Maple Healthcare And Rehab

Based on record review and interview, the facility failed to ensure code status was accurate for one (#8) of 16 sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Advance Directives policy, dated December 2016, read in part, .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . Resident #8 had diagnoses which included unspecified dementia. The admission Record form documented the resident had a DNR. A physician order, dated 08/05/22, documented the resident was a full code. Review of the electronic clinical record revealed an undated, signed DNR had been uploaded on 08/09/22. On 08/30/23 at 10:11 a.m., LPN #1 was asked what the code status was for Resident #8. They reviewed the electronic clinical record and stated the resident was a full code. They were asked what the signed DNR was dated. They reviewed the DNR and stated the form was not dated. On 08/30/23 at…

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

Based on record review and interview it was determined the facility failed to notify a resident representative of changes in condition and treatment for one (#15) of two residents reviewed for notification of change. The Residents Census and Condition of Residents report, dated 08/29/23, documented 23 residents resided at the facility. Findings: A Change in Resident's Condition or Status policy, revised date 2017, read in part .Our facility will promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) . A medication order, dated 07/30/23, documented resident #15 was to be administered Tylenol #3 [acetaminophen with codeine] 300-30 mg every six hours as needed for pain. A progress noted, dated 07/30/23, documented a new order for Tylenol #3 had triggered a drug interaction alert. The alert stated the medication Tylenol #3 could interact with the resident's prescribed medication Mirtazapine [an oral…

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 an Advance Beneficiary Notice of Non-coverage to one (#14) of three residents reviewed for beneficiary notifications. The Entrance Conference Worksheet Beneficiary Notice - Resident discharged Within the Last Six Months form, documented three residents, who had discharged in the previous six months prior to the survey, had remained in the facility after a discharge from a Medicare Part A stay. Findings: Resident #14 had diagnosis which included bipolar disorder and anxiety disorder. A progress note written by the SSD, dated 07/26/23, documented the resident was transferred to an acute care hospital on that date. A progress note written by LPN #3, dated 08/03/23, documented resident #14 was readmitted to the facility on that date. On 08/31/21 the Administrator returned a completed SNF Beneficiary Notification Review form which documented resident #14 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN)…

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 incident of physical assault on a resident was reported to the facility administration and state agency for one (#24) of 16 residents assessed for abuse. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided at the facility. Findings: Resident #24 had diagnosis which included cognitive communication disorder and pneumonia. An abuse investigation and reporting policy, revised date July 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 reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . A nursing note, dated 05/31/23 at 7:08 p.m., documented a resident's family member had attempted to force the resident from their bed. The note read in part, .[they] yanked the blankets off, pulled [their] heel protectors…

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 a written notice of transfer to one (#24) of one resident reviewed for hospitalizations. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided at the facility. Findings: Resident #24 had diagnosis which included cognitive communication disorder and pneumonia. A nursing noted, dated 05/31/23 at 9:08 p.m., documented the resident was transferred to an acute care hospital related to low blood pressure. On 08/31/23 at 12:08 p.m., the administrator was asked if resident #24 was given a written notice of transfer and the bed hold policy prior to being sent to a hospital on [DATE] as indicated by a nurse note of the same date. They stated they would need to check in the resident's records. At 12:38 p.m., the administrator was asked about the written notice of transfers prior to hospitalization for resident #24. They stated they were aware of the regulation but had not found a copy or documentation that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure a PASRR level one assessment form had been completed for one (#1) of one residents reviewed for preadmission screening. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: Resident #1 had diagnoses which included paranoid schizophrenia and major depressive disorder with severe psychotic symptoms. An admission record, print date 08/29/23, documented the resident was admitted to the facility on [DATE]. On 08/29/23, resident #1's medical records were reviewed for the presence of a Preadmission Screening and Resident Review (PASRR) form. None was located in the electronic medical record or paper chart. At 12:10 p.m., resident #1 was observed in their room and an attempt to question them was made. The resident was not interviewable. On 08/30/23 an Oklahoma Healthcare Authority Nursing Facility Level of Care Assessment form, dated 08/30/23, was observed in the…

