Wagoner Health & Rehab

Based on record review and interview, the facility failed to ensure admission assessments were accurate for 1 (#2) of 12 sampled residents whose assessments were reviewed. The administrator identified 46 residents resided in the facility. Findings: An admission assessment, dated 03/07/25, showed Resident #2, had a diagnosis of atrial fibrillation, had received an anticoagulant medication while a resident, during the look back period, and had a BIMS score of 15. The medication administration record and treatment administration record, dated March 2025, did not show the resident had received an anticoagulant medication. On 04/09/25 at 1:52 p.m., the MDS coordinator stated they had coded the assessment inaccurately and should not have coded the resident had received an anticoagulant.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed for 2 (#21 and #41) of 12 sampled residents whose care plans were reviewed. The administrator identified 46 residents resided in the facility. Findings: 1. On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail, on the left side of the bed, in the up position. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail, on the left side of the bed, in the up position. A policy titled Proper Use of Side Rails, dated December 2024, read in part, The use of side rails as an assistive devise will be addressed in the resident care plan. A quarterly assessment, dated 03/13/25, showed Resident #21 had a diagnosis of Alzheimer's disease, a BIMS summary score of three, which indicated the resident was severely impaired in cognition for daily decision making. A care plan, revised 03/18/25, did not show Resident #21 utilized a half side rail on the left side for bed mobility. On 04/09/25 at 1:56 p.m., the MDS coordinator stated…

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

Based on observation, record review, and interview, the facility failed to ensure assessments were completed and consents were obtained for the use of bed rails for 1 (#21) of 1 sampled resident who was reviewed for bed rails. The nurse manager identified two residents who utilized bed rails. Findings: On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail, on the left side, in the up position. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail, on the left side, in the up position. The Evaluation for Use of Side Rails form, dated 10/04/23, did not show the resident was assessed for entrapment with the use of the bed rail or alternatives to the use of the bed rail before they were implemented. The annual assessment, dated 12/11/24, documented Resident #21 had a diagnosis of Alzheimer's disease, and the BIMS score was six, which indicated the resident was severely impaired in cognition for daily decision making. A policy titled, Proper Use of Side Rails, dated December 2024, read in part, When used for mobility or transfer, 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 observation, record review, and interview, the facility failed to ensure treatment carts were secured for 3 (North hall treatment cart, [NAME] hall treatment cart, and the overflow treatment cart) of 5 medication/treatment carts observed. The DON identified five medication/treatment carts in the facility. Findings: On 04/07/25 at 7:32 a.m., the North hall treatment cart and the overflow treatment cart was observed by the nurses station to be unlocked and unattended. On 04/07/25 at 7:34 a.m., the treatment carts were observed to be locked in the front living room area, by the nurses station. On 04/08/25 at 9:25 a.m., the [NAME] hall treatment cart and the overflow treatment cart was observed to be by the nurses station, unlocked, and unattended. On 04/08/25 at 12:38 p.m., the overflow treatment cart was observed to be unlocked and unattended by the nurses station. On 04/09/25 at 10:53 a.m., the North hall treatment cart was observed to be unlocked and unattended. On 04/09/25 at 10:54 a.m., LPN #2 was observed to exit a resident's room, lock the cart, and push it down 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 provide palatable meals for 4 (#2, #17, #20, and #46) of 18 residents interviewed regarding food palatability. The corporate nurse manager reported 46 residents received food from the kitchen. Findings: On 04/07/25 at 1:02 p.m., a test tray was sampled for palatability. The Dorito casserole was lukewarm and not well seasoned. The mixed vegetables were soggy, bland, and lukewarm. On 04/08/25 at 12:33 p.m., a test tray was sampled for palatability. The Spanish rice was warm and bland, and the banana cake was dry and without icing. 1. An admission assessment, dated 03/07/25, showed Resident #2 had a BIMS score (a test for cognitive functioning) of 15 which was indicative of independence for daily decision making. On 04/07/25 at 10:03 a.m., Resident #2 stated when they eat meals in their room the hot foods are not hot, and the cold foods are not cold. 2. A quarterly assessment, dated 01/07/25, showed Resident #17 had a BIMS score (a test for cognitive functioning) of 15 which was indicative of independence for daily decision…

