The Oaks Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review the facility failed to ensure medication carts were properly secured and medication were properly stored and labeled. This had the potential to affect 11 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) of 11 residents residing on 100 hall and 40 residents (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, and #51) of 40 residents residing on 200 hall. The facility census was 72. Findings included: 1. Observation of 100 hall on 06/04/25 at 6:59 A.M., revealed the 100-medication cart was left unlocked and unattended. The medication cart was located between rooms [ROOM NUMBERS]. Interview on 06/04/25 at 7:00 A.M., with Licensed Practical Nurse (LPN) #133 confirmed she had left the medication cart unlocked and unattended. The LPN reported she was on 300 hall getting report. Interview on 06/04/25 at 11:54 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 medical record review, review of self-reported incident (SRI), review of the facility investigation, interview, and policy review the facility failed to ensure all allegations of resident abuse was reported immediately to the administrator and to the state survey agency. This affected two residents (#66, #70) of four residents reviewed for abuse. Findings included: Review of Resident #70's medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, mood disorder, paranoid personality disorder, delusional, depression, anxiety, and hypertension. The resident resided on the secure unit. Review of Resident #66's medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia, diabetes, kidney disease, dementia, and depression. The resident resided on the secure unit, however, was a previous resident of the attached Assisted Living (AL). Review of the SRI 260860 dated 05/27/25 (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a self-reported incident (SRI) and investigation, and interview the facility failed to ensure a dependent resident was provided adequate oral hygiene. This affected one resident (#36) of one resident reviewed for neglect. Findings included: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, lack of coordination, dysphagia, and degenerative disease of the nervous system. Review of Resident #36's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognition impairment. The resident had no rejection of care behaviors. It was very important to have her family involved in discussions about her care. The resident had functional limitation of range of motion on one side of the upper extremity and both sides on lower extremity. The resident required substantial/maximal (helper does more than half of the effort) for oral hygiene.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incident (SRI), review of the facility's investigation, interview, and policy review the facility failed to timely assess, monitor, and report weight gain. This affected one resident (#70) of three residents reviewed for falls and one resident (#20) three residents reviewed nutrition. Findings included: 1. Review of Resident #70's medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, mood disorder, paranoid personality disorder, delusional, depression, anxiety, and hypertension. The resident resided on the secure unit. Review of the SRI 260860 dated 05/27/25 (four days after the incident) revealed on 05/23/25 staff heard yelling coming from Resident #66's room. Upon entering the room, Resident #70 was noted sitting upright on buttocks with Resident #66 standing over her. Resident #66 informed staff that Resident #70 wouldn't leave her room, so she pushed Resident #70 down. Residents were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital notes, review of wound clinic notes, and interviews, the facility failed to comprehensively assess and provide treatment as ordered to a resident foot. This affected one resident (#2) of three residents reviewed for skin alterations. Findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including heart failure, cellulitis, diabetes, protein-calorie malnutrition, immunodeficiency, breast cancer, venous insufficiency, and pulmonary hypertension. Review of Resident #2's hospital skin assessment dated [DATE] revealed the resident had a wound on bottom left great toe that measured 1.0 centimeter (cm) by 0.8 cm and unable to determine depth (UTD) with scant sanguineous drainage. The wound bed was dry, red, and crusted with sanguineous drainage. The peri-wound was calloused, red, and purple and the margins were irregular shaped with a purple rim noted. Review of Resident #2's hospital orders dated 04/29/25…

