Medical Park West Rehabilitation & Skilled Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay was completed for one (#70) of two sampled residents who were reviewed for discharge. The administrator identified 90 residents who resided in the facility. Findings: Resident #70 had diagnoses which included hypertension. The Discharge Instructions for Care form showed the resident was discharged from the facility to home on [DATE]. The undated Interdisciplinary Discharge Summary form in the electronic clinical record was blank in all sections except dietary and activities. The discharge summary did not contain a recapitulation of the resident's stay. On 01/30/25 at 12:30 p.m., the DON stated each department was to complete their section of the Interdisciplinary Discharge Summary form in the electronic clinical record. The DON stated they monitored the discharge summaries and knew they had not been completing them to include a recapitulation of the residents stay.

Based on record review and interview, the facility failed to ensure residents who received dialysis were assessed after dialysis for one (#60) of one sampled resident who was reviewed for dialysis. The DON identified three residents who required dialysis. Findings: The Dialysis - Hemodialysis policy, dated 02/12/20, read in part, Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center.Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C. Resident #60 had diagnoses which included end stage renal disease. The Dialysis Pre/Post Communication Report forms, read in part, This section to be completed by Nursing Home Staff upon resident return and placed in clinical record .Access Type/Assessment. A physician's order, dated 05/28/24, showed the resident was to receive dialysis weekly on Monday, Wednesday, and Friday. The quarterly assessment, dated 10/27/24, showed the resident was cognitively intact for daily decision making and…

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

Based on record review and interview, the facility failed to ensure medications were reviewed monthly by the consultant pharmacist and the pharmacy recommendations were addressed by the physician for one (#60) of five sampled residents who were reviewed for unnecessary medications. The DON identified 89 residents who received medications in the facility. Findings: The Medication Regimen Review and Reporting policy, dated January 2024, read in part, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. Resident #60 had diagnoses which included chronic pain. The Consultant Pharmacist Recommendation to Physician, dated 05/31/24, read in part, In hemodialysis patients, gabapentin is titrated to effect up to 300 mg 3 times per week given after hemodialysis on dialysis days. Some experts recommend cautious titration to a max of 300…

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 labs were obtained as ordered by the physician for one (#60) of five sampled residents whose labs were reviewed. The DON identified 45 residents who had routine labs ordered. Findings: Resident #60 had diagnoses which included diabetes mellitus. Physician orders, dated 05/28/24, showed the facility was to complete a CBC every 6 months in March and September; and the facility was to complete a hemoglobin A1C every 3 months in March, June, September, and December. Review of the clinical record did not show a CBC had been completed in September 2024 or that a hemoglobin A1C had been completed in June, September, or December 2024. On 01/28/25 at 5:04 p.m., the DON stated the ADON was responsible to ensure labs were completed as ordered by the physician. They stated labs had not been completed because they were not put into the lab company's ordering system.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and enhanced barrier precautions were followed during pressure ulcer treatment for one (#10) of two sampled residents reviewed for wound care. The facility matrix identified 10 residents with pressure ulcers. Findings: An Enhanced Barrier Precautions policy, revised 04/01/24, read in parts, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistant organisms (MDROs). This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply .Enhanced Barrier Precautions: An infection control intervention designed to reduce transmissions of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand…

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 adequate supervision to prevent a resident from exiting the facility through a door which alarmed, unobserved by staff for one (#1) of three residents reviewed for elopement. The Administrator identified 98 residents resided in the facility. Findings: Resident #1 had diagnoses which included vascular dementia, unsteadiness on feet, and weakness. An elopement risk assessment, dated 02/01/24, documented the resident was at moderate risk for elopement. A Nurses Note, dated 02/01/24, read in part, .Pt up ambulating t/o building. Pt would not stay in WC and would not stay in the lobby or room to be monitored .walked down to the end of 300 hall where staff could cont to monitor .This nurse went to assist with pt and when returned pt was not at the end of 300. This nurse and staff went to check on pt and found the back dining room door alarm going off. Staff checked the perimeter of the building and saw pt walking in the grass and before staff could get to . fell .no complaints of pain able to MAEx4 and was assisted up.…

