Midwest City Post Acute & Rehab

Based on observation and interview, the facility failed to ensure a call cord was within reach for one (#23) of 13 sampled residents whose call cord availability was observed. The administrator identified 53 residents resided in the facility. Findings: An undated Call Lights policy, read in part, Always be sure the resident has a functioning call light that is the easiest type for them to use. Always place the call light in an accessible location to where the resident is located in their room. Resident #23 had diagnoses which included cerebral infarction and hemiplegia of dominant side. Resident #23's quarterly assessment, dated 11/07/24, documented the resident had functional range of motion limitations to all four extremities and was dependent on staff for all activities of daily living. On 01/27/25 at 12:51 p.m., a touch pad call light was observed attached to the curtain against the wall while Resident #23 was in a specialized mobile chair in front of their bed. The touch pad was not within their reach. On 01/27/25 at 12:53 p.m., LPN #1 stated Resident #23's touch pad call light…

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 restorative therapy was provided to a resident with limited ROM for one (#3) of three sampled residents reviewed for therapy services. The DON identified 11 residents who received restorative therapy resided in the facility. Findings: A Restorative Nursing policy, revised 05/16/19, read in part, .the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable .Restorative Services .actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning .A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy . Resident #3 had diagnoses which included cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. An admission…

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 gait belt was used during a two-person physical assist transfer for one (#7) of three sampled residents reviewed for accident hazards. The administrator identified 58 residents resided in the facility. Findings: A Bed Mobility and Transfers policy, undated, read in part, .Sit to Stand Transfer Procedure .With hands securely on the safety/gait belt, instruct the resident to stand .Bed to/From Wheelchair .Secure a gait belt around the resident's waist .Make sure your hands are securely on the safety/gait belt . Resident #7 had diagnoses which included Parkinson's disease and tremor. A Quarterly Resident Assessment, dated 07/09/24, documented Resident #7 had severe cognitive impairment and required partial/moderate assistance for the sit to stand task and the transfer to and from a bed to a wheelchair task. On 10/16/24 at 9:48 a.m., CNA #5 and CNA #6 were observed placing one arm under each of Resident #7's arms, held the backside of Resident #7's pants, and hoisted the resident up from their wheelchair…

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 homelike environment by maintaining comfortable water temperatures for two (300 hall and 400 hall) of two shower rooms observed for comfortable water temperatures. The maintenance supervisor identified two shower rooms in the facility. Findings: The Water Temperatures, Safety of policy, dated December 2009, read in parts, .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than ____ [degrees] F ., or the minimum allowable temperature per state regulation .Maintenance staff is responsible for checking thermostats and temperature controls and record the water temperatures in a safety log . On 02/13/24 at 11:09 a.m., Resident #6 stated the water in the shower rooms were hard to adjust. They stated the water was either too hot or too cold. On 02/13/24 at 11:16 a.m., the 300 hall shower room was observed. The shower on the left side was observed to register 84 degrees F with only the hot water running. At 11:18 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure licensed nurses received competency/skills checks for two (LPN #1 and LPN #3) of five employee files reviewed for competency/skills checks. The DON identified 16 nurses who currently worked at the facility. Findings: 1. LPN #1 was hired on [DATE]. The ODH Form 283, read in parts, .Incident date: 01-28-2024 .Part B .On [DATE] [LPN #1] was the nurse for [Resident #2]. Resident was on hospice and had a physician order for morphone [sic] 0.5ml q4 hours PRN. [LPN #1] stated that [they] administered this medication outside of physician order and time regulations. [LPN #1] stated [they] filled a 10ml syringe with 3ml of morphine and used this to administer several doses to the resident within [their] shift. Resident expired on [DATE]. [LPN #1] was suspended pending the outcome of the investigation .Part C .[LPN #1] was suspended. [LPN #1] will have another nurse sign off on any narcotics given since [they are] not allowed to be terminated. Education…