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

Based on observation, interviews and record review the facility failed to ensure safety measures were implemented to prevent resident injuries. This affected one resident (#34) of three residents reviewed for accidents. Findings Include: Review of the medical record for Resident #34 revealed an admission date 08/07/24. Diagnoses included diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties. Review of the physician orders dated 06/10/25 revealed wound care for left leg to be cleansed with normal saline, apply skin prep and leave upon to air. Monitor steri strips and allow them to fall off on their own. Review of the wound evaluation dated 12/10/24 revealed new skin tear to right lateral calf noted measuring 3.4 centimeter (cm) by 2.8 cm by 0.2 cm. Resident #34 reported the night before the leg piece of the wheelchair hit her leg. The intervention was to pad the leg rest on the wheelchair. Review of the progress note dated 12/10/24 at 9:34 A.M. revealed new skin tear to right lateral calf noted. 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 interviews and record review, it was determined the facility failed to treat Urinary Tract Infections (UTI) in a timely manner for all residents. This affected one resident (#34) of one resident (Resident #34) for UTI. Findings Include: Review of the medical record for Resident #34 revealed an admission date 08/07/24. Diagnoses included diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties. Resident #34 had intact cognition. Review of the quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition. Resident #34 was dependent on transfers and had frequent incontinence of bowel and bladder. Review of the progress note dated 06/04/25 at 8:00 A.M. revealed the Nurse Practitioner (NP) #300 saw Resident #34. Resident #34 reported worsening burning and discomfort on urination and increase pain with urination. Resident #34 had followed with Infectious Disease (ID) in the past for her frequent,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of Medscape, observation, interview, and policy review the facility failed to ensure the facility medication error rate was not greater than five percent. The facility had five medication errors out of 28 opportunities resulting in a medication error rate of 17.8%. This affected two residents (#20 and #49) of three residents observed for medication administration. Findings included: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including bipolar, anxiety, schizoaffective disorder, depression, obsessive-compulsive disorder, cirrhosis of the liver, type two diabetes, hypertension, non-ST elevation myocardial infarction, hyperlipidemia, edema, atrial fibrillation, and the need for assistance with personal care. Review of Resident #20's current orders dated 06/01/25 revealed Metoprolol Succinate extended release (ER) 25 milligrams (mg) give one tablet by mouth daily for hypertension, Sertraline 150 mg daily for bipolar, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, observation, and policy review the facility failed to ensure residents were free from significant medication errors. This affected one resident (#49) of three residents reviewed for medication administration and one resident (#34) of three residents reviewed for urinary tract infections (UTI). Findings included: 1. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to thrombosis of right posterior cerebral artery, acute respiratory failure, type two diabetes, atelectasis, chronic heart failure, hypertension, dysphagia, peripheral vascular disease, gastro-esophageal reflux disease, and urinary tract infection (UTI). Review of Resident #49's orders dated 05/01/25 and 06/01/25 revealed Metoprolol 100 mg one tablet twice daily for hypertension. Review of Resident #49's Medication Administration Record dated 05/01/25 to 06/04/25 revealed the Metoprolol was not administered at 5:00 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure all residents had required assistive device available during meal times. This affected one resident (#34) of one resident that was reviewed for assistive devices. Findings Include: Review of the medical record for Resident #34 revealed an admission date 08/07/24. Diagnoses included diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties. Resident #34 had intact