Kinzua Nursing And Rehab

Based on review of employee credentials, and staff interviews, it was determined that the facility failed to ensure the employee designated as the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutritional professional, received frequently scheduled consultations from a qualified dietitian and/or failed to employ a full-time qualified dietitian since 1/7/25. Findings include: Review of the employee file/credentials the facility designated as the director of food and nutrition services revealed that he/she lacked the appropriate competencies and skills to function as the director to include any of the following: a certification for food service manager or a similar national certification for food service management and safety from a national certifying body or an associate's or higher degree in food service management or in hospitality or lacked two or more years experience in the position of food safety and completed a course study in food safety and management. There was no evidence that the facility had 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 review of facility policy, job description, and clinical records, and staff interviews, it was determined that the facility failed to accurately and consistently assess a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment on a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for 27 of 85 Residents reviewed (Residents R1, R10, R11, R15, R20, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, and R43) Findings include: Review of facility policy dated 12/2/24, entitled Nutritional Management revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status (refers to the factors that reflect that an individual's nutritional status (includes both nutrition and hydration) is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values) in the context 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 review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of two residents reviewed for hospitalizations (Residents R11 and R12). Findings include: A facility policy entitled Bed-Holds and Return dated 12/2/24, indicated that prior to transfers and therapeutic leaves, that residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident R11's clinical record revealed an admission date of 1/31/25, with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors), flu, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Record review revealed that Resident R11 was transferred to 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 15 Residents reviewed (Resident R1). Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that a comprehensive assessment will be conducted to assist in developing person-centered care plans. It also indicated to identify current interventions and treatments and link these to problems and diagnosis they are to be treating. Resident R1's clinical record revealed an admission date of 1/8/25, with diagnoses that included high blood pressure, pneumonia, and pressure ulcer (damage to the skin and/or underlying tissue that usually occurs over a bony prominence) to his/her right heel and sacrum that is unstageable (when the bottom of the pressure ulcer is covered in slough [debris that appears tan, yellow, green or brown in color] and/or eschar [hard plaque that's tan, brown, or black in color]. Resident R1's clinical record revealed a progress…

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 review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 15 residents reviewed (Residents R9, R10, R8, R15, R16, R20, and R22). Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that comprehensive assessments, care planning, and the care delivery process involves collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Resident R9's clinical record revealed an admission date of 2/2/08, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and anxiety. Review of Resident R9's comprehensive care plan on 3/17/25, revealed that of the 39 care plans present, 37 had an outstanding target date of 2/28/25. The care plans included the problem categories of: skin breakdown related to rash, ADL [activities of daily living] care,…

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 review of clinical records, facility policies and documentation, and staff interview, it was determined that the facility failed to ensure adequate safety measures were implemented related to wheelchair transport and fall precautions for two of four residents reviewed for falls (Residents R13 and R14). Findings include: The facility was not able to provide a policy for staff to reference in the safe utilization of footrests while transporting residents via wheelchair. A facility policy entitled, Falls and Fall Risk, Managing, revised March 2018, indicated that Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Resident R13's clinical record revealed an admission date of 11/28/24, with diagnoses that included stroke, unsteady on feet, Parkinson's Disease (degenerative brain condition, meaning it causes parts of your brain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to comprehensively address the formulation of advance directives (legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself-to include information provided oral and/or written instructions about future medical care in the event of becoming unable to express medical wishes) for two of 24 residents reviewed (Residents R4 and R36). Findings include: A facility policy entitled, Advanced Directives dated [DATE], indicated the following: -upon admission the resident and/or representative will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advanced Directive if he or she chooses to do so. - prior to or upon admission the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence…

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 review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of 24 residents reviewed (Residents R17, Resident R65, and Resident R69). Findings include: Resident R69's clinical record revealed an admission date of 10/24/24, with diagnoses that included stroke, breast cancer, and high blood pressure. Resident R69's clinical record revealed a physician's order dated 10/31/24, for a left arm sling to be worn at all times except for hygiene purposes. There was also an order dated 11/20/24, for a soft cervical (neck) collar to be applied when out of bed, in wheelchair for cervical support and improved posture, may remove for eating. Observation of Resident R69 on 12/03/24, at approximately 10:47 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. Observation of Resident R69 on 12/04/24, at approximately 9:20 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decrease in range of motion for one of two residents reviewed for range of motion (Resident R65). Findings include: Review of Resident R65's clinical record revealed an admission date of 12/27/23, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat), and Hypertension (high blood pressure). Review of Resident R65's Occupational Therapy Discharge summary dated [DATE], revealed a long term goal that include: patient will safely wear a resting hand splint on left hand for up to eight hours with minimal signs or symptoms of redness, swelling, discomfort or pain. Observation made on 12/02/24, at 3:10 p.m.…

