Emerald Care Center Claremore

Based on record review and interview, the facility failed to ensure a resident was not physically restrained for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, The facility must ensure the resident is free of from physical or chemical restraints imposed for the purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. Resident #2 Resident #2 had diagnoses which included vascular dementia. An Incident Report Form, dated 11/09/24, documented LPN #1 had allegedly forced Resident #2 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined LPN #1 had physically restrained Resident #2's arms while attempting to administer medications to the resident. The document stated the facility staff determined the incident had occurred and LPN #1's employment had been terminated. 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 a chemical restraint was not used to keep a resident from repeatedly standing from their wheelchair for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, The facility must ensure the resident is free of from physical or chemical restraints imposed for the purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. 1. Resident #1 had diagnoses which included Alzheimer's disease. A narcotic count sheet for lorazepam (antianxiety medication) 2 ml syringes for Resident #2, documented CMA #2 signed out one syringe of the medication on 11/08/24 at 6:00 p.m. An Incident Report Form, dated 11/09/24, documented LPN #1 had allegedly forced Resident #2 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined 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 record review and interview, the facility failed to ensure an employee reported an allegation of abuse in the mandated time frame for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not late than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through…

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 one (#3) of three sampled residents reviewed for pressure ulcers. The administrator identied 103 residents resided in the facility. Findings: A facility policy titled Care Plan Process, revised 9/2019, read in part, The plan of care must describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and social well-being .Purpose .To ensure a care plan will be developed that is appropriate for each resident's needs and/or wishes based on assessment and reassessment. Resident #3 has diagnoses which included a pressure ulcer to the sacral region and hypertension. A physician order, dated 11/13/24, documented Resident #3 was to receive wound care to the coccyx/sacrum three times a week. A quarterly assessment, dated 11/20/24, documented Resident #3 had an unstageable pressure ulcer. On 11/26/24 at 11:15 a.m., a pressure ulcer was observed on Resident #3's sacrum. A review of Resident #3's care plan did…

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 catheter bags were not on the floor for one (# 2) of four sampled residents reviewed for catheters. The roster matrix, date printed 11/15/24, documented nine residents in the facility had catheters. Findings: Resident #12 had diagnoses which included obstructive and reflux uropathy. A quarterly assessment, dated 09/09/24, documented Resident #12 had an indwelling urinary catheter. On 11/25/24 at 1:50 p.m., Resident #12 was observed seated in a recliner. Their catheter bag was observed on the floor next to the recliner. On 11/26/24 at 10:30 a.m., Resident #12 was observed seated in a recliner. Their catheter bag was observed on the floor next to the recliner. On 11/26/24 at 12:35 p.m., RN #1 stated catheter bags should not be on the ground. On 11/26/24 at 12:45 p.m., the ADON stated catheter bags should not be allowed to touch the floor.

Based on record review and interview, the facility failed to notify a resident's representative when a new antipsychotic medication had been ordered for one (#3) of five sampled residents reviewed for notifications of change. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A facility policy titled Notification of Change Policy, dated 05/2017, read in part, It is the policy of this facility that changes is resident's condition or treatments are immediately shared with the resident and/or the resident's representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Resident #3 had diagnoses which included delusional disorder. A physician's medication order, dated 01/11/24, documented Resident #3 was to be administered risperidone (antipsychotic medication) 0.5 mg tablet by mouth at bedtime for delusional disorder. The order was documented as discontinued on 06/13/24. A physician's medication order, dated 06/14/24, documented Resident #3 was to be…

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 conduct a thorough investigation into a missing container of narcotic pain medications. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A facility policy titled Controlled Medication - Ordering and Receipt, dated 2001, documented medications were to be checked upon arrival to ensure all medications on the packing slip were received. A pharmacy manifest, dated 08/23/24, documented 168 tablets of Oxycodone/APAP (pain medication) 10-325 mg was delivered to the facility and represented a 28-day supply of the medication. The manifest was signed by facility nurse LPN #1. On 10/14/24 at 11:23 a.m., the ADON stated they had investigated 60 unaccounted for Oxycodone/APAP 10-325 mg tablets. They stated they had attempted to reorder the medication on 09/13/24 and were informed by the pharmacy that it was too soon to reorder. They stated that was when they realized there were missing pills. They stated they attempted to contact LPN #1 since that time, but they had not returned…

