Thunder Care and Rehabilitation

Based on observation and interview, the facility failed to ensure all components of the daily staffing information was posted for 2 of 2 observations. The administrator reported 127 residents resided in the facility. Findings: On 04/22/25 at 8:50 a.m., a daily staffing schedule was observed in a glass case on the North hall. The schedule was dated 04/22/25 and did not contain the census or the actual hours worked. On 04/23/25 at 8:42 a.m., a daily staffing schedule was observed in a glass case on the North hall. The schedule was dated 04/23/25 and did not contain the census or the actual hours worked. On 04/24/25 at 12:05 p.m., the administrator reported they did not know the census and actual hours worked had to be on the schedule.

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 1 (#124) of 6 residents sampled for timely administration of medications. The administrator identified 127 residents resided in the facility. Findings: An undated administration time document showed the morning medication pass was from 7:00 a.m. to 11:00 a.m. A policy titled Administering Medications, revised 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescribe orders, including any required time frame. Physician orders for Resident #124, dated 04/20/25, showed to administer the following: a. pristiq (an antidepressant) 50 mg in the morning for depression, b. clozapine (an antipsychotic) 200 mg two times a day for schizophrenia, c. rilutek (benzothiazole drug) 50 mg two times a day for bipolar disorder, d. naltrexone (opioid antagonist) 50 mg in the morning for opioid abuse. An April 2025 Medication Administration Audit Report, showed: a. clozapine…

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 enhanced barrier precautions were utilized for a resident with a wound for 1 (#79) of 1 sampled resident reviewed for wound care. The DON identified 18 residents received wound care. Findings: On 04/23/25 at 9:52 a.m., RN #1 was observed to provide wound care for Resident #79. RN #1 was not observed to utilize a gown during wound care. Signage was not observed near the resident's room. A policy titled Enhanced Barrier Precautions, dated April 2024, read in part, EBP's employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following .wounds. An admission assessment, dated 02/24/25, showed Resident #79 had a stage four pressure ulcer and a BIMS summary score of three, which indicated the resident was severly impaired in cognition for daily decision making. On 04/23/25 at 10:15 a.m., RN #1 stated EBP included a gown and gloves. RN #1 stated they should have worn a gown for wound care. On 04/23/25 at 10:44 a.m., the DON stated 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.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of a medication change for one (#1) of three sampled residents reviewed for notification. The administrator identified 109 residents resided in the facility. Findings: Resident #1 was admitted to the facility with diagnoses which included cerebral palsy, autistic disorder, and spastic quadriplegic cerebral palsy. A physician's order, dated 08/01/24, documented permethrin external cream 5%, apply to entire body topically, leave on and wash off after 8 hours. The resident's record was reviewed and contained no documentation the resident's representative was notified of the new order. On 10/08/24 at 12:27 p.m., licensed practical nurse #1 stated they did not remember if they notified the resident's representative of the new order.

Based on observation, record review, and interview, the facility failed to ensure a proper bed bath was provided for one (#3) of two sampled residents observed receiving bed a bath. The Administrator identified 105 residents resided in the facility and 79 residents needed assistance with bathing. Findings: Resident #3 had a diagnosis of obesity. Resident #3's admission resident assessment, dated 05/03/24, documented Resident #3 had moderate cognitive impairment and they were dependent on another person for bathing. Resident #3's care plan for self-care deficit, dated 05/01/24, documented the Resident required staff participation with bathing. On 07/26/24 at 9:49 a.m., Resident was observed receiving a bed bath. On 07/26/24 at 9:53 a.m., There were no washcloths left to continue the Resident's bed bath. CNA #3 stepped out of the room to get more washcloths. CNA #1 and CNA #2 each had a washcloth in their hands. They both reused the washcloths by dipping them back into the soapy wash basin one time to wash the Resident. On 07/26/24 at 10:00 a.m., CNA #3 cleaned Resident #3's upper…

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's were treated with dignity and respect for one (#1) of three sampled residents. The ADON reported 98 residents resided in the facility. Findings: Res #1 admitted to the facility with diagnoses of intellectual disability disorders, bipolar, and anxiety. An admission assessment, dated 07/19/23, documented the resident's was severely impaired with cognition. A state incident report, dated 01/23/24, documented a staff member grabbed the resident and took her back to her room and sat her down on the bed because she was trying to hit them. A care plan, dated 01/25/24, documented the resident had the potential to demonstrate physical and verbal behaviors. On 01/30/24, the administrator reported the staff member had been terminated and an in-service was held regarding how to respond to resident behaviors.

Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered related to: a. Res #20 not being observed during a breathing treatment, b. Res #30 not receiving insulin as ordered, and c. Res #35 and #54 not receiving the correct dose of nasal spray for four of nine residents whose medications were reviewed. Corporate Nurse Consultant #1 identified six residents who received breathing treatments. The ADON identified 14 residents who received insulin. The MDS coordinator identified 97 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included COPD. A physician order, dated 08/02/18, documented ipratroium albuterol solution (bronchodilator medication) 0.5 - 2.5, 3 mg/3 ml 1 vial inhale orally four times a day. On 12/20/23 at 10:52 a.m., the resident was observed in their bed with a nebulizer mask covering their nose and mouth receiving a breathing treatment. There was no staff present in the resident's room or at their door. On 12/20/23 at 11:25 a.m., the DON entered the resident's room and removed…

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 their medication error rate was less than 5%. There were 33 medication opportunities observed with two medication errors, resulting in a medication error rate of 6.06 %. The MDS coordinator identified 97 residents resided in the facility. Findings: 1. Res #35 had diagnoses which included allergies. A physician order, dated 12/05/23, documented to administer fluticasone nasal spray, two sprays in each nostril twice per day for allergies. On 12/19/23 at 8:41 a.m., CMA #1 was observed passing medications for Res #35. The CMA was observed handing the nasal spray bottle to Res #35 who then self administered one spray per nostril. On 12/19/23 at 08:43 a.m., CMA #1 stated they always handed the resident their nasal spray and as far as they were aware the resident was allowed to self administer the medication. They stated the resident's order was for two sprays per nostril. On 12/19/23 at 11:09 a.m., Corporate RN #1 stated there were no residents in the facility who were assessed to self administer…

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 the kitchen was kept clean and maintained in good repair. The DM identified 96 residents received services from the kitchen. Findings: On 12/18/23 at 8:49 a.m., a tour of the kitchen was conducted. The following observations were made. a. The hand sink was loose from the wall. There was a gap between the wall and the hand sink. b. Light covers were missing off of the ceiling lights and light covers were cracked. c. Floor tiles were missing. The concrete was exposed and not level. d. The sheetrock was cut out of the wall and the wall frame was exposed in the dish wash area. e. There was paint peeling and the metal was rusted on the shelving below the drain board attached to the dish machine, f. The base board was loose from the wall in the dish wash area. g. There was an accumulation of lint on the return vent. h. There was an accumulation of black residue on the floor under equipment and along the base boards, i. There was an accumulation of white residue inside on the inside and outside of the dish machine. j. There 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 notify the physician regarding abnormal lab results for one (#32) of five sampled residents reviewed for unnecessary medications. The MDS coordinator identified 97 residents resided in the facility. Findings: Res #32 had diagnoses which included epilepsy. A physician order, dated 07/20/21, documented to obtain a dilantin level every three months. A physician order, dated 06/07/23, documented to administer dilantin 100 mg three times per day for epilepsy. A laboratory report, dated 07/25/23, documented a low lab result for dilantin. There was no documentation the physician was notified of the abnormal lab results. A monthly drug regimen review, dated 08/01/23, documented the pharmacist had noted the lab result for dilantin was subtherapeutic and requested more information from the facility regarding the medication regimen. There was no documentation the physician was notified of the results or responded to the pharmacist. On 12/20/23 at 10:40 a.m., the ADON stated there should have been a record in the chart documenting 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 record review and interview, the facility failed to accurately complete a PASARR Level I screening for one (#4) of three reviewed for PASARR screening. The administrator identified 97 residents resided in the facility. Findings: Resident #4 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. A PASARR level l form, dated 02/18/22, documented the resident did not have a diagnosis of serious mental illness. On 12/20/23 at 10:49 a.m., the MDS coordinator reviewed the resident's clinical record and stated the PASARR level l completed for the resident was not completed correctly. The coordinator stated a PASARR level ll referral should had been made to the OHCA with a diagnosis of major depressive disorder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide restorative services as ordered by the physician for one (#8) of two resident reviewed for range of motion. The administrator identified 11 residents who received restorative services. Findings: A facility policy titled Restorative Nursing Services, read in part, .Restorative goals may include, but are not limited to supporting and assisting the resident in .developing, maintaining or strengthening his/her physiological and psychological resources . Res #8 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease, hemiplegia, muscle weakness, and contractures. A physician order, dated 11/13/23, documented the resident was to be added to the restorative program and receive range of motion to all extremities and group exercise three times a week. On 12/18/23 at 1:22 p.m., the resident was sitting in a motorized wheelchair in their room. The resident's hands and feet were contracted. The resident…

