventilator care plan had been developed. The resident was discharged to the hospital on [DATE]. Interview on 05/11/21 at 3:37 P.M. with the Director 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 record review and interviews, the facility failed to ensure nutritional assessments were completed in a timely manner for five (Residents #9, #22, #30, #70, and #75 ) of 16 sampled residents. The facility census was 89 residents. Findings include: Record review revealed that Residents #9, #22, #30, #70 and #75, who were all identified in their care plans as being at nutritional risk, did not have a nutritional assessment or a dietary progress note in a reasonable time period. Resident #9 was re-admitted to the facility on [DATE] after a hospital stay for bloody vomit and a torn esophagus. His last Nutritional Assessment was dated 08/27/2020. Resident #22 had a significant change Minimum Data Set assessment dated [DATE] and his last nutritional assessment was 08/17/2020. This resident was care planned as at nutritional risk. Resident #30 was admitted to the facility on [DATE] and care planned at nutritional risk. His last nutritional assessment was 11/30/2020 and there was no evidence of a dietary…

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 test tray evaluation, the facility failed to ensure food was prepared by methods to conserve nutritional value and palatablity. This affected 13 residents, including 10 (Residents #4, #7, #16, #21, #22, #41, #71, #75, #76, and #193) of 10 residents who received a pureed diet, as well as Residents #27, #28, and #194. The facility census was 89 residents. Findings include: 1. On 05/04/2021 at 11:12 A.M., interview with Resident #28 revealed the hot food was usually served warm, not hot. He had asked for cucumber salad, carrot sticks and dip and other fresh fruits and fresh vegetables but had not received any of these items. He stated the food could be a lot better, as it often lacked flavor. Interview on 05/04/21 at 12:02 P.M. and on 05/06/21 at 9:19 A.M. with Resident #194 revealed the food was horrible. Things were overcooked, undercooked, or just looked bad. On 05/06/21 for breakfast his bacon wasn't cooked enough, and the cream of wheat was watery. Interview was conducted on 05/04/2021 at 12:05 P.M. with Resident #27 who said the food was…

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

Based on observation, interview, and pureed food sampling, the facility failed to puree food to the correct consistency. This affected 10 (Residents #4, #7, #16, #21, #22, #41, #71, #75, #76, and #193) of 10 residents who received a pureed diet at the facility. The facilty census was 89 residents. Findings include: On 05/05/21 at 5:05 P.M., observation and tasting of the pureed meatloaf, which had already been prepared and was on the tray-line to be served, revealed the meatloaf was not adequately pureed. When sampled, the meatloaf was not a smooth texture, and was watery, diluted looking, and tasted diluted. Dietary [NAME] #559 and Dietary Manager (DM) #553 tasted the pureed meatloaf and verified it was not fully broken down or adequately thickened. Dietary [NAME] #559 verified the pureed food items were to be of smooth, even consistency and the texture and thickness of pudding. She did not usually sample the pureed foods for taste or texture. On 05/05/21 at 5:12 P.M., interview with Dietary Manager (DM) #553 verified the pureed meatloaf was not pureed adequately or thickened…

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

Based on observation, interview, and record review, the facility failed to ensure one resident's hearing aides were replaced timely. This affected one (Resident #73) of one resident reviewed for missing hearing aides. The facility census was 89 residents. Findings include: Review of Resident #73's medical record revealed an admission date of 08/31/19 and diagnoses including Alzheimer's disease, anxiety, dementia, and schizophrenia. Review of Resident #73's Minimum Data Set 3.0 assessment revealed resident had severe cognitive impairment and needed extensive assistance with bed mobility, locomotion, and activities of daily living. Interview on 05/04/21 at 2:35 P.M. of Family Member (FM) #606 revealed Resident #73's hearing aides were lost two years ago and had not been replaced. Interview on 05/11/21 at 12:12 P.M. with Business Office Manager/Social Worker Delegate (BOM/SWD) #512 revealed the facility Social Worker resigned in October 2020 and she was the Social Worker Delegate. BOM/SWD #512 stated in January 2021 she was looking over resident paperwork and noticed there was an open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a nutritional progress note was completed and interventions implemented after one resident had a recurring Stage II pressure ulcer found on the right buttock. This affected one (Resident #4) of two residents reviewed for pressure ulcer care and services. The facility census was 89 residents. Findings include: Review of Resident #4's medical record revealed an admission date of 12/06/19 and diagnoses including Alzheimer's disease, protein calorie malnutrition, and functional quadriplegia. Review of Resident #4's Minimum Data Set 3.0 assessment dated , 04/28/21 revealed the resident's cognitive status was not assessed, and the resident had total dependence for bed mobility, transfers, and activities of daily living. Resident #4 was transported to the hospital on [DATE] for evaluation of a pressure ulcer. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #4 was at high risk for the development of pressure…

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.

The facility failed to ensure all nurses were trained regarding ventilator care and related documentation. This had the potential to affect one (Residents #59) of three residents reviewed for ventilator care. The facility census was 89 residents. Findings include: Interview on 05/10/21 at 10:56 A.M. of Respiratory Therapist (RT) #506 revealed he was the Respiratory Therapist for four facilities. This facility was the only one of the four that accommodated residents requiring mechanical ventilation, but the other facilities had residents who required BiPap (Bilevel Positive Airway Pressure) (non-invasive form of therapy for patients suffering from sleep apnea, and delivered pressurized air through a mask to the patient's airways). RT #506 said he provided an inservice on mechanical ventilation for nurses when they were hired by the facility. The Administrator would let him know a nurse was hired and needed an inservice. RT #506 said after the initial training on mechanical ventilation no additional inservices were conducted because there was only one Respiratory Therapist for four…

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

Based on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 89 facility residents. Findings include: Observation of the facility's dumpster area on 05/03/21 at 9:31 A.M. revealed one of the two dumpster lids was not closed. Debris including used disposable gloves, boxes, and other garbage was observed on the ground around the bins. Interview on 05/03/21 at 9:31 A.M. with Dietary Manager #553 verified the findings.

Based on observation, interview, and record review, the facility failed to ensure appropriate incontinence care was provided in a manner to prevent cross contamination and infection. This affected one (Resident #63) of one resident reviewed for incontinence care. The facility census was 89 residents. Findings include: Review of Resident #63's medical record revealed an admission date of 02/26/21 and diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dementia. Review of Resident #63's Minimum Data Set (MDS) 3.0 assessment, dated 05/05/21 revealed the resident had moderate cognitive impairment and required extensive assistance with bed mobility, transfers, and activities of daily living. Observation on 5/05/21 at 12:38 P.M. of State Tested Nursing Assistant (STNA) #502 walking into Resident #63's room to provide incontinence care. She gathered disposable gloves, disposable cleansing wipes, and a clean incontinence brief. The resident had a urinary catheter attached to a drainage bag which was observed as STNA #502 turned 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.