Oakmont Guest Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #40) reviewed for unnecessary medications. The facility failed to ensure Resident #40 had an appropriate diagnosis for her prescribed Seroquel (used to treat depression). This failure could place residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #40's admission Record, dated 04/10/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #40's Quarterly MDS Assessment, dated 03/24/25, reflected she had a BIMS score of 12 indicating no cognitive impairment. Her active diagnoses included cerebrovascular…

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 received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 5 residents (Resident #1) reviewed for foot care. The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Record review of Resident #1's Face Sheet, dated 11/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 10/30/24, reflected her diagnoses included cirrhosis (severe scarring) of liver, hypertension, pain, muscle weakness, and need for assistance with personal care. Resident #1 had a BIMS…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan addressed activities of daily living. This failure could place residents at risk of not receiving the care required to meet their individual needs. Findings included: Record review of Resident #1's Face Sheet, dated 11/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 10/30/24, reflected her diagnoses included cirrhosis (severe scarring) of liver, hypertension, pain, muscle weakness, and need for assistance with…

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 standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure DCH A wore a hair restraint while in the kitchen. 2. The facility failed to ensure foods stored in the walk-in cooler, walk-in freezer and dry storage area were properly sealed, labeled and dated. 3. The facility failed to ensure the walk-in cooler maintained an internal temperature below 41 Fahrenheit. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observations of the facility's kitchen on 10/30/24 from 11:19 AM and 11:58 AM revealed the following: - upon entrance, DCH A was observed rolling silverware, near prepared food. DCH A was observed with a hair net on the top half of his hair, the bottom of his hair was not restrained. - an open bag of spaghetti noodles was loosely wrapped in saran wrap in the kitchen's dry storage area. - three half…

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 notify the resident or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one (Resident #1) of three residents reviewed for discharge notices. The facility failed to notify Resident #1 or her representative in writing of her transfer/discharge to the hospital for behavioral reasons, the reason for the transfer, and the right to appeal and they failed to send a copy of the notice to the ombudsman as soon as practicable of the transfer/discharge. This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet, dated 09/04/24, reflected the resident was a [AGE] year-old female who…

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 resident rooms were equipped with privacy curtains the assured full visual privacy for 11 of 53 rooms (Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409) reviewed for visual privacy. 1. LVN C and CNA D failed to ensure Resident #2 had full visual privacy while providing care. 2. The facility failed to ensure the residents in the A beds in Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409 had privacy curtains to assure full visual privacy. This failure could place residents at risk of being exposed to the hallway during cares. Findings included: Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain chemical imbalance), muscle weakness, and reduced mobility. Review of Resident #2's quarterly MDS, dated [DATE]. revealed a BIMS score of 3 indicating severe cognitive…

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 maintain an infection control program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for 1 of 5 residents (Resident #1) reviewed for infection control. Housekeeper A picked popcorn off the floor and placed it back into Resident #1's bag and was subsequently eaten by Resident #1. This failure could place residents at risk of exposure to pathogens from the floor. The noncompliance was identified as PNC. The noncompliance began on 03/20/24 and ended on 03/21/24. The facility corrected the noncompliance before the survey began. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pelvic fracture, history of falls, and dementia. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 10 indicating mild cognitive impairment. 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.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 12 of 12 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 03/19/24 at 10:00 AM during a confidential resident group meeting with 12 residents, revealed the resident council meeting were held once a month in the dining room. The meeting was held in a TV room that was closed off to the staff and private. The residents stated normally the resident council meetings were being held in the dining room, which was an open space and no way to keep staff from walking by or overhearing. The resident further stated they really liked the privacy of the current meeting because they felt like they could speak freely without feeling like they were being overheard by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for 1 (Resident #45) of 16 residents reviewed for quality of care. The facility failed to obtain follow-up orders when Resident #45 returned to the facility from the hospital with a splint after she was diagnosed with an elbow fracture. The failure placed residents at risk of not receiving needed treatments to prevent conditions from worsening. Findings included: Review of Resident #45's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, hemiplegia (paralysis of one side of the body), respiratory failure, fracture of lower end of humerus, and acute cholecystitis (inflammation of the gallbladder). Resident #45 had a BIMS of 9, cognition moderately impaired, and was able to be understood and she understood others. Observation and interview on 03/18/24 at 12:40 PM…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #66) of 6 residents reviewed for care plans. 1. The facility failed to develop a care plan for Resident #66 that addressed her use of dentures. 2. The facility failed to update Resident #66's care plan to address changes in diet texture, weight loss, or health shakes at lunch and dinner. 3. The facility failed to develop a care plan that addressed Resident #66's need to have assistance for eating. 4. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #66, hospice services. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #66's face sheet reflected 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 observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #10 and Resident #66) reviewed for ADLs. The facility failed to ensure Resident #10, and Resident #66 had feeding assistance for more than 30 minutes after lunch trays were delivered to their rooms. This failure could place residents at risk for not receiving appropriate care, assistance when needed, and decreased quality of life. Findings included: Record review of Resident #10's face sheet reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses which included Huntington's Disease (progressive breakdown of nerve cells in the brain), Dementia, muscle weakness, lack of coordination, speech and language deficit, contracture of muscle in both left 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, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weigh or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 2 of 5 residents (Resident #66 and Resident #115) reviewed for nutrition status maintenance. 1.The facility failed to ensure Resident #66 had a heath shake with lunch and dinner. 2. The facility failed to measure and record Resident #115's body weight, as ordered by the resident's physician, for three weeks in November 2023. These failures could place residents at risk of weight loss, weight gain, nutritional deficit, and adverse health consequences. Findings included: 1. Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which…

