Chandler Therapy & Living Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was permitted to return to the facility after they were hospitalized for 1 (#5) of 1 sampled resident reviewed for hospitalization. The DON identified 32 residents who resided in the facility. Findings: A policy titled Bed-Hold and Returns, revised [DATE], read in part, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source .Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. Resident #5 had diagnoses which included persistent mood…

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 PASSAR level I assessment was completed before or on admission for 1 (#7) of 1 sampled resident reviewed for PASSAR. The DON identified 32 residents who resided in the facility. Findings: Resident #7 was admitted to the facility 02/03/25 with diagnoses which included chronic obstructive pulmonary disease, depression, and anxiety disorder. A review of the resident's clinical record was completed and no documentation regarding the completion of a PASSAR level I was found. On 03/13/25 at 3:46 p.m., the DON stated they could not locate documentation a PASSAR level I was completed for the resident. The DON stated it must have been missed.

Based on record review and interview, the facility failed to follow physician's orders for one (#2) of three sampled residents reviewed for medications. The administrator identified 40 residents resided in the facility. Findings: Res #2 was admitted to the facility with diagnoses which included of anxiety disorder, hypertensive heart disease, and unspecified dementia. A physician's order, dated 08/07/24, documented to hold Ativan (benzodiazepine medication) for now and call if behaviors resume. A medication regimen review, dated August 2024, documented the resident was administered Lorazepam (Ativan) on 08/15/24 at 8 a.m. and 4 p.m., 08/16/24 at 8 a.m. and 4 p.m., 08/24/24 at 4 p.m., and 08/25/24 at 8 a.m. and 4 p.m. The resident's record did not contain documentation the order was resumed or the resident had any behaviors. On 10/11/24 at 2:02 p.m., the DON was shown the August 2024 medication administration record and asked if the facility had a physician's order to resume the lorazepam. They stated the medication hold probably fell off. The DON was unable to find an order 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 record review and interview, the facility failed to ensure a PRN order for an antianxiety medication had a 14 day stop date for one (#3) of three sampled residents reviewed for medications. The administrator identified 40 residents resided in the facility. Findings: Res #3 was admitted to the facility with diagnoses which included anxiety disorder, insomnia, unspecified dementia. A physician's order, dated 09/05/24, documented Xanax (benzodiazepine medication) Oral Tablet. Give 1 tablet by mouth every 8 hours for anxiety. The order did not document a stop date. On 10/11/24 at 2:02 p.m., the DON stated the medication should have had a stop date.

Based on record review and interview, the facility failed to ensure an annual comprehensive assessment was completed within 14 days of the ARD for one (#11) of 14 sampled residents whose assessments were reviewed. The DON identified 40 residents who resided at the facility. Findings: Resident #11 had diagnoses which included diabetes. The annual assessment, dated 06/12/24, documented it had been completed on 06/28/24. The MDS 3.0 NH Final Validation Report, dated 08/09/24, documented the annual assessment, dated 06/12/24 was completed more than 14 days after the ARD date and was late. On 08/14/24 at 10:47 a.m., the administrator stated the previous MDS coordinator has not been completing MDS assessments timely. They stated they had not monitored MDS assessments to ensure they were completed timely but the previous DON had monitored.

