Wewoka Healthcare Center

Based on observation, record review and interview, the facility failed to protect residents from physical abuse for 3 (#1, 2, and #4) of 3 sampled residents reviewed for abuse.The administrator identified 59 residents resided in the facility. Findings: An undated facility Abuse Prevention Program policy, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from verbal, mental, sexual or physical abuse. 1. A nurse's note, dated 10/24/25 at 12:40 p.m., read in part, Noise was heard from this resident room, when approached door, [Resident #3] coming out of room. [Resident #4)] reported that [they] was in [their] room and all of a sudden the [Resident #3] came in and then started waving arms around and cussing. [Resident #3] then made contact with their left arm, resulting in small bruise to left forearm. [Resident #3] taken back to room. Call placed to [name withheld] Police department, Admin [administrator] notified. No family listed to notify. Also notified ADON…

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. an abuse allegation was reported to the State Agency within two hours for 1 (#1); andb. a final report was submitted to the State Agency within five business days for 3 (#1, 2 and #3) of 3 sampled residents reviewed for abuse.The administrator identified 59 residents resided in the facility. Findings: An undated facility Abuse Prevention Program policy, read in part, When the allegation involves abuse or results in serious bodily injury you must report within 2 hours of notification of incident .The Administrator or Administrative Designee will complete the Investigation Report within five (5) working days .The investigation Report . shall be faxed within five (5) working days of submission of the incident and accident report. 1. A nurse's note, dated 11/3/25 at 12:10 p.m., read in part, This nurse [LPN #2] was in the dining room when I heard screaming. [CNA #1] arrived at the [Resident #1] first. [CNA #1] stated, 'When they walked in, they were swinging on each other.' When [LPN #2] arrived, residents had been…

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 a physician when a resident verbalized they would harm themself and others for 1 (#17) of 5 sampled residents reviewed for abuse and neglect.The DON identified 71 residents resided in the facility.Findings:An undated admission Record showed Resident #17 had diagnoses which included schizoaffective disorder bipolar type, other hallucinations, unspecified psychosis not due to a substance or known physiological condition, and unspecified depression.Resident #17's admission resident assessment, dated 08/19/25, showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident had hallucinations, delusions, and verbal behavioral symptoms directed towards others.A nursing note, dated 08/17/25 at 5:05 a.m., showed Resident #17 was at the nurses' station screaming and cussing, threatening to kill themself and others. The note showed the resident stated they were hearing voices and evil spirits and was very aggressive to staff. The note showed Resident #17 was put on one-on-one monitoring 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 implement their abuse policy by not: a. conducting a complete and thorough investigation; b. establishing coordination with QAPI; c. implementing new interventions designed to prevent reoccurrence; and d. implementing immediate one-on-one safety measures for 1 (#2) of 5 sampled residents reviewed for abuse. The administrator identified 85 residents resided in the facility. Findings: An undated facility policy titled Abuse Policy and Procedures, read in part, 2. Care Plan. Care Plans will address interventions designed to prevent occurrences, and may include: a) 'At risk' people to be visually monitored by nursing personnel for occurrences that could trigger abusive behavior; and b) Each person who is at risk for abusive behavior will be reassessed for preventative interventions at least quarterly.5. Documentation. Nursing staff shall document the incident and interventions in the Medical Record. 6. Investigation/Interviews: Admin/Designee will interview other cognitive residents and witnesses in the instance 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 thoroughly investigate an allegation of abuse for 1 (#1) of 5 sampled residents reviewed for abuse. The administrator identified 85 residents resided in the facility. Findings: An undated facility policy titled Abuse Policy and Procedures, read in part, 6. Investigation/Interviews: Admin/Designee will interview other cognitive residents and witnesses in the instance of resident-to-resident abuse so that the facility is aware of the scope and/or severity of the allegations. When a resident is not cognitive nursing staff may conduct a head-to-toe assessment for signs of injury if indicated as necessary. An undated facility admission record showed Resident #1 had diagnoses which included frontotemperal neurocognitive disorder, psychosis, persistent mood disorders, anxiety disorder, and focal traumatic brain injury with loss of consciousness. A quarterly assessment, dated 02/11/25, showed Resident #1 was severely impaired cognitively with a BIMS of 3. The assessment showed the resident did not have verbal and/or physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an effective pest management program . The DON reported 81 residents resided in the facility. Findings: On 04/18/25 at 2:49 p.m., Resident #27 was observed in bed in their room. The following observations were made: a. a roach was on the resident by their foot; b. mouse droppings were on the floor along the walls; and c. a mouse trap at the head of the resident's bed. On 04/18/25 at 4:29 p.m., live and dead roaches were observed behind the refrigerator in Resident #27's room. Mouse droppings were observed in the resident's top drawer of their dresser near the window and along the walls on the floor. An undated facility policy titled Pest Control, read in part, This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Resident #27's admission record, dated 12/01/22, showed the resident was admitted with diagnoses which included dysphagia and major depressive disorder. A…