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 that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #42) of 3 residents reviewed for dialysis. The facility failed to ensure dialysis assessments were completed for Resident #42 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #42's, face sheet reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE].Resident #42 had diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis). Record review of Resident #42's quarterly MDS assessment, dated 01/12/24, reflected a BIMS score of 9, which indicated his cognition was moderately impaired.The MDS…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (Hall 507-708 nurses' cart) and 4 of 4 Residents (Resident #43, #91, #93 and #102) reviewed for pharmacy services. 1.The facility failed to ensure the Hall 507-708 nurses medication cart contained accurate narcotic record for Residents #43 and #91. 2. The facility failed to ensure that Resident #93's Bengay Greaseless External Cream 10-15% (Menthol-Methyl Salicylate (Liniments) and one bottle of nicotine lozenges were stored properly. 3. The facility failed to ensure Resident #102 took her medications when they were administered, which resulted in the resident saving the medication in her room. This failure could place residents at risk for drug diversion, delay in medication administration and at risk 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 any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 2 of 5 residents (Resident #14 and #98) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility's Pharmacist Consultant recommended Residents #14 and #98 antipsychotic medication Quetiapine required an additional consent on the Form 3713 to be completed and uploaded to the resident's chart. These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Record review of Resident #14's face sheet dated 03/21/24 revealed the resident was a [AGE] year-old male who originally admitted to the facility 04/05/2023.The diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), delusional disorders and adjustment disorder with mixed disturbance 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, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one of 4 residents (Resident #66) reviewed for dental services. The facility failed to assist in providing dental services for Resident #66. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function is disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), Anemia (blood disorder), Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with…

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 1 (the lunch meal on 03/19/24) of 4 lunches reviewed for food and nutrition services. The facility failed to ensure the seven residents (Residents #9, #10, #46, #66, #75, #79, and #159) on a pureed diet were served pureed bread and pureed chicken fried steak during the lunch meal on 03/19/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. Findings included: Review of an undated list of residents served a pureed diet revealed the facility had a total of seven residents (Residents #9, #10, #46, #66, #75, #79, and #159) on a pureed diet. Review of the facility's menu for the lunch meal on 03/19/24 reflected country fired steak, cream gravy, garlic mashed potatoes, buttered carrots, dinner roll, cookies and cream mousse. Observation and interview on 03/19/24 at 11:00 AM revealed [NAME] Z was using a food processer to puree cooked chicken nuggets instead of chicken fried steak. [NAME] Z said since…

