Ovid Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary care to two of five residents (R22 and R31) reviewed for activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pressure ulcer treatments as ordered for one (Resident 54) of three reviewed, resulting in the potential of a worsened pressure ulcer. Findings include: Review of the medical record reflected that R54 was initially admitted to the facility on [DATE] with diagnoses that included: Periprosthetic (relating to an artificial joint) fracture around internal prosthetic (artificial) right knee joint, morbid obesity, Parkinson's disease, heart failure and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24, revealed R54 had a Brief Interview of Mental Status (BIMS) of 12 out of 15, which indicated moderate cognitive impairment. On 1/6/25 at 10:37 AM R54 was observed sitting up at the edge of her bed. A soiled pillow/pillowcase was observed at the foot of R54's bed with brown/yellow colored stain. When asked what the substance was on the pillowcase she reported that she believed it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data…

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 This citation pertains to intake MI00145732. Based on interview and record review, the facility failed to ensure adequate staff were scheduled to supervise and report residents with sexual behaviors and protect vulnerable residents in a census of 61 residents, resulting in the likelihood of allegations of abuse not identified, reported or documented. Findings include: Facility assessment dated [DATE] indicated the facility was approximately 3200 square feet and the average daily census over the past 12 months was 62 residents. 26 residents had a diagnosis of dementia. 54 out of 62 residents were dependent or required staff assistance for dressing. 59 out of 62 residents were dependent or required staff assist for bathing. 49 out of 62 residents were dependent or required staff assist for transfers. 36 residents were dependent or required staff assist for eating. 52 out of 62 residents were dependent or required staff assist in toileting. Staff Schedule dated 6/27/24 indicated a census of 59 residents. 5…

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 This citation pertains to intake MI00145732. Based on interview and record review, the facility administration failed to operationalize its policy and procedures to manintain effective use its resources and ensure identification, investigation, and protection of residents from mental abuse, verbal abuse, sexual abuse and deprivation of goods and services in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), and failed to ensure sufficient nursing staff to meet residents needs and the likelihood for continued abuse and unmet resident needs in a current facility census of 61 residents. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07…

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 This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to implement their abuse policy and procedures in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in continued allegations of abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to immediately report allegations of abuse in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station 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 This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse, in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and #7), resulting in the likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station 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 This citation pertains to intake MI00145732. Based on interview and record review, the facility failed to prevent involuntary seclusion in one of 10 residents reviewed for abuse (Resident #6), resulting in verbal behaviors and frustration. Findings include: Resident #6 (R6) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R6 was found in the dining room participating in sexual behaviors. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. Interventions included to guide R6 away from the area while redirecting to other activity of interest such as watching game…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received appropriate assessment and treatment for a change of condition in one of 10 residents reviewed for abuse (Resident #8), resulting in delayed treatment and a medication error. Findings include: Resident #8 (R8) During an interview with Interim Director of Nursing (DON) B on 7/19/24 at 1:30 PM, DON B stated on 7/14/24, Licensed Practical Nurse (LPN) J administered Narcan/naloxone (medication that rapidly reversed an opioid [heroin, fentanyl, oxycodone, Vicodin, codeine, morphine] overdose, medication attaches to opioid receptors and reversed/blocked effects of other opioids; Narcan could restore normal breathing to a person if breathing had slowed or stopped due to an opioid overdose). DON B stated there was no indication to administer Narcan, R8's vital signs were stable, Narcan was not prescribed, opioids were not prescribed, and R8 did not have a history of opioid abuse. DON B stated LPN J administered another 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 observation, interview, and record review, the facility failed to 1) maintain a sanitary kitchen, 2) properly date mark potentially hazardous foods, 3) properly cool cooked food, and 3) clean food contact surfaces, resulting in the potential biological contamination of food, increasing the risk of foodborne illness. These deficient practices affecting 65 residents who consume food from the kitchen. Findings include: On 11/13/23 at 6:46 AM, food debris and soil was observed to be accumulating at the wall/floor juncture by the right side of the three-compartment sink, and underneath the drain boards of the dish machine. During an interview on 11/13/23 at 12:22 PM, Certified Dietary Manager (CDM) E stated that the floors are deep cleaned weekly if they have a staff member available to do so. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a sanitary environment, maintain bathroom floors in good repair (room #'s 107, 110, and 306), and provide backflow protection at the salon hair sink, resulting in the potential for a non-homelike environment and contamination of the domestic water supply, affecting 65 residents in the facility. Findings include: On 11/13/23 at 8:04 AM, the bathroom floor of resident room [ROOM NUMBER] was observed to have missing linoleum flooring, approximately a 4-inch by 6-inch section, near the toilet, exposing the sub floor. On 11/13/23 at 8:08 AM, the bathroom floor of resident room [ROOM NUMBER] was observed to have brown stains. The toilet bowl was observed to have significant hard water mineral deposits accumulating. Additionally, debris and wash cloths were observed to be on the floor of resident room [ROOM NUMBER]. At this time, Resident #46 stated that housekeeping usually comes everyday to clean but didn't on Sunday, I don't stray…

