Oakhurst Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to the management of an advanced pressure wound for one resident (Resident #4-R4), constituting harm, and the timeliness of medication administration for three residents (Resident #2 -R2, Resident #3-R3, and Resident #4-R4), in a survey sample of six residents. The findings included: 1. For R4, the facility failed to provide appropriate management of an advanced pressure wound per professional standards of care, subsequently resulting in further wound deterioration, which contstituted harm. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR means it wasn't given and, on the TAR, means it wasn't done. The DON stated, When the nurse found a new wound, that it was to be reported to me and the unit manager, cleaned with soap and water, nurse…

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 documentation review, the facility staff failed to serve meals at a temperature that was palatable to multiple residents eating in their rooms on 4 of 4 wings. The findings included: On 4/28/25, a review of the resident council minutes and grievance logs from June 2024-April 2025 were reviewed and noted that in September 2024, November 2024, and February 2025, concerns were shared about food being cold when served in resident rooms. On 4/28/25, observations were conducted in the kitchen of the evening meal. The meal service began at 4:35 p.m. Residents eating in the dining room were served first and then trays for the residents eating in their rooms were prepared and placed in a transport cart. A test tray was prepared and placed on the cart. It was observed that the facility used insulated plate bottoms and lids but were not using the heated pellets under the plates to hold temperatures. When asked why pellets were not being used, said, They have thick insulated bottoms that hold heat and don't use the pellets. When they run out…

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 documentation review, the facility staff failed to ensure food was distributed in a manner to prevent contamination in the main kitchen. The findings included: In the main kitchen, the facility staff failed to ensure that hair restraints were worn by all staff in the food preparation and distribution areas. On 6/10/25 at 12:02 p.m., observations were conducted in the main kitchen of the lunch meal's plating of food and distribution. While the facility's dietary staff were plating food on the serving line, at 12:21 p.m., the facility's maintenance director entered the kitchen and walked over to the serving line without donning a hair net or beard guard. The dietary aide immediately said, Hey, you need a hair net. To which the maintenance director did not respond. The maintenance director went behind the serving line where the cook was plating food, and pulled out a cell phone. The dietary manager then approached the maintenance director and took the cell phone…

