Oakwood Health And Rehab Center

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed five errors out of forty-one opportunities, resulting in a 12.2% error rate The Findings Include: 1. Resident #2 (R2) was given the wrong dose of Calcium. During a medication pass and pour observation conducted on 7/25/23 at 8:00 AM, license practical nurse (LPN #2) began pulling medications out of the medication cart for R2 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Calcium 600 MG (milligrams) with Vitamin D 5 mcg (micrograms). LPN #1 dispensed the medication into the medication cup and administered to R2. R2's physician's orders were then reviewed to verify accuracy of medications given. There was a physician's order to give Calcium 500 MG/VIT D 400 IU (international units), a combination medication for osteoporosis, which differed from the calcium that had been administered. On 7/25/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices regarding hand hygiene during a dressing change for one of twenty-two residents in the survey sample (Resident #25) and on one of two units during the medication pass (unit 2). The findings include: 1. Infection control practices regarding hand hygiene were not followed during a dressing change to Resident #25's foot callous. Resident #25 (R25) was admitted to the facility with diagnoses that included adult failure to thrive, atherosclerotic heart disease, hypertension, chronic kidney disease, dementia, psychotic/mood disturbance, anxiety and thrombocytopenia. The minimum data set (MDS) dated [DATE] assessed R25 with severely impaired cognitive skills. Resident #25's clinical record documented the resident had a callous on the plantar surface of the right foot with a physician's order dated 7/18/23 for Bacitracin and a dry dressing applied to the wound each…

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

Based on facility document review and staff interview, the facility staff failed to employ a qualified dietitian. There had been no registered dietitian employed since 4/15/22 in the facility with a census of 73. The findings include: On 5/10/22 at 11:27 a.m., the dietary manager (other staff #1) was interviewed about qualified nutrition staff in the facility. The dietary manager stated there was currently no registered dietitian (RD) employed at the facility. The dietary manager stated the previous RD had been gone for approximately two to three weeks. Review of the facility's current personnel list (2022) included no identified RD for the facility. On 5/10/22 at 12:39 p.m., the administrator was interviewed about a RD for the facility. The administrator stated the previous RD quit and she was not sure if a new RD had been hired. On 5/11/22 at 8:22 a.m., the administrator stated the RD left about a week or two weeks ago and there was currently no RD for the facility. The administrator stated they were using the providers for nutritional guidance until a RD was hired. On 5/11/22 at…

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

Based on staff interviews, family interview, clinical record review, and survey findings, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The census in the facility was 73. The facility staff failed to employ sufficient nursing staff which resulted in the identification of Immediate Jeopardy. The findings include: A survey was conducted at from 05/10/2022 through 05/19/2022. During the survey deficient practice was identified in the area of quality of care at F684, F686, F689 and pain management at F697. These identified areas of deficient practice were related to the facility not employing sufficient nursing staff. One of these areas resulted in identified harm for one resident in the survey sample for pain management. Additional deficient practice was identified for failure to follow physician orders, failure to provide services to prevent and/or treat pressure ulcers and failure to provide supervision for residents who were identified as wandering. During the survey interviews were…

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, staff interview, and facility document review, the facility staff failed to implement a Legionella water management program in the facility; failed to follow infection control practices for proper PPE (personal protective equipment) when going in and out of a resident room for one of 22 residents, Resident # 73; and failed to follow infection control practices during a dressing change for one of 22 residents, Resident # 11. 1. The facility failed to implement a Legionella water management program in the facility. 2. Facility staff did not use proper PPE when entering Resident #73's room. There was also no order or care plan in place for droplet precautions for Resident #73. 3. Staff failed to follow infection control practices during a dressing change for Resident # 11. Findings include: 1. The facility's Legionella water management program was reviewed 5/12/22 beginning at 2:20 p.m. The central supply staff presented a test result for the hospital stating that he did not know who was in…

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 staff interview, clinical record review, resident interview, and facility document review, the facility staff failed to develop a baseline care plan for three of 22 residents in the survey sample, Resident # 238, # 188, and # 73. 1. Resident # 238 did not a care plan for NASH (non-alcoholic steatohepatitis). 2. Resident # 188 did not have a baseline care plan for pain related to a fractured ankle, and also did not receive a copy of the baseline care plan. 3. Resident # 73 did not have a baseline care plan for droplet precautions. Findings include: 1. Resident # 238 was admitted to the facility with diagnoses to include, but were not limited to: Non-alcoholic steatohepatitis (NASH), asthma, diabetes, and high blood pressure. There was no MDS (minimum data set) information as the resident was newly admitted less than fourteen days. On initial interview 5/10/22 at approximately 1:00 p.m. the resident conversed appropriately and appeared to be extremely cognitive. The clinical record was reviewed 5/10/22…

