Fair Oaks Health & Rehabilitation

Based on observation, resident interview, staff interview and clinical record review and facility document review, the facility staff failed to accommodate resident's needs for three of 48 residents in the survey sample, Residents #121, (R121), R144, R99 and R72. provide accommodations of resident needs by ensuring the call bell was within reach The findings include: 1. For R121, the facility staff failed to keep the call bell (a device with a button that can be pushed to alert staff when assistance is needed) within reach. R121 was admitted to the facility with a diagnosis that included by not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/01/2025, R121 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R121 was moderately impaired of cognition for making daily decisions. On 02/03/25 at approximately 11:59 a.m., an observation revealed R121's call bell was placed inside the top drawer of the bedside table. When asked to locate and activate…

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 required notification to the ombudsman following resident discharge for four of 48 residents in the survey sample, Residents #74, #104, #26, and #62. The findings include: 1. For Resident #74 (R74), the facility staff failed to notify the ombudsman in writing of the resident's discharge to the hospital on [DATE]. A review of R74's clinical record revealed he was discharged to the hospital on [DATE]. Further review of his record failed to reveal evidence that the ombudsman was notified in writing of the resident's discharge. On 2/5/25 at 10:36 a.m., OSM #10, the director of social services, was interviewed. She stated she thought she had faxed a written notification to the ombudsman of R74's discharge, but she had not retained any records to evidence this. She stated: I don't have it. I haven't kept a notebook as I should have. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, 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 observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the care plan for seven of 48 residents in the survey sample, R47, R46, R130, R23, R59, R62 and R76. The findings include: 1. The facility staff failed to develop the comprehensive care plan for genital warts for R47. R47 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/8/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing 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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for five of 48 residents in the survey sample, Residents #147, #132, #62, #104, and #70. The findings include: 1. For Resident #147 (R147), the facility staff failed to dress the resident in clothes. R147 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 2 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 11:54 a.m. and 3:48 p.m., R147 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 1:01 p.m., R147 was observed lying in bed. The resident was dressed in a gown. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing…

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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to administer medications according to the physician's orders for one of 48 residents in the survey sample, Resident #76 (R76). For R76, the facility staff failed to administer Furosemide (for swelling), Gabapentin (for pain), Lorazepam (for anxiety), Losartan Potassium (for high blood pressure), Metoprolol (for high blood pressure), Mirtazapine (for depression), Oxycodone (for pain), Sertraline (for depression), Tamsulosin (for (BPH) benign prostatic hypertrophy (1)), Aspirin (for (CAD) coronary artery disease (2)), Lidocaine External Patch(for pain), Tylenol (for pain) according to the physician's order. The findings include: R76 was admitted with diagnoses that included but were not limited to depression, high blood pressure, BPH, high cholesterol, anxiety and muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/10/2025, R76 scored 8 (eight) out of 15 on the BIMS (brief…

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 provide care and services to prevent and treat a pressure injury (1) for two of 48 residents in the survey sample, Residents #74 and #98. The findings include: 1. For Resident #74 (R74), the facility staff failed to implement treatment for a pressure injury to the right ischium on 4/30/24. A review of R74's clinical record revealed the following progress note dated 4/30/24: Weekly wound assessment completed. Unstageable Pressure Ulcer to Right ischium. Overall impression: new wound - first observation. A review of R74's Weekly Wound assessment dated [DATE] revealed the following treatment recommendation for the right ischium wound: Calcium alginate and foam dressing. A review of R74's May 2024 TAR (treatment administration record) revealed this order was not implemented until 5/27/24, a total of 27 days after the wound was discovered. On 2/5/25 at 9:21 a.m., RN (registered nurse) #1 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 2. For R56, facility staff failed to place a C-PAP (continuous positive airway pressure) (1) mask is a plastic bag when not in use. R56 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/23/2025, R56 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating R56 was cognitively intact for making daily decisions. On 02/03/25 at approximately 12:19 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 2:49 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 4:25 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/04/25 at approximately 8:20 a.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. The physician's order for R56 documented…

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 and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 48 residents in the survey sample, R59. The findings include: The facility failed to provide evidence of communication with dialysis facility for R59. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan…