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, clinical record review, and facility documentation review, the facility staff failed to implement their infection prevention and control program by failure to implement precautions to prevent the transmission of diseases and infections in accordance with accepted national standards from the Centers for Disease Control and Prevention (CDC) for one resident (Resident #101-R101) in a survey sample of five residents. The findings included: For R101, who had multiple open wounds, the facility staff failed to implement and adhere to enhanced barrier precautions in accordance with their policy and nationally accepted standards from CDC. On 6/10/25 at 11:33 a.m., during a tour of the facility, two certified nursing assistants were observed to enter R101's room, without donning any PPE (personal protective equipment). Observations noted there was no signage on R101's room door to indicate she was on any type of precautions. On 6/10/25 at approximately 11:45 a.m., the certified nursing assistants exited R101's room, and one pushed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled. The findings included: 1. For five residents (R6, R31, R3, R55 and R14), the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season. On 2/20/24 and 2/21/24, clinical record reviews were conducted of R6, R31, R3, R55 and R14's charts. This review revealed no evidence that any of the sampled residents had been offered the COVID-19 spike vaccine. On 02/21/24 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON), who was the facility's Infection Preventionist (IP). During this interview, the DON accessed each of the sampled resident's charts, confirmed their immunization status, 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, facility staff interviews, and facility documentation review, the facility staff failed to maintain a safe, comfortable, and homelike environment on 1 of 4 nursing units and in the main dining room. The findings included: 1. On the 300 unit of the nursing facility, the facility staff failed to ensure a safe and homelike environment, affecting multiple residents. 1a. For resident #58 (R58), the facility failed to maintain the room furnishings of a bedside table that was in good operating condition, which resulted in an environment that was not homelike. On 2/20/24, in the late morning, it was observed that R58's bedside table was missing 2 of the 3 drawers. R58 was not in the room at the time of this observation. On 2/21/24 at 9:28 AM, R58's bedside table was noted to still have only 1 drawer, the other 2 were missing. When questioned, R58 reported that it had been like that for weeks. On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 confirmed 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 failed to review and revise the care plan for 2 of 22 residents (Resident #9 and #32) in the survey sample and failed to invite/involve 2 residents (Resident #6 and #25) in their care plan meeting. The findings included: 1. A review of Resident #9 (R9's) care plan dated 9/6/23 revealed that the care plan had not been revised to indicate a code status change from full code to Do Not Resuscitate (DNR). R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, atrial fibrillation, epilepsy, major depressive disorder, Alzheimer's disease and anxiety disorder. The most current minimum data set (MDS) was an annual assessment dated [DATE], which assessed R9 with severe cognitive impairment. Review of R9's clinical record revealed that R9's power of attorney signed a DNR form on 1/7/24 and the physician placed the DNR order on 1/8/24. R9's care plan, which was revised 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #25- R25) in a survey sample of 22 residents. The findings included: For R25, the facility staff failed to maintain a complete and accurate clinical record with regards to documentation of when showers were provided. On the afternoon of 02/21/24, during interview with R25's roommate, R25 expressed concerns with not getting showers. On 2/21/24, a review of R25's clinical record was conducted, which included review of ADL (activities of daily living) records. Bathing documentation revealed that R25 had 4 occurrences of showers being provided in January 2024 and 2 showers being provided in the month of February 2024. On 02/21/24 at 03:23 p.m., an interview was conducted with Certified Nursing Assistant #4 (CNA #4), who stated that showers are given twice weekly and are scheduled, which is on the CNA's assignment sheet. CNA #4 showed the surveyor the assignment sheet, which indicated R1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) assessment for one of twenty-two residents in the survey sample (Resident #44). The findings include: Resident #44's admission MDS (an assessment tool) dated 1/18/24 inaccurately assessed the resident with having no dental problems, when the resident was edentulous (no natural teeth). Resident #44 (R44) was admitted to the facility with diagnoses that included osteoarthritis, depressive disorder, Parkinson's disease, heart failure and spinal stenosis. The MDS dated [DATE] assessed R44 as cognitively intact. On 2/20/24 at 11:21 a.m., R44 was interviewed about quality of life/care in the facility. R44 stated during this interview that she had pulled all teeth prior to admission to the facility and was waiting to get full dentures. R44 was observed with no natural teeth and stated she was on a soft diet because she was unable to chew some food items because…

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 failed to develop a care plan for three of twenty two residents. 1. Resident #49 (R49) was not care planned for the use of a hoyer lift (hydraulic equipment used to safely transfer residents). 2. R21 had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and a care plan had not been developed. 3. R44 did not have a care plan for dental issues. The Findings Include: Diagnoses for R49 included; Acquired absence or right hip joint, osteoporosis, pathological left femur fracture, right knee replacement, and rheumatoid arthritis. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 out of 15, indicating moderately impaired cognition. Section GG Functional Abilities indicated R49 was impaired on all extremities and was totally dependant on staff with sit to stand and chair/bed to chair. On 2/20/24…

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 documentation review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #22- R22) in a survey sample of 22 residents. The findings included: For R22, who refused lab work, the facility staff failed to notify the physician that the order was not able to be carried out. On 2/20/24 and 2/21/24, a clinical record review was conducted of R22's chart. This review revealed that on 1/26/24, the physician entered an order that read, LAB- Valproic Acid [Valproic acid level], CMP [complete metabolic panel], CBC [complete blood count], LFT [liver function tests] on [DATE] and July 26 every night shift every 6 month(s) starting on the 26th for 1 day(s). According to the treatment administration record, R22 refused the lab draw on 1/26/24. There was no documentation within the progress notes, nor elsewhere, that indicated the physician was made aware that the order for labs was unable to be carried out. 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, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of twenty-two residents in the survey sample (Residents #1 and #3). The findings include: 1. Resident #3 (R3), assessed as needing help with personal hygiene, was observed with long, uneven fingernails. R3 was admitted to the facility with diagnoses that included diabetes, hypertension, chronic pain syndrome, ischemic heart disease, chronic kidney disease, vascular dementia, anemia, and anxiety. The minimum data set (MDS - assessment tool) dated 1/31/24 assessed R3 as cognitively intact and requiring help with self-care. On 2/20/24 at 3:00 p.m., R3 was observed seated in a wheelchair at the doorway of his room. R3 had long fingernails on both hands. The nails extended beyond R3's fingertips, with several nails having uneven/jagged edges. On 2/21/14 at 12:57 p.m., R3 was interviewed about his fingernails. R3 stated that his fingernails were long and needed to be cut. R3 stated, I'd like to have them [fingernails]…

