Edmond Health Care Center

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of abuse/mistreatment for 1 (#2) of 3 sampled residents reviewed for abuse.Administrator #1 identified 80 residents resided in the facility.Findings:An Abuse Investigation and Reporting policy, revised 07/2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.An undated facesheet for Resident #2 showed diagnoses of dehiscence of wound of abdominal wall and acute kidney…

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 place a call light within reach of a resident for 1 (#1) of 1 sampled resident who was observed for call lights.Administrator #1 identified 80 residents resided in the facility.Findings:On 07/23/25 at 2:35 p.m., Resident #1's call light was observed nearest the head of bed laying on top of a pillow. Resident #1 was observed in their Geri-chair approximately two feet away from the bed.An Answering the Call Light policy and procedure, revised 03/2021, read in part, The purpose of this procedure is to ensure timely response to the resident's request and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.A quarterly resident assessment, dated 05/17/25, showed Resident #2 was cognitively intact.An undated care plan for Resident #1 showed the resident had diagnoses which included post traumatic disorder and quadriplegia.On 07/23/25 at 2:38 p.m., Resident #1 stated they could use the call light if it was clipped to their shirt and placed under 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 record review and interview, the facility failed to ensure residents who received dialysis had pre and post monitoring for 2 (#1 and #3) of 3 sampled residents reviewed for dialysis. The DON identified four residents who received dialysis services resided in the facility. Findings: An undated facility policy titled Dialysis Care/Arterial-Venous Fistula, read in part, All residents receiving dialysis will have monitoring before and after their dialysis treatment to ensure condition is stable after treatment. 1. Resident #1's physician's order, dated 03/31/25, showed scheduled visits to the dialysis center every Tuesday, Thursday, and Saturdays with a chair time of 6:15 a.m. to 10:15 a.m., but to be present at the site at 6:00 a.m. to coordinate care accordingly. Resident #1's admission resident assessment, dated 04/03/25, showed the resident had moderate cognitive impairment with a brief interview for mental status score of 11. A review of 04/2025 dialysis communication forms showed Resident #1 had one completed pre and post monitoring dialysis communication form 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 a resident's legal representative was notified of a resident's refusal to use a c-pap for 1 (#3) of 3 sampled residents reviewed for respiratory care. The administrator identified 72 residents resided in the facility. Findings: Resident #3 had diagnoses which included chronic respiratory failure with hypoxia, bipolar disorder, generalized anxiety, and major depressive disorder. A court ORDER APPOINTING GUARDIAN, dated 04/07/21, showed the Resident #3 had a court appointed guardian. The court appointed guardian was listed on Resident #3's electronic health record as the guardian, power of attorney, and emergency contact. Resident #3's quarterly resident assessment, dated 11/21/24, showed the resident's cognition was intact with a BIMS of 15. A care plan, initiated, 07/12/24, showed Resident #3 often will remove the c-pap once staff has left the room, staff has found it under their bed before where they had tossed/tried to hide it. Staff to encourage them to keep it in place and not remove it. A physician's order,…