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 submit accurate payroll based journal staffing data for 24 hour nursing to CMS for three of three months reviewed. The Administrator identified 98 residents resided in the facility. Findings: On 04/24/24 at 12:45 p.m., the QOC monthly reports requested for January, Feburary, and March 2024 were received. The reports documented less than the required 2.9 minimum on 01/14/24, 01/21/24, 01/22/24, 1/28/24, 02/04/24, 02/17/24, 02/18/24, 02/25/24, 03/03/24, 03/16/24, 03/17/24, 03/24/24, and 03/31/24. On 4/26/24 at 2:55 p.m., the Administrator stated the QOC reports did not populate administrative staff that may have worked on those days. They stated that time was entered in to the facility's payroll system but the Corporate system would not recognize the administrative staff worked on the floor. On 04/26/24 at 2:56 p.m., the administrator stated the information was not accurately entered into the payroll based journal to CMS.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was implemented to address the residents needs related to elopement for one (#1) of three sampled residents reviewed for care plans. The Administrator identified 98 residents resided in the facility. Findings: A Comprehensive Care Plans policy, reviewed 04/17/23, read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in a resident's comprehensive assessment . Resident #1 had diagnoses which included vascular dementia, unsteadiness on feet, and weakness. An elopement risk assessment dated [DATE], documented the resident was at moderate risk for elopement. A care plan, dated 01/29/24, for behavioral changes related to elopement in the care area with a goal of…

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 received a gradual dose reduction after the physician ordered the reduction of an antipsychotic medication for one (#6) of three residents reviewed for pharmacy medication regimen reviews. The administrator reported 93 residents resided in the facility. Findings: Res #6 had diagnoses which included delusional disorders and hallucinations. A physician order, dated 10/02/23, documented to administer Risperdal 0.50 mg at bedtime. A December 2023 pharmacist medication regimen review, signed by the physician on 12/27/23, documented the resident was stable and to reduce the resident's Risperdal from 0.50 mg to 0.25 mg at bedtime. The resident's MAR documented the resident continued to receive the 0.50 mg from 12/27/23 through 01/17/24 and had not been reduced. On 01/18/24 at 1:50 p.m., the DON stated the medication regimen review was noted by the DON. They reported the medication regimen review had not been acted upon by the facility staff and the facility had not reduced the anti-psychotic medication as…

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 a facility assessment was updated annually. MDS Coordinator #1 identified 98 residents resided in the facility. Findings: On 10/31/23 at 1:22 p.m., an entrance conference was conducted with the administrator. They were made aware a facility assessment was required to be provided within four hours of entrance. There was no documentation a facility assessment had been updated annually. On 11/07/23 at 4:15 p.m., the administrator stated they did not have an updated facility assessment.

Based on record review and interview, the facility failed to ensure residents' code status was accurate for two (#144 and #201) of four sampled residents reviewed for advance directives. MDS Coordinator #1 identified 98 residents resided in the facility. Findings: 1. Res #144 had diagnoses which included acute cystitis without hematuria, acute pancreatitis without necrosis or infection, muscle wasting, hyperlipidemia, and cognitive communication deficit. A DNR consent form, dated 04/28/23, documented consent for DNR. The document was registered in the resident's EHR on 10/05/23. A physician order, dated 10/18/23, documented full code. On 11/02/23 at 1:12 p.m., RN #1 was asked how staff determined code status for a resident. They stated they looked in the EHR. They were asked what was the resident's code status. They reviewed the resident's EHR and stated they were a full code. They were asked if the resident had a DNR on file in the EHR. They reviewed the resident's EHR and stated they did. 2. Res #201 had diagnoses which included adult failure to thrive. A DNR consent form, dated…

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 bathing was completed for two (#191 and #194) of four sampled residents reviewed for ADLs. The MDS coordinator identified 98 residents resided in the facility. Findings: 1. Res #191 admitted to the facility on [DATE] with diagnoses which included cancer of right breast, shortness of breath, atherosclerotic heart disease, gout, hyperlipidemia, hypertension, anxiety, and presence of cardiac pacemaker. A SNF Bath Schedule documented Res #191 was to be bathed on Tuesday and Friday evenings. A shower sheet, dated 10/31/23, documented Res #191 refused their shower. The sheet had a CNA signature, but no nurse signature. On 11/01/23 at 10:07 a.m., Res #191 was observed in their bed. The resident was observed with a full beard and unbrushed hair. The resident was observed to have a compression bandage around their chest and a drainage tube from their right chest. The resident stated they wanted a shower. The resident stated they had 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 and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident after dialysis for one (#75) of one sampled resident reviewed for dialysis services. The Resident Census and Conditions of Residents report, dated 10/31/23, documented four residents received dialysis services. Findings: The Dialysis-Hemodialysis policy, revised 02/23/20, read in parts, .Documenting dialysis in the EHR .The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection form as follows .Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center .Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C .Place document in the appropriate section of the medical record . Res #75 had diagnosis which included ESRD. A physician order, dated 08/15/23, documented dialysis on Monday, Wednesday, and Friday. The October…