Based on record review and interview, the facility failed to ensure assessments were transmitted within seven days of completion for two (#11 and #92) of 14 sampled residents whose assessments were reviewed. The DON identified 40 residents who resided in the facility. Findings: 1. Resident #11 had diagnoses which included diabetes. The MDS 3.0 NH Final Validation Report, dated 08/09/24 documented the following assessments had been submitted late: a. The annual assessment, dated 06/12/24; and b. The discharge return not anticipated, dated 07/03/24. 2. Resident #92 had diagnoses which included acute kidney failure and sacral ulcer. The MDS 3.0 NH Final Validation Report, dated 08/09/24 documented the admission assessment, dated 06/21/24, had been submitted late. On 08/14/24 at 10:47 a.m., the administrator stated the previous MDS coordinator has not transmitted MDS assessments timely. They stated they had not monitored MDS assessments to ensure they were transmitted timely but the previous DON had monitored.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for three (#22, 27, and #92) of 12 sampled residents whose care plans were reviewed. The DON identified 40 residents who resided in the facility. Findings: The Care Plans - Baseline policy, dated December 2016, read in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 1. Resident #22 had diagnoses which included congestive heart failure and end stage renal disease. The Baseline Care Plan, dated 06/10/24, in the electronic health record, was documented as In Progress and was blank. 2. Resident #27 had diagnoses which included schizophrenia and end stage renal disease. The Baseline Care Plan, dated 01/13/24, in the electronic health record, was documented as In Progress and was blank. 3. Resident #92 had diagnoses which included absence of left leg below the knee, absence of right foot, and schizoaffective disorder bipolar type. The Baseline Care Plan, dated 06/14/24, in 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 ensure a comprehensive care plan was developed for four (#3, 27, and #92) of 14 sampled residents whose care plans were reviewed. The DON identified 40 residents who resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #3 had diagnoses which included end stage renal disease. The annual assessment, dated 05/14/24, documented the resident received dialysis. Review of the electronic clinical record did not reveal a care plan had been developed to address end stage renal disease/dialysis with goals or interventions. On 08/13/24 at 8:32 a.m., CNA #1 stated Resident #3 was getting ready for dialysis. On 08/13/24 at 2:27 p.m., the DON reviewed the electronic clinical record and stated the previous care plan coordinator had 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 observation, record review, and interview, the facility failed to ensure the urinary drainage bag was positioned in a manner to maintain infection control for two (#92 and # 6) of two sampled residents who were reviewed for urinary catheters. The Resident Matrix documented two residents who had urinary catheters. Findings: An undated policy titled Catheter Care, Urinary, read in parts .Be sure the catheter tubing and drainage bag are kept off the floor . 1. Resident #6 had diagnoses which included pressure induced deep tissue damage of the right buttocks and the sacral region. On 08/13/24 at 2:00 p.m., Resident #6 was observed in bed with the urinary catheter bag on the floor. On 08/14/24 at 10:45 a.m., Resident #6 was observed in bed, lying on their left side. The urinary catheter bag was observed to be attached to the bed frame and resting on the floor. On 08/14/24 at 10:49 a.m., LPN #1 was observed to provide urinary catheter care for Resident #6. On 08/14/24 at 10:53 a.m., LPN #1 stated the catheter bag should not be on the floor and repositioned the bag. On 08/14/24 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.

Based on record review and interview, the facility failed to ensure orders for dialysis and pre/post dialysis assessments were completed for three (#3, 22, and #27) of three sampled residents who were reviewed for dialysis. The DON identified three residents who received dialysis. Findings: The End-Stage Renal Disease, Care of a Resident with policy, dated September 2010, read in parts, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . 1. Resident #3 had diagnoses which included end stage renal disease. The annual assessment, dated 05/14/24, documented the resident received dialysis and was cognitively intact for daily decision making. Review of the Dialysis Information forms, dated 07/01/24 through 07/31/24, revealed the following: a. The pre dialysis assessment did not document a weight two times out of 12 opportunities; b. The post dialysis assessment had been completed by dialysis staff, rather than facility staff, seven of 12 opportunities; and c. The clinical record did not contain any documentation, nor 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 and interview, the facility failed to ensure medications were secured one (Southwest treatment cart) and failed to ensure medications were dated when opened for two (Southwest treatment cart and North medication cart) of two medication/treatment carts and one of one medication rooms observed for medication storage. The DON identified four medication/treatment carts and one medication room in the facility. Findings: 1. On 08/11/24 at 11:00 a.m., the Southwest treatment cart was observed to be unlocked by the nursing station. RN #2 was observed to leave the unlocked cart unattended. They were asked who was responsible for the cart and they stated they had forgotten to lock it. RN #2 locked the cart and walked down the hall. On 08/13/24 at 4:08 p.m., RN #3 was observed to obtain the glucometer, blood pressure cuff, and pulse oximeter and entered room [ROOM NUMBER]. The Southwest treatment cart was unlocked and unattended by the nurse. RN #3 was asked who was responsible for 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 and interview, the facility failed to ensure there was qualified dietary staff to meet the needs of the residents. The DON identified 38 residents who received meals from the kitchen. Findings: On 08/12/24 at 11:30 a.m., there were two employees observed in the kitchen, a cook and a dishwasher. On 08/12/24 at 11:45 a.m., cook #1 stated there had not been a DM for more than two weeks. The previous DM had quit without notice. [NAME] #1 stated they are also short staffed on cooks and dietary aides. On 08/12/24 at 12:00 p.m., the administrator provided a list of facility managers. Review of the list identified the dietary manager position was open, no staff name was listed. On 08/13/24 at 1:00 p.m., the administrator stated they had interviews scheduled for the DM position and hoped to have a new DM by next week. They stated it has been difficult keeping dietary staff.