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 records were accurate for one (#2) of five sampled residents whose records were reviewed. The DON identified 64 residents resided in the facilty. Findings: Resident #2 had diagnoses which included nontraumatic intracerebral hemorrhage. A physician order, dated [DATE], documented Resident #2 was ordered lorazepam 2mg/ml give one milliliter every four hours as needed for anxiety. An Order Note, dated [DATE] at 4:26 p.m., documented a new order from hospice had been received for morphine 20ml/mg every four hours as needed for pain/shortness of breath. The Controlled Drug Receipt/Record/Disposition Form, documented on [DATE], LPN #1 administered morphine 0.5ml at 6:00 a.m., 10:15 a.m., and 2:30 p.m. The Controlled Drug Receipt/Record/Disposition Form, dated [DATE], documented LPN #1 administered an additional dose of morphine 0.5ml at 10:15 a.m., 2:30 p.m., and 3:00 p.m. per family request. The MAR, dated [DATE], did not contain documentation…

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 controlled medications were reconciled when they were delivered from the pharmacy for one (#2) of three sampled residents whose medications were reviewed. The DON identified 50 residents had orders for controlled medications. Findings: The Accepting Delivery of Medications policy, dated April 2007, read in parts, .Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt .A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery . Resident #2 had diagnoses which included nontraumatic intracerebral hemorrhage. A physician order, dated 01/24/24, documented an order for morphine 20ml/mg every four hours as needed for pain/shortness of breath. A Packing Slip dated 01/24/24, documented the pharmacy had filled 20mls of morphine 20mg/ml for Resident #2. A Prescription History, dated 01/24/24, documented the pharmacy had delivered the morphine to the facility and it had been signed for by LPN #2. 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 order and administer medication as ordered for one [#1] of four sampled residents reviewed for medication. The Administrator identified 73 residents resided in the facility. Findings: The facility's Medication Administration policy, dated 05/2017, read in part, .PRN medication, reason for administration, and effectiveness in the Nursing Notes or on the back of the MAR .Dispense Medication as ordered . Resident #1 has a diagnosis of anxiety disorder, schizophrenia, dementia along with mood, behavior and agitation deficits. Physician's order: dated 02/26/23, documented Xanax(alaprazolam) 0.25 mg Give 1 tablet by mouth every 6 hours as needed for anxiety. On 12/07/23 at 3:43 p.m., DON stated, according to Resident #1 charts, they missed the 17:45 dose. They stated they put in a order for the medication to be refilled 08/31/23 at 21:43, because they ran out. On 12/06/23 at 3:41 p.m., DON stated Resident #1 nursing notes says they requested a prn dose of Xanax at 1500. On 12/06/23 at 3:23 p.m., DON stated, medications are to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were allowed the opportunity to formulate or decline an advanced directive for two (#12 and #50) of 18 sampled residents reviewed for advance directive. The Resident Census and Conditions of Residents report, dated 10/17/23, documented 70 residents resided in the facility. Findings: An Advance Directives Policy and Procedure policy, undated, read in parts, .The facility provides to all residents the right to accept or refuse .formulate an advance directive . 1. Resident #12 was admitted to the facility on [DATE]. 2. Resident #50 was admitted to the facility on [DATE]. There was no documentation Residents #12 and #50 were provided the opportunity to formulate an Advance Directive or declined. On 10/18/23 at 9:33 a.m., Medical Records stated there was no advanced directive for Resident #12 or Resident #50. On 10/18/23 at 1:20 p.m., The Administrator stated residents were offered the option of formulating or declining an advance directed…

