Ignite Medical Resort Edmond, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a bed hold policy and discharge notice to resident representative for 2 (#76 and #9) of 2 sampled residents reviewed for bed hold policies.The DON identified 162 residents had been discharged from the facility in the last six months.Findings:1. An undated Bed Hold Notice policy, read in part, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave .In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. An admission MDS assessment, dated 09/07/25, showed Resident #76 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included dementia, restless leg…

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 MDS assessments were accurately coded to reflect the resident's status for 2 (#3 and #5) of 23 sampled residents reviewed for accurate MDS assessments.The administrator identified 68 residents resided in the facility. Findings: 1.On 10/02/25 at 9:31 a.m., Resident #3 was observed lying in bed alert and oriented. A white bi-pap machine was observed on the bedside dresser. There were a mask and hose observed attached to the BIPAP with visible moisture in the mask laying in the open top drawer of the bed side dresser. An undated facility's policy titled Conducting an Accurate Resident Assessment, read in part, The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. An undated facility's policy titled 'Noninvasive Ventilation (CPAP, BIPAP,…

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 showers were provided for dependent residents for 1 (#15) of 2 sampled residents who were reviewed for activities of daily living.The DON identified 10 residents who were dependent on staff for showers/bathing.Findings: On 10/01/25 at 9:45 a.m., Resident #15 was observed in bed watching television. The resident was observed to be well-groomed and free from odors. An undated policy, titled Resident Showers, read in part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. An admission assessment, dated 09/16/25, showed Resident #15 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, had a diagnosis of depression, and was dependent on staff for showering/bathing. A care plan, dated 09/16/25, showed Resident #15 required staff assistance with showering/bathing. Review of the electronic clinical record and shower sheets, dated 09/09/25 - 09/30/25, showed Resident #15 had received a shower/bath six out…

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 safe smoking assessment was completed to prevent accidents and hazards for 1 (#10) of 1 sampled resident reviewed for safe smoking assessments to prevent accidents and hazards.The administrator identified no residents who smoke, and the facility was a non-smoking facility.Findings: On 10/02/25 at 10:49 a.m., Resident #10 was observed ambulating with a walker. Resident #10 was observed putting in the door code on the east exit and went outside. Resident #10 sat in a chair outside the door, less than 15 feet from the door. Resident #10 was observed with a lighter and cigarette in their possession. Resident #10 lit a cigarette and sat and smoked less than 15 feet from the entrance unsupervised. Resident #10's admission assessment, dated 09/03/25, showed Resident #10's cognition was moderately impaired with a BIMS score of 9. The assessment showed Resident #10 was a tobacco user.Resident #10's care plan, revised 09/09/25, read in part, I have behaviors of smoking outside and refusing my lactulose,…

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 indwelling urinary catheters were secured for 1 (#1) of 4 sampled residents reviewed for urinary catheters.The DON identified four residents had indwelling urinary catheters.Findings: On 10/01/25 at 10:23 a.m., CNA #1 and CNA #3 were observed to provide catheter care for Resident #1. The catheter was not observed to be secured before or after the care had been provided. A care plan, updated 07/23/25, showed Resident #1 had an indwelling urinary catheter for urinary retention. A quarterly assessment, dated 07/23/25, showed Resident #1 had a BIMS score of four, which indicated the resident was severely impaired in cognition for daily decision making, and had an indwelling urinary catheter. On 10/02/25 at 11:50 a.m., CNA #3 stated they typically utilized a device to secure indwelling urinary catheters. CNA #3 observed Resident #1's catheter and stated they did not know why Resident #1's urinary catheter was not secured. CNA #3 stated they did not know why it had not been secured after catheter care 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 clinical rationale had been documented for a declined gradual dose reduction for 2 (#11 and #5) of 5 sampled residents reviewed for unnecessary medications.The DON identified seven residents who received psychotropic medications.Findings: 1.A physician order, dated 08/24/25, showed Resident #11 had been ordered fluoxetine (an antidepressant medication) 40mg daily. A Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction, dated 03/22/25, showed a gradual dose reduction was recommended for fluoxetine 40mg daily. The physician check marked a box which indicated the minimal effective dose. The Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction, read in part, Continue current use of above stated medication. My Clinical Rationale for continuance is as follows. The section for the clinical rationale from the physician was left blank. An annual assessment, dated 08/24/25, showed Resident #11 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision…