Based on observation and interview, the facility failed to ensure there were sufficient dietary staff to meet the needs of the residents. The DON identified 38 residents received meals from the kitchen. Findings: On 08/14/24 at 3:34 p.m., the maintenance supervisor stated they helped in the kitchen by putting away deliveries, making plates, and cooking sometimes. They stated they have been told about portions, but have not received dietary training. They stated they do not have a food handlers card. On 08/14/24 at 3:34 p.m., the housekeeping supervisor stated they helped cook meals if the dietary staff does not know how to cook an item on the menu and they helped get meals out on time. They stated they had not received dietary training in the facility and do not currently have a food handlers card. On 08/14/24 at 4:22 p.m., the administrator stated they did not cook but helped put things away when they get food deliveries. They stated they have not gotten dietary training for the maintenance supervisor or for the housekeeping supervisor. They do not have training documentation 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, record review, and interview, the facility failed to ensure food was palatable and served at appetizing temperatures for one (evening meal) of one meal observed for palatability. The DON identified 38 residents received meals from the kitchen. Findings: The Resident Council Meeting Minutes, dated 07/31/24, documented a complaint that the food was cold. On 08/11/24 at 12:03 p.m., Resident #3 stated food on the hall trays was cold and the food was not good. On 08/11/24 at 12:19 p.m., Resident #22 stated hot foods were not served hot and cold foods were not served cold. On 08/13/24 at 5:16 p.m., a test tray was received. The pizza and the fruit cocktail were observed to be room temperature. The dressed salad was on the plate with the pizza and was observed to be wilted, soggy, and room temperature. The food was not observed to be a palatable temperature. On 08/13/24 at 5:24 p.m., the administrator stated they had gotten a test tray and tasted the food. The administrator stated they were aware there was a problem with food palatability.

Based on observation and interview, the facility failed to ensure meat was thawed in a sanitary manner and that residents plates were delivered in a sanitary manner. The DON identified 38 residents received meals from the kitchen. Findings: On 08/11/24 at 11:20 a.m., a ten pound roll of hamburger meat was observed thawing in a sink filled with water. On 08/11/24 at 11:47 a.m., [NAME] # 3 stated meat should be thawed under cold running water or in a refrigerator. [NAME] #3 stated meat should not sit in a sink filled with water. On 08/11/24 at 1:00 p.m., the administrator stated meat should be thawed under cold running water or in the refrigerator. On 08/13/24 at 12:30 p.m., LPN #1 was observed assisting a resident into the dining room and locking the wheelchair breaks. The nurse continued delivering plates to other residents without sanitizing their hands. On 08/13/24 at 1:00 p.m., LPN #1 stated they should have sanitized their hands after delivering each plate. On 08/13/24 at 1:30 p.m., the administrator stated the staff should be sanitizing their hands after delivering each…

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

Based on observation and interview, the facility failed to honor a resident's choice of dining location for one (#1) of one resident sampled for choices. The administrator identified 40 residents resided in the facility. Findings: Resident #1 had diagnoses which included a history of traumatic brain injury. On 08/13/24 at 12:51 p.m., Resident #1 was observed being fed lunch in their room. On 08/13/24 at 2:15 p.m., CNA #3 stated Resident #1 liked to eat meals in the living room but they were told because State was in the facility Resident #1 must be fed in their room. CNA #3 asked Resident #1 if they liked to eat in the living room or in their room. The resident stated living room. On 08/13/24 at 2:16 p.m., the DON stated Resident #1 ate their meals in the living room, it was their preference. The administrator stated the resident could communicate their preference and there was no reason they must eat meals in their room.