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

Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube inserted into the bladder to drain urine into a bag) for three of five residents reviewed for catheters (Residents R1, R5, and R11) Findings include: A facility policy entitled Suprapubic Catheter Replacement dated 12/02/24, indicated that the date and time of the procedure, name of individual performing the procedure, and signature and title of the person completing the procedure should be recorded in the resident's medical record. A facility policy entitled Catheter Care, Urinary dated 12/02/24, indicated Maintain Unobstructed Urine Flow 3. The urinary drainage bag must be held or positioned lower than the bladder at all times . and Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. Resident R1's clinical record revealed an admission date of 12/22/22, with diagnoses that included obstructive and reflux uropathy (occurs when the urine flow…

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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) with the date they were opened and discard an opened multi-dose vial of insulin in a timely manner in two of three medication carts (Gold and Red Units) and discard an opened multi-dose vial of Tuberculin solution (solution used to test for the disease tuberculosis) in one of three medication storage rooms (Red Unit). Findings include: A facility policy entitled, Insulin Administration dated [DATE], indicated that staff are to check the expiration date, if drawing from an opened multi-dose vial; if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening. A facility policy entitled, Storage of Medications dated [DATE], indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will…

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 review of facility policies, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations and standards for food safety in the main kitchen and in one pantry reviewed (Gold Pantry). Findings include: Review of facility policy entitled Food Receiving and Storage dated 12/02/24, indicated that Dry food that are stored in bins are removed from original packaging, labeled and dated (use by date). Food and snacks kept on the nursing units. 1. All food items to be kept at or below 41 F [Fahrenheit] are placed in the refrigerator . and labeled with a use by date. 3. Refrigerators . are monitored for temperature according to state specific guidelines. Additional document entitled Food Storage Guide revealed that bakery items including, muffins/pastries/donuts-once opened expires in one week and prepared foods/leftover items, once opened expires in 3 days. Review of facility policy entitled Food Brought by Family/Visitors dated 12/02/24, revealed that 'food brought in by family/visitors that is left with resident to consume later will…

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 observations, review of facility policies and documents, and staff, resident, and visitor interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment in one resident room (520) and clean equipment for one resident (Resident R37). Findings include: A facility policy entitled Quality of Life-Homelike Environment dated 12/02/24, indicated facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting and include a clean, sanitary, and orderly environment. A facility document entitled Daily Resident/Patient Room Cleaning indicated that resident room floors would be dust mopped, all trash and debris will be swept to the door and picked up with a dustpan. Observation on 12/02/24, at 12:09 p.m. of room [ROOM NUMBER] revealed an open bag of cheese curls, two full 20-ounce plastic bottles of Diet Coke and one empty 20-ounce plastic bottle of Diet Coke on…

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

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R26). Findings include: A facility policy entitled Oxygen Administration dated 12/02/24, indicated to verify that there is a physician's order for oxygen administration. Resident R26's clinical record revealed an admission date of 11/06/24, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), dementia (loss of cognitive functioning affecting a persons memory and behaviors), and high blood pressure. Observations on 12/02/24, at 1:45 p.m., 12/03/24, at 11:16 a.m., and 12/03/24, at 12:08 p.m. revealed Resident R26 wearing an oxygen nasal cannula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 2 liters per minute. Resident R26'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 review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean and sanitary resident shower room in one of two shower rooms (Red shower room). Findings include: Review of facility policy entitled Daily Resident/Patient Room Cleaning dated 1/16/24, indicated Wall and Handrail Cleaning Ceramic tile walls Procedure: Wet the wall with clean water, apply quaternary disinfectant on the wall with a rag, then scrub down the wall with the scrub pad and use the grout brush to clean in between the tiles. Observation on 8/20/24, at 11:00 a.m. of the Red shower room revealed a black substance between the white ceramic tiles on the shower room walls and a gray substance covering the surface of the ceramic tiles on the wall closest to the floor. During an interview with Housekeeper Employee E1 on 8/20/24, at 11:00 a.m. he/she revealed that he/she was unsure when the shower room was last cleaned. The facility was unable to provide evidence when the Red shower room was last cleaned. During an interview with the Nursing Home…