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

Based on record review and interview the facility failed to conduct care plan meetings for one (#15) of six residents reviewed for care plans. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, revised date December 2016, read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . Resident #15 had diagnoses which included vascular dementia. On 08/30/23 at 8:02 a.m., a resident representative reported they had not been invited to or attended an interdisciplinary treatment team meeting since resident #15 had resided at the facility. On 08/31/23 at 1:25 p.m., the DON was asked to describe the process…

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 ADL care was provided for dependent residents for two (#7 and #16) of two sampled residents who were reviewed for ADL care. The DON identified 20 residents who were dependent on staff for ADL care. Findings: The Care of Fingernails/Toenails policy, dated April 2007, read in parts, The purposes of this procedure are to clean the nail bed .Nail care includes daily cleaning . The Shaving the Resident policy, dated December 2007, read in parts, .The purpose of this procedure is to promote cleanliness and to provide skin care .The following information should be recorded in the resident's medical record .The date and time the procedure was performed . 1. Resident #7 had diagnoses which included major depressive disorder. The Care Plan, revised 04/02/23, documented the resident had an ADL self care performance deficit. The quarterly assessment, dated 06/15/23, documented the resident was moderately impaired in cognition for daily decision making and required limited one person physical assistance for…

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

Based on observation, record review, and interview the facility failed to provide pre and post dialysis assessments for one (#12) of one resident reviewed for dialysis care. The Resident Census and Conditions of Residents form, dated 08/29/23, documented one resident at the facility attended off-site dialysis treatments. Findings: A hemodialysis policy, undated, read in part, .The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit [an abnormal vascular sound] and palpitating for a thrill [an abnormal vibration] . Resident #12 had diagnoses which included end stage renal disease. A care plan focus for hemodialysis, revised date 05/04/22, documented the resident required dialysis three times weekly. A review of the interventions related to the focus did not include pre and post dialysis checks of the access site nor presence of bruit and thrill. On 08/29/23 at 12:44 p.m., resident #12 was observed in their room. They were asked if the nurses had been checking…

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 pharmacy recommendations were addressed by the physician for of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 08/29/23, identified 23 residents who resided in the facility. Findings: The Medication Regimen Reviews policy, dated April 2007, read in parts, .The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity .Copies of drug/medication drug regimen review reports, including physician responses, will be maintained as part of the permanent medical record . 1. Resident #8 had diagnoses which included schizoaffective disorder. The Recommendation Summary for DON and Medical Director report from the Consultant Pharmacist, dated 11/03/22, read in part, .This resident has been taking the antipsychotic Aripiprazole 5mg qam since [DATE]. Please evaluate the current dose and consider a dose reduction . 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 pureed foods were prepared in the proper consistency for one (the noon meal) of one meal observed. The DON identified two residents who were ordered a puree diet. Findings: On 08/29/23 at 1:08 p.m., the dietary manager was observed to puree kielbasa and fried potatoes. On 08/29/23 at 1:17 p.m., the dietary manager stated they had pureed the food to the consistency in which they would serve it and provided the surveyor a sample of the kielbasa and fried potatoes. The kielbasa was observed to not be smooth, had pieces of meat still visible, and required chewing upon tasting. The fried potatoes were observed to not be smooth, had pieces of potato with the skin on which required chewing upon tasting. On 08/29/23 at 1:27 p.m., the dietary manager plated the pureed foods and handed the tray to the administrator to serve the resident. The administrator was asked to return the tray to the kitchen before it was served to the resident. The dietary manager was asked how they ensured pureed foods were the correct consistency.…

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 opened foods were dated, food with signs of freezer burn was discarded, and scoops were not stored in bulk food bins, b. ensure equipment was maintained in a sanitary manner, c. ensure hair restraints were utilized by staff while in the kitchen for two (the dietary manager and [NAME] #1) of two staff observed during meal preparation and service, and d. maintain proper hand hygiene during meal service for one of one meal services observed. The DON identified 22 residents who received nourishment from the kitchen. Findings: The Sanitization policy, dated October 2008, read in part, .Kitchen .surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . The Refrigerators and Freezers policy, dated December 2014, read in part, .Refrigerators and freezers will be kept clean, free of debris, and mopped with a sanitizing solution on a scheduled basis and more often as necessary . The Preventing Foodborne Illness - Employee Hygiene 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the facility assessment was updated annually. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Facility Assessment policy, dated July 2017, read in parts, .A facility assessment is conducted annually .Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents . The Facility Assessment document, provided by the facility, read in part, .Resident Population Profile - [DATE] - [DATE] . On 08/31/23 at 12:08 p.m., the administrator was asked how often the facility assessment was updated. They stated they were to update it at least annually. They were asked why it had not been updated after 03/14/23. They stated they did not know. They stated the information obtained from 03/15/22 through 03/14/23 was the last time the facility assessment had been updated.