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

Based on record review and interview, the facility failed to ensure a resident received notification when they were within $200 of the Medicaid resource limit of $2000 for 1 (#27) of 3 sampled residents reviewed for notifications of trust balances. The BOM identified 33 residents had money in the trust account. Findings: An undated facility policy titled Resident Funds, read in part, Your Corporate office has put in place a system called National Data Care/Resident Fund Management .This system allows the facility to complete yearly reevaluations for Medicaid and Social Security Administration by providing a detailed transaction report. Resident #27's face sheet, dated 12/01/22, showed the resident had a payer source of Medicaid. Resident #27's annual assessment, dated 11/12/24, showed the resident's BIMS score was 15 indicating their cognition was intact for decision making, had upper and lower extremity impairments on both sides, and was dependent for all activities of daily living. Resident #27's trust account ledger, dated 04/21/25, showed a current balance of $2353.44. There 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 observation, record review, and interview, the facility failed to ensure a clean, comfortable, and sanitary home like environment during 3 of 3 observations. The DON reported 81 residents resided in the facility. Findings: 1. On 04/09/25 at 2:04 p.m., an observation was made in Resident #25's room. Under the sink cabinet were black and green spots approximately 20 inches along the back wall of the cabinet. The spots ranged in various sizes from 0.5 inches to 3 inches with a height between 7 to 11 inches. The flooring under the sink had multiple cracks of various sizes and with reddish brown stains. The facility's policy titled Maintenance Service, revised December 2009, read in part, The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe operable manner at all times .2. Functions of maintenance personnel include, but are not limited to: d. Maintaining heat/cooling fixtures, plumbing fixtures, wiring, etc. [and other things/and so forth], in good working…

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 prevent abuse for 1 (#31) of 3 sampled residents reviewed for abuse. The DON stated 81 residents resided in the facility. Findings: A facility policy titled Abuse Policy and Procedure, dated 07/23/21, read in part, It recognizes residents rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation .Social media, pictures, and videos that demean, and or violate the residence, rights, privacy and or dignity are considered forms of abuse and will be treated as such. Resident #31's admission record, dated 11/06/24, showed the resident was admitted with diagnoses which included personal history of traumatic brain injury and dementia. Resident #31's significant change assessment, dated 03/19/25, showed the resident's BIMS score was 9 indicating they were moderately impaired for decision making. The assessment showed they ambulated with a wheel chair and required supervision or touching assistance for all transfers. Resident…

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

Based on observation, record review and interview, the facility failed to ensure a treatment cart was secured for 1 of 1 treatment cart observed. The DON identified 81 residents resided in the facility. Findings: On 04/04/25 at 12:26 p.m., the Southwest hall treatment cart observed on the East side of the nurses station was found unlocked and unattended. Resident#12's Lantus SoloStar Subcutaneous Pen-injector 100 units per milliliter (insulin glargine) was observed in the first drawer of the treament cart. A facility policy titled Medication Storage in the Facility, revised January 2018, read in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 04/04/25 at 12:27 p.m., LPN #6 stated their policy indicated the treatment cart was supposed to locked and attended to at all times.

Based on observation, record review, and interview, the facility failed to have a working call lights for 1 of 3 sampled shower rooms used by residents. The DON reported 81 residents resided in the facility. Findings: On 04/04/25 at 1:23 p.m., the call light was found not working in the shower room on the East side of the middle hall. The facility's policy titled Maintenance Service, revised December 2009, read in part, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. On 04/04/25 at 1:25 p.m., advanced certified medication aide #2 stated the call light in the middle shower room was not working. On 04/04/25 at 2:14 p.m., the administrator stated the call lights were supposed to work in the shower rooms. On 04/08/25 at 3:30 p.m., the maintenance supervisor stated they had no work orders for call lights.

Based on record review and interview, the facility failed to ensure a resident's chart was updated with a new antibiotic order for one (#15) of one resident sampled for antibiotics. The DON reported 73 residents resided in the facility. Findings: Res #15 admitted to the facilty with diagnoses which included overactive bladder, hypertension, and anxiety. A review of the resident's progress notes documented the resident began Cipro (antibiotic) 500 mg twice a day on 12/06/24. The physicians orders did not document an order for the antibiotic. The medication administration record did not document the order for the antibiotic. A count sheet for the Cipro documented the first dose was administered on 12/06/24 at 8:00 p.m. On 12/11/24 at 12:21 p.m., CMA #1 was asked if they had been documenting the antibiotic when it was administered. The CMA reported they had not documented it on the MAR . On 12/12/24 at 11:04 a.m., the ADON reported if the medication was not on the MAR it should not have been given.

Based on observation, record review, and interview, the facilty failed to ensure the temperature log was maintained for the medication refrigerator in the medication room. The DON reported 73 residents resided in the facilty. Findings: On 12/12/24 at 12:06 p.m., a tour of the medication room was performed with CMA #1. Temperature logs for the medication refrigerator was observed. There was no log for December 2024, the log for November 2024 was observed to have 21 days of missing temperatures, and October 2024 was observed to have eight days of missing temperatures. CMA #1 reported the nurses were responsible for the logs. On 12/12/24 at 12:24 p.m., LPN #1 reported the night shift nurses were responsible for the temperature logs. On 12/12/24 at 12:26 p.m., the DON was shown the logs for the medication refrigerator and reported the temperature logs were supposed to be filled out daily.