Based on record review and interview, the facility failed to ensure quarterly assessments were completed within 14 days of the ARD for one (#27) of 14 sampled residents whose assessments were reviewed. The DON identified 40 residents who resided in the facility. Findings: Resident #27 had diagnoses which included end stage renal disease. The quarterly assessment, dated 07/16/24, documented it had been completed on 08/09/24. The MDS 3.0 NH Final Validation Report, dated 08/09/24, documented the quarterly assessment had been completed more than 14 days after the ARD. On 08/14/24 at 10:47 a.m., the administrator stated the previous MDS coordinator has not been completing MDS assessments timely. They stated they had not monitored MDS assessments to ensure they were completed timely but the previous DON had monitored.

Based on record review and interview, the facility failed to ensure a level two PASARR was requested for one (#27) of one sampled residents who were reviewed for PASARR. The DON identified seven residents who had a diagnoses of a serious mental illness. Findings: Resident #27 had diagnoses which included schizophrenia and unspecified psychosis. The electronic health record documented the diagnoses of schizophrenia and unspecified psychosis were both present upon admission to the facility. The admission assessment, dated 01/19/24, documented the resident had a diagnoses of schizophrenia. The Nursing Facility Level of Care Assessment, dated 02/01/24, documented the primary diagnoses was sepsis and the secondary diagnoses was diabetes. The assessment read in part, .Diagnoses of serious mental illness (for example, schizophrenic, paranoid, panic, mood .or other psychotic disorder?) . The question was documented as no. Review of the electronic health record did not reveal a level two PASARR had been requested. On 08/13/24 at 11:48 a.m., documentation for the request of a level two PASARR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a care plan was reviewed for one (#141) of one sampled resident reviewed for care plans. The administrator identified 40 residents resided in the facility. Findings: Resident #141 was admitted on [DATE] and had diagnoses which included dementia, hypertension and anxiety. On 08/11/124 at 3:10 p.m., a family member for Resident #141 was interviewed and stated they were not notified of or offered an opportunity to participate in the resident's care plan meeting. On 08/11/24 at 3:30 p.m., the Resident #141's clinical record was reviewed. There was no documentation the resident's representative participated in a care planning process. On 08/13/24 at 10:03 a.m., the social services coordinator stated they have not had a care plan meeting for Resident #141. They stated they usually did a care plan meeting within one week, but they were behind and had not had one yet.

Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the residents stay was completed for one (#39) of one sampled resident who was discharged . The DON identified 13 residents who had been discharged in the past three months. Findings: Resident #39 had diagnoses which included dementia. A physician's order, dated 05/14/24, documented the resident was discharged from skilled services to home with home health. The Discharge Summary progress note, dated 05/14/24 at 12:00 p.m., documented the Resident #39 was transported home by family with all personal belongings, medications, discharge instructions, and information regarding upcoming appointments. The progress note did not document a recapitulation of the resident's stay. On 08/12/24 at 12:14 p.m., the DON stated they assumed the MDS coordinator or the DON would complete discharge summaries. They stated they would need to find out. On 08/13/24 at 12:07 p.m., the DON stated they were not sure what information the facility's discharge summary form contained but 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 and interview, the facility failed to ensure an enteral tube feeding bag was properly labeled for one (#33) of two sampled residents reviewed for tube feeding management. The Facility Matrix, identified two residents who received enteral tube feeding via continuous pump. Findings: On 08/12/24 at 10:44 a.m., Resident #33 was observed with tube feeding running at 45ml/hr. No label was observed on the tube feeding bag. On 08/13/24 at 8:42 a.m., Resident #33 was observed with tube feeding running at 45ml/hr. The hand written label, on the tube feeding bag, documented, Jevity 08/13/23 @ 0300. The resident's name or prescribed rate was not documented on the label. On 08/13/24 at 10:11 a.m., RN #1 stated by looking at the tube feeding bag they could not tell what resident it was for or the rate it should be running. RN #1 stated there should be a label on the bag with the resident's name, date, time, formula, and rate. On 08/13/24 at 11:00 a.m., the DON stated the tube feeding bag should contain a label with the resident's name, time the formula was hung, the type 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 record review and interview, the facility failed to monitor for side effects of an anticoagulant medication and obtain hemoglobin A1C monitoring as ordered by the physician for one (#27) of five sampled residents who were reviewed for unnecessary medications. The DON identified eight residents who received anticoagulant medications and 13 residents who were diabetic. Findings: Resident #27 had diagnoses which included diabetes mellitus and hypertension. A physician order, dated 01/12/24, documented the resident was ordered Eliquis (an anticoagulant medication) 2.5 mg twice daily. A physician order, dated 03/11/24, documented a hemoglobin A1C was ordered every March, June, September, and December. The Nursing Clarification/Comments form from the consultant pharmacist, dated 05/09/24, documented to monitor for side effects of Eliquis. The quarterly assessment, dated 07/16/24, documented the resident received anticoagulant and hypoglycemic medications. Review of the electronic clinical record did not reveal side effect monitoring for the use of anticoagulants had been…

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 menus were followed for one (evening meal) of two meal services observed. The DON identified 38 residents who received meals from the kitchen. Findings: An undated policy titled Menus, read in parts, .Deviations from posted menus are recorded, including the reason for the substitution and/or deviation and archived . A menu, dated April 29, June 3, July 8, August 13, and September 23, documented dinner was to be cheese pizza, tossed salad with dressing, vegetable soup, seasonal fruit cup, and milk or beverage of choice. On 08/13/24 at 5:00 p.m., vegetable soup was not observed to be served during the evening meal with pizza and salad. On 08/13/24 at 5:17 p.m., cook #2 stated they could not find vegetable soup so it was not served with the meal. On 08/13/24 at 5:26 p.m., the administrator stated the dietary staff were to notify them if they did not have an item on the menu.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were utilized for one (#6) of one sampled residents observed for infection control and failed to ensure the glucometer was disinfected between uses for three (#3, 93, and #25) of three sampled residents who were observed during glucose monitoring. The administrator identified one resident with a tracheostomy, two residents with urinary catheters, and 13 residents who required glucose monitoring. Findings: An Enhanced Barrier Precautions policy, dated 02/28/22, read in part, The facility may expand the use of PPE and refer to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to hands/clothing. 1. Resident #6 had diagnoses which included atrial fibrillation. On 08/14/24 at 7:31 a.m., signage was posted for EBP on Resident #6's door. LPN #1 was observed during tracheostomy care and catheter care for Resident #6. The nurse changed their gloves four times during tracheostomy care without sanitizing their…

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

Based on observation, record review, and interview, the facility failed to ensure the menu was followed and substitutions to the menu were reviewed and/or approved by the registered dietitian. The ADON identified 35 of 37 residents received nutrition from the kitchen. Findings: A facility menu for Tuesday 23-24 5 week - week 1 documented the lunch was Swedish meatballs with cream gravy, buttered noodles, lima beans, cornbread, butter, peach dump cake, and beverage of choice. A facility menu for Wednesday 23-24 5 week - week 1 documented the lunch was barbeque pork, baked potato, sliced zucchini, Texas toast, chocolate cake with vanilla icing, and beverage of choice. A menu substitution sheet documented the following: a. undated entry: cheese burgers were served instead of beans and ham b. undated entry: corn bread was served instead of biscuits c. undated entry: cheese sticks were served instead of crackers d. 12/22/23: Salisbury steaks were served instead of fish e. 12/24/23: grilled chicken was served instead of fried chicken f. 01/01/24: shrimp was served instead of beans an ham…

