Complete Care At Oak Ridge LLC

Based on resident interview, record review and staff interview the facility failed to ensure residents were treated with respect and dignity. Resident #24 was provided care by a male Nurse Aide when it was known she preferred a female Nurse Aide to provide her care. In addition a Nurse Aide took photographs of Resident #63, #65, #24, #36, and #28 to prove they were in need of incontinence care before providing the needed care. This failed practice was true for five (5) of five (5) residents reviewed for the care area of dignity during the long term care survey process. Resident Identifiers: #63, #65, #24, #36 and #28. Facility Census: 63. Findings Include: a) Resident #24 During an interview on 07/22/24 at 1:29 PM Resident #24 stated, I don't think they can read to good here. When she was asked to elaborate the resident stated, They know I only want a female nurse aide. It is written down somewhere, but a few days not too long ago I had a male nurse side. He is a good aide and he took good care of me, but I did not like it because he was a man. A review of the residents 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 resident interview, staff interview, and record review the facility to ensure residents were free from mental abuse and additionally failed to identify what happened to the residents as Mental Abuse when the investigation was complete. Nurse Aide #160 took photos of Resident #63, #65, #24, #36, and #28 which to a reasonable person would cause the resident to suffer humiliation, shame and/or degradation. This was true for Five (5) of eight (8) residents reviewed for the care area of Abuse during the long term care survey process. Resident Identifiers: #63, #65, #24, #36 and #28. Facility Census: 63. Findings include: a) Nurse Aide (NA) #160 A review of the facility's reportable incidents found on 05/13/24 the facility reported five (5) separate reportable incidents related to the same nurse aide. A review of each reportable found they all contained the following allegation, Nurse aide took photos of resident to prove incontinence care was needed. Photos of resident's did not include their face; however…

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 record review and staff interview the facility failed to implement their policy titled: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation. The faicliity failed to report all allegations of abuse related to Resident #12. Also for Resident #63, #65, #24, #36 and #28 the facility failed to identify the actions of Nurse Aide #160 as mental abuse when she took pictures of the residents in their briefs. This failed practice was true for six (6) of eight (8) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: #12. #63, #65, #24, #36, and #28. Facility Census: 63. a) Resident #12 On 07/24/24 at 1:28 PM the Director of Rehab (DOR) was interviewed in regards to a complaint investigation in which it was alleged Physical Therapist (PT) #102 was documenting and billing for therapy services which the residents never received. When asked if anyone had ever brought to her attention that PT #102 may be billing and documenting therapy services…

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 record review and staff interview the facility failed to report all allegations of abuse and/or neglect to the appropriate agencies as required by regulation. Resident Identifiers: #12 and #5. Facility Census: 63 Findings included: a) Resident #12 On 07/24/24 at 1:28 PM the Director of Rehab (DOR) was interviewed in regards to a complaint investigation in which it was alleged Physical Therapist (PT) #102 was documenting and billing for therapy services which the residents never received. When asked if anyone had ever brought to her attention that PT #102 may be billing and documenting therapy services which the residents never received she stated, Yes Physical Therapist Assistant (PTA) #98 had reported this to her. She stated, she called her corporate office and they advised her to take the social worker and go talk to all the residents currently receiving therapy. During an interview with Social Worker #75 on 07/24/24 at 2:18 PM, Social Worker #75 stated, PTA #98 came into her office and reported that Resident #12 stated she did not receive her therapy yesterday. (She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to notify the resident and/or the resident representative of the bedhold policy when Resident #23 was transferred from the facility on three (3) occasions. This was true for one (1) of four (4) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifier: #23. Facility census: 63. Findings Include: a) Resident #23 A review of Resident #23's medical record on 07/23/24 found the resident was transferred to the hospital on [DATE], 05/31/24, and 07/12/24. The facility was asked to provide the bedhold policy notification for the three (3) discharges. They provided a bed hold policy for Resident #23 for each of the dates listed, however the bed hold policies were not signed by the resident and/or their representative. There was also no notes indicating the facility had verbally spoke with the resident and/or representative about the bed hold policy to see if they wanted to pay the bed hold fee. 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 record review and staff interview the facility failed to implement physicians orders, failed to follow their weight policy for reweighs and failed to identify a significant weight gain. This was true for one (1) of two (2) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #40 Facility Census: 63 Findings Include: a) Physician orders On 07/23/24 at 1:02 PM a review of Resident #40's medical record found a 17.6 pound weight gain from 07/09/24 until 07/16/24. According to the diagnosis sheet for this resident which was provided by the facility, Resident #40 had an active diagnosis of Congestive Heart Failure (CHF). According to further record review of the last six (6) months, the following weeks had no weight documented for this resident. 01/23/24, 04/16/24, 04/30/24 and 06/25/24. The facility failed to follow the active physicians order for: Weekly weights every Tuesday every day shift for Congestive Heart Failure. This was confirmed with the Director of Nursing on 07/23/24 at 1:30 PM who agreed with the missed…

