South Pointe Rehabilitation and Care Center

Based on observation, record review and interview, the facility failed to ensure physician ordered abdominal girth measurement amounts were completed for 1 (#21) of 1 sampled resident reviewed for non pressure skin conditions. The DON identified one residents with orders to measure abdominal girth resided in the facility. Findings: On 04/25/25 at 9:38 a.m., LPN #3 was observed measuring Resident #21's abdominal girth. They placed the measuring tape across the mid section of the abdomen and stated it measured 53 inches. A physician order policy, last reviewed 09/28/22, read in part, Physician Orders that are missing required components, are illegible or unclear must be clarified prior to implementation. A quarterly resident assessment, dated 02/12/25, showed Resident #21's cognition was intact (BIMS 15). A physician order, dated 02/25/25, showed daily girth/abdomen measurement one time a day for increased girth/abdomen. A nurse progress note, dated 03/02/25, showed the resident's girth measurement was 48.2 inches. A nurse progress note, dated 03/16/25, showed the resident's girth…

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 PRN order for an anti-psychotic drug was limited to 14 days for 1 (#92) of 5 sampled residents reviewed for unnecessary medications. The DON identified 177 residents resided in the facility. Findings: A policy titled PSYCHOTROPIC MANAGEMENT GUIDELINES, dated 07/26/23, read in part, PRN medications will be ordered for no longer than 14 days. Resident #92's order summary report, dated 04/2025, showed the resident had diagnoses which included senile degeneration of the brain and unspecified psychosis not due to a substance or known physiological condition. Resident #92's physician's order, dated 02/25/25, showed lorazepam (antianxiety medication) 2 mg/ml, give 0.5 ml by mouth every two hours as needed for agitation and restlessness. The end date for the lorazepam order showed indefinite. The March and April 2025 MAR, showed the resident received the lorazepam 12 times outside of the 14 days. On 04/28/25 at 12:45 p.m., the DON stated the lorazepam was ordered on 02/25/25. They stated the order did not have an end…

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

Based on record review and interview, the facility failed to ensure labs were obtained as ordered for: a. 1 (#24) of 1 sampled resident reviewed for dialysis; and b. 1 (#92) of 5 sampled residents reviewed for unnecessary medications. The DON identified 177 residents resided in the facility and three residents received dialysis services. Findings: 1. In the electronic health record, Resident #24's diagnosis sheet, dated 04/24/05, showed diagnoses which included renal dialysis and atrial fibrillation. Resident #24's Physician Order, read in part, revised 02/07/24 A1C Now AND EVERY 3 MONTHS (FEBRUARY, MAY, AUGUST, NOVEMBER). (A lab test that measures the average level of sugar in your blood over the past 2-3 months.) Labs services for Resident #24 was due for the month of Feburary 2025 and was not found. On 04/23/25 at 2:37 p.m., the DON stated the last A1C they had for Resident #24 was November 2024. On 04/24/25 at 11:21 a.m., LPN #4 stated they did not know how Resident #24's labs got missed. On 04/24/25 at 2:27 p.m., the director of nurses stated she did not think they had a…

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

Based on record review and interview, the facility failed to: a. notify the physician of missing labs for 1 (#24) of 1 residents reviewed for dialysis. b. develop a lab policy. The DON identified 177 residents resided in the facility. Findings: Resident #24's diagnosis sheet, dated 04/24/25, showed a diagnosis of renal dialysis. Resident #24's Physician Order, read in part, revised 02/07/24 A1C Now AND EVERY 3 MONTHS (FEBRUARY, MAY, AUGUST, NOVEMBER). (A lab test that measures the average level of sugar in your blood over the past 2-3 months.) Labs services for Resident #24 was due for the month of Feburary 2025 and was not found. On 04/23/25 at 2:37 p.m., the DON stated the last A1C they had for Resident #24 was November 2024. On 04/24/25 at 11:21 a.m., LPN #4 stated they did not know how Resident #24's labs got missed. On 04/24/25 at 2:23 p.m., the director of nurses stated we just notified the physician today. On 04/24/25 at 2:27 p.m., the director of nurses stated they did not think they had a policy for laboratory services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: a. provide an adequate supply of towels for bathing on resident halls or in the laundry room; b. ensure shower beds were clean and in good repair for two of two shower beds; c. ensure a shower hose was not missing in the shower room located next to room [ROOM NUMBER]; and d. ensure broken tiles on the floor and wall of a shower located in the shower room on Hall 300 were repaired. ADON #1 identified 182 residents resided in the facility. The DON identified the facility had two shower beds and seven shower rooms. Findings: 1. On 02/24/25 at 4:29 p.m., a confidential interview was held with a resident. The resident stated, Sometimes we don't have towels. On 02/25/25 at 9:40 a.m., Resident #3 stated, For a few months we don't have towels. On 02/27/25 at 9:12 a.m., CNA #6 stated they were limited on supplies. They stated they run out of towels a lot. CNA #6 opened room [ROOM NUMBER] with a total of 11 towels observed available for use. They stated, This is…