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 complete an annual skills review for 10 of 15 nurse aides and four of five medication aides employed for longer than 12 months. The MDS coordinator identified 98 residents resided in the facility. Findings: Annual competencies were provided for 2022, they were dated for 08/05/2022. On 11/02/23 at 3:00 p.m., the DON was asked to provide the skills reviews for 2023 On 11/07/23 at 9:35 a.m., the skills reviews were provided for 2023. The documents were dated 09/26/2023. CNA #1, CNA #7, CNA# 8, CMA #3, CNA #9, CNA #10, CNA #11, CNA #12, CNA #13, CNA #14, CNA #15, CMA #4, CMA #5, and CMA #6, did not have a documented annual skills review. On 11/07/23 at 3:23 p.m., the DON stated there were no competencies for the above listed staff. They stated they were unsure why their sheets were not in the provided documentation.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 26 opportunities were observed with five errors. Total medication error rate was 19.23%. The MDS coordinator identified 98 residents in the facility. Findings: Res #140 had physician orders for the following stock medications: acidophilus (lactobacillus acidophilus) one capsule daily, aspirin 81 mg chewable tablet daily, Benefiber clear sugar free 3 gram/3.5 gram oral powder packet twice daily, and probiotic 100 billion cell capsule twice daily. Res #140's physician order, dated 10/19/23, documented to administer phenytoin sodium extended 100 mg capsule, 2 capsules twice daily for epilepsy. On 11/03/23 at 8:49 a.m., CMA #2 was observed during medication pass for Res #140. The CMA prepared and administered atorvastatin 20 mg, carvedilol 3.125 mg, ezetimibe 10 mg, isosorbide 30 mg, amlodipine 5 mg, and phenytoin 100 mg one tablet On 11/03/23 at 8:50 a.m., CMA #2 asked if the surveyor wanted to observe Res #140's stock medications, too. They were…

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

Based on observation and interview, the facility failed to ensure expired supplies and medications were disposed of. The MDS coordinator identified 98 residents in the facility. Findings: On 11/06/22 at 10:05 a.m., a tour of the medication rooms were conducted. The following expired medications and supplies were observed in the medication rooms: - one insulin flex pen expired 04/07/22 - 138 bisacodyl suppositories expired 01/2023 - eleven suction toothbrushes expired 11/10/21 - 23 unisex collection swabs expired 01/2022 - 50 cholestyramine suspension packets expired 03/2023 - 49 cholestyramine suspension packets expired 05/2023 - 1 laceration tray kit expired 01/15/22 - Twenty-five 27-gauge safety needles expired 10/15/22 - 60 central line dressing change kits expired 03/2023 - one 60 ml syringe luer lock expired 05/2020 - one oxygen mask expired 04/23/19 - 14 enteral feeding tubes expired 08/2016 On 11/06/23 at 12:06 p.m., the DON stated the ADON assigned to the hall was responsible for ensuring expired medications and supplies were disposed of. They stated the medication rooms…

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 maintain a system for tracking and trending infections, and failed to initiate infection control protocols for one (#198) of two sampled residents reviewed for active infections. The MDS coordinator identified 98 residents resided in the facility. Findings: 1. A facility Infection Prevention and Control Surveillance policy, dated January 2022, documented in part .This facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method of collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes . On 10/31/23 at 1:22 p.m., the infection prevention tracking and trending documentation was requested. On 11/02/23 at 12:10 p.m. the DON stated the tracking and trending of infections was not being completed. They stated the EHR program tracked…

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 maintain an antibiotic stewardship program. The MDS coordinator identified 98 residents resided in the facility. Findings: A facility Antibiotic Stewardship policy, dated January 2022, documented in part .it is our policy to maintain an Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics to treat infections and reduce the possible adverse events associated with antibiotic use . On 10/31/23 at 1:22 p.m., the antibiotic stewardship program documentation was requested. On 11/02/23 at 12:10 p.m., the DON stated the antibiotic stewardship program was not being completed. They stated they had taken over the position of DON two months ago and had not established a program in that time. They stated there had been six DONs in the past year and it fell through the cracks. They stated they were unable to locate any documentation for antibiotic stewardship prior to their employment.

