Heritage Villa Care & Rehab Center

Based on record review and interview, the facility failed to: a. monitor the amount of meals a resident who experienced weight loss consumed for one (#43); and b. provide a physician ordered health shake with breakfast for one (#43) of one sampled resident reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: Resident #43 had diagnoses which included dementia. A Physician Order, dated 10/03/21, documented regular diet, mechanical soft texture, regular consistency with thin liquids. A Significant Change Resident Assessment, dated 07/31/23, documented the resident had severe cognitive impairment, and required supervision, setup help only for the task of eating. The July 2023 Amount of Meal Eaten record documented: a. blanks 48 out of 93 opportunities and b. na 18 out of 93 opportunities. A Nutrition/Dietary Note, dated 08/18/23, documented Resident #43 had experienced a significant weight loss of 11 percent over three months and 16 percent weight loss in six months. It documented a…

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

Based on observation, record review, and interview, the facility failed to ensure an accurate account of controlled medications was maintained for three (#62, 175, and #176) of three sampled residents reviewed for medication storage. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: A Controlled Substance Disposal policy, dated 04/18, read in parts, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations . On 09/20/23 at 10:04 a.m., CMA #2 was asked what the process was for removing a discontinued controlled medication from circulation. They stated they would pull the narcotic card and the narcotic sheet, take them to the DON, and log them into the double lock narcotic book. The CMA stated together they would drop it in the drop slot so there was always two people with it in the medication room.…

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 a physician provided a reason for disagreeing with a pharmacy GDR for one (#28); b. ensure a resident who received psychotropic medications received a gradual dose reduction in a timely manner for one (#15); and c. a prn psychotropic medication was limited to 14 days and had an end date for one (#3) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 51 residents received psychoactive medications. Findings: The Psychotropic Management Guidelines policy, dated 07/26/23, read in part, .Residents who use Psychotropic Drugs receive a Gradual Dose Reduction (GDR) and Behavioral Interventions, unless clinically contraindicated, to discontinue these Drugs .PRN Orders Psychotropic Drugs are limited to 14 days and should not be renewed unless the Attending Physician/Prescriber evaluated the Resident for appropriateness of that Medication .Prescribers should document their rationale in the Resident's Medical Record and indicate…

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 provide hot and palatable meals for six (#10, 19, 20, 31, 62, and #65) of six sampled residents reviewed for hot and palatable meals. The Administrator identified 70 residents who received their meals from the kitchen. Findings: The Food Holding and Service policy, revised 06/01/2019, read in part, .Serve all hot foods at a temperature of 135 degrees Fahrenheit or greater .Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts . 1. On 09/18/23 at 11:03 a.m., [NAME] #1 provided extended lunch menu. The lunch menu for 09/18/23 had baked pork chop, mushroom rice, sliced zucchini, garlic cheese bread, margarine, salt and pepper packets, choice of beverage, and water. On 09/18/23 at 1:04 p.m., the last resident hall tray was served. On 09/18/23 at 1:06 p.m., a test tray was delivered with one piece of pork chop, a small bowl of Zucchini, rice, cheese biscuit, and 2 individual packets of butter. There was a slice of lemon cake on the side. On…

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

Based on observation, record review and interview, the facility failed to: a. ensure food was prepared and served in a sanitary manner for one of one meal service observed; and b. failed to prevent bare hand contact with resident food for one (#43) of four sampled residents reviewed for ADLs. The Administrator identified 70 residents who received their meals from the kitchen. Findings: The Employee Sanitation policy, dated 10/01/18, read in part, .Cups, glasses and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces . The FOOD HANDLING & USE OF GLOVES policy, revised 08/16/23, read in part, .When donning gloves, hands must be washed first. Once gloves are donned, one job should be completed. When changing jobs or major tasks, gloves should be removed and discarded. New gloves should be put on after hands are washed . 1. Resident #43 had diagnoses which included dementia. A Significant Change Resident Assessment, dated 07/31/23, documented the resident had severe cognitive impairment, and required supervision, setup help only…

