Shawnee Care Center

Based on record review and interview the facility failed to provide notices to Medicaid recipients trust account holder when balances was within $200 of the resource limit for a medicaid recipient resident for one (#1) of three sampled residents reviewed for active trust account balances. The Business office manger identified 24 residents that have money in the trust account, were current residents and had Medicaid as their payer source. Findings: A review of the current trust account ledger dated 07/08/24, documented Resident # 1 had a current balance in their trust account of $2,874.59. Resident #1 face sheet documented they were a Medicaid recipient. There was no documentation to indicate the facility had notified the resident when they were within $200 of the $2,000 resource limit. On 07/09/24 at 10:48 a.m., the business office manager stated the resource limit for medicaid recipient residents was $2,000. They were asked to provide the notification provided to Resident #1 when they were within the $200 of the resource limit. They stated they had not provided and had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident trust accounts were closed out with funds conveyed within 30 days for three (#106. #107 and #108 ) of three residents who expired and were no longer in the facility over 30 days. The business office manager identified five residents who have been gone from the facility over 30 days and had open trust accounts. Findings: An undated Nursing Home Resident Trust Fund policy, read in part, If the resident leaves the home for any reason or passes away, funds must be returned to the resident or the resident's estate within 30 days . discharged residents with accounts still open: 1. A review of Resident #106 face sheet documented they expired on [DATE]. A review of the recipient trust account balance, dated [DATE], indicated Resident #106 had a current balance of $6,890.62. Resident #106 trust account remained open 131 days after they had expired. 2. A review of Resident #107 face sheet documented they were discharged from the facility on…

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

Based on record review and interview the facility failed to secure a surety bond with sufficient coverage for the account balance. The Business office manger identified 24 residents that have money in the trust account and were current residents. Findings: A review of the current surety bond for the resident trust account documented the surety bond had coverage of $20,000 The resident trust account monthly bank statement, 04/30/24, documented the account balance was $26,681.86. The resident trust account monthly bank statement, dated 05/31/24, documented the account balance was $32, 329.75. On 07/09/24 at 10:48 a.m., the business office manager confirmed the surety bond was only for $20,000. They then stated they had noticed the account balance had gone up and there was no system in place to ensure the surety bond was sufficient for the account balance.

Based on record review and interview the facility failed to ensure residents: a. were offered the choice to formulate an advanced directive for one (#21) of two sampled resident for advanced directives, b. DNR (Do Not Resuscitate) forms were filled out correctly. The corporate nurse reported 49 residents resided in the facility. Findings: 1. Res #21 admitted to the facility with diagnoses of vascular dementia, and malignant neoplasm of uterine adnexa. A review of the resident's record did not contain an advance directive acknowledgement. On 07/09/24 at 9:00 a.m., the administrator was asked to provide the resident's advanced directive acknowledgment. On 07/09/24 at 9:32 a.m., the Administrator reported the resident does not have an advanced directive acknowledgment. 2. Res #33 admitted to the facility with diagnoses of dementia, hypertension, and anemia. On 07/07/24 at 2:04 p.m., a DNR was located in the resident's chart. The form does not have a resident name on it. On 07/08/24 10:35 AM DNR is not located in the resident's paper chart 07/08/24 at 10:41 a.m., the corporate nurse was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined the facility failed to notify a family of falls for one (#29) of three sampled residents reviewed for notification of a change in condition. The corporate nurse reported 49 residents resided in the facility. Findings: An undated policy, Change in a Resident's Condition or Status, read in part, .in addition to notifying the resident and/or their representative .of a change . Resident #29 had diagnosis to include abnormalities of gait, history of falling, and cognitive communication deficit. An incident report dated 05/17/24 documented the resident had a fall while in the shower. A nursing progress note, dated 05/17/24 at 2:25 p.m., read in part, .While getting a shower this morning, upon standing to transfer to shower chair . There was no documentation on the incident report or in the clinical record the family had been notified of the fall. An incident report dated 05/27/24 documented the resident had a fall while in the shower. A nursing progress note,…

