The Oaks at Radford Hills Healthcare Center

Based on interviews and record review the facility failed to promptly resolve grievances for 12 of 12 confidential residents reviewed for grievances. The facility did not ensure grievance concerns voiced in a Resident Council meeting were addressed or that a resolution had been communicated back to 12 of 12 confidential residents. This deficient practice could place the residents at risk of unresolved grievances and a decreased quality of life. The findings included: During a confidential interview on 11/19/2024 at 10:00 a.m., 12 of 12 confidential residents stated they did know how to file a grievance. They stated the AD wrote down grievances voiced in the Resident Council meetings, but the Resident Council members did not get told the facility's responses to their grievances. They stated they felt that management of the facility did address some of their concerns but not all of them. 1 of 12 confidential residents stated they no longer came to Resident Council meetings because they felt it did not do any good and nothing changed in the facility. Record review of Resident Council…

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 and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #6, Resident #30, Resident #68, and Resident #43) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of nebulized breathing treatments for Resident #6. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of oxygen therapy for Resident #30. The facility failed to develop a comprehensive care plan based on the assessed needs with measurable objectives and timeframes in area of care needs with a resident who required trach maintenance and care for Resident #68. 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 observations, interviews, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, and residents' choices during a confidential meeting for 12 of 12 residents reviewed for quality of care. The facility failed to ensure that licensed staff were not withheld resident wipes, which led to the staff having to use paper towels and toilet paper for resident care. This failure could put residents at risk of being unclean and skin sheer during direct resident care. Findings included: During an observation on 11/18/2024 at 10:00 AM, cases of resident wipes were being stored in the DON's office. The supply closets on Hall C and E were observed to have no wipes available. During an interview on 11/18/2024 at 10:00 AM, CNA-C stated the wipes were kept in the DON's office with only a few kept on one or two hall carts. She stated the DON locked them in her office storage closet. During an observation on 11/18/2024 at 10:09 PM there were no wipes on the linen carts of Halls D, E, F with only half 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 3 of 18 residents (Resident #30, Resident #37, and Resident #54) reviewed for sufficient staffing The facility failed to ensure the facility had sufficient staffing based off facility assessment. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. The findings include: Record review of Resident #30's electronic face sheet dated 11/20/2024 revealed Resident #30 was a [AGE] year-old female admitted into facility on 10/18/2022 with diagnoses to include: fracture of left patella (left knee fracture), schizoaffective disorder bipolar type (a mental health…

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 and record review, the facility failed to ensure drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #30) reviewed for (DRR) Drug Regimen Review. The facility failed to have record of Resident #30's medication regimen review for anti-psychotic medication since last survey on 10/19/2023. This failure could place resident as risk of not having their medications reviewed by pharmacy consultants for appropriate doses or pharmacy recommendations implemented. The findings included: Record review of Resident #30's electronic face sheet dated 11/20/2024 revealed Resident #30 was a [AGE] year-old female admitted into facility on 10/18/2022 with diagnoses to include: fracture of left patella (left knee fracture), schizoaffective disorder bipolar type (a mental health condition with a combination of symptoms including hallucinations, delusions, mania,…