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 the intervention of a fall mat was in place for one (#41) of two sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 10/17/23, documented 70 residents resided in the facility. Findings: Resident #42 had diagnoses which included left femur fracture. A Resident Assessment, dated 08/03/23, documented Resident #41 required extensive assistance for transfers. A Care Plan, last revised 08/16/23, documented Resident #41 has had an actual fall and is at risk for further falls. It documented an intervention of a fall mat had been implemented on 02/11/23. A Physical Therapy evaluation, dated 08/28/23, documented Resident #41 required two person assistance and was at risk for falls. On 10/17/23 at 10:24 a.m., Resident #41 was observed in bed. They were observed to have bruising to their forehead, both eyes, and left chin. Resident #41 stated they had fallen trying to get up. No fall mat was observed in the resident's room. On 10/19/23 at 2:07 p.m., Resident #41 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 record review and interview, the facility failed to ensure antipsychotic medications were ordered with an appropriate diagnoses for one (#39) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 10/17/23, documented 70 residents resided in the facility. Findings: A Psychotropic Drugs Usage policy, undated, read in part, .The following specific conditions are acceptable to warrant the use of anitpsychotic medications. The following diagnoses must be documented by the physician or consultant psychiatrist in the clinical record of the resident receiving an antipsychotic medication . Alzheimer's was not included as an appropriate diagnoses for an antipsychotic. Resident #39 had diagnoses which included Alzheimer's disease and vascular dementia. A Physician's Order, dated 11/17/22, documented to administer Seroquel (antipsychotic medication) 25 mg daily at bedtime related to Alzheimer's disease. On 10/19/23 at 1:13 p.m., the DON was asked how they ensured appropriate diagnosis for antipsychotic medications.…

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 and interview, the facility failed to ensure a homelike environment in a resident's room for one (#71) of three sampled residents reviewed for homelike environment. The Resident Census and Condition of Residents report, dated 10/17/23, documented 70 residents resided in the facility. Findings: Resident #71 had was admitted to the facility on [DATE]. On 10/17/23 10:42 a.m., Resident #71 was observed in their room, in bed. The wall behind the headboard was observed to be in disrepair. There were multiple areas paint was missing, wall board was peeled of and other areas were it was starting to peel. Resident #71 was asked how long the wall had been in that condition. They stated it had been that way when they moved in. On 10/20/23 at 10:24 a.m., the maintenance supervisor was asked how they ensured a comfortable, home like environment. They stated by making sure everything was up to code and working. The maintenance supervisor if they where aware of the wall behind Resident #71's wall behind…

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 a mattress was in good repair for one (#25) of 24 sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: Resident #25 had diagnoses which included anoxic brain injury and pain. On 11/17/22 at 2:29 p.m., Resident #25 was observed in bed. The mattress was observed to be peeling from the residents shoulders to the top of their head and from their knees to the end of their legs. jasmine crying out, staff On 11/18/22 at 8:51 a.m., LPN #1 was asked how they ensured a resident's mattress was in good repair. They stated if we have somebody that needs a new bed, we let the supply person know. They stated they discussed concerns in morning meeting and via a group text. LPN#1 was shown Resident #25's mattress. They stated, It's peeling. They were asked if the mattress was in good repair. They stated, No, we need a new one.

Based on record review, observation, and interview the facility failed to implement a care plan for falls for one (#25) of two sampled resident reviewed for accident hazards. A Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: A Baseline Care Plan Assessment/Comprehensive Care Plans policy, undated, read in parts .Policy: The facility interdisciplinary team .will discuss and develop quantifiable objectives along with appropriate interventions in a effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident . Resident #25 had diagnoses which included unspecified convulsions, anoxic brain damage, and diffuse traumatic brain injury. A fall Care Plan, target date 10/28/22, read in part, .9/24/22- Fall matt (sic) next to bed Date Initiated: 11/16/2022 . On 11/16/22 at 8:45 a.m., Resident #25 was observed lying in bed. No fall mat was observed on the resident's floor. On 11/17/22 at 1:26 p.m., Resident #25 was observed lying in…

