Homestead of Hugo

Based on observation, record review, and interview, the facility failed to ensure: a. infection control policy were implemented in the kitchen. b. food was distributed in a sanitary manner. The administrator identified 50 residents who received meals from the kitchen. Findings: An undated facility policy titled Employee Health Policy Agreement, read in part, Reporting: Symptoms of illness I agree to report to the manager when I have: 1. diarrhea 2. Vomiting .If you have any of the symptoms or illness listed above, you may be excluded*or restrictedfrom work .if an employee is on duty during the onset of symptoms, their immediate supervisor will release them to leave the facility until they are free of symptoms . 1. Times cards were reviewed for 03/16/24 for DA #1 and DA #2. DA #1 worked from 6:00 a.m., to 11:06 a.m. DA #2's time card documented they had clocked in at 10:59 a.m. on 03/16/24 to relieve DA #1. On 04/09/24 at 3:45 p.m., DA #1 stated on 03/16/24 I was sick and came to work sick. DA #1 stated the DM made them stay at work until someone came into relieve them. DA #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a sufficient number of staff to ensure residents received the needed care and services for two (#2, and #4) of four residents reviewed for staffing. The administrator identified 50 resident residing in the facility. Findings: 1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition. A physician order, dated 7/13/21, documented the resident required one person assist with bathing. A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing. On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath. Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower…

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 bathing to residents as scheduled for two (#2 and #4) of four residents reviewed for bathing. The administrator identified 50 resident residing in the facility. Findings: 1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition. A physician order, dated 07/13/21, documented the resident required one person assist with bathing. A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing. On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath. Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower sheets revealed eight refusals on scheduled days, and no documentation was provided for the remaining shower days. 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 double portions were provided for one (#2) of four residents who were reviewed for nutrition. The administrator identified 15 residents who had weight loss. Findings: Res #2 had diagnoses which included moderate protein calorie malnutrition. A physician order, dated 08/02/23, documented the resident was to receive a regular diet with double portions. A quarterly assessment, dated 01/15/24 documented the resident's weight was 209 pounds and had not had a loss or gain. The assessment documented the resident required supervision or touch assist with eating. A dietary note, dated 04/08/24, documented the resident weight was 204.5 pounds with a BMI of 26.3, WNL. The note documented no significant weight changes. The resident's diet was documented as a regular diet with double portions and the resident's intake was 76 to 100% of their meal. The note documented to continue care. On 04/09/24 at 11:21 a.m., Res #2 stated the food in the facility sucks and was delivered cold. Res #2 stated they had been hungry…

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 transmitted to CMS within the required timeframes. The administrator identified 41 residents who resided in the facility. Findings: An Electronic Transmission of the MDS policy, last revised on October 2010, read in part, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . The facility was unable to provide QIES transmission reports, but was able to provide transmission records from their EHR system. Transmission records from 09/06/23 though 01/03/24 were reviewed. 69 of 98 MDS/Resident assessments were submitted late. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the MDS coordinator's last day was 11/11/23 and none of the facility staff had login credentials…

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

Based on record review, observation, and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The administrator identified 39 residents who receive their meals from the kitchen. Findings: On 01/02/24 at 9:39 a.m., an initial tour of the kitchen was completed. Observations made in the refrigerators were peaches in cups not dated and labeled, two sandwiches in plastic bags were not dated or labeled, a glass of juice not covered, sliced cheese open to air and not dated or labeled, and hamburger patties wrapped up not labeled or dated. On 01/02/24 at 9:45 a.m., [NAME] #1 the acting DM stated the items in the refrigerators should be labeled and dated and not open to air. On 01/02/24 at 9:48 a.m., the freezer was observed with ice all over the boxes of food, the ceiling, door, and floor. [NAME] #1 the acting DM stated they had been working on the freezer but it had been that way a while. On 01/04/23 at 3:38 p.m., DA #1 was observed to touched the trash can lid with her hand and did not wash her hands. 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 interview and record review, the facility failed to ensure quarterly resident assessment were completed within the required timeframe for 12 (#5, 6, 23, 26, 30, 31, 35, 36, 37, 39, 42 and #44) of 15 sampled residents whose resident assessments were reviewed. The administrator identified 41 residents who resided in the facility. Findings: A review of resident assessments was conducted with the following results: a. Res #5's annual resident assessment was completed on 07/31/23. A quarterly resident assessment was due on 10/31/23 but was not completed. b. Res #6's annual resident assessment was completed on 08/25/23. A quarterly resident assessment was due on 11/25/23 but was not completed. c. Res #23's annual resident assessment was completed on 08/06/23. A quarterly resident assessment was due on 11/06/23 but was not completed. d. Res #26's annual resident assessment was completed on 08/16/23. A quarterly resident assessment was due on 11/16/23 but was not completed. e. Res #30's quarterly resident assessment was completed on 08/13/23. A quarterly resident assessment was due…