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 that the menu was followed for the lunch meal on 11/18/24 and the supper menu on 11/19/24 for 2 of 2 meals (the lunch service on 11/18/24 and the supper service on 11/19/24) reviewed for nutritional adequacy. The facility did not serve the lunch menu posted for Monday 11/18/24, but instead served the lunch menu posted for Tuesday 11/19/24 and did not inform the residents that the menu would be switched. The facility did not follow the supper menu for Tuesday 11/19/24 and did not inform the residents that a substitute would be served. These failures could affect all residents who ate food from the kitchen by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Review of the weekly menu week 4 Monday lunch revealed roast pork, black-eyed peas, stewed okra and tomatoes, cornbread, and peanut butter pie. Further review of the weekly menu week 4 Tuesday lunch revealed Swiss steak, mashed potatoes, green peas, a garlic cheese biscuit, 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 observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation of the freezer on 11/18/24 at 09:40 AM, revealed what the DM identified as 6 pork loins, 8 loafs of bread, 1 turkey pot roast, and 4 bags of tatter tots out of original boxes with no labels and no open dates. During an interview on 11/18/24 at 09:45 AM, the DM stated all food should have been labeled with what they were, when they expired, and when they were received. She stated not having food labeled could lead to serving expired food which could cause illness. During an observation of meal preparation on 11/18/24 from 11:15…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (CNA-B, CNA-C and CNA-D) staff observed during incontinent care. The facility failed to ensure CNA B, CNA C, and CNA D performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #23 and Resident #12. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care. Findings included: Resident #23 Record Review of the Resident #23's Face Sheet dated 11/19/2024, revealed he was a [AGE] year-old male. His original admission to the facility was on 2/08/2022 with his most recent admission on [DATE]. Resident #23 had a diagnosis of Cerebral Infarction (stroke), and non-pressure chronic ulcer of…

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

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure effective communication training was completed by the DON and CNA B during orientation. The facility did not ensure effective communication training was completed by RN I and LVN F annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the employee files revealed no evidence that the following staff had completed effective communications training during orientation: DON hire date 6/24/2024 CNA B hire date 11/11/2024 Record reviews of the employees' files revealed no evidence the following staff had completed effective communications training annually: RN I hire date 9/27/2022 LVN F hire date 2/22/2023 During an interview on 11/18/2024 at 11:56 a.m., CNA B stated she had filled out hiring paperwork on the orientation app 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.

Based on interview and record review, the facility failed to ensure employees received the required training on resident rights mandatory training for 2 of 16 employees (RN I and LVN F) reviewed for training requirements in that: The facility did not ensure resident rights training was completed by RN I and LVN F annually. This failure could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record reviews of the employees' files revealed no evidence the following staff had completed resident rights training annually: o RN I hire date 9/27/2022 o LVN F hire date 2/22/2023 During an interview on 11/20/2024 at 6:16 p.m., the CHRL stated RN I and LVN F did not complete annual resident rights training. She stated each department head is responsible for making sure their staff have received all the required training. She stated there was a combination team work to monitor training performed due to HR cannot perform certain educational trainings. She stated Ultimately the ADMN should hold supervisors responsible for their 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.

Based on interview and record review, the facility failed to ensure employees received the required training on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (RN I and LVN F) of 19 employees reviewed for staff training. The facility did not ensure abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting training was completed by RN I and LVN F annually. These failure could place the residents at risk of abuse, neglect, exploitation, and misappropriation. The findings included: Record reviews of the employees' files revealed no evidence the following staff had completed activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management training annually: o RN I hire 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 interview and record review, the facility failed to ensure employees received the required training an infection prevention and control program mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure an infection prevention and control program training was completed by the DON and CNA B during orientation. The facility did not ensure an infection prevention and control program training was completed by RN I and LVN F annually. These failure could affect residents and place them at risk of poor care or infections due to lack of staff training. Findings included: Record review of the employee files revealed no evidence that the following staff had completed an infection prevention and control program training during orientation: DON hire date 6/24/2024 CNA B hire date 11/11/2024 Record reviews of the employees' files revealed no evidence the following staff had completed an infection prevention and control program training annually: RN I hire date 9/27/2022 LVN F hire date 2/22/2023 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.