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 to ensure residents were assisted with dining in a dignified manner for one (#43) of four sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 23 residents were independent, 46 residents required the assistance of one or two staff members, and four residents were dependent on staff for the task of eating. Findings: A Nutrition and Foodservice policy, dated 10/01/18, read in part, .The facility believes that all residents would be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status . Resident #43 had diagnoses which included dementia. A Significant Change Resident Assessment, dated 07/31/23, documented the resident had severe cognitive impairment, and required supervision, setup help only for the task of eating. On 09/20/23 at 12:55 p.m., CNA #1 walked over to Resident #43 took a scoop 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.

Based on observation, record review, and interview, the facility failed to ensure privacy was provided while performing a finger stick for blood sugar reading and while administering insulin to one (#50) of three sampled residents observed for insulin administration. The Resident Roster Matrix report, undated, documented 15 residents received insulin. Findings: An Administration Procedures For All Medications policy, dated 04/18, read in part, .Provide privacy for resident during administration of medication . Resident #50 had diagnoses which included Type 2 diabetes with diabetic neuropathy, and hyperglycemia. On 09/20/23 at 7:57 a.m., LPN #2 was observed to perform a FSBS on Resident #50 in the dining room. There were 11 other residents present in the dining room at the time. On 09/20/23 at 8:02 a.m., LPN #2 was observed administering Resident #50's insulin to their right arm in the dining room. On 09/02/23 at 8:04 a.m., LPN #2 was asked what the policy and procedure was for medication administration in the dining room. They stated to make sure they had the right patient, right…

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 a resident was not involuntarily discharged while an appeal order was pending for one (#219) of one sampled residents reviewed for involuntary discharge. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. The Administrator identified one resident who had been given a 30-day discharge notice from the facility in the past 12 months. Findings: The DISCHARGE/TRANSFER-INVOLUNTARY policy, dated 11/01/18, read in part, .The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria, as outlined below, are met .The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in the decision of where to transfer .Involuntary discharge will be effected after the minimum notice requirements prescribed by applicable law and regulation, or thirty day notice if no state…

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 a discharge summary was completed after a discharge for one (#169) of three sampled resident reviewed for discharge. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: Resident #169 had diagnoses which included history of falls, dementia, anxiety, type two diabetes mellitus, and age related debility. An incomplete Oklahoma Human Services notification regarding a patient in a long term care facility form, signed on 11/04/22, documented Resident #169's Family transferred resident out. On 09/21/23 at 8:51 a.m., the DON was asked the reason the resident was discharged from the facility. They stated they had no idea. The DON was asked what the procedure was when a resident discharges from the facility. They stated, depending on the discharge, the nurses would complete a discharge summary, and then the social services director would complete their discharge summary. On 09/21/23 at 8:53 a.m., the DON was asked where Resident #169's discharge…

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: a. residents were provided assistance with eating in a timely manner for one (#43); and b. residents were provided assistance with hygiene, eating, and bathing for one (#169) of four sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. It documented 23 residents were independent, 46 residents required the assistance of one or two staff members, and four residents were dependent on staff for the task of eating. Findings: A Nutrition and Foodservice policy, dated 10/01/18, read in part, .Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining .Residents eating in their rooms will be provided assistance as needed. Residents who require dining assistance will not be delivered a meal tray until a staff member is available to assist the resident with eating . 1. Resident #43 had diagnoses which included dementia. A Significant…

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 a resident did not experience a significant medication error when a long acting insulin was administered instead of the short acting insulin ordered for one (#50) of three sampled residents observed for insulin administration. The Resident Roster Matrix, undated, documented 15 residents who received insulin resided in the faciilty. Findings: An Administration procedures for all medications policy, dated 04/18, read in part, .Review 5 rights (3) times: Prior to removing the medication package container from the cart/drawer, .Check MAR/TAR for order .Prior to removing the medication from the container .Check the label against the order on the MAR . Resident #50 had diagnoses which included type 2 diabetic neuropathy, type two diabetes mellitus, and hyperglycemia. A physician order, dated 03/21/23, documented to administer insulin detemir solution six units at bedtime. A physician order, dated, 07/17/23, documented to administer Humalog three units before meals. A physician order, dated 07/17/23,…