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

Based on record review and interview, the facility failed to ensure: a. the results of an abuse/mistreatment investigation were reported to the State Agency within 10 business days for 1 (#2); and b. an allegation of abuse/mistreatment was reported to the appropriate licensing board in a timely manner for 1 (#2) of 3 sampled residents reviewed for timely care and treatment. The administrator identified 72 residents resided in the facility. Findings: The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised 04/2021, read in part, Findings of all investigations are documented and reported. Resident #2 had diagnoses which included altered mental status and quadriplegia. An Initial INCIDENT REPORT FORM, dated 03/03/25, showed an allegation of abuse/mistreatment. The report showed Resident #2 told LPN #1 that they were sick. The report showed Resident #2 vomited on themselves, and LPN #1 refused to clean them up and left them covered in their vomit until the aide on the next shift came in to clean them up. The report showed the appropriate licensing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide ADL care for a dependent resident for one (#3) of three sampled residents reviewed for ADL care. The DON identified 76 residents resided in the facility. Findings: The facility's Bath, Shower/Tub policy, revised 02/2018, read in part, Documentation 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data obtained during the bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). The facility's Activities of Daily Living (ADL), Supporting policy, revised 03/2018, read in part, Appropriate care services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care.) Resident #3 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 add an intervention to a residents care plan to prevent future accidents after a fall for one (#12) of three sampled residents reviewed for accident hazards. The DON identified 76 residents resided in the facility. Findings: The facility's Falls- Clinical Protocol policy, revised 03/2018, read in part, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significance consequences of falling. Resident #12 was admitted [DATE] with diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery, type two diabetes, unspecified, lack of coordination, muscle, weakness, and contusion of right lower leg. Resident #12's annual assessment, dated 5/31/24, documented the resident's cognition was fully intact and required substantial to maximal assistance for chair to bed transfers. The facility's #1420 Witnessed Fall with Injury report, dated 12/29/24,…

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 and interview, the facility failed to ensure call lights were accessible for one (#5) of seven sampled residents reviewed for call lights. The DON identified 82 residents resided in the facility. Findings: A Falling Leaves Fall Prevention Program, dated 08/25/23, read in part, 22. Call lights in reach and in good working order. Res #5 had diagnoses which included heart failure, emphysema, paraplegia and quadriplegia. A physician order, dated 05/07/24, documented falling leaves prevention program. On 09/12/24 at 1:54 p.m., Res #5's call light was not accessible while resting in bed. On 09/12/24 at 1:55 p.m., LPN #1 stated Res #5's call light was supposed to be within reach while resting in bed. On 09/17/24 at 4:12 p.m., Res #5's call light was not in accessible while resting in bed. On 09/17/24 at 4:13 p.m., RN #1 stated Res #5's call light was not within reach. They stated their call light was stuck behind their pillow in their bed.

Based on observation and interview, the facility failed to have an effective pest control for one (#9) of nine sampled residents reviewed for pest control. The DON identified 82 residents resided in the facility. On 09/17/24 at 2:50 p.m., Res #9 was observed with eight flies located on different areas of their body. On 09/17/24 at 2:52 p.m., housekeeping #1 stated there were lots of flies, but they sprayed. On 09/17/24 at 2:56 p.m., CMA #1 stated there had always been a lot of flies on hall 400.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#8) of three sampled residents reviewed for abuse. The Administrator identified 82 residents resided in the facility. Findings: An Abuse and Neglect policy, undated, read in part, .no resident shall be subject to abuse and/or neglect .All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing immediately .Any staff member involved in any incident will report it immediately to his/her supervisor, and a written statement would be obtained through interview about the incident. The Administrator will be the person to notify appropriate agencies .the employee will be suspended pending the investigation . Resident #8 had diagnoses which included quadriplegia, post-traumatic stress disorder, and schizoaffective disorder bipolar type. An Initial State Reportable Incident form, dated 06/02/24, documented an allegation of abuse/mistreatment. It documented the family of Resident #8 observed video footage of CNA #3 cursing and arguing…

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 results of abuse investigations were submitted to the State within five business days for two ( #7 and #8) of three sampled residents reviewed for abuse. The Administrator identified 82 residents resided in the facility. Findings: An Abuse and Neglect policy, undated, read in part, .no resident shall be subject to abuse and/or neglect .All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing immediately .Any staff member involved in any incident will report it immediately to his/her supervisor, and a written statement would be obtained through interview about the incident. The Administrator will be the person to notify appropriate agencies .the employee will be suspended pending the investigation . 1. Resident #7 had diagnoses which included Alzheimer's disease, dysphagia, and anxiety disorder. An Initial State Reportable Incident form, faxed 07/08/24 at 2:10 p.m., documented an allegation of abuse/mistreatment. It documented a family member of Resident #7…

