Okemah Care Center

Based on observation, record review, and interview, the facility failed to maintain a clean homelike environment for: a. residents who ate their meals in the dining room and who watched TV in the television room, and b. prevent lingering urine odors for two (#9 and #33) of all residents who resided in the facility. The Administrator identified 43 residents resided in the facility. Findings: An undated Housekeeping policy, read in part .It is the policy of this facility that housekeeping services will be provided every day. Housekeeping will be responsible to clean the residents area Housekeeping will also be responsible for cleaning the .halls .dining room . A. Dining Room On 06/03/24 at 11:54 a.m., Resident #3 was observed entering the television room and sitting near the coke machine. A puddle of water was observed on the floor near the resident and coke machine. On 06/03/24 at 12:05 p.m., the windows in the dining room were observed to have noted to have dust/dirt and dead flies lying on the window ledges. There was a dead fly in the southwest window, two dead flies and dirt and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for activities for one (#38) of one sampled residents reviewed for activities. The Administrator identified 43 residents resided in the facilty. Findings: A Goals and Objectives, Care Plans policy, dated 8/2006, read in part, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The policy also read, Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and area able to report whether or not the desired outcomes are being achieved. Goals and objectives are reviewed and/or revised . at least quarterly. A Care Plans-Comprehensive policy, dated 10/2009, read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. The policy also read,…

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

Based on record review and interview, the facility failed to administer tube feeding bolus according to physician order for one (#32) of one sampled resident reviewed for tube feeding. The administrator identified two residents received tube feeding resided in the facility. Findings: A Intake, Measuring and Recording policy, dated 9/2005, read in part, The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. The policy also read, Record the fluid intake as soon as possible after the resident has consumed the fluids. At the end of you shift total the amounts of all liquids the resident consumed . The policy also read, The following should be recorded in the resident's medical record per facility guidelines: .The amount (in mls) of liquid consumed .notify the supervisor if the resident refuses the procedure. Res #32 had diagnoses which included anorexia, cachexia. A physicians order dated 09/02/23 documented mighty shake one time a day for weight loss. A physicians order dated 10/19/23 documented regular diet mechanical…

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 medication error rate was not greater than 5% for two (#6 and #12) of three sampled residents observed during medication observation The Administrator identified 43 residents resided in the facility. Findings: An undated Medication Administration and General Guidelines policy, read in part .Medications are administered in accordance with written orders of the attending physician . 1. Resident #6 had diagnoses which included hypertension and mood disorder. A physician order, dated 02/06/24, documented to administer aspirin 81 milligram chewable tablet one time a day. On 06/05/24 7:58 a.m., CMA #1 was observed to prepare and administer Resident #6's medications. CMA #1 did not instruct Resident #6 to chew the Aspirin tablet when administered. 2. Resident #12 had diagnoses which included Atherosclerosis of native arteries of extremities. A physician order, dated 06/27/2, documented to administer aspirin 81 milligrams chewable tablet one time a day. On 06/05/24 at 8:17 a.m., CMA #1 was observed to prepare…

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. staff wore PPE during provision of care for one (#21) of one sampled residents reviewed for EBP and b. failed to ensure a syringe used for tube feeding administration was stored in a manner to prevent cross contamination for one (#32) of one sampled resident reviewed for tube feeding. The Administrator identified 43 residents resided in the facility. The Director of Nursing identified two residents received tube feeding. Findings: An Enhanced Barrier Precautions Policy and Procedure, dated 04/01/24, read in part .EBP will be used for resident with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug - resistant organism .procedure to use EBP when .other high-contact resident care activities . 1. Resident #21 had diagnoses which included, pressure ulcer of right buttock Stage 4, dementia, and depressive disorder. On 06/05/24 at 10:57 a.m., upon entry to the room, the resident was lying in the bed with their shorts pulled down with their buttocks exposed to…