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

Based on observation, record review and interview, the facility failed to ensure resident records were accurate for one (#43) of one sampled resident reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: Resident #43 had diagnoses which included dementia. A Physician Order, dated 08/23/23, documented health shakes with meals. The September 2023 MAR documented the resident received a health shake with their morning meal on 09/19/23. On 09/19/23 at 8:24 a.m., CNA #3 delivered a meal tray to Resident #43. They stated the resident's name several times, stated they had breakfast for them, placed the meal tray on the bedside table, turned on the light, and opened the tray. The only liquid observed on the tray was a brown liquid in a tall cup. There was no health shake observed on the tray. Resident #43's meal service was observed until they received the last bite of food at 10:14 a.m. No health shake was provided with the resident's meal. On 09/19/23 at 10:19 a.m., CNA #3 was asked 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 observation, record review and interview, the facility failed to ensure used linens were not placed on the floor during incontinent care for one (#12) of three sampled residents observed for incontinent care. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 40 residents were occasionally or frequently incontinent of bladder, and 31 residents were occasionally or frequently incontinent of bowel. Findings: A Handling of Linen policy, dated 09/19, read in part, .The facility strives to reduce the risk of infection to the resident/patient and employees .All soiled linen will be bagged and/or placed in containers at the location where it is used . Resident #12 had diagnoses which included Alzheimer disease and dementia, A Quarterly Resident Assessment, dated 08/02/23, documented Resident #12 was always incontinent of bowel and bladder. On 09/20/23 at 9:42 a.m., CNA #1 and CNA #2 were observed transferring Resident #12 to the bed from the geriatric chair using a mechanical lift. On 09/20/23 at 9:45 a.m., CNA #3 obtained a grey container 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure the ice machine and scoop bucket were maintained in a sanitary manner. The dietary manager identified 65 residents who received ice from the machine. Findings: The facility's procedure for the ice machine, dated 09/2018, documented, The ice machine, scoop, and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once per day. 1. On 04/19/21 at 10:24 a.m., cook #1 was asked to open the locked ice machine. The surveyor used a clean paper towel and wiped across the upper metal housing of the inside of the ice machine. Multiple black specks came off onto the paper towel. On 04/19/21 at 10:30 a.m., the dietary manager was asked who was responsible to clean the ice machine. She stated maintenance cleaned it. She was asked if they told her when they would clean it. She stated no. She was asked if they had a schedule to clean it. She stated she did not…

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

Based on interview and record review, it was determined the facility failed to ensure the QAPI program made good faith attempts to identify and correct quality deficiencies. The facility identified 65 residents who resided at the facility. Findings: On 04/26/21 at 10:33 a.m., the administrator was asked prior to the survey if the facility had identified and developed a QAA plan for the RAI process. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for the restorative care. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for elopement. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for ADLs. He stated, no. He stated, currently they are working on that. He stated it was coming in place. He stated, the facility staff were getting the audits done right now, then they will collect the audits, and we will meet as a team and develop a plan. (The facility had F677 ADL care provided for dependent residents deficiency cited on a…

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

Based on interview and record review, it was determined the facility failed to have complete documentation of the seasonal influenza vaccine and the pneumococcal vaccine, for three (#11, #1, and #59) of five residents sampled for immunizations. The facility identified 65 residents resided at the facility. Findings: 1. An influenza vaccine consent form for resident #11 documented the POA refused the vaccine on 9/28/20. The form had a vaccine sticker with lot number TM72J attached to the form. The form included a nurse's signature with a date of 12/08/20. There was no documentation provided regarding the pneumococcal vaccine. 2. An influenza vaccine consent form for resident #15, dated 12/09/20, documented the influenza vaccine was given but had no documentation on the form indicating the screening questions were asked. The consent form had no documentation on the time the vaccine was given. The vaccine form contained no signature or date of the resident or POA consenting to the vaccine. A consent form for the pneumococcal vaccine was produced but had no documentation if the resident…