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 monitoring for anticoagulants for 1 (#11) of 5 sampled residents reviewed for unnecessary medications.The DON identified 22 residents received an anticoagulant medication.Findings: An undated policy titled, Medication Monitoring, read in part, Interventions shall be identified on the resident's comprehensive plan of care for the systematic monitoring of high risk medications to facilitate early identification of adverse consequences. A physician order, dated 08/23/24, showed Resident #11 was ordered Xarelto (an anticoagulant medication) 10mg daily for quadriplegia. An annual assessment, dated 08/24/25, showed Resident #11 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision making, had a diagnosis of multiple sclerosis, and had received an anticoagulant medication during the look back period.A care plan, dated 08/24/25, showed the resident received Xarelto and staff were to monitor, document, and report to the physician signs or symptoms of anticoagulant complications.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 observation, record review, and interview, the facility failed to ensure treatment carts were secured for 1 (400 hall) of 4 treatment carts observed.The DON identified four treatment carts in the facility. Findings:On 10/01/25 at 1:55 p.m., the 400-hall treatment cart was observed to be unlocked and unattended by room [ROOM NUMBER]. The cart was observed to contain insulin, heparin, medicated ointments, and wound cleanser/wound care supplies.On 10/01/25 at 1:57 p.m., RN #1 was observed to lock the 400-hall treatment cart.An undated policy titled Medication Storage, read in part, During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 10/01/25 at 1:57 p.m., RN #1 stated the treatment cart was to be locked when unattended.On 10/01/25 at 2:06 p.m., the DON stated treatment carts were to be kept locked when unattended to ensure medications were secured.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure radiology services were provided for 1 (#2) of 1 sampled resident reviewed for radiology services.The DON identified 68 residents resided in the facility.Findings: An undated policy titled Diagnostic Testing Services, read in part, The facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. A care plan, updated 01/13/25, showed Resident #2 had pain related to osteoarthritis and chronic pain, and to administer pain medication per physician orders. A physician visit note, dated 06/05/25, read in part, Assessments 1. Pain in left upper arm.Treatment 1. Pain in left upper arm. Notes: order x-ray of the left humerus and elbow then escalate to MRI evaluation. A physician visit note, dated 06/30/25, read in part, Assessments 1. Pain in left upper arm.Treatment 1. Pain in left upper arm. Notes: order x-ray of 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 an allegation of abuse was reported to the State agency within two hours for 1 (#1) of 3 sampled residents reviewed for abuse.The DON identified 55 residents resided in the facility. Findings:The facility abuse, neglect, and exploitation policy, dated 2025, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes .Immediately, but no more than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.A quarterly resident assessment, dated 06/04/25, showed Resident #1's cognition was intact (brief…

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 were free from physical abuse for two (#2 and #5) of three sampled residents reviewed for abuse. LPN #1 identified 59 residents resided in the facility. Findings: An undated Abuse, Neglect and Exploitation policy, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect, exploitation and misappropriation of resident property. The policy also read, The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse. 1. Resident #2 had diagnoses which included anxiety disorder and depression. A MDS assessment, dated 01/05/24, documented the resident's cognition was intact with a BIMS score of 15. It documented the resident was always incontinent of bladder and required substantial/maximal assist of staff for toileting hygiene. An initial OSDH Incident Report, received at OSDH on 08/19/24…

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. food items in the refrigerator were properly labeled and had identified use by dates, b. food items were discarded on or before the manufacturer expiration dates, c. leftovers in the refrigerator were dated and used within at least 3 days, d. food items were stored at the appropriate temperatures, e. only clean utensils were used when accessing bulk foods, f. staff in the kitchen with beards wore beard restraints, g. clean dishware was not exposed to splash and covered or inverted, and h. dishwasher rinse cycles were routinely tested for proper chemical sanitization. The Administrator identified 58 residents resided at the facility. Fifty-six residents received meals prepared by dietary services. Findings: A 'Dishwashing Machine Use' policy, revised August 2010, read in parts, A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution .once a week . A 'Food Safety Requirements' policy, undated, read in parts, Dietary staff must wear hair restraints (e.g.,…