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

Based on observation, record review, and interview, the facility failed to ensure beds/bed rails were monitored for safety for 1 (#21) of 1 sampled resident who was reviewed for bed rails. The nurse manager identified two residents who utilized bed rails. Findings: On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail in the up position on the left side. The bed rail was observed to be loose when moved side to side and back and forth. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail in the up position on the left side. The bed rail was observed to be loose when moved side to side and back and forth. A policy titled, Bed Safety, dated June 2024, read in part, Inspection by maintenance staff of all beds and related equipment as part of regular bed safety program to identify risks and problems including potential entrapment risks. The annual assessment, dated 12/11/24, documented Resident #21 had a diagnosis of Alzheimer's disease, and had a BIMS score was six, which indicated the resident was severely impaired in cognition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the call light system was functioning in one of six occupied rooms resident rooms reviewed for call light functionality. The administrator reported the census was 53. Findings: A facility policy, reviewed 07/24, titled Maintenance Service read in part, .Functions of maintenance personnel include, but are not limited to .Maintaining the paging and nurse call system in good working order . On 10/08/24 at 10:05 am, LPN #1 stated when the call light was activated a light should illuminate in the hallway by the resident's door. At 10:10 am, CNA #1 stated when they observed that the light in front of a resident's door was illuminated that indicated the resident needed assistance. At 11:50 am, the call system in room [ROOM NUMBER] was activated, no light was illuminated in the hallway or at the nurse's desk. LPN #2 stated the call light for room [ROOM NUMBER] was not functioning. At 1:30 am, the maintenance supervisor stated they tested the call lights…

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 maintained to promote food safety and sanitation. The administrator identified 55 residents residing in the facility. Findings: On 12/21/23 at 9:10 a.m., a tour of the kitchen and dining area were conducted. The following observation was made: There were no dates on four partially used gallons of milk in refrigerator #1. On 12/21/23 at 9:20 a.m., the dietary manager stated the four gallons of milk should have open dates on them. The dietary manager removed the milk from the refrigerator.

Based on record review and interview the facility failed to ensure section the care plan decision column of the care area assessment section [section V] was completed on an annual assessment for one (#3) of two sampled resident reviewed for care plans. A facility Census List, dated 12/21/23, documented there were 55 residents living at the facility. Findings: A Comprehensive Assessment and the Care Area Process policy, dated 2001 and revised 2023, read in part, .Comprehensive assessment will be conducted to assist in the developing person-centered care plans . Resident #3 had diagnoses which included schizophrenia and recurrent depressive disorder. An annual assessment, dated 08/17/23, documented in the behaviors section [section E] the resident had rejected care one to three times during the look back period. The care planning decision column of section V [the section of the assessment were an interdisciplinary team (IDT) from the facility meet and decide wether to care plan any triggered care areas] was blank. On 12/27/23 at 1052 a.m. the MDS Coordinator stated they had found 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.

Based on record review and interview the facility failed to create a comprehensive care plan for one (#3) of two sampled resident reviewed for care plans. A facility Census List, dated 12/21/23, documented there were 55 residents living at the facility. Findings: A Care Plan, Comprehensive Person Centered policy, dated 2001 and revised 2023, read in part, .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident . Resident #3 had diagnoses which included schizophrenia and recurrent depressive disorder. On 12/21/23 at 11:31 a.m., Resident #3 stated they had not attended a care plan meeting at the facility. On 12/27/23 at 1052 a.m. the MDS Coordinator stated they had found no documentation Resident #3 had attended a care plan meeting. On 12/28/23 at 9:43 a.m., the MDS Coordinator stated the care areas psychotropic medications, psychosocial, and behaviors had triggered on the last annual assessment, dated 08/17/23, but they had missed care planning…

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 prescribed medication was available for administration to a resident for one (#109) of seven sampled resident observed for medication administration. Findings: A Pharmacy Services Overview policy, dated 2001 and revised 2023, read in part, Residents have sufficient supply of their prescribed medications (routine, emergency, or as needed) in a timely manner .Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration . Resident #109 had diagnoses which included heart failure and chronic atrial fibrillation. A medication administration record, dated 12/01/23 through 12/31/23, documented the resident had missed two doses of Eliquis 5 mg two tabs twice daily on 12/21/23 and one dose on 12/22/23. On 12/22/23 at 8:00 a.m., CMA #1 was observed preparing medication for resident #109. They stated the resident's Eliquis [a blood thinner] was not in the building. They stated it had not arrived since it…