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 record review and staff interview the facility failed to ensure Nurse Aides (NA's) completed all required competencies. This was true for five (5) of five (5) NA competencies reviewed during the long term care survey process. Identifier: NA #9, NA #20, NA #28, NA #40 and NA #53 Census: 63. Findings included: On 07/23/24 at approximately 7:30 PM during a review of the completed competencies provided for NA #09, NA #20, NA #28, NA #40 and NA #53 the following competencies was identified. a) NA #09 - Date of Hire - 04/18/24 * NA safe O2 (oxygen) handling competency * Competency Validation Total Lift * Competency Validation Invacare Sit to Stand Lift b) NA #20 - Date of Hire - 12/16/21 * NA safe O2 (oxygen) handling competency c) NA #28 - Date of Hire - 09/22/09 * NA safe O2 (oxygen) handling competency * Competency Validation Total Lift * Competency Validation Invacare Sit to Stand Lift d) NA #40 - Date of Hire - 04/18/24 * NA safe O2 (oxygen) handling competency * Competency Validation Total Lift * Competency Validation Invacare Sit to Stand Lift e) NA #53 - Date of Hire -…

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 and staff interview the failed to ensure appropriate environmental controls for safe medication storage by not obtaining the temperature in the Medication Refrigerator and maintaining these temperatures on the temperature log on a daily basis. This discovery was made during the Long Term Care Survey Process. Facility census: 63. Findings include: a) Facility On 07/23/24 at approximately 2:30 PM, a observation was made of the facility medication storage room. At this time a log was noted for the medication refrigerator titled, Temperature Log for Refrigerator and Freezer which was dated July 2024. Upon reviewing this log, it revealed several areas without the required information documented. These areas were as follows: Staff Initials for dates 07/04/24 dayshift, 07/05/24 dayshift and 07/19/24 dayshift. Room temperature for dates 07/04/24 dayshift, 07/05/24 dayshift and 07/19/24 dayshift. Exact time for dates 07/04/24 dayshift, 07/05/24 dayshift and 07/19/24 dayshift. Furthermore, the instructions on this log states temperatures are to be checked 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, staff interview and the facility policy for Safe Handling for Foods from Visitors, the facility failed to ensure the freezers in the resident rooms was being monitored for temperatures daily. This was true for three (3) of three (3) refrigerators/freezers observed during the long term care survey process. Identifiers: Resident room [ROOM NUMBER]B, Resident room [ROOM NUMBER]B and Resident room [ROOM NUMBER]B. Census: 63. Findings included: a) Resident room [ROOM NUMBER]B, Resident room [ROOM NUMBER]B and Resident room [ROOM NUMBER]B During a tour of the facility, Resident room [ROOM NUMBER]B, Resident room [ROOM NUMBER]B and Resident room [ROOM NUMBER]B all were observed and had refrigerators with freezers. Temperatures were noted to only be documented for the refrigerator and not for the freezer. During a review of the facility policy for Safe Handling for Foods from Visitors it is identiifed on page one (1) under number five (5) stated the refrigerators/freezers will be properly…

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 record Review and staff interview the facility failed to ensure the residents medical record was complete and accurate. This was true for one (1) of 25 residents reviewed during the long term care survey process. Resident Identifier: #10. Facility Census: 63. Findings Include: a) Resident #10 A review of Resident #10's medical record on 07/23/24, found an order for Hydrocodone five (5) milligram - 325 milligrams as needed every 24 hours. A review of the controlled substance log and medication administration record (MAR) since April 2024 through current found on through current found on the following days the Hydrocodone was signed out on the Controlled Substance log but was not documented as administered on the MAR: 04/24/24 04/30/24 05/09/24 05/13/24 and 05/21/24. An interview with the Director of Nursing on 07/23/24 at 11:55 AM confirmed the above findings.