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 a nurse aide performance review once every 12 months for two (CNA #1 and CNA #2) of two CNA records reviewed for annual competencies. The staff roster, dated 04/24/24, documented 31 CNAs are employed by the facility. Findings: A Competency Evaluation policy, dated 2023, read in part, subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations .employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. CNA #1 had a hire date of 11/23/21. There was no CNA annual competency review located in the employee's file. CNA #2 had a hire date of 07/20/22. There was no CNA annual competency review located in the employee's file. On 04/25/24 at 1:38 p.m., the DON and Executive Director stated CNA competency reviews were completed upon hire and annually. The DON 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 record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for two (#31 and #163) of 15 sampled residents reviewed for advanced directives. The Administrator identified 58 residents resided in the facility. Findings: 1. Resident #31 was admitted on [DATE] and had diagnoses which included status post displaced comminuted fracture of shaft of humerus right arm. The resident's clinical records did not document the resident and/or their representative was offered the choice to formulate an advanced directive. 2. Resident #163 was admitted on [DATE] and had diagnoses which included aftercare following joint replacement surgery left knee. The resident's clinical records did not document resident and/or their representative were offered the choice to formulate an advanced directive. On 04/23/24 at 10:51 a.m., the Admissions Coordinator was asked if Resident #31 or Resident #163 had been offered the choice to formulate advanced directives. They…

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

Based on record review and interview, the facility failed to obtain a discharge order for one (#61) of three discharged residents reviewed. The Executive Director identified 58 residents resided in the facility. Findings: Resident #61 had diagnoses which included conversion disorder with seizures. A Transfer and Discharge (including AMA) policy, revised 2023, read in part, Obtain physicians' orders for transfer or discharge . A progress note, dated 01/25/24, read in part, Date/Time of Discharge/Death: 1/25/24 @1300 . On 04/23/24 at 1:38 p.m., the DON stated there was not a physician's order for discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#28) of 15 sampled residents reviewed for baseline care plans. The Executive Director identified 58 residents resided in the facility. Findings: A Baseline Care Plan policy, dated 2023, read in part, The baseline care plan will . be developed within 48 hours of a resident's admission. Resident #28 admitted on [DATE] with diagnoses which included acute kidney failure and gastrointestinal hemorrhage. There was no baseline care plan located in the resident's clinical record. On 04/24/24 at 11:05 a.m., MDS Coordinator #2 stated the baseline care plan was not developed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop and implement a comprehensive care plan for two (#9 and #28) of 15 residents reviewed for care plans. The Executive Director identified 58 residents resided in the facility. Findings: A Comprehensive Care Plans policy, dated 2023, read in part, The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment .The comprehensive care plan will describe, at a minimum .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. Resident #9's comprehensive care plan, initiated on 02/13/24, documented the ability to walk in the room and hallway with staff assistance and the use of a walker. An admission assessment, dated 02/18/24, documented resident #9 required substantial assistance with bed mobility and did not attempt to transfer or walk due to medical or safety concerns. On 04/24/24 at 1:08 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.

Based on record review and interview, the facility failed to ensure a discharge summary was complete for one (#61) of three sampled residents reviewed for discharge. The Executive Director identified 58 residents resided in the facility. Findings: Resident #61 had diagnoses which included conversion disorder with seizures. A Discharge Summary policy, dated 2023, read in part, The discharge summary should include .reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications . A Discharge Summary, dated 01/25/24, documented the resident received skilled nursing services and therapy services. The discharge summary documented the resident was stable and the resident and representative were educated to see the PCP for follow up after discharge. A Clinical Discharge Instruction Form, dated 01/25/24, had a section for medications sent home. That section was observed to be incomplete. On 04/23/24 at 1:38 p.m., the DON stated medication reconciliation was not documented.

Based on observation, record review, and interview, the facility failed to administer medications as ordered for one (#264) of five sampled residents observed for medication administration. The Executive Director identified 58 residents resided in the facility. Findings: The Medication Administration policy, dated 2024, read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician . Resident #264 had a diagnosis of hypertension. A physician's order, dated 04/24/24, documented losartan potassium-HCTZ 100-25 mg give 1 tablet by mouth daily for hypertension. Hold if systolic BP is less than 105 or diastolic is less than 65 and notify physician. On 04/24/24 at 7:55 a.m., RN #2 was observed documenting that she was holding the losartan due to a low pulse. RN #2 did not administer the medication. On 04/24/24 at 10:24 a.m., RN #2 stated the order was to hold the medication if the BP was low and to notify the physician. RN #2 stated they would clarify the order with the physician.