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

Based on record review and interview, the facility failed to assess and promptly treat a resident following an unobserved fall for one (#6) of two sampled residents reviewed for falls. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: Resident #6 had diagnoses which included hemiplegia and hemiparesis. A Falls Management policy and procedure, dated 04/2015, read in part, In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. Remain with the resident while calling for assistance, if at all possible. A progress note, dated 04/15/24 at 10:36 a.m., documented Resident #6 complained of pain in their right hip when they moved their right leg. The note documented the nurse observed the resident's right leg externally rotated and the resident was unable to straighten their leg. It further documented a nurse practitioner was in the building and ordered the resident to be sent to an emergency 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 prevent a medication administration record from erroneously recording a resident received a medication when the medication was not available for administration for one (#3) of six sampled residents reviewed for medication administration. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A MAR, dated 06/01/24 through 06/30/24, documented Resident #3 had been administered Nuplazid (antipsychotic medication) 11 times between 06/14/24 and 06/30/24. A MAR, dated 07/01/24 through 07/31/24, documented Resident #3 had been administered Nuplazid five times between 07/01/24 and 07/26/24. On 10/15/24 at 9:30 a.m., CMA #1 stated they had reviewed the June and July MARs for Resident #3 and found they had documented they had administered Nuplazid to the resident on multiple dates. They stated those entries were in error as that medication had never arrived in the building because of an insurance issue. On 10/15/24 at 9:53 a.m., the ADON stated documents from their contracted pharmacy…

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 scoops were not stored inside the bins of flour and corn starch for two of two bins observed; b. ensure foods stored in the refrigerator were labeled and dated for one of one walk in refrigerators observed; c. ensure the dish machine reached minimum specifications for sanitation for one of one dish machines observed; d. ensure the ice machine was maintained in a sanitary manner for one of two ice machines observed; e. ensure the proper use of hair restraints, including facial hair; f. ensure infection control was maintained when plating meals for one (the noon meal) of one meal service observed; and g. ensure kitchen equipment, surfaces, and floors were maintained in a sanitary manner. The ADON identified 111 residents who received meals from the kitchen. Findings: The Food Preparation Guidelines policy, dated November 2017, read in part, .Food should be protected from contamination while being stored . The Ice Machine and Ice Storage Chests policy, dated January 2024, read in parts, .Ice machines…

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 three (#40, 55, and #64) of 22 sampled residents whose care plans were reviewed. The DON identified 114 residents who resided in the facility. Findings: 1. Resident #40 had diagnoses which included dementia. The significant change assessment, dated 05/02/24, documented the resident was severely impaired in cognition for daily decision making and wandered one to three days during the look back period. On 05/13/24 at 10:04 a.m., Resident #40 was observed to wander, in their wheel chair, on the memory care unit. Resident #40 was observed to be redirected out of another resident's room by staff. 2. Resident #55 had diagnoses which included dementia. The quarterly assessment, dated 04/29/24, documented the resident was severely impaired in cognition for daily decision making. On 05/13/24 at 10:17 a.m., Resident #40 was observed to wander, in their wheel chair, on the memory care unit. 3. Resident #64 had diagnoses which included dementia. The admission assessment,…