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

Based on interview and record review, it was determined the facility failed to: ~ ensure all staff were routinely tested for COVID-19; and ~ ensure outbreak testing was conducted until 14 days of no new positive COVID-19 cases had been achieved. This had the potential to affect all 65 residents who resided in the facility. Findings: 1. Review of the COVID-19 employee testing log did not reveal documentation the administrator had been tested for COVID-19 since 03/29/21. On 04/27/21 at 2:38 p.m., the administrator was asked if he had any documentation of being tested for COVID-19 during April 2021. He stated he thought he had been tested. On 04/28/21 at 10:45 a.m., the DON stated she had not found documentation the administrator had been tested for COVID-19 for April 2021. 2. Resident #1 had diagnoses which included COVID-19. A nurse's note, dated 01/08/21, documented the resident was experiencing elevated temperature, urine frequency, pain, decreased appetite, and was sent to the hospital. A hospital laboratory report, dated 01/08/21, documented the resident was positive 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 observation, interview, and record review, it was determined the facility failed to ensure survey results were accessible to residents/visitors. This had the potential to affect all 65 residents who resided in the facility. Findings: On 04/20/21 at 10:48 a.m., a resident group meeting was conducted. The three residents in attendance were asked if they knew where survey results were located for their viewing if desired. They all three stated they did not know where the survey results were located. On 04/21/21 at 11:18 a.m., a sign on the counter at the nurses' station documented the survey results were available here. The survey results were not observed on the nurses' station counter. On 04/21/21 at 11:22 a.m., LPN #1 was asked where the survey results were located. She stated they were usually in a big, black book. She stated the book had been moved and she would try to locate it. At 11:25 a.m., the administrator was observed looking for the survey results behind the nurses' station. LPN #1 delivered the book to the surveyor at the nurses' station. She was asked where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to provide facility failed to provide liability and appeals notices as required for three (#25, #29, and #64) of three sampled residents for liability and appeals notices. The BOM identified 23 residents had been discharged from skilled services in the last six months. Findings: On 04/20/21 at 10:05 a.m., asked the SSD to complete the SNF beneficiary protection notification review form for the three sampled residents. The SSD was asked to provide the surveyor with the liability and appeals notices if provided for three residents. On 04/20/21 at 10:22 a.m., the SSD returned the SNF beneficiary protection notification review forms. The form for resident #64 documented the resident started Medicare Part A skilled services on 11/13/20 and ended on 12/21/20. The form documented the SNFABN and NOMNC had been provided. The Advance Beneficiary Notice of Non-coverage form documented the reason medicare may not pay for the Part A care as 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 2. Resident #33 had diagnoses which included rheumatoid arthritis and spondylitis. The resident's clinical record contained a quarterly assessment, dated 12/20/20. The resident's next assessment to be completed, an annual assessment, dated 03/12/21, documented a status of pending. Based on interview and record review, it was determined the facility failed to ensure comprehensive assessments were conducted in a timely manner for two (#23 and #33) of 24 sampled residents whose assessments were reviewed. This had the potential to affect all 65 residents who resided in the facility. Findings: 1. Resident #23 was admitted on [DATE]. Review of the electronic clinical record for resident #23 revealed the last completed comprehensive assessment was an admission assessment with an assessment reference date of 03/30/20. On 04/27/21 at 4:39 p.m., the electronic record revealed an annual assessment was in progress. The assessment reference date of the annual assessment was 03/31/21. On 04/27/21 at 5:30 p.m., the MDS nurse…