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

Based on observation, record review, and interview, the facility failed to obtain a physician order for oxygen therapy for one (#64) of one sampled resident reviewed for respiratory care. MDS Coordinator #1 identified 97 resident resided in the facility. Findings: Res #64's quarterly resident assessment, dated 11/30/23, documented the resident received oxygen therapy while a resident. On 12/18/23 at 10:56 a.m., the resident was observed with oxygen in place. The oxygen concentrator was set at 1 liter per minute. On 12/19/23 at 10:19 a.m., the resident was observed with oxygen in place. The oxygen concentrator was set at 1 liter per minute. There was no physician order for the resident to receive oxygen therapy. On 12/19/23 at 10:23 a.m., LPN #1 was asked if the resident had an order for oxygen therapy. They reviewed the resident's EHR and stated they did not see an order for the resident to receive oxygen.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the use of bed rails prior to installation for one (#86) of one sampled resident reviewed for physical restraints. The administrator identified one resident with bedrails. Findings: Res #86 had diagnoses which included senile dementia. A health status note, dated 12/02/23, documented hospice brought supplies for the resident which included a bed, mattress, and bed rails. On 12/18/23 at 10:29 a.m., the resident was observed seated on the side of the bed with their feet on the floor. There were two half rails observed in the upward position on the upper half of the bed. The resident was observed utilizing the bed rail to move from a seated position to a lying position in their bed. There was no documentation the resident was assessed for the use of bed rails. On 12/20/23 at 11:56 a.m., LPN #1 was asked was asked what was the purpose for the half rails on the resident's bed. They stated hospice provided the bed and the bed rails. They stated the resident used the bed rails 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 ensure diet orders were followed for one (#20) of five sampled resident reviewed for nutrition. The DM identified 96 residents received services from the kitchen. Findings: Res #20's physician order, dated 10/19/21, documented regular diet, regular texture, regular liquids consistency, double portions, fortified foods, 60 ml Med Pass between meals, and house supplement with lunch and dinner. A quarterly resident assessment, dated 10/24/23, documented the resident's cognition was intact. On 12/18/23 at 11:52 a.m., the resident was asked about the food. They stated they did not get enough to eat. They stated they were supposed to get double portions and did not always get them. On 12/18/23 at 12:45 p.m., the resident received their lunch tray. The weekly menu documented residents were to receive Frito pie, corn, chopped lettuce and tomatoes, grated cheese, and four layer delight. The resident's meal ticket documented the resident was to receive double portions. They were not observed to have received double…

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 follow infection control practices during wound care treatment for one (#57) of one resident reviewed for wound care. The corporate nurse identified 14 residents who received wound care. Findings: The facility's Handwashing/Hand Hygiene policy, read in part, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Hand hygiene is the final step after removing and disposing of personal protective equipment . Res #57's physician order, dated 11/03/23, documented the staff was to apply Calazime skin protectant paste to the left buttock two times a day for blisters. On 12/19/23 at 11:20 a.m., a wound care observation was completed. RN #1 prepared a tray with clean equipment needed for the treatment. The RN washed their hands and donned a pair of gloves to position the resident for the treatment. The RN changed their gloves and obtained a wet washcloth to clean the resident's buttock. The RN cleaned the resident's buttock, placed the soiled washcloth on 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 record review and interview, the facility failed to offer residents the choice to formulate advance directives for six (#14, 26, 56, 58, 67, and #71) of eight sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 70 residents resided in the facility. It documented 16 residents who had advance directives. Findings: A facility Advance Directives policy, revised April 2008, read in part .Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives . 1. Res #14 was admitted to the facility on [DATE]. There was no documentation the resident and/or their representative was offered the choice to formulate an advance directive. On 01/04/23 at 11:43 a.m., the COO was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide showers to dependent residents for one (#24) of one residents sampled for ADLs. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility. Findings: Res #24 had diagnoses which included COPD, dementia, and Parkinson's disease A care plan, last reviewed 10/21/22, documented to check nail length and trim and clean on bath days and as needed. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had no rejection of care behaviors, had range of motion impairment to bilateral lower extremities, and required extensive assistance of one staff for bathing and personal hygiene. A physician order, dated 11/15/22, documented Res #24 was to receive a shower/bath every day shift on Tuesday, Thursday, and Saturday. The resident's bathing record from 11/15/22 through 12/31/22 documented the resident received a shower six times and refused once out of 21 opportunities. On…

