Accel At Crystal Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure toileting was provided in a timely manner for one (#142) of three sampled residents reviewed for timely ADLs. The DON identified 46 residents who needed assistance with ADLs resided in the facility. Findings: Resident #142 had diagnoses which included shortness of breath. Resident #142's care plan for elimination, dated 01/10/25, documented the resident would have a decrease in the number of incontinent episodes by implementation of a scheduled toileting program over the next 90 days. On 01/14/25 at 9:10 a.m., during medication administration, Resident #142 informed CMA #1 they needed to urinate. CMA #1 turned on the resident's call light and exited the room. On 01/14/25 at 9:14 a.m., Resident #142's call light remained on and was beeping. On 01/14/25 at 9:19 a.m., CMA #1 and LPN #2 were observed on the resident's hall. LPN #2's cart was positioned opposite the resident's room. Resident #142's call light remained on and 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 and interview, the facility failed to ensure the admission weight and weekly weights were obtained for a resident on dialysis for one (#21) of one sampled resident reviewed for dialysis. The DON identified three dialysis residents resided in the facility. Findings: A Weight monitoring policy, reviewed 05/2023, read in part, Newly admitted and re-admitted residents are weighed upon admission and weekly x 4 and then monthly thereafter, unless otherwise indicated by physician's order. The policy also read, Weekly weights and reweighs results are to be recorded in the EHR. Resident #21 was admitted on [DATE] with diagnosis which included end stage renal disease and dependence on dialysis. A physician order, dated 12/28/24, read in part, Weekly weights every Wednesday on day shift 28 days on admission then x 4 weeks then monthly if stable. The Resident weight record, had only one weight for 01/01/25 at 2:24 p.m. On 01/12/25 at 11:36 a.m., Resident #21 stated they did not get weighed weekly. 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 observation, record review, and interview, the facility failed to ensure a discharge hospital order for a fluid restriction was followed upon admission for one (#241) of three sampled residents reviewed for fluid restrictions. The administrator identified three residents on fluid restrictions resided in the facility. Findings: The FLUID RESTRICTION policy, revised 04/14/23, read in part, The Dining Services Department will coordinate with nursing services to verify that the resident's order for fluid restriction is implemented. Resident #241 had diagnoses which included chronic kidney disease and pulmonary edema. A hospital After Visit Summary, dated 12/26/24, documented fluid restriction, no more than 2000 milliliters in a 24 hour period. Resident #241 had no fluid restriction orders. On 01/13/25 at 12:28 p.m., Resident #241 stated staff were not sure if they were on fluid restriction. There was a water pitcher observed on the bedside table with 700 ml clear fluids. On 01/14/25 at 10:39 a.m., CNA #2 stated the nurses would inform them if a resident was on a fluid…

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 oxygen was administered as ordered and a resident was supervised during the administration of a nebulizer treatment for one (#243) of one sampled resident reviewed for respiratory care. The DON identified 20 residents who received continuous oxygen therapy in the facility. Findings: The Medication Administration, Nebulizers Updraft policy, revised 01/2023, read in part, Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. Resident #243 had diagnoses which included acute respiratory failure, unspecified whether with hypoxia or hypercapnia. A physician's order, dated 01/08/25, documented oxygen 2 liters per minute inhalation every two shifts via nasal cannula, oxygen saturation check related to acute respiratory failure, unspecified whether with hypoxia or hypercapnia. A physician's order, dated 01/09/25, documented albuterol sulfate 2.5mg/3 ml (0.083%) solution for nebulization, one vial inhalation three times per day. Minute check 15. 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 dialysis communication forms were consistently filled out for one (#21) of one sampled resident reviewed for dialysis. The administrator identified three residents in the facility received dialysis services. Findings: A Dialysis-Hemodialysis policy, reviewed 04/2023, read in part, c. Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C. Resident #21 had diagnoses which included end stage renal disease. A physician's order, dated 12/28/24, documented Resident #21 was to receive dialysis every Tuesday, Thursday, and Saturday. A Dialysis Pre/Post Communication Report, dated 01/09/25, did not have any documentation for the This section to be completed by the nursing home staff upon return part of the form. The section was to included the vital signs and assessment of the resident. A Dialysis Pre/Post Communication Report, dated 01/11/25, did not have any documentation for the This section to be completed by the nursing home staff upon…