Based on record review and interview the facility failed to assess the need for education and influenza, pneumonia, or COVID-19 vaccinations for one (#19) of three residents reviewed for immunizations. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: Resident #19 had diagnoses which included atherosclerotic heart disease. A review of resident #19's medical records found no documentation of the resident or their representative having been assessed for the need of influenza, pneumonia, and COVID-19 immunizations. There was no documentation of the resident or their representative having been educated or offered the opportunity to receive immunizations for the three diseases. On 08/31/23 at 4:33 p.m., the Administrator and DON reported they had been unable to find any documentation the resident or their representative have been question regarding the resident's immunization status or that they had been given the opportunity for education and immunization while at the facility.

Based on record review and interview, the facility failed to ensure training was provided regarding activities that constitute abuse/neglect, procedures for reporting incidents of abuse/neglect, and dementia management/resident abuse prevention. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Abuse Prevention Policy and Procedure, dated 02/26/19, read in parts, .Training .All facility personnel will be trained at Orientation and annually thereafter on; The facility policy and procedures relative to abuse and neglect .Appropriate interventions to deal with aggressive reactions of residents . On 08/31/23 at 8:00 a.m., the inservices/training related to abuse/neglect, procedures for reporting abuse/neglect, and dementia management/resident abuse prevention were requested from the administrator. The administrator stated they were unable to locate the inservice book to show evidence of training. They stated they had the book in the DONs office on 08/28/23 but was afraid someone had thrown the binder…

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 12 hours of nurse aide inservice training for 12 of 12 months of inservice training records requested. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Staff Development Program policy, dated December 2009, read in part, .All personnel must participate in .regularly scheduled in-service training classes . On 08/31/23 at 8:00 a.m., the facility's nurse aide inservice training documentation was requested from the administrator. The administrator stated they were unable to locate the inservice documentation for the past 12 months. They stated they had the book in the DONs office on 08/28/23 but was afraid someone had thrown the binder away. On 08/31/23 at 1:26 p.m., CNA #2 was asked how often they received inservice training. They stated they had not received any inservices/training since January 2023. They stated at times there was a paper for the staff to review and sign. On 08/31/23 at 1:29 p.m., CNA #1 was asked how often 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 observation, interview, and record review, it was determined the facility failed to: ~ Ensure the dish machine reached the proper temperature/chemical sanitation level for one of one dish machines observed; ~ Ensure opened food products were labeled/dated and properly stored for two of two refrigerators and one of three freezers observed; and ~ Ensure food temperatures were obtained before serving to ensure proper holding temperature for one (noon meal) of one meals observed. The facility identified eight residents who received nourishment from the kitchen. Findings: 1. On 07/06/21 at 10:39 a.m., dietary aide #1 was asked if she would test the sanitation on the dish machine. She stated they had some test strips but did not know where they were located. The specifications on the dish machine documented the minimum wash/rinse temperature was 120 degrees Fahrenheit and the sanitization was 50 ppm. At 1:56 p.m., the dietary manager tested the dish machine. The sanitation strip was observed to test at 10 ppm, the wash temperature was 100 degrees Fahrenheit, and the rinse…