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

Based on record review and interview the facility failed to monitor for bowel movement frequency and document bowel movements for one (#171) of one resident reviewed for bowel movement documentation. The Resident Census and Conditions of Resident report, dated 01/03/23, documented 70 residents resided in the facility. Findings: Res #171 had diagnoses which included congestive heart failure, chronic kidney disease, major depressive disorder, schizophrenia, and hypothyroidism. A care plan, dated 08/19/19, documented to monitor and document the side effects of antidepressant medications including dry mouth, constipation, and urine retention. A quarterly assessment, dated 01/19/22, documented the resident was cognitively intact, independent with most activities of daily living including toileting, and always continent of bowel. A monthly Activities of Daily Living Flowsheet, dated January 2022, documented one bowel movement. No documentation of a monthly Activities of Daily Living Flowsheet was provided by the facility for February 2022 upon request. A progress note, dated 02/22/22,…

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 consistently employ an RN for at least eight consecutive hours a day and seven days a week for July, August, and September of 2022. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 70 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 07/01/22 through 09/30/22, documented no RN hours for 07/24/22, 08/21/22, 09/04/22, and 09/18/22. On 01/10/23 at 8:45 a.m., the administrator confirmed no RN coverage for the dates in question.

Based on record review and interview, the facility failed to administer medications as ordered for one (#48) of seven residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility. Findings: Res #48 had diagnoses which included malignant neoplasm of larynx, hypothyroidism, and mood disorder. A physician order, dated 11/06/21, documented Oxycontin ER (a pain relieving medication) 20 mg two times a day for pain. A physician order, dated 03/04/22, documented Percocet (a pain relieving medication) 10-325 mg every 6 hours related to malignant neoplasm of larynx. A quarterly assessment, dated 10/31/22, documented the resident was cognitively intact, independent with activities of daily living, and had frequent severe pain. The October 2022 MAR had no documentation of Oxycontin ER administration for two of 62 opportunities and no documentation of Percocet administration for nine of 124 opportunities. The November 2022 MAR had no documentation of Oxycontin ER administration for one of 60 opportunities and no…

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 did not receive medications in excessive dose for one (#70) of seven residents whose medications were reviewed. Findings: Res #70 had diagnoses which included epilepsy. A physician order, dated 06/14/22, documented to administer Dilantin (an anti-seizure medication) 200 mg twice daily. A hospital discharge note, dated 08/26/22 documented a Dilantin critical high level of 45.3. It documented to continue to hold Dilantin and levels should be normalized before restarting. The note documented to continue increased Keppra (an anti-seizure medication) dose to 1250 mg twice daily until Dilantin restarted then decrease the Keppra to 1000 mg by mouth twice daily. The note was initialed and dated by the physician on 09/01/22. The note was also initialed by a nurse. A physician order, dated 08/26/22, documented to hold Dilantin until 09/01/22. A physician order, dated 08/26/22, documented to administer Keppra 1250 mg by mouth twice daily. A nurse…

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

Based on record review and interview, the facility failed to monitor behaviors and/or side effects for three (#3, 29 and #33) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 55 residents were receiving psychoactive medications. Findings: 1. Res #3 had diagnoses which included anxiety. A care plan, dated 03/22/22, documented the resident used antianxiety medications. It documented to monitor and document side effects and effectiveness. A physician order, dated 03/24/22, documented to monitor for behaviors related to the use of buspirone (antianxiety medication) every shift. A physician order, dated 04/28/22, documented buspirone HCL 10 mg two times a day. A physician order, dated 12/05/22, documented Remeron (antidepressant medication) 15 mg in the morning for appetite stimulant. There was no documentation behaviors or side effects were monitored 11/01/22 through 01/05/23. On 01/06/23 at 10:50 a.m., the DON was asked to locate documentation behaviors and side effects had been monitored…