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

Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature and was palatable. The ADON identified 35 of 37 residents received nutrition from the kitchen. Findings: A facility menu for Wednesday 23-24 5 week - week 1 documented the lunch was barbeque pork, baked potato, sliced zucchini, Texas toast, chocolate cake with vanilla icing and beverage of choice. On 01/03/23 at 11:56 a.m., lunch preparation and service was observed. On 01/03/23 at 12:17 p.m., [NAME] #1 was observed removing a cake from the oven. The cook stated the cake mix was biscuit mix. They directed cook #3 to put honey on top and serve it. On 01/03/23 at 12:35 p.m., the trays for the hall left the kitchen. On 01/03/23 at 12:50 p.m., the last resident tray was delivered on the hall. A test tray was removed from the cart. On 01/03/23 at 12:52 p.m., the test tray was observed with barbeque pork, steamed zucchini, sweet potato fries, and a cake. The pork was 89.9 F, the zucchini was 92.1 F, the sweet potato fries were 90.9 F. The food on the plate was cold upon tasting.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were conducted for six (#31, 32, 81, 82, 131, and #182) of 24 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form, dated 07/06/23, identified 45 residents resided in the facility. Findings: 1. Resident #31 was admitted to the facility on [DATE]. The MDS Scheduling Report, dated 07/17/23, read in part, .Comprehensive due .ARD: 4/23/2023 Complete by 4/23/2023 85 days overdue . Review of the electronic clinical record did not reveal an admission assessment had been completed and the entry assessment was export ready. 2. Resident #32 was admitted to the facility on [DATE]. The MDS Scheduling Report, dated 07/17/23, read in part, .Comprehensive due .ARD: 4/20/2023 Complete by 4/20/2023 88 days overdue . Review of the electronic clinical record did not reveal an admission assessment had been completed and the entry assessment was export ready. 3. Resident #81 was admitted 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 record review and interview, the facility failed to ensure quarterly assessments were completed and submitted for five (#6, 9, 14, 29, and #30) of 24 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form, dated 07/06/23, documented 45 residents resided in the facility. Findings: 1. Resident #6 had diagnoses which included end stage renal disease. The MDS 3.0 Assessment History Report, dated 07/17/23, read in part, .04/28/23 .In Progress .Quarterly . 2. Resident #9 had diagnoses which included dementia. The MDS 3.0 Assessment History Report, dated 07/17/23, read in part, .04/28/23 .In Progress .Quarterly . 3. Resident #14 had diagnoses which included chronic obstructive pulmonary disease. The MDS 3.0 Assessment History Report, dated 07/17/23, read in part, .04/28/23 .In Progress .Quarterly . 4. Resident #29 had diagnoses which included dementia. The MDS Scheduling Report, dated 07/17/23, read in part, .Quarterly due .ARD .5/26/2023 .Complete by 6/9/2023 .38 days overdue. 5. Resident #30 had diagnoses which 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 record review and interview, the facility failed to complete a base line care plan within the required 48 hour time frame for three (#82, 92, and #96) of three sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 07/06/23, documented 45 residents resided in the facility. Findings: The Baseline Care Plan policy, dated 05/24/22, read in part, .The facility will develop and implement a baseline care plan for each resident .The baseline care plan will .Be developed within 48 hours of a resident's admission . 1. Resident #82 was admitted to the facility on [DATE]. Review of the clinical record did not reveal a baseline care plan had been completed. 2. Resident #92 was admitted to the facility on [DATE]. Review of the clinical record did not reveal a baseline care plan had been completed. 3. Resident #96 was admitted to the facility on [DATE]. Review of the clinical record did not reveal a baseline care plan had been completed. On 07/17/23 at 5:55…