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 clinical record review, the facility failed to administer medication according to physician orders for 1 of 22 residents (Resident #27). The findings included: The facility staff failed to follow physician orders during administration of artificial tears for Resident #27 (R27). On 2/20/24 at 3:52 PM, during the task of medication administration, licensed practical nurse #3 (LPN#3) was observed administering one drop of artificial tears to the left eye of R27, with no artificial tears applied to the right eye. Review of R27's clinical record revealed an order (dated 1/29/24) for artificial tears ophthalmic solution, instill 1 drop in both eyes three times a day for eye lubrication, related to acute angle closure glaucoma. On 2/20/24 at 4:52 PM, when questioned about the order for artificial tears for R27, LPN #3 stated that the right eye drop was missed during med administration. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concern. No additional…

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 clinical record review, the facility failed to ensure parameters were put in place for supplemental oxygen for one of 22 residents. An oxygen order for resident #49 (R49) did not have a rate of delivery. The Findings Include: Accorning to the clinical record, diagnoses for R49 included Respiratory failure, asthma, chronic obstructive pulmonary disease, emphysema, and supplemental oxygen dependant. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 indicating moderately cognitively impaired. On 2/20/24 at 12:17 PM, R49 was observed with oxygen via nasal cannula being delivered at 2 liters per minute (LPM). When asked about the oxygen, R49 verbalized using it all the time. Review of R49's physician order for oxygen dated 11/23/23 and revised on 2/5/24 read Oxygen Continuous. There was no information regarding how much and what route to administer the oxygen. On 2/21/24 at 1:25 PM, registered nurse (RN #2 ) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to identify the specific trauma or triggers regarding post-traumatic stress disorder (PTSD) for 1 of 22 residents in the survey sample (Resident #21). The findings included: The facility staff failed to identify and document the experiences that caused Resident #21 (R21)1 to develop PTSD or preferences to eliminate or mitigate triggers that may cause re-traumatization. Review of the clinical record revealed that R21 was admitted with diagnoses that include PTSD, Alzheimer's disease, schizophrenia, bipolar, anxiety, major depressive disorder and cerebral infarction. It was also documented that R21 was assessed on 12/30/23 as having moderate cognitive impairment. Review of R21's care plan, initiated 12/14/22 with a revision date of 5/19/23, revealed that R21 had a behavior problem due to diagnosis of PTSD but did not include the specific cause of the PTSD, what the behaviors were, or what triggers caused…

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, and clinical record review, the facility staff failed to provide social services to assist with obtaining glasses for 1 of 22 residents (Resident #32). The findings include: The facility staff failed to assist resident #32 (R32) with obtaining glasses that were prescribed on 12/13/23. Review of the clinical record revealed that R32 had diagnoses that included congestive heart failure, schizophrenia, chronic kidney disease, hypertension, depression and anxiety. It was also documented that R32 was assessed on 12/2/23 as cognitively intact. On 2/20/24 at 3:08 PM, an interview was conducted with R32, during which R32 voiced concerns that she had attended an appointment with an .eye doctor and had not received the glasses yet. Review of R32's clinical record documented an appointment with an optometrist on 12/13/23, in which R32 received a prescription for glasses. On 2/22/24 at 8:31 AM, the social worker, other staff #1 (OS#1) was interviewed regarding glasses for R32. OS#1 stated that R32 has no funds available and that R32 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to respond to pharmacy recommendations for 1 of 22 residents in the survey sample (Resident #9). The findings included: The facility staff failed to respond to a pharmacist recommendation to attempt a gradual dose reduction of Seroquel for Resident #9 (R9). Acording to the clinical record, R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, major depressive disorder, Alzheimer's disease, and anxiety disorder. The most current minimum data set (MDS - an assessment tool), an annual assessment dated [DATE], assessed R9 with severe cognitive impairment. Review of R9's clinical record documented a physician's order for Seroquel 100 mg tablet, give 1 tablet by mouth at bedtime that started on 11/25/22. Review of R9's psychiatric assessments, dated 9/22/23 and 12/20/23, documented the most recent attempt for a gradual dose reduction for Seroquel was on 8/14/22. On 1/18/24, the consulting…