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 free of significant medication errors for one (#70) of 19 residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility. Findings: 1. Resident #70 had diagnoses which included epilepsy. A physician order, dated 06/14/22, documented to administer Dilantin (an anti-seizure medication) 200 mg twice daily. A hospital discharge note, dated 08/26/22 documented a Dilantin critical high level of 45.3. It documented to continue to hold Dilantin, levels should be normalized before it was restarted. The note documented to collect daily Dilantin levels, and when normal restart Dilantin at 150 mg by mouth twice daily. The note was initialed and dated by the physician on 09/01/22. The note was initialed by a nurse. A physician order, dated 08/26/22, documented to hold Dilantin until 09/01/22. A nurse progress note, dated 08/26/2022 at 11:31 p.m., documented 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 record review and interview, the facility failed to obtain laboratory services as ordered for two (#23 and #70) of six residents who were reviewed for laboratory studies. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility. Findings: 1. Res #70 had diagnoses which included epilepsy. A physician order, dated 06/14/22, documented to administer Dilantin (an anti-seizure medication) 200 mg twice daily. A hospital discharge note, dated 08/26/22 documented a Dilantin critical high level of 45.3. It documented to continue to hold Dilantin, levels should be normalized before it was restarted. The note documented to collect daily Dilantin levels, and when normal restart Dilantin at 150 mg by mouth twice daily. The note was initialed and dated by the physician on 09/01/22. The note was initialed by a nurse. A physician order, dated 08/26/22, documented to hold Dilantin until 09/01/22. A nurse progress note, dated 08/26/2022 at 11:31 p.m., documented the discharge…

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 pre-employment background checks were completed for one of five employees upon hire. The administrator identified nine staff hired in the last four months. Findings: Cook #1 had a hire date of [DATE]. On [DATE] at 11:45 a.m., the HR director provided OK-SCREEN registry results for five employees. She stated cook #1 had a delay with the finger printing service so did not have a clearance letter from the state yet. On [DATE] at 12:02 p.m., the HR director stated she was aware cook #1's provisionary period had expired. She stated she had not received a letter stating the employee was eligible or ineligible for employment. She stated she sent an email to OK Screen on [DATE] and was told the letter had been sent to the employee's address on [DATE] via certified mail. The HR director stated the address the letter was sent to was incorrect. On [DATE] at 12:15 p.m., the administrator stated the facility was sending in an appeal application to OK screen…

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 O2 was administered per physician orders and the changing of O2 tubing was documented for one (#56) of one sampled resident reviewed for respiratory services. The ADON identified 13 residents with physician orders for O2. Findings: Res #56 had diagnoses which included SOB. A physician order, dated 12/20/22, documented O2 via N/C at 2-3 lpm to maintain saturation greater than 89 percent as needed. A quarterly assessment, dated 12/20/22, documented the resident's cognition was intact. On 01/03/23 at 3:10 p.m., Res #56 was observed with O2 in place. The O2 concentrator was observed running at 4 lpm and the O2 tubing was not labeled with the change date. Res #56 was asked how often staff changed their O2 tubing. They stated staff did not change their tubing. On 01/05/23 at 2:00 p.m., CNA #1 was asked who set or adjusted the lpm on the resident's O2 concentrator and changed the tubing. She stated the nurse and the tubing should be dated. She was asked to verify the date on the tubing. She stated the tubing…

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 hand hygiene was performed during wound care for one (#27) of one residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented one residents had pressure ulcers. Findings: Resident #27 had diagnoses which included heart failure, obesity, dementia, and muscle weakness. A quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired, required extensive to total assistance with ADLs, and was always incontinent of bowel and bladder. A physician order, dated 12/15/22, documented to cleanse sacral wound with wound cleanser, pat dry, apply Santyl to wound bed, cover with calcium alginate as the primary dressing, then cover with bordered gauze as secondary dressing daily. On 01/06/23 at 1:37 p.m., LPN #1 was observed performing wound care for Res #27. The LPN was observed donning two pairs of gloves. There was no dressing in place to remove. The LPN cleansed the wound…

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.