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 2. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia. A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors. A PASRR I, dated 08/29/22, documented the resident had a serious mental illness. The PASRR documented a PASRR II was not needed this stay per administrator. A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received an antipsychotic and an antianxiety medication. On 01/04/24 at 8:30 a.m., the administrator stated they did not make medical decisions and that the PASRR was completed by the last DON. The administrator stated according to the documentation of the resident having a serious mental illness OHCA should have been contacted. 3. Res #41 admitted to the facility on [DATE] with the following diagnoses…

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 there was RN coverage eight hours daily, seven days a week and failed to ensure a DON was employed. The administrator identified 41 residents who resided in the facility. Findings: Upon entrance and throughout the investigation there was no RN in the DON position. The administrator identified 12/23/23 as the last day a DON worked in the facility. The administrator provided a list of RN coverage from 12/23/23 through 01/08/24. There was no documented RN coverage for the following dates: 12/24/23, 12/27/23, 12/28/23, and 01/01/24. On 01/08/24 at 4:50 p.m., the administrator reported they unfortunately did not have RN coverage for three days in December and one day in January. The administrator stated they were in the process of hiring a DON.

Based on record review, and interview, the facility failed to provide MRRs for twelve months for five (#1, 6, 27, 39, and #41) out of five residents reviewed for unnecessary medications. The administrator identified 41 residents resided in the facility. Findings: A policy dated November 2018, read in part, .MEDICATION REGIMEN REVIEW .The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly . 1. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia. A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors. A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received antipsychotic and antianxiety medication. The corporate nurse provided MRRs for January, February, April, and July of 2023. The other eight months 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 unnecessary psychotropic medications were not administered for one (#39) of five sampled residents reviewed for unnecessary medication. The administrator identified 41 residents resided in the facility. Findings: 1. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia. A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors. The care plan documented to attempt to give the lowest dose possible. A MRR, dated 07/12/23, documented the resident was currently receiving Ativan 1 mg BID for anxiety and requested to an attempt to reduce Ativan to 0.5 mg BID for anxiety. The physician agreed and signed the MRR but did not date the MRR and the MRR was not noted. The Ativan was not decreased for the resident and the current order was for Ativan 1 mg BID. A discontinued medication order for Ativan 0.5 mg administer 1 mg BID was in place from…

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

Based on observation, record review, and interview, the facility failed to ensure a dietary manager was hired for the facility. The administrator identified 39 residents who received meals from the kitchen. Findings: On 01/02/24 at 9:39 a.m., during the initial tour of the kitchen, there were two staff working in the kitchen. [NAME] #1 stated they were the acting DM because the facility did not currently have a DM. On 01/05/24 at 12:50 p.m., [NAME] #1 stated the facility had a dietitian that come to the facility once a month. On 01/05/24 at 1:08 p.m., [NAME] #1 stated they did not want the DM position. [NAME] #1 stated they had not had a DM for several months but was not sure of the date. [NAME] #1 stated the administrator interviewed someone for the DM position today. On 01/08/24 at 1:55 p.m., the dietitian stated they were in the facility once a month for as long as they need them, about six hours. The dietitian stated they were not filling in as the facilities DM while they were without one. The facility records documented the dietary managers last day was 09/01/23. On 01/08/24…

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 review, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: a. ensure DNR forms were dated and signed; b. ensure background checks were completed for new hires; c. ensure an annual resident assessment was completed within the required timeframe.; d. ensure quarterly assessments were completed within the required timeframe; e. ensure resident assessments were transmitted to CMS within the required timeframes; f. ensure MDS assessments were accurate; g. ensure a level II PASRR referral was made to the Oklahoma Health Care Authority; h. ensure a resident received services to prevent an ADL decline; i. ensure there was RN coverage eight hours daily, seven days a week; j. ensure a DON was employed; k. ensure daily staffing information was documented, accessible, and retained; l. ensure MRRs were provided for twelve months; m. ensure unnecessary psychotropic…