cognition. Review of physician orders for June 2025 revealed regular diet, regular texture and thin consistency for liquids. Divided plate, Kennedy cup (cup with handles and lid) and built-up utensils for all meals as tolerated dated 11/26/24. Review of the plan of care for Resident #34 revealed the resident had an activity of daily living (ADL's) self-care performance deficit related to cognitive impairment, fluctuating ADL's, generalized weakness and poor coordination. Interventions 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 Based on medical record review, observation, interview, and policy review the facility failed to ensure medication administration was accurately documented on the medication administration record (MAR). This affected one resident (#49) of three residents reviewed for medication administration. Findings included: 1. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, chronic right heart failure, hypertension, peripheral vascular disease, and the need for assistance with personal care. Review of Resident #49's current orders revealed on 04/03/25 the resident was ordered Metoprolol 100 milligrams (mg) twice daily for hypertension. Observation on 06/04/25 at 7:29 A.M., of Resident #49's medication administration revealed no evidence Metoprolol was available to administer. Licensed Practical Nurse (LPN) #179 reported the Metoprolol 100 mg had been unavailable since 05/24/25. The LPN stated she called the pharmacy on 05/24/25 to re-order the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the facility failed to ensure enhanced barrier precaution (EBP) were maintained during resident care and failed to ensure infection control practices were maintained during medication administration. This affected one resident (#4) of 72 residents observed during the tour and one resident (#49) of three residents observed for medication administration. Findings included: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including calculus of gallbladder with acute cholecystitis with obstruction, acute renal failure, diabetes, need for assistance with personal care, urine retention, and stress incontinence. Review of Resident #4's orders dated 06/04/25 revealed the resident had a cholecystostomy tube and was on enhanced barrier precautions (EBP). Review of Resident #4's impaired gastrointestinal status related to status post gallbladder stone cholestostomy plan of care dated 05/23/25 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure residents #16, #18, #40, and #59, had comprehensive care plans that addressed activity of daily living (ADL), wandering behaviors, and contracture. This affected four residents (#16, #18, #40, and #59) of 22 residents whose care plans were reviewed. The facility census was 69. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 07/22/20 with diagnoses including multiple sclerosis, aphasia, dementia, heart failure, anxiety disorder, peripheral vascular disease, mixed receptive-expressive language disorder, depression, GERD, and dysphagia. Review of Resident #18 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed severely impaired cognition. Review of Resident #18's plan of care profile care guide dated 06/12/24 revealed she required the extensive assistance of one person for incontinence care, showers, and transfers. Review of Resident #18's plan of care revealed it was absent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to appropriately document, revise, and implement care plans, and appropriately address Resident #35's dementia related behaviors. This affected one (Resident #35) of five residents reviewed for dementia and had the potential to affect all 12 residents on the memory care unit. The facility census was 69. Findings include: Review of the medical record for Resident #35 revealed an admission date of 02/10/24 with diagnoses including Alzheimer's disease, dementia without behavioral disturbance, attention and concentration deficit, Crohn's disease, anxiety disorder, depression, unspecified convulsions, and overactive bladder. Review of Resident #35's physician order dated 02/10/24 to 02/13/24 and from 02/13/24 to 02/24/24 revealed an order for Lorazepam 0.5 mg one time a day as needed. Review of Resident #35's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a severe cognitive impairment. Wandering was the only behavior…