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, it was determined the facility failed to ensure quarterly assessments were completed every three months for four (#11, #20, #29, and #35) of 24 sampled residents whose assessments were reviewed. The facility identified 65 residents resided in the facility. Findings: 1. Resident #11 was admitted to the facility with diagnoses which included Alzheimer's Disease and need for assistance with personal care. The resident's clinical record contained a significant change assessment dated [DATE]. The resident's next assessment to be completed was a quarterly assessment. The resident's clinical record contained a quarterly assessment dated [DATE]. The quarterly assessment's status had a pending documented. 2. Resident #29 was admitted to the facility with diagnoses which included hypertension, Alzheimer's Disease, hemiplegia, and muscle weakness. The resident's clinical record contained the previous quarterly assessment dated [DATE]. The resident's next assessment to be completed 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 interview and record review, it was determined the facility failed to develop comprehensive care plans to meet the needs of residents for four (#20, #23, #29, and #52) of 22 sampled residents whose comprehensive care plans were reviewed. The facility identified 65 residents who resided at the facility. Findings: 1. Resident #20 had diagnoses which included unspecified injury at C4 level of cervical spinal cord, hemiplegia, and muscle wasting and atrophy. The resident's care plan, dated 03/07/19, did not document the resident's preferred activities. The care plan documented she would exercise the right to not participate in structured activities. The care plan goal was for the resident to verbalize satisfaction with the number and variety of structured and independent activities she had participated in. The care plan documented the resident would be provided a monthly calendar. A significant change assessment, dated 02/24/20, documented the resident was cognitively intact; and the resident's activity…

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, it was determined the facility failed to have a qualified activities director. This had the potential to affect all 65 residents who resided in the facility. Findings: On 04/20/21 at 10:58 a.m., resident #20 was asked how the activities were at the facility. She stated they were pretty good until they lost their activity director approximately two and a half weeks ago. On 04/21/21 at 4:20 p.m., the resident was asked what activities she had done. She stated there had not been any activities. She stated she was going to ask the dietary manager (after her vacation) to call Bingo. Random observations throughout the survey did not reveal activities were provided. The activity calendar posted in the facility was dated for March 2021. On 04/26/21 at 10:51 a.m., CNA #1 was asked who provided activities. She stated no one because the facility did not have an activity director. She was asked how long the facility had been without an activity director. She stated approximately one month. On 04/27/21 at 11:28 a.m., the administrator was asked…

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, it was determined the facility failed to ensure residents with limited ROM received treatment and services to prevent further decrease or maintain ROM for three (#20, #23, and #52) for three sampled residents reviewed for ROM/restorative services. The facility identified three residents with contractures. Findings: 1. Resident #23 had diagnoses which included hemiplegia; traumatic brain injury; and contractures of bilateral shoulders, elbows, wrists, hips, and knees. An admission assessment, dated 03/30/20, documented the resident required extensive assistance with ADLs and had range of motion impairment on both sides of her upper and lower extremities. A care plan, updated 01/17/21, documented, .I am on the restorative program and we work on wearing my splints . A restorative nursing flow sheet, dated February 2021, documented the last day restorative services had been provided was 02/25/21. A therapy to restorative nursing communication form, dated 03/05/21, documented, .PT/OT/ST Recommendations: PROM of upper & low body in all…

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, it was determined the facility failed to ensure pre and post dialysis assessments and physician's orders for dialysis were completed for one (#16) of one sampled resident who was reviewed for dialysis. The facility identified three residents who received dialysis. Findings: A policy titled Hemodialysis: Out of Facility Provider, dated October 2016, documented, .Responsibility of the Long Term Care Provider .The facility will maintain a medical record that includes documentation of dialysis treatments. The resident's nurse will be responsible for utilizing the dialysis communication form and/or receiving verbal report from the dialysis provider following a dialysis treatment .Predialysis Care .Assess vital signs .Document care in the medical record .Record weight .Assess the vascular access site to assess for thrill .Assess vascular access site for sign/symptom of infection .Document in medical record .Palpate vascular access site to assess for thrill .Document in the medical record .Postdialysis Care .Assess and document vital signs, weight,…