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 one of 22 residents in the survey sample was free of unnecessary medications (Resident #9). The findings included: The facility staff failed to attempt a gradual dose reduction of Seroquel for Resident #9 (R9). According to the clinical record, R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, major depressive disorder, Alzheimer's disease and anxiety disorder. The most current minimum data set (MDS - an assessment tool), an annual assessment dated [DATE], assessed R9 with severe cognitive impairment. Review of R9's clinical record documented a physician's order for the antipsychotic Seroquel 100 mg tablet, give 1 tablet by mouth at bedtime that started on 11/25/22. Review of R9's psychiatric assessments dated 9/22/23 and 12/20/23 documented the last attempt for a gradual dose reduction for Seroquel was on 8/14/22. Psychiatric notes also documented nursing reports patient can be irritable 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 observation, facility documentation, and staff interview, the facility failed to accurately label open medication to ensure safe administration and storage. The Findings Include: The facility failed to ensure that a multi-dose vial of medication was labeled with a open date. On 2/21/24 at 11:16 a.m., an observation of the medication storage room was conducted on the nursing unit, in the presence of license practical nurse (LPN1), who provided access. An opened, multidose vial of the influenza vaccine was observed in the refrigerator. No open date was noted on the label. When questioned about this, LPN1 examined the medication, verbalized not seeing an opened date, and removed the medication from the refrigerator. On 2/21/24 at 11:30 a.m., when questioned further, LPN1 stated that an open date should be placed on the vial when medication is opened. A facility policy titled, Medication Storage, read in part, Medications requiring refrigeration must be stored in a refrigerator and medications must be labeled accordingly. On 2/21/24 at 4:05 p.m., the above information 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 staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory (Lab) services for one of 22 residents (Resident #38 - R38) in the survey sample; a CBC (Complete Blood Count) and A1C (Glycated Hemoglobin Test) were not collected as ordered for R38. The Findings Include: According to the clinical record, diagnoses for R38 included Diabetes, and kidney failure. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/19/24. R38 was assessed with a cognitive score of 6 out of 15, indicating moderately impaired cognition. Review of R38's physician order set documented an order, dated 6/24/23, for a CBC and A1C to be collected every three months on March 27th, June 27th, September 27th, and December 27th. Review of lab results did not evidence the lab was collected on December 27th, 2023. Review of R38's treatment administration record (TAR) for December showed a blank box (where a nurse would sign off that the order was completed) for December 27th. On 2/21/24 at 1:17 PM, an…

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 and facility document review, the facility failed to provide sufficient nursing staff. Daily staffing logs evidenced low nursing staff during Christmas 2022. The Findings Include: Review of daily working logs (actual hours worked) for nursing staff revealed on 12/25/22 (Christmas day) the working shift from 7:00 AM through 7:00 PM consisted of two nurses and one certified nurses aide (CNA). Review of the scheduled for 12/25/23 indicated there were supposed to be two nurses and three CNA's. The schedule or any other documentation did not evidence what the census was on 12/25/23 in this 60 bed facility. However, documentation did evidence nurse staffing prior to Christmas day and after Christmas day had three nurses and up to 5 CNA's working. On 12/12/23 at 1:10 AM, CNA #1 (identified as the CNA working on Christmas day) was interviewed. CNA #1 verbalized that Christmas was a busy day and between himself, the two nurses, and any other available staff members, residents were being taken care of including meals, incontinence care, and activities of daily living…