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, it was determined the facility staff failed to provide evidence of the frequency of physician visits at least every 60 days for two of 48 residents in the survey sample, R59 and R46. The findings include: 1. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 9/5/24 revealed, FOCUS: Renal insufficiencies…

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, resident/staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for one of 48 residents in the survey sample, R130. The findings include: The facility staff failed to ensure R130 was free of unnecessary medications by monitoring anticoagulant as ordered. R130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to pulmonary embolism, spondylosis and cord compression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/7/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of 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, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen and in two of three nourishment rooms. The findings include: The facility staff failed to store food in a sanitary manner in A) one of one kitchen and B) two of three nourishment rooms. A) On 02/03/25 at 11:11 a.m. an observation was conducted of the facility kitchen. Observation of the dry storage area revealed an 11 lb. container of chocolate fudge icing that was approximately 1/2 full, with a label which documented a prep date of 12/19/24 and a use by date of 1/19/25. A five-pound bag of white cake mix approximately one-quarter full was observed with a label which documented a prep date of 12/27/24 and a use by date of 1/25/25. A ten-pound bag of elbow noodles was observed with approximately one-quarter of the bag remaining which was observed to be opened with the end of the bag open to air. Observation of the walk-in refrigerator…

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 clinical record review, staff interview and facility document review, the facility staff failed to provide rehabilitation services for one of 48 residents in the survey sample, Resident #76 (R76). For R76, speech therapist failed to follow the physician's order to evaluate and treat. The findings include: R76 was admitted with diagnoses that included but were not limited to communication. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/10/2025, R76 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. The POS (physician's order sheet) for R76 dated 02/04/2025 documented in part, ST (speech therapy) eval (evaluate) and treat as indicated. Order Date: 01/04/2025. Review of R76's EHR (electronic health record) failed to evidence documentation of intervention by speech therapy. On 02/04/2025 at approximately 1:46 p.m., an interview was conducted with OSM (other staff member) #8, speech-language pathologist. When…

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 facility document review, it was determined the facility staff failed to notify the RP (responsible party) of a change in condition for one of 48 residents in the survey sample, R47. The findings include: The facility failed to notify the RP for R47's genital warts. R47's genital warts last outbreak began in July 2024. R47 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/8/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide required Medicare discharge notice for three of three resident records reviewed, Residents #82, #104, and #26. The findings include: 1. For Resident #82 (R82), the facility failed to issue the resident an ABN (advance beneficiary notice) prior to his discharge from Medicare Skilled Nursing services on 10/2/24. A review of R82's clinical record revealed he was discharged from Medicare Skilled Nursing services on 10/2/24. At the time of his discharge, he still had days remaining in his Skilled Nursing benefit. Further review of R82's clinical record failed to reveal the required ABN prior to the resident's discharge from Skilled Nursing services. On 2/5/25 at 9:46 a.m., ASM (administrative staff member) #4, the regional director of clinical operations, was interviewed. She stated that the ABNs were the responsibility of the therapy department, but at the time of the discharge, the therapy department was not aware the ABN was their responsibility. She stated R82 should…