Based on observation, record review, and interview, the facility failed to update a fall care plan with interventions for one (#28) of one sampled resident reviewed for accidents. The DON identified 73 residents resided in the facility. Findings: Res #28 had diagnoses which included rheumatoid arthritis. A fall care plan, dated 08/06/23, documented interventions as the following: a. uses wc for mobility, b. refer to restorative program if changes in function are noted, and c. monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. An incident report, dated 11/02/24, documented the facility was going to initiate a low bed with a fall mat at bedside for Res #28. A care plan, initiated 11/06/24, did not document low bed with mat as a fall intervention. On 12/09/24 at 10:31 a.m., Res #28 was observed in their bed in their room. The bed was observed in the lowest position. There was a fall mat at bedside. The resident denied having any recent falls. On 12/12/24 at 10:45 a.m., the MDS coordinator stated there was not a set process to…

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

Based on observation, record review, and interview, the facility failed to ensure scheduled activities were conducted for residents. The administrator identified 74 residents resided in the facility. Findings: A November 2024 activity calendar documented activities for 11/14/24 were Dominoes at 10:00 a.m. and Bingo at 2:00 p.m. It documented activities for 11/15/24 were fancy nails at 9:00 a.m. through 11:00 a.m. and outside games at 12:00 p.m. On 11/14/24 at 9:53 a.m., Resident #12 was asked if the facility had activities for the facility. They stated they offered Bingo once a month or so. Resident #12 stated they needed activities and it would give them something to do. On 11/14/24 at 10:05 a.m., there were no activities observed to be in progress. On 11/14/24 at 2:15 p.m., there were no activities observed to be in progress. On 11/15/24 at 12:10 p.m., there were no activities observed to be in progress. On 11/15/24 at 1:14 p.m., Resident #13 stated the facility had no activity director and no one to do activities. Resident #13 looked at their November activity calendar and 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: a. a smoking assessment was completed for one (#3); and b. a resident did not receive a burn hole in their clothing due to not having enough space in the smoking area for one (#2) of three sampled residents reviewed for accident hazards. The administrator identified 74 residents. Findings: A Smoking policy, dated December 2011, documented safe smoking assessments would be performed at admit and periodically as needed. A Resident Smoking policy, dated 12/05/23, documented to provide maximum safety to all residents at all times. 1. Resident #2 had diagnoses which included schizophrenia. A comprehensive resident assessment, dated 09/27/24, documented Resident #2 used tobacco. On 11/14/24 at 9:11 a.m., Resident #2 was observed smoking a cigarette in the smoking area with staff present. Resident #2 was not observed to have a smoking apron on. On 11/14/24 at 9:18 a.m., Resident #2's hands were observed to be shaky while smoking. A staff member was observed placing a smoking apron on Resident #2. On 11/14/23…

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

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan included smoking for one (#2) of three sampled residents reviewed for accident hazards. The administrator identified 74 residents resided in the facility. Findings: A Care Plans - Comprehensive policy, dated 12/04/20, read in part, resident's comprehensive care plan is developed within seven (7) working days of completion of the resident's comprehensive assessment. Resident #2 had diagnoses which included schizophrenia. On 11/14/24 at 9:10 a.m., Resident #2 was observed outside in the smoking area. A staff member was observed to give the resident two cigarettes and lit one for them. Resident #2 was observed to smoke the cigarettes. A comprehensive resident assessment, dated 09/27/24, documented tobacco use. A comprehensive care plan was to be completed by 10/04/24. There was no care plan located in Resident #2's clinical record. On 11/14/24 at 2:15 p.m., the MDS coordinator stated they were behind on care plans and had not completed one for Resident #2.

Based on record review and interview, the facility failed to accurately document the occurrence of adverse behaviors for one (#5) of four sampled residents whose TARs were reviewed for adverse behaviors. The administrator identified 72 residents resided in the facility. Findings: Resident #5 had diagnoses which included hallucinations and other psychotic disorder. A physician's order, dated 08/12/24, read in parts, .Behaviors Monitoring .document Y if monitored and behaviors were observed. Every shift . Nursing Progress Notes documented the following, a. 09/08/24- resident urinated in the lobby, was agitated and aggressive, b. 09/09/24- resident became aggressive and squeezed nurse's fingers, c. 09/11/24- resident assaulted another resident with a cane, d. 09/13/24- resident took walker away from another resident and got physical with them, e. 09/22/24- resident urinated on the floor in other residents' rooms, f. 09/28/24- resident went in another resident's room and slapped them twice, g. 10/15/24- resident urinated on the floor and chair in other residents' rooms, h. 10/21/24-…

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

Based on record review and interview, the facility failed to the notify the mental health physician following incidents of resident-to-resident abuse for two (#5 and #6) of two sampled residents receiving routine mental health services and reviewed for resident-to-resident abuse. The administrator identified there were 72 residents residing in the facility. Findings: An Abuse policy, updated 07/23/2021, read in parts, .If a person is suspected of abusing another person, his or her physician .will be notified .to implement actions to prevent a reoccurrence . 1. Resident #5 had diagnoses which included hallucinations and other psychotic disorder. An Incident Report Form, dated 09/11/24, documented Resident #5, while in another resident's room, grabbed their cane and hit them in the head when asked to leave. An Incident Report Form, dated 09/13/24, documented Resident #5 took away another resident's walker and became physical with them while they were ambulating in the hallway. A Physical Aggression Initiated Form, dated 09/28/24, documented Resident #5 went into another resident's…