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

Based on observation, interview, and record review, it was determined the facility failed to ensure survey results were accessible to residents/visitors. This had the potential to affect all eight residents who resided in the facility. Findings: On 07/08/21 at 10:08 a.m., a resident group meeting was conducted. The one resident in attendance was asked if he knew where survey results were located for their viewing if desired. He stated he did not know where the survey results were located. On 07/08/21 at 10:18 a.m., went to the nurse's station with resident #62. The survey book was not observed. CNA #1 stated the survey book was usually right here and pointed to the chart rack on the right hand side and stated it was usually right here. The DON came up and stated here it is. She stated it should be up on the desk so the residents do not have to ask for it. There were no other survey results after 02/2019 annual survey. The facility had a COVID survey that had been conducted on 06/29/20. On 07/08/21 at 10:55 a.m., showed the administrator the survey report book and told her that 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 interview and record review, it was determined the facility failed to provide iability and appeals notices as required for two (#64 and #65) of two sampled residents for liability and appeals notices. The BOM identified two residents who had skilled days remaining had been discharged from skilled services in the last six months. Findings: On 07/07/21 at 11:25 a.m., asked the BOM to complete the SNF beneficiary protection notification review form for the two sampled residents. The BOM was asked to provide the surveyor with the liability and appeals notices if provided for two residents. At 12:39 p.m., the administrator reported the forms were not completed for resident #65 and resident #64 had the signed original and they could not find their copy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to complete baseline care plans for four (#62, #63, #112, and #113) of four sampled residents whose baseline care plan were reviewed. The facility identified eight residents who resided at the facility. Findings: 1. Resident #62 was admitted to the facility on [DATE]. The resident had diagnoses which included spastic quadriplegic, cerebral palsy, and functional quadriplegic. The resident's clinical record did not include a baseline care plan. 2. Resident #63 was re-admitted to the facility on [DATE]. The resident had diagnoses which included cerebral palsy, epileptic seizures, and gastrostomy status. The resident's clinical record did not include a baseline care plan. 3. Resident #112 was admitted on [DATE] and had diagnoses which included paraplegia and diabetes mellitus. Review of the clinical record did not reveal a baseline care plan had been developed. 4. Resident #113 was admitted on [DATE] and had diagnoses which included COPD 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, interview, and record review, it was determined the facility failed to ensure a resident with a gastrostomy tube received the appropriate treatment and services for one (#63) of one sampled resident reviewed with a gastrostomy tube. The facility identified one resident who resided at the facility who had a gastrostomy tube. Findings: Resident #63 had a re-admission date of 02/22/21. The resident had diagnoses which included cerebral palsy, epileptic seizures, and gastrostomy status. A quarterly assessment, dated 05/22/21, documented the resident was severely cognitively impaired related to cognitive skills for daily decision making, required total care of ADLs, and had enteral tube for nutrition. The resident's clinical record did not include a comprehensive care plan. A physician's order, dated 06/12/21, documented to administer 165 ml/hr of Water Oral Liquid (Infant Foods) via peg tube two times a day related to gastrostomy status. A physician's order, dated 06/27/21, documented to administer 30 cc of Water Oral Liquid (Infant Foods) per peg tube four times a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure residents' monthly drug regimen reviews were acted upon by the DON and physician for two (#62 and #63) of three sampled residents whose pharmacy DRRs were reviewed. The facility identified eight residents who received medications who resided at the facility. Findings: 1. Resident #63 had a re-admission date of 02/22/21. The resident had diagnoses which included cerebral palsy, epileptic seizures, and gastrostomy status. A physician's order, dated 03/31/21, documented to administer Guiatuss Syrup 100 mg/5 ml to give 30 cc via peg tube as needed for cough. A pharmacy DRR/MRR, dated 05/13/21, documented to clarify the Guiatuss order as the order did not include how often the medication could be given. A quarterly assessment, dated 05/22/21, documented the resident was severely cognitively impaired related to cognitive skills for daily decision making, required total care of ADLs, and had enteral tube for nutrition. On 07/13/21 at…

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

Based on interview and record review, it was determined the facility failed to ensure residents were not on prn antianxiety medications for greater than 14 days without physician rationale to extend the use of the prn medication for one (#112) of three sampled residents who were reviewed for unnecessary medications. The facility identified one resident who was ordered prn antianxiety medications. Findings: Resident #112 had diagnoses which included paraplegia and diabetes mellitus. A telephone order, dated 05/26/21, documented the resident was ordered Clonazepam 0.5 mg as needed twice daily for anxiety Review of the order summary report, dated 07/12/21, revealed the prn Clonazepam was an active physician's order with a start date of 05/26/21. Review of the clinical record did not reveal documentation of a rationale to extend the duration of the prn antianxiety medication past 14 days. On 07/13/21 at 3:11 p.m., the DON was asked who monitored to ensure residents were not ordered prn psychotropic medication for greater than 14 days without physician rationale to extend the use. She…