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 topical pain medication was administered as ordered for one (#85) of five sampled residents reviewed for unnecessary medications. The administrator identified 56 residents resided in the facility. Findings: The Medication Administration policy, dated 01/2024, read in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Resident #9 had diagnoses which included pain. A physician's order, dated 01/08/25, documented Voltaren arthritis pain 1% topical gel. Apply by topical every 12 hours right knee for pain. The January 2025 MAR documented x for Resident #85's Voltaren arthritis pain 1% topical gel for the 9:00 a.m. administration on the 9th, 11th, 12th, 13th and the 9:00 p.m. administration on the 11th. It documented due to special parameters on the above dates. There was no documentation to explain what due to special parameters was for the above dates. On 01/15/25 at 8:42…

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 medication error of less than five percent for one (#142) of four residents observed during medication administration. The medication error rate was 7.14% The administrator identified 56 residents resided in the facility. Findings: A Medication Administration policy, dated 01/2024, read in part, Medications are administered as prescribed in accordance with the manufacturers' specifications, good nursing principle and practices. The policy also read, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. The policy also read, Medications are administered in accordance with written orders of the prescriber. The policy also read, Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. The policy also read, Verify medication is correct three (3) times before administering the medication. The policy also read, Medications are administered within 60…

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. the enhanced barrier precautions policy was implemented for a resident with a pressure ulcer for one (#6) of one sampled resident observed during wound care; b. wound care was provided in a manner that prevented cross contamination for one (#6) of one sampled resident observed during wound care; c. incontinent care was provided in a manner that prevented cross contamination for three (#1, 5, and #6) of three sampled residents observed during incontinent care; and d. staff members washed/sanitized their hands after providing care to a resident and before assisting another resident for four (#1, 4, 5, and #6) of four residents observed receiving assistance from staff. The DON identified seven residents with enhanced barrier precautions and eight residents with pressure ulcers resided in the facility. MDS Coordinator #1 identified 23 incontinent residents resided in the facility. LPN #2 identified 53 residents resided in 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 ensure the physician was notified when a resident experienced a change in condition for one (#2) of three sampled residents reviewed for change in condition. LPN #2 identified 53 residents resided in the facility. Findings: A Change in Condition policy, revised 02/13/23, read in part, .Document in the medical record the date, time, and name of each physician notified, actions taken and/or patient's response to treatment . Resident #2 had diagnoses which included acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. Resident #2's face sheet documented they admitted to the facility on [DATE] and discharged on 07/05/24. A Physician Order, dated 06/25/24, documented Resident #2 was to receive three LPM inhalation via nasal cannula. A Nurse Note, dated 06/28/24, documented Resident #2 took off their oxygen. It documented the resident's family member requested the resident be sent to the hospital…