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 chemicals/medications were secure on the memory care unit for four (#40, 55, 64, and #98) of four sampled residents who were reviewed for wandering and failed to implement fall interventions for one (#96) of four sampled residents who were reviewed for falls. The ADON identified nine residents who wandered on the memory care unit and 26 residents who experienced falls in the past 30 days. Findings: The MSDS for Lantiseptic (a skin barrier cream), read in part, .Irritating if placed in eyes or if ingested . The MSDS for peri wash, read in part, .Irritating if placed in eyes or if ingested . A Falls Management policy, revised 01/24, read in part, .A Risk Reduction, Falls and Injuries Program will be used to assess residents/patients to determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence . 1. 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 interventions were in place to prevent the unnecessary weight loss of three (#12, 21, #65) of four sampled residents reviewed for food/nutrition. The ADON identified three residents with significant weight loss. Findings: 1. Resident #12 had diagnoses which included morbid obesity and malignant neoplasm of breast. A care plan, dated 04/03/24, documented Resident #12 had a risk for malnutrition and would maintain adequate nutritional and hydration status including stable weight, no signs or symptoms of malnutrition or dehydration through the review date. The care plan documented to develop an activity program that included exercise and mobility, and to offer activities of choice to help divert attention from food. On 01/13/24 at 8:27 p.m., a Nutrition/Dietary Note, read in part, admission nutrition assessment completed. Diet is Regular with variable po intake that is fair overall. Stage 3 pressure ulcer to left heel and unstageable DTI [deep tissue injury] to right heel. Recommend Pro-Heal 30 mL [milliliters] BID…

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 physician was notified of weight loss for two (#12 and #21) of four sampled residents who were reviewed for weight loss. The ADON identified three residents who had significant weight loss. Findings: Resident #12 had diagnoses which included morbid obesity and malignant neoplasm of breast. A care plan, revised 04/03/24, documented Resident #12 had a risk for malnutrition and would maintain adequate nutritional and hydration status including stable weight, no signs or symptoms of malnutrition or dehydration through the review date. The care plan documented to develop an activity program that included exercise and mobility, and to offer activities of choice to help divert attention from food. On 01/13/24 at 8:27 p.m., a Nutrition/Dietary Note, read in part, admission nutrition assessment completed. Diet is Regular with variable po intake that is fair overall. Stage 3 pressure ulcer to left heel and unstageable DTI [deep tissue injury] to 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 adequate staffing to ensure bathing was completed according to resident preferences for two (#73 and #93) of five sampled residents who were reviewed for ADL care. The ADON identified 22 residents who required assistance with bathing. Findings: 1. Resident #73 had diagnoses which included diabetes type two and depression. A quarterly assessment, dated 03/12/24, documented Resident #73 required substantial/maximal assistance of staff for most ADLs and bathing was documented as not applicable. Review of the electronic clinical record and the shower sheets, dated 04/15/24 through 05/15/24, documented Resident #73 had received/was offered four showers out of 13 opportunities. On 05/13/24 at 1:55 p.m., Resident #73 stated they only received one shower per week but wanted more. 2. Resident #93 had diagnoses which included hemiplegia and stoke. A shower sheet, dated 04/01/24, documented I did not have time, I was the only aide for the reason Resident #93's scheduled shower was not completed. A quarterly assessment, 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 record review and interview, the facility failed to ensure adequate monitoring of side effects for residents who received antipsychotic medications for two (#4 and #64) of five sampled residents who were reviewed for unnecessary medications. The ADON identified 20 residents who received an antipsychotic medication. Findings: 1. Resident #64 had diagnoses which included dementia. A physician's order, dated 04/15/24, documented Resident #64 was ordered Olanzapine (an antipsychotic medication) 2.5 mg twice daily. Review of the electronic clinical record not reveal monitoring for side effects related to the use of antipsychotic medication. On 05/17/24 at 11:09 a.m., the DON stated they previously documented side effect monitoring on the MAR/TAR but they removed it because it was the standard of practice to monitor for side effects of medications. They stated they documented in the progress notes if a resident experienced any side effect from any medication. The DON stated they assessed for tardive dyskinesia by conducting an AIMS assessment every 90 days. They stated the charge…

