The Oaks at Longview

ased on interview and record review the facility failed to complete a performance review of each Certified Nurse Assistant (CNA) at least once every 12 months, for 5 of 5 (CNA J, CNA F, CNA H, CNA K, and CNA G) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA J, CNA F, CNA H, CNA K and CNA G based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have a competency evaluation on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 5:07 p.m., the DON said the staffing coordinator was responsible for the CNA trainings and competency evaluations. She said CNAs evaluation were supposed to be done annually. She said…

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 each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 33, Resident #35, Resident #54, Resident #69) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #33 had side effect monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Seroquel ((is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)), Buspirone (antianxiety; is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety, and Venlafaxine (antidepressant; is…

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 the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 19 of 74 residents (Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60, Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110) reviewed for immunizations. The facility failed to offer and administer the influenza and pneumococcal vaccination to Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60. The facility failed to offer and administer the pneumococcal vaccination to Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110. The facility failed to offer and administer the influenza vaccination to Resident #67, Resident #68, Resident #60.…

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.

ased on interview and record review, the facility failed to maintain ensure the required in-service trainings were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year for 5 of 5 staff, (CNA F, CNA G, CNA H, CNA J, and CNA K) records reviewed for staff training. The facility failed to provide CNA F, CNA G, CNA H, CNA J, and CNA K 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have 12 hours of training per year on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 4:59 p.m., the HR Payroll said she had been at the facility for 4 months. She said she was responsible for training records, background checks, EMR and OIG results. She said she was responsible to notify the DON about training that needed to be…

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 ased on interview and record review the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 18 residents reviewed for resident rights. (Resident #178) The facility failed to treat Resident #178 with respect and dignity when staff told her to urinate in her brief. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of the face sheet dated 07/17/24 revealed Resident #178 was [AGE] years old female and admitted on [DATE] with diagnoses including Unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (persistent problems falling and staying asleep) and Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors). Record review of the MDS dated [DATE] revealed Resident #178 BIMS was not performed and required maximal assistance for toilet…

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 ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 5 residents (Resident #31) reviewed for a homelike environment. The facility failed to ensure Resident #31's wheelchair was clean. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and abnormalities of gait and mobility. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes…

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 all alleged violations involving abuse, including injuries of unknown source were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 18 residents (Resident #35) reviewed for abuse and neglect. The facility failed to report Resident #35's injury of unknown origin to her face, within 24 hours to the state agency. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of a facility's Abuse Prevention and Prohibition Program policy…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions. (Resident #69) The facility failed to complete a baseline care plan for Resident #69 within 48 hours of admission. The facility failed to provide Resident #69's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. The face sheet indicated Resident #69 family member were her responsible party. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 18 residents (Resident #17 and Resident #68) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #17's positioning rail. 2. The facility failed to ensure Resident #68 was care planned as smoker. 3. The facility failed to perform quarterly smoking assessments for Resident #68. 4. The facility failed to perform Resident #68's quarterly elopement risk assessments. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #17's face sheet dated 7/17/24 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #17 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 that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents who were reviewed for quality of care. (Resident #279) 1. The facility failed to ensure Resident #279 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 279 had orders catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #279's face sheet dated 7/17/24 indicated Resident #279 was a [AGE] year old female and admitted to the facility initially on 7/13/24 with diagnosis chronic kidney disease stage 3 unspecified (when the kidneys have mild to moderate damage and less able to filter waste and fluid out of your blood).…

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 respiratory care was provided consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care. (Resident #35) The facility failed to ensure Resident #35's nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was stored in a bag when not in use. The facility failed to ensure Resident #35's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. These failures could place residents at risk of respiratory infections. 1. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and acute and chronic respiratory failure with hypercapnia (is a condition in which your lungs…

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 employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 7 (Dietary Aide A) reviewed for qualified dietary staff. The facility failed to ensure the DA A met the requirements for food handling by obtaining a food handler's certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. Findings: During an interview and record review on 07/16/24 at 10:11 AM, the DM provided an undated Employee Demographics list that revealed DA A was hired 11/3/23. She said DA A did not have his food handler's certificate. She said he should have had it within 2 weeks of hire, but he did not get it. She said she talked to HR about it and let HR know he had not gotten it after she had reminded him numerous times. She said it was her responsibility and the responsibility of HR to make sure DA A got his food handler's certificate within 2 weeks 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 observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 4 resident (Resident#31) reviewed safe, functional equipment. The facility failed to ensure Resident #31's wheelchair brake handle was not loose. This failure could place resident at risk for usage of unsafe equipment. Findings included: Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and abnormalities of gait and mobility. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31…