Based on record review, observation, and interview, the facility failed to ensure a resident was safe to self-administer medication for one (#47) of one sampled resident reviewed for self-administering medications. The MDS coordinator identified 98 residents resided in the facility. Findings: A Medication Administration: Self-Administration by Resident policy, dated 01/2023, read in part, .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT . Res #47 had diagnoses that included HTN, diabetes, and asthma. A physician order, dated 03/31/22, documented Res #47 was to receive fluticasone propionate (Flonase) 50mcg nasal spray, one spray in each nare at bedtime. On 11/01/23 at 3:08 p.m., Res #47 was observed in their room. A one-half full bottle of fluticasone propionate (Flonase) 50 mcg nasal spray was observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the state was notified of a serious mental illness for one (#62) of two sampled residents whose Level I PASRR Screenings were reviewed. The MDS Coordinator identified 98 residents resided in the facility. Findings: Resident #62 admitted on [DATE] with diagnoses which included bipolar disorder, generalized anxiety disorder, and depression. A Level I PASRR Screen, dated 08/08/23, documented Res #62 had no evidence of serious mental illness including possible disturbance in orientation or mood and no diagnosis of a serious mental illness. On 11/02/23 at 12:14 p.m., the admissions coordinator was asked to review Res #62's diagnoses and questions #1 and #2 of their Level I PASRR screening completed on 08/15/23. After review, the admissions coordinator acknowledged questions #1 and #2 had been answered incorrectly and the state should have been notified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure assessment and monitoring was completed for a surgical wound for one (#191) of three sampled residents reviewed for non-pressure skin conditions. A Wound Report documented five residents with surgical wounds. Findings: Res #191 admitted to the facility on [DATE] with diagnoses which included cancer of the right breast. A physician order, dated 10/31/23, documented to monitor output of JP drain every shift. There was no order for monitoring of the incision site on the chest. Upon record review, no wound assessment of the surgical incision was documented in Res #191's EHR. On 11/01/23 at 10:07 a.m., Res #191 was observed resting in bed. The resident had an elastic bandage wrapped around the middle of their chest. An incision was observed on the resident's chest below the nipple line with staples in place. The incision on the chest was clean and dry. On 11/03/23 at 9:29 a.m., the DON stated the wound should be monitored every shift…

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 pressure ulcer care was performed as ordered for one (#43) of three sampled residents reviewed for pressure ulcers. The DON identified 11 residents in the facility had pressure ulcers. Findings: A facility Pressure ulcer/pressure injury policy, effective April 2022, documented in part .Pressure ulcers/injuries will be identified, evaluated and treated in accordance with generally accepted guidelines . Res #43 admitted to the facility on [DATE] with diagnoses which included pressure ulcers, paraplegia, low BMI, depression, and contractures. A physician order, dated 08/10/23, documented to apply bacitracin topical ointment Monday and Wednesday to pressure ulcer of other site, stage IV. A TAR for August 2023, documented the bacitracin was not administered on two of 9 opportunities. A physician order, dated 08/10/23, documented to cleanse wound to left posterior inferior knee, pat dry, apply bacitracin, apply xeroform, and cover 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 and interview, the facility failed to ensure medications were administered as prescribed for one (#69) of one sampled resident reviewed for receiving medications as ordered. The MDS coordinator identified 98 residents residing in the facility. Findings: A Medication Administration Policy, dated 01/2023, read in part, .1. Medications are administered in accordance with written orders of the prescriber .14. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule . Res #69 had diagnoses that included chronic viral hepatitis C and ileostomy. A physician order, dated 08/11/23, documented Res #69 was to receive octreotide acetate 50 mcg/ml (1 ml) injection syringe 1 syringe subcutaneous three times per day. The medication was not given as prescribed 9:00 a.m. on 08/13/23 nor 3:00 p.m. on 08/13/23. Documentation on the August MAR for the missed doses read due to special requirement parameters. There were no special requirement parameters documented on the MAR nor in Res #69'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 record review and interview, the facility failed to ensure the drug regimen for each resident was reviewed by a licensed pharmacist for the month of June 2023 and a physician response to a MRR was obtained for two (#8 and #21) of five sampled residents reviewed for unnecessary medications. The MDS coordinator identified 98 residents in the facility. Findings: 1. Res #8 had diagnoses which included anxiety, depression, and schizophrenia. A pharmacist MRR, dated 4/22/23, documented a request to reduce Res #8's trazodone 100 mg. The pharmacist recommendation had no response nor was it signed by the physician. A pharmacist MRR, dated 4/22/23, documented a request to reduce Res #8's haloperidol 10 mg and risperidone 2 mg. The pharmacist recommendation had no response nor was it signed by the physician. 2. Res #21 had diagnoses which included depression and dementia. A pharmacist MRR, dated 4/23/23, documented a request to reduce Res #21's antidepressant citalopram 20 mg. The pharmacist recommendation had no response nor was it signed by the physician. A pharmacist MRR, dated…