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 comprehensive care plans were developed and/or implemented to address the residents' needs related to a urinary catheter for one (#32) and activities of daily living, and anticoagluant therapy for one (#35) of residents whose care plans were reviewed. The corporate RN identified 49 residents who resided in the facility. The corporate RN identified five residents with a urinary catheter. Findings: A Comprehensive Person-Centered Care Plan policy, revised December 2016, read in part, .The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A care plan, revised 05/07/24, documented the resident was occasionally incontinent of bladder due to inability to move fast. The care plan documented the resident wore adult undergarments while out of bed 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 update the care plan related to pressure ulcers for one (#32) of one resident reviewed for pressure ulcers. The infection preventionist identified two residents with pressure ulcers. Findings: Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A quarterly assessment, dated 02/21/24, documented the resident was cognitively intact, required partial to moderate assistance with mobility, and did not have a pressure ulcer. A care plan, revised 05/07/24, documented the resident was at risk for pressure ulcers due to the inability to walk far, malnutrition, and a bony appearance. The care plan documented a goal of intact skin without evidence of redness, irritation, maceration, or open areas. A quarterly assessment, dated 05/21/24, documented the resident was cognitively intact, required partial to moderated assistance with mobility, and had one stage II pressure ulcer not present upon admission. There was no documentation related to the presence of a pressure…

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 bathed according to standards of care for two (#31 and #35) of three sampled residents reviewed for bathing. The corporate nurse reported 49 residents resided in the facility. Findings: 1. Res #31 admitted to the faiclity with diagnoses of cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle wasting and atrophy. On 07/07/24 at 9:25 a.m., the resident reported there isn't enough CNAs on her showers nights so she is going to take them during the day. A care plan last revised on 05/09/24 documented the resident requires extensive assist of 1 person with bathing. A Point of Care ADL category report documented the resident had a partial bath on 06/09/24, the report contained no other documentation of bathing from 06/09/24 to 07/08/24. On 07/10/24 at 9:02 a.m., the corporate nurse reported the residenrt did not received showers according to standards of care. 2. Res #35 dmitted with metabolic encephalopathy, acute kidney…

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 perform weekly skin assessments and wound care per physician order for one (#32) of one resident reviewed for pressure ulcers and failed to obtain weekly weights for one (#35) of one sampled residents. The corporate RN identified 49 residents who resided in the facility. The infection preventionist identified two residents with pressure ulcers. Findings: 1. Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A physician order, dated 12/28/23, documented weekly skin assessment to be completed every Friday. A care plan, revised 05/07/24, documented the resident was at risk for pressure ulcers due to the inability to walk far, malnutrition, and a bony appearance. The care plan documented a goal of intact skin without evidence of redness, irritation, maceration, or open areas. A nurse note, dated 05/08/24, documented a stage II pressure wound was discovered during assessment. The note documented treatment of the wound was initiated. A quarterly assessment,…

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 physician order for an indwelling urinary catheter and failed to ensure a resident with an indwelling urinary catheter received services to help prevent urinary tract infections for one (#32) of three residents reviewed for catheters. The corporate RN identified five residents with a urinary catheter. Findings: Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A care plan, revised 05/07/24, documented the resident was occasionally incontinent of bladder due to inability to move fast. The care plan documented the resident wore adult undergarments while out of bed for dignity. A quarterly assessment, dated 05/21/24, documented the resident was cognitively intact, required partial to moderate assistance with toileting, was frequently incontinent of bladder, and did not have an indwelling catheter. A nurse note, dated 06/04/24, documented Res #32 had an indwelling urinary catheter placed. A 5-day assessment, dated 06/05/24, documented 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, record review, and interview, the facility failed to ensure snacks were offered between meals and at bedtime as ordered and weights were documented weekly on a resident who experienced a significant weight loss for one (#21) of two sampled residents reviewed for nutrition. The corporate nurse reported 49 residents resided in the facility. Findings: Res #21 admitted to the facility with diagnoses of abnormal weight loss and muscle waisting and atrophy. A physician's order, dated 12/16/24, documented Regular diet Regular Texture, Thin liquids. House supplement with meals. A physician's order, dated 01/05/24, documented to offer snacks between meals and HS, Special Instructions: between meals and HS After Meals 10:00, 14:00, 20:00 A physician's order, dated 02/20/24, documented Weekly Weights on Thursdays Once A Day on Thu 07:00 - 15:00. On 07/07/24 at 9:00 a.m., Res #21 was observed sitting in the assisted dining room. The resident was observed to have liquids, including a healthshake but does not have meal yet. Resident's weights were reviewed, on 01/05/2024,…