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 staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 5 of 22 residents in the survey sample, Residents #62 #51, #6, #70, and #76. Resident #62's CCP did not include a focus areas with goals and interventions for the use of an anticoagulant. Resident #51's CCP did not include a focus area with goals and interventions for hospice care. Resident #6's CCP did not include a focus area with goals and interventions for nutritional/dietary needs. Resident #70's CCP did not include a focus area with goals and interventions for palliative care. Resident #76's CCP did not include a focus area with goals and interventions for mood disorder and behaviors. The findings include: 1. Resident #62 was admitted to the facility with diagnoses that included atrial fibrillation, congestive heart failure, bipolar disorder, above knee amputation, history of fails, hyperkalemia, type 2 diabetes, hypothyroidism, and heart failure. The most recent minimum data set…

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 resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 22 residents in the survey sample, Residents #6, #62, #188, and #33; and failed to assess and monitor a left hip hematoma for one of 22 in the survey sample, Resident #47. Resident #6 did not have Debrox drops administered as ordered. Resident #62 did not have prophylactic medications administered as ordered. Resident #188 did not have fluid intake monitored for compliance with fluid restriction as ordered. Resident #47 did not have a hematoma monitored. Resident #33 did not have the medication Abilify administered as ordered. The findings include: 1. Resident #6 was admitted to the facility with diagnoses that included chronic pain, dysphasia, peripheral vascular disease, hypertension, congestive heart failure, gastro-esophageal reflux disease (GERD), muscle weakness, and glaucoma. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed…

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, staff interview, clinical record review, and facility document review, the facility staff failed to assess and implement interventions for the treatment of pressure ulcers for eight of 22 residents, Resident #73, #80, #238, #20, #62, #51, #11, and #35. Resident #73 was admitted to the facility with a Stage IV pressure ulcer to the sacrum. There was no skin assessment, measurement, or intervention for treatment of the pressure ulcer at the time of admission. Resident #80, #238, #20, #62, and #51, all identified as being at risk for the development of pressure ulcer/skin injury, did not have weekly skin assessments completed. Resident #11 did not have weekly skin assessments completed and the facility staff failed to follow infection control practices during a dressing change. Resident #35 did not have accurate and timely skin assessments for pressure ulcer prevention and the facility failed to adequately monitor and provide ongoing assessments of a facility acquired deep tissue injury.…

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, resident interview, family interview, staff interview, and clinical record review, the facility staff failed to ensure supervision and interventions to prevent accidents for two of 22 residents in the survey sample, Resident #47, and #9. The facility failed to provide appropriate footwear and supervision to prevent falls as per the comprehensive care plan for Resident #47. Resident #9, with a non-functioning wander prevention device, eloped from the facility without staff knowledge and/or supervision. Findings include: 1. Resident #47 was admitted to the facility with the following diagnoses, including but not limited to: Alzheimer's disease, diabetes mellitus, hypertension, history of falling and conduct disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/2022 assessed Resident #47 as severely impaired with a cognitive summary score of 00. On 05/10/2022 beginning at approximately 11:15 a.m., Resident #47 was observed walking in the hallway on Unit…

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 staff interview, facility document review and clinical record review, the facility failed to ensure medications were available for administration for two of twenty-two residents in the survey sample, Resident #33 and #62. Resident #33's prescribed medication Abilify was not available resulting in six missed doses. Resident #62's medications for urinary health were not available for administration. The findings include: 1. Resident #33 was admitted to the facility with diagnoses that included multiple sclerosis, hyperlipidemia, insomnia, major depressive disorder, morbid obesity, anxiety, polyneuropathy, hypertension, chronic pain syndrome, overactive bladder and obstructive sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #33 as cognitively intact. Resident #33's clinical record documented a physician's order dated 12/15/21 for the medication aripiprazole (Abilify) 100 mg (milligrams) to be administered each day for treatment of major depressive disorder. Resident #33's medication…