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety for 5 (Administrator, [NAME] Z, Dietary Aide X, Dietary Aide W, and Dietary Aide V) of 5 staff and 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. [NAME] Z placed food containers of the lunch meal in the steamtable that contained contaminated water. 2. The Administrator, Dietary Aide X, Dietary Aide W, and Dietary Aide V failed to wear a hair restraint while in the kitchen. These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1. In a continuous observation on 03/19/24 from 11:08 AM to 11:11 AM of the kitchen's steamtable revealed of the five compartments, the second compartment from the left side had a few inches of brown tinted water in it as well as food particles. [NAME] Z placed a tray of cooked mashed potatoes in the dirty steamtable compartment. [NAME] Z a tray 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 maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #115) of 5 residents reviewed for clinical records. 1. The facility failed to ensure staff accurately documented on Resident #115's October 2023 MAR that he received his medications. 2. The facility failed to ensure staff kept copies of Resident #115's shower sheets from September and October 2023. These failures could affect residents and place them at risk of inaccurate or incomplete clinical records. Findings included: 1. Review of Resident #115's face sheet, dated 03/21/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/26/23. His diagnoses included anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self induced behaviors towards thinness), major depressive…

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 each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of three meals (lunch on 03/19/24) reviewed for food and nutrition services. The facility failed to prepare food that conserved nutritive value and was at an appetizing taste and temperature for the lunch meal on 03/19/24. This deficient practice could place residents at risk of poor intake of nutrition, weight loss, and illness. Findings included: Review of an undated list of residents served a pureed diet revealed the facility had a total of seven residents on a pureed diet. Review of the facility's menu for the lunch meal on 03/19/24 reflected country fired steak, cream gravy, garlic mashed potatoes, buttered carrots, dinner roll, cookies and cream mousse. Review of the facility's pureed buttered carrots recipe card, dated 03/21/24, reflected the following: Step #2: Measure number of servings using the regular prepared recipe portion. Drain well to minimize…

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 parenteral fluids were administered consistent with professional standards for one (Resident #2) of three residents reviewed for intravenous fluids. 1. The facility failed to date and maintain the integrity of the PICC/CVC line dressing per professional standards for Resident #2. 2. The facility failed to ensure LVN C had training on IV administration and IV dressing changes. This failure could affect residents by placing them at risk for infections and cross-contamination. Findings included: Review of Resident #2's MDS assessment, dated 09/09/23, revealed the resident was admitted to the facility on [DATE], and she had severe cognitive impairement with a BIMS score of 7. The resident had diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and encephalopathy (a broad term for any brain diseases that alters brain function or structure). The MDS did not address the need for IV…

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 reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 (Resident #1) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #1's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #1's face sheet, printed on 12/07/23, revealed Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side of the body due to tissue damage to the brain or spinal cord), chronic allergic conjunctivitis (inflammation of the conjunctiva caused by an allergic reaction), and vascular dementia (problem with thought processes caused by brain damage from impaired blood flow 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 observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for two (Residents #1 and #6) of ten residents reviewed for care plans. 1. The facility failed to develop a comprehensive person-centered care plan to address Resident #1's use of an antipsychotic medication-Seroquel, diabetes, insulin use and hospice care. 2. The facility failed to develop a comprehensive person-centered care plan to address Resident #6's seizures. This failure could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her active diagnoses included non-Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medication and treatments, at each visit and wrote, signed and dated progress notes at each visit for five (Residents #1, #3, #5, #9 and #10) of 10 residents reviewed for physician visits. The facility failed to ensure there were physician progress notes available for Residents #1, #3, #5, #9 and #10 that were signed and dated by the physician(s) for each visit via the physical charts or electronic record. The physicians were, however, consulted about critical lab values and changes in condition. These failures could place residents at risk of not receiving the appropriate care as ordered by the physician and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. Findings included: 1. Review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or at the option of the physician, after the initial visit, alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four of 10 residents (Residents #1, #5, #9 and #10) reviewed for physician services. 1. The facility failed to ensure Residents #1 was seen one every 30 days for the first 90 days after admission. 2. The facility failed to ensure Residents #5, #9 and #10 were seen by the facility's attending physician and/or the physician's extender at least once every 60 days. The physicians were, however, consulted about critical lab values and changes in condition. These failures could place residents at risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible; and Systematically organized for one of 10 residents (Resident #2) reviewed for clinical records documentation. 1. The facility failed to ensure the medication aide accurately documented medication administration in Resident #2's chart. 2. The facility failed to ensure the charge nurse accurately documented monitoring for signs and symptoms of exit seeking, wandering and other prescribed nursing observations for Resident #2. This failure could place residents at risk of not receiving their medications at the prescribed times and outside of their therapeutic time effectiveness; it also placed other nursing staff at risk of being unaware and double dosing a resident with a medication, which could cause negative side effects and indicate a nursing task was completed for a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident/RP has the right to be informed of, and participate in, his or her treatment for one (Resident #2) of ten individuals reviewed for resident and RP rights. Resident #2's RP was not notified or provided any information of a doctor's appointment to which she needed to attend due to the resident having vascular dementia and having recently eloped when he was let out of the facility unknowingly by a staff member. The RP was denied the opportunity to attend the doctor's appointment post-elopement to help be a part of the treatment decisions. Findings included: Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes…