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 free of a significant medication error for one (#32) of five residents reviewed for significant medication errors. The Resident Census and Conditions of Residents form documented 45 residents received medication. Findings: Resident #32 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, traumatic brain injury, schizophrenia unspecified, major depressive disorder, and anxiety disorder. A physician order, dated 05/21/23, documented to administer Haldol Decanoate 100 mg and 50 mg IM every 28 days. A progress note, dated 05/19/23, documented the medication was not available and the pharmacy had been notified. The MAR, dated May 2023, documented Haldol Decanoate was administered on 05/22/23. The MAR, dated June 2023, documented the medication was due on 06/19/23 but had not been administered. A risk management report, dated 06/28/23, documented resident #32 hit resident #31. The anger and hitting were not preceded by any other altercation. 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 record review and interview, the facility failed to ensure lab tests were completed as ordered by the physician for two (#14 and #21) of five sampled residents whose labs were reviewed. The Regional Director of Operations identified 45 residents who had physician orders for lab services. Findings: 1. Resident #14 had diagnoses which included diabetes mellitus. A physician order, dated 06/19/19, read in part, .CHECK CBC .q 6 MONTHS .TSH YEARLY . A physician order, dated 04/02/21, read in part, .A1C Q 6 MONTHS . Review of the clinical record revealed the last CBC and A1C completed was on 06/08/22. On 07/17/23 at 1:28 p.m., the DON was asked how often Resident #14 was to have labs completed. They stated they would check the clinical record. On 07/17/23 at 1:57 p.m., the DON provided lab results from 2022 and 2023 and stated the A1C was ordered every three months, some labs were ordered every six months, and some were yearly. The DON stated labs had not been completed as ordered by the physician. The provided lab results did not reveal a TSH had been completed. The DON 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 be administered effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administration failed to ensure: a. residents were free from physical abuse and neglect. b. a safe, functional, sanitary, comfortable environment was provided. c. comprehensive assessments were completed within 14 days of admission. d. quarterly assessments were completed every three months. e. base line care plans were completed on admission. f. prepared meals were of adequate portion size, palatable, and met resident preference. g. sufficient nutritional intake to maintain health and weights. h. infection were tracked and analyzed for trend routinely. i. the facility assessment was updated with changes in resident care needs. j. resident funds were conveyed for discharged residents. k. resident to resident abuse incidents were reported to OSDH in the required time frame. l.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the facility assessment was updated yearly and reflected the resources necessary to meet the needs for the residents. The Resident Census and Conditions of Residents report, dated 07/06/23, documented 45 residents resided in the facility, one resident received dialysis, and one resident had a tracheostomy. Findings: The Facility Assessment, dated 05/31/22, documented the facility did not have any residents who received dialysis or had a tracheostomy. Resident #6 was admitted on [DATE], had diagnoses which included end stage renal disease, and required dialysis. Resident #92 was admitted on [DATE], had diagnoses which included acute respiratory failure with hypoxia, and had a tracheostomy. On 07/07/23 at 4:43 p.m., the administrator stated the facility's resident population and their needs, related to mental illness, had changed since new ownership in April 2023. The administrator was asked when the facility assessment had last been updated 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 record review and interview, the facility failed to develop and implement plans to correct or improve identified concerns with resident care. The Resident Census and Conditions of Residents form, dated 07/06/23, documented 45 residents resided at the facility. Findings: The Quality Assurance and Performance Improvement policy, dated 08/05/22, read in part, .These policies are intended to ensure the facility develops a plan that that [sic] describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement . On 07/17/23 at 6:29 p.m., the administrator was asked, if prior to the survey, the facility had identified a concern regarding resident to resident abuse. They stated incidents were discussed each morning during a meeting. They stated they had not implemented anything except they had psychiatric services in place and undocumented one on one. The administrator was asked, if prior to the survey, the facility had identified a concern regarding significant/severe weight loss. They stated…

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 QA committee met at least quarterly. The Resident Census and Conditions of Residents form, dated 07/06/23, identified 45 residents who resided in the facility. Findings: The QAA Committee policy, dated 08/05/22, read in part, .The committee must .Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program . On 07/17/23 at 6:29 p.m., the administrator was asked when the last QA meeting had been conducted. They stated in March 2023. They stated the Medical Director had just completed reviewing the March 2023 QA information. They stated they typically held QA meeting monthly but the physician or the DON had lost the information they had compiled for the QA meetings.

