The Oaks Healthcare Center

Based on observation, record review, and interview the facility failed to assess a resident for self administration of medication for 1 (#35) of 1 sampled residents who was reviewed for self administration of medication. The DON identified 5 residents that self administered medication. Findings: Resident #35 had diagnoses which included chronic obstructive pulmonary disease. On 02/21/25 at 9:15 a.m., Resident #35 was observed at the bedside self administering Albuterol Sulfate HFA Aerosol Solution 108 (90 base) MCG/ACT. The Self Administration of Medications policy, dated December 2016, read in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. In addition to general evaluation of decision making capacity the staff and practitioner will perform a more specific skill assessment. The annual assessment, dated 11/28/24, showed the resident was cognitively intact for daily decision making. On 02/26/25 at 8:30 a.m., LPN #5 reviewed the electronic clinical record…

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 notification was made to a resident's guardian for 1 (#15) of 1 resident reviewed for notification of change. The administrator identified 87 residents who resided at the facility. Findings: A Change in a Resident's Condition or Status policy, revised May 2017, read in part, Our facility shall promptly notify the resident, [their] Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .changes in level of care, billing/payments, resident rights. Resident #15 had diagnoses which included major depressive disorder, schizophrenia, and anxiety. A behavior note, dated 02/06/25 at 9:23 p.m., showed the nurse had overheard Resident #15 state they wanted to die to their roommate. A behavior note, dated 02/06/25 at 9:26 p.m., showed the nurse entered the room of Resident #15 and asked if they were okay. Resident #15 stated they wanted to be changed and put to bed. The note showed Resident #15 was frustrated about having to wait to be changed for bed. A behavior…

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

Based on record review and interview, the facility failed to assess and monitor the dialysis port for 1 (#24) of 1 resident who was reviewed for dialysis services. The corporate nurse identified four residents who received dialysis services. Findings: A Hemodialysis Access Care policy, revised September 2010, read in part, Central catheters for hemodialysis are generally inserted in the neck, chest or groin area. This is not the preferred site for long-term placement. There is more risk of clotting and infection than with either fistulas or grafts. Central dialysis catheters are used for short term dialysis (less than three weeks) while [arteriovenous fistula] or [arteriovenous graft] is healing.Care of Central Dialysis Catheters 1. The central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device. 2. Catheter lumens should be capped and clamped when not in use. 3. Dialysis catheters should be marked for dialysis use only so they are not confused with central venous access devices. 4. Flushing, drawing blood or administering…

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

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for 1 (#58) of 5 sampled residents whose labs were reviewed. Corporate Nurse #1 identified 75 residents who had physician's orders for labs. Findings: Resident #58 had diagnoses which included diabetes, hyperlipidemia (high cholesterol), congestive heart failure, and end stage renal disease. A physician's order, dated 06/03/24, showed the resident was to have labs which included a complete blood count, hemoglobin A1C, comprehensive metabolic panel, lipids, and a liver function test every 3 months. The September 2024 medication administration record showed the ordered labs were completed on 09/03/24 and were documented as completed by LPN #1. Review of the clinical record did not reveal the lab reports for September 2024. On 02/25/25 at 11:14 a.m., the DON stated lab orders were documented on the treatment record by the nurse when they were completed. On 02/25/25 at 11:22 a.m., LPN #1 stated they documented on the treatment record when labs were completed. LPN #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the facility did not initiate a discharge of a resident for the use of authorized electronic monitoring of the resident's room for one (#2) of one sampled resident whose facility initiated discharge was reviewed. The DON identified 107 residents who resided in the facility. Findings: The facility Transfer or Discharge Notice policy, dated March 2021, read in part, .2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare and Medicaid) a stay at the facility . 63 O.S. § 1-1956.2 of the [NAME] E. [NAME] Act (a section of…

