White Oak At North Grove Inc

Based on observation, interview, and facility policy review, the facility failed to keep food scoops, food preparation and service pans, a kitchen drawer, and a kitchen shelf clean. The facility also failed to discard lettuce that had signs of spoilage and failed to cover or date food that was stored in the kitchen's refrigeration and freezer units. These failures had the potential to create an environment for food-borne illnesses which could affect 128 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation/Infection Control, dated 08/2010, specified, . Policy: Clean equipment and utensils will be handled in a manner to prevent contamination . 2. Cleaned and sanitized equipment and utensils shall be stored in a clean, dry location in a manner to protect them from splashes or dust . Review of the facility's policy titled, Storage of Food and Supplies, dated 08/2010, specified, Purpose: To ensure foods and supplies are stored appropriately to maintain wholesomeness and meet regulatory requirements . 5.…

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, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience which included timely meal service and eating meals at the same time as tablemates for two of two residents (Resident (R) 67, and R78) reviewed for dignity in dining out of a total sample of 32. This failure had the potential to cause R67 and R78 to feel less dignified. Findings include: Review of the facility's policy titled, Meal Delivery Service, dated 09/12/16, indicated, Considerations for Optimal Meal Service and Delivery Desired Components . Guidelines For an Orderly and Timely Meal Delivery System: . III. Supervision: . E. All residents must be at the table when meal delivery begins. Trays should be served by tables . Review of R67's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located in the electronic medical record (EMR) under the MDS 3.0 Assessments tab, revealed the resident had problems with short-term memory and long-term memory. Review of R78's quarterly MDS, with an ARD of 03/12/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to administer oxygen as ordered by the physician for one of two residents (Resident (R) 23) out of a total sample of 32. This failure had the potential for R23 to experience adverse reactions by not receiving the prescribed oxygen concentration. Findings include: Review of the facility's undated policy titled, Oxygen Therapy indicated, . To administer oxygen in conditions in which insufficient oxygen is carried by the blood stream . The policy did not indicate to administer the oxygen by physician's orders. Review of the facility's policy Comprehensive Team Care Planning, dated 01/09/12, indicated . Specific, individualized steps or approaches that staff will take to assist the resident to achieve the goals. These approaches serve as instructions for resident care and provide for continuity of care by all staff . Review of R23's Face Sheet, located under the Resident tab in the electronic medical record (EMR), indicated R23 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 interview, record review, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer pneumococcal vaccinations per CDC recommendations for two of five residents (Residents (R)14 and R31) reviewed for immunizations out of a total sample of 32. This failure had the potential to place the residents at increased risk of pneumonia. Findings include: Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] 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 observations, interviews, and review of the facility policy, the facility failed to correctly label, date, and remove expired foods for 2 of 6 kitchens reviewed for storage and sanitization. Findings include: Review of the facility policy titled, Storage of Food and Supplies with a revision date of 12/05/17 states, Food and supplies are received and checked for accuracy, damage, and appropriate temperature. Non - Time/Temperature Control for Safety (TCS) foods should be dated when opened and may be used until the expiration or use-by manufacturer's date. TCS foods should be discarded by the use-by or manufacturer's expiration date. During an initial tour of the kitchen on 06/25/24 at 1:19 PM, revealed an opened and undated jar of minced garlic, a 12-pack of opened hamburger buns with no open date, with an expiration date of 06/22/24. There were also six bags of 12-count Ballpark hot dog buns noted with an expiration date of 06/21/24. A bottle of caramel sauce was noted to be opened and undated. During an observation of the dry storage area revealed, 13 - 4-ounce cups 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 observations, interviews, record reviews, and review of Facility Policy, the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of infections and communicable diseases. Specifically, the facility failed to: 1. Ensure that during dining services, staff wore gloves instead of using bare hands to grab and serve baked potatoes to residents. 2. Ensure that during laundry services, the laundry attendant (LA) did not contaminate a clean linen cart while wearing soiled personal protective equipment (PPE) and ensure that the laundry attendant removed PPE without contaminating herself with the dirty gown. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program revised on 06/23/17 revealed, Infection Prevention, 6). Proper hand hygiene is the single most important way to decrease the risk of infection and cross contamination. Review of the facility's undated policy titled Infection Prevention and Control Program…

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 Review of the facility's policy titled Comprehensive Team Care Planning revision date 01/09/12 revealed, Residents and/or their designated representatives are encouraged to participate in the development of their plan of care. Each resident will be invited by the Social Services Department to participate to the extent practicable or designate a representative to participate on his behalf. If a resident is unable due to mental or physical impairment, the resident ' s representative must be afforded the opportunity to represent the resident. An explanation must be included in the resident ' s medical record if the participation of the resident and his resident representative is determined not practicable for the development of the resident Care Plan . Review of R69's Face sheet dated June 2024 revealed R69 was admitted to the facility with diagnoses including, but not limited to, muscle weakness, ataxic gait, atrial fibrillation, hypoxemia, polyneuropathy, diastolic congestive heart failure, edema, type 2 diabetes…

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 the facility procedure for Advanced Beneficiary Notice, record reviews, and interviews, the facility failed to provide the correct form for notice of financial liability. The form CMS-10055 was not issued to Resident #112 (R112) notifying them of full financial responsibility for 1 of 3 residents reviewed for advance beneficiary notice. Review of the facility procedure titled, Skilled Nursing Facility Advance Beneficiary Notice, states: Providers are requires to give a notice of financial liability anytime a Medicare beneficiary is or will be receiving a service, normally covered by Medicare, but which the Provider believes is not (a) medically necessary or (b) is custodial care. This notice allows the beneficiary to make a choice about receiving the service with the knowledge the Medicare, probably, will not pay and the full financial liability will be theirs. The Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN{CMS-10055}) is the form used to issue the notice to the beneficiary. The SNF-ABN will be issued: 1. When a resident is coming off a Medicare Part A stay,…