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, observation, and interview, the facility failed to ensure a resident care plan was updated for one (#25) and a resident was asked to participate in a care plan meeting for one (#18) of 13 sampled residents whose care plans were reviewed. A Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: A Baseline Care Plan Assessment/Comprehensive Care Plans policy, undated, read in parts .Policy: The facility interdisciplinary team .will discuss and develop quantifiable objectives along with appropriate interventions in a effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident .The facility Social Service Director or designee will notify the resident of their scheduled care plan conference and will invite and encourage the resident to attend. This notification will continue for any subsequent care plan conferences. These notifications will…

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, observation, and interview, the facility failed to ensure toenail care was provided to dependent residents for two (#111 and #25) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: A Skin and Foot Care, policy, revised March 2015 read in part, .Toenails should only be trimmed by personnel qualified to do so (this can be regular staff, and does not have to be a podiatrist), according to facility policy . 1. Resident #111 re-admitted to the facility on [DATE] with diagnoses which included Atherosclerotic heart disease. A Resident Assessment, dated 10/02/22, documented the resident required oversight for personal hygiene. On 11/17/22 at 8:51a.m., Resident #11 was observed in bed. Their feet were observed to be uncovered. Their toenails were observed to be extremely long and curling under into their skin. They were asked how frequently staff trimmed their toenails.…

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 dialysis resident had been assessed upon return from dialysis for one (#13) of one sampled resident reviewed for dialysis. The Resident Census and Conditions of Residents' report, dated 11/15/22, documented two residents received dialysis services. Findings: A Community Hemodialysis policy, undated, documented the facility would monitor the resident after dialysis for any signs and symptoms of disequilibrium syndrome, nausea, vomiting or bleeding from the dialysis access site. Resident #13 had diagnoses which included chronic kidney disease. A Dialysis Communication form, documented upon a residents' return from dialysis, staff were to assess a residents' vital signs, status of access site, medications administered upon return, and the residents' condition. Nursing Progress notes, dated 09/04, 09/17, 09/29, 10/11, 10/13, 10/20, 10/25, and 10/27/22, documented Resident #13 had returned from dialysis. There was no documentation the resident had been assessed for vital signs, the status of the access site,…

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 ensure sufficient staffing to meet the minimum requirements for four of thirty days reviewed for sufficient staffing. The Resident Census and Conditions of Residents report, documented, 11/15/22, documented 58 residents resided in the facility. Findings: The Quality of Care Monthly Report for September 2022, documented, the facility did not meet the required 2.90% staffing for the following days: On September 11, the facility had 2.23%, on September 17, the facility had 2.37%, on September 18, the facility had 1.77%, and on September 25, the facility had 2.32%. On 11/18/22 at 12:38 p.m., the DON stated the staffing numbers for these days did not meet the requirement for sufficient staffing.

Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. A Resident Census and Conditions of Residents report dated 11/15/22, documented 58 residents resided in the facility. Findings: An undated Registered Nurse Coverage policy, read in part, .it is the policy of the facility to provide the services of an RN for at least 8 consecutive hours per 24 hour day, 7 days weekly . Review of Punch Detail report documents there was no RN coverage for 5/5, 5/6, 5/17, 5/28, and 5/29/2022. On 11/18/22 at 9:40 a.m., the DON was ask for the RN coverage. On 11/18/22 at 11:22 a.m. the DON stated we did not have RN coverage on 5/5. 5/6, 5/17, 5/28, and 5/29/2022. On 11/18/22 at 12:32 p.m. the Administrator stated, we follow regulation for RN coverage. On 11/18/22 at 12:38 p.m. the DON stated there should be 8 hours RN coverage 7 days a week.