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, it was determined the facility staff failed to provide evidence of required physician documentation after a resident is transferred to the hospital for one of 48 residents in the survey sample, R59. The findings include: The facility staff failed to evidence required physician documentation after a resident is transferred to the hospital for R59. R59 was transferred to the hospital on 3/14/24. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the 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 staff interview, facility document review, and clinical record review, the facility staff failed to implement PASARR (preadmission screening and resident review) requirements for one of 48 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to ensure a level I PASARR was completed. R2 was admitted to the facility on [DATE]. A review of R2's clinical record failed to reveal a level I PASARR. On 2/5/25 at 10:39 a.m., an interview was conducted with OSM (other staff member) #10 (the director of social services). OSM #10 stated all residents should have a level I PASARR completed, and the admissions department is responsible for making sure it is done prior to admission. OSM #10 stated that if a PASARR is not completed prior to admission then she completes it. OSM #10 stated R2 was admitted to the facility from a sister facility, prior to her (OSM #10's) employment, and someone should have checked to ensure she had a level I PASARR completed. On…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 48 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to review and revise the resident's current comprehensive care plan for the use of a left-hand splint. R10's comprehensive care plan dated 6/12/24 documented, ADL (activities of daily living) Self care & mobility deficits as evidenced by muscular weakness, and left hemiplegia (paralysis) related to CVA (cerebrovascular accident [stroke]). Splint wear Left hand resting splint on as ordered. R10's care plan was cancelled, and the current care plan was initiated on 1/10/25. The current care plan failed to reveal documentation regarding a left-hand splint. On 2/4/25 at 3:51 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated a corporate decision was made to revamp care plans, so they were more aligned and cohesive across the company so new care plans 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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide toenail care for two of 48 residents in the survey sample, Residents #104 and #62. The findings include: 1. For Resident #104 (R104), the facility staff failed maintain R104's toenails in a trimmed and clean manner, and failed to wash and apply lotion to his feet to prevent them from being dry and scaly. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/24/24, R104 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of staff for grooming and personal care. On the following dates and times, R104 was observed sitting up in bed: 2/3/25 at 12:53 p.m. and 4:01 p.m., 2/4/25 at 9:38 a.m., and 2/5/25 at 10:17 a.m. At all observations, R104's toenails on the left foot 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, facility document review, and clinical record review, the facility staff failed to provide care and services for a resident with limited range of motion for one of 48 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to implement a left-hand splint. A review of R10's clinical record revealed an occupational Discharge summary dated [DATE] that documented, Skill: Pt (Patient) and Caregiver Training: Instructed patient and primary caregivers in splinting/orthotic schedule in order to facilitate improved functional abilities. Instruction in proper use, care and wearing time of prosthetic device and therapeutic stretch techniques. Patient Response: Progress and Response to Tx (treatment): patient tolerated wearing L (left) hand resting splint for up to 7 hrs with no redness, swelling or pain. Orthotic Management: Splint/Orthotic Recommendations: It is recommended the patient wear a resting hand splint on left…

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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide an environment to prevent avoidable accidents for one of 48 residents in the survey sample, Resident #90. The findings include: For Resident #90 (R90), the facility staff failed to assess the resident's bed for weight restrictions to ensure safety per the manufacturer's instructions. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/17/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R90's clinical record revealed the resident's weights as followed: 9/2/24- 495.6 pounds 12/23/24- 484 pounds Further review of R90's clinical record failed to reveal an assessment to determine if the resident's bed met weight restrictions and was safe for use. On 2/3/25 at 12:04 p.m., R90 was observed sitting on the bed. The bed contained a trapeze bar and an air mattress.…

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, facility document review, and clinical record review, the facility staff failed to administer tube feeding in a sanitary manner for one of 48 residents in the survey sample, Resident #131. The findings include: For Resident #131 (R131), the facility staff failed to utilize clean tubing to administer a tube feeding to R131 on 2/3/25. On the following dates and times, R131 was observed lying in bed, receiving tube feeding at 45 mls (milliliters) per hour. At each observation, the outside of the tubing contained a brown sticky substance over approximately 50% of the tubing: 2/3/25 at 12:58 p.m., 1:52 p.m., and 3:45 p.m. On 2/5/25 at 9:21 a.m., RN (registered nurse) #1 was interviewed. She stated if a nurse discovers a sticky brown substance on the outside of tube feeding tubing, the nurse should stop the feeding and replace the tubing. She stated the brown sticky substance is likely tube feed material that has leaked out from the bottle onto the tubing. She stated the resident may not be getting the full amount of tube feeding if there is a leak.…

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, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 48 residents in the sample R46. The facility failed to evidence provision of trauma informed care for R46. R46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post traumatic stress disorder), viral hepatitis and pulmonary fibrosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section I: Active Diagnosis (dated 8/31/24) I6100. Post Traumatic Stress Disorder (PTSD)-coded 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence a physician writing a recommendation for a resident be admitted to the facility (admission note) for one of 48 residents in the survey sample, R59. The findings include: R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 9/5/24 revealed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of 48 residents in the sample R46. The findings include: For R46 the facility staff failed to provide psychosocial follow up following the resident being admitted with a diagnosis of PTSD (post-traumatic stress disorder). R46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), viral hepatitis and pulmonary fibrosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for…