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, it was determined the facility failed to ensure the DON did not work as a charge nurse when the resident census was 60 or greater. This had the potential to affect all 65 residents who resided in the facility. Findings: Review of the 04/2021 detailed facility census report documented the resident daily census was as follows: ~ 04/14/21 the resident census was 68; ~ 04/15/21 the resident census was 66; ~ 04/17/21 the resident census was 66; and ~ 04/18/21 the resident census was 65. On 04/27/21 at 4:30 p.m., the DON reported she had worked as a charge nurse several days since becoming the DON. She stated herself and LPN #4 had worked together as charge nurses on those days. She stated she had done what she needed to do to take care of the residents. She stated she had been the DON for two weeks. She was asked what days she had worked as a charge nurse. She stated she would check. On 04/28/21 at 1:21 p.m., the DON stated she had worked as a charge nurse on 04/14/21, 04/15/21, 04/17/21, and 04/18/21. She was asked if she was the DON on the above…

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 it was determined the facility failed to ensure CNAs had received performance/competency reviews yearly for five (CNA #2, #3, #4, #6, and CNA #7) of five employee files reviewed for NA competency reviews. This had the potential to affect all 65 residents who resided in the facility. Findings: On 04/28/21 at 10:23 a.m., corporate RN #1 was asked if the facility had completed yearly CNA competency reviews. She stated they had a skills checklist. She was asked for the skills checklist for CNA #2, #3, #4, #6, and CNA #7. On 04/28/21 at 10:42 a.m., the administrator provided the surveyor a blank CNA annual skill evaluation form. He stated the yearly skills evaluation forms had not be completed for the CNAs.

Based on interview and record review, it was determined the facility failed to ensure resident medical records were complete and accurate for five (#1, #10, #52, #57, and #60) of 24 sampled resident whose records were reviewed. The DON identified 65 residents in the facility with medical records. Findings: 1. Resident #1 had diagnoses which included vascular dementia, generalized anxiety disorder, and major depressive disorder. Review of the behavior and side effect monitoring flow sheets, dated February 2021, revealed the following: ~ Behavior and side effect monitoring was documented for 23 out of 28 opportunities for the day shift. Review of the behavior and side effect monitoring flow sheets, dated March 2021, revealed the following; ~ Behavior and side effect monitoring was documented for 12 out of 31 opportunities for the day shift. Review of the behavior and side effect monitoring flow sheets, 04/01/21 through 04/21/21, revealed the following: ~ Behavior and side effect monitoring was documented for two out of 21 opportunities for the day shift. 2. Resident #10 had diagnoses…

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, it was determined the facility failed to ensure the QAA committee developed and implemented appropriate plans of action to correct quality deficiencies. The facility identified 65 residents who resided at the facility. Findings: On 04/26/21 at 10:33 a.m., the administrator was asked prior to the survey if the facility had identified and developed a QAA plan for the RAI process. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for the restorative care. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for elopement. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for ADLs. He stated, no. He stated, currently they are working on that. He stated it was coming in place. He stated, the facility staff were getting the audits done right now, then they will collect the audits, and we will meet as a team and develop a plan. (The facility had F677 ADL care provided for dependent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to implement an effective infection control program to prevent potential infections for four (#1, #11, #29, and #55) of 21 sampled residents reviewed for infection control. The facility failed to: a. ensure catheter care was provided in a manner to prevent UTIs for resident #11, b. ensure indwelling urinary catheter bags(privacy bags) and tubing did not touch the floor for residents #1, #29, and #55, and c. ensure tracking and trending of infections were monitored and analyzed with steps taken to prevent further infections on a monthly basis. This had the potential to affect the 65 residents who resided at the facility. The facility identified 65 residents who resided at the facility. Findings: The facility's catheter urinary care and maintenance procedure, dated effective 03/2019, r/t catheter care, documented, - To cleanse the entire perineal with soap and water or premoistened wipe. - For a male - cleanse from urethra…