Based on observation and staff interview the facility failed to develop and implements an ongoing infection prevention and control program (PCP) to prevent, recognize, and control the onset and spread of infection. This was a random opportunity for discovery. Resident identifiers: Resident #270 and #5. Facility census: 63. Findings include: a) Facility On 07/23/24 at 07:55 AM, a medication administration observation was made with RN #41. At this time, RN #41 entered Resident #270's room to administer medication and obtain a blood glucose reading using the glucometer from the medication administration cart. Upon entering Resident #270's room, RN #41 was observed to lay the glucometer on Resident #270's bed with no barrier. RN #41 then performed the blood glucose test on Resident #270. RN #41 then carried the glucometer out into the hallway and was observed to wipe the glucometer off with an alcohol prep pad and lay the glucometer on the medication cart, RN #41 was then was observed to place the glucometer into the top drawer of the medication cart. This Surveyor then asked RN #41,…

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

Based on facility record review and staff interview, the facility failed to ensure all Nursing Assistants (NA's)received the required minimum of 12 hours of nurse aide training per year. This was true for one (1) of five (5) NA's reviewed during the long term care survey process. Identifier: NA #28. Census: 63. Findings include: a) NA #28 - Hire date - 09/22/09 On 07/23/24 at approximately 7:15 PM during a review of the 12 hours of nurse aid training, the NA training reviewed from 05/01/23 to current identified the following nurse aide training hours completed: *11/22/23 - Abuse Neglect and Exploitation - .75 hours * 07/07/24 - Catheter and Perineal Care - .25 hours In reviewing the required minimum of 12 hours of nurse aid training per year, and NA #28's one (1) hour of completed training with the Administrator on 07/24/25 at approximately 11:45 AM. The Administrator agreed NA #28 had not completed the required minimum of 12 hours of nurse aid training per year.

Based on record review and staff interview, the facility failed to ensure the resident and or representative was informed in advance by the physician, other practitioner or health professional of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative option preferred prior to the administration of an psychotropic medication. This was true for 1 (one) of 5 (five) residents reviewed for unnecessary medications in the Long Term Care Survey Process. Resident identifier: #5. Facility census: 63. Findings include: a) Resident #5 On 07/24/24 at approximately 2:24 PM, a review of Resident #5's medical record was performed which revealed Resident #5 was receiving 2 (two) antipsychotic's and 1 (one) antidepressant. The physicians orders were as follows: * Quetiapine Fumarate (Seroquel) 25 mg 1 (one) tablet by mouth at bedtime for dementia with behavioral disturbance. * Nuplazid 34 mg 1 (one) capsule by mouth one time a day for Parkinson's with psychosis as evidenced by delusions/hallucination. * Fluoxetine (Prozac) 20 mg 1 (one)…

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 record review and staff interview the facility failed to notify the physician of a significant weight loss for Resident #14. This was true for 1 (one) of 2 (two) residents reviewed for the care area of nutrition during the Long Term Care Survey Process.Resident identifier: Resident #14.n Facility census: 63. Findings include: a) Resident #14 On 07/24/24 at 10:09 AM, a review of Resident #14's medical record was conducted which revealed on 02/02/24, Resident #14 weighed 203.2 lbs. On 07/09/24, Resident #14 weighed 178.2 pounds which is a -12.30 % loss. Further review of Resident #14's medical record revealed no evidence te residents attending physcian had been notified of the residents weight loss. On 7/24/24 at approximately 2:30 PM, a review of Policy and Procedure titled, Weight Monitoring revealed that the physician should be informed of a significant change in weight. On 07/24/24 at 3:38 PM, during an interview with the Director of Nursing (DON), the DON acknowledged that per facility policy and procedure Resident #14's physician should have been notified of the weight…