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

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#2) of three sampled residents reviewed for abuse. The Administrator identified 101 residents resided in the facility. Findings: The Abuse Prevention Program policy, revised 12/16, read in part, Our residents have the right to be free from abuse .Protect our residents from abuse by anyone including .other residents. The Abuse and Neglect Clinical protocol policy, revised 03/18, read in part, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Resident #2 had diagnoses which included autistic disorder, hemiplegia and hemiparesis. Resident #2's annual resident assessment, dated 08/15/24, documented Resident #2 had severe cognitive impairment. A Combined Initial and Final State Reportable Incident form, dated 08/19/24, documented an allegation of abuse/mistreatment. It documented Resident #1 put their arm around Resident #2. Resident #2 had no apparent injuries. A Combined Initial and Final…

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

Based on record review and interview, the facility failed to provide a written summary/findings of a grievance investigation for a resident/resident representative for one (#1) of one sampled residents whose grievances were reviewed. The administrator identified 99 people who residedd in the facility Findings: The Filing Grievances/complaints procedure which is posted on a bullentin board in the common area by the nursing station, read in part, The resident, or person filing the grievance and/or compliant on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .A written summary of the report will also be provided to the resident The Grievances/Complaints, Filing policy, revised April 2017, read in part, .The resident, or person filing the grievances and/or complaint on behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions that will be taken to correct any identified problems . A Grievance/Complaint Report was completed 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 record review and interview, the facility failed to report an allegation of abuse to OSDH for one (#3) of one sampled resident whose record was reviewed for abuse. The administrator identified 99 residents who resided in the facility. Findings: The Abuse Policy, undated, read in parts, All suspected abuse will be investigated and reported to the appropriate agencies. The Abuse Investigation and Reporting policy, revised July 2017, read in part, All alleged violations involving abuse .will be reported by the facility Administrator .to the State licensing/certification agency responsible for surveying/licensing the facility . On 04/12/24 an in-service was conducted on the facility's Abuse Policy for all facility staff. On 07/10/24 at 3:34 p.m. CNA #1 reported they heard a rumor about some inappropriate behavior between CNA #2 and Res #3. CNA #1 reported the incident occurred in April and had to do with CNA #1's breasts and Res #3, but did not provide any details. On 07/10/24 at 3:50 p.m., CNA #3 reported hearing the aides talk about a situation of inappropriate behavior…

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 investigate an allegation of abuse for one (#3) of one sampled resident whose record was reviewed for abuse. The administrator identified 99 residents who resided in the facility. Findings: The Abuse Policy, undated, read in parts, All suspected abuse will be investigated and reported to the appropriate agencies. The Abuse Investigation and Reporting policy, revised July 2017, read in part, All reports of resident abuse .shall be promptly reported .and thoroughly investigated by facility management . The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, read in part, Identify and investigate all possible incidents of abuse . On 04/12/24 an in-service was conducted on the facility's Abuse Policy for all facility staff. There was no documented investigation regarding Res #3 and CNA #2. On 07/10/24 at 3:34 p.m. CNA #1 reported they heard a rumor about some inappropriate behavior between CNA #2 and Res #3. CNA #1 reported the incident occurred in April and had to do with CNA #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were updated with physician's orders for one (#1) of six sampled residents whose physician's orders were reviewed. The administrator identified 99 residents who resided in the facility. Findings: Res #1 had diagnoses which included dementia and stage 3 chronic kidney disease. A physician's progress note from Urologic Specialist, faxed to the facility on [DATE], documented an order for the facility to ensure the resident is drinking water, No coke/tea. Res #1's care plan was not revised with the physician's order from Urologic Specialist On 07/11/24 at 11:05, the DON reported Res #1's care plan was noted updated with the order from Urologic Specialist. The DON was not sure why the order was overlooked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician's orders were implemented for one (#1) of six sampled residents whose physician's orders were reviewed. The administrator identified 99 residents who resided in the facility. Findings: Res #1 had diagnoses which included dementia and stage 3 chronic kidney disease. A physician's progress note from Urologic Specialist, faxed to the facility on [DATE], documented an order for the facility to ensure the resident is drinking water, No coke/tea. The order was not written or implemented for Res #1. On 07/11/24 at 11:05 a.m., the DON reported the order from Urologic Specialist was not written or implemented. The DON was not sure why this was overlooked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to: a. ensure there was hot water in the resident's room for one (#41) of 32 sampled residents reviewed for comfortable water temperatures; and b. maintain comfortable air temperatures in the resident's dining room for three (#56, #74, and #89) of three sampled residents reviewed for comfortable air temperatures in the dining room. The DON identified 10 to 30 residents received their meals in the dining room. The DON identified 104 residents resided in the facility. Findings: The Homelike Environment policy, revised 02/21, read in part, .comfortable and safe temperatures (71 degrees Fahrenheit to 81 degrees Fahrenheit . 1. Resident #41 was admitted on [DATE]. Resident #41's admission resident assessment, dated 09/14/23, documented Resident #41 was cognitively intact. On 10/24/23 at 1:26 p.m., Resident #41 stated they had no hot water from the sink in their room since they were admitted to the facility. Resident #41 stated they were unable 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 observation, record review and interview, the facility failed to provide showers for two (#46 and #98) of three sampled residents reviewed for ADLs. The DON identified 104 residents who needed assistance with showers. Findings: A Bath, Shower/Tub policy, revised 02/18, read in parts, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation .the date and time the shower/tub bath was performed .The name and title of the individual(s) who assisted the resident .All assessment data ( .any reddened areas, sores, etc, on the resident's skin) .How the resident tolerated the shower/tub bath .If the resident refused the shower/tub bath, the reason(s) . 1. Resident #98 had diagnoses which included morbid obesity, abnormalities of gait and mobility, and fracture of the shaft of the right femur. Resident #98's admission resident assessment, dated 09/20/23, documented the resident was cognitively intact. They required two person physical assist for transfers and one person physical…