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, it was determined the facility failed to accurately complete an annual assessment for one (#57) of 24 sampled residents whose assessments were reviewed for accuracy. Findings: Resident #57 had diagnoses which included paraplegia and neurogenic bladder. An annual assessment, dated 06/10/20, documented the resident was cognitively intact, required a two person hoyer assist for most ADLs, had impairment on both sides of the lower extremities, used a wheelchair for mobility, and had an indwelling urinary catheter, urinary continence not rated. A care plan, dated 01/14/21, documented a care area of impaired mobility due to paraplegia with interventions of no ambulation, total assist with hoyer, and required assistance as needed. A quarterly assessment, dated 03/13/21, documented the resident was cognitively intact, required the assist of two for most ADLs; balance during transitions was not steady but able to stabilize with staff assistance for moving from seated to standing, walking, turning around and surface to surface transfer; had…

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

Based on interview and record review, it was determined the facility failed to address a resident's elopement risk in the baseline care plan for one (#114) of one newly admitted resident who was at risk for elopement whose baseline was reviewed. The facility identified two residents who were at risk for elopement. Findings: The facility's elopement prevention and management program, dated effective 07/2018, documented, .Develop individualized interventions . Review and revise Interdisciplinary Plan of Care (IPOC) as needed . The facility's elopement prevention procedure, dated effective 07/2018, documented, .Include resident/patient and family in development of the Plan of Care . The facility's elopement program algorithm, dated effective 07/2018, documented, if the resident is an elopement risk, evaluate the contributing factors, identify prevention interventions, and develop plan of care for elopement. The resident's baseline care plan, dated 12/22/20, documented the resident was an elopement risk, a wanderguard was in place, and to implement the elopement prevention protocol. 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 interview and record review, it was determined the facility failed to review/revise resident care plans for two (#11 and #29) of 22 sampled residents whose care plans were reviewed. The facility identified 65 residents who resided at the facility. Findings: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses included Alzheimer's Disease and need for assistance with personal care. A significant change assessment, dated 11/12/20, documented the resident was severely cognitively impaired, required assistance of staff with most ADLs, had a indwelling urinary catheter, had pain, and had lost 5% or more weight. The resident's care plan, dated 10/02/20, documented the next target (review) date was 02/28/21. The care plan had not been reviewed after the 11/12/20 significant change assessment. The resident's care plan did not address his weight loss. On 04/27/21 at 12:36 p.m., corporate RN #1 was asked if the resident's current care plan had been reviewed/revised. She reviewed 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, interview, and record review, it was determined the facility failed to ensure an activity program that met residents preferences and/or needs for two (#20, and #29) of five sampled residents reviewed for activities. The facility identified 65 residents resided at the facility. Findings: 1. Resident #20 had diagnoses which included unspecified injury at C4 level of cervical spinal cord, hemiplegia and muscle wasting & atrophy. The resident's care plan, dated 03/07/19, did not document the resident's preferred activities. The care plan documented she would exercise her right to not participate in structured activities. The care plan goal for the resident was to verbalize satisfaction with the number and variety of structured and independent activities she had participated in. The care plan documented the resident would be provided a monthly calendar. A significant change assessment, dated 02/24/20, documented the resident was cognitively intact; the resident's activity preferences that were very important to her were for her to choose her clothes; take care 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with an indwelling urinary catheter received appropriate care and services for one (#11) of seven sampled residents whose indwelling urinary catheters were reviewed. The facility identified seven residents with indwelling urinary catheters. Findings: The facility's catheter urinary care and maintenance procedure, dated effective 03/2019, r/t catheter care, documented, - To cleanse the entire perineal with soap and water or premoistened wipe. - For a male - cleanse from urethra outward. Retract foreskin of uncircumcised male, cleanse, and replace foreskin. - Hold and support catheter to avoid traction/unnecessary movement. - Gently cleanse the urethral/catheter junction. - Gently cleans about three inches of the catheter from the urethra outward avoiding traction. - Rinse thoroughly and gently dry. - Check that the catheter is attached to the thigh or abdomen (male) as ordered. Resident #11 had diagnoses which included BPH and Alzheimer's Disease. A care plan, dated…

