The Merriman

Based on record review, observation, interview and facility policy review, the facility failed to ensure pressure ulcer treatments were completed as ordered for resident #5. This affected one resident (#5) of three residents reviewed for pressure ulcers. The facility census was 45.Findings include:Review of the medical record for Resident #5 revealed an admission date of 04/08/24 with diagnoses including multiple sclerosis and pressure ulcer stage IV (a severe, open wound with full-thickness tissue loss that extends down to the muscle, bone, or other supporting structures like tendons or joints) of the penis.Review of the physician's orders for Resident #5 revealed he had an order dated 07/30/25 to cleanse the penis with soap and water, apply Skin Prep (forms a protective barrier on the skin) to the left penis peri wound area, apply collagen filler to the wound and cover with an abdominal (ABD) pad at bedtime. Review of the Medication Administration Record (MAR) for November 2025 revealed nursing had performed Resident #5's treatment to his penis on 11/11/25.Observation on 11/12/25…

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, observation, interview and review of the facility policy, the facility failed to maintain a safe smoking environment for Resident #13. This affected one resident (#13) of two residents reviewed for smoking. The facility census was 45.Findings include:Review of the medical record for Resident #13 revealed an admission date of 03/24/23 with diagnoses including schizophrenia, muscle weakness, and hypertension.Review of the physician's orders for Resident #13 identified an order for supervised smoking with a smoking apron beginning 01/23/25.Review of the care plan dated 07/28/25 revealed Resident #13 was at increased risk for injury related to smoking cigarettes. Interventions included, but were not limited to, supervision at all times while smoking (07/28/25) and a smoking apron to be worn while smoking (07/28/25).Review of the smoking and safety assessment dated [DATE] revealed Resident #13 required supervision for smoking due to dropping ashes on self, unable to light tobacco or marijuana…

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 interview, the facility failed to provide evidence of timely Foley catheter care for Resident #5. This affected one resident (#5) out of three reviewed for activities of daily living (ADL). The facility census was 45.Findings include:Review of the medical record for Resident #5 revealed an admission date of 04/08/24 with diagnoses including Multiple Sclerosis, anxiety disorder, and muscle weakness.Review of the health status note dated 02/19/25 at 6:37 A.M. revealed Resident #5 had moderate hematuria (bloody urine) in his brief, and new orders were given to obtain a urine sample for a urinalysis. Review of the health status note dated 02/19/25 at 2:18 P.M. revealed Resident #5 had blood in his brief, new orders were given to obtain a urine sample which was unable to be collected, and Resident #5 requested to go to the hospital due to having pelvic pain.Review of the health status note dated 02/20/25 at 2:43 A.M. revealed Resident #5 was admitted to the hospital due to renal calculi…

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 record review, resident interview, staff interviews, facility investigation, and facility policy review, the facility failed to ensure pain medication was available as needed. This affected one resident (#7) of one resident reviewed for pain management. The facility census was 45.Findings include:Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses including spondylolisthesis, lumbar region, acute upper respiratory infection, unspecified, colostomy status.Review of the baseline care plan dated 02/20/25 revealed Resident #7 was at risk for pain related to fractures with interventions that included assessing pain levels and administer pain medications per order.Review of the physician orders dated 02/20/25 revealed an order to monitor pain every shift and an order for 10 milligram (mg) oxycodone (opioid pain medication) oral tablet to be given by mouth every four hours as needed for pain. Review of the physician orders dated 02/21/25…