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: a. monitor the amount of meals and fluids a resident at risk for weight loss and dehydration consumed; and b. provide a physician ordered health shake for one (#9) of two sampled residents reviewed for nutrition. The DON identified 104 residents resided in the facility and two residents received their nutrition through tube feeding. Findings: Resident #9 had diagnoses which included dementia, muscle wasting, and atrophy. A physician's order, dated 11/28/22, documented regular diet, pureed texture, and honey consistency. A physician's order, dated 11/28/22, documented honey thick liquids. A physician's order, dated 05/15/23, documented mighty shake three times a day. Resident #9's quarterly resident assessment, dated 07/24/23, documented Resident #9 had severe cognitive impairment and required one person physical assist for the task of eating. Resident #9's care plan for nutrition, dated 08/02/23, documented, a. Resident #9 will maintain adequate nutrition by consuming at least 50% of two meals daily, and b.…

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. appropriate crush, cocktail, and water flush for PEG tube medication orders were present for one (#260) ; and b. a cocktail order was obtained for one (#13) of 15 residents observed during medication administration. The DON identified 104 residents resided in the facility. The ADON identified two residents with orders to flush peg tube medications, 36 residents with medication crush orders, and three residents with medication cocktail orders. Findings: A Crushing Medications policy, dated 04/18, read in part, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .Crushing each medication separately and administering each with food is considered best practice . An Administering Medications through an Eternal Tube policy, dated 11/18, read in part, .Administer each medication separately and flush between medications. Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility…

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 psychotropic medication had a specified duration for two (#24 and #37) of five sampled residents reviewed for unnecessary medications. The ADON identified 71 residents with psychoactive medication orders resided in the facility. Findings: A Psychotropic Medication Use policy, dated 07/22, read in part, .Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record .PRN orders for psychotropic medications are limited to 14 days .If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . 1. Resident #37 had diagnoses which included bipolar disorder, anxiety, and paranoid schizophrenia. A Physician Order, dated 08/04/23, documented valium five mg give one tablet by mouth every four hours as needed for anxiety/agitation. There was no 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 observation, record review and interview, the facility failed to ensure: a. dented canned goods were removed from circulation; b. food items were not stored on the floor in the walk-in cooler; and c. food debris was not on the floor in the dry storage room during one of two kitchen observations. The DON identified 102 residents received food from the kitchen. Findings: A Food Storage policy, dated 03/11, read in part, .Food storage areas shall be clean at all times .All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning . On 10/24/23 at 1:08 p.m., the following items were observed to be stored directly on the floor of the walk in cooler: a. five boxes of gallon sized milk stacked on top of each other by the door of the cooler; b. one box of gallon sized milk on the floor by the storage rack; and c. one five gallon container of pickles. The CDM stated the items should not be stored on the floor. They stated the items should be up off the floor. On 10/24/23 at 1:15…