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 controlled medications were not misappropriated for two (#8 and #9) of three sampled residents who were reviewed for misappropriation. The LPN #2 identified 53 residents resided in the facility. Findings: An Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, reviewed 02/12/20, read in part, .Each resident has the right to be free from . misappropriation of resident's property . 1. Resident #8 had diagnoses which included unspecified fracture of shaft of left fibula and low back pain. An admission assessment, dated 08/01/24, documented there cognition was intact. A physician's order, dated 08/08/24, documented to administer hydrocodone 10 mg - acetaminophen 325 mg (pain medication) every four hours as need for pain. 2. Resident #9 had diagnoses which included low back pain, unspecified, pain in left hip, and pain in right hip. An admission assessment, dated 08/11/24, documented they had severely impaired cognition. A physician's order, dated 08/08/24, documented to 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 on record review and interview, the facility failed to ensure physician ordered vital signs were obtained for one (#2) of three sampled residents reviewed for a change in condition. The DON identified all 53 residents in the facility had physician ordered vital signs. Findings: Resident #2 had diagnoses which included acute respiratory failure with hypoxia, cervical disc disorder with myelopathy and dysphagia oropharyngeal phase. A Physician Order, dated 06/24/24, read in part, Vital Signs every 2 shift Systolic BP Check Diastolic BP Check Pulse Check Respirations Check Temperature Check O2 Saturation Check. The medication administration record for June 2024 documented blanks for the night vital signs on the 26th, 28th, and 30th. On 09/06/24 at 2:23 p.m., the DON was asked who the most appropriate nurse would be to interview regarding this closed record. They stated the facility had several new nurses and the resident was not at the facility long. On 09/09/24 at 9:50 a.m., the DON stated they would answer questions related to Resident #2. They stated none of the nurses would…

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 treatment was provided as ordered for one (#6) of one sampled resident observed during wound care. The DON identifed eight residents with pressure ulcers resided in the facility. Findings: A Pressure Ulcer policy, revised 07/2018, read in part, .Pressure ulcers/injuries will be identified, evaluated and treated in accordance with generally accepted guidelines . Resident #6 admitted to the facility on [DATE] with diagnoses which included pressure ulcer of the sacral region unspecified stage. A Physician Order, dated 09/04/24, documented cleanse wound as needed, clean sacrum with normal saline, pat dry, pack with mesalt, cover with nonbordered dressing and secure with tape. It documented change daily and prn. On 09/05/24 at 5:25 a.m., CNA #2 and CNA #3 provided incontinent care to Resident #6 and LPN #3 placed a five by nine inch xeroform on Resident #2's coccyx. LPN #3 placed a six by six inch foam bordered dressing…

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 oxygen therapy was consistent with professional standards of practice for one (#2) of three sampled residents reviewed for oxygen therapy. The DON identified 18 residents with orders for oxygen therapy resided in the facility. Findings: Resident #2 had diagnoses which included acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A Physician Order, dated 06/25/24, documented Resident #2 was to receive three LPM inhalation via nasal cannula. A Nurse Note, dated 06/28/24, documented Resident #2 took off their oxygen. It documented the resident's family member requested the resident be sent to the hospital due to difficulty breathing. It documented staff assessed the resident's oxygen to be 76% with labored breath sounds. It documented staff put oxygen back on Resident #2 and hyperventilated the resident at 10 L. It documented the resident's oxygen came up to 98. It documented the staff titrated the resident's oxygen back down to 7 L, 5 L, and then 3 L. It…

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 showers in a timely manner and according to the plan of care for one (#1) of four sampled residents reviewed for assistance provided with showers. The administrator identified 53 residents resided in the facility. Findings: Resident #1 had diagnoses which included fracture of lower end of left femur and muscle atrophy. A Bathing policy, revised 01/20/23, documented staff will provide bathing services for residents within standard practice guidelines and that the procedure should be recorded in the record. A Self-Care Deficit care plan, initiated 01/18/24, documented the resident will assist with bathing and hygiene on a daily basis over the next 90 days. A physician order, initiated on 01/30/24, documented the resident was to receive baths on Tuesdays and Fridays. On 05/20/24 at 3:25 p.m., the ADON stated showers should be given twice a week, and they were only able to locate documentation that a bath or shower was offered on two days during the two weeks' stay. On 05/21/24 at 11:24 a.m., the regional nurse stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a dirty bedside commode was stored in a manner to prevent cross contamination to facility residents. The administrator identified 53 residents resided in the facility. Findings: On 05/20/24 at 2:35 p.m., CNA #1 stated that a bedside commode would never be used for more than one person without being sterilized. Dirty bedside commodes or bedpans would never be stored in the hallway. On 05/20/24 at 2:44 p.m., CNA #2 stated bedpans would never be shared between patients and bedside commodes must be sterilized between patients. Dirty bedside commodes or bedpans would never be stored in the hallway. On 05/21/24 at 10:13 a.m., a dirty bedside commode was observed sitting in the hallway outside room [ROOM NUMBER]. It had a small amount of yellow orange substance in the bottom of it. An IV pole with a blue baseball cap hanging from it, a red cane, and footrest attachments to a wheelchair were also observed sitting in the hallway. There was no staff…