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 facility assessment was updated annually. The administrator identified 41 residents resided in the facility. Findings: Review of the facility assessment did not contain a date of when the assessment was formed, updated, or last reviewed. On 01/08/24 at 4:40 p.m., the administrator was asked when the facility assessment was dated. The administrator stated they thought the assessment had been updated with COVID in 2020. The administrator stated the facility assessment did not have a date. There was no way to prove when the facility assessment was updated or reviewed. The administrator stated the facility assessment was reviewed last January when they were getting ready in 2023 survey but there is not a date on it. On 01/08/24 at 4:52 p.m., the administrator stated they started working at the facility in 2010 and the lock unit was the first thing they got up and running in 2011. The administrator stated they did not see the locked unit on the facility assessment.

Based on record review and interview, the facility failed to employ the services of a qualified social worker on a full times basis. The administrator identified 41 resident resided in the facility. Findings: On 01/08/24 at 4:36 p.m., the social service/activities director was out of the facility at this time buying cigarettes for the residents. On 01/08/24 at 4:38 p.m., the administrator stated the social service director did not have a degree. The administrator identified the facility was licensed for 124 beds. The administrator stated the facility did not currently have a qualified social worker. On 01/08/24 at 5:04 p.m., the employee file for the social service director was reviewed. The social service director did not have the credentials required for 124 bed facility.

Based on observation, record review, and interview, the facility failed to ensure equipment was sanitized between residents. The administrator identified 41 residents who resided in the facility. Findings: An Equipment and Supplies Used During Isolation policy, last revised on October 2009, read in part, .When possible, dedicate the use of non-critical resident-care equipment items such as stethoscope, sphygmomanometer .thermometer to a single resident (or cohort of residents) to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. On 01/04/24 at 8:50 a.m., CMA #1 was observed to enter Res #12's room to take their vital signs and administer their medication. Equipment brought into the room was a wrist blood pressure cuff and pulse ox. Equipment was taken out of the room and placed on the medication cart after use without being sanitized. On 01/04/24 at 9:00 a.m., CMA #1 was observed to enter Res #1's room to take their vital signs. Res #1 was in transmission based precautions for COVID.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure DNR forms were dated and signed appropriately for two (#27 and #98) of 16 residents who were reviewed for advance directive/DNR status. The administrator identified 41 residents who resided in the facility. Findings: 1. Res #27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, benign neoplasm, pain, and atrial fibrillation. A physician order, dated 11/29/22, documented the resident's code status was DNR. The care plan, dated 11/29/22, documented the resident had a signed DNR form. The care plan documented the staff was to verify the DNR and label the resident's chart with the physician order. An undated form titled Certification of Physician documented the form was used by a physician to certify the incapacitated person without a representative would not have consented to use of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. The signature was not legible and was not printed…

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 annual resident assessment was completed within the required timeframe for one (#8) of 15 sampled residents whose resident assessments were reviewed. The administrator identified 41 residents who resided in the facility. Findings: Res #8 had a quarterly resident assessment completed on 08/14/23. Their annual resident assessment was due 11/14/23 but was not completed. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported Res #8's annual assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.

Based on record review and interview the facility failed to ensure MDS assessments accurately reflect the resident's status related to GDR attempts for one (#39) of five residents reviewed for unnecessary medications. The administrator identified 41 residents resided in the facility. Findings: Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia. A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLs. The assessment documented the resident received an antipsychotic and an antianxiety medication. The assessment documented the resident had not had a gradual dose reduction attempted. A MRR, dated 02/08/23, documented the resident had an order for Zyprexa 5.0 mg BID. The MRR documented a request for a reduction attempt for Zyprexa to 2.5 mg in the a.m. and 5.0 mg in the evening. The EHR documented on 02/17/23, the resident's Zyprexa was decreased to 2.5 mg in the morning and 5.0 mg at night. On 01/04/24 at 11:59 a.m., the Corporate Nurse Consultant #1 stated the MDS was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident received services to prevent an ADL decline for one (#13) of two residents who were reviewed for ADL decline. The administrator identified one resident with an ADL decline in the past three months. Findings: Res #13 was admitted to the facility on [DATE] with diagnoses which included anemia, dehydration, muscle wasting and atrophy multiple sites, lack of coordination, muscle weakness, and difficulty with walking. The care plan, dated 05/19/23, documented the resident had a problem with ADL functions and required assistance with transfers, dressing, toileting, and personal hygiene. The care plan documented the resident needed physical therapy, occupational therapy, and speech therapy related to dehydration. The staff were to monitor progress, therapist and nursing to collaborate care, and provide services to maximize resident accomplishments. A physical therapy Discharge summary, dated [DATE], documented the resident's…