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 a resident who was incontinent of bladder received appropriate treatment and services for 3 of 5 residents (Resident #13, #18, #215) reviewed for urinary catheters. 1.Resident #13 had an indwelling urinary catheter since admission on [DATE] without a physician's order with an acceptable diagnosis for use. 2.The facility failed to ensure Resident #215 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. 3.The facility failed to ensure Resident #215's and Resident #18's foley catheters were properly secured to prevent pulling or trauma. These deficient practices could affect residents who had urinary catheters at risk of not receiving care needed. The findings included: 1.Record review of Resident #13's face sheet dated 06/14/23 indicated the resident was a [AGE] year old female who admitted to the facility on [DATE] with the diagnosis acute cystitis of the bladder (a urinary infection…

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 establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 02:00 PM, the following medications were observed in the controlled medication storage area waiting to be disposed: *Lorazepam 2mg/ml suspension- 22 mls RX# C743209 *ABH gel 2mg/25mg/5mg/ml- 4 mls RX# C742813 *Tramadol 50mg- 14 tablets RX# 4039352 *Lorazepam 1mg- 16.5 tablets RX# 529545…

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.

2.During an observation on 06/12/23 at 11:32 a.m., RN A left the medication cart #2 unlocked when entering a resident's room. Staff and other residents observed in hallway. RN A came back to the medication cart, left medication cart unlock again leaving access to unauthorized personal to enter the cart. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to lock the medication cart before walking into the resident's room. RN A said she was aware she was supposed to lock the medication cart anytime she stepped away. RN A said failure to lock the medication cart could leave access for anyone to get into the cart and take medication. During an observation and interview on 06/13/23 at 8:53 a.m., RN B observed to walk down hallway leaving the treatment cart unlocked. Observed staff, residents and visitors walking the by the nurse's station unlocked treatment cart. RN B returned to the nurse's station and when questioned, said she did not lock the treatment cart because she did not have the key. She said she knew it could be a hazard to leave the treatment cart open…

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, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure expired foods were not in the refrigerator. 3. The facility failed to ensure food was thawed properly. These failures could place residents at risk for food-borne illness. Findings included: During an observation on 06/11/23 at 09:18 AM, two frozen pork loins and one roll of frozen ground beef were found in a sink full of water without running water. They were not labelled or dated. During an interview on 06/11/23 at 09:20 AM, [NAME] D said she was working in the kitchen on 06/11/23. She said she had just put the meat in the sink before surveyors arrived to the facility. She said she forgot to leave the water running over the thawing meat. She said there should have been running water over the thawing meat. She said residents could…

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 comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 of 3 (Resident #41) residents reviewed for advance directive The facility failed to ensure Resident #41 ' s code status was communicated and correctly indicated in his physical chart. This failure could result in residents receiving unwanted treatment or not receiving desired treatment. Findings include: Record review of Resident #41's face sheet, dated [DATE], indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body), and anxiety (feelings of nervousness, panic and fear as well as sweating and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #13) of 6 residents reviewed for privacy and confidentiality. The facility failed to ensure RN A protected Resident#13's Medication Administration Record (MAR). This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye diseases that can cause vision loss and blindness) and anxiety ( feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 1 of 1 resident (Resident #16) reviewed for accident hazards. The facility failed to ensure Resident #16's oxygen cylinder was properly stored. This deficient practice could place residents at risk of injury. Findings included: Record review of Resident #16's face sheet, dated 06/13/23, indicated she was a [AGE] year-old female, admitted on [DATE]. She had diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness (a lack of strength in muscles) , and chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Record review of Resident #16's quarterly MDS, dated [DATE], indicated she was usually…

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 2.Record review of Resident #46's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (impaired ability to remember, think, or make decisions), and stroke( occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Record review of Resident #46's quarterly MDS assessment, dated 03/31/23, indicated Resident #46 was sometimes understood and sometimes understood others. Resident #46's BIMs score was 04s, which indicated she was severely cognitively impaired. Resident #46 required total assistance with eating, toilet use, dressing, and bathing, limited assist with bed mobility, transfer, and personal hygiene. 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 2. Record review of Resident #41's face sheet, dated 06/14/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body),and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated 05/21/23, indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. Resident #41 was independent with transfer, dressing, bathing, bed mobility, personal hygiene and required supervision with toilet use. The MDS indicate Resident #41 received 6 doses of antianxiety medication during the 7 days look…

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 establish and 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 1 of 6 residents (Resident #13) reviewed for infection control. The facility failed to ensure RN A performed hand hygiene while preforming glucometer checks (a small, portable device that lets you check your blood sugars) and administering insulin for Resident #13. This deficient practice could place residents at risk for infection due to improper care practices. Findings include: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye…

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.