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 complete a facility assessment. The facility identified eight residents who resided in the facility. Findings: On 07/07/21 at 10:50 a.m., the administrator was asked for the facility assessment. She stated she did not have access to the facility assessment. She stated the previous administrator had the access.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure resident records were complete, accurate, and well organized for four (#3, #7, #8, and #63) of eleven sampled residents whose records were reviewed. The facility identified eight residents who resided in the facility. Findings: 1. On 07/13/21 at 3:27 p.m., it was revealed to the MDS #1 nurse the resident #63's last comprehensive assessment was completed on 06/20/19. She was asked why an annual assessment was not completed in 06/2020. She stated she had started doing the MDS assessment the end of 03/2021 or the beginning of 04/2021. She stated she could not see anything before 02/16/21 in the computer system. She stated when the new company took over the facility the new company took everyone out of the computer system. 2. Resident #8 was admitted to the facility on [DATE]. He was discharged from the facility on 03/16/21. A nurse's note, dated 03/16/21 at 11:00 a.m., documented the resident discharged to his family. 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 interview and record review, it was determined the facility failed to identify deficient practices and develop and implement plans of actions to correct identified concerns for seven (#3, #5, #8, #62, #63, #112, and #113) of eleven sampled residents who were reviewed during the survey. The facility identified eight residents who resided in the facility. Findings: See F636, F637, F641, F655, F656, F661, F756, F825, F842, and F883. On 07/13/21 at 04:28 p.m., the DON was asked if the facility had addressed any concerns in the QAA. She stated she did not know. She stated she had not since she had started working at the facility on 06/21/21. She stated there was nothing in the QA book since 10/16/20. The DON was asked prior to the survey did the facility staff identify and develop a QA plan r/t the RAI process. She stated no. She stated it was her understanding the medical director was going to come to facility in 07/2021 and would have a QA meeting. The DON was asked prior to the survey did the facility staff identify and develop a QA plan r/t the clinical records not being…

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

Based on interview and record review, it was determined the facility failed to ensure the QAA meeting was held quarterly for two (1st and 2nd quarters of 2021) of three quarters that were reviewed. The facility identified eight residents who resided at the facility. Findings: On 07/06/21 at 1:44 p.m., during the entrance conference with the administrator she was given a copy of the entrance conference worksheet. The worksheet asks for the frequency of the QAA meetings. On 07/06/21 at 02:54 p.m., the DON reported the last QAA meeting at the facility 10/16/20.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure infection control policy and procedures were implemented to prevent possible infections as evidenced by: -a resident with a gastrostomy tube received the appropriate treatment and services for one (#63) of one sampled resident reviewed who had a gastrostomy tube, ~hand washing was performed during a medication pass observation for one (#5) of five sampled residents observed during medication pass, ~a Influenza vaccination was offered to a resident for one (#7) of five sampled residents for influenza vaccination review, ~received education r/t COVID-19 vaccinations, were offered the COVID-19 vaccinations, and/or if the vaccinations were declined had the required documentation for two (#62 and #112) of five sampled residents and five (CNA #2 and #3, LPN #2 and #3, and RN #1) of five staff members employee files that were reviewed for the COVID-19 vaccinations. The facility identified one resident who resided at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure influenza immunization were offered to residents for one (#7) of five sampled residents reviewed for influenza immunizations. The facility identified eight residents who resided at the facility. Findings: 1. Resident #7 was re-admitted to the facility on [DATE]. There was no documentation in the resident's clinical record that the influenza immunization had been offered or was given. On 07/13/12 at 1:30 p.m., the DON was asked if there was any documentation for the resident's influenza immunization. She stated she could not find any documentation of the vaccinations, consents, or refusals in any of the charts she had available. She stated there was much of the residents' prior history that was not able to be accessed at that time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure residents and family staff members received education r/t COVID-19 vaccinations, were offered the COVID-19 vaccinations, and/or if the vaccinations were declined had the required documentation for: two (#62 and #112) of five sampled residents and, five (CNA #2 and #3, LPN #2 and #3, and RN #1) of five staff members employee files that were reviewed for the COVID-19 vaccinations. The facility identified eight residents who resided at the facility. Findings: 1. Resident #62 was admitted to the facility on [DATE]. The resident had diagnoses which included spastic quadriplegic, cerebral palsy, and functional quadriplegic. No immunization history, consents, or denials were located in the resident's clinical record for the COVID-19 vaccination. 2. Resident #112 was admitted on [DATE] and had diagnoses which included paraplegia and diabetes mellitus. No immunization history, consents, or denials were located in the resident's clinical…