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, interview and facility policy review, the facility failed to ensure wound care was overseen by a physician. This affected two residents (#20 and #46) of seven reviewed for wound management. The facility identified 11 current residents (#5, #10, #12, #17, #20, #25, #32, #37, #38, #39 and #45) with wounds. The facility census was 45.Findings include:1. Review of the closed medical record for Resident #46 revealed an admission date of 07/29/25. Resident #46 was transferred to the hospital on [DATE] and did not return to the facility. Resident #46 had diagnoses including congestive heart failure, dementia, diabetes, muscle weakness and epilepsy.Review of the care plan dated 07/30/25 revealed Resident #46 was at risk of skin breakdown due to diabetes, cognitive decline and immobility. Interventions included administering treatments as ordered, assisting in turning and repositioning as needed, educating family and caregivers about causes of skin breakdown and following the facility protocol 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 record review and interview, the facility failed to ensure Resident #13 received medications as ordered. This affected one resident (#13) of eight residents reviewed for medication administration. The facility census was 45.Findings include:Review of the medical record for Resident #13 revealed an admission date of 03/24/23 with diagnoses including schizophrenia, hypertension and history of falling.Review of the medication error investigation by the Director of Nursing (DON) dated 09/23/25 at 3:42 P.M. revealed Licensed Practical Nurse (LPN) #568 administered the wrong medication to Resident #13. LPN #568 stated he had two different residents' medications in the top of his medication cart in medication cups. Resident #13 was in the hallway and stopped so the nurse could provide his medication. When LPN #568 reached into the medication cart, he knocked over the two different residents' medication cups in the drawer. He then replaced the medications in the cups and administered Resident #13 his medications. After Resident #13 took the medications, LPN #568 noted that he 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 record review, observation, interview and facility policy review, the facility failed to ensure medications were properly stored. This affected one resident (#38) of three reviewed for proper medication storage. The facility census was 45.Findings include:Review of the medical record for Resident #38 revealed and admission date of 10/20/25. Diagnoses included fracture of the left foot, difficulty walking, and muscle weakness.Review of the self-medication administration assessment dated [DATE] revealed Resident #38 required assistance to administer oral medication.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. He required substantial to maximum assistance with toileting and showering, partial assistance with personal hygiene and was independent and eating in oral care.Review of the physician's orders for October 2025 revealed the resident began taking Bactrim (used to treat bacterial infections) 800 milligrams (mg) one tablet by…

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, interview and facility policy review, the facility failed to maintain proper infection control practices while providing wound care for Resident #12. This affected one resident (#12) of two residents observed for wound care. The facility census was 45.Findings include:Review of the medical record for Resident #12 revealed an admission date of 09/09/25 with diagnoses including congestive heart failure, diabetes mellitus and chronic venous ulcers of bilateral lower extremities.Review of the physician's orders for Resident #12 revealed an order dated 09/10/25 for enhanced barrier precautions (EBP) (infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) due to wounds.Review of the care plan dated 09/10/25 for Resident #12 revealed he had EBP related to open wounds requiring a dressing. Interventions included using gowns and gloves when providing high-contact resident care activities including wound care.Observation was performed on 11/10/25 at 1:45 P.M. of wound care to Resident #12's right…

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 observations and interviews with staff the facility failed to label and date food and failed to ensure dietary staff wore hair restraints. This had the potential to affect all 49 residents who received food from the kitchen. The census was 49. Findings include: Observation and interview on 06/24/25 at 10:45 A.M. of the kitchen revealed [NAME] #305 and Dietary Aide #227 were not wearing hair restraints in the food preparation area. They verified they did not have hair restraints on at that time. Observation and interview on 06/24/25 at 10:55 A.M. of the cooler revealed a small pan of two hamburgers in broth, a large plastic bucket of meatballs and a large pan of hamloaf were all undated and unmarked. Dietary Supervisor #412 verified the observation at this time. Review of the facility policy titled Labeling and Dating, undated, revealed proper date labeling was essential for food safety, legal compliance and quality contorl in the kitchen. Review of the facility policy titled Food Safety and Sanitation, copyrighted 2023, revealed hair restraints were required and should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record reviews and interview, the facility failed to ensure resident medical records contained all required discharging information and appropriate information was communicated to the receiving facility. This affected two residents (Resident #55, and Resident #65) of three residents reviewed for discharge planning. The census was 49. Findings include: 1. Review of the closed medical record for Resident #65 revealed an admission date of 03/13/25 and a discharge of 03/28/25. Diagnoses included aftercare following major joint replacement, dementia and osteoarthritis. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) 3.0 dated 03/28/25 revealed Resident #65 was cognitively impaired. He required maximum assistance for showering and moderate assistance with toileting. Review of the progress notes revealed there was no indication Resident #65 was being discharged or to where. Review of the March 2025 orders revealed Resident #65 had a follow-up appointment ordered on 03/17/25…