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 handrails were firmly secure to the wall in 2 (Hall 100 and Hall 200) of 7 shower rooms observed. ADON #1 identified 182 residents resided in the facility. The DON identified seven shower rooms in the facility. Findings: On 02/27/25 at 9:26 a.m., the first shower in shower room on Hall 200 was observed to have loose hand rails underneath both shower heads. Both hand rails wiggled easily and the metal coverings where they meet the wall were loose. CNA #6 stated it scared them to use. CNA #6 stated they reported it to the nurse who put it in the electronic maintenance notification system. They stated the issue was maintenance getting it fixed. The second shower had hand rails that wiggled significantly under each shower head. The metal coverings where the handrails meet the wall were observed loose. There was a third handrail on the back wall of this shower that was observed to be loose from the wall. On 02/27/25 at 10:37 a.m., CNA #8 opened the shower room on Hall 100. The first shower was observed to have a handrail…

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 report an allegation of abuse to the OSDH for 1 (#12) of 3 residents sampled for abuse. ADON #1 identified 182 residents resided in the facility. Findings: The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents . Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress. Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins. Resident #12's annual assessment, dated 01/23/25, documented Resident #12's cognition was intact with a BIMS score of 15. An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard…

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 a care plan was updated for 1 (#12) of 14 sampled residents whose care plans were reviewed. ADON #1 identified 182 residents resided in the facility. Findings: A Comprehensive Person Centered Care Plan policy, dated 01/2019, read in part, Each resident will have a person centered care plan to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins. Resident #12's annual assessment dated [DATE], showed Resident #12's cognition was intact. An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard the med-delivery person verbally abuse a staff member by yelling and…

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

Based on record review and interview, the facility failed report an allegation of abuse to OSDH for two (#11 and #12) of seven sampled residents reviewed for abuse. The Administrator identified 170 residents resided in the facility. Findings: The Abuse Prevention policy, revised 10/21/22, read in part, The Administrator, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required. An OSDH Incident Report Form, dated 09/01/24, read in part, On 9.1.24 CNA [name withheld] reported to the DON that [resident name withheld] informed [them] that [they] did not want CNA [name withheld] to care for [them] anymore because [they] were rough with [them] and won't clean inside [their] labia. [resident] stated that the incident happened on 8.31.24. and [they] felt abused by this CNA. The charge nurse completed a head to toe assessment and pain eval, no new issues noted. The investigation included 10…

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: a. protect resident from abuse for four (#3, 5, 8, and #9 ), and b. conduct a thorough investigation for allegations of abuse for five (#3, 5, 7, 8, and #9) of five sampled residents reviewed for abuse. The Administrator identified 170 residents resided in the facilty. Findings: The Abuse Prevention policy, revised 10/21/22, read in part, The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The policy also read, In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. The policy also read, Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. The policy also read, Findings will be reviewed by 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 medication and treatments were administered as ordered for one (#6) of three sampled residents who were reviewed for medication administration. The Administrator identified 170 residents resided in the facility. Findings: Resident #6 had diagnosis which included DM type two and diabetic wound. A physicians order dated 06/29/24 - 07/18/24, documented wound care to left ankle change once daily and as needed. Scheduled on day shift. The TAR was blank on 07/18/24 day shift. A physicians order dated 06/29/24 - 07/24/24, documented wound care to left heel change once daily and as needed. Scheduled on day shift. The TAR was blank on 07/24/24 day shift. A physicians order dated 07/19/24 - 07/25/24, documented wound care to left ankle once daily. Scheduled on day shift. The TAR was blank on 07/25/24 day shift. There was no other documentation located of the treatments completed for left ankle on 07/18/24 or 07/24/24, and the left heel for 07/25/24. On 10/16/24 at 3:58 p.m., the DON stated if it was not documented then it was…