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 utilize a safe transfer technique when transferring a resident who required two-person physical assistance for one (#10) of one sampled resident observed during a transfer. The Administrator identified 82 residents resided in the facility. Findings: A Safe Lifting and Movement of Residents policy, revised 07/17, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Manual lifting of residents shall be eliminated when feasible .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . Resident #10 had diagnoses which included nontraumatic subarachnoid hemorrhage and hemiplegia affecting left nondominant side. Resident #10's Care Plan, initiated on 09/24/23, documented the resident required one to two person assistance with all ADLs due to left sided hemiplegia from a stroke. It…

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 nutritional intake for two (#1 and #2) of three sampled residents reviewed for nutrition. The Administrator identified 82 residents resided in the facility. Findings: A Snacks policy, revised 09/10, read in part, .The purpose of this procedure is to provide the resident with adequate nutrition .Supplements to be offered if meal consumption is less than 50 [percent] .To document supplement - Y - for yes supplement given N .supplement not given .record the following information in the resident's medical record .date and time the snack was served .The amount of snack eaten by resident . 1. Resident #1 had diagnoses which included senile degeneration of the brain, dementia, and Parkinson's disease. Resident #1's Care Plan, revised 03/29/24, documented provide regular diet, document how much is eaten after each meal. A Physician Order, dated 05/20/24, documented Resident #10 had a regular diet regular texture, regular thin consistency. A Quarterly Resident Assessment, dated 06/09/24, documented Resident #1's cognition…

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 medication was swallowed by the resident for one (#1) of one sampled resident observed with a medication on their shirt. The Administrator identified 82 residents resided in the facility. Findings: An Administering Medications policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones . Resident #1 had diagnoses which included senile degeneration of the brain, dementia, constipation, and Parkinson's disease. A Physician Order, dated 05/21/24, documented Colace 100mg give one capsule by mouth one time a day related to constipation. A Quarterly Resident Assessment, dated 06/09/24, documented Resident #1's cognition was moderately impaired. On 08/07/24 at 12:10 p.m., Resident #1 was observed to have a red circular pill on the top of their blue shirt. On 08/07/24 at 12:15 p.m., LPN #1…

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 promote resident dignity by during dining for two (#6 and #21) of four sampled residents reviewed for dignity. The Administrator identified 82 residents resided in the facility. Findings: 1. An admission assessment, dated 05/10/24, documented Res #6's cognition was intact. It was documented the resident had impairment of their upper extremities and required partial to moderate assistance with eating. 2. A quarterly assessment, dated 05/08/24, documented Res #21's cognition was severly impaired. It was documented the resident was understood, was able to understand, and had adequate vision. It was documented the resident required partial to moderate assistance with eating. On 07/08/24 at 8:43 a.m., CNA #1 was observed standing over Res #6 while assisting them with their breakfast meal. On 07/08/24 at 8:47 a.m., Res #21 was observed with their breakfast plate on the table in front of them. They were placed at the same table as Res #6. Res #21 was observed watching CNA #1 assist Res #6 with their breakfast. 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 refer residents with newly evident or possible serious mental illnesses to the OHCA for a level II PASARR evaluation for three (#22, 71 and #8) of four sampled residents reviewed for PASARR's. The Administrator identified 82 residents resided in the facility. Findings: 1. A level I PASARR, dated 12/08/23, documented Res #71 did not have evidence or diagnosis of a serious mental illness. The resident's primary diagnosis was documented as CVA and their secondary diagnosis was documented as dementia. On 04/23/24, the resident had a new diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms. There was no documentation the resident had been referred to the OHCA for a level II PASARR evaluation. On 07/10/24 at 11:31 a.m., MDS Coordinator #1 was made aware the resident had a negative level I pre-screen and was later identified with newly evident of possible serious mental illness. They were asked if the resident was referred to the OHCA for a level II PASARR evaluation. They stated they did not contact…