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

Based on interview and record review the facility failed to address and resolve grievances brought forth by the Resident Council resulting in unmet needs, missing items, and not getting their basic needs met. Findings include: During a record review of the past year's grievance forms, several of the forms were not filled out completely. The last option on the form was the follow up section to be completed by the facility person addressing the complaint. Resident Council President had signed off on many of these grievances agreeing to the action that was documented to take place, not knowing the follow up findings from the facility. During an interview on 11/14/23 at 2:45PM, Resident Council President stated Next time she would not be signing any forms until she knows for sure that the grievance was resolved. During a resident council meeting on 11/14/23 at 02:00 PM, there were concerns voiced from the group of 18 residents that had not been resolved. 1) Call light response time was an ongoing problem, it was resolved for one month, and then not the next month. Resident Council…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise care plans for four (Resident #6, #48, #60, #61) of 16 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. Review of R6's Kardex (care guide) revealed R6 was on a 1500 milliliter (mL) fluid restriction. R6's Fluid Overload care plan also revealed R6 was on a 1500 mL fluid restriction as of 1/29/21. On 11/13/23 at 12:26 PM, R6 was observed feeding herself in the dining room. Review of R6's tray ticket revealed no mention of a fluid restriction. Review of the Physician's Order revealed R6's fluid restriction was discontinued on 7/22/22. In an interview on 11/13/23 at 1:37 PM, Certified Dietary Manager (CDM) E reported R6 was no longer on a fluid restriction. In an interview on 11/13/23 at 2:08 PM, Minimum Data Set (MDS) Coordinator D reported R6 was no longer on a fluid…

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

Based on observation, interview, and record review the facility failed to follow acceptable professional practice for maintaining controlled medication for three out of four medication carts resulting in the potential for controlled medication diversion. Findings included: During observation the 100 hall Controlled Substance Shift to Shift Count Sheet, on 11/14/2023 at 01:12 p.m., demonstrated that Signature On coming was left blank for the date of 11/14/2023 at the time of 06:35 a.m The document did contain Signature Off going for the same date and time. During an interview on 11/14/2023 at 01:12 a.m. Registered Nurse (RN) Q explained that she was the ongoing nurse for the day shift on 11/14/2023. She explained that it was professional practice to count the controlled mediation, of the mediation stored in the controlled medication drawer, of the cart at the beginning and end of each shift or when a control of the medication cart was changed. RN Q confirmed that she had not signed the Controlled Substance Shift to Shift Count Sheet for 11/14/2023 at 06:35 a.m. but stated her and 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, interview, and record review, the facility failed to monitor for adverse side effects of antipsychotic medications for four (Resident #12, #31, #34, and #37) of five reviewed, resulting in the potential of adverse medication side effects. Findings include: Resident #31 (R31) Review of the medical record revealed R31 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included Alzheimer's Disease, schizophrenia, and bipolar disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/23 revealed R31 received antipsychotic medication on a routine basis. On 11/14/23 at 8:57 AM, R31 was observed awake in bed. Review of the Physician's Order dated 3/8/23 revealed an order for Risperdal (antipsychotic medication) 0.5 milligrams (mg) two times a day. Review of the Physician's Order dated 3/9/23 revealed Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated (Document the number…