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

Based on observation, record review, and interview, the facility failed to ensure residents have access to the grievance procedure and failed to post information regarding the name of the grievance official. The DON identified 176 residents resided in the facility. Findings: The GRIEVANCE/MISSING PROPERTY policy, revised 04/26/23, read in part, To provide an opportunity for Residents, Residents Representatives, and/or Families to present concerns or Grievances to the proper authorities at the Facility and receive responses to the issue(s) raised. On 08/12/24 at 10:25 a.m., a tour of the facility was conducted. Ombudsman contact name, resident rights, and the facility's senior management concern procedure poster was observed on a wall near the main dining room entrance. There was no signage to indicate the person to contact to file a grievance or available forms in the resident units. On 08/12/24 at 11:47 a.m., Resident #3 stated they did not know who the grievance official was or where to locate the information to file a grievance. On 08/12/24 at 1:17 p.m., Resident #2 stated 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 observation, record review, and interview, the facility failed to ensure the menu was followed and adequate portion sizes were offered to residents for one of one meal service observed. The DON identified 173 residents received services from the kitchen in the facility. Findings: The NUTRITIONAL SERVICES MENUS policy, revised 03/31/21, read in part, Menus shall be followed which have been reviewed and approved by a Registered Dietitian (RD) in compliance with the Federal and State Regulations and consistent with Standards of Practice on nutritional care. A menu, dated 08/12/24, documented the following for regular/NAS lunch: Meat sauce with spaghetti noodle - 8 oz ladle, Italian vegetable blend - 1/2 cup (4 oz), Garlic bread - one slice. A menu, dated 08/12/24, documented the following for pureed lunch: Meat sauce with spaghetti noodle - #8 scoop spaghetti (4 oz) and #8 scoop meat sauce (4 oz), Italian vegetable blend - #10 scoop, Garlic bread one slice - #20 scoop. On 08/12/24 at 10:53 a.m., the CDM identified the above menu as scheduled to be served for lunch on 08/12/24.…

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 record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for two (#1 and #2) of three residents reviewed for abuse. The DON reported 171 residents resided in the facility. Findings: A facility Abuse Prevention policy, dated 10/21/22, read The Administrator and Director of Nursing must be promptly notified of suspected abuse or incidents of abuse. A State Incident Investigation Report, dated 05/17/24, documented the DON received a call reporting CNA #2 had been abusive to residents #1 and #2. The reports documented that LPN #1 was made aware of the issue and had not reported it to the DON or facility administration. Res #1 admitted to the facility with diagnoses of dementia, psychosis, and other specified depressive episodes. Res #2 admitted to the facility with diagnoses of cerebral infarction, insomnia, major depressive disorder, and anxiety. On 07/16/24 at 1:00 p.m., the DON reported LPN #1 reported she had handled the allegation herself and did not report it to the DON. The DON reported LPN #1 was terminated for not…

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

Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three residents reviewed for abuse investigations. The DON reported 171 residents resided in the facility. Findings: The facility policy Abuse Prevention, dated 10/21/22, read in part, . Any allegation of abuses, or neglect, misappropriation of property, or mistreatment shall be thoroughly investigated. A report to the Oklahoma State Department of Health, dated 05/17/24, documented an allegation of abuse from CNA #1 who alleged CNA #2 was abusive to Residents #1 and #2. The report documented CNA #1 had reported the allegation to LPN #1 and nothing had been done. A review of the investigation of the allegation contained interviews with the three staff members involved. On 07/16/24 at 1:00 p.m., the DON reported they had only interviewed the three staff members directly involved. Reported they should have interviewed other staff that worked with the three staff members involved.