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 residents were free of significant medication errors for one (#140) of four residents observed during medication administration. MDS coordinator identified 98 residents in the facility. Findings: A facility policy dated 01/2023, titled Medication Administration, read in part .Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label .9. Verify medication is correct three times before administering medication .a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose is administered Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . 1. Resident #140 had diagnosis which included epilepsy. A physician order, dated 10/19/23, documented to administer phenytoin sodium extended-release capsule (an anti-seizure medication) 100…

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 a resident was safe to self-administer medication, b. ensure residents' code status was accurate, c. ensure a resident did not suffer emotional distress from neglect, d. ensure a Level II PASARR was initiated, e. ensure bathing was completed, f. ensure assessment and monitoring was completed for a surgical wound, g. ensure pressure ulcer care was performed as ordered, h. ensure a resident received adequate pain management, i. ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident after dialysis, j. complete an annual skills review for nurse aides and medication aides employed for longer than 12 months, k. ensure medications were administered as prescribed, l. ensure a physician response to a MRR, m. ensure the medication error rate was less…

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 an emergency contact with a change in condition for one (#4) of three sampled residents reviewed for a change in condition. The Resident Census and Condition of Residents report, dated 08/08/23, documented 83 residents resided in the facility and four residents received dialysis. Findings: A Change of Condition policy, dated 02/13/23, read in parts .Document in the medical record the date, time and name of each physician notified, actions taken .Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status. Examples .Transfer or a patient to another healthcare community for assessment, treatment or care . Resident #4 had diagnoses which included high blood pressure, type two diabetes mellitus, and sepsis. Resident #4's clinical health record did not document the communication from the dialysis center and the facility or that the Resident had been sent to the ER. There was no documentation Resident #4's family had been…

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

Based on record review and interview, the facility failed to ensure: a. a complete and thorough investigation of an allegation of abuse was conducted, and b. alleged involved staff were reported to the appropriate state agency for one (#30) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 09/28/22, documented 90 residents resided in the facility. Findings: An Abuse policy, dated June 23, 2017, read in part, .reporting to state and local agencies .The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident report, which are to be forwarded directly to the Abuse Coordinator .initiate an investigation into the allegation . An Incident Report form, dated 07/22/22, read in part, .Resident contacted the police over an incident which occurred a few weeks ago when, during an activity involving water balloons, a balloon filled with water broke when it hit [the resident]. Resident had previously stated the occurrence was not done intentionally or with malicious intent; however, [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 dependent residents received: a. scheduled baths for one (#52), b. timely incontinent care for six (#3, 9, 23, 27, 52, and #68), and c. feeding assistance for one (#192) of seven sampled residents reviewed for ADLs. Findings: A bathing policy, revised 02/12/20, documented staff would provide bathing services for residents within standard practice guidelines. A perineal care policy, revised 02/12/20, documented staff would perform perineal/incontinent care after each incontinent episode. It documented the following for female residents: a. to retract the labia from the thigh and wash from perineum to rectum on both sides, b. separate labia to expose meatus and vaginal orifice and wash downward from pubic area toward rectum, c. clean anal area by wiping from vagina toward anus with one stroke, and d. repeat with clean cloth until skin is clear of fecal material. An assisting residents with eating policy, reviewed September 9, 2022, documented qualified nursing staff would assist residents who are unable…