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, it was determined the facility failed to ensure pharmacy consultations/recommendations were addressed by the physician for one (#1) of five sampled residents who were reviewed for unnecessary medications. This had the potential to affect all 65 residents who resided in the facility. Findings: Resident #1 had diagnoses which included vascular dementia, generalized anxiety disorder, and major depressive disorder. A pharmacy consultation report, dated 02/09/21, documented, .Please note CMS guidelines implemented in November 2017 advise against the use of an 'as needed' or PRN psychotropic agents .for longer than 14 consecutive days without physician evaluation and justification for continued use .This patient has such an order: Ativan 0.5 mg every 4 hours as needed for anxiety. Unless clinically contraindicated, please consider discontinuing this medication and re-evaluating clinical necessity. If continued PRN use is of clinical necessity and the patient's condition would be compromised by discontinuing this order, please document as such below…

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, it was determined the facility failed to ensure laboratory monitoring for a medication was completed for one (#1) of five sampled residents who were reviewed for unnecessary medications. The facility identified all 65 residents received medications. Findings: Resident #1 had diagnoses which included vascular dementia, generalized anxiety disorder, and major depressive disorder. A physician's order, dated 07/31/20, documented, .Obtain Depakote & CMP Level one time a day every 6 month[s] starting on the 1st .related to GENERALIZED ANXIETY DISORDER .MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED . A physician's order, dated 01/23/21, documented the resident was ordered Depakote delayed release tablet 125mg by mouth three times a day. A treatment administration record, dated February 2021, documented the resident refused to have the Depakote and CMP levels completed on 02/01/21. On 04/27/21 at 3:16 p.m., the DON was asked who monitored to ensure labs were completed as ordered and reported to the physician. She stated the charge nurses. She 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, it was determined the facility failed to ensure antianxiety medications were not ordered for more than 14 days for one (#1) of five sampled residents who were reviewed for unnecessary medications. The facility identified ten residents who received antianxiety medications. Findings: Resident #1 had diagnoses which included vascular dementia, generalized anxiety disorder, and major depressive disorder. An annual assessment, dated 01/27/21, documented the resident had received an antianxiety medication for seven of seven days during the look back period. Review of the MARs, dated February through April 2021, documented, .Ativan 2MG/ML [LORazepam] Give 0.25 mg/ml sublingually every 4 hours as needed for Anxiety -Start Date- 02/02/2021 1045 -D/C Date- 04/21/2021 1435 . The MARs documented the resident had received the Ativan prn February through April 2021. Review of the clinical record did not reveal physician justification for continuing the Ativan on an as needed basis longer than 14 days. On 04/28/21 at 1:23 p.m., the DON was asked what the time…

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, it was determined the facility failed to ensure a resident was provided radiology services as ordered by the physician for one (#11) of three sampled residents who were reviewed who had radiology services. The facility identified 65 residents resided at the facility. Findings: Resident #11 had diagnoses which included CVA and dysphagia. A significant change assessment, dated 11/12/20, documented the resident was severely cognitively impaired, required assistance with ADLs, and had lost 5% or more weight. A ST treatment encounter note, dated 01/07/21, documented, the ST had written a note to send to the resident's physician that the resident was having pain when swallowing. The ST documented the physician had responded with refer for EGD. A nurse's progress note, dated 01/07/21 at 6:55 a.m., documented the nurse had contacted the resident's physician about the ST requesting a gastric intestinal consult r/t weight loss and painful swallowing as well as gagging and vomiting. The physician gave a new order for a referral for an EGD. On 04/27/21 at…

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