Based on observation, record review, and interview, the facility failed to ensure ADL care was provided according to the plan of care for three (# 1, 7, #8) of four sampled residents reviewed for ADL care. The Assistant Administrator identified 183 residents resided in the facility. A Turning and Repositioning policy, dated 07/21/22, read in part, .The Facility will aid with Turning & Repositioning residents to prevent skin breakdown. Nursing employees will Turn & Reposition residents as reflected in their plan of care . A Incontinent Care policy, dated 07/21/22, read in part, .The Facility will Provide Incontinent Care as Directed in the Plan of Care . 1. Resident #7 had diagnoses which included need for assistance with personal care. Resident #7 care plan dated 07/11/24 documented the resident had self care performance deficit and required staff participation. Resident #7 ADL documentation of blanks as follows: April 2024: Bed mobility were eight out of 29 opportunities. Personal hygiene were seven out of 19 opportunities. Toilet use there were nine out of 31 opportunities. Bowel…

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 ice machine was clean and free from debris for one of one ice machine observed in the kitchen. The Assistant Administrator identified 183 residents resided in the facility. Findings: A Work History Report documented preventative maintenance to the ice machine and bins and to check filters, clean coils, sanitize interior, delime was due on 03/31/24 and was completed on 03/04/24. It also documented it was due on 02/29/24 and had been done on 03/04/24 as well. On 04/17/24 at 11:26 a.m., the ice machine was observed with the Dietary manager and Maintenance #1. There was black, brown and white slimmy residue and particles present at the right bottom corner of the machine on the other side of the coils above the ice bin. Maintenance #1 touched it with bare fingers and stated it was food. They stated it was to be cleaned every 30-40 days and had just been redone and was due at the end of the month. On 04/18/24 at 3:57 p.m., the Area Director stated that if the water sits too long it can become stagnant,…

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 SNF ABN and NOMNCs were provided timely for two (#113 and #236) of three sampled residents reviewed for SNF Beneficiary notices. A Beneficiary Notice form, documented 13 residents had been discharged from skilled services in the past six months. Findings: A Skilled Care policy, dated 04/25/19, read in part, .Anticipated last covered therapy day/Medicare end date/Date NOMNC and ABN will be issues .Must Provide[more than]2 Day Notice . A NOMNC, dated 08/26/23, documented Resident #236's last covered day of a Medicare part A stay was 08/26/23. It documented verbal consent had been obtained on 08/26/23. A SNF ABN, dated, 08/26/23, was signed as verbal consent on 08/26/23. A NOMNC, dated 12/04/23, documented Resident #113's last covered day of a Medicare part A stay was 12/04/23. The form was not signed by the resident. An undated SNF ABN notice for Resident #113, was not signed by the resident or dated. On 01/11/24 at 8:34 a.m., the SSD was asked what the policy was for SNF ABNs. They stated they usually do them at 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, the facility failed to ensure sufficient staffing was in place to conduct destruction of medications. The DON identified 181 residents resided in the facility. Findings: On 01/10/24 at 4:00 p.m., a medication room was observed to be unlocked with multiple containers holding various loose medications in them. On 1/10/24 at 4:15 p.m., the DON stated that destruction of medication requires two nurses and they have not had enough staff to conduct destruction of medications.

Based on observation and interview, the facility failed to ensure the census was documented on the daily staffing sheets and it was posted in a prominent place which was readily accessible to residents and visitors. The DON identified 181 residents resided in the facility. Findings: On 01/09/23 at 9:09 a.m., a daily staffing sheet was observed on the nurses' station counter on hall 300. There was no census documented on the daily assignment sheet. LPN #3 was asked how residents in a wheel chair would be able to see the staffing sheet. LPN #3 stated the daily nurse staffing was normally kept on the counter for the staff and if residents had questions the staff would address them. On 01/09/23 at 9:16 a.m., LPN #2 stated they had no idea about 2-10 or 10-6 shift postings and that the other shifts made the assignments. A blank white board was noted by the nurses station. On 01/10/24 at 9:02 a.m., a daily staffing sheet was observed on the nurses station counter of hall 200. LPN #5 stated the census was not on the daily assignment sheets for hall 200, and the charge nurse was responsible…