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. adequate staff to meet the needs of dependent residents for six (#9, 23, 27, 52, 68, and #192) of seven sampled residents reviewed for ADL care, and b. they met the minimum requirements for staffing ratios for 7 days (09/15/22, 09/16/22, 9/17/22, 09/18/22, 09/20/22, 09/23/22, and 09/24/22) of 14 days reviewed for staffing. Findings: A bathing policy, revised 02/12/20, documented staff would provide bathing services for residents within standard practice guidelines. A perineal care policy, revised 02/12/20, documented staff would perform perineal/incontinent care after each incontinent episode. An assisting residents with eating policy, reviewed September 9, 22, documented qualified nursing staff would assist the resident who was unable to feed themselves. A1. Resident #52 had diagnoses which included encephalopathy. A resident assessment, dated 08/24/22, documented the resident had severe cognitive impairment and required extensive assistance for bathing. On 09/29/22 at 11:01 a.m., Resident #52'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, record review, and interview, the facility failed to ensure nurse aides demonstrated competency in skills and techniques necessary to provide adequate incontinent care for one of one (#52) resident observed for incontinent care. The Resident Census and Conditions of Residents report, dated 09/28/2022, documented 68 residents for toilet use. Findings: The Perineal Care policy, revised 02/12/2020, read in part .Standard of Practice: Staff will provide cleanliness of genitalia to avoid skin breakdown and infection. Staff will perform perineal/incontinent care with each bath and after each incontinent episode .Procedures: .Assemble equipment: washcloths, towel, soap or peri-wash and basin with warm tap water. Position resident with legs flexed at knees and spread apart. Waterproof pad under buttocks .For female resident: A. Wash Labia Majora 1) Retract labia from thigh, washing carefully in skinfolds from perineum to rectum. Repeat on opposite side using separate section of washcloth. 2) Rinse if soap used and dry. If peri-wash used, then dry only. 3) Separate…

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. medications were administered as ordered for two (#36 and #89) of five sampled residents reviewed for medication administration, and b. medication carts were secured for two of two medication carts observed unlocked. The Resident Census and Condition of Residents report, dated 09/28/22, documented 90 residents resided in the facility. Findings: A medication storage policy, dated 2007, documented medications and medication carts would only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. Resident #36 had diagnoses which included depression and hypertension. A physician's order, dated 01/15/22, documented to administer metoprolol tartrate 25 mg one tablet by mouth every 12 hours. A physician's order, dated 05/18/22, documented to administer Mirtazapine 15 mg tablet one tablet by mouth at bedtime. A MAR, dated 09/27/22, documented Mirtazapine was scheduled for 9:00 p.m., and had not been administered until 10:32 p.m.,…

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 dietary staff had the competencies to monitor the temperature and sanitizing levels of the dish machine and the three compartment sink. The Administrator identified 90 residents resided in the facility, 88 received services services from the kitchen and two were NPO. Findings: A Dish Machine Temperature Log policy, effective [DATE], read in part, .Dish machine temperatures are monitored and recorded to ensure proper sanitizing of dishes .Employees are trained to monitor dish machine temperatures and test sanitizer (low temp dish machines only) throughout the dishwashing process . On [DATE] at 2:15 p.m., Dishwasher #1 was observed loading dishes into the dish machine. They were asked how often the level of sanitizer in the dish machine was checked. They stated, Every shift. They were asked to test the level of sanitizer in the dishmachine. After searching around the kitchen, Dishwasher #1 returned with a bottle of purple test strips…

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. expired food items were removed from the refrigerator, b. foods were not stored on the floor in the walk in freezer, and c. plates and bowls were stored inverted. The Administrator identified 90 residents resided in the facility, 88 received services from the kitchen and two were NPO. Findings: A Food Storage policy, dated August 1, 2018, read in part, .Refrigerator .Opened containers of thickened liquids are stored in the refrigerator with both open and discard dates .Freezer .All foods are stored off the floor . Title 310. Oklahoma State Department of Health, Chapter 257. Food Establishments, 310:257-7-105. Equipment, utensils, linens, and single-service and single-use articles, read in part, .Clean equipment and utensils shall be stored .Covered or inverted . On 09/28/22 at 2:04 p.m., a refrigerator was observed to have four unopened cartons of yogurt with an expiration date of 09/27/22, and one opened carton of Thickened Dairy Drink with an opened date of 07/23/22. The walk-in refrigerator 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 observation, record review, and interview, the facility failed to ensure staff: a. washed/sanitized hands and changed gloves during incontinent care and prior to touching personal items for six (#52, 3, 27, 68, 23, and #9), b. provided proper peri care for three (#52, 23 and #9), and c. did not place soiled linens on the floor for two (#3 and #27) of six sampled residents reviewed for incontinent care. A Resident Census and Conditions of Residents report, dated 09/28/22, documented 86 residents required assistance with toileting. Findings: A laundry infection control policy, reviewed January 2022, documented linen is not to be placed on the floor. An infection control policy, reviewed January 2022, documented hand hygiene is one of the most important components for preventing the spread of infection. It documented hand hygiene should be done before and after resident contact, after contact with soiled or contaminated articles, after personal care, and after removing gloves. 1. Resident #52 had diagnoses which included encephalopathy. On 10/03/22 at 4:35 a.m., Resident #52…

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.