Callaway Nursing Home

Based on observation, record review, and interview, the facility failed to provide a clean and homelike environment for the residents. The administrator reported 44 residents resided in the facility. Findings: On 04/21/25 at 2:15 p.m., a tour of the facility was conducted. Floors in the main lobby, hallways, dining room, and common areas were observed to have dirt and brown stains. A common area at the end of the womens hall was observed to have a fast-food sack of trash on the floor and the area smelled strongly of urine. In the same common area, a door was observed to have a plastic bag shoved into a hole where the door knob had previously been. On 04/24/25 at 8:18 a.m., the common area at the end of the womens hall was observed to still have the plastic bag shoved into the hole of the door where a door knob would be. [NAME] wrappers and a soiled brief/diaper was observed in the corner of the room beside a chair. The floor was noted with brown stains/spills. On 04/24/25 at 11:41 a.m., housekeeping staff were observed in the hallway of the womens hall near the common area. 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 residents received a shower as scheduled and requested for 1 (#9) of 1 sampled resident reviewed for activities of daily living assistance. The administrator reported 44 residents resided in the facility. Findings: On 04/22/25 at 12:05 p.m., Resident #9 was observed using a wet wipe to clean their body. An undated policy titled Shower/Tub Bath showed the purpose was to promote cleanliness and comfort, relax the resident, stimulate circulation, and facilitate observation of the residents's skin condition. A MDS assessment for Resident #9, dated 02/09/25, showed the resident was cognitively intact with a BIMS score of 15. The assessment showed the resident had diagnoses which included congestive heart failure, renal insufficiency, diabetes mellitus, depression, and schizophrenia. A progress note for Resident #9, dated 03/15/25 at 9:00 p.m., showed the resident refused a shower when asked by staff. The note showed the resident refused a shower before dinner as well. On 04/22/25 at 12:05 p.m., Resident #9…

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 designate a staff member to serve as the infection preventionist. The administrator reported 44 residents resided in the facility. Findings: An undated facility policy titled Infection Prevention and Control Program, read in part, The facility must establish an infection prevention and control program that must include .A system for preventing, identifying .and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment and following accepted national standards .'infection preventionist' .designated by the facility to be responsible for the infection prevention and control program. An undated staff roster showed no infection preventionist. On 04/21/25 at 2:23 p.m., the DON reported the facility was currently without an infection preventionist.

Based on record review and interview, the facility failed to ensure a refund was completed within 30 days from the resident's date of discharge for one (#8) of one sampled resident reviewed for timely refunds. The administrator identified one resident in the past six months who required a refund. Findings: A Resident Funds policy, not dated, documented in part, Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days of the resident's funds, and a final accounting of those funds, to the resident .in accordance with State law. A physician's order, dated 01/29/24, documented Resident #8 was to be discharged to another long term care facility. A progress note, dated 01/29/24 at 1:00 p.m., documented Resident #8 was transferred to another long term care facility via private car with their family member. Refund check #5426 in the amount of $328.00, dated 03/25/24, documented a refund for Resident #8 was made to the facility where the resident was transferred. Refund check #5422 in the amount 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 report allegations of abuse to the State Agency (OSDH) and other officials as required for two (#1 and #5) of two sampled residents reviewed for abuse. The administrator identified two allegations of abuse in the past 120 days. Findings: An undated Allegations of Abuse, Neglect, Exploitation or Mistreatment policy, read in part, Purpose: Ensure alleged violations related to mistreatment, exploitation, neglect, or abuse .the results of all investigations are thoroughly investigated and reported to the proper authorities within required time frames .reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Resident #1 had diagnoses which included Huntington's disease, depression, vascular dementia, mood disorder, and anxiety. A care plan for Resident #1, dated 07/22/24, documented…

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

Based on record review and interview, the facility failed to thoroughly investigate allegations of abuse and report the results of the investigations for two (#1 and #5) of two residents reviewed for abuse. The administrator identified two allegations of abuse in the past 120 days. Findings: An undated Allegations of Abuse, Neglect, Exploitation or Mistreatment policy, read in part, Purpose: Ensure alleged violations related to mistreatment, exploitation, neglect, or abuse .the results of all investigations are thoroughly investigated and reported to the proper authorities within required time frames .reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Resident #1 had diagnoses which included Huntington's disease, depression, vascular dementia, mood disorder, and anxiety. A care plan for Resident #1, dated 07/22/24, 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 record review and interview, the facility failed to electronically transmit completed MDS data to the CMS system within 14 days of completion. The administrator identifed 47 residents resided in the facility. Findings: An undated MDS policy, read in part, Policy Objectives .Maintain compliance with quality reporting requirements .Submit MDS data to the CMS database as required .Monitor submission compliance and address issues proactively .Submit MDS data to CMS via the Quality Improvement and Evaluation System within the required timeframes. On 11/13/24 at 4:00 p.m., review of MDS data documented MDS assessments were not submitted from 05/01/24 to 07/08/24. On 11/13/24 at 4:11 p.m., a phone interview was conducted with LPN #1. The LPN reported they had started working for the facility in July 2024 as the MDS coordinator. The LPN reported the facility was having difficulty transmitting MDS data and the issues had just recently been resolved. The LPN reported they were able to transmit a batch of approximately 200 MDS assessments on 10/08/24.