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 implement their abuse policy and procedure for screening of employees before hire for four (RN #1, LPN #2 and #3, and CNA #3) of five employee files that were reviewed. The facility identified eight residents who resided at the facility. Findings: The facility's abuse prevention policy and procedure, dated revised on 02/26/19, documented, .Criminal Background Check . In states where Criminal Background Checks are required; all employment candidates are required to authorize the facility to conduct a background check for conviction of crimes . Background screens are submitted after a conditional offer is extended and must be received within the appropriate timeframes per state requirements . Prior Employment Reference(s)- Reference check(s) of the candidate's prior employment must be conducted by the department director, or designee,prior to hiring the candidate . 1. LPN #2 had a hire date of 06/30/21. A time clock adjustment form for LPN #2, dated 07/01/21, documented the punch date was 06/30/21 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to complete comprehensive assessments for two (#8 and #63) of eight sampled residents whose comprehensive assessments were reviewed. The facility identified eight residents who resided at the facility. Findings: 1. Resident #63 had a re-admission date of 02/22/21. The resident had diagnoses which included cerebral palsy, epileptic seizures, and gastrostomy status. The resident's clinical record documented the resident's last full comprehensive assessment (annual) was dated 06/20/19. The resident's clinical record documented quarterly assessments were completed on 09/20/19, 12/21/19, 03/22/20, 09/20/20, and 05/22/21. There was no comprehensive annual assessment completed in 06/2020 and no comprehensive admission assessment completed after the resident's re-admission on [DATE]. On 07/13/21 at 3:27 p.m., it was revealed to the MDS #1 nurse the resident's last comprehensive assessment was completed on 06/20/19. She was asked why an annual…

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

Based on interview and record review, it was determined the facility failed to ensure a significant change assessment was completed when a resident elected hospice services for one (#5) of one residents who was reviewed for hospice services. The facility identified one resident who received hospice services. Findings: Resident #5 had diagnoses which included COPD and pain. A hospice order, dated 06/11/21, documented, .I CERTIFY THAT THE PATIENT HAS A TERMINAL DIAGNOSIS OF COPD AND PROGNOSIS IS SIX MONTHS OR LESS IF THE DISEASE RUNS ITS NORMAL COURSE .PT admitted TO HOSPICE FOR COPD, END STAGE . Review of the assessments did not reveal a significant change assessment had been completed when the resident elected hospice services. On 07/13/21 at 4:03 p.m., the MDS coordinator was asked why a significant change assessment had not been completed when the resident elected hospice services on 06/11/21. She stated the resident should have had a significant change assessment completed. She stated she did not know the resident had been placed on hospice services.

Based on interview and record review, it was determined the facility failed to ensure an admission assessment accurately reflected the resident's status for one (#112) of nine residents whose assessments were reviewed. The facility identified two residents who had been admitted in the past 30 days. Findings: Resident #112 had diagnoses which included paraplegia and diabetes mellitus. A skilled nurse note, dated 05/13/21, documented the resident had an indwelling urinary catheter and a colostomy. An admission assessment, dated 05/26/21, documented the resident had an indwelling urinary catheter and an ostomy. The assessment documented the resident was always continent of bowel and bladder. The assessment documented the resident received an antianxiety medication one day during the seven day look back period and had not received an antibiotic during the seven day look back period. Review of the May 2020 MARs revealed the resident had received an antianxiety medication and an antibiotic for seven of seven days of the look back period. On 07/13/21 at 3:28 p.m., the MDS coordinator was…