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

Based on observation interview and record review the facility failed to monitor medication refrigerators for three of three medication refrigerators resulting in the potential for residents to receive medication that is not providing its effective efficiency. Finding included: During observation of the 100 hall/200 hall medication storage room on 11/14/2023 at 01:17 p.m. it was observed that the medication storage room had one medication refrigerator. Review of the facility Vaccine Storage Temperature Log demonstrated that the temperature of the medication refrigerator was to be documented twice each date. Review of the Vaccine Storage Temperature Log demonstrated that the temperatures were not recorded for: 11/01/2023 a.m. shift, 11/04/2023 a.m. and p.m. shifts, 11/05/2023 a.m. shift, 11/08/2023 p.m. shift, 11/11/2023 a.m. shift, 11/12/2023 a.m. and p.m. shifts, and 11/13/2023 a.m. and p.m. shifts. During observation of the 300 hall/400 hall medication storage room on 11/14/2023 at 01:32 p.m. it was observed that the medication storage room had two medication refrigerators. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain laboratory draws on four (Resident #11, #34, #37 and #47) of seven reviewed for laboratory monitoring, resulting in the potential for unrecognized and/or untreated abnormal laboratory results. Findings include: Resident #34 (R34): Review of the medical record reflected R34 admitted to the facility on [DATE], with diagnoses that included unspecified dementia, major depressive disorder and anxiety disorder. On 11/13/23 at 02:02 PM, R12 was observed self-propelling his wheelchair out of his room, into the hallway. A Pharmacy Consultation Report with a recommendation date of 3/7/23 reflected R34 received a magnesium supplement but did not have a serum magnesium concentration documented in the medical record in the past 6 months. The recommendation was to monitor a serum magnesium concentration on the next convenient lab day and every six months thereafter. The physician accepted the recommendation on 3/13/23. Review of R34's laboratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess the use of a full lap tray as a potential chair restraint for one (Resident #60) of one reviewed for restraints, resulting in the potential for residents not having the least restrictive devices. Findings include: Review of the medical record reflected Resident #60 (R60) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included autistic disorder, repeated falls and Lennox-Gastaut syndrome with status epilepticus (seizure disorder). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/23, reflected R60 had short-term and long-term memory problems, used a wheelchair for mobility and was dependent for many aspects of care. R60 was not coded for the use of restraints. On 11/13/23 at 07:52 AM, R60 was observed in the dining room, receiving total feeding assistance by a staff member that was seated beside him. A full lap tray was observed on his wheelchair. A seatbelt 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 interview and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to the hospital for one (Resident #68) of three reviewed for transfer/discharge, resulting in the potential for residents and/or family being uninformed of the reason for transfer. Findings include: Review of the medical record reflected Resident #68 (R68) admitted to the facility on [DATE], with diagnoses that included encephalopathy (a change in brain function that may cause altered mental state and confusion), disorientation, vascular dementia and urinary tract infection. R68 did not reside in the facility at the time of the survey. A Progress Note for 9/27/23 at 2:15 PM reflected R68 had an unobserved fall and was observed on the floor, with blood coming from their right ear and mouth. R68 was sent to the emergency room for evaluation. There was no documentation of a written transfer notice in R68's medical record. On 11/15/23 at 12:31 PM, an email was sent 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 Resident #12 (R12): Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/23, reflected R12 was coded for routine antipsychotic use. The MDS reflected a gradual dose reduction (GDR) had not been attempted and was not documented by a physician as clinically contraindicated. A Physician's Order, with a start date of 6/21/23, reflected Zyprexa (antipsychotic medication) 15 milligrams (mg) was to be given daily, at bedtime. R12's Zyprexa order history reflected a prior dose of 20 mg daily with a start date of 5/12/23 and a stop date of 6/20/23. During an interview on 11/15/23 