Based on record review and interview, the facility failed to have a registered nurse on duty for at least eight consecutive hours a day, seven days a week, and failed to have a director of nursing on a full time basis. The administrator identified 47 residents resided in the facility. Findings: An undated Registered Nurse policy, read in part, .Ensure that a Registered Nurse is available for supervision in the facility .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .Except when waived, the facility must designate a registered nurse to serve as the director of nursing on a full-time basis. A review of staff time cards and schedules for August 2024 documented no RN or DON coverage on 08/01/24, 08/02, 08/05, 08/06, 08/07, 08/08, and 08/09/24. A review of staff time cards and schedules for September 2024 documented the DON worked 09/23/24, 09/24, 09/25, 09/26, 09/27, and 09/30/24. No other RN coverage was documented. A review of staff time cards and schedules for October 2024 documented the last day the…

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

Based on observation and interview, the facility failed to grant access to the EMR for the survey team. The administrator identified 47 residents resided in the facility. Findings: On 11/13/24 at 12:15 p.m., surveyors entered the facility to conduct complaint investigations. The administrator reported the facility utilized an EMR and staff members were observed to utilize the EMR. The administrator was informed surveyors would require access to the EMR for record review during the investigations. On 11/13/24 at 3:50 p.m., the administrator reported they were informed by the receiver their company did not provide access of the EMR to surveyors. The administrator was informed they were required to grant access to surveyors to avoid impeding the survey process. On 11/13/24 at 4:00 p.m., the receiver reported they did not grant access of the EMR to surveyors, but would print off any requested documentation. The receiver was informed they were required to grant access of the EMR to surveyors, but the receiver refused to comply.

Based on record review and interview, the facility failed to have a licensed administrator. The DON reported 47 residents resided in the facility. On 01/02/24 at 12:39 p.m., the facility Receiver reported the facility was currently without a licensed administrator. She stated she had talked with staff at OSDH and explained she was currently filling in until a new administrator could be hired. On 01/05/24 at 10:32 a.m., the DON reported the facility had a couple of administrator applicants and the Receiver had stepped up to fill in while they were without a licensed administrator.

Based on record review and interview, the facility failed to submit mandatory direct care staffing information to CMS as required. The DON reported 47 residents resided in the facility. Findings: The facility PBJ Staffing Data Report, for Quarter 4 2023, documented the facility had failed to submit the required direct care staffing information. On 01/02/24 at 12:39 p.m., the facility Receiver reported the administrator was responsible for submitting the required data and the facility was currently without an administrator. The Receiver reported they were hoping to train the business office manager to submit the staffing data until a new administrator could be hired. On 01/04/24 at 3:30 p.m., staffing schedules, healthcare authority reports, and agency staff hours were reviewed and documented sufficient staff for the reported resident census.

Based on record review and interview, the facility failed to follow their policy and procedure to ensure a safe environment for all residents. The facility did not screen and conduct a criminal history background check for the billing manager. The DON reported 47 residents resided in the facility. Findings: The facility policy, Criminal History Background Checks, read in part, . ensure compliance with state and federally required criminal background checks need to provide a safe environment for residents, staff, and visitors .all background checks are conducted by OKScreen .if the results of a criminal history background check reveal that the subject person has been convicted of .a felony or misdemeanor offense .the employer shall not hire or contract with the person . On 01/04/24 at 10:15 a.m., the DON and ADON reported they were aware the facility's billing manager was a registered offender. They reported the billing manager was in the facility for a couple of hours every one to two weeks to discuss orders for needed supplies and to pick up anything related to bills. On 01/04/24…

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

Based on record review, observation, and interview, the facility failed to follow physician orders for administration of a medication for one (#36) of nine residents reviewed for medication administration. The DON reported 47 residents resided in the facility. Findings: A facility Medication Administration policy, not dated, documented in part, .Right Dose .verify against MAR .check the medical record for the physician's order . A physician order for Res #36, dated 09/28/21, documented Exelon Patch, 4.6 mg/24, apply one patch topically daily, date/time patch, and chart site, initial under correct date that old patch was removed and destroyed. A medication administration record, dated January 2024, documented, Exelon patch, 4.6mg/24, 9am site, 9am off. On 01/03/24 at 9:28 a.m., ACMA #1 reported she could not find the old patch anywhere on resident #36 that should have been placed the previous morning. The ACMA was observed to have another CMA go with her to check the resident to ensure the patch was not still on the resident's body. Resident #36 reported she could not remember if…