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 develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #2) of one residents reviewed for discharge planning. The facility failed to implement an effective discharge plan for Resident #2 that made him and his RP an active partner in the process and prepared him when he was discharged to the [hospital] hospital after an elopement from the facility. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten (Resident #7) residents reviewed for pharmacy services. The facility failed to ensure Resident #7 was administered his prescribed sliding scale insulin on 08/10/23 for 4PM and 9PM med pass when his blood sugar was elevated. This failure could place residents at risk of damage to the nerves, blood vessels and organs, as well as put them at risk of harm due to not following doctor's orders as prescribed. Findings include: Record review of Resident #7's quarterly MDS assessment, dated 07/11/23, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #7's active diagnoses included diabetes (high blood glucose-too much sugar in the blood), dysphagia (swallowing difficulties) and vascular dementia (problems…

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, based on the comprehensive assessment of a resident, that a resident who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one of six residents (Resident #1) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #1, who had a diagnosis of dementia, was not prescribed an anti-psychotic medication (Seroquel) prior to determining if there were other causes for her behaviors. 2. The facility failed to ensure Resident #1 was prescribed Seroquel without adequate indications for its use. 3. The facility failed to monitor Resident #1's behaviors after she was prescribed Seroquel to evaluate its effectiveness or ineffectiveness. These failures could place residents at risk for possible adverse side effects (including stroke, heart failure, fast/irregular heartbeat), adverse consequences…

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 provide laboratory services to meet the needs of its residents for one of 10 residents (Resident #3) reviewed for laboratory services. The facility failed to ensure Resident #3's Keppra lab was completed as ordered. The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions. Findings include: Record review of Resident #3's quarterly MDS assessment, dated 06/15/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had active diagnoses which included seizure disorder (a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain), hypertension (when the pressure in the blood vessels is too high (140/90 mmHg or higher)), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), dementia (the loss of cognitive functioning,…

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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to follow the physician orders to complete follow-up with the surgeon for staple removal for Resident #1's surgical wound. This failure could place residents with wounds at risk for a deterioration in the condition of their wounds or additional wounds. Findings included: Review of Resident #1's Face Sheet, dated 08/19/23, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses orthopedic aftercare following surgical amputation, osteomyelitis of the left ankle and foot, muscle weakness, pain, hypertensive heart disease with heart failure, peripheral vascular disease. Review of Resident #1's discharge MDS assessment, dated…

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

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #1) reviewed for quality of care. 1. The facility failed to obtain clarification of an order for a blood pressure medication to be given at QHS PRN. 2. The facility failed to take Resident #1's blood pressure QHS to determine if the PRN medication was needed. These failures could place residents at risk for illness or injury caused by elevated blood pressure. Findings include: Record review of Resident #1's Order Summary Report, dated 8/1/2023, revealed as of 5/18/2023 Clonidine 0.1 mg tablet as needed for hypertension, as needed at HS for SBP (top number) >160 or DBP (bottom number) >90. Record review of Resident #1's MAR, dated May 2023, revealed as of 5/18/2023 Clonidine 0.1 mg for elevated blood pressure at HS for systolic > 160 or Diastolic >90. MAR reflected 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for food prepared in a form designed to meet individual needs. The facility failed to ensure all foods on Residents #1's lunch tray followed ordered food texture for mechanical soft foods. This failure could place residents at risk of aspiration and weight loss. Findings include: Record review of Resident #1's face sheet, dated 8/1/2023, revealed Resident #1 was admitted to the facility on [DATE] with a re-admission on [DATE]. His diagnoses included: stroke resulting in limited mobility of the left side, difficulty swallowing and limited ability to speak. Record review of Resident #1's annual MDS assessment, dated 5/10/2023, revealed No BIMS summary score as resident was rarely/never understood. Resident #1 required the assistance of 1 staff member for set up of his meals. Record…

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