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 hand hygiene was performed between providing care for two (#12 and #43) of two sampled residents observed for hand hygiene. The DON identified 104 residents resided in the facility. Findings: A Handwashing/Hand hygiene policy, dated 9/19, read in part, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations .Before and after direct contact with residents . Resident #12 had diagnoses which included fusion of spine and type 2 diabetes mellitus with diabetic nephropathy. Resident #43 had diagnoses which included hypertension, conversion disorder with seizures or convulsions and panic disorder. On 10/25/23 at 12:14 p.m., CNA #1 was observed feeding Resident…

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

Based on observation and interview, the facility failed to ensure a resident's personal items were in reach and their bed was made for one (#46) of 32 sampled residents reviewed for accommodation of needs. The DON identified 104 residents resided in the facility. Findings: An Accommodation of Needs policy, revised 03/21, read in parts, .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .The resident's individual needs and preferences are accommodated to the extent possible .The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis .arranging toiletries and personal items so that they are in easy reach of the resident . Resident #46 had diagnoses which included encounter for orthopedic aftercare following surgical amputation. The resident's Plan of Care, dated 01/20/23, read in parts, .[Resident name withheld] needs a safe…

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 systemic approach was used to update a resident's code status for one (#86) of 32 sampled residents reviewed for Advanced Directives. The DON identified 104 residents resided in the facility. The ADON identified 33 residents who had DNR orders. Findings: An Advanced Directives policy, dated 12/16, read in part, .Changes or revocations of a directive must be submitted in writing to the Administrator .The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan . A Do Not Resuscitate Order policy, dated 03/21, read in part, .A Do Not Resuscitate (DNR) order form must be completed and signed .and placed in the front of the resident's medical record. Resident #86 admitted on [DATE] and had diagnoses which included left artificial knee joint, cerebral infarct, and chronic pain syndrome. Resident #86's code status on the EMR dashboard documented full…

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. the risk versus benefits was discussed with the resident or resident representative prior to installing side rails on a resident's bed; and b. side rails were properly secured to the bed for one (#47) of one sampled resident reviewed for side rails. Human Resources identified 17 residents with side rails resided in the facility. Findings: A Bed Safety and Bed Rails policy, dated 08/22, read in part, .Bed rails are properly installed .The use of bed rails or side rails .is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent .Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent . Resident #47 had diagnoses which included osteoporosis, cerebral infarction, and muscle wasting and atrophy. An admission Resident Assessment, dated 08/09/23,…

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

Based on record review and interview, the facility failed to notify the resident's representative of changes with plan of care for one (#140) of one sampled resident reviewed for notification. The Census and Conditions of Residents report, dated 07/11/22, documented 94 residents resided in the facility. Findings: Resident #140 was admitted with diagnoses of frequency of micturition, chest pain, and abdominal aortic aneurysm. A Health Status Note, dated 06/08/21, read in part, .New order received from Dr. [name deleted] to have ECHO done at [local hospital] . There was no documentation the resident's representative was notified. A Communication note, dated 06/29/21, read in part, .[Resident #140] c/o burning when [they] urinates. Urine is amber in color/clear with foul odor Obtain UA for symptoms of UTI . There was no documentation the resident's representative was notified. A Communication note, dated 07/13/21, read in part, .[Resident #140] proceed to show this nurse that [they] had blood in [their] brief. UA hat was place in [Resident #140's] commode to collect UA. [Resident #140]…