Based on record review and interview, the facility failed to ensure infections were tracked and data was analyzed to determine trends for ten (August 2022 through June 2023) of 12 months reviewed for infection monitoring. The Resident Census and Conditions of Residents form, dated 07/06/23, identified 45 residents resided in the facility. Findings: The Infection Control, General policy, dated 08/05/22, read in part, .Surveillance reports will include infection .data and process measure data .to the director of nursing and medical director on a monthly basis. Reports will also be reviewed by the Quality Assurance and Advisory Committee . The Antibiotic Usage Reports, dated August 2022 and September 2022, documented the name of the resident and type of infection. The Antibiotic Usage Reports, dated October 2022 and November 2022, documented the name of the resident, type of infection, and what antibiotic was ordered. The Antibiotic Usage Report, dated December 2022, documented the name of the resident and type of infection. The Antibiotic Usage Report, dated January 2023, documented…

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 a safe, functional, sanitary environment for three (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of three resident rooms observed on the [NAME] hall, one (the [NAME] hall) of four halls observed, one (the MDS office) of one office observed, and one (West hall lobby) of three common areas/lobbies observed. The Resident Census and Conditions of Residents form, dated 07/06/23, documented 45 residents resided in the facility. Findings: The Safe Environment policy, dated 08/10/22, read in part, .It is the policy of the facility to provide safe environment, in accordance with State and Federal Regulations . On 07/07/23 at 9:11 a.m., the [NAME] hall, outside of the MDS office, was observed to have a tan-discolored area approximately 12 inches long and six inches wide. On 07/07/23 at 9:19 a.m., the MDS office was observed with a bath blanket in the floor by the doorway. On 07/07/23 at 10:53 a.m., the MDS coordinator 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 record review and interview, the facility failed to ensure conveyance of personal funds within 30 days of discharge/death for two (#95 and #99) of three sampled residents who were reviewed for personal funds. The Regional Director of Operations identified eight residents who had been discharged /expired in the past three months who were in the trust account. Findings: 1. Resident #95 was discharged from the facility on [DATE]. The Trust Current Account Balance form, dated [DATE], documented the resident had a balance of $1,598.44. 2. Resident #99 was discharged from the facility on [DATE]. The Trust Current Account Balance form, dated [DATE], documented the resident had a balance of $2926.31. On [DATE] at 12:30 p.m., the business office manager was asked who was responsible to ensure personal funds were conveyed within 30 days of discharge/death. They stated if they were aware a resident had been discharged or expired they would ensure the funds were conveyed. They were asked why the personal funds 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 that an allegation of abuse was reported to OSDH for one (#31) of three sampled residents reviewed for allegations of abuse. The Resident Census and Conditions of Residents form, dated 07/06/23, documented 45 residents resided in the facility. Findings: An undated form titled, Abuse Policy and Procedure, documented in part, .We will endeavor to protect our occupants from maltreatment, which means .physical abuse .It recognizes resident rights to be free from physical or mental abuse .All allegations of resident maltreatment, including .abuse .shall be promptly reported to Administrator and investigated by the Facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the Local Police . Resident #31 has diagnoses which include MERRF, (a multisystem mitochondrial syndrome characterized by progressive myoclonus and seizures). The resident is 5'11 and weighs 124 lbs. The resident is non ambulatory and uses a wheelchair. Resident #32 has diagnoses which…

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 transportation to dialysis for one (#6) of one sampled resident reviewed for dialysis services. The Resident Census and Condition form, dated 07/03/23, documented one resident for dialysis treatment. Findings: An undated policy tilted Nursing Home Dialysis Transfer Agreement, read in part, .Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident .Facility shall be responsible for, and shall provide the necessary personnel for, assisting the Designated Resident in entering into and exiting from Center Resident #6 had diagnoses which include end stage renal disease. A physician order, dated 03/13/23, read in part, dialysis .every Monday Wednesday and Friday . The TAR documented the resident did not have dialysis on 4/28/23, 05/10/23, 05/17/23, or 07/03/23. On 07/17/23 at 01:29 p.m., the DON stated the resident goes in the transport van, 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.