Based on record review and interview, the facility failed to administer medications as ordered for three (#10, 25 and #33) of six sampled residents reviewed for medication administration. A Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: A Medication Administration Guidelines policy, undated, documented staff were to verify each medication against the MAR. It documented staff were to sign the MAR immediately after administering medications, document necessary medication administration information, and document withheld medications per facility policy. 1. Resident #10 had diagnoses which included HTN, major depressive disorder, other rheumatic valve disease, COPD, Alzheimer's disease and unspecified osteoarthritis. Resident #10 had the following physician's orders: a. Apixaban tablet 2.5 mg give one tablet PO BID, start date of 03/01/22, b. Depakote tablet delayed release 250 MG give one tab PO BID, start date 03/01/22, c. Ferrous Sulfate tablet 325 MG give one tab PO BID, start date 03/01/22, d.…

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 observation, the facility failed to ensure a resident's call light was in reach for one (#111) of 13 sampled residents reviewed for call lights. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: Resident #111 had diagnosis which included anoxic brain injury. On 11/7/22 at 8:51 a.m., Resident #111 was observed laying in bed. The resident's call light was observed to be off the bed and was on top of a small shelf at the end of the bed. On 11/17/22 at 9:04 a.m., Resident #111 was asked how they called for staff assistance. They stated with the call light if they can find it. On 11/17/22 at 9:11 a.m., CNA #2 was asked what the policy was for call lights. They stated we go in each room and double check and make sure they had them. They were asked if Resident #111 was able to use the call light. They stated yes. CNA #2 was asked to locate the resident's call light. They stated it was on the shelf at the end of the bed. On 11/17/22 at 10:33 a.m., the ADON was informed of Resident…

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

Based on record review and interview, the facility failed to implement their abuse policy for one (#20) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: An Abuse Prevention Program policy, updated 05/02/17, read in part, .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .The facility will take steps to prevent mistreatment while the investigation is underway .Staff members who are suspected of abuse or misconduct shall immediately (regardless of the time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately per state and federal regulations .Department of Health, Ombudsman, APS, local police department…

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 allegation of abuse had been reported to OSDH within two hours for one (#20) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: An Abuse Prevention Program policy, updated 05/02/17, read in part, .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately per state and federal regulations .Department of Health . Resident #20 had diagnoses which included dementia. A Resident Assessment, dated 10/11/22, documented Resident #20's cognition was intact. An undated, hand written statement from CNA #4, documented they heard an altercation between Resident #20, their family member, and CMA #3. They stated CMA #3 threw the medication cart keys in the air and stated 'All this for no [expletive] reason' as they were walking away. CMA #3's time…

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 allegation of abuse had been thoroughly investigated and residents had been protected from further potential abuse for one (#20) of one sampled resident reviewed for an allegation of abuse. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: An Abuse Prevention Program policy, updated 05/02/17, read in part, .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .The facility will take steps to prevent mistreatment while the investigation is underway .Staff members who are suspected of abuse or misconduct shall immediately (regardless of the time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such…

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 accurate resident assessments for one (#13) of one sampled resident reviewed for dialysis. The Resident Census and Conditions of Residents' report, dated 11/15/22, documented two residents received dialysis services. Findings: A Community Hemodialysis policy, undated, documented the facility would monitor the resident after dialysis for any signs and symptoms of disequilibrium syndrome, nausea, vomiting or bleeding from the dialysis access site. Resident #13 had diagnoses which included chronic kidney disease. A Resident Assessment, dated 09/03/22, did not document dialysis services. Dialysis services was checked No. A Physician's order, dated 11/08/22, documented dialysis three times a week on Tuesday, Thursday, and Saturday. On 11/15/22 at 10:00 a.m., Resident #13 was asked if they received dialysis services. They stated they did. They stated they had been receiving dialysis services for about three years. On 11/18/22 at 8:31 a.m., the ADON was asked if Resident #13 received dialysis services. They stated 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 observation and interview, the facility failed to ensure a resident room was free from potential accident hazards for one (#26) of 24 sampled resident reviewed for accident hazards. Resident #26 had diagnoses which included Dementia. A Resident Assessment, dated 09/09/22, documented the resident had impaired cognition and required extensive assistance with transfers. An ADL careplan, dated 11/26/22, read in parts, . has risk for falls .needs a safe environment with: even floors free .clutter . On 11/15/22 at 1:41 p.m., Resident #26's room was observed to have a sheet stuck to the floor in front of the resident's recliner. The sheet was approximately three to four feet wide and was on top of a black sticky substance. On 11/17/22 at 7:55 a.m., the sheet was again observed to be stuck to the floor in front of the resident's recliner. On 11/17/222 at 7:55 a.m., RN #1 was asked how long the sheet stuck to the black sticky substance had been on floor. She stated she was not sure, but thought it was about three weeks ago. On 11/17/22 CNA #1 was asked how long the sheet stuck to the…