at 08:47 AM, Social Worker (SW) C reported R12 had a GDR of Zyprexa on 6/21/23. Psychiatric Services Notes for 7/11/23, 9/12/23 and 10/11/23 documented GDRs as clinically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan summary was provided for one (Resident #68) of 12 reviewed for care plans, resulting in the potential for care preferences not being honored and unmet care needs. Findings include: Review of the medical record reflected Resident #68 (R68) admitted to the facility on [DATE], with diagnoses that included encephalopathy (a change in brain function that may cause altered mental state and confusion), disorientation, vascular dementia and urinary tract infection. R68's medical record reflected they transferred to the hospital on 9/27/23 and did not reside in the facility at the time of the survey. According to the medical record, R68 was his own responsible party. The medical record did not reflect documentation that a care conference had been provided to R68 or that they had been provided with a summary of the baseline care plan. During an interview on 11/15/23 at 12:53 PM, Nursing Home Administrator (NHA) A reported R68 was his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide range of motion/restorative services for one (Resident #61) of two reviewed, resulting in the potential for a decrease in range of motion and worsening contractures. Findings include: Review of the medical record revealed Resident #61 (R61) was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included cerebral infarction and bipolar disorder. the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed R61 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had functional limitation in range of motion impairments on both sides of upper and lower extremities. On 11/13/23 at 8:45 AM, R61 was observed with contractures in both hands. R61 did not have a brace or splint on either hand. There was a brace observed on R61's roommate's side of the room. R61's roommate reported the brace did not belong 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, interview, and record review, the facility failed to follow physician ordered parameters upon administration of blood pressure medications for one (Resident #31) of 5 reviewed for unnecessary medications, resulting in the potential for adverse drug consequences. Findings include: Review of the medical record revealed Resident #31 (R31) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included hypertension (high blood pressure). On 11/14/23 at 8:57 AM, R31 was observed awake in bed. Review of the Physician's Order with a start date of 6/8/23 revealed an order for Bumex 1 milligram (mg) two times a day, hold if blood pressure is not above 120/80. The Physician's Order with a start date of 6/9/23 revealed an order for Amlodipine 10 mg daily, hold if blood pressure is not above 120/80. Review of the Medication Administration Record (MAR) revealed Amlodipine and Bumex were given when R31's blood pressure was not above 120/80 on 7/13/23, 7/16/23, 7/22/23, 7/28/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain radiology services for one (Resident #11) of one reviewed, resulting in the potential for misdiagnosed medical conditions and ineffective treatment. Findings include: Review of the medical record revealed Resident #11 (R11) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 11/14/23 at 8:12 AM, R11 was observed awake in bed. R11 reported she recently had a respiratory infection with chest congestion and yellow and brown sputum. Review of the telehealth note dated 11/6/23 revealed R11's dialysis center order an antibiotic for chest congestion. The note revealed Ordered CXR [chest x-ray] and CBC with diff [lab work] as well. There was no documentation or results 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, interview and record review, the facility failed to ensure appropriate transmission-based precautions (TBP) and disposal of personal protective equipment (PPE) for one (Resident #12) of one reviewed for TBP, resulting in the potential for the spread of infection to other facility residents. Findings include: Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. R12's medical record reflected a bronchial wash laboratory result that was collected on 11/2/23, with detection of rhinovirus (virus), pseudomonas aeruginosa (bacteria), proteus (bacteria), staphylococcus aureus (bacteria) and strep agalactiae (bacteria). A Physician's Order, with a revision date of 11/10/23, reflected R12 was to be on droplet precautions (precautions intended to prevent transmission of pathogens spread through close respiratory…

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.