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 allegations of abuse were investigated for two (#5 and #6) of three sample residents reviewed for abuse. The DON identified 46 residents resided in the facility. Findings: An Abuse policy, dated 02/12/20, read in part, .Upon receiving an allegation [of] abuse .the Abuse Coordinator will .initiate an investigation into the allegation . 1. Resident #5 had diagnoses which included unspecified displaced fracture of the fifth cervical vertebra. A Progress Note, dated 12/21/23, read in part, .Unfortunately, [Resident #5] has severe [quadriplegia] .limited use of all extremities with some preservation of right hand/wrist . A Safe Survey, dated 12/22/23, documented Resident #5 stated they didn't feel the night nurse or aide treated them with respect. It documented Resident #5 didn't feel comfortable or safe at night. A Grievance Summary, dated 12/27/23, read in part, .Date of Grievance/Concern 12/21/2023 .Family is upset that staff moved the call light away from the patient and told [Resident #5] [they were] pushing it too…

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 staff to ensure medications were administered timely for two (#2 and #5) of two sampled resident reviewed for staffing. The DON identified 46 residents resided in the facility. Findings: 1. Resident #2 had diagnoses which included chronic pain. A Summary Report, documented Resident #2 was to receive oxycodone-acetaminophen 5 mg every four hours from 12/08/23 to 12/22/23. It documented Resident #2 was to receive oxycodone-acetaminophen 7.5 mg every four hours from 12/14/23 to 12/22/23. Resident #5's MedAid MAR, dated from 12/01/23 to 12/27/23, documented the resident received oxycodone-acetaminophen 5 mg late two times. It documented the resident received oxycodone-acetaminophen 7.5 mg late four times. 2. Resident #5 had diagnoses which included pain. A Resident's Consolidated Order, dated 12/17/23, documented Resident #5 was to receive gabapentin three times a day and a Lidocaine patch was to be placed on in the morning and taken off in the evening. Resident #5's MedAid MAR, dated 12/01/23 to 12/27/23,…

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 timely for two (#2 and #5) of three sampled residents reviewed for medications. The DON identified 46 residents resided in the facility. Findings: 1. Resident #2 had diagnoses which included chronic pain. A Summary Report, documented Resident #2 was to receive oxycodone-acetaminophen 5 mg every four hours from 12/08/23 to 12/22/23. It documented Resident #2 was to receive oxycodone-acetaminophen 7.5 mg every four hours from 12/14/23 to 12/22/23. Resident #5's MedAid MAR, dated 12/01/23 to 12/27/23, documented the resident received oxycodone-acetaminophen 5 mg late two times. It documented the resident received oxycodone-acetaminophen 7.5 mg late four times. 2. Resident #5 had diagnoses which included pain. A Resident's Consolidated Order, dated 12/17/23, documented Resident #5 was to receive gabapentin three times a day and a Lidocaine patch was to be placed on in the morning and taken off in the evening. Resident #5's MedAid MAR, dated 12/01/23 to 12/27/23, documented 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 record review and interview, the facility failed to ensure residents had the right to view or receive copies of their clinical record for one (#1) of three residents reviewed. The DON reported 46 residents resided in the facility. Findings: Resident #1 had diagnoses which included depression. An Oklahoma Standard Authorization To Use Or Share Protected Health Information form, dated 12/11/23, documented Resident #1 requested Entire Medical Record was to be shared. A Social Note, dated 12/13/23, documented Resident #1 wanted their medical records and they weren't going to pay for them. It documented the SSD told the resident, per their policy, the resident had to fill out the paperwork for the request, it would be submitted to corporate to be processed, and then the records would be released. On 12/28/23 at 11:07 a.m., the medical records personnel was asked what was the policy when a resident requested medical records. They stated the resident was to fill out the release form, it was scanned to corporate with the records that were requested, and they would receive direction…