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

Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed food items were an appropriate texture, requiring surveyor intervention. This affected six residents (Residents #6, #9, 11, #16, #49 and #320) who had an ordered pureed diet. The facility census was 69. Findings Include: Observations completed on 06/18/24 from 4:02 P.M. to 4:37 P.M. with Dining Services Assistant (DSA) #123 of pureed swiss steak revealed the facility had six residents on an ordered pureed diet and the cook would be preparing seven servings of swiss steak. DSA #123 washed his hands with soap and water at the sink and donned clean gloves. DSA #123 added seven whole swiss steak patties to the puree blender at 4:06 P.M. At 4:08 P.M., DSA #123 added one cup and one teaspoon of beef base and added ¼ teaspoon and ½ teaspoon of thickener to the swiss steak. DSA #123 stated he tasted the pureed food items prior to serving them to ensure an appropriate smooth texture was reached. At 4:12 P.M., DSA #123 stopped the blender and tasted the pureed swiss steak. DSA #123…

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

Based on observations, staff interviews, and facility policy review, the facility failed to follow appropriate hand hygiene and glove use during dinner meal service. Additionally, the facility failed to ensure prepared food temperatures were taken prior to delivering the foods to be served to the residents who resided on the Memory Care Unit (Residents #5, #18, #34, #35, #37, #42, #43, #48, #51, #59, #60, and #174). This had the potential to affect a total of 68 residents who resided in the facility and received foods from the kitchen. The facility had one resident (Resident #21) on an ordered nothing by mouth (NPO) diet. Findings Include: Observations of food temperatures with [NAME] #123 were attempted on 06/18/24 at 4:55 P.M. The Director of Food Services (DHS) #159 informed this surveyor at that time the steam table located in the kitchen was not working properly and food temperatures would be taken from the steam tables in the dining room areas. DHS #159 instructed Dining Services Assistant (DSA) #123 to escort this surveyor to the locked Memory Care Unit to observe food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and interviews the facility failed to have enhanced barrier precautions (EBP) in place for Resident #58, #63, #171, and #371. This affected four (Resident #58, #63, #171, and #371) out of eight residents reviewed for enhanced barrier precautions. Also, the facility failed to follow contact isolation precaution procedures. This affected one (Resident #2) of five residents reviewed for infection control. The census was 69. Findings include: 1. Review of the medical record revealed Resident #58 was admitted on [DATE] with diagnoses that included but not limited to orthopedic aftercare, dysphagia, and an artificial opening status. Review of physician orders dated 05/06/24 revealed Resident #58 had orders for enteral feeding. An observation on 06/18/24 at 2:31 P.M. revealed no evidence of Resident #58 being on EBP. Interview on 06/18/24 at 3:00 P.M. Director of Nursing (DON) verified Resident #58 did not have any EBP signs or personal protective equipment (PPE) in place.…

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, review of medical records, and facility policy review, the facility failed to report potential abuse between Resident #35 and #37 to the state agency. This affected two residents (#35 and #37) of three residents reviewed for abuse. The facility census was 69. Findings include: Review of the medical record for Resident #37 revealed an admission date of 11/08/23 with diagnoses including dementia, depression, diverticulosis, age-related osteoporosis without pathological fracture, repeated falls, and mixed-receptive-expressive language. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's progress note dated 04/30/24 revealed another resident (Resident #35) attempted to bite a staff member and Resident #37 slapped the other resident on her right arm and screamed at her not to bite people. Both residents were separated. Review of the medical record for Resident #35 revealed an admission date 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 have an initial care conference in a timely manner for Resident #53. This affected one (Resident #53) out of one reviewed for care planning. Facility census was 69. Findings include: Review of the medical record revealed Resident #53 was admitted on [DATE] with diagnoses that included but not limited to joint replacement surgery, osteoarthritis, pain, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #53 was cognitively intact. A progress note dated 05/17/24 at 11:46 A.M. revealed a family first meeting was scheduled for 05/22/24. Interview on 06/17/24 at 9:51 A.M. Resident #53 revealed a care conference was not held until Resident #53's family requested a care conference. Interview on 06/20/24 at 4:42 P.M. Director of Social Services (DSS) #161 stated initial care conferences were to be held within five days of admission. DSS #161 verified an initial care conference for Resident #53 was not held until 26 days after…