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 and clinical record review, the facility failed to ensure an accurate clinical record for one of 7 residents. Resident #1 (R1) had an inaccurate activities of daily living (ADL) record. The Findings Include: Diagnoses for R1 included; seizure disorder, traumatic brain disorder, dementia, anxiety, and bipolar. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/1/23. R1 was assessed with a score of 10 indicating moderately cognitive impairment. Review of R1's clinical record in regards to a complaint indicated there were no entries made on the ADL record on day shift on 12/25/23 for eating, meal intake, and bowel and bladder elimination. On 12/12/23 at 1:10 PM, CNA #1 was interviewed. CNA #1 verbalized working on 12/25/22 (Christmas day), which was busy because of low staffing, but did remember providing incontinence care to R1 around midmorning. CNA #1 said that while working on the hallway were R1 resides, R1's sister was observed helping to change R1. CNA #1 verbalized the taking over…

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 implement their abuse prevention policies regarding promptly reporting an injury of unknown origin to the state agency for 1 for 18 in the survey sample, Resident #48; and failed to follow their pre-employment screening policies for 13 out of 25 employees reviewed. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples. This injury of unknown origin was not reported to the state survey agency or other local agencies as required by the facility's policy for abuse reporting/investigation. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan for four of eighteen residents in the survey sample, Resident #31, #38, #46, and #11. Resident #31 was not care planned for self-administration of an albuterol inhaler; Resident #38 was not care planned for smoking; Resident #46 was not care planned for dental issues; and Resident #11 was not care planned with interventions for an existing pressure ulcer. Findings were: 1. Resident #31 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Fibromyalgia, depression, respiratory disorder, and chronic ischemic heart disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/19/2021, assessed Resident #31 as cognitively intact with a summary score of 15. On 10/05/2021 at approximately 8:00 a.m., Resident #31 was observed sitting on her bed.…

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 ensure care in accordance with the resident's plan of care for 1 of 18 in the survey sample, Resident #27. Resident #27 was not weighed per facility standing orders, and to ensure that she was maintaining weight as directed in her care plan. The findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses that included hypertension, anemia, paraplegia, mild-protein-calorie malnutrition, adult failure to thrive, gastro-esophageal reflux disease (GERD), depression, and dementia with behavioral disturbance. The most recent minimum data set (MDS) dated [DATE] was the annual/comprehensive assessment and assessed Resident #27 has having long and short term memory problems with continuous inattention and behaviors including delusions, rejection of care and behaviors towards others. Resident #27's clinical record was reviewed on 10/05/2021. The weights section of the clinical record documented the last…