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 facility policy, record reviews and interviews, the facility failed to ensure Resident #62 (R62) and Resident #46 (R46) and/or their personal representative received the Bed Hold Policy which specifies the duration of the bed hold and the bed hold amount in a timely manner for 2 of 2 residents reviewed for hospitalization. Review on 06/27/2024 at 02:43 PM of the facility policy titled, Bed Hold Policy, A medicaid resident cannot pay to hold a bed prior to admission. Medicaid will pay up to 10 days to hold a bed only if the resident is hospitalized . The resident continues to pay the recurring income during the ten day bed hold. A medicaid resident can pay to hold a bed following this 10 day period by making prior arrangements with the Business Office or Social Worker. Medicaid residents that are not readmitted from the hospital within 10 days and choose not to hold the bed will be readmitted to the facility immediately upon the first available bed in a semi private room. All other conditions of admission must be satisfied. The Bed Hold Policy did not include the bed hold…

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

Based on interview, observation, record review, and review of facility policy, the facility failed to provide needed care and services consistent with the professional standards of practice for 2 of 2 (Residents (R)10 and R26) reviewed for dressing changes, Specifically R10 was observed on multiple occasions without appropriate labeling on her foam dressing and R26 was observed without appropriate labeling on her tube feed dressing. Findings include: Review of the facility's policy titled, Dressing-Nonsterile last revised 08/04 states, To protect wound from contamination and/or injury, furthermore, it states under Key Points Date and initial dressing. During observations on 06/25/24 at 4:34 PM, 06/26/24 at 11:29 AM, and 06/27/24 at 11:09 AM, R10's left lateral foot dressing was observed without a label (date/initials). During observations on 06/25/24 at 1:40 PM, 06/26/24 at 11:35 AM, and 06/27/24 at 11:13 AM, R26's tube feed dressing was observed without a label (date/initials). Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/24…

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 observation, interview, and record review, the facility failed to ensure medications were safely stored. Specifically, Resident (R)69's medications were left at the resident's bedside. Findings include: Review of R69's Face Sheet revealed, R69 was admitted to the facility with diagnoses including, but not limited to, muscle weakness, ataxic gait, atrial fibrillation, hypoxemia, polyneuropathy, diastolic congestive heart failure, edema, Type 2 Diabetes Mellitus, venous insufficiency, hyperlipidemia, lymphedema, and acute kidney failure. Review of R69's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R69 was cognitively intact. During an observation on 06/27/24 at 12:40 PM, revealed two medication cups on R69's bed, with a white cream in them and a pair of non-latex gloves noted on the resident's bed beside the medication cups. During an observation on 06/27/24 at 1:07 PM, the two medication cups containing a white cream, in a ribbon pattern, were still…

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 interviews, record reviews, and review of facility policies, the facility failed to ensure the right to be free from restraints was exercised for one of one resident (Resident (R) 62) reviewed for restraints. Specifically, staff physically restrained (restrict freedom of movement) R62 to obtain nasal swab for COVID-19 test after R62 refused the procedure. The facility's deficient practice had potential to inflict mental anguish and/or physical harm to R62. Findings include: Review of facility-provided policy titled Physical Devices/ Restraints dated 12/10 revealed PHYSCIAL RESTRAINTS-Any manual method . to the resident's body that . restricts freedom of movement . [of] one's own body . Residents have the right to be free of restraints . restraints must have a physician order . RISK FACTORS RELATED TO RESTRAINT USEAGE . Accidents Agitation/delirium Confusion . Dignity issues . Review of facility-provided policy titled, NEGLECT, ABUSE, MISTREATMENT, THREATENED OR ALLEGED ABUSE OF RESIDENTS dated 08/16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policies, the facility failed to ensure one of one resident (Resident (R) 62) reviewed for abuse were protected during the facility's investigation of an allegation of abuse. Specifically, the facility failed to ensure the staff (perpetrators) were suspended pending outcome of R62's facility investigation for allegation of abuse. The facility deficient practice had potential for R62 to suffer alleged abuse to include mental anguish and/or physical harm. Findings include: Review of facility-provided policy titled, NEGLECT, ABUSE, MISTREATMENT, THREATENED OR ALLEGED ABUSE OF RESIDENTS dated 08/16 revealed, .It is the policy . that all residents have the right to be free from verbal, sexual physical, mental, and emotional abuse: . Resident must not be subjected to abuse by anyone including but not limited to, facility, staff other residents, consultants contractors, volunteers, staff of other agencies serving the individual, family members or legal…

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, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code hospice services on the Minimum Data Set (MDS) assessment for one of one residents (Resident (R) 81) reviewed for hospice services. Findings include: Review of the October 2019 Resident Assessment Instrument manual, page 0-5, showed: . Hospice care . Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. Review of R81's admission Record, located under the electronic medical record (EMR) Profile tab, showed a facility admission date of 05/15/17 with medical diagnoses that included COVID-19, unspecified protein calorie malnutrition, and unspecified Dementia (memory disorder). Review of the facility's resident matrix (a form that shows different services/diagnoses for the current…

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.