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 medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. A medication pass and pour observation conducted on 05/10/2022 with 27 opportunities and 22 errors, yielded an medication error rate of 81.48 percent. Findings were: A medication pass and pour observation was conducted on 05/10/2022 beginning at approximately 11:00 a.m. with RN (registered nurse) #2. RN #2 was observed preparing medications for Resident #206. Two of the medication cards had administration instructions from the pharmacy, Prednisone 10 mg- Take with food or milk, and Metoprolol 25 mg- Give with or immediately following meal. Those two medications were given along with six other oral medications and eye drops. The oral medications were not given with food or milk. Also, ordered for Resident #206 was a 4% Lidocaine patch. The patch was not on the medication cart. RN #2 looked on the stock carts on the unit and was unable to locate the correct percentage. She left the floor and returned at…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration; and also failed to date open vials of insulin and stock medications on the medication carts on three of three units. 1. Unit 3 medication carts included open vials of undated insulin and expired insulin. 2. Unit 1 and Unit 2 medication carts included a total of twenty-one house stock medications that were not dated, four vials of insulin open and not dated, and one bottle of expired insulin still in the medication cart and available for administration. Findings include: 1. On 5/10/22 beginning at 2:00 p.m. two medication carts were inspected with licensed practical nurse (LPN) # 2. One cart included three open vials of insulin that were not dated. The second medication cart included 1 vial of open insulin not dated, one vial of insulin dated 11/5/21, and one vial of insulin dated 3/19/22. LPN # 2 was asked about the insulins. LPN # 2 stated Yes, insulin should be dated when open as the 'shelf life' is shorter once 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 observation, facility document review and staff interview, the facility staff failed to store resident food in a sanitary manner on three of three nursing units. Expired and/or undated food items were observed in the nourishment refrigerators on unit 1, unit 2 and unit 3. The findings include: On 5/11/22 at 11:19 a.m. the unit 3 nourishment refrigerator was inspected. Stored and available for use were five cartons of milk with use by date of 5/10/22. On 5/11/22 at 11:20 a.m., licensed practical nurse (LPN) #2 was interviewed about the expired milk. LPN #2 stated milk was usually consumed prior to the use by dates and the cartons needed to be discarded. On 5/11/22 at 11:57 a.m., the unit 2 nourishment refrigerator was inspected. Stored and available for use was an opened 16 ounce container of cottage cheese with use by date of 5/7/22. There was a Styrofoam container with a grilled ham/cheese sandwich with no date labeled for Resident #80. There were six cartons of milk with use by date of 5/10/22. On 5/11/22 at 12:00 p.m., LPN #1 was interviewed about the expired and/or…

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 family interview, staff interview and clinical record review, the facility staff failed to notify the physician and resident representative of an elopement for one of twenty-two residents in the survey sample, Resident #9. Resident #9's family and physician were not notified when the resident was found out of the facility unsupervised. The findings include: Resident #9 was admitted to the facility with diagnoses that included vascular dementia with behavioral disturbance, vitamin D deficiency, major depressive disorder, hypothyroidism, atherosclerotic heart disease, benign prostatic hyperplasia, hypertension and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. On 5/10/22 at 2:18 p.m., Resident #9's family member was interviewed about quality of care in the facility. The family member stated the resident was found several days ago by hospital staff wandering in the adjacent hospital without supervision. The family member stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to follow the abuse policy to report and investigate an injury of unknown orgin in a timely manner. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section G - Functional Status, the MDS assessed Resident #51 as requiring extensive assistance with one person physical assistance for dressing, personal hygiene, bed mobility, and toileting; total dependent for bathing; and supervision for eating. On 05/10/2022…

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 clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to report an injury of unknown origin to the state agency in a timely manner. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section G - Functional Status, the MDS assessed Resident #51 as requiring extensive assistance with one person physical assistance for dressing, personal hygiene, bed mobility, and toileting; total dependent for bathing; and supervision for eating. On 05/10/2022 during the initial tour…

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 staff interview and clinical record review, the facility staff failed to obtain order for the immediate care of Stage IV sacral pressure ulcer for one of 22 residents, Resident #73. Findings were: Resident #73 was admitted to the facility with the following diagnoses including but not limited to: osteoarthritis, hypertension, morbid obesity, acute respiratory failure, diabetes mellitus, and Stage IV Sacral pressure ulcer. Due to her recent admission there was no MDS (minimum data set) assessment. According to her admission assessment dated [DATE], she was oriented to person, place, time, and situation. The clinical record was reviewed on 05/10/2022 at approximately 1:30 p.m. The admission nursing assessment dated [DATE] contained a base line care plan under skin integrity for Pressure Ulcer. Interventions included: Administer treatments as ordered, monitor dressing to ensure it is intact and adhering . The physician orders were reviewed. There were no orders for treatment of a pressure ulcer. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for two of 22 residents in the survey sample, Resident # 84 and # 76. 1. Resident # 84, was coded in the electronic medical record (EMR) as discharged to an acute hospital, when the resident actually transferred to another facility. 2. Resident # 76 did not have sections C, D, and Q completed of the MDS. Findings include: 1. Resident # 84 was admitted to the facility with diagnoses to include, but not limited to: acute respiratory failure and high blood pressure. On 5/12/22 at 7:45 a.m. the clinical record was reviewed. A review of the progress notes dated 4/25/22 revealed facility staff faxed copies of medications, and prescriptions to the receiving nursing facility, as well as reporting to the nurse receiving the patient. The notes documented the resident had requested to be transferred to a nursing facility closer to family. The discharge MDS (minimum data set)…

