Eufaula Manor Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were provided with a comfortable, homelike environment for two (#60 and #75) of six sampled residents who were reviewed for noise level/comfortable, homelike environment. The DON identified 76 residents who resided in the facility. Findings: Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. On 07/30/24 between 9:00 a.m. and 10:45 a.m., observed Res #74 yelling loudly the same phrases repeatedly. The resident was also observed to be yelling profanity very frequently. The yelling was continual for approximately 1 hour and 45 minutes. On 08/02/24 at 11:15 a.m., Res #74 was observed to be yelling loudly the same phrases repeatedly for approximately 5 minutes. On 07/30/24 at 10:30 a.m. Res #60 reported they couldn't eat breakfast this am due to…

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

Based on record review and interview, the facility failed to ensure physician's orders were documented properly for one (#49) of six residents whose physician's orders were reviewed for accuracy. The DON identified four residents who had tube feedings Findings: Res #49 had diagnoses which included cerebral infarction and dysphagia. A physician's order, dated 03/29/24, documented Res #49 is to receive Jevity 1.5, 250ml via peg tube every 6 hours. A physician's order, dated 06/12/24, documented Res #49 is to receive Jevity 1.5, 350ml via peg tube every 6 hours. The July and medication administration record documented both feedings were administered each time the resident was administered a feeding. The August medication administration record documented both feedings were administered each time the resident was administered a feeding. On 08/02/24 at 3:32 p.m., the DON reported they aren't sure why there are two physician's orders for Res #49's feeding. On 08/02/24 at 4:05 p.m., the DON reported they wrote a new physician's order to clarify the feeding and reported the nurses were…

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 maintained in good repair. The administrator identified 73 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: On 08/01/24 at 8:30 a.m., a tour of the kitchen was conducted. The following observations were made. a. the wall was not finished and base boards were missing in the ice machine area, b. ceiling lights were burned out and/or not working and not shielded, c. base boards were missing in the dish wash area. There were gaps between the wall and the floor, d. the gasket on the walk in cooler door was split on the bottom of the door, e. the metal threshold on the door opening to the walk in cooler was not secure to the floor, f. the metal floor in the walk in cooler was raised and not level. There was brown residue and standing water on the floor, and g. there was an accumulation of ice on the walk in freezer door. On 08/01/24 at 11:02 a.m., the DM was how staff ensure the kitchen was maintained in good repair. 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.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#74) of six sampled residents whose assessments were reviewed for accuracy. The DON identified 76 residents who resided in the facility. Findings: The facility had no policies regarding resident assessments. Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. Progress noted, dated 07/18/24, documented Res #74 had a fall and sustained a laceration above their left eye which resulted in the resident being transferred to the local hospital emergency department where they received seven sutured to the laceration. An admission resident assessment, dated 07/22/24, did not document any behaviors or a fall with injury for Res #74. On 08/02/24 at 2:00 p.m., the administrator reported they had no policies regarding resident assessments and use the RAI Manual as guidance. On 08/02/24 at 3:45 p.m., 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 care plan behaviors for one (#74) of six sampled residents whose care plans were reviewed for accuracy. The DON identified 76 residents who resided in the facility. Findings: Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. Res #74's comprehensive care plan did not have a care plan for behaviors. On 07/31/24 between 9:00 a.m. and 10:45 a.m., observed Res #74 yelling loudly the same phrases repeatedly. The resident was also observed to be yelling profanity very frequently. The yelling was continual for approximately 1 hour and 45 minutes. On 08/02/24 at 11:15 a.m., Res #74 was observed to be yelling loudly the same phrases repeatedly for approximately 5 minutes. On 08/02/24 at 4:20 p.m., the MDS Coordinator reported the behaviors for Res #74 should have been care planned.

Based on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for three (#32, 53, and #60) of 26 residents whose assessments were reviewed. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility. Findings: 1. Res #60 had diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris. A physician order, dated 05/06/23, documented the facility was to administer Eliquis (an anticoagulant medication) once daily for a diagnosis of atherosclerotic heart disease. An admission Assessment, dated 05/12/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment did not documented the resident was on an anticoagulant medication. A physician order, dated 05/26/23, documented the facility was to administer Eliquis two times a day related to atherosclerotic heart disease. On 06/16/23 at 09:30 a.m., Res #60 was observed in her bed. Res #60 stated they were taking the blood…

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.

2. Res #7 had diagnoses which included heart failure, COPD and lower back pain. A physician order, dated 06/10/22, documented the facility was to administer furosemide (a diuretic medication) one time a day for edema related to heart failure. A physician order, dated 08/13/22, documented the facility was to administer tramadol (an opioid medication used for pain) two times a day for pain related to lower back pain. A physician order, dated 02/19/23, documented the facility was to administer Norco (a pain medication) every eight hours as needed for pain. A quarterly assessment, dated 06/20/23, documented the resident was intact with cognition and required supervision to limited assistance with most ADLs. The assessment documented the resident used diuretic and opioid medications. Res #7's care plan was reviewed and did not observe a care plan for diuretic or opioid use. On 06/20/23 at 4:36 p.m., the MDS coordinator stated they did not develop a care plan for the use of diuretic or opioid medications for Res #7. 3. Res #32 had diagnoses which included other recurrent depressive…

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

Based on interview and record review, it was determined the facility failed to conduct annual CNA competencies for three of five employee records reviewed. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility. Findings: On 06/23/23, the facility was asked for the CNA performance reviews for CNAs who had been employed at the facility for more than a year. The facility was unable to provide documentation of annual skill competencies for three CNAs whose records were provided for review. On 06/23/23 at 11:30 a.m., the DON stated they were not able to locate the competency documents for the CNAs.