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

Based on record review and interview, the facility failed to accurately assess the occurrence of adverse behaviors on the comprehensive assessment for one (#5) of four sampled residents whose assessments were reviewed for adverse behaviors. The administrator identified 72 residents resided in the facility. Findings: Resident #5 had diagnoses that included hallucinations and other psychotic disorder. Nursing progress notes documented the following, a. 09/08/24- resident urinated in the lobby, was agitated and aggressive, b. 09/09/24- resident became aggressive and squeezed nurse's fingers, c. 09/11/24- resident assaulted another resident with a cane, d. 09/13/24- resident took a walker away from another resident and got physical with them, e. 09/22/24- resident urinated on the floor in other residents' rooms, f. 09/27/24- resident urinated in pharmacy bin at nurses station, and g. 09/28/24- resident went in another resident's room and slapped them twice. A Significant Change MDS, dated 10/08/24, contained the following documentation in Section E- Behaviors, a. E0200 Behavioral…

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 update care plans with interventions to: a. protect vulnerable residents from abuse for two (#2 and #4), and b. prevent further potential abuse for one (#5) of seven sampled residents reviewed for resident-to-resident abuse. The administrator identified 72 residents resided in the facility. Findings: An Abuse policy, updated 07/23/21, read in parts, .Care Plans will address interventions designed to prevent occurrences .Each person who is at risk for abusive behavior will be reassessed for preventative interventions at least quarterly . 1. Resident #2 had diagnoses that included dementia and legal blindness. An Incident Report Form, dated 09/13/24, documented Resident #2 had their walker taken away and was assaulted by another resident while they were ambulating in the hallway. A Physical Aggression Received Form, dated 09/28/24, documented Resident #2 was slapped twice in the head by another resident who entered their room uninvited. 2. Resident #4 had diagnoses that included ESRD and hypertensive heart disease. An…

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

Based on record review and interview, the facility failed to employ a full-time DON and ensure RN coverage for eight consecutive hours, seven days per week. The BOM identified 68 residents who resided in the facility. Findings: On 09/30/24 at 10:00 a.m., the administrator stated the facility had been without a full-time DON for several months. They stated a corporate registered nurse had filled in occasionally as the interim DON. A Timecard Report, dated August 2024, documented no RN coverage for eight consecutive hours on 20 of the 31 days. A Timecard Report, dated September 2024, documented no RN coverage for eight consecutive hours on 20 of the 30 days. On 09/30/24 at 2:27 p.m., the administrator stated the facility had not maintained RN coverage for eight consecutive hours, seven days per week, for several months due to not having a full-time DON. On 10/02/24 at 1:57 p.m., the interim DON stated the facility had been without a full-time DON since 05/15/24. They stated they had not ensured regular attendance in the facility since becoming the interim DON on 08/01/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain COVID-19 isolation procedures per policy for four (#3, 10, 11, and #12) of nine sampled residents reviewed for infection control. The BOM identified 68 residents who resided in the facility. Findings: A COVID-19 Isolation and Re-Testing protocol, dated 05/15/23, read in part, .Resident that tests positive for COVID-19 will be immediately isolated .They will remain in the area/room for at least 10 days from the onset of symptoms or the first positive test .If they remain asymptomatic for the entire duration of 10 days, they may be removed from isolation 10 days past the first positive test . A Coronavirus Testing policy, dated 05/15/23, read in part, The facility will provide signage and or instruction to all staff and all persons entering the facility, such as vendors, volunteers, and visitors, for signs and symptoms of COVID-19 .Staff or residents with signs and symptoms .Outbreaks (any new case arising in the facility) . A…

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

Based on record review and interview, the facility failed to designate an individual as the infection preventionist. The BOM identified 68 residents who resided in the facility. Findings: On 09/30/24 at 9:45 a.m., the administrator was asked to identify the infection preventionist. They stated the infection preventionist was the ADON. There was no documentation of an infection preventionist certification found for the ADON during record review. On 09/30/24 at 12:42 p.m., the interim DON stated they had an infection preventionist certification, but had been on vacation since 09/10/24. They stated the ADON had been responsible for the infection preventionist duties over the past several months. On 10/01/24 at 8:45 a.m., the ADON stated they had the required infection preventionist certification, but had never been asked to perform the duties of the infection preventionist for the facility. They stated the former full-time DON had completed the duties of the infection preventionist. The ADON stated they had tried to manage the Covid outbreak procedures during the past few weeks, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a scheduled court hearing was attended for one (#3) of two sampled residents reviewed for choices. The BOM identified 68 residents who resided in the facility. Findings: Res #3 had diagnoses which included chronic pain and generalized anxiety disorder. A psychiatric hospital Discharge summary, dated [DATE], documented Res #3's guardianship court hearing was scheduled to be held on 08/20/24. The note documented a contact phone number for Res #3's public defender. An admission assessment, dated 08/19/24, documented Res #3's cognition was intact. On 09/30/24 at 11:45 a.m., Res #3 was observed ambulating in the lobby. Res #3 stated they missed a scheduled court hearing regarding guardianship on 8/20/24. They stated they had made social services and the administrator aware of the scheduled hearing when they were admitted to the facility on [DATE]. Res #3 stated the facility made no effort to ensure they attended the hearing in person and now they had…