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, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 22 residents, Resident #47. Resident #47 fell at the facility on 04/01/2022 resulting in a large hematoma to her left hip. Her care plan was not revised to include treatment of the area. Findings were: Resident #47 was admitted to the facility with the following diagnoses, including but not limited to: Alzheimer's disease, diabetes mellitus, hypertension, history of falling and conduct disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/2022 assessed Resident #47 as severely impaired with a cognitive summary score of 00. Review of the clinical record beginning on 05/10/2022 revealed that Resident #47 had sustained fall on 04/01/2022 resulting in a large hematoma to her left hip: 4/1/2022 19:09 (7:09 p.m.) .CNA .told writer that pt (patient) fell in hallway w (with)/ herself and np (nurse practitioner). She described it as…

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 family interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of twenty-two residents in the survey sample, Resident #9. Resident #9 eloped from the facility without staff knowledge and/or supervision. Nursing made no record of the incident, documented no assessment of the resident when found, and made no notification to administration, the provider or family about the incident. The findings include: Resident #9 was admitted to the facility with diagnoses that included vascular dementia with behavioral disturbance, vitamin D deficiency, major depressive disorder, hypothyroidism, atherosclerotic heart disease, benign prostatic hyperplasia, hypertension and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. On 5/10/22 at 2:18 p.m., Resident #9's family member was interviewed about quality of care in the facility. The family member…

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 resident interview, clinical record review, and staff interview, the facility staff failed to ensure a complete and accurate record for two of 22 residents in the survey sample, Resident # 80 and # 238. 1. Resident # 80 had weights inaccurately recorded. 2. Resident # 238 did not have a code status documented. Findings include: 1. Resident # 80 was admitted to the facility with diagnoses to include, but not limited to: stroke, peripheral artery disease, high blood pressure, and dysphagia following a stroke. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had Resident # 80 coded with moderate impairment in cognition with a score of 04 out of 15. The clinical record was reviewed 5/11/22 beginning at 8:00 a.m. The following weights were recored for Resident # 80: 4/27/22 (admission weight)- 204.3 via weight chair. 5/2/22- 254.4 sitting (this weight was crossed out with staff documentation Wrong chart.) 5/2/22- 254.2 via weight chair 5/9/22- 145.4 via weight chair 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide records of weekly hospice visits as required in the hospice services agreement, for one of 22 residents in the [NAME] sample, Resident #51. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section O - Special Treatments, Procedures, and Programs, Resident #51 was assessed as receiving Hospice services. Resident #51's electronic health record (EHR) was reviewed on 05/10/22. Observed within the order summary was an order for hospice care dated 04/07/2022. Observed within the miscellaneous section of the EHR were…

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, clinical record review, resident interview, and staff interview, the facility staff failed to develop a person centered plan of care to address the residents' use of side rails for four of 21 residents in the survey sample, Residents # 14, 20, 21 and 36. The plan of care for each of the four residents had the same problem, goal, and interventions. The findings include: 1. Resident # 21 in the survey sample was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included cancer, hypertension, diabetes mellitus, hyperlipidemia, and depression. According to the most recent Minimum Data Set (MDS), a Quarterly review with an Assessment Reference Date (ARD) of 12/16/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. During the orientation tour at 10:20 a.m. on 2/4/2020, Resident # 21 was observed in street clothes, lying on the bed, sleeping. Both one-quarter bed rails,…

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 clinical record review, staff interview, and facility document review, the facility staff failed to ensure an advance directive was signed by the authorized representative for one of 21 residents, Resident #78. Findings include: Resident #78 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: history of cancer, coronary artery disease, high blood pressure, pneumonia, and dementia. The most current MDS (minimum data set) was a quarterly review dated 11/21/19. This MDS assessed the resident with a cognitive 4, indicating the resident had severe impairment in daily decision making skills. On 02/05/20 during the clinical record review, Resident #78's advance directive was reviewed. The resident was listed as a DNR (Do Not Resuscitate) in the electronic clinical record. No other information could be located. On 02/05/20 at 1:30 PM, the ADON (assistant director of nursing) was asked for assistance in locating the actual DNR form and any advance directive…

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 staff interview, and clinical record review, the facility failed to ensure a quarterly MDS (minimum data set) was completed timely for one of 21 Resident's. Resident #2 did not have a quarterly MDS completed within 92 days. The findings Include: Resident #2 was admitted to the facility on [DATE]. Diagnoses for Resident #2 included: Osteoporosis, pain, and anxiety. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/30/20. Resident #2 was assessed with a cognitive score of 15 indicating cognitively intact. Review of Resident #2's clinical record indicated Resident #2's comprehensive MDS with an ARD of 9/23/19 was completed on 10/1/19. Further review of Resident #2's MDS's indicated there was not an MDS completed within the 92 days following the comprehensive MDS. Documentation did show a quarterly MDS was created on 1/29/20 with an ARD of 1/30/20 and without a completion date. On 02/06/20 at 8:44 AM, RN #2 (MDS coordinator) was interviewed…

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.