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

Based on observation, record review, and interview, the facility failed to provide ADL care to dependent residents for two (#26 and #85) of three sampled residents reviewed for ADLs. The Administrator identified 82 residents resided in the facility. Findings: 1. Res #26 had diagnoses which included aphasia, need for assistance with personal care, and flaccid hemiplegia affecting the left dominant side. An annual assessment, dated 05/30/24, documented the resident's speech was not clear, sometimes understood, and usually understands. It was documented the resident required substantial/maximal assistance with personal hygiene. The June 2024 survey report for personal hygiene documented personal hygiene to include combing the resident's hair was not completed six out of 30 opportunities. On 07/08/24 at 7:49 a.m., the resident was observed with a bonnet on their head. On 07/08/24 at 9:31 a.m., the resident was observed without a bonnet on their head. Their hair was not combed. 07/11/23 at 8:56 a.m., the resident was observed without a bonnet on their head. The hair on the back of 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 record review and interview, the facility failed to monitor and document blood pressures as ordered by physician for two (#60 and #189) of 22 sampled residents reviewed for following physician's orders. The Administrator identified 82 residents resided in the facility. Findings: 1. Resident #189 had diagnoses which included anoxic brain damage. A physician order, initiated on 03/21/24, documented the resident was to receive amlodipine 10 mg daily via peg tube. Hold if blood pressure is less than 110/65. March, April, May, June, and July 2024 MARs/TARs were reviewed for blood pressure monitoring. There was no documentation blood pressures had been monitored. On 07/12/24 at 9:45 a.m., the DON stated the medication order initiated 3/21/24 was to be held if BP was less than 110/65. There was no documentation blood pressure had been monitored from 03/21/24 through 04/25/24. There were 34 missing blood pressure entries to ensure blood pressure had been monitored. The DON stated the nurses would be unable to hold the medications appropriately if the blood pressures were 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 food was palatable and served at appetizing temperatures during meals. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: 1. A quarterly assessment, dated 04/11/24, documented Res #1's cognition was intact. On 07/08/24 at 6:09 a.m., the resident was asked how was the food. They stated the food was not warm. 2. A quarterly assessment, dated 06/20/24, documented Res #52's cognition was intact. On 07/08/24 at 7:45 a.m., the resident was asked how was the food. They stated the food was cold. 3. A quarterly assessment, dated 05/15/24, documented the Res #28's cognition was moderately impaired. On 07/08/24 at 8:22 a.m., the resident was asked how was the food. They stated the food was not great. They stated they received a mechanical soft diet and the meat was like mush. 4. A annual assessment, dated 04/20/24, documented Res #55's cognition was intact. On 07/08/24 at 8:37 a.m., the resident…

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

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: On 07/09/24 at 11:20 a.m., a tour of the kitchen was conducted. The following observations were made. a. There was a hole in the wall below the two compartment sink, b. There was black and white residue on the floor and the wall below the dish washer area c. There was a gap between the floor and the wall below the dish washer area, d. Two of two door gaskets were torn on the True two door reach in cooler, e. One of two door gaskets were torn on the True three door reach in freezer, f. Base boards were missing near the microwave rack, g. Grout was missing between the counter tiles on the serve out window, h. Black and white residue was on the floor under the ice machine, i. One of two oven hood lights were burned out and/or not working, j. Plastic lids on bulk dry ingredient containers of oatmeal,…

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

Based on observation, interview, and record review, the facility failed to: a) Place dirty linens in a plastic bag before removing from the res room for 1 (#22) of who were dependent on staff for ADL care, b) Provide environmental cleaning, disinfection, and reprocessing of reusable resident medical equipment for wrist blood pressure cuff (CNA #1) between residents, and proper hand hygiene breaks in infection control (CNA #2) wiping sanitized hands on front of their top and pant legs without re-cleaning hands, c) Replace O2 tubing after the NC touched the floor and was placed back into the res nose for 1 (#85) of 12 residents who were O2 dependent; and d) Maintain an infection control program for enhanced barrier precautions by donning gowns prior to wound care for 2 (#60 and #40) of who received wound care at the facility. The Administrator identified 82 residents residing at the facility. Findings: An Enhanced Barrier Precautions policy, dated 04/01/24, read in part, .an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs…

