Ardmore Center for Rehabilitation and Healthcare

Based on record review and interview, the facility failed to ensure a resident's representative was issued a written discharge form for 1 (#152) of 1 sampled resident reviewed for involuntary discharge. The DON reported 52 residents resided in the facility. Findings: The facility's Transfer or Discharge Notice policy, dated 12/01/16, read in part, A resident, and/or [their] representative, will be given a thirty day advance written notice of an impending transfer or discharge from our facility .Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: The safety of individual in the facility endangered .The resident and/or resident representative will be notified in writing. Resident #152 had diagnoses which included chronic obstructive pulmonary disease, diabetes, Alzheimer's dementia, and cognitive communication deficit. Progress notes for Resident #152, dated October through November 2024, showed multiple behaviors in which the resident was aggressive and abusive toward staff members, as well as being disruptive…

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: a. ensure an allegation of abuse was fully investigated for one (#1); and b. prevent the potential for further abuse while an investigation was in progress for one (#1) of three sampled residents reviewed for abuse. The DON identified 47 resided in the facility. Findings: An Abuse Policy, dated 10/01/2020, read in part, Begin taking written statements from the person reporting the allegation or suspicion and any witnessess including staff, family, and/or residents/patients. The policy also read, Assess all residents/patients who may have been affected by the allegation or suspicion of abuse. An Abuse Prevention Program policy, revised 12/2016, read in part, Protect residents during abuse investigations. Resident #1 had diagnoses which included Adult failure to thrive, dementia, heart failure. A care plan dated 6/2024 documented Resident #1 had dementia and required extensive assistance with ADL's. A nurse note dated 07/30/24 at 8:12 a.m. documented CNA #2 stated Resident #1 bit their arm when getting them dressed 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.

Based on record review and interview, the facility failed to ensure the physician and/or the resident's representative were notified after a change in the resident's condition for one (#1) of three sampled residents reviewed for notification. The DON identified 42 residents resided in the facility. Findings: An Assessing Falls and Their Causes policy, dated 11/23/20, documented to notify the resident's attending physician and family in an appropriate time frame after a fall. Res #1 had diagnoses which included Alzheimer's disease and psychosis. A witnessed fall report, dated 06/25/24, documented the resident was walking and grabbed onto the nurses' station, slid down the wall, and went to the ground. It was documented the resident was assessed and there were no injuries. There was no documentation the resident's representative was notified. An incident note, dated 07/02/24 at 5:28 a.m., documented the aide was going to get Res #1's roommate up. It was documented Res #1 appeared to have fallen going to the restroom. It was documented the resident had a small laceration to their upper…

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

Based on record review and interview, the facility failed to assess and monitor a resident after an unwitnessed fall for one (#1) of three sampled residents reviewed for accident hazards. The DON identified 42 residents resided in the facility. Findings: Res #1 had diagnoses which included Alzheimer's disease and psychosis. An annual assessment, dated 05/17/24, documented the resident's cognition was severely impaired. It was documented the resident required supervision or touching assistance with transfers and was independent with walking. An incident note, dated 07/02/24 at 5:28 a.m., documented the aide was going to get Res #1's roommate up. It was documented Res #1 appeared to have fallen going to the restroom. It was documented the resident had a small laceration to their upper left brow area. It was documented the fall was not witnessed by staff. It was documented neurological checks were to be started. There was no documentation neurological checks began at the time of the resident's fall. An incident note, dated 07/02/24 at 5:37 a.m., documented the laceration was over the…

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

Based on observation, record review, and interview, the facility failed to store and serve food to ensure food service safety. The Resident Census and Condition of Residents documented a census of 39 residents. Findings: On 09/12/22 at 9:56 a.m., a tour of the kitchen facility was conducted with the dietary manager (DM). Personal staff items, including an employee's purse and drink, were observed on the preparation counter. The DM reported staff were allowed to store personal items in her office if needed. The DM reported a designated area would be established for storage of personal items. The microwave and toaster were observed to have food debris build-up. The DM reported she did not currently have a cleaning schedule and equipment was cleaned as needed. The food storage area was observed and a bowl, being used as a scoop, remained in the flour bulk container. The DM reported staff had just used the flour that morning and scoops should not be left in the bulk food items. A refrigerator was observed to have a watery liquid in the bottom of the cooler. Eggs in a cardboard carton…

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 maintain their infection control program. The facility failed to label and date a solution used to sanitize a glucometer for one (#25) of one sampled resident for finger stick blood sugar (FSBS) monitoring. The DON identified eight residents who required FSBS monitoring. Findings: A policy titled, Finger Stick Blood Sampling, not dated, read in parts, .It is the policy of this facility to use lancets to obtain finger stick blood samples in a safe manner for residents and staff .Procedure .Clean the Glucometer with germicidal wipes/or bleach/h2o solution diluted with a 1 to 10 ratio before initial use, after final use and between each resident following manufacturer recommendations . A Physician Order, for resident (Res) #25, dated 08/20/22, read in parts, .check finger stick AC & HS before meals and at bedtime for DM (Diabetes Mellitus) . On 09/14/22 at 11:30 a.m., LPN #1 was observed to perform a FSBS for Res #25. LPN #1 was asked if the glucometer was shared between residents and she stated, yes. After 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 observation, record review, and interviewed, the facility failed to ensure assessments accurately reflected the resident's use of oxygen for one (#4) of five residents reviewed for therapy. The Resident Census and Conditions of Residents, dated 09-12-22, documented 7 residents received respiratory treatment. Findings: Resident #4 was admitted to the facility on [DATE] with a diagnoses of COPD. A Physician Telephone Order, dated 07/03/21, documented O2 at 2-3 LPM via NC, may remove for ADLs. The resident's MDS Assessment, dated 05/26/22, documented no oxygen therapy. On 09/14/22 at 2:51 p.m., the DON reported .resident #4 had received oxygen since July 2021 but she had failed to transfer the telephone order to the resident's monthly physician orders and treatment administration record. The DON agreed the oxygen therapy was not reflected on the resident's assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for one (#4) of 13 residents whose care plans were reviewed. The Resident Census and Conditions of Residents, dated 09-12-22, documented 39 residents resided in the facility. Findings: Resident #4 was admitted to the facility on [DATE] with a diagnoses of COPD. A Physician Telephone Order, dated 07/03/21, documented O2 at 2-3 LPM via NC, may remove for ADLs. The resident's MDS Assessment, dated 05/26/22, documented the resident's cognition to be intact. The resident's Comprehensive Care Plan was reviewed and contained no documentation related to COPD or oxygen therapy. On 09/12/22 at 2:18 p.m., the resident was observed in her room, up in recliner, and wearing oxygen tubing via NC. On 09/14/22 at 2:51 p.m., the DON reported .resident #4 had received oxygen since July 2021 but she had failed to transfer the telephone order to the resident's monthly physician orders and treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure: a. oxygen therapy was provided per professional standards of care for one (#4), and b. oxygen tubing and humidifier bottles were labeled and dated per professional standards of care for two (#4 and #34) of five residents reviewed for respiratory services. The Resident Census and Conditions of Residents, dated 09/12/22, documented, 7 residents received respiratory treatment. Findings: The facility's oxygen administration policy, dated 10/2010, read in parts, .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .The name and title of the individual who performed the procedure .The rate of oxygen flow, route and rationale .The frequency and duration of the treatment . Resident #4 was admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disease. A Physician Telephone Order,…

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