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 clinical record review and staff interview it was determined that the facility staff failed to provide pharmacy services for one of 48 residents in the survey sample, Resident #76 (R76). For R76, facility staff failed maintain the availability of Diltiazem (for high blood pressure), Ezetimibe (for cholesterol), and Methylcobalamin (for low iron) for administration. The findings include: R76 was admitted with diagnoses that included but were not limited to high blood pressure and high cholesterol. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/10/2025, R76 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. The POS (physician's order sheet) for R76 dated 02/05/2025 documented in part, Diltiazem HCl (hydrochloride) ER (extended release) Beads Oral Capsule Extended Release 24 Hour 360 MG (milligrams). Give 360 mg by mouth one time a day for HYPERTENSION HOLD FOR SBP (systolic blood pressure) < (less than) 110.…

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, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of three residents observed during the medication administration observation, Resident #88 (R88). During the medication administration observation, two errors out of 38 used to treat glaucoma opportunities occurred, resulting in a six and twenty-five hundredths' percent (6.25%) percent medication error rate. The findings include: For R88, the facility staff failed to administer eye drops according to physician's orders. RN (registered nurse) #3 administered two drops of Timoptic Ophthalmic Solution (1) in each eye and failed to administer one drop of Trusopt Ophthalmic Solution in the left eye. The POS (physician's orders sheet) for R88 dated 02/05/2025 documented in part, Timoptic Ophthalmic Solution 0.5% (five tenths of a percent). Instill 1 (one) drop in both eyes one time a day for glaucoma. Order Date: 09/19/2024. Trusopt Ophthalmic Solution 2% (two percent). Instill 1 (one) drop in left eye two…

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, it was determined that the facility staff failed to implement a complete immunization program for two of five record reviews for immunizations, Resident #2 and Resident #97. The findings include: 1. For Resident #2 (R2), the facility staff failed to evidence that the resident and/or representative was offered the pneumonia vaccine or educated on the vaccine. R2 was admitted to the facility on [DATE]. Review of R2's immunization documentation evidenced a pneumovax 23 completed on 3/7/2019 prior to admission. An undated entry for Prevnar 20 documented Consent pending. On 2/4/25 at 2:04 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing, for evidence of offering, education or administration of the pneumonia vaccine for R2. On 2/5/25 at 8:49 a.m., LPN (licensed practical nurse) #4 provided a vaccine consent form for R2 which documented education provided to R2's representative, consent for 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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to promote residents' rights for two of 12 residents in the survey sample, Residents #10 and #11. The findings include: 1. For Resident #10 (R10), the facility staff failed to provide the resident with dignity and self-determination. R10 was not allowed to independently access the elevator from the second floor. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/3/24, R10 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R10's clinical record (including progress notes, safety assessments, physician's orders, and the care plan) failed to reveal documentation that R10 could not safely and independently access the elevator on the second floor and propel around on the first floor. An elopement assessment dated [DATE]…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain a physician ordered laboratory test for one of 12 residents in the survey sample, Resident #2. The findings include: The nurse's note dated 8/10/23 at 8:00 p.m., documented, Resident remains alert and responsive with some weakness, took all his medications as ordered but only drinks the juice and other fluids, called to (name of doctor) and new order given to start resident on Megestrol 400 mg po (by mouth) bid (twice a day) and also to do lab (laboratory test) in the morning for CMP (comprehensive metabolic panel), resident daughter (name of daughter) have been updated and aware of the new orders, nursing will continue to monitor and follow the plan of care. The physician order dated, 8/10/23 documented, Draw lab in morning for CMP one time only for 1 day. Review of the clinical record failed to evidence the results of the physician ordered lab test. The resident was transferred to the hospital on 8/14/23. The comprehensive care plan dated, 12/17/21,…