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. document a rational for a gradual dose reduction on one (#50), b. ensure a PRN antianxiety medication was limited to 14 days for one (#56) and c. ensure a pharmacy recommendation was acted upon for one (#56) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 07/11/22, documented 59 residents received psychoactive medications. Findings: An Antipsychotic Medications Use policy, revised 12/2016, read in part, .The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences 1. Resident #56 was admitted with a diagnosis of anxiousness. A Physician's Order, dated 02/23/22, read in part, .Clonazepam Tablet 0.5 MG .as needed . The medication was not limited to 14 days. A Pharmacy Consultant Report Psychoactive PRN Use, dated 03/15/22, documented Resident #56 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 record review, observation, and interview, the facility failed to ensure: a. food products were properly stored, b. food service equipment was kept clean, and c. sanitary hand hygiene practices were implemented while handling food and clean dishes. The Resident Census and Conditions of Residents report, dated 07/11/22, documented 94 residents resided in the facility, and four residents received tube feeding. The DON identified two of the four residents received nutrition and hydration solely through a feeding tube. Findings: A Refrigerator-Reach In policy, revised March 2011, read in parts, .Frequency: Daily .Wipe up spills on .sides .of refrigerator .Wash doors . A Handwashing and Glove Use policy, revised March 2015, read in parts, .Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed .Handwashing is a priority for infection control .Gloves may be used when working with food to avoid contact with hands .Gloves must also be worn if an employee has a cut or wearing a bandage . On 07/13/22 at 8:30…

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

Based on record review, observation, and interview, the facility failed to ensure: a. staff properly wore masks, and b. sanitary hand hygiene practices were implemented while handling food and clean dishes. The Resident Census and Conditions of Residents report, dated 07/11/22, documented 94 residents resided in the facility, and four residents received tube feeding. The DON identified two of the four residents received nutrition and hydration solely through a feeding tube. Findings: The Handwashing and Glove Use policy, revised March 2015, read in parts, .Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed .Handwashing is a priority for infection control .Gloves may be used when working with food to avoid contact with hands .Gloves must also be worn if an employee has a cut or wearing a bandage . On 07/13/22 at 8:30 a.m., a tour of the kitchen was conducted. The following observations were made: a. dietary cook #1 was observed with their mask below their mouth. They were observed licking their fingers…

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. residents were offered an influenza vaccination for three (#22, 29, and #37), and b. residents were offered a pneumococcal vaccination for three (#29, 30, and #37) of five sampled residents reviewed for immunizations. The Resident Census and Conditions of Residents report, dated 07/11/22, documented 94 residents resided in the facility. Findings: A Pneumococcal Vaccine policy, revised October 2019, read in part, .All residents will be offered pneumococcal vaccines An Influenza, Prevention and Control of Season policy, revised August 2020, read in parts, .All residents are offered the vaccine prior to onset of influenza season .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents 1. There was no documentation Residents #22, #29, and #37 were offered the influenza vaccination in 2021. 2. There was no documentation Residents #29, #30, and #37 were offered the pneumococcal vaccination. On 07/13/22 at 9:55 a.m., the ADON reported the residents should have been offered an…

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 staff were fully vaccinated, had been granted an exemption or delay from the COVID-19 vaccine for 12 of 109 staff members. This resulted in a staff vaccination rate of 89%. The Resident Census and Conditions of Residents report, dated 07/11/22, documented 94 residents resided in the facility. Findings: An Employee Vaccine % Report, dated 07/12/22, documented one staff member was partially vaccinated, and 11 staff members had pending exemptions. There was no documentation the facility had followed up to ensure staff were fully vaccinated, had been granted an exemption or delay from the COVID-19 vaccine. On 07/11/22 at 2:48 p.m., the ADON stated the one staff member identified being partially vaccinated was due for their second vaccine in May 2022, and they didn't get it. The ADON was asked what the facility's policy was to ensure staff were vaccinated or had a granted exemption. They stated they encouraged staff to get vaccinated or get an exemption. They stated the DON and the administrator handled the exemptions.…

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.