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 food in a sanitary manner in the main kitchen. The findings include: On 10/4/21 at 6:25 p.m., accompanied by the dietary manager (other staff #2) the kitchen and food storage areas were inspected. Stored in the dry storage room were the following: one carton of Thick and Easy dairy beverage - opened and not dated; one 46-ounce carton of nectar thick orange juice - opened and not dated; two 46-ounce cartons of thickened apple juice - opened and not dated. The seals on these beverage were punctured and the product partially used from the cartons. These beverages were not refrigerated but were stored in the dry storage room along with unopened cartons of thickened beverages and juices. The manufacturer's label on each of these cartons stated to Refrigerate after opening. On 10/4/21 at 6:30 p.m., the dietary manager was interviewed about the opened, unrefrigerated dairy/juice beverages. The dietary manager stated the opened beverages should have been dated when opened and stored in 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, facility document review, staff interview and clinical record review, the facility staff failed to inspect a bed frame and mattress for possible entrapment risks for one of eighteen residents in the survey sample. Resident #11's bed, installed with a specialty air mattress for over 5 months, had not been inspected for entrapment risks. The facility's most recent bed inspections had no documented date of completion and did not include all facility beds in use. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a nursing note dated 4/28/21 stating, Outside vendor arrived at facility at 2130 [9:30 p.m.] to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess one of eighteen (18) residents for self-adminstration of medications, Resident #31. Resident #31 was observed with an albuterol inhaler at her bedside for self administration as needed. Resident #31 had not been assessed by the interdisciplinary team to ensure safe usage of the inhaler. Findings were: Resident #31 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Fibromyalgia, depression, respiratory disorder, and chronic ischemic heart disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/19/2021, assessed Resident #31 as cognitively intact with a summary score of 15. On 10/05/2021 at approximately 8:00 a.m., Resident #31 was observed sitting on her bed. She was wearing oxygen via a nasal cannula at 3 liters per minute. Resident #31 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to ensure a safe, operational bed for one of eighteen residents in the survey sample, Resident #11. Resident #11 was in a bed with no functional controls to raise the head, foot or height of the bed. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. On 10/5/21 at 11:48 a.m., accompanied by a hospice registered nurse (RN #1), Resident #11 was observed in bed. The head of the bed was raised approximately 30 degrees. RN#1 repositioned the resident for a dressing change and stated the resident's bed did not work. RN #1 stated the bed controls were broken and she was unable to move 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, clinical record review and facility document review, the facility staff failed to ensure an injury of unknown origin was reported to the State Survey Agency and adult protective services for 1 of 18 in the survey sample, Resident #48. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 has requiring limited assistance with one person physical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility staff failed to accurately completed a PASARR (Preadmission screening) for one of eighteen residents in the survey sample, Resident #46. Findings were: Resident #46 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: Schizophrenia, dementia with behavioral disturbance, alcohol abuse, chronic viral hepatitis, and post traumatic stress syndrome. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/09/2021. Resident #46 was assessed as cognitively intact with a summary score of 15. Resident #46's clinical record was reviewed on 10/05/2021 at approximately 3:00 p.m. There was no PASARR observed in the clinical record. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant, the above information was discussed. The DON stated that she would locate the PASARR. The copy of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clincial record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 18 in the survey sample, Resident #48. Resident #48's care plan was not revised for falls, including an injury of unknown origin. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 has requiring limited assistance with one person physical assistance for transfers, ambulation, eating and locomotion; extensive assistance with one person physical 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.

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 perform a pressure ulcer dressing change in a manner to prevent infection for one of eighteen residents in the survey sample, Resident #11. A nurse failed to perform hand hygiene and gloves changes during a dressing change to Resident #11's pressure ulcer. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented physician orders dated 9/14/21 with instructions to cleanse the wound, pat dry, apply Santyl ointment and alginate foam dressing daily for treatment of the right gluteal fold pressure ulcer. On 10/5/21 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 follow infection control practices with placement of urinary catheter bag for one of eighteen residents in the survey sample, Resident #11. Resident #11's catheter bag was observed in the floor beside the resident's bed. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills.On 10/5/21 at 8:50 a.m., Resident #11 was observed in bed. The resident's urinary catheter bag was in the floor beside the bed on the window side of the room. On 10/5/21 at 10:51 a.m., Resident #11's urine collection bag was again observed in the floor beside the bed. On 10/5/21 at 11:48…