Based on record review and interview, the facility failed to have a proper indication for the use of ordered medications for two (#4 and #262) of six sampled residents reviewed for unnecessary medications The Executive Director indicated 58 residents resided in the facility. Findings: A Unnecessary Drugs-Without Adequate Indication for Use policy, undated, read in parts, indication for use is the identifed, documented clinical rationale for administering a medication .will be determined by assessing the resident's underlying condition . 1. Resident #4 had diagnosis which included dementia and pain. A Active Order summary, dated 04/25/24, read in part, Lorazepam [antianxiety medication] 0.5mg give one tab by mouth two times a day for pain . On 04/25/24 at 3:21 p.m., the DON was asked if pain was a proper indication for the Lorazepam use. They stated No, it is not 2. Resident #262 had physicain orders for: a. torsemide 20mg 3 tablets daily for diuretics, and b. apixaban 5mg every 12 hours for anticoagulant therapy. On 04/25/24 at 11:31 a.m., the DON stated that neither medications had…

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 disinfection a glucometer before or after its use on a resident. RN #2 identified three residents required the use of this glucometer for blood glucose monitoring. Findings: A Glucometer Disinfection policy, dated 2023, read in part, The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . On 04/23/24 at 11:30 a.m., RN #2 was observed completing glucose monitoring with a glucometer. RN #2 did not disinfect the glucometer before or after the use. On 04/23/24 at 11:33 a.m., RN #2 stated the glucometer gets cleaned by the night shift. They provided a Glucometer Control Log that documented that the glucometer was in range, but did not document any cleanings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facilty failed to ensure a bath/shower was provided to a resident who required assistance from staff for one (#1) of three sampled residents reviewed for ADL assistance. The facility census, dated 12/04/23, documented 67 residents resided in the facility. Findings: An Activities of Daily Living Policy, dated 2023, read in part, .Care and services will be provided for the following activities of daily living .bathing . Resident #1 admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, sepsis, and stage four chronic kidney disease. An admission Resident Assessment, dated 11/21/23, documented Resident #1's cognition was intact, and they needed partial assistance from another person for bathing. Resident #1 had a shower review sheet completed on 11/22/23 and 12/02/23. There was no other documentation Resident #1 had received any other bath/shower in the facility. On 12/05/23 at 12:05 p.m., Resident #1 stated they did not receive a bath or…

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 available and administered as ordered for one (#1) of three sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 54 residents resided in the facility. Findings: Resident #1 had diagnoses which included heart failure, essential (primary) hypertension, Atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and heart failure, unspecified. A Physician's Order, dated 03/02/23, documented amlodipine Besylate oral tablet 5mg, give one tablet by mouth one time a day related to essential (primary) hypertension. A Physician's Order, dated 03/02/23, documented hydralazine HCI oral tablet 100mg, give one tablet by mouth with meals related to essential (primary) hypertension. A March 2023 MAR documented the following: a. Amlodipine Besylate 5mg had not been administered three out of 29 opportunities. Nurse notes documented three of the 29 opportunities the medications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a physician was notified timely when: A. an unstageable wound had been identified by staff for one (#157), B. a resident had a stage two pressure ulcer to obtain a treatment and when signs and symptoms of infection had been identified for one (#153), and C. a medication was unavailable and could not be administered as ordered for one (#19) of three sampled residents reviewed for notification. The Resident Census and Conditions of Residents report, dated 03/13/23, documented 59 residents resided in the facility. Findings: A Notification of Changes policy, dated 01/03/23, read in part, .The purpose of this policy is to ensure the facility promptly .consults the resident's physician .when there is a change requiring notification Circumstances that require a need to alter treatment .New treatment . 1. Resident #153 admitted to the facility on [DATE] with diagnoses which included pressure ulcers. A Nursing Admission 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 record review and interview, the facility failed to ensure a medication was administered timely for one (#19) of six sampled residents reviewed for medication. The Resident Census and Conditions of Residents report, dated 03/13/23, documented 59 residents resided in the facility. Findings: A Medication Ordering policy, dated January 2023, read in part, .Medications and related products are received from the provider pharmacy on a timely basis . Resident #19 had diagnoses which included rash and other nonspecific skin eruption. A Resident Assessment, dated 02/22/23, documented Resident #19's cognition was moderately impaired. A Skin/Wound Note, dated 03/12/23 at 9:22 p.m., documented the resident had a rash to their chest and was scratching at it. A new order was received for Bactroban cream to be applied twice a day for five days. An eMAR note, dated 03/13/23 at 10:21 a.m., documented waiting on pharmacy for the Bactroban cream. An eMAR note, dated 03/14/23 at 12:47 a.m., documented the Bactroban had been ordered and would not be available until possibly Wednesday…

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.