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

Based on record review and interview, the facility failed to ensure the physician responded to a GDR for four (#52, 54, 85, and #162) of five sampled residents reviewed for unnecessary medications. The DON identified 181 residents resided in the facility. Findings: A Monitoring of Anti-Psychotics policy, dated 2021, read in part, .The continued need for and the effectiveness the antipsychotic medication is reassessed monthly by the responsible physician .Gradual dose reduction is attempted with all residents who receive antipsychotic medications, unless clinically contraindicated. Contraindication to dose reductions must be documented in the resident's medical record by the responsible physician . 1. Resident #52 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, depression, and dementia unspecified severity with mood disturbance. A Medical Director Report, dated 10/19/23, documented a request for Vistaril to be discontinued. There was no documented response from the physician. A Medical Director Report,…

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: a. Ensure medications were secured for one of five medication/treatment carts observed for medication storage; b. Have a system in place for an accurate account of discontinued medications awaiting destruction; c. Ensure expired medications were removed from stock; and d. Ensure medication room clean from debris. The DON identified 181 residents resided in the facility. The DON identified no residents resided on Hall 500. Findings: A Medication storage in the facility policy, dated 2021, read in part, Medications and biologicals are stored safely, securely, and properly .The medications supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, one without secure closures are immediately removed from stock, disposed of according to the procedures for…

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

Based on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff to serve the residents in a timely manner for two of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: A Mealtimes document, undated, documented breakfast was at 7:30 a.m. and lunch was at 11:30 a.m. A Meal policy, dated 03/31/21, documented meal services were provided to residents on a regular schedule based on facility established times. A Work Schedule, dated 01/08/24, documented one cook and one dietary aide was scheduled to work from 5:00 a.m. to 2:00 p.m. It documented one cook and two aides were scheduled to come into work at 2:00 p.m. On 01/08/24 at 8:05 a.m., the CDM stated breakfast was served between 7:30 a.m. and 8:30 a.m. and lunch was served between 12:00 p.m. to 12:30 p.m. On 01/08/24 at 9:37 a.m., Resident #83 stated breakfast was late again this morning. On 01/08/24 at 9:40 a.m., Resident #484 stated they haven't…

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 menu was followed for one of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: A Menu Substitutions Log, dated 01/08/24, documented roasted turkey and mixed vegetables will be served. On 01/08/24 at 11:18 a.m., the CDM stated lunch was turkey, gravy, rice, mixed vegetables or roasted broccoli and cauliflower, and a roll. On 01/08/24 at 2:27 p.m., DA #1 stated they were out of vegetables and turkey. They were observed to put hamburgers, rice and a roll on six meal trays. On 01/10/24 at 1:31 p.m., the CDM stated they followed a weekly menu. They stated they didn't have enough turkey on 01/08/24 and served hamburgers when they ran out.

Based on observation, record review, and interview, the facility failed to ensure a therapeutic diet was served as ordered for two (#130 and #59) of two sampled residents reviewed for diets. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: 1. Resident #130 had diagnoses which included dysphagia. An Order Summary Report, dated 08/23/22, Resident #130 was to receive a ground meat with honey thicken liquids. On 01/08/24 at 2:36 p.m., Resident #130 was observed to receive their lunch meal. A hamburger was observed on the tray. On 01/08/24 at 2:43 p.m., CMA #1 was observed to bring medication and a cup of regular water to Resident #130. Resident #130 was observed to take their medication and drank the regular water. On 01/08/24 at 2:45 p.m., CMA #1 stated they looked at the meal ticket so they knew what diet the resident was to receive. They stated Resident #130's ticket documented the resident was to receive ground meat and honey thicken liquids. They stated the hamburger was…

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

Based on observation, record review, and interview, the facility failed to ensure meals were served in a timely manner for two of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: A Mealtimes document, undated, documented breakfast was at 7:30 a.m. and lunch was at 11:30 a.m. A Meal policy, dated 03/31/21, documented meal services were provided to residents on a regular schedule based on facility established times. On 01/08/24 at 8:05 a.m., the CDM stated breakfast was served between 7:30 a.m. and 8:30 a.m. and lunch was served between 12:00 p.m. to 12:30 p.m. On 01/08/24 at 9:37 a.m., Resident #83 stated breakfast was late again this morning. On 01/08/24 at 9:40 a.m., Resident #484 stated they haven't received breakfast. On 01/08/24 at 10:01 a.m., Resident #64 and #114 were seated in the hallway. Both residents stated they had not received breakfast. They were observed asking staff if they would be receiving breakfast. On 01/08/24 at 10:31 a.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 observation and interview, the facility failed to ensure food items were covered for one of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: On 01/08/24 at 10:32 a.m., bowls of hot cereal and a bowl of eggs on the hall trays on hall 200 cart was not observed to be covered. On 01/08/24 at 10:35 a.m., CMA #3 was asked if the if the bowls of cereal and eggs were covered. They stated they weren't covered. On 01/10/24 at 1:31 p.m., the CDM stated food was to be covered before it left the kitchen.