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 staff failed to provide respiratory care and services for one of 12 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain physician's orders to direct the administration of oxygen and a CPAP (Continuous Positive Airway Pressure) machine (1). R1 was admitted to the facility on [DATE] and discharged on 2/10/23. A review of R1's clinical record failed to reveal physician's orders for oxygen and for a CPAP machine. Nurses' notes dated 2/3/23, 2/6/23, 2/7/23, 2/8/23, and 2/9/23 documented R1 was receiving oxygen at two liters per minute. Nurses' notes dated 2/7/23, 2/8/23, and 2/9/23 documented R1 was not ready at that time to wear her CPAP. On 7/31/24 at 10:09 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated residents should have a physician's order for oxygen administration and CPAP administration, so the nurses know…

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 interview, facility document review and clinical record review, it was determined the facility staff failed to review advance directives periodically with four of 42 residents in the survey sample, Residents #70, #71, #34 and #60. The findings include: 1. For Resident #70 (R70), the facility staff failed to review the advance directive since 10/13/2021. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/16/2022, the resident scored a zero out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. The physician order dated 10/19/2021, documented, DNR/DNT (do not resuscitate/do not transport). The Social Services Assessment and History dated, 10/13/2021, documented in part, Does the patient make his/her own decisions - no. Name of patient's decision maker - wife. Does the patient/patient's decision maker report that advance care planning has been completed - no. Does the patient/patient's decision maker want information on…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens and in three of three nourishment rooms. 1. The facility staff failed to close a box containing a bag of diced carrots, exposing them to the environment, in one of one walk-in freezers. 2. The facility staff failed to label and date food available for use, found in the first floor, PARC unit and second floor nourishment room refrigerators in three of three nourishment room refrigerators. The findings include: 1. The facility staff failed to close a box containing a bag of diced carrots, exposing them to the environment, in one of one walk-in freezers. On 09/26/2022 at approximately 10:45 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #1, dietary manager. At approximately 10:58 a.m., an observation of the inside of the facility's walk-in freezer revealed a 30 pound box of diced carrots sitting on a shelf. Observation of the box revealed the diced carrots were in a…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to maintain a complete clinical record for five of 42 residents in the survey sample, Residents #47, #222, #121, #34 and #118. The findings include: 1. For Resident #47 (R47), the facility staff failed to maintain wound physician/nurse practitioner notes on the resident's clinical record. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/22, the resident scored 7 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of R47's clinical record revealed a nurse's note dated 8/9/22 that documented, Resident seen for skin assessment by this writer and the wound MD (medical doctor). The findings are as follows. 1. Sacral fissure measuring 3.0cmx3.0cmx0.3cm . Further review of R47's paper and electronic clinical record failed to reveal wound physician/nurse practitioner notes. On 9/27/22 at 2:17 p.m., LPN (licensed practical…

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 interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to notify a resident's representative (RR) of a need to alter treatment for one of 42 residents in the survey sample, Resident #222. The findings include: For Resident #222 (R222) the facility staff failed to notify the RR when the medication ferrous sulfate (iron) was discontinued on 8/25/21 and a new medication calcitriol (1) was initiated on 1/19/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/24/22, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of R222's clinical record revealed a nurse practitioner's note dated 8/25/22 that documented, Pt (Patient) has CKD (chronic kidney disease) stage IV w (with) chronic onset. Condition is exacerbated by history of type 2 diabetes, frequent urinary tract infections, poor PO (by mouth) intake of water…

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 clinical record review and staff interview, it was determined that the facility staff failed to complete an accurate MDS (minimum data set) for three of 42 residents in the survey sample, Residents #120, #88, and #26. The findings include: 1. For Resident #120 (R120), the facility staff failed to accurately code the significant change MDS with an ARD (assessment reference date) of 9/13/22 for the resident's cognitive status. On the most recent MDS, a significant change assessment with and ARD of 9/13/22, R120 was not coded for cognitive status or for results of the resident's BIMS (brief interview for mental status). Each box in Section C (BIMS) of the MDS contained a dash. On 9/27/22 at 1:15 p.m., RN (registered nurse) #3, the MDS coordinator, was interviewed. She stated the social workers are ordinarily responsible for completing Section C (BIMS scoring) of the MDS. On 9/27/22 at 1:49 p.m., OSM (other staff member) #6, Social Services Coordinator, and OSM #7, social worker, were interviewed. OSM #7 stated RN #3 had completed section C for R120's 9/13/22 MDS. She stated:…