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 document, retain and make accessible to all residents and guests the required daily staffing information. The administrator identified 41 residents who resided in the facility. Findings: On 01/03/24 at 9:06 a.m. and throughout the investigation, a whiteboard at the east wing nursing station was observed to include the date and staff name and titles. There was no documentation of the facility name, census, or staffing hours worked. There was no staffing board in the memory care unit. On 01/08/24 at 4:00 p.m. the Corporate RN #1 reported the staffing board did not have the required components and 18 months of staffing records were not retained. On 01/08/24 at 4:55 p.m. the administrator reported they were not aware of the requirements for posted staffing or retention of staffing records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed. The administrator identified 39 resident who receive their meals from the facility kitchen. Findings: Res #43's annual assessment, dated 09/18/23, documented the resident's cognition was intact. On 01/02/24 at 12:26 p.m., Res #43 was observed in the dining room eating lunch. The resident stated the food was good today; the barbeque chicken was just messy. Res #43 stated the only problem they had was when they ask for food from the alternate menu the facility sometimes did not have it. The fall/winter 2023-2024 week 3 day 19 menu for 01/04/24 documented taco soup, shredded cheese, corn, lettuce and tomato chopped, tortilla chips, salsa, and a fruit cup. On 01/04/24 at 3:31 p.m., DA #1 was working in the kitchen preparing the evening meal. DA #3 was on break at this time. DA #1 stated they were having chicken fingers, mashed potatoes and gravy, spinach with eggs, rolls, 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 a resident received the necessary services to maintain grooming and personal hygiene for one (#1) of four residents sampled for assistance with bathing. The administrator stated 44 residents lived in the facility. Findings: Res #1 was admitted on [DATE] and had diagnoses which included congestive heart failure, muscle wasting, and pain in the thoracic spine. An admission assessment, dated 09/24/23, documented the resident was severely impaired in cognition, required extensive assistance with hygiene, and bathing did not occur. A facility document, titled CNA SKIN SHEET, dated 09/26/23, documented the resident had received a bed bath. A nurse note, dated 10/01/23, documented the resident had received a partial bath. The EHR documented Res #1 was discharged on 10/20/23. On 11/15/23 at 3:30 p.m., Corporate Nurse Consultant #1 stated there were only two documents for bathing related to Res #1. The corporate nurse stated no other baths 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident with wounds received the necessary assessments, treatments, and services for one (#1) of three residents reviewed for pressure ulcers and other wounds. The administrator stated 44 residents lived in the facility. Findings: Res #1 was admitted on [DATE] and had diagnoses which included congestive heart failure, muscle wasting, and pain in the thoracic spine. An admission nursing note, dated 09/21/23, documented the resident had a small open area, which they documented as a stage II, on their buttocks. The note did not document measurements of the area or if the resident's physician had been notified of the open area. A review of the resident's EHR did not document a treatment was put in place on 09/21/23 for care of the open area. The resident's care plan, dated 09/21/23, did not document a plan of care related to pressure ulcers. An admission assessment, dated 09/24/23, documented the resident was severely impaired in cognition 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 notify the physician of a change in condition for one (#51) of three residents whose records were reviewed for a change in condition. The Resident Census and Conditions of Residents report, dated [DATE], documented a census of 53 residents. Findings: Res #51 was admitted with diagnoses which included diabetes and hypertension. A Condition Change, Of the Resident (Observing, recording and Reporting), policy undated, documented in parts, .observe, record and report any condition change to the attending physician so proper treatment will be implemented . [Recorded as Late Entry on [DATE] at 1:11 p.m.] A progress note, dated [DATE] at 8:00 a.m., read in parts, Resident had vomited scant amount of greenish clear emesis . There was no documentation of physician notification for Res #51's change in condition. A progress note, dated [DATE] at 11:34 a.m., read in parts, Went into room to check resident FSBS (finger stick blood sugar), he was acting strange with…