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 documentation review, the facility staff failed to administer the COVID vaccine in a timely manner to one of 18 residents, Resident #27. Resident #27's Responsible Party consented to administration of the COVID vaccine on 06/04/2021, the vaccine was not given until 09/30/2021. Findings were: Resident #27 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: hypertension, paraplegia, mild-protein-calorie malnutrition, adult failure to thrive, gastro-esophageal reflux disease (GERD), depression, and dementia with behavioral disturbance. The most recent minimum data set (MDS) with an ARD (assessment reference date) of 08/09/2021 was an annual assessment. Resident #27 was assessed as has having long and short term memory problems with continuous inattention and behaviors including delusions, rejection of care and behaviors towards others. Resident #27's clinical record was reviewed on 10/06/2021 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 and clinical record review, the facility staff failed to ensure an accurate meal ticket for one of 19 residents in the survey sample. In addition, the facility failed to ensure a system for printing meal tickets in the facility that accurately reflected physician ordered therapeutic diets, food allergies and resident preferences. Resident #23, served a puree diet, had a meal ticket for a mechanical soft diet. The ticket documented the resident was served ground pork when puree turkey was actually served. The ticket indicated ground pork was served when ticket instructions stated No Pork. The facility had an unresolved issue with inaccurate meal tickets since April 2018. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #23 included dementia, dysphagia, high blood pressure and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, the facility staff failed to ensure a dignified dining experience during lunch observation for one of 19 residents in the survey, Resident #40. Resident #40, was identified as needing to be fed, was fed by a staff member who stood over the resident while feeding her. Findings include: Resident #40, was admitted to the facility on [DATE]. Diagnoses included malnutrition, Vitamin D Deficiency, falls, dehydration, acute kidney failure, hypernatremia, Alzheimer's Dementia, osteoporosis, septic shock, encephalopathy, and hospice services. The most recent minimum data set (MDS) dated [DATE], was a quarterly assessment and assessed Resident #40 as being severely cognitively impaired with a score of 1 out of 15. The MDS dated [DATE], under Section G (Functional Status), at item G0110 (H), Eating assessed Resident #40 as requiring extensive assistance with one-person physical assistance for eating. A dining observation was conducted in the main dining room…

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 Resident #8 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had a complaint. The resident stated that an aide had stated to her hat she was going to punch the resident in the face. The resident stated that she didn't know why the aide said that to her, but stated that maybe it was dominance and stated that the aide has…

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, clinical record review and facility document review, the facility staff failed to implement written policies and procedures for the prevention of abuse and investigation of abuse allegations, for one of 19 residents in the survey sample, Resident #8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 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 resident interview, staff interview, clinical record review and facility document review, the facility staff failed to report an allegation of sexual abuse to the state agency and/or officials in accordance with State law. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had 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 resident interview, staff interview, clinical record review and facility document review, the facility staff failed to thoroughly investigate an allegation of sexual abuse for one 19 residents in the survey sample, Resident #8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to issue written notice of the bed-hold policy at the time of transfer for one of 19 residents in the survey sample. No written bed-hold notice was provided when Resident #109 was transferred to the hospital. The findings include: Resident #109 was admitted to the facility on [DATE] and was discharged to the hospital on 3/28/18. Diagnoses for Resident #109 included hip fracture, high blood pressure, peripheral vascular disease and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #109 with moderately impaired cognitive skills. Resident #109's clinical record documented the resident was sent to the emergency room on 3/28/18 due to an altered mental status. The clinical record documented no written notification to the resident or her responsible party concerning the bed-hold policy. On 3/21/19 at 10:30 a.m., the director of nursing (DON) was interviewed about any bed-hold notification 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.

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 PASARR (preadmission screening and resident review) was completed prior to admission to the facility for one of 19 residents in the survey sample, Resident 8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. During clinical record review for Resident #8, no preadmission…

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 develop a comprehensive care plan for three of 19 residents in the survey sample. 1. Resident #23 had no plan of care regarding use of plastic eating utensils due to unsafe behaviors. 2. Resident #29 had no individualized care plan developed regarding unsafe wandering and elopement prevention. 3. Resident #59 had no comprehensive plan of care regarding suicidal ideation. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #23 included dementia, dysphasia, high blood pressure and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. On 3/19/19 at 12:30 p.m., Resident #23 was observed eating lunch in her room. The resident was using plastic utensils while eating. The meal ticket on Resident #23's lunch tray documented, Plastic Silverware. Resident #23's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to review and revise a comprehensive care plan for one of nineteen residents. Resident #20's care plan was not revised regarding code status. The findings include: Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included eczema, bursitis of hip, perforated appendicitis, muscle weakness, chronic bronchitis, dementia with behaviors, depression, hypertension and anorexia. The most recent minimum data set (MDS) dated [DATE], was a significant change and assessed Resident #20 as severely cognitively impaired with a score of 01 out of 15 for daily decision making. Resident #20's clinical record was reviewed on 03/20/18 at 10:00 a.m. Observed on the physician's order form were orders for Do Not Resuscitate - Do Not Intubate, dated 12/22/18. Resident 20's care plans were reviewed and documented the following: Focus - [Resident #20], has advance directives r/t (related to) his choice not to execute advance…