Based on interview and record review, the facility failed to ensure employees received the required training on compliance and ethics mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure compliance and ethics training was completed by the DON and CNA B during orientation. The facility did not ensure compliance and ethics training was completed by RN I and LVN F annually. These failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of the employee files revealed no evidence that the following staff had completed compliance and ethics training during orientation: DON hire date 6/24/2024 CNA B hire date 11/11/2024 Record reviews of the employees' files revealed no evidence the following staff had completed compliance and ethics training annually: RN I hire date 9/27/2022 LVN F hire date 2/22/2023 During an interview on 11/18/2024 at 11:56 a.m., CNA B stated she had filled out hiring paperwork on the orientation app but had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure before a resident was transferred or discharged that the facility notified the resident's guardian of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #54) reviewed for transfer or discharge. The facility failed to provide Resident #54 ' s guardian written notice of the resident ' s transfer before Resident #54 was transferred to Facility B on 11/29/2024. The facility failure could affect residents who were discharged from the facility and could place them at risk of having their discharge rights violated. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #59 had diagnoses which included hypertensive heart disease, hypertension,…

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 review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure CNA B documented the accurate dinner meal intake for Resident #1. These failures could place residents at risk of weight loss and a decline in health status. Findings included: Record review of Resident #1's Face Sheet revealed she was a [AGE] year-old female who was admitted on [DATE], with the following diagnoses: epilepsy (a condition associated with abnormal electrical activity in the brain that is marked by convulsions episodes of sensory disturbance, or loss of consciousness, hypertension (high blood pressure), and schizoaffective disorder ( a mental disorder that includes symptoms of schizophrenia such as delusions, and of mood disorders such as high and low mood swings). Record review of Resident #1's OSA MDS with an ARD date of 8/7/24 documented her BIMS score was 00,…

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, and record review the facility failed to inform the resident representative of a significant change in the residents' physical status and the need to significantly alter the resident's treatment for 1 of 3 residents (Resident #1) reviewed for notification. The facility failed to notify Resident #1's representative of hospital transfer on 09/16/2024 resulting in resident not having an advocate the make decisions at the hospital. This failure could affect residents by placing them at risk for not having an advocate, delay in medical treatment, or decline in health. The findings included: Review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with latest return on 09/19/2024 from hospital with diagnoses to include: diabetes, amputation of left leg, and altered status. Further review of face sheet revealed Resident #1's representative and responsible party was an assigned legal guardian. Review of Resident #1's Quarterly MDS assessment…

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 record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 4 residents' rooms reviewed for homelike environment, in that: 1. Resident #2's bathroom tile was discolored and covered in multiple dried, dark brown stains, toilet base caulking and tile grout lines were covered in a dark black substance, and the cove base around the wall and floor between the toilet and inside wall had an indention and had pulled away from the wall, which exposed the drywall. Resident #2's floor in his room was wet and stained with dark streaks; a piece of toilet paper was observed on the floor with a wet, brown substance, and Resident #2's oxygen machine had a dried liquid stain that ran down the front of the machine and several dried splatter spots. 2. Resident #6's bathroom tile around the base of the toilet was broken, cracked, and exposed the bare floor. The toilet base that was caulked to the floor was cracked and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 7/3/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include osteomyelitis (inflammation or swelling that occurs in the bone), shortness of breath, type 2 diabetes mellitus, and hypertension. Record Review of Resident #1's Against…

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 develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 3 residents (Residents #1) reviewed for care plans as follows: Resident #1 did not have a care plan for going out on pass for personal needs. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Record review of Resident #1's face sheet, dated 5/2/24, reflected a [AGE] year-old male with an admission date of 2/15/24. Resident #1 had a diagnosis which included respiratory failure, unsteadiness on feet, and lack of coordination. Record review of Resident #1's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. Record review of Resident #1's Care Plan dated 4/30/24 indicated Resident #1 does not show any plan for going out on pass for personal needs. Record review of facilities release 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure orders were provided for the resident's immediate care and needs for 1 of 3 residents (Resident #1) reviewed. The facility failed to ensure a physician order was put in-place/received to allow Resident #1 to go out on pass daily. This failure had the potential to place residents at risk of not having their medical care supervised. Findings included: Record review of Resident #1's face sheet, dated 5/2/24, reflected a [AGE] year-old male with an admission date of 2/15/24. Resident #1 had a diagnosis which included respiratory failure, unsteadiness on feet, and lack of coordination. Record review of Resident #1's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. Record review of Resident #1's Orders indicated Resident #1 does not show any orders from the physician to allow Resident #1 to go out on pass daily. Record review of facilities release of responsibility for leave 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 (Resident #2 and Resident #4) of 10 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. The facility failed to ensure that Resident #4 had a baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 03/05/2024 with diagnoses to include: repeated falls, muscle weakness, anxiety, and depression. Review of Resident #2's Quarterly MDS assessment, dated 03/20/2024, revealed BIMS score (09) which indicated moderate cognitive impairment. Review…