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 oxygen tubing and humidifier bottles were labeled with a date, when changed per professional standards of care, for five (#1, 3, 6, 14, and #25) of five residents reviewed for oxygen therapy. The facility's Resident Census and Conditions of Residents, dated 12/06/22, documented 11 residents received respiratory treatments. Findings: 1. Resident #1 had a diagnoses which included congestive heart failure. The resident's Care Plan, dated 04/10/22, read in parts, .Resident has a history of congestive heart failure, and is at risk for shortness of breath, chest pain, increased edema and elevated blood pressure .Apply oxygen as needed for complaints of chest pain, and labored respirations .Oxygen at 2 liter per minute via nasal cannula to keep O2 sats greater than 90 .Initiate O2 for complaints of shortness of breath and notify the physician . A Physician's Order, dated 08/02/22, documented O2 at 2 liters per minute via nasal cannula to keep O2 Sats > 90%, check O2 Sats every shift. The resident's Quarterly…

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. the ice machine was maintained and sanitary, and; b. the ice chest used for ice storage remained sanitary throughout the day. The Resident Census and Conditions of Residents documented 44 residents resided in the facility. Findings: The facility's Ice Machine Cleaning and Disinfecting policy, dated 09/15/22, read in parts, .The outside of the ice machine and the basic structure that can be wiped down are maintained by the dietary department on a daily basis while using the equipment .The internal components that require maintenance inspection and further cleaning are the responsibility of maintenance department on a monthly basis to ensure proper operation of the machine. On 12/05/22 at 10:50 a.m., an initial tour of the kitchen was conducted. The ice machine was located in the facility's main dining room and was observed to be locked. An ice chest on a rolling cart was observed next to the ice machine and observed to contain ice. An unknown resident was observed using a scoop to get ice out of the…

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

Based on record review and interview, the facility failed to electronically submit direct care staffing information, based on payroll data, per CMS requirements. The Resident Census and Conditions of Residents'' form documented 44 residents resided at the facility. Findings: Facility staffing records and healthcare authority reports were reviewed. There was no Payroll Based Journal (PBJ) direct care staffing data submitted by the facility. On 12/08/22 at 9:11 a.m., the DON was interviewed regarding staffing and reporting of PBJ staffing data. The DON stated she didn't know much about the PBJ staffing report. The DON stated she wasn't sure but she was under the impression the Administrator didn't think the facility was required to submit this data since the facility did not take Medicare payments. On 12/08/22 at 9:34 a.m., The Administrator was interviewed regarding the PBJ direct care staffing report. The Administrator stated she had been under the impression the facility was not required to submit this report.

Based on record review, observation, and interview, the facility failed to ensure resident assessments accurately reflected the status of the resident for one (#6) of 11 residents whose assessments were reviewed. The Resident Census and Conditions of Residents'' form documented 44 residents resided at the facility. Findings: Resident #6 had diagnoses which included chronic obstructive pulmonary disease and dementia. A Physician's Order, dated 12/03/21, documented an order for hospice services. The resident's Care Plan, dated 07/31/22, read in parts, .The resident has the potential for complications and signs/symptoms related to chronic obstructive pulmonary disease .The resident has elected to have hospice care with Centric hospice related to the diagnosis of chronic obstructive pulmonary disease. The resident's Quarterly MDS Assessment, dated 09/04/22, documented severely impaired cognition and no assistance needed with most ADLs. The assessment did not reflect the resident received hospice services. On 12/06/22 at 10:00 a.m. the resident was observed on the COVID unit in bed…

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 residents at least once every three months for three (#10, 16, and #30) of three residents reviewed for quarterly assessments. The Resident Census and Conditions of Residents'' form documented 44 residents resided at the facility. Findings: The facility policy, Resident Assessments revised March 2022, documented in parts .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews .admission Assessment (Comprehensive) .Quarterly Assessment .Annual Assessment (Comprehensive) .Significant Change in Status Assessment (Comprehensive) .Discharge Assessment. The facility policy, MDS Completion and Submission Timeframes revised July 2017, documented in parts .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' QIES Assessment Submission and…

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

Based on record review and interview, the facility failed to electronically transmit MDS Assessments within 14 days after completion for two (#11 and #32) of three residents reviewed for timely transmission of resident assessments. The Resident Census and Conditions of Residents'' form documented 44 residents resided at the facility. Findings: The facility policy, MDS Completion and Submission Timeframes revised July 2017, documented in parts .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with federal and state guidelines .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 1. Resident #11 was reviewed for timely transmission of an MDS assessment. The resident had a comprehensive assessment completed on 10/23/22 but the 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.