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

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for one (#1) of three sampled residents reviewed for bathing. The BOM identified 68 residents who resided in the facility. Findings: Res #1 had diagnoses which included edema and morbid obesity. An admission assessment, dated 09/05/24, documented the resident was cognitively intact and dependent with bathing. A facility shower schedule documented Res #1 was to receive a bath/shower on Tuesdays, Thursdays, and Saturdays weekly. There was no documentation of completed baths found in the medical record. On 09/30/24 at 9:15 a.m., Res #1 was observed lying shirtless in bed. Breadcrumbs were observed on and around the resident's upper body. Res #1 stated they had only received three baths since admission. On 10/01/24 at 2:50 p.m., CNA #2 stated completed baths should be documented in the EHR. They stated all refusals should be documented in the EHR or on a paper shower sheet and then given to the charge nurse. On 10/02/24 at 9:50 a.m., the ADON stated there was 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 interviews, the facility failed to investigate an allegation of abuse for two (#2 and #4) of four sampled residents reviewed for abuse. The administrator identified 76 residents resided in the facility. Findings: An undated facilty Abuse Policy and Procedure, read in part, The Administrator or Administrator Designee will conduct an immediate investigation of all alleged or actual incidents of abuse .Documentation .Nursing staff shall document the incident .in the Medical Record . 1. Res #2 had diagnoses that included cognitive communication deficit. A MDS assessment, dated 04/30/24, documented the resident's brief interview for mental status was at a 14/15. 2. Res #4 had diagnoses that included aphasia and dementia with behavioral disturbances. A MDS assessment, dated 05/28/24, documented the resident had severely impaired cognitive skills for daily decision making. On 06/12/24 at 2:06 p.m., CNA #1 stated Res #8 made them aware they witnessed Res #2 force Res #4 into their room and started to strip them. They stated Res #8 told someone to call 911. CNA #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to prevent physical abuse for one (#3) of three sampled residents reviewed for abuse allegations. The administrator identified 76 residents resided in the facility. Findings: An undated facility Abuse Policy and Procedure, read in part We will endeavor to protect our occupants from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of resident property . A quarterly MDS, dated [DATE], documented Res #3 was severely cognitively impaired, and was dependent on staff for most ADLs. An email correspondence to the ADON, dated 06/07/24 at 8:21 a.m., documented CNA #2 had witnessed CNA #3 grab Res #3's groin with force on their brief. The email documented CNA #3 had yelled at Res #3 during care and was rough during the incontinent care. On 06/12/24 at 1:40 p.m., Res #3 was observed in their bed. They were cognitively unable to participate in an interview. On 06/13/24 at 11:21…

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 an allegation of abuse was reported within 2 hours to OSDH for one (#3) of four sampled residents reviewed for allegations of abuse. The administrator identified 76 residents resided in the facility. Findings: An undated facilty Abuse Policy and Procedure, read in part, .When the allegation involves abuse or results in serious bodily injury you must report within 2 hours of notification of incident . An email correspondence from CNA #2 to the ADON, dated 06/07/24 at 8:21 a.m., documented CNA #2 witnessed potential abuse from CNA #3 towards Res #3. The email documented the incident occurred around 8:00 p.m. on 06/06/24. An incident report was filed with OSDH on 06/07/24 at 9:48 a.m. On 06/13/24 at 10:23 a.m., the administrator stated they were aware CNA #2 did not report the incident within two hours and an inservice had been completed.

Based on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The DM identified 74 residents who received services from the kitchen. Findings: A Sanitization policy, revised October 2008, read in part, .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .If a sink is used for washing utensils, cooking equipment or dishes, and also used to wash produce or thawed food, it will be cleaned between uses with an approved cleaning and sanitizing agent .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . A Refrigerators and Freezers policy, revised December 2014, read in parts, .Refrigerators and freezers will be kept clean, free of debris, and mapped with sanitizing solution on a scheduled basis and more often as necessary .Monthly tracking sheets for all refrigerators and freezers will be posted to record…

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

Based on observation and interview, the facility failed to maintain an effective pest control program. The BOM identified 74 residents who resided in the facility. Findings: On 05/20/24 at 9:15 a.m., a tour of the kitchen was conducted. Numerous cockroaches, both dead and alive, were observed in the kitchen and dry storage area underneath the wire racks and food bins. Dead cockroaches were observed around the refrigerators and freezers. Three live cockroaches were observed crawling around the open trash cans in the meal preparation area of the kitchen. On 05/20/24 at 9:40 a.m., [NAME] #1 stated cockroaches had been present in the kitchen for a while now. They stated the cockroach problem had improved some recently but remained a problem. On 05/21/24 at 10:22 a.m., Res #4 stated they had found a cockroach in their eggs during breakfast a few months ago. They stated the staff were aware of the cockroach problem but had done nothing to fix it. On 05/21/24 at 10:35 a.m., Res #3 stated they had observed cockroaches in the dining area on numerous occasions. On 05/21/24 at 2:15 p.m., 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 a medical appointment was completed for one (#1) of two sampled residents reviewed for quality of care. The BOM identified 74 residents who resided in the facility. Findings: A Transportation, Social Services policy, revised December 2023, read in parts, .Our facility shall help arrange transportation for residents as needed .Social services will help the residents as needed to obtain transportation for dialysis, pcp appointments, and etc . Res #1 was admitted with diagnoses which included cerebral infarction, urinary catheter, hemiplegia, and stage II pressure ulcers to the left and right buttocks. A care plan, dated 11/01/23, documented Res #3 had a supra-pubic catheter related to urinary retention and needed social services to assist as needed with appointment scheduling and arranging transportation. A quarterly assessment, dated 02/26/24, documented Res #1 was cognitively intact, dependent with most ADLs and mobility, and had an indwelling urinary catheter. A nurse note, dated 02/29/24 at 8:45…