Based on observation, record review, and interview, the facility failed to ensure the blood pressure and heart rate were monitored before holding a medication as ordered by the physician for two (#32 and #48) of five sampled residents whose medications were reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility. Findings: 1. Res #32 had diagnoses which included HTN , myocardial infarction, and atherosclerosis of the aorta. A physician order, dated 05/08/23, documented losartan (an anti hypertensive medication) administer two times a day related to HTN, no parameters for holding the medication were documented. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition. A care plan, last reviewed 05/30/23, documented the resident had hypertension. The care plan documented to give the anti hypertensive medications as ordered and to monitor for side effects such as orthostatic hypotension, increased heart rate, and effectiveness. The May 2023 MAR had areas 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 ensure the kitchen was maintained in good repair. The Residents Census and Conditions Of Residents form documented 65 residents resided in the facility. Findings: On 06/15/23 at 6:40 a.m., an initial tour of the kitchen was conducted. On 06/15/23/ at 6:50 a.m., the walk-in refrigerator and walk-in freezer was observed to have ice build-up around the door of the freezer section which would not allow the door to the freezer to close completely. Water from the ice buildup around the door of the walk-in freezer was observed to have melted and was present on the floor of the walk-in refrigerator. On 06/15/23 at 6:52 a.m., the DM stated even when the ice was removed around the door of the walk-in freezer and with the door shut completely the ice would build up again and cause the same issue. The DM stated they were approved for a kitchen remodel and the freezer was supposed to be on the list but did not know when the remodel was going to happen. On 06/15/23 at 7:17 a.m., the wall behind the dish machine was observed to have…

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 significant change assessment after the resident was admitted to hospice services for one (#116) of 26 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 65 residents who resided in the facility. Findings: Res #116 had diagnoses which included emphysema and protein-calorie malnutrition. A physician order dated, 05/30/23, documented to admit Res #116 to hospice care. The resident's medical record was reviewed and did not document a significant change assessment had been completed within the required timeframe. On 06/20/23 at 2:59 p.m., the MDS coordinator was asked if the facility had completed and submitted a significant change assessment for Res #116 upon their admission to hospice services. The MDS coordinator stated they had overlooked it and a significant change related to admission to hospice had not been completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement interventions to prevent falls for one (#168) of five residents sampled for accident hazards and falls. Res #168 was admitted to the facility on [DATE] for skilled nursing and therapy related to a fall at home which had resulted in a right hip fracture. The resident had a fall in the facility on 03/14/22 which resulted in a second broken right hip that required another surgery. No interventions were in place to prevent falls from the resident's admit until the fall on 03/14/22. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility. Findings: 1. Res #168 was admitted to the facility on [DATE] and had diagnoses which included fracture of right leg, polyneuropathy, Alzheimer's disease, chronic pain, insomnia, and scoliosis. A nurse practitioner progress note, dated 02/15/22 at 8:59 a.m., documented Res #168 was admitted to the facility after a recent hospitalization due to a right hip…

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

Based on record review and interview, the facility failed to ensure the physician and/or NP responded in the proper time frame to a pharmacist MRR for two (#7 and #32) of five sampled for unnecessary medications and failed to ensure the MRR policy documented the required components. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility. Findings: A Monthly Drug Regimen Review Policy, Rev 11-22-16 read in part .The facility will ensure that the Consultant Pharmacist will review each Resident's drug regimen monthly and address issues identified promptly. Procedure 1. The Pharmacist shall submit a written report at least monthly to the Administrator/designee which shall be a summary of thee duties performed by the consultant pharmacist any error or problems found in the facility, delivery of pharmaceutical services and a detailed listing of any discrepancies and/or irregularities noted by the pharmacist during his drug regimen reviews. 2. Upon identification of an irregularity that would require urgent action 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 ordered medications documented an appropriate diagnosis for one (#32) of five residents reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility. Findings: Res #32 had diagnoses which included depressive disorders, anxiety disorders, and dementia without behaviors. A physician order, dated 05/09/23, documented risperidone (an antipsychotic medication) was ordered to treat dementia without behaviors. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident received an antipsychotic and antidepressant medication six days of the seven day assessment period. The assessment documented antipsychotics were received on a routine basis. On 06/20/23 at 9:50 a.m., the DON stated the diagnosis of dementia was not an appropriate diagnosis for the risperidone. The DON…

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.