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

Based on observation, record review, and interview, the facility failed to change oxygen tubing per physician order and best standard practice for one (#10) of one resident reviewed for oxygen therapy. The corporate RN identified four residents who received oxygen therapy. Findings: A Respiratory Therapy - Prevention of Infection policy, revised November 2011, read in part, .Change the oxygen cannulae and tubing every seven days, or as needed . Res #10 had diagnoses which included acute respiratory disease, asthma, and nasal congestion. A physician order, dated 06/26/23, documented to change and date oxygen tubing weekly on Tuesdays. A quarterly assessment, dated 03/18/24, documented the resident was cognitively intact, short of breath with exertion, and received oxygen therapy. A care plan, reviewed 04/16/24, documented the resident had episodes of shortness of breath and was at risk of respiratory distress/failure. The care plan documented to change oxygen tubing per the orders and date and time when changing. On 07/07/24 at 10:39 a.m., Res #10 was observed wearing oxygen per…

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 as scheduled for three (#28, #47 and #40) of three sampled residents reviewed for meal service in the assisted dining room. The Administrator identified 49 residents received services from the kitchen and ten required asssistance with their meals. Findings: An undated schedule of meal times, documented breakfast was to be served at 7:30 a.m. and lunch at 12:30 p.m. On 07/07/24 at 8:05 a.m., eleven residents were observed in the main dining room waiting for there morning meal. During the initial tour of the kitchen on 07/07/24 at 8:07 a.m., the steam table was observed with the food ready to be served. The dietary manager was asked when meal service was and they stated 7:30 a.m They the morning meal was ready to be served they were waiting on nursing to be able to serve the meal. On 07/07/24 at 8:20 a.m. the dietary staff was observed serving the first meal tray to the main dining room. The main dining room was served 50 minutes past the scheduled time. On 07/07/24 at 8:25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection control program for enhanced barrier precautions for three (#5, 32, and #43) of three residents reviewed for infection control. The corporate RN identified two residents with pressure ulcers and five residents with urinary catheters. Findings: An Enhanced Barrier Precautions policy, dated 05/10/24, read in parts, .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .High-contact resident activities include: dressing, bathing, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use: urinary catheter, and wound care: any skin opening requiring a dressing .Gowns and gloves will be available immediately near or outside of the resident's room .Enhanced barrier…

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 call devices were within reach for one (#34) of one sampled resident reviewed for call lights. The corporate nurse reported 49 residents resided in the facility. Findings: Res #34 admitted to the facility with diagnoses of heart failure and need for assistance with personal care. On 07/09/24 at 10:05 a.m., Res #34 was observed resting in bed with eyes closed. The call light was observed out of reach and placed inside the top drawer of the bedside dresser. On 07/09/24 at 10:49 a.m., Res #34 was observed resting in bed with eyes closed. The call light was observed out of reach and placed inside the top drawer of the bedside dresser On 07/09/24 at 2:34 p.m., Res #34 was observed resting in bed with eyes closed. The call light was observed out of reach and placed inside the top drawer of the bedside dresser. On 07/09/24 at 2:48 p.m., Res #34 was observed resting in bed with eyes closed. The call light was obsrved out of reach and placed inside the top drawer of the bedside dresser. On 07/09/24 at 2:52 p.m.…

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

Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#34) of one sampled residents reviewed for PASRR. The corporate nurse reported 49 residents resided in the facility. Findings: Res #34 admitted to the facility with diagnoses of heart failure, chronic pain, other recurrent depressive disorders, and anxiety. A review of the Resident #34's record documented a PASSR level I was completed on 2/17/22. On 02/21/22, the resident received a new diagnosis of delusions. The resident's record contained no documentation that OHCA was notified of the new mental health diagnosis no documentation of On 07/10/24 at 9:22 a.m., the corporate nurse reported that OHCA was not notified of the new mental health diagnosis.

Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for three (#1, #2, and #3) of three residents reviewed for abuse investigations. The Administrator identified 52 residents who currently resided in the facility. Findings: The facility policy, Abuse Prevention Program dated 10/12/20, read in part, .The development of investigative protocols governing resident abuse .Timely and thorough investigations of all reports and allegations of abuse . 1. A Report to the Oklahoma State Department of health, dated 05/14/24, documented an allegation of abuse from Resident #1 who alleged Certified Medication Aide #1 told them everyone was special at the facility and Resident #1 was not the only at the facility. A review of the investigation of the allegation contained no documented statements from other employees regarding the allegation of abuse. On 06/26/2024 at 12:54 p.m., the social service director was asked about the investigation of the alleged abuse and if they had completed a through investigation. The social service…

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 centered fall prevention plan was completed for one (#3) of three sampled residents reviewed for falls. The ADON reported 55 residents resided in the facility. Findings: A facility Fall Protocol Policy documented: the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Res #3 admitted to the facility with diagnoses of vascular disturbance with psychotic disturbance, anxiety, and altered mental status. A fall report, dated 11/25/23, documented the resident had a fall. The care plan was not reviewed or revised. A fall report, dated 12/07/23, documented the resident had a fall. The care plan was not reviewed or revised. A fall report, dated 01/10/24, documented he resident had a fall. The care plan was not reviewed or revised. A fall report, dated 02/09/24, documented the resident had a fall. The care plan was not reviewed or revised. A fall…

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

Based on observation, record review, and interview, the facility failed to ensure medication was no set up and left sitting on top of the medication cart. The ADON reported 55 residents resided in the facility. Findings: On 03/06/24 at 5:16 a.m., the medication cart for the south hall was observed to have four medication cups containing one pill each and one cup containing unknown amount of crushed medication sitting on top of the cart. The medication cups were not labeled or dated. There was no staff observed near or around the cart. On 03/06/24 at 5:20 a.m., LPN #1 was asked how she knew whose medications were in the cups. LPN #1 stated I have them memorized. On 03/06/24 at 5:36 a.m., LPN #1 was asked if medications are supposed to be set up before time to administer. LPN #1 reported no they are not. LPN #1 was asked if medications are supposed to be left unattended on top of carts. LPN #1 reported no they are not.

Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all the residents and visitors. The ADON reported 55 residents resided in the facility. Findings: On 03/04/24 at 12:05 p.m., no nurse staffing information was posted. On 03/05/24 at 9:08 a.m., no nurse staffing information was posted. On 03/06/24 at 10:00 a.m., no nurse staffing information was posted. On 03/07/24 at 10:30 a.m., the corporate nurse consultant reported the staffing information should have been posted daily.

Based on observation, record review, and interview, the facility failed to ensure sufficient dietary staff were on duty to meet the residents' needs. The ADON identified 54 residents resided in the facility. Findings: The September 2023 dietary schedule documented two dietary staff for the morning shift and two for the evening shift most days on Monday through Friday and two dietary staff total for the morning and evening shift on Saturday and Sunday. The schedule documented one dietary staff member present on 09/30/23. The October 2023 dietary schedule documented two dietary staff for the morning shift and two for the evening shift most days on Monday through Friday and two dietary staff total for the morning and evening shift on Saturday and Sunday. The schedule documented one dietary staff member present on 10/07/23, 10/08/23, 10/15/23, 10/21/23 and 10/22/23. On 11/05/23 at 12:00 p.m., residents were observed seated in the dining room. No lunch meal was observed being prepared or served. No staff were observed in the kitchen. At 12:05 p.m., the ADON stated all the dietary staff…

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

Based on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The ADON identified 54 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 11/13/23 at 10:30 a.m., Corporate Nurse #1 stated the prior administrator was responsible for completion of the third quarter PBJ staffing report. They stated the prior administrator must not have completed the report.

Based on observation, record review, and interview, the facility failed to conduct a thorough investigation into allegations of abuse for Res #2 and take corrective action following an investigation of a verified allegation for Res #5 of two sampled residents reviewed for abuse allegations. The ADON identified 54 residents resided in the facility. Findings: An Abuse - Reportable Events policy, dated 01/2020, read in part, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately report the allegation or suspicion to the charge nurse on the unit .The charge nurse will begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents .Assess…

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

Based on observation, record review, and interview, the facility failed to ensure residents were free from physical restraints which were not required to treat the resident's medical symptoms for one (#1) of three residents reviewed for restraints. The ADON identified 54 residents resided in the facility. Findings: A Use of Restraints policy, undated, documented the facility recognizes and upholds the resident's right to be free from any physical restraint used for the purpose of discipline or convenience and are not required to treat the resident's medical symptom. The policy documented the resident must be allowed to attain or maintain his/her practical level of functioning and all restraints must have a physician order and an order for evaluation by designee for the least restrictive device that is appropriate for the resident. Res #1 had diagnoses which included dementia, cognitive communication deficit, and history of falls. An annual assessment, dated 03/22/23, documented the resident was severely cognitively impaired in daily decision making and required limited assistance…