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 dental needs were provided for two (#6 and #73) of two sampled residents who were reviewed for dental needs. The administrator identified 114 residents resided in the facility. Findings: 1. Resident #66 had diagnoses which included hemiplegia, seizures, and anxiety. A progress note from the dentist, dated 03/07/23, documented the resident should be seen by an oral surgeon to extract a cracked tooth. On 05/14/24 at 10:56 a.m., Resident #66 stated they had a cracked tooth on their right lower jaw which caused pain while eating. On 05/17/24 at 9:28 a.m., the social services director stated they had not seen a dental referral for Resident #66 to see an oral surgeon. They stated they did not know if the appointment had been made since they were recently employed by the facility. On 05/17/24 at 9:30 a.m., the DON stated the charge nurse should give the information for a referral to the receptionist, who would then make the appointment and transportation arrangements. The DON stated ultimately it was their responsibility…

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 provided in a palatable and attractive manner. The ADON identified 112 residents who ate food from the kitchen. Findings: On 05/13/24 at 1:42 p.m., Resident #73 stated the food was cold. On 05/14/24 at 2:00 p.m., Resident #96 stated the food was delivered cold to their room. On 05/17/24 at 8:31 a.m., CNA #5 delivered styrofoam drinks to burgandy hall, uncovered, and placed on drink cart. The drinks were milk. On 05/17/24 at 9:09 a.m., a meal cart arrived on burgandy hall. On 05/17/24 at 9:10 a.m., staff began to pass meal trays on burgandy hall. On 05/17/24 at 9:11 a.m., meals were observed to be served on styrofoam plates with plastic covers and no heated bottoms. The milk on drink cart was observed to be uncovered and not on ice. Staff delivered the milk with the food to residents. On 05/17/24 at 9:14 a.m., the meal cart was observed to be left open during meal pass. The staff were not observed to sanitize hands between passing trays. On 05/17/24 at 9:17 a.m., a cleaning cart was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an effective pest control program in resident rooms, the dining room, and the kitchen. The DON identified 114 residents who resided in the facility. Findings: The Pest Control Program policy, dated January 2024, read in part, .Facility will maintain an effective pest control program that eradicates and contains common household pests . The Maintenance Request Log, dated 03/06/24, documented Resident #7 complained there had been a roach in their bed and pest control was contacted. The Maintenance Request Log, dated 03/10/24, documented roaches were observed in room [ROOM NUMBER] and pest control was contacted. The Maintenance Request Log, dated 03/30/24, documented ants in room [ROOM NUMBER]. The response was documented as done. The Maintenance Request Log, dated 03/31/24, documented ants in room [ROOM NUMBER]. The response was documented as done. The Maintenance Request Log, dated 03/31/24, documented ants in room [ROOM NUMBER] and…

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

Based on observation, record review, and interview, the facility failed to ensure staff provided dignity with dining for residents who required assistance with meals for two (morning and noon meal) of two meals observed for dining. The ADON identified 13 residents who were dependent on staff for eating. Findings: 1. Resident #65 had diagnoses which included Alzheimer's disease. The quarterly assessment, dated 04/09/24, documented the resident was severely impaired in cognition for daily decision making and required supervision/touch assist of staff for eating. On 05/13/24 at 9:33 a.m., CNA #1 was observed to stand and assist Resident #65 with the morning meal. 2. Resident #7 had diagnoses which included aphasia. The quarterly assessment, dated 03/13/24, documented the resident was severely impaired in cognition for daily decision making and was dependent on staff for eating. On 05/13/24 at 12:32 p.m., CNA #2 was observed to stand and assist Resident #7 with the noon meal. On 05/17/24 at 10:01 a.m., CNA #1 stated they had not sat to assist Resident #65 with their meal because there…