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 resolution of grievances for one (#5) of three sampled residents reviewed for grievances. The DON identified 46 residents resided at the facility. Findings: A Grievance policy, dated 01/12/20, read in part, .The resident .will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems within three .working days of the filing of the grievance . A Grievance, dated 12/21/23, documented Resident #5 reported they don't receive pain medication during the night when they request it. It documented Resident #5 reported the nurse said they would be back but they didn't come back. It documented Resident #5 reported the night shift ignored them. There was no documentation the grievance had been resolved. On 12/27/23 at 12:35 p.m., Resident #5 stated they didn't receive pain medication timely. They stated they have told staff about their complaints. On 12/28/23 at 12:32 p.m., the Administrator was asked what the process was when a resident made a grievance. She stated…

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 care plan fall interventions were in place for one (#3) of three sampled residents reviewed for falls. The DON identified 46 residents resided in the facility. Findings: Resident #3 had diagnoses which included fracture of unspecified part of right femur. A Care Plan, dated 12/21/23, documented Resident #3 was at risk for falls related to joint mobility interferes with balance, orthopedic surgery, generalized weakness, and a fall within the last month. It documented to keep the call light within reach and remind the resident to call for assistance. On 12/27/23 at 7:52 a.m., Resident #3 was observed laying in bed. The call light was observed hanging on the back of the left side of the bed, out of reach of the resident. Resident #3 stated the staff treat them wonderful when they could get staff to come in to their room. Resident #3 stated, Need a better way to call for the nurse other than a little button. Resident #3 was observed to look around for the call light and stated, I don't know where it's at.…

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 assessment was accurate for one (#55) of 15 sampled residents whose assessments were reviewed for accuracy. The DON identified 42 residents resided in the facility. Findings: A Resident Assessment policy, revised 01/12/20, read in part, .It is the standard at this facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guideline set forth in the Resident Assessment Instrument (RAI) manual .Each individual who completes a portion of the assessment will sign to certify the accuracy of that portion of the assessment . Resident #55 had diagnoses of Raynaud's syndrome without gangrene and drug induced Cushing's syndrome. Resident #55's discharge resident assessment, dated 11/03/23, documented the resident was discharged to short-term general hospital (acute hospital). On 12/05/23 at 2:37 p.m., the MDS Coordinator #1 stated Resident #55 discharged home with home health. They stated the…

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

Based on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident after dialysis for one (#115) of one sampled resident reviewed for dialysis. The DON identified 42 residents resided in the facility. Findings: A Dialysis - Hemodialysis policy, reviewed 04/14/23, read in part, .The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection form as follows .EHR>Resident Data Collection>Dialysis .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 . Resident #115 had diagnoses which include end stage renal disease and secondary hyperparathyroidism of renal origin. A physician order, dated 11/22/23, documented dialysis on Monday, Wednesday, and Friday. 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 and interview, and facility failed to ensure medications were secured for one of two medication carts observed during medication pass. The DON identified two medication carts and two treatment carts were utilized in the facility. Findings: A Storage of Medication policy, dated 2007, read in part, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . On 12/06/23 at 8:39 a.m., CMA #1 during medication observation, locked the medication cart, stated they needed to obtain scissors and would be back. CMA #1 walked away with six medication cards (hydralazine 25mg, divalproex sodium ER 500 mg, lisinopril 10 mg, gabapentin 400 mg, duloxetine 20 mg, and carvedilol 6.25 mg) and one bottle of aspirin sitting on top of the cart. On 12/06/23 at 8:43 a.m., CMA#1 stated I thought…