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, facility document review, and in the course of a complaint investigation, the facility staff failed to provide evidence of ADL (activities of daily living) care for one of 42 residents, Resident #424. The findings include: The facility staff failed to evidence that personal hygiene, specifically showers and/or bed baths was provided to Resident #424. Resident #424 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dementia, and acute pulmonary embolism. Resident #424 was discharged home on 3/29/21. The most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an ARD (assessment reference date) of 3/29/21, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not able to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfers,…

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 interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to follow the physician's order for medication administration one of 42 residents in the survey sample, Resident #372 (R372). The findings include: The facility staff failed to administer Ambien (1) as ordered to R372 on 11/10/2021 at 9:00 p.m., which was available in the facility's automated medication dispensing system. On the most recent MDS (minimum data set), a five-day admission assessment with an ARD (assessment reference date) of 11/13/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The physician orders for R372 documented in part, Ambien Tablet 10 MG (milligram) (Zolpidem Tartrate) Give 2 (two) tablet by mouth at bedtime for Insomnia. Order Date: 11/9/2021. Start Date: 11/9/2021. The eMAR (electronic medication administration record) for R372 dated 11/1/2021-11/30/2021 was reviewed…

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 maintain a safe environment for one of 42 residents in the survey sample, Resident #42. The facility staff failed to ensure Resident #42 (R42) did not have access to [NAME]'s goo (1) a compound medicated cream containing medication that R42 was allergic to. The findings include: On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/25/22, the resident's cognitive skills for daily decision making were coded as severely impaired. On 9/26/22 at 12:20 p.m., R42 was observed sitting on a walker in the bedroom. On 9/26/22 at 1:28 p.m., R42 was observed sitting in the bedroom and eating. During both observations, a plastic jar of [NAME]'s goo (containing zinc oxide, hydrocortisone and nystatin) was observed on R42's nightstand. The jar was labeled with another resident's name and was three fourths full. A review of R42's clinical record failed 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.

Based on staff interview, facility document review and clinical record review, the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for one of 42 residents in the survey sample, Resident #30. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/15/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of Resident #30's (R30) clinical record revealed a physician's order dated 2/16/22 for hemodialysis at (name of company) every Tuesday, Thursday and Saturday. A review of the facility dialysis contracts failed to reveal a contract for R30's dialysis provider. On 9/27/22 at 12:27 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated she did not have a contract for R30's dialysis provider but she had a call out to the administrator at the provider.…

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 interview, facility document review and clinical record review, it was determined the facility staff failed to coordinate hospice care services for one of 42 residents in the survey sample, Resident #121. The findings include: The facility staff failed to have the hospice care provider's documentation on the clinical record for Resident #121 (R121). On the most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 9/15/2022, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section O - Special Treatments, Programs and Procedures, the resident was coded as receiving hospice care during the look-back period. The physician order dated 9/8/2022, documented, Resident admitted to (Name of hospice) Hospice with diagnosis of sequala CVA (stroke) please call (phone number) with any question or change of condition. Review of the electronic and paper clinical record failed to evidence…

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, it was determined the facility staff failed to maintain the dumpster area in a sanitary manner to prevent pests. Approximately four clear gloves were noted on the ground around the dumpsters and bits of paper trash was observed on the ground throughout the area around the dumpsters The findings include: Observation was made of the dumpster area on 4/7/2021 at 8:49 a.m. accompanied by other staff member (OSM) #7, the dietary manager. There were three metal dumpsters. One for cardboard and two for trash. Approximately four clear gloves were noted on the ground around the dumpsters. When asked which department uses the clear gloves, OSM #7 stated that they are used throughout the facility. There were bits of paper trash throughout the area around the dumpster's. The trash did not appear to be fresh as it had dirt and mud on it. When asked whose responsibility is it to keep the area clean, OSM #7 stated it's both the kitchen and housekeeping staff. OSM #7 informed this surveyor that they had a raccoon problem. He stated…