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 response was received from the physician for a gradual dose reduction recommendation for one (#7) of five sampled residents reviewed for unnecessary medications. The DON reported the census was 55. Findings: An undated facility policy titled Antipsychotic Medication Use, read in part, .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . Resident #7 had diagnoses which included depression and hypokalemia. A quarterly assessment, dated 11/16/23, documented the resident was cognitively intact and was receiving antianxiety and antidepressant medications. A MRR, dated 10/25/23, documented Resident #7 was receiving Vistaril 50 mg by mouth four times a day and Buspirone 10mg by mouth twice a day. The pharmacist asked the physician to consider a gradual dose reduction on these medications. Review of the clinical record did not document the physician had addressed the MRR. On 12/29/23 at 10:35 a.m., the DON…

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 gradual dose reductions were attempted for psychotropic medications without an appropriate rationale to continue the current regimen for one (#38) of five sampled resident reviewed for unnecessary medications. A facility Census List, dated 12/21/23, documented there were 55 residents living at the facility. Findings: Resident #38 had diagnoses which included bipolar disorder and depression. A pharmacy note to Resident #38's prescriber documented the resident was prescribed Abilify, Lexapro, Lamictal, and Depakote for bipolar disorder. The pharmacy form further documented a request for the physician to attempt a gradual dose reduction for those medication if appropriate. Physician #1 checked the box for disagree and hand wrote, needs ask staff. On 12/28/23 at 11:46 a.m., physician #1 stated what they wrote said, needs, ask staff and that means they asked the nurses if the resident needed to stay on the four medications as they were. They stated the staff confirmed they need to stay on the medication and they…

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

Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's orders for one (# 2) of five residents reviewed for laboratory services. The administrator reported the census was 55. Findings: An undated policy titled Lab and Diagnostic Test Results - Clinical Protocol, read in part, .The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs . If resident refuses, documentation from lab will be obtained and documented in the medical record . Resident #2 had diagnoses which included a fractured tibia and hypokalemia. A quarterly assessment, dated 09/16/23, documented the resident had severe cognitive impairment and was total dependent on staff for transfers. A physician order, dated 09/28/23, documented a valproic acid level was to be drawn on 10/02/23 and then every month on the first Monday. A review of Resident #1's clinical record did document any VPA levels were drawn for October, November, or December. A review of Resident #1's clinical record did not document 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 maintain records of the quality assurance and performance improvement (QAPI) program. Findings: The facility's QAPI Plan, dated 2019, read in part, .The Administrator, Director of Nursing, and Medical Director are responsible and accountable for developing, leading, and closely monitoring the QAPI program . On 12/29/23 at 9:50 a.m., the Administrator stated QAPI issues were discussed in every morning meeting. They stated the QAPI team meets quarterly. They were asked for documentation the meeting had occurred. At 9:58 a.m., the Administrator stated they could not locate the meeting documentation and that the staff were looking for them. At 10:10 a.m., the staff searched the MDS office. The Administrator stated they could not find the QAPI folder. At 10:30 a.m., the Administrator presented documentation for one meeting that occurred on 11/01/23. They stated the rest of the QAPI documentation was not found.

Based on record review and interview, it was determined the facility failed to ensure assessments were submitted in a timely manner for four (#21, 27, 31, and #45) of four residents who were reviewed for assessments. The Resident Census and Conditions of Residents form identified 45 residents who resided in the facility. Findings: The CMS Submission Report, dated 07/19/22, documented the quarterly assessment for Resident #27 had a target date of 05/27/22. The report read in parts, .Record Submitted Late: The submission date is more than 14 days after Z0500B [the MDS completion date] on this new .assessment . The CMS Submission Report, dated 09/03/22, documented the quarterly assessment for Resident #21 had a target date of 08/08/22. The report read in parts, .Record Submitted Late: The submission date is more than 14 days after Z0500B [the MDS completion date] on this new .assessment . The CMS Submission Report, dated 12/20/22, documented the admission assessment for Resident #45 had a target date of 08/29/22. The report read in parts, .Assessment Completed Late: Z0500B [the MDS…