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 and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #2 and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of risk for falls for Resident #2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of risk for falls for Resident #3. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 03/05/2024 with diagnoses 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 interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 2 (Resident #1 and Resident #2) out of 2 residents reviewed for administration of medications and maintaining a central line. The facility failed to ensure LVN A had the knowledge and skills to provide nursing services to 2 residents (Resident #1 and Resident #2) receiving intravenous medications. This failure could place residents at risk for worsening or spread of infection that could impact level function and/or physical health and well-being. Findings included: Record review of Resident #1's Face Sheet revealed the resident was admitted on [DATE] with the following diagnoses: metabolic encephalopathy (a chemical imbalance in the blood that affects the brain) , high blood pressure, candida stomatitis (a fungal…

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 and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to wear hair net during meal preparations. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures placed residents at risk for food borne illness and cross-contamination. Findings included: During an observation on 10/17/2023 at 9:53 a.m. of the dry storage pantry revealed: 1 unsealed bag of a 24 oz Pink Lemonade Drink Mix with no open date. 1 10 oz container of Parsley Flakes with an expiration date of 05/22/2023, and 1 12 oz container of Poultry Seasoning with an expired date of 09/06/2023. During an observation on 10/17/2023 at 9:39 a.m. of the Refrigerator revealed: 1 large clear plastic container of what appeared to be Jell-O, not labeled, or dated. 1 clear plastic sealed package of what appeared to be bologna. 1 clear…

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 interviews and record reviews, the facility failed to implement and maintain an effective training program for all new and existing staff for 9 of 15 (ADMIN, DON, SW E, DM, RN F, LVN G, LVN H, LVN J, HSK K) personnel files reviewed for training. 1. The facility failed to train for Communications for SW E, DM, RN-F, LVN-SM, LVN-HP, and HSK K. 2. The facility failed to train for Resident Rights for SW E, DM, RN F, LVN G, and HSK K. 3. The facility failed to train for Infection Control for SW E and DM. 4. The facility failed to train for Compliance and Ethics for SW E and DM. 5. The facility failed to train for HIV either during orientation or annually for DON, DM, RN F, LVN G, LVN J, and HSK K. 6. The facility failed to train for Restrain Reduction during orientation or annually for ADMIN, DON, DM, RN F, LVN G, LVN H, LVN J, and HSK K. 7. The facility failed to train for Prevention of Falls during orientation or annually for DM, RN F, LVN G, and HSK K. 8. The facility failed to train for Dementia during orientation or annually for DON, RN F, LVN G, and HSK K. These failures…