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 interviews, the facility failed to ensure physician ordered scheduled appointments were not canceled for one of (#1) of 5 sampled residents reviewed for outside appointments. Findings: Resident #1 was admitted on [DATE] and had diagnoses of chronic pain, dry eye syndrome, and carcinoma of the face. Resident #1 had a consult appointment scheduled for 08/02/23 with a specialty physician for carcinoma of the face. Resident #1 had been rescheduled for the consult appointment to 08/27/23 without notifying Res #1 or their representative. A grievance form, dated 08/02/23 at 2:00 p.m., documented the administration had received a complaint from the resident's representative regarding the canceled appointment. The grievance form documented an in-service with the social service director on 08/02/23. The grievance form documented monitoring of the appointment schedule was conducted in the daily stand up meeting and was ongoing at the time of the survey. On 08/14/23 at 08:42 a.m., an interview 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 and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 38 residents resided at the facility. The form documented one resident with tube feeding. Findings: On 05/01/23 at 9:30 a.m., an initial tour of the kitchen and food storage areas was conducted. In the refrigerator macaroni salad was observed, which had been opened and served out of and was dated 04/22/23. A bag of shredded lettuce in a re-sealable bag was observed and was not dated. A thick amber liquid, labeled caramel and out of the original container was dated 04/23/22. A container labeled chili was observed with a date 04/19/23. In the first chest freezer a large bag of bread sticks were observed to be open to air. In the small refrigerator a container of prune juice was observed to have been opened and not dated. The floor in the kitchen and storage areas were observed to not have been thoroughly cleaned around the edges and debris was observed on the floor. The lid to the sugar bin 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 observation and interview, the facility failed to ensure the environment was free of dust and kept the vents and ceiling tiles in good repair. The Resident Census and Conditions of Residents form, documented 38 residents resided at the facility. Findings: On 05/02/23 at 9:30 a.m., an environmental tour of the facility was conducted to look at the vents in the resident rooms. The vents in room [ROOM NUMBER] were observed to have been full of dust, room [ROOM NUMBER] had one vent observed with dust, room [ROOM NUMBER] had one vent which was observed broken with paint chips and one vent with dust. room [ROOM NUMBER] was observed to have ceiling tiles with brown areas on them, tiles which had been taped, and the tape was observed to be peeling. Another ceiling tile was observed to have been cracked across the width of the tile. The vent was observed to have dust and what appeared to have been rust. room [ROOM NUMBER]'s intake vent was observed to be very dusty and room [ROOM NUMBER]'s ceiling tile around…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments were encoded and transmitted to CMS in the required time frame for two (#28 and #36) of twenty residents whose assessments were reviewed. The Resident Census and Conditions of Resident form documented 38 residents resided in the facility. Findings: 1. Res #28 had diagnoses which included congestive heart failure and diabetes. A quarterly assessment, dated [DATE], was completed and transmitted to CMS. A nurse note, dated [DATE], documented the resident had expired. A discharge, death in the facility, assessment was not located in the resident's records. On [DATE] at 11:07 a.m., the corporate nurse confirmed the discharge, death in the facility, assessment had not been completed in the required time frame. 2. Res #36 had diagnoses which included COPD, end stage renal disease, anxiety, and dementia. An admission assessment, dated [DATE], was completed and transmitted to CMS. The resident's clinical records documented a 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 observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for five (#2, 5, 9, 10 and #30) of twenty residents whose assessments were reviewed. The facility failed to accurately code for: a. the presence of the state level II PASRR process to have serious mental illness for Res #2, 5, 10, and #30. b. the use of insulin for Res #5. c. falls for Res #9. The Resident Census and Conditions of Resident form documented 38 residents resided in the facility. Findings: 1. Res #2's PASRR level II evaluation, dated 06/04/19, documented the resident had a major mental illness as defined by CMS. The resident was admitted , on 06/05/19, and had diagnoses which included schizophrenia, obsessive-compulsive disorder, and other recurrent depressive disorders. An annual assessment, dated 03/02/23, revealed the facility documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual…

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 the menu and provide pureed foods listed on the menu for the puree diets from the kitchen. The Resident Census and Conditions of Residents form, documented 16 residents resided at the facility who had mechanically altered diets including pureed and all chopped food. Findings: The breakfast menu for week three documented the pureed meal should have been assorted juice, pureed hot or pureed cold cereal, pureed egg of choice, pureed breakfast meat, pureed breakfast bread, margarine/jelly, and milk/beverage. On 05/03/23 at 7:48 a.m., preparation of the puree meal was observed. [NAME] #1 did not provide any bread in the pureed meal. On 05/03/23 at 8:27 a.m., four pureed meals were observed being plated. [NAME] #1 plated eggs, sausage with gravy, and oatmeal. The cook did not serve toast or other bread with the pureed meals. On 05/03/23 at 12:02 p.m., the DM stated the pureed meals should have received what all the other residents received. She stated when toast was on the menu the pureed should contain toast…