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 provide a discharge summary when Resident #66 was discharged . This affected one (Resident #66) out of two residents reviewed for discharge. Facility census was 69. Findings include: Review of the medical record revealed Resident #66 was admitted on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis, kidney disease, and dependence on renal dialysis. An order dated 05/17/24 revealed Resident #66 was to be discharged to the attached assisted living facility. An order dated 05/20/24 revealed Resident #66 needed a hospital bed with side rails. A notice of transfer/discharge date d 05/28/24 revealed the long-term care ombudsman was notified Resident #66 was transferred/discharged on 05/24/24 to an assisted living facility. On 06/18/24 at 2:20 P.M. Executive Director provided a handwritten discharge planning form dated 05/24/24. The discharge planning form revealed Resident #66 was discharged from the health care facility to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide Resident #53 with bathing as scheduled and per Resident #53's preference. This affected one (Resident #53) out of three reviewed for assistance with activities of daily living. Facility census was 69. Findings include: Review of the medical record revealed Resident #53 was admitted on [DATE] with diagnoses that included but not limited to joint replacement surgery, osteoarthritis, pain, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #53 was cognitively intact. The MDS also revealed Resident #53 required substantial to maximal assistance for bathing. Review of the bathing schedule revealed Resident #53 was scheduled to be bathed in the evenings of Wednesday and Saturdays. Review of the electronic record and paper documentation from 05/02/24 to 06/17/24 revealed Resident #53 received three showers, two bed baths, four partial bed baths, and refused bathing once. Interview on 06/17/24 at 9:53 A.M. Resident #53…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, medical record review, review of hospital records, and review of invoices for wound care equipment, the facility failed to ensure one resident's (Resident #63) wound vac and supplies were received prior to admission. This affected one resident (Resident #63) of one reviewed for medical equipment. The facility census was 69. Findings Include: Review of the medical record for Resident #63 revealed an admission date on 05/28/24 at 5:12 P.M. Medical diagnoses included sepsis, disruption of external operation (surgical) wound, generalized peritonitis (inflammation of the membrane lining of the abdominal wall and covering the abdominal organs), encounter for surgical aftercare following surgery on the digestive system- resection and infectious disease, volvulus (an obstruction due to twisting or knotting of the gastrointestinal tract), partial intestinal obstruction, ileus (inability of the intestine to contract normally and move waste out of the body), congenital malformations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to timely identify, accurately assess, and timely treat one resident's (Resident #9) pressure ulcer areas of her right heel and ankle. This affected one resident (Resident #9) of two residents reviewed for pressure ulcers. The facility census was 69. Findings Include: Review of the closed medical record for Resident #9 revealed an admission date on 02/02/23 and a discharge date of 06/22/24. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with unspecified complications, mixed receptive-expressive language disorder, difficulty in walking, unsteadiness on feet, generalized weakness, cognitive communication deficit, and need for assistance with personal care. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required…

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 orders were in place for Resident #171 who had a catheter. This affected one resident (#171) of one resident reviewed for catheters. The facility census was 69. Findings include: Review of the medical record for Resident #171 revealed an admission date of 06/05/24 with diagnoses including Parkinsonism, type two diabetes mellitus, chronic kidney disease stage four, anxiety disorder, and Rheumatoid arthritis. Review of Resident #171's physician's orders from 06/05/24 to 06/23/24 revealed no orders related to catheter care. Review of Resident #171's progress note dated 06/05/24 revealed the resident admitted to the facility with a Foley catheter in place. Review of Resident #171's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. The resident had an indwelling catheter. Review of Resident #171's plan of care dated 06/19/24 revealed Resident #171 used a suprapubic catheter or Foley…

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 timely address all pharmacy recommendations. This affected one (Resident #31) of five residents reviewed for medication administration. The census was 69. Findings Include: Resident #31 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, psychosis, hypertensive heart disease, chronic kidney disease (stage III), heart failure, old myocardial infarction, osteoarthritis, syncope and collapse, major depressive disorder, hyperlipidemia, hypomagnesemia, hypokalemia, mild cognitive impairment, anxiety disorder, dysphagia, cognitive communication deficit, and pain in right shoulder. Review of her minimum data set (MDS) assessment, dated 03/31/24, revealed she was cognitively intact. Review of Resident #31 pharmacy recommendation, dated 02/07/24, revealed the pharmacy recommendation that this medication was not recommended to be used for Parkinson's associated dementia. The recommendation was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to timely address all pharmacy recommendations. This affected one (Resident #31) of five residents reviewed for medication administration. The census was 69. Findings Include: Resident #31 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, psychosis, hypertensive heart disease, chronic kidney disease (stage III), heart failure, old myocardial infarction, osteoarthritis, syncope and collapse, major depressive disorder, hyperlipidemia, hypomagnesemia, hypokalemia, mild cognitive impairment, anxiety disorder, dysphagia, cognitive communication deficit, and pain in right shoulder. Review of her minimum data set (MDS) assessment, dated 03/31/24, revealed she was cognitively intact. Review of Resident #31 progress note, dated 10/11/23, revealed nurse practitioner recorded a visit for medication management and psychiatric evaluation. Within this note, there was no evidence to support any signs…