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 care plans were reviewed and revised for four (#5, 7, 12, and #17) of four care plans reviewed. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: The Care Plans, Comprehensive Person - Centered policy, dated July 2022, read in parts, .The Interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident's condition .At least quarterly, in conjunction with the required quarterly MDS assessment . 1. Resident #5 admitted with diagnoses which included depression and edema. A Care Plan, revised 01/22/21, documented Resident #5 was ordered to take an antidepressant of Remeron, a diuretic of HCTZ, and a supplement of Klor-Con. Physician's Orders, dated January 2023, did not document orders for the antidepressant, diuretic, and supplement. On 01/23/23 at 3:32 p.m., the ADON was asked who was responsible for reviewing and revising care plans. They stated the MDS coordinator was responsible for the care plans…

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 services of an RN were utilized eight hours a day from 01/12/23 through 01/22/23. The Resident Census and Condition of Residents form identified 45 residents who resided in the facility. Findings: The Staffing policy, dated 11/2022, read in part, .RN must be on duty 8 hours a day 7 days a week . On 01/13/23 at 4:45 p.m., the administrator was asked if a RN/DON was on staff. They stated no the DON had quit after working an eight hour shift that day. The administrator was asked if a plan was in place for RN coverage. They stated they were working on it and had calls out to several and had not heard back as of yet. On 01/19/23 at 9:22 a.m., the administrator was asked if an RN had worked during the time of the survey. They stated no and added an RN may be filling in over the weekend. The administrator was asked to provide a punch detail for registered nurses for during the dates of survey. They stated they did not have an RN beginning the day after state entered to present. On 01/19/23 at 9:36 a.m., the ADON/LPN was…

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

Based on record review and interview, the facility failed to ensure gradual dose reductions were addressed for one (#8) and medications were monitored by physician ordered labs for one (#34) of five sampled residents who were reviewed for unnecessary medications. Corporate nurse #1 identified 46 residents who received medications. Findings: The Lab and Diagnostic Test Results - Clinical Protocol policy, dated July 2022, read in parts, .The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . 1. Resident #8 had diagnoses which included schizophrenia and dementia. A Single Page for Reviewed Residents form, from the consultant pharmacist, dated 12/23/22, read in part, .[Resident #8] has an order for Risperidone (an antipsychotic medication) 0.5 mg by mouth once a day. Please consider a gradual dose reduction with this therapy, if appropriate . The recommendation had not been addressed by the physician. Physician Orders, dated January 2023, 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, observation, and interview, the facility failed to ensure scoops were not stored in food bins for five of five bins observed and ensure refrigerator shelves were free of spilled liquids for one of one refrigerators observed. Corporate nurse #1 identified 46 residents who received nourishment from the kitchen. Findings: The Sanitization policy, dated October 2022, read in parts, .The food service area shall be maintained in a clean and sanitary manner . On 01/11/23 at 5:09 p.m., the refrigerator in the kitchen was observed to have a metal pan with a log of ground beef in it. The log of ground beef was observed to hang out of the pan and a dark red/brown liquid was observed under the end of the ground beef, on the bottom of the refrigerator. The other side of the refrigerator was observed to have cartons of eggs. Yellow and clear liquid was observed under and in front of the cartons on the bottom of the refrigerator. On 01/11/23 at 5:19 p.m., bins with blueberry muffin mix, brown sugar, flour, granulated sugar, and corn meal were observed to contain scoops…

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 and/or the resident representative of clinical changes to the resident for one (#17) of three sampled residents. The Resident Census and Conditions of Residents form, documented 45 residents resided in the facility. Findings: The Change in a Resident's Condition or Status policy, dated May 2022, read in parts, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative .of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . Resident #17 admitted with diagnoses which included Parkinson's disease. Review of the Face Sheet for Resident #17 revealed the resident was not self responsible. A Nurse Note, dated 01/06/23, documented Resident #17 had congestion and the doctor had ordered an antibiotic. The clinical record did not document the resident representative was notified of a change in condition. On 01/12/23 at 5:32 p.m., during an interview with the resident representative 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 interview and record review, it was determined the facility failed to ensure assessments were accurate for one (#8) of three residents who were reviewed for limited range of motion/contractures. The Resident Census and Conditions of Residents form identified four residents who had contractures. Findings: Resident #8 had diagnoses which included generalized osteoarthritis and idiopathic gout, multiple sites. A quarterly assessment, dated 09/27/22, documented Resident #8 had no impairment in range of motion for their upper or lower extremities. A quarterly assessment, dated 12/27/22, documented Resident #8 had no impairment in range of motion for their upper or lower extremities and the resident was moderately impaired in cognition for daily decision making. On 01/12/23 at 9:07 a.m., Resident #8 was observed to open their left hand but the third and fourth digit was observed to remain bent downward. Resident #8 was asked how long they had experienced limited range of motion in the third and fourth digits. They stated for a little while. On 01/23/23 at 3:48 p.m., corporate…