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

Based on observation and interview, the facility failed to ensure food was palatable, attractive, and at appetizing temperatures for two of two meal services observed. The DM identified 74 residents who received services from the kitchen. Findings: A Food and Nutrition Services policy, revised October 2017, read in parts, .Food and nutrition services staff will inspect food trays to ensure the food appears palatable and attractive, and is served at a safe and appetizing temperature . A Food Preparation and Service policy, revised October 2017, read in parts, .Proper hot and cold temperatures are maintained during food service . The temperature of food held in steam tables are monitored throughout the meal by food and nutrition services staff . A Food Temperature Chart, dated 05/12/24 through 05/18/24, had no documentation of steam holding temperatures for the 05/15/24 breakfast meal or any of the meals on 05/16/24, 05/17/24, or 05/18/24. On 05/20/24 at 11:45 a.m., the lunch service was observed. The food containers were uncovered on the steam table prior to the serving process.…

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 garbage containers in the food preparation area were covered with lids. The DM identified 74 residents who received services from the kitchen. Findings: A Food-Related Garbage and Refuse Disposal policy, revised October 2017, read in parts, .All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . On 05/20/24 at 9:15 a.m., a tour of the kitchen was conducted. A large plastic garbage can without a lid was observed next to the metal food preparation table. The garbage can was filled with refuse including food waste from the breakfast meal. A second large plastic garbage can without a lid was observed next to the refrigerator and freezer area. The garbage can was filled with refuse including food waste. Three live cockroaches were observed crawling around the open garbage cans. On 05/20/24 at 9:34 a.m., [NAME] #1 stated the garbage cans…

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 menus were followed for one of one meal service observed. The BOM identified 74 residents who received services from the kitchen. Findings: A Substitutions policy, revised April 2007, read in part, .The Food Services Manager, in conjunction the Clinical Dietician, may make food substitutions as appropriate or necessary. The Food Services Shift Supervisor will make substitutions only when unavoidable . The lunch menu for 05/20/24 documented residents were to have turkey pot pie with biscuit top, oven roasted potatoes, tossed side salad with dressing, frosted cinnamon roll, and a beverage of choice. On 05/20/24 at 11:40 a.m., [NAME] #1 stated they did not have all the ingredients to prepare turkey pot pie for lunch. They stated meat loaf would be served instead per instruction from the DM. [NAME] #1 stated the DM had been on sick leave for several days and would not be present in the facility until the following day. On 05/20/24 at 11:45 a.m., the lunch service was observed. The residents were served…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for three (#1, 3 and #6) of three sampled residents reviewed for assistance with ADLs. The DON identified 67 residents who resided in the facility. Findings: 1. Res #3 was admitted with diagnoses which included cerebral infarction, hemiplegia, and stage II pressure ulcers to the left and right buttocks. A quarterly assessment, dated 09/05/23, documented Res #3 was cognitively intact and dependent with bathing. A shower schedule sheet documented the resident was to be bathed every Tuesday, Thursday, and Saturday. The December 2023 shower sheets documented the resident was bathed four out of 10 opportunities. The January 2024 shower sheets documented the resident was bathed one out of nine opportunities. On 01/29/24 at 3:10 p.m., Res #3 was observed lying in bed with shoulder length brown matted hair. A large amount of white skin flakes was observed in and around Res #3's hair and upper body. Res #3…

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 food was palatable and served at the appropriate temperature. The ADON identified 67 residents who received meals from the kitchen. Findings: A Food and Nutrition Services policy, revised October 2022, documented nutrition services staff will inspect food trays to ensure the food appears palatable and attractive and is served at a safe and appetizing temperature. A schedule of mealtimes documented the following meal service times: breakfast 7:00 a.m. to 9:00 a.m., lunch 11:30 a.m. to 1:30 p.m., and supper 5:00 p.m. to 7:00 p.m. On 01/29/24 at 3:00 p.m., Res #1 was observed sitting on an electric scooter in their room. Res #1 stated meals are always served cold and rarely taste good. On 01/30/24 at 1:26 p.m., a sample meal tray was obtained from the serving cart on the northeast hall. The country fried steak was 94.6 degrees F, the mashed potatoes with white gravy were 91.4 degrees F, the green beans were 86 degrees F, the bread roll was 87 degrees F, and the yellow-colored pudding was 78.4 degrees F.…

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 urology consult was completed in a timely manner per physician order for one (#3) of four sampled residents reviewed for social services. The DON identified 67 residents who resided in the facility. Findings: Res #3 was admitted with diagnoses which included cerebral infarction, hemiplegia, and stage II pressure ulcers to the left and right buttocks. A care plan, dated 12/01/22, documented Res #3 had frequent urinary tract infections related to suprapubic catheter use. A quarterly assessment, dated 09/05/23, documented Res #3 was cognitively intact, dependent with most ADLs, and had a suprapubic catheter. A physician order, dated 09/18/23, documented to set resident up with urologist ASAP related to suprapubic catheter irritation. A physician order, dated 10/19/23, documented to make sure the resident gets an appointment with urologist that was ordered last month. A physician order, dated 11/16/23, documented to follow up with urology consult. There was no documentation of attempts to schedule a…