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 accurate PASARR screening was completed for one (#9) of four sampled residents reviewed for PASARR screenings. The Administrator identified 82 residents resided in the facility. Findings: A level 1 PASARR, dated 11/04/21, documented Res #9 had a diagnosis of a serious mental illness and a recent history of mental illness or was prescribed a psychotropic medication. There was no documentation in the resident's chart or on the form indicating a determination for level 2 PASARR was made. On 07/09/24 at 1:25 p.m., the MDS coordinator stated there should have been documentation on the form with the determination for a level 2. They stated the facility was likely told a level 2 was not necessary but did not document it on the form or in the resident's chart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure CPR was administered in accordance with standards of practice and facility policy. The Administrator identified 82 residents resided in the facility. Findings: A facility policy documented a rate of 30 compressions to two rescue breaths during the administration of CPR. On [DATE] at 12:58 p.m., a staff member retrieved LPN #1 to assist with an unresponsive resident. On [DATE] at 1:04 p.m., CPR was initiated. On [DATE] at 1:09 p.m., the Ambu-bag was observed squeezed five times. On [DATE] at 1:11 p.m., the Ambu-bag was observed squeezed four times, 30 compressions were administered, and a single rescue breath was given and compressions were re-started during the administration of the second rescue breath. On [DATE] at 2:10 p.m., the DON stated they observed compressions and rescue breaths were alternated until EMS responded to the scene. They stated they had corrected the issue with the rescue breaths immediately.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide treatment and services to treat a contracture for one (#22) of one sampled residents reviewed for range of motion. The DON identified three residents with contractures. Findings: 1. Res #22 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction. A physician order, dated 05/17/24, documented Res #22 was to have a hand roll to the left hand at all times except when showering. A quarterly MDS, dated [DATE], documented Res #22 was severely cognitively impaired and had impairment to range of motion on one side. A care plan, revised 07/09/24, documented Res #22 had a contracture to their left hand due to a cerebral vascular accident. The care plan documented the resident was to have a hand roll in their left hand at all times except when showering. On 07/09/24 at 9:32 a.m., Res #22 was observed in their geri-chair being pushed by a staff member. No hand roll was observed in their left hand. The hand was…

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

Based on observation, record review, and interview, the facility failed to ensure O2 was administered as ordered by the physician for one ( #85) of three sampled residents reviewed for respiratory therapy. The ADON identified 12 residents who received O2. Findings: Res #85 had diagnoses which included SOB and failure to thrive. A physician order, dated 06/27/24, documented O2 via NC 3 liters continuously. On 07/12/24 at 9:50 a.m., the resident was observed with their O2 tubing not in place. The tubing was on the floor. The O2 concentrator was set at 1.5 LPM. On 07/12/24 at 10:06 a.m., the resident was observed with O2 in place. The O2 concentrator was set at 1.5 LPM. On 07/12/24 at 10:16 a.m., LPN #3 was asked what was the resident's O2 supposed to be set at. They stated they thought they saw it set at 2 LPM, but did not know what the physician ordered. They reviewed the order in the EHR and stated it was supposed to be set at 3 LPM. LPN #3 was asked to verify what the resident's O2 concentrator was set at. They stated 1.5 and it should be 3. They stated that is the reason 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 expired supplies were disposed, narcotic medications were kept behind two locks, refrigerator temperatures were checked daily, and multi-use vials were dated when opened. The Administrator identified 82 residents resided in the facility. Findings: On 07/10/24 at 10:29 a.m., the medication room was observed with LPN #2. On 07/10/24 at 10:35 a.m., the white refrigerator was observed containing an undated opened vial of TB skin test, an unopened vial of lorazepam concentrate, not in the clear locked narcotic box, and a bottle of vancomycin solution prepared for enteral administration that was frozen. The temperature log on the front of the refrigerator did not document the month, and had no temperatures documented for the sixth and seventh day. On 07/10/24 at 10:37 a.m., LPN #2 stated they were unable to determine when the TB skin test vial was opened. They stated the narcotic should have been behind two locks. They stated they were unsure how often the med aides were supposed to check the medication room for expired…

