Opus Post Acute Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility neglected the needs of Resident (R)1 by failing to ensure the resident had access to their call light, after a Certified Nursing Assistant (CNA) removed the call light from the resident's reach for 1 of 1 resident reviewed.Findings include: Review of the facility policy titled Prevention of and Prohibition Against Abuse, with a revision date of 12/2023, indicated the facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle weakness, cognitive communication deficit, hypertension, lack of coordination, need for assistance with personal care, and abnormalities of gait and mobility. Review of R1's quarterly Minimum Data Set (MDS) with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to promote a homelike dining experience. Specifically, the facility failed to ensure staff did not stand to assist residents with the meals for one (1) of one (1) dependent resident (Resident (R)8). Additionally, the facility failed to remove the plated food, eating utensils, and drinks from the serving tray onto the table for three (3) of three (3) residents that dined communally (R1, R2, and R9). Findings include: Review of the facility's policy titled, Resident Rights revised on 10/2015 revealed, . It is the policy of this facility that all residents be treated with kindness, dignity and respect. During a dining observation and interview on 04/15/25 at 12:20 PM, R1, R2, and R9 dined communally in the main dining room, where they all ate directly from the tray the meals were served on. R9 stated, They don't move the tray. During an interview on 04/16/25 at 3:17 PM, the Director of Nursing (DON) confirmed the staff did not…

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, observation, record review and interview, the facility failed to ensure call lights were within reach for 6 of 13 residents reviewed. Additionally, the facility failed to ensure that a resident wheelchair arms were not in need of repair, for 1 of 1 resident. Findings include: Review of the facility's Call Light/Bell policy, revised on 05/2007, revealed, . It is the policy of this facility to provide the resident a means of communication with nursing staff . Place the call device within resident's reach before leaving room. Review of R1's Electronic Medical Record (EMR) revealed R1 had an admission date of 08/29/24, with diagnoses including but not limited to: unspecified dementia, unspecified severity, with agitation, repeated fall, other sequelae of cerebral infraction, muscle weakness, restlessness and agitation. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicates R1 suffered from severe cognitive impairment.…

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 interviews the facility failed to ensure (1) the fall mat was in a position to prevent an accident for 1 of 5 residents reviewed, Resident (R)2. The facility also failed to ensure resident bathroom/shower room floors were not excessively slippery, for 4 of 5 residents reviewed, R3, R7, R10, R11. Additionally, (2) the facility failed to provide appropriate supervision for R1, resulting in R1 falling and suffering injuries, for 1 of 5 residents reviewed. Findings include: Review of the facility's Environment Conditions/Environmental Rounds, policy revised on 11/2019, revealed, . it is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public though monthly environmental rounds. (1) Review of R1's Electronic Medical Record (EMR) revealed R1 had an admission date of 08/29/24, with diagnoses including but not limited to: unspecified dementia, unspecified severity, with agitation, repeated fall, other sequelae of cerebral infraction, muscle weakness,…

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 assist or offer residents hand hygiene before and/or after meals for 4 of 4 residents. Additionally, the facility failed to ensure bath basins were labeled and cover for 3 of 4 residents. Findings include: Review of R2's Electronic Medical Record (EMR) revealed R2 had an admission date of 10/28/24, with diagnoses including but not limited to: unspecified sequelae of cerebral infarction, spinal stenosis, cervical region, and major depressive disorder, single episode. Review of R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicates R2 was moderately cognitively impaired. Review of R3's EMR revealed R3 had an admission date of 06/15/23, with diagnoses including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus with unspecified complications, major depressive disorder,…

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, interviews and review of the facility policy, the facility failed to ensure foods was labeled, stored, and discarded according to the expiration date, in 1 of 1 main kitchen. This failure had the potential to cause foodborne illnesses. Findings include: Review of the facility policy titled, Labeling and Dating of Foods dated 2020, documented All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . (EXCEPTION: Milk is to be used by its stamped expiration date.) During an initial tour of the kitchen on 11/24/24 at 10:10 AM, the dry storage revealed the following: - 25 lb bag of brown rice with no open date and no label. - 40 oz bag of Seasoned Homestyle Croutons with no open date and no label. - 10 oz bag of Puff Marshmallow opened with no label. - 5 lb bag of Spaghetti noodles opened with no expiration. - ¼ bag of Macaroni Noodles with 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 observation, interviews, record review and facility policy review, the facility failed to ensure a comfortable and homelike environment was provided for 2 residents, (Resident (R)56, R12), of 10 sampled residents whose rooms were reviewed. Finding include: Review of a facility policy titled, Environmental Conditions/Environmental Rounds with a revised dated of 11/19, revealed, It is the policy of this facility that the facility must provide a safe, functional, sanitary and comfortable environment for residents, staff and the public . residents rooms must be designed and equipped for adequate nursing care, comfort and privacy of residents. Review of R56's, Face Sheet revealed R56 was admitted to the facility with diagnoses including but not limited to: presence of chronic diastolic congestive heart failure, alcohol abuse, generalized anxiety disorder, major depressive disorder, hypertension, unspecified psychosis, chronic kidney disease stage 3A, unsteadiness on feet, weakness and need for assistance with personal care. During an observation and interview on 11/27/24 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 interviews, record review, and review of facility policy, the facility failed to provide services or care that are acceptable standards of practice. Specifically, the facility failed to obtain lab orders for a redraw, after an anticoagulant (Coumadin) adjustment for 1 (Resident (R)388's) of 1 resident reviewed for unnecessary medications. Findings include: Review of the facility policy titled Anticoagulation -Clinical Protocol last revised in November 2018, revealed, The physician will prescribe anticoagulation therapy (for example, low molecular weight heparin, warfarin, or other oral anticoagulant) appropriately, consistent with the recognized guidelines . The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR very closely while the individual is receiving warfarin, to ensure that the PT/INR [A prothrombin time (PT or PT/INR) test measures how quickly your blood clots.] stabilizes within a therapeutic…