Based on observation, record review, and interview, the facility failed to ensure staff donned PPE while performing COVID-19 testing on residents. The DON identifed 181 residents resided in the facility. Findings: A COVID-19 Testing policy, dated 09/02/20, documented staff were to maintain proper infection control by wearing full PPE during specimen collection. On 01/08/24 at 10:28 a.m., RN #2 was observed performing COVID-19 testing on residents on hall 200. RN #2 was observed to wear a surgical mask and gloves. They were not observed to have on gown or goggles. On 01/08/24 at 10:59 a.m., RN #2 stated they wore a mask and gloves for testing. They stated more PPE was worn if a resident was symptomatic or they worked on the COVID-19 hall. On 01/17/24 at 2:04 p.m., DON reviewed the policy and stated gown, gloves, N95 mask, and face shield was to be worn when performing COVID-19 testing.

Based on record review and interview, the facility failed to ensure pneumococcal vaccine was offered to two (#113 and #79) and ensure influenza vaccine was offered to one (#79) of five sampled residents reviewed for vaccines. The DON identified 181 residents resided in the facility. Findings: An Influenza Vaccine policy, dated 04/28/22, documented residents will be offered the influenza vaccine on an annual basis. A Pneumococcal Vaccine policy, dated 04/28/22, documented residents will be offered the pneumococcal vaccine upon admission. There was no documentation Resident #79 had received/refused the influenza or pneumococcal vaccine. There was no documentation Resident #113 had received/refused the pneumococcal vaccine. On 01/17/24 at 1:27 p.m., the Corporate Regional Nurse Consultant stated they would ask the IP if there was a binder with vaccine documentation. No documentation was provided prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure call devices were in working order for one of six halls sampled for call devices. The DON identified 181 residents resided in the facility. Findings: A facility policy titled, Resident Call System, dated 10/20/22, read in part, .The facility call system relays calls directly to a centralized work area from the residents bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines .Upon admission nursing will orientate resident to accessing the resident call system .During rounds nursing & IDT team members will ensure resident call system is within reach of the resident .In the even resident call system is down: call bells will be utilized until power is restored .Maintenance Director will complete routine resident call system inspections . On 01/08/24 at 8:09 a.m., an observation was made of the call light cord hanging over the call system box in room [ROOM NUMBER]. 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 and interview, the facility failed to ensure a pest free environment. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: On 01/08/24 at 8:00 a.m., the dish washing area in the kitchen was observed. Two food traps were observed full of left over food. Three live cockroaches were observed climbing on the walls, two live cockroaches were on the floor, and one dead cockroach on the floor under the sink. On 01/08/24 at 8:25 a.m., the CDM stated they have been having pest problems. She stated they tell the administrator when they see them. She stated she thought they sprayed last week. On 01/08/24 at 2:25 p.m., a live cockroach was observed crawling on the floor in the kitchen area where staff were preparing lunch trays. On 01/10/24 at 10:27 a.m., Resident #6 was observed laying in bed sleeping. One large live cockroach was observed on the wall next to Resident #6. On 01/10/24 at 10:29 a.m., Resident #6 was observed awake. They stated they have seen…