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 review of facility policy and clinical record, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of five residents reviewed (Resident R1). Findings include: A facility policy entitled Change in Resident's Condition or Status last reviewed 1/16/24, indicated that the facility must inform the resident's representative, or family member when there is a Significant Change an example of which was the development of Stage 2 (partial-thickness skin loss) skin breakdown. Resident R1's clinical record revealed an admission date of 5/06/2018, with diagnoses that included Dementia, Type II Diabetes (condition of improper blood sugar control), Heart Failure and Pain. Review of an admission / re-admission Evaluation form dated 1/03/24, documented that Resident R1 had newly developed a Stage 2 open area around the coccyx area. There was no further documentation to indicate that Resident R1's responsible party was notified of these areas of skin breakdown. During an interview on 3/06/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations, and resident and staff interviews it was determined that the facility failed to promote self-determination through the support of resident choices about aspects of their lives that were identified as important for five of 24 residents reviewed (Residents R14, R37, R40, R82, and R186). Findings include: A facility policy entitled, Dining and Food Preferences dated 1/16/24, indicated the following: - licensed nurse will notify the dining services department of food allergies upon admission and prior to any meals served. - Dining Services Director or designee will interview the resident/representative to complete a Food Preference Interview within 48 hours (two days) of admission. - Food Preference Interview will be entered into the medical record. -Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile menu management software system. - individual tray assembly ticket will…

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 review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three stand up refrigerators and one of one dry storage areas reviewed in the kitchen. Findings include: Review of facility policy entitled Food Receiving and Storage dated 1/16/24, indicated Dry foods that are stored . labeled and dated use by date. Such foods are rotated using a first in first out system and Refrigerated foods are labeled dated and monitored so they are used by their use by date, frozen or discarded. Observation during kitchen tour on 1/23/24, at 11:35 a.m. revealed an open half used container of parsley flakes with an open date of 11/9/21, a use by date of 11/9/23, and a manufacturer best by date of 9/19/22. Further observations revealed three unshelled hardboiled eggs in the refrigerator with a use by date of 1/22/23, and ten cans of tomato soup with a manufacturer's expiration date of 1/17/24. During an interview with the Dietary Manager on 1/23/24, at 11:43 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 24 residents reviewed (Residents R29 and R73). Findings include: Review of facility policy dated 1/16/24, entitled, Resident Participation - Assessment/Care Plan indicated: - the resident and his or her representative have the right to participate in the development and implementation of his or her care plan. - the resident and his/her legal representative are encouraged to attend and participate in development of the resident's person-centered care plan. - the care planning process will facilitate the inclusion of the resident and/or representative. - a seven (7) day advance notice of the care planning conference is provided to the resident and/or representative - the Social Services Director or designee is responsible…

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for two of 24 residents reviewed (Residents R8 and R19). Findings include: Review of facility policy entitled Bed holds and Returns dated 1/16/24, indicated that All residents/representatives are provided written information regarding the facility and state bed-hold policies . regardless of payor source . at the time of transfer . Review of Resident R8's clinical record revealed an initial admission date of 9/8/23, with diagnoses that included osteomyelitis (an infection in the bone), diabetes (a disease that cause high blood sugars due to the body not releasing enough insulin), and hypertension (high blood pressure). Review of Resident R8's clinical record revealed progress notes dated 9/26/23, at 6:05 p.m. and 12/1/23, at 3:16 p.m. indicating transfers…

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans timely and to reflect the current necessary care and services for one of 24 residents reviewed (Resident R66). Findings include: Review of facility policy entitled Care Plans,Comprehensive Person-Centered dated 1/16/24, indicated that the care plan is reviewed and updated with clinical changes. Review of Resident R66's clinical record revealed an admission date of 11/2/21, with diagnoses that included dementia (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), dysphagia (difficulty swallowing), pain and weakness. Review of Resident R66's nutrional care plan revealed that the diet was a regular diet/ mechanical soft texture with a revision date of 11/20/23. The care plan also identified that the last review or revision date was 1/24/24. Review of Resident R66's physcian's orders dated 11/17/23, revealed an order for a regular diet mechanical soft,…

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 review of facility policy and clinical records, observation, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R286). Findings include: Review of a facility policy dated 1/16/24, entitled, Oxygen Administration indicated to verify that there is a physician's order for procedure. Resident R286's clinical record revealed an admission date of 1/15/24, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), fractured hip, and hypertension (high blood pressure). Observations on 1/23/24, at 2:10 p.m. and on 1/26/24 at 8:38 a.m. revealed Resident R286 wearing an oxygen nasal canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 3 liters per minute (lpm - 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement all safety measures related to following all care planned fall precautions for one of eight residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Perineal [area of the pelvic cavity where incontinence care is provided] Care Policy revealed that the first step by staff is to review a resident's care plan for any special needs of the resident. Review of Resident R1's clinical record revealed an admission date of 11/09/23, with diagnoses that included age related osteoporosis (condition of bone deterioriation), general weakness, pain, and abnormal walking. Resident R1's Minimum Data Set (MDS-periodic assessment of resident care needs), dated 10/31/23, indicated that Resident R1 is dependent on staff for daily functions such as toileting, hygiene and bathing/washing self. Review of Resident R1's care plan for risk for falls initiated on 11/11/23, revealed the intervention to provide extensive assist of two staff…

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