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 residents were safe to self-administer medication for two (#22 and #31) of two sampled residents who were reviewed for self-administering medication. The administrator identified 114 residents resided in the facility. Findings: An undated policy titled Bedside Storage of Medications, read in part, .A written order for the bedside storage of medication is placed in the resident's medical record .Lockable drawers or cabinets are required . 1. Resident #22 was admitted to the facility with diagnoses which included dementia. On 05/13/24 at 9:43 a.m., a bottle of medicated powder was observed on the resident's night stand. The label on the medicated powder documented to keep out of reach of children. On 05/13/24 at 11:00 a.m., the DON stated the medicated powder was to be secured and not kept at the resident's bedside for self-administration. On 05/17/24 at 2:49 p.m., LPN #1 stated the resident did not have an order for medicated powder and did not know where the powder came from. LPN #1 stated when they…

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 an accurate code status was documented for one (#67) and residents were offered the choice to formulate an advanced directive for one (#96) of two sampled residents reviewed for advanced directives. The administrator reported 112 residents resided in the facility. Findings: A policy titled Advance Directive Policy and Procedure, dated [DATE], read in part It is the policy of the facility to establish, implement and maintain written policies and procedures for advance directive .The resident has the right and the facility will assist the resident to formulate an advance directive at their option .The facility will inform and provide resident with a written description of the facility's policy to implement advance directives .Resident has the right to accept, request, refuse and/or discontinue medical and surgical treatment and to participate in or refuse to participate in experimental research .Resident choices will be incorporated into…

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 ADLs were provided according to the care plan for two (#73 and #93) of two sampled residents for ADLs. The ADON identified 22 residents who required assistance with bathing. Findings: 1. Resident #73 had diagnoses which included diabetes type two and depression. An annual assessment, dated 09/24/23, documented Resident #73 required physical help of one person for bathing. A quarterly assessment, dated 03/12/24, documented Resident #73 bathing as not applicable, dressing required maximum assistance and for toileting Resident #73 was dependent for assistance. Review of the electronic clinical record and the shower sheets, dated 04/15/24 through 05/15/24, documented Resident #73 had received/four showers out of 13 opportunities. On 05/13/24 at 1:55 p.m., Resident #73 stated they only received one shower per week, but wanted more. On 05/16/24 at 3:21 p.m., CNA #4 stated showers were offered every other day, but did not know when the last shower was offered. On 05/16/24 at 3:26 p.m., LPN #4 stated 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 record review and interview, the facility failed to ensure appointments were scheduled for one (#73) of one resident sampled for vision appointments. The ADON identified 114 residents resided at the facility. Findings: Resident #73 had diagnoses which included diabetes type two, nicotine dependence, and hypertension. On 02/28/23 at 4:21 p.m., a social services note, documented Resident #73 had requested an eye and dental appointment through the [name removed] clinic. The note documented social services had provided the request to the receptionist to schedule the appointment and arrange transportation. On 05/13/24 at 1:54 p.m., Resident #73 stated they had not seen an eye doctor since admission. On 05/17/24 at 9:28 a.m., the social services director stated they were responsible for ensuring appointments were arranged. On 05/17/24 at 9:29 a.m., the DON stated the nurse on duty enters the order in the electronic record and provides the request to the receptionist to arrange the appointments. They stated it was ultimately their responsibility to see that it as followed through.