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 accurate coding of MDS assessments: a. for anticoagulant use for three (#28, 31, and #35) of 18 sampled residents and b. for antipsychotic use for one (#38) of 18 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 54 residents resided in the facility. Findings: 1. Res #28 had diagnoses which included chronic obstructive pulmonary disease, cardiomyopathy, atherosclerotic heart disease, and hypertension. An admission MDS assessment, dated 05/28/23, documented Res #28 received an anticoagulant seven out of seven days during the review period. Res #28's records were reviewed and did not document an order for an anticoagulant during the review period. 2. Res #31 had diagnoses which included cerebral infarction, chronic atrial fibrillation, hypertension, and atherosclerotic heart disease. An admission MDS assessment, dated 05/09/23, documented Res #31 received an anticoagulant seven out of seven days during the review period. Res #31's records were…

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

Based on observation, record review, and interview, the facility failed to revise the care plan with fall interventions for one (#38) of four residents sampled for falls. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: 1. Res #38 had diagnoses which included vascular dementia, muscle weakness, and chronic pain. A fall report, dated 03/02/23, documented the resident had an unwitnessed fall without injury. The report documented the resident had a fall mat at bedside. A care plan, revised 04/30/23, did not document a fall mat at bedside. On 06/25/23 at 4:37 p.m., Res #38's room was observed. The resident had a fall mat at bedside. On 06/28/23, at 9:01 a.m., the ADON/MDS coordinator was asked about Res #38's fall interventions. She stated the interventions were in the progress notes after a fall occurs. The ADON/MDS coordinator was asked to review the resident's care plan for these interventions. She stated the care plan was not updated but should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop interventions for preventions of falls for three (#16, 45, and #101) of four residents sampled for falls. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: 1. Res #16 had diagnoses which included HTN, reduced mobility, atrial fibrillation, and diabetes. A care plan, revised 04/28/23, documented Res #16 was at risk for falls due to unsteadiness while walking, muscle weakness, and previously injured hip. The care plan documented all interventions as initiated 12/27/22. A facility incident report, dated 05/12/23, documented Res #16 had a non-injury fall in their bathroom. The incident report documented None of above for immediate measures taken. The incident report documented No Interventions Used for outcome of interventions. A facility incident report, dated 05/15/23, documented Res #16 had a non-injury fall in their bedroom. The incident 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.

Based on observation, record review, and interview, the facility failed to ensure: a. O2 tubing was labeled for two (#12 and #31, and b. a resident's O2 concentrator was set according to the physician's order for one (#27) of three sample residents reviewed respiratory. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. Findings: 1. Res #12 had diagnoses which included acute respiratory disease and severe morbid obesity. A physician order, dated 03/21/23, documented O2 via nasal cannula at 2 to 4 liters to keep O2 above 90 percent. A quarterly assessment, dated 05/16/23, documented the resident's cognition was intact and they had received O2 therapy in the last 14 days. A physician order, dated 06/26/23, documented to change and date O2 tubing weekly on Tuesdays on the 11:00 - 7:00 a.m. shift. On 06/26/23 at 8:18 a.m., Res #12 was observed with an O2 concentrator in their room with no O2 in place. They stated they used O2 as needed. The O2 tubing was not labeled. On 06/26/23 at 9:22 a.m., LPN #2 was asked how…