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 call devices were within reach for one (#162) of 40 sampled residents reviewed for accommodation of needs. The DON identified 181 residents resided in the facility. Findings: A facility policy titled, Resident Call System, dated 10/20/22, read in part, .During rounds nursing & IDT team members will ensure resident call system is within reach of the resident . Resident #162 had diagnoses which included bipolar disorder and cerebral infarction due to thrombosis of unspecified precerebral artery. An annual MDS, dated [DATE], documented Resident #162 was cognitively impaired and required partial/moderate assistance with most of their ADLs. On 01/08/24 at 8:37 a.m., Resident #162's call light was not in reach. The call light was observed on the floor at the foot of the bed. On 01/08/24 at 8:39 a.m., CNA #4 stated the call light was not in reach of Resident #162. On 01/11/24 at 2:45 p.m., the DON stated the facility policy for call…

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 observations, record review, and interview, the facility failed to maintain a comfortable room temperature and a clean bathroom for two (#114 and #93) of 40 sampled residents. The DON identified 181 residents resided in the facility. Findings: 1. A facility Test and log air temperatures form, undated, documented, .required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit .consider the effective air temperature and the impact that .air movement in the building may be having on comfort . On 01/09/24 at 8:43 a.m., Resident #114 stated their room was cold and there was not a heater in the room. Resident #114 stated the outside door was opened and closed all of the time, day and night, and it gets very cold. Resident #114's room was located near an outside door with frequent activity of staff going through the door during the interview. An ambient room temperature was obtained. The temperature was 65.5 Fahrenheit. On 01/11/24 at 8:52 a.m., RN #2 was asked if Resident #114 ever complained their room was…

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

Based on record review and interview, the facility failed to follow their abuse policy to ensure an injury of unknown origin was investigated and reported the to OSDH for one (#88) of two residents reviewed for abuse. Findings: A facility Abuse Prevention policy, dated 08/30/18, read in parts, .identify events, such as suspicious bruising .All violations .including injuries of unknown source . are reported immediately but not later than 2 hours after the allegation is made . Resident #88 had diagnoses which included confusion, anxiety, depression and a delusional disorder. A Nurse Note, dated 11/8/2023 at 8:13 p.m., read in parts, .CNA on duty informed this nurse this resident has bruises to [the resident's] left hip. immediately head to toe assessment was done. bruises noted. resident was asked what happened resident states 'I don't know . A Skin Integrity care plan, read in parts, .11/8/23--bruise to left hip of unknown cause . A Quarterly Assessment, dated 11/22/23, documented Resident #88 had severe cognitive impairment, hallucinations and delusions, and rejected care four 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.

Based on record review and interview, the facility failed to ensure a significant change had been completed after a resident had been admitted to hospice for one (#156) of 35 residents reviewed for assessments. The DON identified 181 residents resided in the facility. She identified five residents were on hospice. Findings: Resident #156 had diagnoses which included dementia. A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice. On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services. There was no documentation a significant change assessment had been completed for Resident #156. On 01/11/24 at 2:07 p.m., the MDS coordinator #1 stated a significant change assessment was completed within 14 days after a resident was admitted to hospice. They stated they were just notified Resident #156 had been admitted to hospice at the end of November 2023. They stated a significant change had not been completed.

Based on record review and interview, the facility failed to ensure an MDS assessment was accurate for one (#156) of 35 sampled residents reviewed for assessments. The DON identified 181 residents resided in the facility. Findings: Resident #156 had diagnoses which included dementia. A Fall Investigation, dated 12/25/23, documented Resident #156 was on the floor with a laceration to the center of their forehead. A Quarterly Assessment, dated 01/03/24, documented the resident had two or more non injury falls. It did not document a fall with injury had occurred. On 01/12/24 at 10:08 a.m., MDS Coordinator #1 stated if the resident had a fall since their last assessment, they would enter it on the MDS assessment. The MDS Coordinator #1 was asked to review the quarterly assessment from January 2024. They stated two or more non injury falls had been documented. They stated the injury fall had not been captured on the MDS.

Based on record review and interview, the facility failed to ensure a care plan had been revised for a resident who had been admitted to hospice for one (#156) of 35 residents reviewed for care plans. The DON identified five residents were receiving hospice services and 181 residents resided in the facility. Findings: Resident #156 had diagnoses which included dementia. A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice. On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services. There was no documentation Resident #156's care plan had been updated to address the resident was receiving hospice. On 01/11/24 at 2:07 p.m., the MDS Coordinator #1 stated care plans were updated every day. They stated the care plan was updated when a resident was admitted to hospice. They stated Resident #156's care plan had not been updated to address hospice until today.