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 coordinate assessments with the PASRR program and to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into the residents' assessment and care plan for three (#2, 10, and #30) of seven residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented three residents with intellectual and/or developmental disability and 22 residents with documented psychiatric diagnosis who resided in the facility. Findings: 1. Res #2's PASRR level II evaluation, dated 06/04/19, documented the resident had a major mental illness as defined by CMS. The resident was admitted , on 06/05/19, and had diagnoses which included schizophrenia, obsessive-compulsive disorder, and other recurrent depressive disorders. An annual assessment, dated 03/02/23, revealed the facility documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 05/01/23 at 4:48…

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 develop and implement a care plan which included the residents' needs for three (#10, 17, and #21) of 15 residents whose care plans were reviewed. The facility failed to develop a care plan related to: a. hydration needs for Res #10. b. nutrition needs for Res #17. c. mobility and range of motion needs for Res #21. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: 1. Res #10 had diagnoses which included spastic quadriplegic cerebral palsy, severe intellectual disabilities, blindness, both eyes, contractures, calculus of kidney, calculus of ureter, and acute kidney failure. A quarterly assessment, dated 05/27/22, documented the resident was severely impaired in cognitive skills, and required total assistance with most ADLs. An admission assessment, dated 08/17/22, documented the resident was severely impaired in cognitive skills, and required total assistance with most ADLs. The care area assessment documented hydration and fluid maintenance…

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 resident care plans were updated related to falls for two (#9 and #21) of 15 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 38 residents resided at the facility. Findings: 1. Res #9's care plan, dated 07/13/22, documented the resident had a potential for falls and was to be up in a geri/chair daily. The care plan documented interventions which included a fall risk assessment was to be done quarterly and as needed and to notify physician with any changes. The care plan did not contain any updates. An incident report, dated 02/22/23, documented Res #9 had a fall and the intervention was to check on the resident more frequently. A quarterly assessment, date 04/05/23, documented the resident was severely impaired with cognition; required extensive assistance with bed mobility, and was totally dependent with transferring; and had no falls. On 05/02/23 at 9:10 a.m., an observation was made 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 observation, record review, and interview, the facility failed to ensure a resident with limited ROM received the appropriate treatment and services to increase or prevent further decrease in ROM for one (#21) of four residents sampled for ROM. The Resident Census and Conditions of Residents form documented seven residents who had contractures resided at the facility. Findings: Res #21's admission assessment, dated 03/22/23, documented the resident was severely impaired with cognition and required limited to extensive assistance with ADLs. The assessment documented the resident was impaired on one side of the upper body and impaired on both sides of the lower body. A nurse note, dated 03/22/23, documented the resident had left side weakness, contracture in the left arm and hand, and had not attempted to ambulate while being at the hospital. The note documented the resident required feeding assistance had dysphagia and aphasia . A nurse note, dated 04/29/23, documented Res #21 was pleasant and squeezed with right hand on command. The note documented the resident's left hand…

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, interview, and record review, it was determined the facility failed to ensure a resident was supervised while smoking for tone (#21 and #41) of four sampled residents who were reviewed for accidents. The corporate nurse consultant identified 15 residents who smoked cigarettes. Findings: Res #41 was admitted to the facility on [DATE] with diagnoses which included critical illness myopathy, seizures, and disorder of the brain. A 48-hour care plan, dated 03/15/23, was initiated which documented resident was a supervised smoker. A smoking assessment, dated 03/17/23, documented the smoking policy and procedure was discussed with Res #41 and their family. Both resident and family agreed with the policy and procedure which documented Res #41 would be supervised related to previous injuries from smoking. An admission assessment, dated 03/22/23, documented the resident was cognitively intact; was independent with bed mobility, and minimum assistance with transferring and other ADLs; and used…