Based on observation, record review, and interview, the facility failed to ensure pureed food was prepared to meet the needs of the resident for one (the noon meal) of one meal observed during meal preparation. The ADON identified five residents who received a puree diet. Findings: The Therapeutic Diet Orders policy, dated January 2024, read in part, .To assure that residents receive and consume foods in the appropriate form . On 05/14/24 at 11:52 a.m., dietary aide #3 was observed to puree the noon meal. The taco meat was observed to be grainy and have pieces of meat which remained after it was pureed. The flour tortillas were observed to be lumpy and have chewable pieces of tortilla which remained after it was pureed. The pureed taco meat and the pureed tortillas were not a smooth consistency and were placed on the steam table for serving. On 05/14/24 at 12:19 p.m., dietary aide #1 plated a pureed diet for Resident #22 and placed it on the hall cart. On 05/14/24 at 12:23 p.m., dietary aide #5 began wheeling the meal cart out of the kitchen for service. Dietary aide #1 and 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 garbage cans were available at the handwashing sink and garbage cans had lids in the kitchen. The ADON identified 111 residents who received meals from the kitchen. Findings: The Disposal of Garbage and Refuse policy, dated January 2024, read in part, .Garbage should be disposed of in refuse containers, which have plastic liners and lids . The Nutrition Services Visit, dated 03/02/24, read in parts, .Areas for Corrective Action .No lids on large trash cans .Action Plan .Keep lids on all trash cans . The Nutrition Services Visit, dated 04/02/24, read in parts, .Areas for Corrective Action .No lids on large trash cans .Action Plan .Keep lids on all trash cans . On 05/13/24 at 8:29 a.m., a garbage can was not observed to be at the handwashing sink. Three large barrel-type garbage cans, without lids, were observed across from the handwashing sink near the stove, at the service line, and in the food preparation area. On 05/14/24 at 11:50 a.m., a garbage can was not observed to be at the handwashing sink.…

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 follow infection control practices during wound care for four (#4, 6, 7, and #8) of five sampled residents whose wound care was observed. The administrator identified 106 residents resided in the facility. Twenty-three residents received wound treatments. Findings: 1. Resident #8 had diagnoses that included MASD to sacrum. A physicians' order, dated 04/16/24, documented treatment order to cleanse with NS, pat dry, and apply clotrimazole cream then zinc and large foam dressing daily. On 04/29/24 at 4:12 p.m., RN #1 was observed during wound care for Resident #8. Resident #8's wound had no dressing on it when we arrived at their bedside. When cleaning the wound RN #1 wiped back and forth around the area of skin breakdown five times using the same gauze soaked in NS. 2. Resident #4 had diagnoses that included stage 2 pressure ulcer to sacrum A physicians' order, dated 04/11/24, documented treatment order to cleanse with NS, pat dry, and apply calcium alginate and Medi honey with foam bandage daily. On 04/29/24 at 4:15 p.m., RN…

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 update the care plan with significant changes in condition for one (#2) of five sampled residents whose care plans were reviewed. The Administrator identified 106 residents resided in the facility. Findings: A 'Care Plan Process' policy, revised 09/2019, read in parts, .Responsibilities of the Interdisciplinary Team .complete a care plan review after each PPS Assessment for Managed Care residents to ensure the care plan is updated as the resident's status changes . Resident #2 had diagnoses that included senile degeneration of the brain and dementia. A physician's order, dated 11/06/23, documented Resident #2 was to receive a regular diet, pureed texture and thin consistency. A Significant Change MDS assessment, dated 11/19/23, documented Resident #2 required a mechanically altered diet and Hospice care. A physician's order, dated 12/12/23, documented Resident #2 was to be admitted to hospice as of 11/06/23 with diagnoses of senile degeneration. A review of Resident #2's care plan did not show it had 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 observation and interview, the facility failed to follow enhanced barrier precautions during wound care for two (#4 and #8) of five sampled residents whose wound care was observed. The administrator identified 106 residents resided in the facility. Twenty-three residents received wound treatments. Findings: 1. Resident #8 had diagnoses that included MASD to sacrum. On 04/29/24 at 4:12 p.m., RN #1 was observed during wound care for Resident #8. 2. Resident #4 had diagnoses that included stage 2 pressure ulcer to sacrum On 04/29/24 at 4:15 p.m., RN #1 was observed during wound care for Resident #4. RN #1 did not don a gown before providing wound care to Resident #4 nor Resident #8. On 04/29/24 at 4:45 p.m., RN #1 was asked when enhanced barrier precautions were used according to facility policy. They stated when providing direct care to residents with catheters, drains, PEG tubes, or IV's and when providing wound care. RN #1 was informed of the observations made during dressing changes for Resident #4 and #8. They acknowledged they had not followed facility policy 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, observation, and interview, the facility failed to ensure sufficient staff to meet the resident needs for five(#18, 23, 64, 86, and #161) of five residents reviewed for sufficient staffing. The Resident Census and Conditions of Residents report documented 111 residents resided at the facility. Findings: Resident #18 admitted with diagnoses which included major depression. Review of the shower task for Resident #18 revealed four showers that were documented as not applicable. Resident #18 was scheduled for showers on Tuesday, Thursday, and Saturday evening. On 03/28/23 at 3:33 p.m., Resident #23 stated they wait long enough for their call light to be answered, they go out to the hall or nurses station to get someone. On 03/28/23 at 4:16 p.m., Resident #86 stated they feel like the facility needed more staff. On 03/29/23 at 10:31 a.m., Resident #64 stated call lights take a bit because the facility is short staffed. Resident #64 stated they take water pills and if they feel it is taking too long they call the nurses desk on the phone and they come. Resident #64…