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

Based on record review, observation, and interview, the facility failed to serve, store, and prepare food in a sanitary manner for the residents. The Resident Census and Conditions of Residents report, documented 73 residents resided in the facility. Findings: On 09/14/23 at 9:50 a.m., a kitchen observation was conducted. A carton with one egg was noted in the refrigerator. The carton did not document the egg was pasteurized. The refrigerator contained a plastic bag of lettuce with brown spots that was not dated, a bowl of white gravy that was not dated, and a container of green beans that was dated 08/02/23. On 09/14/23 at 9:51 a.m., the DM looked at the egg carton and stated there were no other eggs in the facility. The DM stated the carton did not document the eggs were pasteurized. The DM stated the eggs were used for breakfast and prepared as scrambled or fried. On 09/14/23 at 10:05 a.m., the dietary freezer contained a large plastic bag of mixed vegetables that was not sealed. On 09/14/23 at 10:09 a.m., the handwashing sink was leaking water on the floor. The DM stated there…

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 residents were not served with plastic ware and disposable plates. The Resident Census and Conditions of Residents report, dated 09/14/23 , documented 73 residents resided in the facility. Findings: On 09/14/23 at 12:42 p.m., [NAME] #1 was observed serving the lunch meal. The cook lined up three trays and placed the food on a disposable plate and plastic ware on each tray to serve the residents. The cook stated they were using disposable plates and ware because they had ran out of regular plates and silverware. On 09/14/23 at 12:50 p.m., the DM stated the facility only had enough regular plates and silverware to serve about 50 residents. On 09/14/23 at 12:52 p.m., Res #18 was sitting in the dining room for the lunch meal. The res stated they did not like using disposable plastic ware, but that was what they were usually given.

Based on record review and interview the facility failed to a complete a performance review of every nurse aide at least once every 12 months. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: On 09/20/23 the DON provided documentation of annual nurse aide competency for four CNAs who had worked at the facility for greater than one year. The forms provided documented three of the four CNAs had last had their competencies assessed in April of 2022. On 09/20/23 at 9:46 a.m., the DON was asked if the dates on the competency forms were correct and if there was documentation of more recent skills assessments. On 09/20/23 at 10:52 a.m., the DON stated they were unable to locate the documentation of skills check offs completed with the last 12 months for the three CNAs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure competent/sufficient dietary staff to prepare and serve meals for the residents. The Resident Census and Conditions of Residents report, documented 73 residents resided in the facility. Findings: A sign posted in the dining room documented a meal schedule. The sign documented breakfast was from 7:00 a.m. to 9:00 a.m., lunch was from 11:30 a.m. to 1:00 p.m., and dinner was from 5:00 p.m. to 7:00 p.m. On 09/14/23 at 12:28 p.m., the dietary staff was placing meal trays through a window area for meals in the dining room. A resident was observed to handle three food trays passed through the window. On 09/14/23 at 12:30 p.m., there was no staff in the dining room. The dietary staff came out to the kitchen to monitor tray pass. On 09/15/23 at 2:08 p.m., Res #20 in room [ROOM NUMBER] was in their doorway looking up and down the hall. The resident stated they were looking for their lunch tray. The resident remained in the doorway until 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, observation, and interview the facility failed to ensure food was palatable and served at the appropriate temperature. The Resident Census and Conditions of Residents report, documented 73 residents resided in the facility. Findings: 1. On 09/14/23 during kitchen observation the Meal Temperature Record was reviewed. The record did not document food temperatures taken before serving for breakfast, lunch, or dinner on 09/12/23, 09/13/23, or for breakfast on 09/14/23. On 09/14/23 at 12:22 p.m., [NAME] #2 opened a bag of flour tortillas that were lying on the counter. The cook did not heat the flour tortillas and continued to make the tacos. On 09/14/23 at 12:25 p.m., the DM stated the cook should have heated the flour tortillas. On 09/14/23 at 12:52 p.m., Res #18 was in the dining room for lunch. The resident stated the food was always cold. The resident stated they did not like tacos and if they did not let dietary know before 10:00 a.m. an alternate food was not available. On 09/18/23 at 3:00 p.m., a sample meal tray was obtained. The pork fritter was 90.8…

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, observation, and interview, the facility failed to ensure meals were served timely for the residents. The Resident Census and Conditions of Residents report, documented 73 residents resided in the facility. The report documented two residents received nutrition via tube feeding. Findings: A sign posted in the dining room documented a meal schedule. The sign documented breakfast was from 7:00 a.m. to 9:00 a.m., lunch was from 11:30 a.m. to 1:00 p.m., and dinner was from 5:00 p.m. to 7:00 p.m. On 09/15/23 at 2:08 p.m., Res #20 in room [ROOM NUMBER] was in their doorway looking up and down the hall. The resident stated they were looking for their lunch tray. The resident remained in the doorway until they received their meal tray at 2:15 p.m. On 09/15/23 at 2:12 p.m., the cook stated they did not know why lunch was late. The cook stated they went on break and when they returned no other meal trays had been prepared. On 09/15/23 at 2:21 p.m., the last lunch tray was served. On 09/15/23 at…