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 code status was updated and accurate for one (#18) of five residents sampled for code status accuracy. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: The Advance Directives policy, dated 2022, read in part, .Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. 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 . On 01/12/23 at 11:18 a.m., the clinical record for Resident #18 was reviewed for code status. The clinical record had a DNR and a red sticker on the face sheet and spine of chart. A Physician's Order, dated November 2022, documented the code status for Resident #18 as a full code. On 01/19/23 at 11:29 a.m., LPN #1 was asked why Resident #18 had a physician's order for a full code when a DNR was in the clinical record. They stated…

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

Based on record review, observation, and interview, the facility failed to ensure treatment and services to prevent further decrease in range of motion was provided for one (#8) of three residents who were reviewed for limited range of motion. The Resident Census and Conditions of Residents form identified four residents who had contractures. Findings: Resident #8 had diagnoses which included generalized osteoarthritis and idiopathic gout, multiple sites. A Care Plan, revised 08/25/22, did not document any limitation in ROM for Resident #8. A quarterly assessment, dated 09/27/22, documented Resident #8 had no impairment in range of motion for their upper or lower extremities. A quarterly assessment, dated 12/27/22, documented Resident #8 had no impairment in range of motion for their upper or lower extremities and the resident was moderately impaired in cognition for daily decision making. On 01/12/23 at 9:07 a.m., Resident #8 was observed to open their left hand but the third and fourth digit was observed to remain bent downward. Resident #8 was asked how long they had experienced…

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

Based on record review and interview, the facility failed to ensure medications were monitored with labs ordered by the physician for one (#33) of five sampled residents who were reviewed for unnecessary medications. Corporate nurse #1 identified 46 residents who received medications in the facility. Findings: Resident #33 had diagnoses which included benign neoplasm of the brain. The care plan, dated 11/19/22, read in parts, .Obtain labs as ordered through the next review date .CBC, CMP q 3 months while on Methotrexate . Physician Orders, dated January 2023, documented Resident #33 had an order for Methotrexate (a cancer medication) 10mg by mouth weekly starting 12/06/21 and a CBC/CMP every three months while taking Methotrexate starting 01/12/22. Review of the clinical record revealed did not reveal the CMP had been completed every three months. The clinical record documented a CMP dated 02/08/22 and 08/09/22 were obtained. On 01/23/23 at 3:16 p.m., the ADON was asked how labs were monitored to ensure they were completed as ordered by the physician. They stated the labs would…

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 medication administration error rate was less than five percent. There were two errors out of 25 opportunities observed during a medication pass which made the medication error rate 8%. Corporate nurse #1 identified 46 residents who received medications. Findings: The Administering Medications policy, dated December 2022, read in parts, .Medications shall be administered .as prescribed .Medications must be administered in accordance with the orders . 1. Resident #12 had diagnoses which included GERD. On 01/17/23 at 4:01 p.m., Resident #12 was observed during medication pass. CMA #2 was observed to administer 30 mls of antacid by mouth and document on the back of the MAR. Physician Orders, dated January 2023, did not reveal an order for antacid. On 01/19/23 at 11:27 a.m., the ADON was asked if Resident #12 had an order for antacid. The ADON reviewed the monthly physician orders and telephone orders and stated no. The ADON was asked why the resident had received antacid. They stated the resident may…

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 completed as ordered by the physician for one (#8) of five sampled residents whose labs were reviewed. Corporate nurse #1 identified 41 residents who had physician orders for routine labs. Findings: The Lab and Diagnostic Test Results - Clinical Protocol policy, dated July 2022, read in parts, .The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . Resident #8 had diagnoses which included schizophrenia. Physician Orders, dated January 2023, documented the resident was to have a CBC every six months with a start date of 06/21/21. Review of the clinical record did not reveal a CBC had been completed. On 01/19/23 at 2:27 p.m., the ADON was asked for documentation of completed CBC lab results for Resident #8. On 01/23/23 at 3:16 p.m., the ADON was asked how labs were monitored to ensure they were completed as ordered by the physician. They stated the labs would automatically…

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.