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. arbitration agreements contained clear language to indicate the resident or their representative were not required to sign the agreement as a condition of admission; and b. failed to ensure the arbitration agreement granted the resident or their representative the right to revoke the agreement within 30 calendar days of signing for three (#84, #98, and #106) of three residents reviewed for arbitration agreements. The administrator identified 34 residents who resided at the facility had entered into binding arbitration agreements since 09/16/19. Findings: A copy of the facility's, Voluntary Arbitration Agreement, provided by the administrator, read in parts, .Please know you can choose care at another facility if you do not wish to sign .This Voluntary Agreement to Arbitrate may be revoked within 30 days after being signed. Otherwise, this Agreement will be given full force and effect .This Agreement may be revoked by written notice delivered…

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 arbitration agreements provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue that is convenient to both parties for three (#84, #98, and #106) of three residents who were reviewed for arbitration agreements. The administrator identified 34 residents who resided at the facility had entered into binding arbitration agreements since 09/16/19. Findings: A copy of the Voluntary Arbitration Agreement, provided by the administrator, read in parts, .Place of Arbitration: The seat or place of arbitration shall be the State and Country where Facility that provided care to the Resident is located . 1. Resident #84 was admitted to the facility on [DATE]. Review of the clinical record revealed a Voluntary Arbitration Agreement had been signed by the resident's representative on 02/17/23. The signature page of the agreement had been scanned into the electronic clinical record with the admission packet.…

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 provide education and offer pneumonia vaccinations for four (#23, #33, #50, and #66) of five residents reviewed for pneumonia vaccinations. The Resident Census and Conditions of Residents report identified 111 residents who resided in the facility. Findings: The undated Pneumococcal Vaccine policy, read in parts, .It is our policy to offer our residents .immunization against pneumococcal disease .The resident's medical record shall include documentation .The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization .The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal . 1. Resident #23 had diagnoses which included diabetes mellitus. The quarterly assessment, dated 03/20/23, documented the resident's pneumonia vaccination was not up to date. Review of the Immunization Report did not reveal documentation the pneumonia vaccination had been provided. Review of the clinical record did…

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 education was provided and declinations were documented for the COVID vaccine for three (#42, #56, and #87) of five residents reviewed for COVID vaccinations. The Resident Census and Conditions of Residents report identified 111 residents resided in the facility. Findings: 1. Resident #42 had diagnoses which included hypertension. Review of the Immunization Report revealed the resident had refused the COVID vaccination. No date of refusal was provided. Review of the clinical record did not reveal education had been provided regarding the vaccine or a signed declination. 2. Resident #56 had diagnoses which included hypertension. Review of the Immunization Report revealed the resident had refused the COVID vaccination. No date of refusal was provided. Review of the clinical record did not reveal education had been provided regarding the vaccine or a signed declination. 3. Resident #87 had diagnoses which included diabetes mellitus. Review of the Immunization Report revealed the resident had refused the COVID…

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 significant change assessment was completed timely for one (#94) of one residents reviewed for hospice and end of life. The Resident Census and Conditions of Residents report identified 16 residents who were on hospice services. Findings: Resident #94 admitted with diagnoses which included Huntington's Disease. A Physician's Order, dated 01/24/23, documented Emerald hospice to eval and treat. The Emerald Hospice plan of care documented Resident #94 was admitted to hospice care and services for a diagnosis of Huntington's Disease. A significant change assessment, dated 03/21/23, documented Resident #94 elected the hospice benefit. A significant change assessment was due 14 days after Resident #94 was admitted to hospice care on 01/24/23. On 04/03/23 at 3:54 p.m., the MDS coordinator was asked if the significant change assessment was completed timely when Resident #94 elected the hospice benefit. They stated no.