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 maintain infection control for one of one ice chest observed. The DON identified 42 residents resided in the facility. Findings: The Ice Storage and Ice Making Machine, Sanitary Care and Maintenance policy, revised 08/18, read in part, Sanitary care and maintenance of ice-storage and ice making machines will be accomplished in accordance with the Facility practice guidelines .Employees responsible for handling ice .Ice storage equipment are taught the following precautions .Limit access to the handling of ice and ice storage devices to minimize contamination .Do not leave ice chests in hallways where there is uncontrolled access . Resident #209 had diagnoses which included extended spectrum beta lactamase (ESBL) resistance and peritonitis. On 12/05/23 at 9:11 a.m., Resident #209 was observed getting ice with a scoop from the ice chest on hall 300. Resident #209 left the ice chest open and wheeled themselves back to their room. On 12/05/23 at 9:36 a.m., the Housekeeping Supervisor closed the lid to the ice…

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 timely and as ordered for one (#2) of three sampled residents reviewed for timely medication administration. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 49 residents resided in the facility. Findings: A Medication Administration General Guidelines policy, dated 09/18, read in part, .Medications are administered within 60 minutes of scheduled time .unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . Resident #2 had diagnoses which included ataxia, tremors, muscle wasting and atrophy, repeated falls and TIA. A physician's order, dated 08/18/23, documented buprenorphine hcl 8 mg two times a day. The scheduled date was 08/21/23 at 8:00 a.m. A physician's order, dated 08/17/23, documented hydroxyzine pamoate 50 mg four times a day. The scheduled date was 08/21/23 at 8:00 a.m. A physician's order, dated 08/17/23, documented…

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 used insulin needles were disposed of properly for two (#9 and #45) of two sampled residents observed during insulin administration. RN #2 identified nine residents received insulin injections. Findings: The facility's undated policy titled, Syringe and Needle Disposal, read in part, .Immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose . 1. Resident #9 had a physician's order to administer Levemir Insulin. On 10/26/22 at 7:30 a.m., RN #3 was observed to administer Levemir Insulin to Resident #9. After administration, RN #3 was observed to twist the needle off the insulin pen, doffed their gloves with the needle, and threw the gloves and needle away in the resident's trash can prior to leaving the resident's room. 2. Resident #45 had a physician's order to administer insulin glargine. On 10/26/22 at 7:40 a.m., RN #3 was observed to administer insulin glargine to Resident #45. After administration, RN #3 was observed 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.

2. Resident #45 had diagnosis which included acute and chronic respiratory failure. A physician's order, dated 10/06/22, documented, administer Wixela Inhub 500 mcg-50 mcg for inhalation twice a day. On 10/26/22 at 7:40 a.m., RN #3 was observed to administer Trelegy Elllipta 100-62.5-25 inhaler to Resident #45. On 10/26/22 at 11:05 a.m., RN #3 was asked how staff ensured medications were administered as ordered by the physician. RN #3 stated they looked at the name and medication and compared to the EHR. RN #3 was asked what inhaler was administered to Resident #45 this morning. RN #3 stated, Treledy. RN #3 was asked if the resident had a physician's order for Trelegy. RN #3 was observed to look at EHR. RN #3 stated the resident didn't. RN #3 was asked if the correct inhaler was administered to Resident #45. RN #3 stated, No. 3. Resident #158 had diagnoses which included seasonal allergies and constipation. A physician's orders, dated 10/11/22, documented, administer Magnesium Citrate tablet once a day, and Cetirizine 5 mg tablet once a day. On 10/26/22 at 7:52 a.m., CMA #1 was…