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 perform annual nurse aide performance reviews. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: On 06/25/23 at 9:01 a.m., the facility provided in-service records. The records did not include an annual nurse aid performance review. On 06/27/23 at 2:48 p.m., the annual nurse aid performance reviews were requested. On 06/28/23 at 10:19 a.m., the DON stated annual nurse aid performance reviews were not completed.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for two (#16 and #18) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. Findings: 1. Res #16 had diagnoses which included diabetes mellitus. A physician order, dated 12/13/22, documented Novolog (insulin) Flexpen U-100 before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. It documented 100 units/3 ml, amount 0 - 12 units. It documented if BS 0-150 give 0 units, if BS 151-200 give 2 units, if BS 201-250 give 4 units, if 251-300 give 6 units, if 301-350 give 8 units, if over 350 give 10 units and notify PCP. The May 2023 MAR was reviewed and the following was documented: a. on 05/07/23 at 4:30 p.m. the resident's BS was 374 and 10 units of Novolog was administered, and b. on 05/13/23 at 4:30 p.m., the resident's BS was 371 and 10 units of Novolog was administered. There was no documentation the PCP was notified. The June 2023 MAR was reviewed and 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 the pharmacist MRRs were reviewed by the physician and acted upon for three (#42, 45, and #47) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. 1. Resident #42 had diagnoses which included schizoaffective disorder and anxiety. A MRR, dated 01/04/23, documented the pharmacist made a recommendation to reduce olazaopine (antipsychotic medication) 2.5 mg HS for schizoaffective disorder. There was no documentation the physician responded to the recommendation. A MRR, dated 03/06/23, documented the pharmacist made a recommendation to reduce lorazepam (benzodiazepine medication) 0.5 mg TID. There was no documentation the physician responded to the recommendation. On 06/28/23 at 9:49 p.m., the ADON was asked to provide documentation the physician had responded to the MRR's for 01/04/23 and 03/06/23. On 06/28/23 at 10:40 a.m., LPN #1 stated they could not locate documentation where 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, record review, and interview, the facility failed to ensure diet orders were followed for one (#5) of three sampled residents reviewed for diet orders and food alternatives. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. Findings: Res #5 had diagnoses which included pressure ulcers, and muscle wasting and atrophy. A physician order, dated 12/29/22, documented regular diet with double protein with all meals. A quarterly resident assessment, dated 03/21/23, documented the resident's cognition was intact. It documented they required supervision with eating and they had no weight loss. On 06/25/23 at 8:07 p.m., Res #5 was asked about the food. The stated they did not always get double protein when they received their meals. On 06/26/23 at 8:11 a.m., CNA #2 was observed delivering Res #5's breakfast tray. The resident's diet card documented the resident was to have received two pieces of bacon. There was one piece of bacon observed on the resident's breakfast tray. CNA #2 was shown the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to offer bedtime snacks to all residents. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: On 06/25/23 at 6:58 p.m., the snack cart was observed delivered to north hall. On 06/25/23 at 7:07 p.m., CNA #3 began the snack pass. On 06/25/23 at 7:10 p.m., CNA #3 did not approach room [ROOM NUMBER] to offer a snack. On 06/25/23 at 7:11 p.m., a resident was observed in room [ROOM NUMBER] laying in bed looking at a tablet. On 06/25/23 at 7:16 p.m., CNA #3 offered resident in room [ROOM NUMBER] B bed a snack, but did not offer a snack to resident resting in the A bed. The resident observed in the A bed with eyes open. On 06/25/23 at 7:17 p.m., CNA #3 skipped room [ROOM NUMBER]. Resident was observed in their recliner in their room with eyes open. On 06/25/23 at 7:17 p.m., CNA #3 offered a snack to resident in B bed in room [ROOM NUMBER]. Resident in A bed observed laying in bed with eyes…

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 the kitchen was kept clean, maintained in good repair and in use cleaning cloths were properly stored. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. Findings: On 06/25/23 at 4:07 p.m., a tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of black residue on the floor and the walls in the dish wash area, b. a base board was missing from the wall in the dish wash area, c. there was an accumulation of brown and black residue on the dish machine and tables in the dish wash area, d. there was paint/material peeling off of the ceiling in the dish was area, e. water was leaking from the cold and hot water knobs on the spray nozzle sink in the dish wash area, f. light shields were cracked and/or lights not secure to the ceiling, g. there was an accumulation of brown residue on the ceiling and light shield in the cook area, h. there was an accumulation of lint on the floor fan near the hand wash sink,…

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 an antibiotic stewardship program. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: An undated facility policy, titled Facility Antimicrobial Stewardship Mission and Commitment Statements, documented in parts .The members of the Antimicrobial Stewardship Program Committee will develop, endorse, or adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines .The members of the Antimicrobial Stewardship Program Committee will meet at least quarterly to review collected data and facility trends, analyze performance, and develop action plans to improve antimicrobial use. Essential data to review includes: a. Antimicrobial orders b. Clinical documentation c. Supplemental information from .Infection surveillance logs .Microbiology testing .Other tests used to confirm infection such as imaging .Trends in infections .Trends by prescriber . On 06/26/23 at 2:16…