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 change an indwelling urinary catheter per physician order, keep the catheter bag off the floor, and positioned below the resident's bladder for one (#21) of two residents reviewed for indwelling urinary catheter. The Resident Census and Conditions of Residents, form documented four residents resided at the facility who had indwelling urinary catheters. Findings: Res #21 had diagnoses which included pressure ulcer of sacral region. An admission assessment, dated 03/22/23, documented the resident had an indwelling urinary catheter and was receiving hospice services. A physician order, dated 03/22/23, documented to change the urinary catheter every 30 days. A physician order, dated 04/01/23, documented to change urinary catheter every 30 days. A care plan, dated 04/04/23, documented the resident had a urinary catheter related to skin breakdown as evidenced by sacral wound. A physician order, dated 04/23/23, documented the urinary catheter was to be changed every 30 days. The resident's record did not document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one (#10) of one resident reviewed for hydration. The Resident Census and Conditions of Residents form documented two residents were dependent for eating. Findings: A facility policy, titled Resident Hydration and Prevention of Dehydration dated December 2008, read in parts, .6. Nursing will assess for signs and symptoms of dehydration during daily care. 7. Nurses Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff . Res #10 had diagnoses which included spastic quadriplegic cerebral palsy, severe intellectual disabilities, blindness, both eyes, contractures, calculus of kidney, calculus of ureter, and acute kidney failure. A quarterly assessment, 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 observation, record review, and interview the facility failed to ensure residents were assessed for the need of bed rails and informed consent was obtained prior to the use of bed rails for one (#21) of four residents reviewed for accident hazards. The Resident Census and Conditions of Residents form, documented 38 residents resided at the facility. Findings: Res #21's admission assessment, dated 03/22/23, documented the resident was severely impaired with cognition, required limited to extensive assistance with ADLs, and was receiving hospice care. A restraint assessment, dated 03/22/23, documented side rails were not indicated at that time. A care plan, dated 03/31/23, documented the resident required extensive to total assist with most ADLs related to illness as evidenced by decreased physical activity. The care plan documented the resident required extensive assist with dressing, bed mobility, personal hygiene, transfers at times, and bathing. The care plan did not include bed rails for the resident. On 05/01/23 at 11:28 a.m., a fall mat was observed in the resident's…

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

Based on observation, record review, and interview, the facility failed to acquire physician ordered medication for one (#18) of three residents observed during medication administration. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: Res #18 had diagnoses which included chronic embolism and thrombosis of unspecified deep veins of the lower bilateral extremities. A quarterly assessment, dated 04/13/23, documented the resident received an anticoagulant daily during the assessment period. A physician order, dated 04/20/23, documented to administer Apixaban (Eliquis) 5 mg one time daily. On 05/01/23 at 12:16 a.m., CMA #1 was observed during medication administration for Res # 18. During the administration, Eliquis 5 mg was not available to administer. The CMA was observed to order the medication during the medication pass. On 05/02/23 at 1:07 p.m., the corporate nurse consultant stated the facility received a three day supply that morning so the resident would be covered until the pharmacy sent the rest of the medication.…

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 medication error rate was less than 5% for one (#18) of four residents observed during medication pass. A total of 29 opportunities were observed with three errors and the total error rate was 10.34%. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: A facility policy, titled Self-Administration of Drugs dated August 2006, read in part, .13. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications. Res #18 had diagnoses which included chronic embolism and thrombosis of unspecified deep veins of the lower bilateral extremities, chronic obstructive pulmonary disease, and seasonal allergic rhinitis. A medication self administration assessment, dated 07/15/22, documented the resident was to be assisted by a CMA or nurse for inhaling with inhalers and no medications were to be left in the room. There were no other self administration…

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 demonstrated proper infection control practices related to removing gloves after catheter care for one (#21) of two residents reviewed for catheters. The Resident Census and Conditions of Residents form documented four residents resided at the facility who had indwelling urinary catheters. Findings: A facility policy, titled Catheter Care, Urinary, revised December 2007, read in parts, . 19. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly .23. Clean the bedside stand and/or overbed table. Return the overbed table to its proper position . Res #21 had diagnoses which included chronic atrial fibrillation, COPD, and pressure ulcer of sacral region. An admission assessment, dated 03/22/23, documented the resident had an indwelling urinary catheter. A physician order, dated 03/23/23, documented to perform catheter care with soap and water daily. On 05/02/23 at 1:17 p.m., LPN #1 was observed to place gloves 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 ensure a system to conduct regular inspection of all bed frames, mattresses, and bed rails, was in place. The Resident Census and Conditions of Residents form documented 38 residents resided at the facility. Findings: On 05/01/23 at 11:28 a.m., a fall mat was observed in Res #21 room next to his bed and a quarter bed rail was observed attached to the bed and was in the up position. On 05/04/23 at 11:12 a.m., the maintenance person stated they did bed rail inspections once a month but did not document the inspections. He stated they did not install the bed rail for Res #21. He stated the beds in the facility were old and most the bed rails did not fit the beds properly.