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 keep accurate medical records for two residents (Residents #9 and #48). This affected two residents (Residents #9 and #48) of 21 residents reviewed in the sample. The facility census was 69. Findings include: 1. Review of the closed medical record for Resident #9 revealed an admission date on 02/02/23 and a discharge date of 06/22/24. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with unspecified complications, mixed receptive-expressive language disorder, difficulty in walking, unsteadiness on feet, generalized weakness, cognitive communication deficit, and need for assistance with personal care. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required substantial assistance from staff to complete most Activities of Daily…

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 personal funds record review, interview and facility policy and procedure review the facility failed to ensure residents and/or representatives were notified timely and aware of the need to spend-down personal funds once the account balance reached/exceeded the maximum resource limit. This affected two residents (#13 and #38) of five current residents reviewed for facility-managed funds. The facility managed 39 resident personal funds accounts. The total census was 71. Findings include: 1. On 06/23/22 at 6:09 P.M. record review revealed Resident #13 had $3330.04 in the personal fund account, managed by the facility as of 06/23/22. Review of the October through December 2021 quarterly statement revealed the account had been over the Medicaid limit since 10/08/21 when the account had $4012.06 ($12.06 over the funds limit allowed taking into account the grace period for government stimulus checks). Review of her last quarterly statement revealed from January 2022 through March 2022 revealed 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to notify Resident #6's representative when the resident experienced a skin tear on the arm requiring treatment. This affected one resident (#6) of 21 sampled residents reviewed for notification. Findings include: Review of the medical record for Resident #6 revealed an admission date of 06/01/21. A Minimum Data Set (MDS) 3.0 assessment, dated 03/10/22 revealed the resident had short and long term memory impairment and received Hospice services. An event note, dated 06/07/22 at 6:42 A.M. revealed the aide alerted the nurse Resident #6 had a skin tear on her right forearm. The resident was unable to state what caused the skin tear. The area was cleansed and a dry clean dressing applied. A physician's order was obtained on 06/07/22 to cleanse the right forearm with normal saline and cover with foam dressing. The dressing was to be changed every three days. The event note documented the resident representative was notified on 06/07/22 at 6:42 A.M. On 06/21/22 at 2:50 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, facility policy and procedure review and interview the facility failed to ensure an allegation of rape, involving Resident #9 was thoroughly investigated and included written details of the total circumstances of the allegation being made. This affected one resident (#9 of three residents reviewed in facility self-reported incidents (SRIs). Findings include: Review of Resident #9's medical record revealed a 09/08/21 admission date with diagnoses including dementia without behavioral disturbance, multiple subsegmental pulmonary emboli without acute cor pulmonale, occlusion and stenosis of left carotid artery, major depressive disorder, single episode, hypertension, constipation, shortness of breath, disorientation, and syncope and collapse. A 03/23/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, required staff supervision set up assistance for bed mobility and transfers and was independent for ambulation. Review of the resident's plan of care revealed no plan of care had been developed related…

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 closed record review, facility policy and procedure review and interview the facility failed to ensure Resident #70 was provided a notice of the facility bed hold policy prior to a hospital transfer. This affected one resident (#70) of one resident reviewed for hospitalization. Findings include: Review of Resident #70's closed medical record revealed an admission date of 05/04/22 with diagnoses including hemiplegia, and hemiparesis following cerebral infarction affecting left non dominant side. facial weakness, hypertensive heart, congestive heart failure, chronic kidney disease stage 3, atherosclerotic heart failure, atrial fibrillation, chronic pulmonary edema and osteoporosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/10/22 revealed the resident was moderately impaired for daily decision making, was sad two to six days with a poor appetite and had trouble concentrating twelve to fourteen days of the review period. The assessment revealed the resident required limited assistance from one staff for bed mobility, transfers, personal hygiene,…