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 sanitary environment in the laundry room. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: On 06/28/23 at 4:01 p.m., the following observations of the laundry room was made: a. missing and soiled ceiling tiles above the dryers; b. lint buildup on ceiling tiles, on top of dryers, and on top of washers; c. dirt, lint, and debris behind the washers; d. black and brown slimy build up in drainage trough behind washers; e. leaking water spout behind washers; and f. hard water/lime/calcium deposits on washer door window. On 06/28/23 at 4:35 p.m. the administrator was made aware of above findings. They stated the findings could be fixed tomorrow.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct a significant change assessment after a resident elected hospice services for one (#16) of one residents sampled for hospice services. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: Res #16 had diagnoses which included diabetes, HTN, and chronic pain. A quarterly MDS, dated [DATE], documented Res #16 did not have a terminal prognosis. A physician order, dated 06/13/23, documented Res #16 had elected hospice services. Record review did not document a significant change assessment after 06/13/23. On 06/28/23 at 1:50 p.m., the ADON/MDS coordinator stated significant change assessments should be conducted after a resident goes on or off of hospice. The ADON/MDS coordinator reviewed Res #16's records and stated the significant change was not conducted but should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#49) of 18 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 54 residents resided in the facility. Findings: Res #49 was admitted on [DATE] with diagnoses which included chronic kidney disease, chronic atrial fibrillation, and generalized edema. On 05/10/23, an admission assessment was completed. The clinical record contained no comprehensive care plan. On 06/28/23 at 10:55 a.m., the ADON stated a comprehensive care plan was not completed before the resident discharged on 06/07/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#50) of three sampled residents reviewed for discharge summaries. The Resident Census and Conditions of Residents form documented 54 residents resided in the facility. Findings: Res #50 was admitted [DATE] with diagnoses which included acute promyelocytic leukemia, chronic pulmonary embolism, and hypertension. A progress note, dated 04/24/23 at 12:45 p.m., documented a family member of the resident picked them up and transported them home. There was no documentation a discharge summary had been completed. On 06/28/23 at 11:45 a.m., the ADON stated the resident had left the facility for a brief stay at home but later decided not to return to the facility. They stated they were not sure if a discharge summary was completed. On 06/28/23 at 1:30 p.m., LPN #1 stated they had not completed the discharge summary for the resident.

Based on record review and interview, the facility failed to ensure monitoring of Depakote for one (#45) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 39 residents received psychotropic medications. Findings: Res #45 had diagnoses which included vascular dementia, depression, and generalized anxiety disorder. A physician order, dated 04/25/23, documented to administer Depakote 250 mg three times a day as a mood stabilizer. A MRR, dated 05/02/23, documented a new order for Depakote. The review documented a request for side effect monitoring and yearly Depakote level. A record review did not document side effect monitoring for Depakote or physician order for yearly Depakote level. On 06/28/23 at 1:12 p.m., the DON stated they had discovered in April that the facility was not getting physician responses. They stated there was no process to ensure the DON report portion of the MRR was responded to.

Based on observation and interview, the facility failed to ensure medication rooms were locked and secured. The Resident Census and Conditions of Residents form, dated 06/25/23, documented 54 residents resided in the facility. Findings: On 06/28/23, at 4:15 p.m., the medication room door on north hall was observed unlocked and open. The door remained open, unlocked, and unsupervised for 15 minutes as staff walked the halls without securing medication room. On 06/28/23 at 4:30 p.m., the ADON entered the hall and noted the door was unlocked, open, and unsupervised. They stated the door should remain locked at all times.

Based on record review and interview, the facility failed to ensure labs were collected as ordered by the physician for one (#42) of five sampled residents reviewed for labs. The Resident Census and Conditions of Residents report, dated 06/25/23, documented 54 residents resided in the facility. Findings: Res #42 had diagnoses of deficiency of vitamins and HTN. A physician order, dated 11/09/21, documented to obtain vitamin D level on the fourth Thursday of November. A physician order, dated 11/23/21, documented to obtain CBC and CMP on fourth Thursday of May and November. A nurse note, dated 05/11/23, documented the lab tech was here from the hospital and was not able to get the resident's lab today. It was documented they would try again next week. On 06/28/23 at 9:59 a.m., LPN #1 was asked to locate a vitamin D lab for November 2022, and a CMP and CBC for May 2023 On 06/28/23 at 10:40 a.m., LPN #1 stated there was no CBC or CMP collected in May. They stated the re-draw was not done. On 06/28/23 at 12:14 p.m., LPN #1 stated the vitamin D lab test was not collected for November.