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 establish, maintain, and implement an infection control program to help prevent the transmission of communicable diseases and infections. The facility failed to: a. identify what type of PPE was required related to the type of isolation residents required. b. follow their COVID-19 infection control policy. c. to implement their Legionnaires prevention policy. d. to identify a resident with an MDRO on admission and implement appropriate infection control measures to prevent the spread. e. to track and trend infections since May of 2023. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: A facility policy titled Nursing Management Manual, effective date 05/15/23, read in part, .While it is safer for visitors not to enter the facility during an outbreak, visitors must still be allowed if they choose and they should be made aware of the risk prior to the visit and it is recommended that the resident and the visitor wear a mask regardless of their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the state was notified of a new serious mental illness for one (#46) of four residents reviewed for PASRR completion. The Resident Census and Conditions of Residents report documented 50 residents received antipsychotic medication. Findings: Res #46 was admitted to the facility on [DATE] with diagnoses which included protein-calorie malnutrition and major depressive disorder. A PASRR level I form, dated 05/06/22, documented the resident had a diagnosis of major depressive disorder a serious mental illness. The form documented a referral was sent to OHCA and no PASRR level II was needed. The resident's clinical record documented the resident received a diagnosis of schizoaffective disorder on 09/16/22. The quarterly assessment, dated 07/18/23, documented the resident was moderately impaired for daily decision making and required supervision with most activities of daily living. The assessment documented the resident had diagnoses of depression…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the OHCA was notified of residents with serious mental illnesses for two (#19 and #51) of four sampled residents reviewed for PASRR evaluations. The Resident Census and Conditions of Residents form documented 50 residents received antipsychotic medication. Findings: 1. Res #19 was admitted on [DATE] with diagnoses which included dementia with behavioral disturbance, delusional disorder, paranoid personality disorder, anxiety disorder, and primary insomnia. A Level I PASRR, dated 04/26/23, documented the resident did not have a serious mental health diagnosis. The PASRR did not document the OHCA was notified of the resident's mental health diagnoses. A quarterly assessment, dated 08/01/23, documented the resident was severely impaired in cognition, required supervision with ADLs, and received antipsychotic, antianxiety, and antidepressant medications. On 09/20/23 at 8:58 a.m., the DON was asked to review the PASRR. The DON stated the state should…

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, observation, and interview, the facility failed to ensure interventions were in place to prevent reoccurrence of falls and update the resident's plan of care for one (#6) of two sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, documented 73 residents resided in the facility. Findings: Res #6 was admitted to the facility on [DATE] with diagnoses which included acquired absence of the right and left leg above knee, diabetes, obesity, and anxiety. The care plan, dated 05/23/23, documented the resident was at risk for ongoing falls. The care plan documented the following interventions: a) Refer the resident for a physical therapy evaluation. b) Use a wheelchair for long distance mobility. c) Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. d) Keep the resident's area free of clutter. e) Keep the call light within reach. f) Keep personal items within reach. An incident report, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure: a. the consultant pharmacist addressed a possible reduction of psychotropic medications annually for one (#25), b. irregularities noted by the pharmacist was sent to the attending physician for review for one (#25), c. they responded to a physician approved pharmacist request for one (#51), and d. the primary care provider provided a rational for not attempting a reduction of a medication for one (#25) of five sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: 1. Res #25 had diagnoses which included generalized anxiety disorder, sequelae of Guillain-Barre syndrome, chronic pain, and major depressive disorder. A physician order, dated 04/22/19, documented to administer 40 mg of Citalopram (an antidepressant) daily for a diagnosis of depression. A physician order, dated 04/22/19, documented to administer 15 mg of Remeron…

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 have an adequate diagnosis for the use of an antipsychotic medication (Haloperidol) for one (#6) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 50 residents received antipsychotic medication. Findings: Res #6 was admitted to the facility on [DATE] with diagnoses which included insomnia due to other mental disorder and anxiety disorder. A physician order, dated 06/30/23, documented the resident was to receive Haloperidol (an antipsychotic medication) 5 mg three times a day for a diagnosis of anxiety disorder. The quarterly assessment, dated 08/15/23, documented the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toilet use. The assessment documented the resident had received antipsychotic medication on a routine basis. On 09/19/23 at 1:42 p.m., the DON reviewed the resident's clinical record. The DON stated the anxiety…

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 resident call lights were within reach for three (#3, 5, and #6) of three sampled residents observed for call lights. The Resident Census and Conditions of Residents form, dated 08/04/23, documented 57 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included quadriplegia (paralysis of all four limbs). An ADL care plan, dated 05/31/21, read in part, .Ensure call button is placed by [Resident #3]'s head .Encourage [Resident #3] to use soft touch call light to call for assistance . On 08/04/23 at 12:09 p.m., Resident #3's soft touch call light was not within reach of the resident's head. Resident #3 attempted to activate the call light with their head and was unable to reach the soft touch call light pad. Resident #3 was asked if they could reach the call light. Resident #3 shook their head side to side, indicating, No. On 08/04/23 at 12:12 p.m., LPN #1 stated the soft touch call light was not within reach of Resident #3's head. LPN #1 stated if Resident #3 could not reach…

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 wound care was performed as ordered by the physician for one (#4) of three sampled resident who were reviewed for wound care. The DON identified five residents who had wounds. Findings: Resident #4 had diagnoses which included cellulitis and venous wound of the right and left leg. Resident #4's current physician's orders, dated 08/2023, documented to cleanse open area on right arm with normal saline, pat dry, apply medical honey product, then wrap with bandage wrap as needed and cleanse left and right lower leg with normal saline pat dry, apply triamcinolone topical to open areas, cover with an antimicrobial soft wound dressing, wrap with unna boot (A compression dressing to protect open areas and help improve blood flow.), and cover with absorbent pad, bandage wrap, and self-adherent wrap twice weekly on Tuesdays and Fridays. A nurse's progress note, dated 08/04/23 at 1:12 p.m., documented Resident #4's wound care was completed as ordered. The progress note did not document the location of the wound…

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.