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 develop a comprehensive psychotropic plan of care identifying target behaviors related to the use of antipsychotic, anti-anxiety and antidepressant medications for Resident #50. This affected one resident (#50) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #50's medical record revealed a 04/29/21 admission with diagnoses including dementia without behavioral disturbance, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, major depressive disorder, single episode, Type 2 diabetes mellitus with diabetic neuropathy, psychosis not due to a substance or known physiological condition, severe protein-calorie malnutrition, anxiety disorder, diverticulosis of intestine (part unspecified) without perforation or abscess without bleeding, gastroesophageal reflux disease without esophagitis, allergic rhinitis, dizziness and giddiness and repeated falls. Review of the 05/12/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure non-pressure related wound care was provided for a surgical wound for Resident #168 and a skin tear for Resident #6 as ordered. This affected two residents (#6 and #168) of two residents reviewed for non-pressure skin conditions. Findings include: 1. A review of Resident #168's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following a surgical amputation, an acquired absence of the left leg above the knee, chronic total occlusion of an artery of the extremities and peripheral vascular disease. A review of Resident #168's physician's orders revealed an order, dated 06/17/22 to cleanse left above knee amputation (LAKA) incision with soap and water, pat dry, and apply a dry clean dressing wrapping it with Kerlix daily and as needed (PRN) until his follow up with the vascular surgeon on 06/30/22. A review of Resident #168's admission/ 5 day Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to adequately assess a pressure ulcer for Resident #67 to identify the proper stage of the ulcer. This affected one resident (#67) of two residents reviewed for pressure ulcers. Findings include: A review of Resident #67's medical record revealed the resident was originally admitted to the facility on [DATE]. He was hospitalized on [DATE] and was readmitted to the facility on [DATE]. Resident #67 had diagnoses including a fracture of the second and third lumbar vertebrae, morbid obesity and adult onset diabetes mellitus. A review of Resident #67's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/30/22 revealed the resident was assessed to be at risk for pressure ulcers and also had an unhealed pressure ulcer. The unhealed pressure ulcer was noted to be a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough that…

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, facility policy and procedure review and interview the facility failed to ensure fall prevention interventions were implemented as planned for Resident #14 and Resident #51 to decrease the residents' risk of falls. This affected two residents (#14 and #51) of four residents reviewed for falls. Findings include: 1. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including myocardial infarction, hypertropic cardiomyopathy, Alzheimer's disease late onset, unspecified dementia with behavioral disturbance, mood disorder due to known physiological condition, mixed receptive-expressive language disorder, unspecified psychosis not due to substance or known psychological condition. Deficiency of B vitamin, hypothyroidism, history of falling, osteoarthritis, hypertension, dry eye syndrome. cognitive communication deficit, difficulty walking, muscle weakness, constipation, dysphasia and altered mental status. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #49's weights were obtained as recommended by the dietician to adequately monitor the resident's nutritional status and to identify a significant weight loss in a timely manner. This affected one resident (#49) of three residents reviewed for nutrition. Findings include: A review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adult onset diabetes mellitus, depression, anxiety, anemia, Vitamin D deficiency, hyperlipidemia and rheumatoid arthritis. A review of Resident #49's nutrition admission assessment, dated 05/10/22 revealed the resident's current body weight was 195 pounds upon admission. The weight was stable with the weight obtained in the hospital. The dietician indicated the facility would monitor the resident's weight trends and weekly weights were ordered. Interventions listed as part of the nutrition admission…

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, facility policy and procedure review and interview the facility failed to identify and/or monitor and measure specific targeted behaviors, perform Abnormal Involuntary Movement Scale (AIMS) testing and/or complete gradual dose reductions as required for the use of psychotropic medication to ensure psychotropic medications were justified and administered at the lowest effective dose for each resident. This affected three residents (#41, #50 and #51) of five residents reviewed for unnecessary medication use. The facility identified 55 residents who received psychoactive medications. The facility census was 71. Findings include: 1. Review of Resident #50's medical record revealed a 04/29/21 admission with diagnoses including dementia without behavioral disturbance, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, major depressive disorder, single episode, Type 2 diabetes mellitus with diabetic neuropathy, psychosis not due to a substance or known physiological condition, severe protein-calorie malnutrition, anxiety…

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.