Based on observation, record review, and interview, the facility failed ensure fall interventions were maintained when DME was replaced by hospice for one (#156) of one sampled resident reviewed for hospice. The DON identified five residents were receiving hospice services. Findings: Resident #156 had diagnoses had diagnoses which included dementia, muscle weakness, difficulty with walking, and unsteadiness on feet. A Quarterly Assessment, dated 10/11/23, documented Resident #156 had severely impaired cognition. It documented Resident #156 required substantial/maximal assistance with ADLs and mobility. A Fall Incident Report, dated 07/03/23, documented the resident had a fall. It documented the intervention was to put a concave mattress in place. A Fall Incident Report, dated 10/06/23, documented the resident had a fall. It documented the intervention was to drop the back seat of the wheelchair. A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice. On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services. 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 resident who required peg tube feedings: A. had been administered feedings as ordered by the physician, and B. had their peg tube feeding bag labeled and dated for one (#35) of one sampled resident reviewed for peg tube feeding. The DON identified five residents received peg tube feedings. Findings: Resident #35 had diagnoses which included dysphagia following unspecified cerebrovascular disease and dysphagia, oropharyngeal phase. A Physician's order dated 12/02/23, documented Nepro at 60 cc/hr x 18 hours via peg off at 10:00 a.m. and on at 4:00 p.m. On 01/10/24 at 10:00 a.m., peg tube feeding pump observed not running. The tube feeding bag was not labeled or dated. On 01/10/24 at 10:10 a.m., LPN #5 was observed to enter Resident #35's room and set the tube feeding pump for 60 cc/hr and start the pump. On 01/10/24 at 10:12 a.m., LPN #5 stated the bag was to be hung by the night shift. They stated the peg tube feeding bag was not labeled and the bag contained Nepro at 60 cc/hr. On 01/10/24 at 10:19…

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 before and after dialysis for one (#35) of one sampled resident reviewed for dialysis services. The DON identified five residents received dialysis. Findings: A facility policy, titled Dialysis Communication Transfer, revised 09/27/23, read in part, .A Dialysis Communication Transfer Form is completed each time a resident receives .outpatient dialysis. This ensures enhanced communication between the two facilities .Procedure .The top section of the Dialysis Communication Transfer Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility .The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident . Resident #35 had diagnoses which included end stage renal disease and dependence on renal dialysis. Physician's orders, dated 12/02/23, documented to monitor dialysis site, obtain vital…

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

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#484) of six sampled residents reviewed for medications. The DON identified 181 residents resided in the facility. Findings: Resident #484 had diagnoses which included opioid dependence. An Order Summary report, dated 01/05/24, documented Resident #484 was to receive Buprenorphine every morning. An MAR, dated January 2024, documented blanks for Buprenorphine from 01/06/24 to 01/08/24. On 01/09/24 at 9:09 a.m., Resident #484 stated they have been without the Buprenorphine for several days. An admission Assessment, dated 01/12/24, documented the resident's cognition was intact. On 01/17/24 at 10:23 a.m., the DON stated when a resident was admitted to the facility with orders for narcotics, the hospital faxed narcotic scripts to the pharmacy. The DON stated blanks on the MAR indicated the staff didn't give the medication or they didn't document. The DON reviewed Resident #484's MAR and stated it looked like Resident #484 didn't receive Buprenorphine for January 6th,…

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: a. ensure cooked items were stored,covered and labeled with dates in the walk-in, b. ensure food items were not stored on the floor, c. ensure raw meats were not stored with or above uncooked food items, and d. clean a food processor container and blade using standardized cleaning practices between uses. The Resident Census and Condition of Residents report, dated 01/14/23, documented 174 residents resided in the facility. The Administrator identified two residents who did not receive nutrition from the kitchen. Findings: A Refrigeration policy, effective 03/31/21, read in parts, .All leftovers shall be labeled and dated with expiration date of no more than three days . Stock labeled with dates when received include month day and year. Raw foods, including raw meats, fish and egg shall be stored on the lower shelves of the refrigeration units. Cooked and ready-to-eat foods shall be stored above raw food and foods that are thawing. Foods, being thawed, other than those in single service containers, must be…

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.