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 interviews and record reviews, the facility failed to implement and maintain an effective communications training program for all new and existing staff for 6 of 15 (SW E, DM, RN F, LVN G, LVN J, and HSK K) personnel files reviewed for training. The facility failed to train for Communications for SW E, DM, RN F, LVN-G, LVN J, and HSK K. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: SW E-Hire date of 10/13/2023 - Had no Communications training. DM- Hire date of 09/22/2023 - Had no Communication training. RN F-Hire date of 9/27/2022 - Had no Communication training. LVN G-Hire date of 12/07/2021 - Had no Communications training. LVN J-Hire date of 5/18/2023 - Had no Communications training. HSK K-Hire date of 12/08/2021 - Had no Communications training. During an interview on 10/19/2023 at 3:30 p.m. with HR M, she said she had not been with the facility for long and she had some difficulties getting some of the salary employee's information. She said the personnel files had been 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 interviews and record reviews, the facility failed to implement and maintain an effective Resident Rights and Facility Responsibilities training program for all new and existing staff for 5 of 15 (SW E, DM, RN F, LVN G, and HSK K) personnel files reviewed for training. The facility failed to train for Resident Rights for SW E, DM, RN F, LVN G, and HSK K. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: SW E-Hire date of 10/13/2023-had no Resident Rights training. DM- Hire date of 09/22/2023- had no Resident Rights training. RN F-Hire date of 9/27/2022 - had no Resident Rights training. LVN G-Hire date of 12/07/2021- had no Resident Rights training. HSK K-Hire date of 12/08/2021- had no Resident Rights training. During an interview on 10/19/2023 at 3:30 p.m. with HR M, she said she had not been with the facility for long and she had some difficulties getting some of the salary employee's information. She said the personnel files had been a mess when she started, and she worked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #64) of one resident reviewed for person-centered plans of care. The facility failed to include Resident #64 in her Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care. The findings included: Record review of Resident #64's face sheet, dated 10/19/2023, revealed Resident #64 was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side (weakness or inability to move extremities after a stroke), Major depressive disorder (mood disorder that can cause feeling of sadness and loss of interest), Muscle weakness, Unsteadiness on feet, Lack of coordination, and Generalized anxiety disorder. Record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to transmit an MDS for 1 of 3 (Resident #13) residents reviewed for closed records. Facility failed to transmit a Discharge MDS for Resident #13 on 6/08/2023. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: Record review of Resident #13's Face sheet dated 10/19/2023 revealed an [AGE] year-old male who admitted to the facility on [DATE] and discharged on 06/08/2023 to another SNF. Record review of Discharge MDS dated [DATE] revealed it was complete but never submitted. During an interview on 10/19/2023 at 1:30 p.m., with MDS, she said she started the first of June 2023 and was unaware that there was a finalized button that needed to be checked in the computer system to submit an MDS. She said she had since learned that she needed to check the finalized button in the computer system to submit an MDS. MDS said things were a mess when she…

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 interviews and record reviews, the facility failed to implement and maintain an effective Infection Control training program for all new and existing staff for 2 of 15 (SW E and DM) personnel files reviewed for training. The facility failed to train for Infection Control for SW E and the DM. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: SW E-Hire date of 10/13/2023-Had no Infection Control training. DM- hired 09/22/2023- Had no Infection Control training. During an interview on 10/19/2023 at 3:30 p.m. with HR M, she said she had not been with the facility for long and she had some difficulties getting some of the salary employee's information. She said the personnel files had been a mess when she started, and she worked had been working on them. HR M said staff did not do orientation prior to working on the floor, they usually waited for a group to do the orientation. She could not identify how long from hire to orientation would entail. During an interview on 10/19/2023 at 4:30…

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 interviews and record reviews, the facility failed to implement and maintain an effective Compliance and Ethics training program for all new and existing staff for 9 of 15 (SW E, DM) personnel files reviewed for training. The facility failed to train for Compliance and Ethics for SW E and the DM. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: SW E-Hire date of 10/13/2023-had no Compliance & Ethics training. DM- hired 09/22/2023- had no Compliance & Ethics training. During an interview on 10/19/2023 at 3:30 p.m. with HR M, she said she had not been with the facility for long and she had some difficulties getting some of the salary employee's information. She said the personnel files had been a mess when she started, and she worked had been working on them. HR M said staff did not do orientation prior to working on the floor, they usually waited for a group to do the orientation. She could not identify how long from hire to orientation would entail. During an interview on 10/19/2023…

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 record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 6 residents (Resident #1, and Resident #2) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #1 and Resident #2 with respect and dignity while removing care products from their personal space. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Review of Resident # 1's face sheet dated 08/31/2023 revealed [AGE] year-old male admitted on [DATE], with the following diagnosis: epilepsy, depressive disorder, and vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes) Review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderately impaired).…

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.