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 implement a bowel regimen program for one of 19 residents in the survey sample, Resident #26. Resident #26 stated that he had not had a bowel movement in 5 days and was uncomfortable. Findings include: Resident # 26 was admitted to the facility on [DATE]. Diagnoses for Resident #26 included, but were not limited to: atrial fibrillation, high blood pressure, anxiety disorder and depression. The most recent MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS documented the resident with a cognitive score of 14, indicating the resident was cognitively intact for daily decision making skills. The resident also was assessed as requiring supervision with one person physical assist for most all ADL's except bathing, which was extensive assist of person. He was coded a 0 (always continent) for bowel and 1 for urinary (occasional incontinent). On 03/20/19 at approximately 2:30 PM, 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, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure supervision for the prevention of accidents for one of 19 residents in the survey sample, Resident #29. Resident #29, assessed as an elopement risk was not provided supervision and found outside of the facility on June 5, 2018 and November 28, 2018. Findings include: Resident #59 admitted to the facility on [DATE]. Diagnoses included, but were not limited to: anemia, thyroid disorder, osteoarthritis, MS (multiple sclerosis), anxiety disorder, depression, neuralgia, neuritis, chronic pain syndrome, intractable migraines, and opioid abuse. An annual MDS (minimum data set) dated 05/30/18 documented the resident was a score of 15 for cognition, indicating the resident was cognitively intact for daily decision making skills. The resident was documented with a score of 23 [range 0-27] for total severity of mood and was also assessed on this MDS as 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.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Medication pass observations revealed three errors out of 39 opportunities resulting in a 7.6 % error rate. The findings include: 1. A medication pass observation was conducted on 3/20/19 at 8:00 a.m. with registered nurse (RN) #1 administering medications to Resident #18. During this observation, RN #1 administered the medication Carbamazepine 200 mg (milligrams) to Resident #18. Resident #18's clinical record documented a physician's order dated 5/31/17 for Carbamazepine 400 mg to be administered each day at 8:00 a.m. for treatment of a seizure disorder. On 3/20/19 at 8:50 a.m., RN #1 was interviewed about the Carbamazepine administered to Resident #18. RN #1 reviewed the physician's order and stated the resident had two orders for the Carbamazepine with 400 mg to be given at 8:00 a.m. and 600 mg to be given at 8:00 p.m. RN #1 at this time reviewed Resident #18's medication supply cards in the cart. Resident #18 had a card 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 staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 19 residents in the survey sample. Resident 109's closed clinical record did not include records of treatments/dressing changes provided for wound care and the resident's bathing records were incomplete. The findings include: Resident #109 was admitted to the facility on [DATE] and was discharged to the hospital on 3/28/18. Diagnoses for Resident #109 included hip fracture, high blood pressure, peripheral vascular disease and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #109 with moderately impaired cognitive skills. a) Resident #109's closed clinical record documented the resident was admitted to the facility with a surgical wound on her left hip, a pressure ulcer to the sacrum and chronic wounds on toes of her left foot. The record documented a physician's order dated 3/10/18 for a Hydrogel dressing to the web of her left toes to be changed daily,…

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 follow infection control practices regarding hand hygiene during housekeeping; failed to implement infection control protocols for the prevention of Legionella and other water borne pathogens; and failed to follow infection control protocols during medication administration. A housekeeping staff member failed to perform hand hygiene after glove removal between cleaning of resident rooms and offices. The facility had no evidence of implementing maintenance and service items required in their water management program for the prevention of Legionella and other water borne pathogens. During a medication pass observation, a nurse dropped a medication on the top of the cart and then administered the medication to a resident. The findings include: 1. On 3/19/19 at 11:15 a.m., a housekeeping staff member was observed with gloves on, sweeping the floor in room [ROOM NUMBER]. The housekeeper went into the resident's bathroom,…

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.