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

Based on record review, observation, and interview, the facility failed to ensure a medication administration observation error rate was less than five percent. There were three errors out of 32 opportunities observed during a medication pass which made the medication error rate 9.38%. The Resident Census and Conditions of Residents report, dated 10/25/22, documented 45 residents resided in the facility. Findings: The facility's Medication Error policy, revised 01/12/20, read in part, Types of Medication Errors .Administration Error .Wrong .Dose .Medication .Omission . 1. Resident #45 had diagnosis which included acute and chronic respiratory failure. A physician's order, dated 10/06/22, documented, administer Wixela Inhub 500 mcg-50 mcg for inhalation twice a day. On 10/26/22 at 7:40 a.m., RN #3 was observed to administer Trelegy Elllipta 100-62.5-25 inhaler to Resident #45. On 10/26/22 at 11:05 a.m., RN #3 was asked how staff ensured medications were administered as ordered by the physician. RN #3 stated they looked at the name and medication and compared to the EHR. RN #3 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 staff cleaned reusable blood pressure cuff and pulse ox monitor between residents for three (#158, #157 and #52) of three residents observed for vital signs. The Resident Census and Conditions report, dated 10/25/22, documented 45 residents resided in the facility. Findings: On 10/26/22 at 7:52 a.m., CMA #1 was observed to place blood pressure cuff on Resident #158's right upper arm and placed pulse ox monitor on Resident #158's left index finger. CMA #1 removed cuff and monitor and took them back to the medication cart. CMA #1 did not clean equipment after use. On 10/26/22 at 8:32 a.m., CMA #2 was observed to take the same blood pressure cuff and pulse ox monitor into Resident #52's room. CMA #2 was observed to place blood pressure cuff on the resident's left arm and placed pulse ox monitor on the resident's right index finger. CMA #2 did not clean equipment after use. On 10/26/22 at 8:38 a.m., CMA #1 was observed to take the same blood pressure cuff and pulse ox monitor into Resident #157's room. CMA #1 placed the…

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

Based on record review, observation, and interview, the facility failed to ensure call lights were kept within reach for one (#45) of 16 sampled residents reviewed for accommodation of needs. The Resident Census and Conditions of Residents report, dated 10/25/22, documented 45 residents resided in the facility. Findings: Resident #45 had diagnoses which included right ankle sprain, muscle weakness, and difficulty in walking. Resident #45's care plan, dated 10/06/22, documented to keep call light with in reach. Resident #45's admission assessment, dated 10/09/22, documented the resident's cognition was moderately impaired and the resident required extensive assistance with bed mobility and toilet use. On 10/25/22 at 9:11 a.m., Resident #45 was observed laying in bed. Resident #45 stated the staff didn't come on time. Resident #45 was asked what they meant. Resident #45 stated they were looking for their call light. A red push pad call light was observed sitting on the dresser, out of reach of the resident. On 10/25/22 at 9:26 a.m., Resident #45 was heard yelling for help from the…

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

Based on record review and interview, the facility failed to assess, intervene and consult the physician for a resident with tachycardia (heart rate over 100 beats/minute), bradycardia (slow heart rate below 60 beats/minute) and an elevated blood pressure for one (#119) of three sampled residents reviewed for vital signs. The Resident Census and Condition report, dated 10/25/22, documented 45 residents resided in the facility. Findings: Resident #119 was admitted with diagnoses which included hypertension, hypo-osmolality (levels of electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia (produced by retention of water, by loss of sodium or both). There was no nurses note with assessment or intervention dated to coincide with the March medaid (sic) MAR which documented, 03/13/22 heart rate 105, 03/14/22 heart rate 115, 03/14/22 heart rate 105, 03/15/22 heart rate 116, 03/16/22 heart rate 135, 03/17/22 heart rate 134, 03/19/22 heart rate 34 and blood pressure 138/111, 03/19/22 heart rate 103. On 10/27/22 at 12:23 p.m., RN#2 stated medication aides…

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.