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 laboratory tests were obtained per physician's orders for one (#67) of five sampled residents reviewed for laboratory testing. The Administrator identified 82 residents resided in the facility. Findings: A Lab Policy & Procedure, undated, documented all laboratory tests will be done as ordered by the physician in a timely manner and the results reported to the physician. Resident #67 had diagnoses which included bipolar, major depression, Diabetes Mellitus, and CHF. A physician's order, dated 06/11/24, documented to obtain a CBC and CMP weekly times two. A laboratory test, dated 06/12/24, documented a CBC and CMP had been collected. There was no documentation the second test had been collected. On 07/12/24 at 4:02 p.m., LPN #4 was asked where Resident #67's second CBC and CMP would be located. LPN #4 looked in Resident #67's EMR and stated they only saw the 06/12/24 lab. LPN #4 then looked in the facilities lab online and stated, I'm not pulling up anything. On 07/12/24 4:21 p.m., the ADON stated, We are missing 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 meals were served as scheduled. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: An undated schedule of meal times, documented breakfast was to be served at 7:30 a.m. On 07/08/24 at 8:31 a.m., food trays were observed being delivered to residents in the dining room. 1. A quarterly assessment, dated 06/20/24, documented Res #52's cognition was intact. On 07/08/24 at 7:45 a.m., the resident was asked about the food. They stated the meals were not always on time. 2. A annual assessment, dated 04/20/24, documented Res #55's cognition was intact. On 07/08/24 at 8:37 a.m., the resident was asked how was the food. They stated the meals were usually late. 3. A quarterly assessment, dated 06/21/24, documented Res #56's cognition was moderately impaired. On 07/08/24 at 8:41 a.m., the resident was asked how was the food. They stated the meals were served late. 4. 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 provide medical record to a resident's representative upon request for one (#3) of one sampled resident reviewed for medical records. The Administrator identified 80 residents resided in the facility. Findings: An Access to Personal and Medical Records policy, revised 05/17, read in part, .Access to the resident's personal and medical records will be provided to the resident within 1 week .of his or her request .The resident .may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information is to be released . Resident #3 had diagnoses which included bipolar and schizophrenia. An AUTHORIZATION FOR ACCESS BY PATIENT OR DISCLOSURE OF PROTECTED HEALTH INFORMATION form, dated 02/20/24, documented Resident #3 signed the release of their medical records to their representative. On 03/06/24 at 12:58 p.m., the Administrator stated they were not aware Resident #3's family had requested medical records. They stated it takes…

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

Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged for one (#2) of three sampled residents reviewed for involuntary discharge. The Administrator identified 80 residents resided in the facility. Findings: A Transfer or Discharge Documentation policy, revised 12/16, read in part, .Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by a physician .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The following information will be communicated to the receiving facility or provider .Resident representative information including contact information . A Transfer or Discharge, Emergency policy, revised 08/18, read in part, .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .Notify the representative (sponsor) or other family…

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 items were stored and labeled in the refrigerator; and kept at safe temperatures in the freezer. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility, and three residents received tube feeding. Findings: An undated Receiving Food and Supplies policy, undated, read in part, Food items will be received and handle in accordance with good sanitary practice .All foodstuffs [sic] are to be dated . An undated Purchasing, Receiving and Storage policy, undated, read in part, .Food will be properly stored to preserve flavor, nutritive value, appearance, and safety .The food service director is responsible for inventory control . On 07/05/23 at 8:10 a.m., the initial tour of the kitchen was conducted with the kitchen supervisor as the CDM was not available. Observations of the refrigerator were as follows: a. Beef patties with no label or date, b. Fried okra with no label or date, c. A plastic container of mashed potatoes with no label or…