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, clinical record review, facility document review and staff interview, it was determined facility staff failed to review and revise the comprehensive care plan for three of 33 current residents in the survey sample, (Resident #75, #51, and #94). The facility staff failed to review and revise the comprehensive care plans for Resident #75 to include the use of a physician ordered splint; for Resident #51 to include the use of bilateral lower extremity prostheses, and for Resident #94 to address the residents lower extremity edema and the use of physician ordered compression wraps to the residents bilateral feet and legs. The findings include: 1. The facility staff failed to review and revise the comprehensive care plan of Resident #75 to include the use of a wrist splint ordered by the physician. Resident #75 was admitted to the facility with diagnoses that included but were not limited to diabetes (1), dementia (2), and epilepsy (3). Resident #75's most recent MDS (minimum…

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, it was determined the facility staff failed to store and serve food in a sanitary manner in the kitchen. The findings include: Observation was made of the freezer. A box of frozen biscuit was open and the plastic bag inside the box was observed open exposing the contents to air and contamination. On the top shelf a disposable tin container of sweet potato casserole was observed with the lid to the container not secured exposing the casserole to air. Further observation of the lid revealed it was labelled with the date of 10/8/2020. OSM #7 stated that he didn't even know why that was in the freezer. A box of gluten free glazed donuts was observed on the shelf in the freezer. The box was opened and the plastic wrapper around the donuts, was also opened to air and contamination. There was no date indicating when the box was opened. When asked if the box should be open with the plastic opened to air, OSM #7 stated, no it should be closed after opening. When asked when the donuts were opened, OSM #7 stated he couldn't…

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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of six residents in the medication administration observation, Resident #13; and for two other current residents in the survey sample, Residents #74 and #38. The MARs (medication administration record) for Resident #13, #74 and #38 inaccurately documented the wrong staff as administering medications to the residents on 4/7/21 at 9:00 a.m. The findings include: 1. Resident #13's MAR (medication administration record) for 4/7/21 for 9:00 a.m. medications was inaccurate. Resident #13 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including Multiple Sclerosis (1) and Parkinson's disease (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/4/21, she was coded as being cognitively intact for making daily decision, having…

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, it was determined that the facility staff failed to follow infection control practices for two of 33 current residents in the survey sample, (Residents #336 and #38). A physical therapist failed to wear an isolation gown into Resident #336's room when he was providing treatment to the resident. The resident had a physician's order for droplet and airborne isolation precautions and the facility staff failed to sanitize an unclean blood pressure cuff before using it on Resident #38. The findings include: 1. Resident #336 was admitted to the facility on [DATE] with diagnoses including history of a stroke and right side paralysis. Resident #336 had not been admitted to the facility long enough for an MDS (minimum data set) to be completed. On the admission nursing assessment dated [DATE], Resident #336 was documented as being, alert and oriented X 3 [person, place, and time]. On 4/06/21 at 1:56 p.m., Resident #336 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.

Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to serve lunch in a manner to promote resident dignity for one of 33 current residents in the survey sample, Resident # 101. CNA (certified nursing assistant) # 3 was observed standing next to Resident 101's bed, while feeding Resident # 101 their lunch meal. The findings include: Resident # 101 was admitted to the facility with diagnoses that included but were not limited to: dementia [1], and malnutrition. Resident # 101's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/11/2020, coded Resident # 101 as unable to complete the BIMS [brief interview for mental status]. The Staff Assessment for Mental Status coded Resident # 101 as being moderately impaired for making daily decisions. Resident # 101 was coded as requiring extensive assistance of one staff member for eating. On 04/06/2021 at 2:32 p.m., an observation was conducted of CNA [certified nursing assistant] # 3 assisting…