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

Based on record review and interview, the facility failed to ensure the physician responded to a GDR for one (#33) of five sampled residents reviewed for unnecessary medications. A Resident Census and Conditions of Residents report, dated 11/15/22, documented nine residents received antipsychotic medications. Findings: A Psychotropic Monitoring policy, dated 06/21/17, read in part, .For any individual who is receiving a psychotropic medication, the GDR may be considered clinically contraindicated if .The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . Resident #33 had diagnoses which included vascular dementia with behavioral disturbances and psychosis. A physician's order, dated 09/10/21, documented, seroquel tab 50 MG give one tab PO at bedtime for psychosis. A Physician Recommendation from pharmacy, dated 06/14/22, read in part, .This resident currently takes Seroquel 50 mg HS. Please assess and if appropriate, consider a dose reduction…

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 obtain physician ordered labs for one (#25) of six sampled residents whose records were reviewed for laboratory services. A Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: A Lab Scheduling/Tracking policy, undated, read in part, .It is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically scheduled and tracked so that ordered lab work is obtained and results are received and reported timely .The Charge Nurse will monitor the scheduled labs daily to check to ensure that any collected lab results are received timely as well as to confirm that received results are reported to the physician . Resident #25 had diagnoses which included anoxic brain damage, unspecified convulsions, and diffuse traumatic brain injury with loss of consciousness. A physician's order, dated 12/22/20, documented keppra level every three months in the months of January, April, July, and October. The resident's record 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 record review, observation and interview, the facility failed to ensure the ice machine was clean and sanitary. The Resident Census and Conditions of Residents report, dated 11/15/22, documented 58 residents resided in the facility. Findings: The Nutritional Services policy, dated 09/12/14, read in part, .The Facility will maintain the ice machine .storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once quarterly or more often as needed . On 11/15/22, at 12:13 p.m. the ice machine on hall 400 was wiped with a white paper towel underneath the dispenser flap. A large amount of black substance on paper towel and on the bottom of the entire length of the dispenser edge. On 11/15/22, at 12:45 p.m. the administrator was shown the black substance on the white paper towel, and on the dispenser edge that had the black substance. The administrator was asked when the machine was last maintenanced. They stated they just had a company come out. The administrator was asked how often the ice machine was cleaned and sanitized. They…

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

Based on record review, observation, and interview, the facility failed to ensure oxygen tubing wasn't stored on the floor for one (#111) of one sampled resident reviewed for oxygen. The facility Matrix report, dated 11/15/22, documented two residents received oxygen services. Findings: Resident #111 had diagnoses which included anoxic brain injury. On 11/17/22 at 8:51 a.m., Resident #111's oxygen tubing was observed to be laying on the floor. On 11/17/22 at 9:11 a.m., CNA #2 was asked what the policy was for storing oxygen tubing. They stated if it was not in use, it was placed in a bag and dated. They were shown the oxygen tubing on the floor. CNA #2 was observed to pick up the oxygen tubing, placed it in a plastic bag and tied it to the oxygen concentrator. On 11/17/22 at 10:33 a.m., the ADON was made aware of the oxygen tubing laying on the floor. She was informed CNA #2 picked the tubing up off the floor, bagged it, and fastened it to the oxygen concentrator.