Based on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed and documented for one (#11) of one residents who were reviewed for dialysis. The Resident Census and Conditions of Residents report identified five residents who received dialysis. Findings: The undated Dialysis Care policy, read in parts, .All residents receiving dialysis will be assessed before and after dialysis treatment and for compliance with their individualized plan of care .All residents receiving dialysis treatment will have their access site assessed every shift. Assessment includes the following: Check bruit and thrill [the sound and feel of blood flowing through the dialysis port] . Resident #11 had diagnoses which included end stage renal disease. The annual assessment, dated 03/07/23, documented the resident received dialysis. The Care Plan, revised 03/16/23, documented the resident received dialysis three days a week, to evaluate the resident pre and post dialysis, to fill out pre and post dialysis evaluations, and observe for bruit at dialysis port.…

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 nurse staffing was posted for residents and visitors to see. The Resident Census and Conditions of Residents report documented 111 residents resided at the facility. Findings: On 03/28/23 at 1:30 p.m., nurse staffing was observed to not be posted. The LPN at the desk was asked where the schedule for staffing was located. They provided a book that was kept behind the counter of the nursing station. The schedule book did not provide the census every day. Several days had staff names marked through and changes to staffing were unclear. On 04/04/23 at 10:00 a.m., The DON was asked where the nurse staffing was posted for residents and visitors to see. They stated the only thing they had was the staffing book. The DON was asked if it were always available to residents and visitors. They stated no, sometimes it is in the office.

Based on record review, observations, and interview the facility failed to ensure a medication error rate of less than 5%. Two medication errors were made out of 25 opportunites observed. This created a medication error of 8%. The administrator identified 109 residents received medications. Findings: Resident #94 admitted with diagnoses which included Huntington's Disease. A Physician's Order, dated 06/22/22 to start 06/23/22, documented to administer one tablet of clonazepam (a benzodiazepine for anxiety) 1 mg by mouth three times a day. A Physician's Order, dated 01/27/23 to start 01/28/23, documented to administer one tablet of metoclopramid (an anti-nausea medication) 5 mg by mouth before meals and at the hour of sleep. On 04/03/23 at 4:36 p.m., CMA #2 prepared clonazepam and metoclopramid for Resident #94. CMA #2 popped the medications into a medication cup and proceeded to knock on Resident #94's door. CMA #2 stated the resident must be in the dining room and went to the dining room where they identified Resident #94. CMA #2 attempted to administer the medications. 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 follow-up procedures/tests were completed as ordered for one (#23) of three residents who were reviewed for falls. The Resident Census and Conditions of Residents reprot identified 111 residents resided in the facility. Findings: Resident #23 had diagnoses which included muscle weakness. A nurse's note, dated 01/27/23, documented the resident had hit their head when they had fallen and was sent to the hospital for evaluation. A nurse's note, dated 01/30/23, documented the resident returned from the hospital. A physician progress note, dated 01/31/23, documented the resident had a small left basal ganglia hemorrhage. A nurse's note, dated 02/01/23, documented the resident had an appointment for a CT which was rescheduled to 02/13/23 at 1:30 p.m. due to road conditions. The Order Summary Report, documented an order, dated 02/08/23, for a repeat CT of the head to be completed on 02/13/23. A physician progress note, dated 03/07/23, read in part, .still needs repeat head CT . Review of the clinical record did not reveal…

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.