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 review of facility policy, the facility failed to ensure 1 (Resident (R)78) of 1 resident reviewed for nutrition was provided nutritional supplements per physician orders to prevent potential nutritional problems or further weight loss. Findings include: Review of a facility policy titled Diet Orders states, Diet orders prescribed by the physician will be provided by the Food and Nutrition Services department. Nursing will send a Diet order Communication slip to the Food and Nutrition Services department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. The diet profile and tray card will be removed upon discharge or transfer. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with nursing. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE], with diagnoses including but not limited 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 observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 1 (Resident (R)140) of 5 residents reviewed for respiratory care, received the correct oxygen flow rate per the physician order. Findings include: Review of a facility policy titled, Oxygen Administration with a revision date of 05/2007, revealed that it is the policy of this facility that oxygen therapy is administered, as ordered by the physician, or as an emergency measure until the order can be obtained. Purpose: The purpose of oxygen therapy is to provide sufficient oxygen to the bloodstream and tissues. Review of R140's Face Sheet revealed that R140 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic systolic (congestive) heart failure, and nonrheumatic mitral (valve) insufficiency.…

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 the facility policy, observations and interviews, the facility failed to ensure that drugs and biologicals were properly stored in 2 of 5 treatment/medication carts. Findings include: Review of the facility policy, copyright 2014, titled, Medication Storage in the Healthcare Centers documents, Medications and biological are stored safely, securely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible to licensed nursing personnel and pharmacy personnel. Respiratory Therapist may access medications used in the provision of respiratory services . 3. Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts, routinely. Medication storage areas are to be kept clean, well-lit and free of clutter. Nursing staff who administer medications are responsible for the cleaning and organization of medication carts 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 facility policy review, record review, observations, and interviews, the facility failed to ensure respiratory equipment was maintained and stored appropriately for three of three residents (Resident (R) 245, R71, and R48) reviewed for respiratory care out of a total sample of 28 residents. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: Review of the facility's Oxygen Concentrator - Policy and Procedure, dated 04/2022, revealed It is the policy of this facility to provide oxygen in a safe and therapeutic manner using the oxygen concentrator equipment. 1. Review of R245's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed R245 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (low oxygen levels) and dependence on supplemental oxygen. Review of R245's admission Minimum Data Set (MDS) with an Assessment Reference Date…

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 the facility's policy, observation, and interviews, the facility failed to store ice cream in a kitchen freezer at zero degrees Fahrenheit (F) or lower. This had the potential to affect residents who consumed ice cream from the kitchen. Findings include: Review of the facility's policy, dated 2018 and titled, Procedure for Freezer Storage, specified, Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0 [degrees] F [Fahrenheit] or lower. Review of the monthly December 2022 and January 2023 temperature logs for the kitchen's chest freezer revealed daily temperatures that ranged from nine degrees F. to 12 degrees F. Further review of these temperature logs revealed the freezer temperature never measured at zero or below. Observations on 02/06/23 at 8:35 AM revealed the interior temperature of the kitchen's chest freezer was measured at ten degrees F. Ice cream was the only food observed stored inside this freezer. Review of the monthly February 2023 temperature log for this freezer revealed…

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 review, document review, and interviews, the facility failed to complete resident assessments (Minimum Data Set (MDS)) quarterly (every 3 months) for one (Resident (R) 66) of the 28 residents reviewed for Resident Assessment. Findings include: Review of the facility policy ''Resident Assessment,'' Revised in March of 2022, revealed PPS Assessments .1. The resident assessment coordination is responsible for the ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirement: .(2) Quarterly Assessments. Review of R66's electronic medical record (EMR) Census tab revealed an admission date of 03/16/22. Review of the EMR MDS tab revealed R66's last assessment was a comprehensive MDS assessment completed 09/15/22. The facility failed to perform the next quarterly assessment. During an interview with the Director of Nursing, DON, on 02/08/23 at 3:15 PM she stated, I am unsure why that assessment was missed, I will look into that. During an interview with the MDS Coordinators, (MDSC 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.