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

Based on interview and record review, it was determined the facility failed to ensure comprehensive care plans were completed for one (#63) of eight sampled residents whose care plans were reviewed. The facility identified eight residents who resided at the facility. Findings: Resident #63 had a re-admission date of 02/22/21. The resident had diagnoses which included cerebral palsy, epileptic seizures, and gastrostomy status. The resident's clinical record did not include a comprehensive care plan. On 07/13/21 at 11:30 a.m., the DON was asked for the resident's care plan. The DON stated the MDS #1 nurse had three more care plans to complete.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure discharge summaries were completed for two (#3 and #8) of three sampled discharged residents who were reviewed for discharge summaries. The facility identified two residents who discharged from the facility in the last month. Findings: 1. Resident #8 was admitted to the facility on [DATE]. He was discharged from the facility on 03/16/21. A nurse's note, dated 03/16/21 at 11:00 a.m., documented the resident discharged to his family. The resident's discharge summary was not in the resident's clinical record. On 07/13/21 at 11:50 a.m., the administrator was asked for the resident's discharge summary. The administrator stated the previous owners used 'Matrix' (a different electronic health record computer system). She stated they did not have access to 'Matrix' (where the resident's previous electronic record was located).2. Resident #3 had diagnosis which included schizoaffective disorder. On 07/12/21 at 11:09 a.m., the discharged…

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

Based on interview and record review, it was determined the facility failed to ensure coordination of care for hospice for one (#5) of one sampled residents who was reviewed for hospice. The facility identified one resident who received hospice services. Findings: Resident #5 had diagnoses which included COPD and pain. A hospice order, dated 06/11/21, documented, .I CERTIFY THAT THE PATIENT HAS A TERMINAL DIAGNOSIS OF COPD AND PROGNOSIS IS SIX MONTHS OR LESS IF THE DISEASE RUNS ITS NORMAL COURSE .PT admitted TO HOSPICE FOR COPD, END STAGE . Review of the resident's care plan did not reveal a care plan had been developed for hospice services. On 07/13/21 at 3:13 p.m., the DON was asked how care was coordinated with hospice. She stated she communicated with the hospice nurses about showers provided and what medications the hospice would supply. She was asked who was responsible to develop a plan of care when a resident elected hospice services to ensure staff knew how care was coordinated between the hospice company and the facility. She stated the MDS coordinator had recently been…

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

Based on interview and record review, it was determined the facility failed to ensure a yearly NA competency review was completed yearly for one (CNA #4) of one CNAs who had worked at the facility for over one year. The facility identified eight residents resided at the facility. Findings: On 07/06/21 at 1:44 p.m., during entrance conference with the administrator the administrator was asked for a list of CNAs who have worked at the facility for over one year. Later a list was provided which documented CNA #4 was the only CNA who had worked at the facility for over one year. CNA #4 had a hire date of 10/15/18. On 07/13/21 at 11:10 a.m., the BOM was asked for the yearly NA competency review for CNA #4. The BOM stated CNA #4 had been hired as the SSD. She was asked if the SSD still worked as a CNA. She stated yes.

Based on interview and record review, it was determined the facility failed to notify the physician of resident lab results for one (#112) of three sampled residents whose labs were reviewed. The facility identified three residents who had routine lab orders. Findings: Resident #112 had diagnoses which included paraplegia and diabetes mellitus. Review of the clinical record revealed the following lab reports dated 06/24/21: ~ CBC; ~ CMP; ~ Lipid panel; ~ PreAlbumin; ~ TSH; ~ Hemoglobin A1C; and ~ A ferritin level. Review of the clinical record did not reveal the physician had been notified of the lab results. On 07/12/21 at 3:30 p.m., the DON was asked what the facility protocol was for notification of lab results to the physician. She stated the lab results were faxed to the physician for review. The physician signed the results and sent them back to the facility. She stated if the lab was critical they called the physician. She was asked if the physician had been notified of the lab results dated 06/24/21. She stated the notification should be documented in the nurse notes and she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure residents were evaluated for physical therapy services as ordered by the physician for one (#112) of two sampled residents who were reviewed for therapy services. The facility identified five residents who had limited range of motion. Findings: Resident #112 was admitted on [DATE] and had diagnoses which included paraplegia and diabetes mellitus. A admission assessment, dated 05/26/21, documented the resident was cognitively intact for daily decision making, had limited range of motion on one side of the upper and lower extremities, utilized a wheelchair, required extensive assistance with most ADLs, and the resident's overall goal was to be discharged to the community. A care plan, dated 05/28/21, documented the resident had limited physical mobility related to paraplegia and staff were to provide gentle range of motion as tolerated with daily care. A physician order, dated 06/14/21, documented physical therapy was to evaluate…

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.