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 residents were offered the opportunity to formulate an Advance Directive for three (#23, 27, and #63) of 24 sampled residents reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility. Findings: 1. Resident #27 had an initial admission date of 07/13/18 and a current admission date of 03/30/23. There was no documentation Resident #27 had been given the opportunity to formulate an Advance Directive. 2. Resident #63 had an initial admission date of 02/01/23. There was no documentation Resident #63 had been given the opportunity to formulate an Advance Directive. 3. Resident #23 had an initial admission date of 06/12/13 and a current admission date of 08/19/22. There was no documentation Resident #23 had been given the opportunity to formulate an Advance Directive. On 07/06/23 at 1:42 p.m., the CNO stated they were unable to locate the Advance Directive acknowledgement form for Resident #27 and Resident #63. The CNO was asked…

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

Based on record review and interview, the facility failed to ensure physician ordered weekly skin assessments were completed on residents with pressure ulcers for three (#63, 65, and #182) of four sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 07/05/23, documented nine residents with pressure ulcers greater than a stage I. Findings: A Pressure Ulcers/Skin Breakdown policy, revised 04/18, read in part, .the nurse shall describe and document/report the following .Full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . 1. Resident #63 had diagnoses which included stage III pressure ulcer of the right lateral plantar foot and stage III pressure ulcer of the right calcaneous. A Physician Order, dated 04/19/23, documented weekly skin assessments on Wednesday on night shift. A Wound Assessment, dated 05/17/23, documented Resident #63 had a stage III pressure ulcer of the right lateral plantar foot which measured 1.5 length x 1.5 width x 0.2 cm depth. It…

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. spare keys to medication and treatment carts were secured and not accessible; b. controlled medications were secured behind two locks; and c. medications were administered as ordered for two (#32 and #34) of five sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 81 residents resided in the facility. Findings: A Medication Disposal and Returns policy, dated 05/16/23, read in part, .Full chain of custody should be documented to clearly indicate the removal of the medications from the cart and placed into a secure storage area for destruction . 1. On 07/11/23 at 10:09 a.m., the DON was asked what the policy was for dc'd controlled medications. They stated they were put in a narcotic cabinet and locked. They were asked where the narcotics cabinet was located. The DON stated it was in their office inside a locked closet. They stated the closet was locked…

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

Based on observation, record review, and interview, the facility failed to provide a homelike environment for one (#51) of 24 sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility. Findings: A Homelike Environment policy, revised 02/21, read in parts, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible .clean, sanitary and orderly environment .clean bed and bath linens that are in good condition . On 07/05/23 at 9:46 a.m., Resident #51 was observed lying in bed with a pillow under their head. The pillow did not have a pillow case on it. The pillow was observed to have a large purple/black colored area measuring approximately 12 inches in length by approximately 2 1/2 inches in width on the bottom right side of the pillow (orientation facing the resident). The resident was unable to answer questions about the pillow. On 07/05/23 at 9:48 a.m., RN #1 was asked the reason…

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 received a diagnostic test for one (#41) of one sampled resident reviewed for diagnostic tests. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 81 residents resided in the facility. Findings: Resident #41 had diagnoses which included cerebral infarction and seizures. An After Visit hospital summary, dated 05/26/23, documented an appointment for a CT angiogram of the heart and an echo cardiogram to be conducted on 06/22/23 at the hospital. It documented the following medications to take prior to the CT angiogram: a. prednisone 50 mg, 13 hours, seven hours, and one hour prior to test; b. benadryl 50 mg, one hour prior; c. metoprolol 50 mg, 12 hours prior, and 50-100 mg one hour prior; d. valium 5-10 mg, one hour prior; and e. diltiazem if patient has COPD or asthma. On 07/10/23 1:37 p.m., the DON was asked about Resident #41's diagnostic tests. They stated the pharmacy didn't send all of the medication protocol, so the tests had to be rescheduled. On 07/10/23 at 2:11 p.m.,…

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