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 record review and staff interview the facility failed to notify the ombudsman when Resident #23 was transferred to the hospital. This was true for one (1) of four (4) residents reviewed for the care area of hospitalization during the Long term care survey process. Resident Identifier: #23. Facility Census: 63. a) Resident #23 A review of Resident #23's medical record on 07/23/24 found the residents was transferred to the hospital on [DATE]. An interview with Social Worker #75 on 07/25/24 at 9:45 AM found the resident did not print on the discharge list because he was on behold during this hospital stay. She confirmed the ombudsman was not notified of this transfer because he did not print on the discharge list for March 2024 and that is the list she faxes to the ombudsman monthly.

Based on medical record review and staff interview, the facility failed to complete an accurate [NAME] Virginia Pre-admission Screening (PASR) to include all diagnosis with a new condition. This was true for two (2) of two (2) residents whose PASR's were reviewed during the long term care survey process. Resident identifier #1 and #20. Facility Census: 63 Findings included: a) Resident #1 During a medical record review of Resident #1 on 07/22/24 at 3:09 PM it was identified the most recent PASR was completed on 08/02/21 and this PASR did include a level II completion. A further review of this PASR found the PASR did not identify Resident #1's diagnosis of major depression disorder dated 07/01/21 and Resident #1 diagnosis of psychotic disorder with delusions dated 10/20/21 as Resident #1's current conditions at the time the PASR was completed. During an interview on 07/23/24 at approximately 9:15 AM with Registered Nurse Clinical Reimbursement Coordinator (RN CRC) #16, she stated, the diagnosis should have been added to the PASR and it would be resubmitted now. b) Resident #20 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 record review, observation, and staff interview the facility failed to ensure an accurate comprehensive care plan was developed for Resident #37 in the area of dental and for Resident #64 in the area of pressure ulcers. This was true for two (2) of 25 sampled residents reviewed during the long term care survey process. Resident Identifiers: #37 and #64. Facility Census: 63. Findings Include: a) Resident #37 An observation of Resident #37 on 07/22/24 at 1:28 PM found the resident had metal pieces visible in lower gum line. On 07/24/24 at 2:45 PM the Director of Nursing was asked to look into the residents mouth to determine what the metal which was visible was. Upon the completion of the observation it was discovered the resident had a partial plate on the bottom and the metal was visible because she had no natural teeth left to hook it to. The Director of nursing was asked if she had any natural teeth in her mouth and she stated there was not any. A review of Resident #37's medical record found a care plan related to her dental status which read: Resident is at risk 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 medical record review and staff interview, the facility failed to update a care plan in regards to a diagnosis of psychosis r/t (related to) dementia. This was true for one (1) of five (5) residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review during the long term care survey process. Resident Identifier: #1. Facility Census: 63. Findings include: a) Resident #1 During a medical record review on 07/23/24 at 11:35 AM, Resident #1 was identified to have a physician diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations, dementia in other diseases classified elsewhere moderate with agitation and a diagnosis of psychotic disorder with delusions due to known physiological condition. It is further identified the resident receives seroquel which is ordered for Resident #1's psychosis r/t (related to) dementia with the pharmacy reference to the diagnosis of the dementia in other diseases classified elsewhere, moderate with agitation and psychotic disorder with delusions due to know physiological…

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 record review and staff interview the facility failed to take appropriate measures when they had knowledge a resident's court appointed guardian was no longer able to serve as the guardian because they had lost decision making capacity for themselves while a resident at the same facility as Resident #68. Resident Identifiers: #68 and #372. Facility Census: 63. Findings include: A review of records on 07/23/24 at 10:24 AM of care plan note dated for 5/23/2024 at 4:18 PM revealed the following: Resident's niece requested to meet to discuss palliative care and hospice options. Nursing discussed resident has been declining and is not eating, drinking, etc. Her niece indicated she is agreeable to making resident palliative care and asked for a referral to hospice. She stated her biggest concern is resident be kept comfortable and pain managed. She noted she currently appears comfortable and does not appear to be in pain. No concerns or complaints voiced. Interview with Social Worker #77 on 7/23/24 at 3:10 PM in regards to why resident's niece was in attendance to meeting 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.