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

Based on record review, observation, and interview, the facility failed to provide showers for two (#40 and #45) of three residents reviewed for showers. The Resident Census and Conditions of Residents, dated 01/30/23, documented six residents were dependent for bathing. Findings: Res #40 was admitted with diagnoses which included chronic kidney disease, diabetes, and muscle weakness. A quarterly assessment, dated 11/25/22, documented Res #40 was cognitively intact and required extensive assistance with bathing. A bathing sheet, dated December 2022, documented Res #40 received four of 13 scheduled showers. A bathing sheet, dated January 2023, documented Res #40 received seven of 13 scheduled showers. A care plan, reviewed 01/24/23, read in part, .Bathing extensive .give shower . On 01/30/23 at 10:34 a.m., Res #40 reported they were not receiving showers three times a week as scheduled. Res #40 stated there were not enough staff to ensure their showers were given. Res #45 was admitted with diagnoses which included atrial fibrillation and dementia. A care plan, reviewed 05/18/22, read…

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 sufficient staff to care for the needs of the residents. The Resident Census and Conditions of Residents, dated 01/30/23, documented a census of 53 residents. Findings: An undated facility assessment read in parts, Direct Care Staff 1:6 days, 1:8 evenings, 1:15 nights. Total licensed or certified. The Quality of Care report, dated October 2022, documented 30 of 31 days were not staffed per the facility assessment. The nursing schedule, dated October 2022, documented 30 of 31 days were not staffed per the facility assessment. The Quality of Care report, dated November 2022, documented 16 of 30 days were not staffed per the facility assessment. The nursing schedule, dated November 2022, documented 16 of 30 days were not staffed per the facility assessment. The Quality of Care report, dated December 2022 documented 10 of 31 days were not staffed per the facility assessment. On 01/30/23 at 10:34 a.m., Res #40 reported they had not received showers three times a week as scheduled. The resident reported it was due to 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 record review, observation, and interview, the facility failed to ensure food was prepared and stored in a sanitary manner. The Resident Census and Conditions of Residents report, dated 01/30/23, documented 51 residents received meals from the kitchen. Findings: A policy titled Food Preparation and Service, dated 07/14, read in parts, .Foods will not be thawed at room temperature . A policy titled Preventing Foodborne Illness-Employees Hygiene and Sanitary Practices, dated 10/08, read in parts, .food service employees will be trained in the proper use of utensils . On 01/30/23 from 9:20 to 9:45 a.m., a turkey breast was observed sitting on the food preparation counter to thaw. On 01/30/23 from 9:24 to 9:45 a.m., common scoops were observed in the flour and sugar bins. On 02/04/23 from 10:40 to 10:50 a.m., during puree preparation, cook #1 was observed repeatedly using the blender bowl and blade without placing them in the dishwasher between uses. On 01/30/23 at 9:45 a.m., the DM reported the turkey breast should not have been left at room temperature to thaw and the common…

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 regarding weight loss for one (#30) of one resident reviewed for weight loss. The DON identified five residents who had weight loss in the last six months. Findings: Res #30 was admitted with diagnoses which included CVA. A Registered Dietician progress note, dated 10/11/22 at 2:10 p.m., read in parts, Oct wt 118.6 .underweight. Sig wt loss 8.1%/3mo . A quarterly assessment, dated 10/29/22, did not document the significant weight loss. A quarterly assessment, dated 01/29/23, documented in parts, .Loss of 5% or more in the last month .on physician-prescribed weight-loss regime . On 02/06/23 at 10:58 a.m., RN #2 reported the significant weight loss should have been documented on the quarterly assessment for 10/29/22 and Res #30 was not on a physician-prescribed weight-loss regime and it should not have been documented on the assessment.

Based on record review and interview, the facility failed to revise a care plan with fall interventions for one (#30) of one resident reviewed for falls. The DON identified 15 residents who had falls in the last six months. Findings: A Fall - Evaluation and Prevention policy, dated 03/15, read in parts, .It is the policy of this facility to evaluate residents for their fall risk and develop interventions for prevention .Review all falls immediately .review of nurses note documentation and care plan updating. Fall interventions are to be reviewed for appropriateness, to ensure that they are a new intervention, and to ensure that they have been implemented . Res #30 was admitted with diagnoses which included difficulty walking, lack of coordination, and muscle weakness. A nursing note, dated 09/14/22 at 1:17 a.m., read in parts, .slipped and fell on .buttock .put bedside commode beside bed . A nursing note, dated 10/20/22 at 2:15 p.m., read in parts, .resident found in .room floor . A comprehensive care plan, dated 01/17/23 at 2:50 p.m., was not revised with fall interventions 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.