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, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodations of resident needs for two of 33 current residents in the survey sample, Residents # 44 and # 49. The facility staff failed to ensure the call bells [a device with a button that can be pushed to alert staff when assistance is needed] for Resident #44 and Resident #49's were maintained within reach for use. The findings include: 1. Resident # 44 was admitted to the facility with diagnoses that included but were not limited to: arthritis and dementia [1]. Resident # 44's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/04/2021, coded Resident # 44 as scoring a 9 [nine] on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 - being moderately impaired of cognition for making daily decisions. Resident # 44 was coded as requiring extensive assistance of one staff member for activities 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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for three of 33 current residents in the survey sample, (Residents #336, #128, and #44). The facility staff failed to develop and implement a comprehensive care plan to include physician ordered transmission based precautions for Resident #336, failed to implement Resident #128's comprehensive care plan to administer oxygen as prescribed by the physician, and failed to develop a comprehensive care plan for Resident # 44's use of the physician ordered C-PAP [continuous positive airway pressure], with mask, and incentive spirometer. The findings include: 1. Resident #336 was admitted to the facility on [DATE] with diagnoses including, but not limited to a stroke and right side paralysis. Resident #336 had not been admitted to the facility long enough for an MDS (minimum data set) assessment to be completed. On 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 observations, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for nursing documentation for one of six residents in the medication administration observation, (Resident #13), and for two other current residents in the survey sample, (Residents #74 and #38). RN (registered nurse) #7 an agency nurse used a facility nurse's computer name and password to sign of medications that she administered to Residents #13, during the medication pass observation, and used a facility nurse's computer name and password to sign of medications that she administered to Resident #74 and #38. The findings include: 1. An outside agency nurse used a facility nurse's computer username and password to sign off on medications given to Resident #13 on 4/7/21. Resident #13 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including Multiple Sclerosis (1) and Parkinson'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 observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure respiratory services were provided by qualified persons in accordance with the written plan of care for one of 33 current residents in the survey sample, Resident #128. Resident #128 was removed from her oxygen concentrator by CNA (certified nursing assistant) #10, who then switched and connected the resident to a new oxygen concentrator and turned on the machine, which had a flow rate of 3 LPM (liters per minute) and not the physician ordered 2 LPM. CNA #10 is not qualified to remove residents from or place residents on an oxygen concentrator. The findings include: Resident # 128 was admitted to the facility on [DATE] with diagnoses that included cancer of the lung, high blood pressure, fractured ribs and depression. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/25/2021, coded the resident as scoring…

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, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide treatment and care in accordance with profession standards of practice and the comprehensive care plan for three of 33 current residents in the survey sample, (Resident #94, #120 and Resident #75). 1. Resident #94 was observed without compression wraps to both feet/legs (knee height) while awake for peripheral edema as ordered by the physician. 2. The facility nurse did not remain with Resident #120 for the duration of a nebulizer (1) treatment to ensure all of the nebulizer medication was administered as ordered by the physician. Resident #120 was observed unattended while receiving a nebulizer treatment and was observed pulling the nebulizer mask off his face multiple times during the treatment. 3. The facility staff failed to apply a splint to Resident #75's right wrist as ordered by the physician. The findings include: 1. Resident #94 was admitted to 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, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for three of 33 current residents in the survey sample, Residents #128, #44 and #73. 1. The facility staff failed to administer oxygen per the physician order and failed to follow professional standards of practice for the administration of oxygen for Resident #128. 2. The facility staff failed to store Resident #44's CPAP (continuous positive airway pressure) mask in a sanitary manner and failed to provide the resident with a incentive spirometer for use as ordered by the physician. 3. The facility staff failed to provide respiratory services in a sanitary manner for Resident #73. Resident #73's nasal cannula oxygen tubing was observed on the floor on 4/6/21 at 12:40 PM during initial resident observation rounds. LPN (licensed practical…

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, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to provide prosthesis (1) services for one of 33 current residents in the survey sample, Resident #51. Resident #51 was unable to wear their right prosthetic leg due to an improper fit which was known by facility staff and not addressed. The findings include: Resident #51 was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (2), diabetes (3) and bilateral below the knee amputation (4). Resident #51's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2021, coded Resident #51 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section G coded Resident #51 requiring supervision from one staff member for bed mobility, dressing and eating and limited assistance of one person for transfers, toilet use and personal hygiene. Section G coded…

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, it was determined the facility staff failed to ensure residents' that require dialysis, receive services, consistent with professional standards of practice for one of thirty-three residents in the survey sample, Resident #436. The facility staff failed to evidence ongoing communication and collaboration with the dialysis facility for Resident #436, during her Monday/Wednesday/Friday dialysis treatments. The findings include: Resident #436 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease (ESRD) (final stage of irreversible kidney disease) (1), COVID-19 (coronavirus 19) (2) and atrial fibrillation (rapid/random contractions of the upper chambers of the heart) (3). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 3/31/21, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for…

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.