Based on medical record review and staff interview, the facility failed to ensure resident had monthly drug regimen reviews. This was true for one (1) of five (5) residents reviewed for unnecessary medications, psychotropic medications, and Medication Regimen Review (MRR) during the long term care survey process. Resident Identifier: #1. Facility Census: 63. Findings include: a) Resident #1 During a medical record review on 07/23/24 at 11:35 AM a review of the past 12 months of MRR's identified the month of 10/01/23 did not have an MRR on file for Resident #1. During an interview with the Director of Nursing (DON) on 07/23/24 3:30 PM the DON stated the MRR for October had not addressed by the physician during the month of October so the pharmacy had made recommendation again 11/29/23. She further stated this November MRR order was not entered until 12/04/23. The DON stated she did not know what had happened to the MRR for October.

Based on observations and staff interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered a dietary aide was not wearing a beard guard, a dirty drip pan and dirty dish racks. Also, no temperatures were taken for resident's personal refrigerators. This had the potential to affect any resident receiving nourishment from the kitchen or from personal refrigerators. Facility census: 67. Findings included: a) Kitchen tour During the kitchen tour on 02/13/23 at 10:07 AM, it was discovered Dietary Aide (DA) #123 was not wearing a beard guard. The drip pan for the gas stove had a great amount of grease buildup, and food debris was found on the storage dish racks. An interview with the Dietary Director #126 on 02/13/23 at 10:30 AM, verified DA #123 needed a beard guard and the drip pan had a grease buildup, and the dish racks needed to be cleaned. b) Resident refrigerators During a random opportunity for discovery on 02/13/23 at 1:10 PM, it was discovered Residents…

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 record review and staff interview, the facility failed to notify the ombudsman of a facility-initiated transfer for Resident #71. This failed practice was true for one (1) on one (1) Residents reviewed for hospitalizations. Resident identifier: #71. Facility census: 67. Findings included: a) Record review A review of Resident #71's medical record found a transfer form dated 12/02/22 which stated: Resident went unresponsive at dialysis this afternoon. Received one liter of IV fluids while at dialysis. Resident alert, not talking. Family with resident requesting resident Resident to go to emergency room (ER) for evaluation. Resident was transferred to hospital at 8:40 PM. Record review indicated the Resident never returned to the facility from the hospital, and was discharged from the facility on 12/06/22 with return not anticipated. Record review showed no documentation to indicate the ombudsman was notified of Resident #71's transfer to the hospital. b) Staff Interview During an interview on 02/15/23 at 1:28 PM, Licensed Social Worker (LSW) #86 stated they only send planned…

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.

The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Residents on transmission-based precautions did not have signage at their doors to indicate the type of transmission based precautions to be observed and the personal protective equipment required. These were random opportunities for discovery that had the potential to affect a limited number of residents. Resident identifiers: #21, #59. Facility census: 67. Findings included: a) Resident #21 On 02/13/23 at 11:30 AM, this surveyor entered Resident #21's room to interview the resident. The resident had no signage on the door to indicate the resident had transmission-based precautions. Subsequent review of Resident #21's medical records showed the resident had enhanced barrier precautions due to the presence of a feeding tube. During an interview on 02/13/23 at 12:27 PM, Licensed Practical Nurse (LPN) #43 confirmed Resident #21 had enhanced barrier precautions but did not have signage to indicate…

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 employee record reviews and staff interview the facility failed to provide the 12 hour training in-services required annually for nurse aides (NA). This was true for two (2) of five (5) employee training records reviewed for staffing during the Long Term Care Survey Process. Employee Identifiers: NA #4 and #40. Facility census: 67. Findings included: a) Annual 12 hour training. During a review of employee records on 02/14/23, it was discovered the required annual 12 hour in-services training for NA #4 and #40 were incomplete. NA #4 and #40 were three (3) to four (4) hours short of meeting the requirement. An interview with the Nursing Home Administrator on 02/15/23 at 12:38 PM, verified NA #4 and #40 annual 12 hours of required training was incomplete. .