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, interviews, and record review the facility failed to ensure there was sufficient dietary staff for timely meal service. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who did not eat by mouth. The facility census was 53. Findings include: Review of the mealtimes provided by the facility revealed breakfast at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:00 P.M. Observations during the initial tour of the kitchen on 01/21/25 from 9:45 A.M. to 10:11 A.M. revealed three staff plating breakfast trays for resident meal service. Interview on 01/21/25 between 10:11 A.M. and 10:16 A.M. with Dietary [NAME] (DC) #376, DC #309 and Dietary Aide (DA) #372 revealed the kitchen was short staffed and this affected meals not being served from the kitchen in a timely manner. DC #376 verified today's breakfast was late, as it should have went out at 8:00 A.M., lunch would then be late too, and late meals happened due to not enough staffing in the kitchen. Interviews on 01/21/25 between 10:10 A.M.…

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 observations, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 53 residents receiving meals from the kitchen, as the facility identified no residents who did not eat by mouth The facility census was 53. Findings include: Observations during the initial tour of the kitchen on 01/21/25 from 9:45 A.M. to 10:11 A.M. revealed the following sanitation concerns: • The floor of the small storage room where pots, pans and various kitchware for resident meal servce was stored was dirty with dirt stains and debris under the storage racks. • The stove had a heavy build-up of stains and food debris. • The prep table across from the stove had moderate food debris and stains on it. • The robotcoup (blender used to mechanically alter food) had various dried food debris and stains all over it. • The large, black plug in fan next to the robotcoup had a moderate amount of dust on the fan blades and blade cover. • The floor where the steamer and plate warmer were located had a…

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

Based on observation, interview and review of facility policy the facility did not maintain clean bathing and shower rooms for all residents excluding 20 residents (Resident #2, # 3 #7, #8, #9, #12, #15, #17, #19, #21, #22, #23, #24, #25, #26, #28, #32, #33, #35 and #46) the facility identified as not using the bathing and shower rooms. The facility census was 53. Findings include: Observation on 01/21/25 at 10:42 A.M. of the facility bathing room used for all residents who preferred and/or needed bathing revealed the toilet in the bathing room had no water in the toilet and had feces in the bowl. There was no signage on the toilet saying it was not to be used. The floor was dirty and there was dirt built up around the edges of the floor. Observation on 01/21/25 at 10:50 A.M. of the facility shower room used for all residents who could shower revealed there were missing tiles on the floor of the shower area, and the shower was leaking with a black substance on the wall of the shower. The grout along the bottom of the shower was black/brown in color. Used gloves were on the floor, a…

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

Based on observation, interview, and record review the facility failed to ensure the correct serving size of mechanical soft meat was served to Resident #5, #14, #25, #32, #35 and #156. This affected six residents (#5, #14, #25, #32, #35, and #156) of seven residents (#5, #9, #14, #25, #32, #35, and #156) the facility identified as receiving a mechanical soft diet excluding Resident #9 who had a physician order for mechanical soft diet with pureed meats only. The facility census was 53. Findings include: Review of the menu revealed for 01/22/25 lunch meal included Salisbury steak, mashed potatoes, and lima beans. Review of the menu/diet spreadsheet revealed for the mechanical soft diet the ground Salisbury steak serving utensil was a #6 scoop (5.33 ounces). Review of the diet type report dated 01/22/25 revealed Residents #5, #14, #25, #32, #35, and #156 had physician orders for the mechanical soft diet. Observation on 01/22/25 between 11:52 A.M. and 1:02 P.M. of lunch tray line service revealed Dietary [NAME] (DC) #361 serving the mechanical soft (ground) Salisbury steak using 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 observation, interview, record review and review of facility policy, the facility did not ensure Resident #5 had properly sized clothing to maintain his right to dignity. This affected one resident (Resident #5) out of 21 residents reviewed for dignity. The facility census was 53. Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/24/23 with diagnoses including schizophrenia, anemia, pain in left knee, muscle weakness, essential hypertension, history of falling, and other abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/25, revealed Resident #5 was cognitively intact, hallucinated and had delusions, had not rejected care, could walk independently with a walker, and required setup or clean up assistance for upper and lower body dressing and for putting on footwear. Observation on 01/21/25 at 11:11 A.M. revealed Resident #5 was in his room in full view of the hallway. The resident's gray sweatpants were so large on him he had to hold them up with his hand and every time…

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 interviews the facility failed to develop person-centered care plans to identify triggers of Post Traumatic Stress Disorder (PTSD) for Resident #10 and Resident #29. This affected two residents (#10 and #29) of 21 residents reviewed for care plans. The facility identified three residents (#10, #29, and #37) with PTSD. The facility census was 53. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 02/03/23. Pertinent diagnoses included post traumatic stress disorder, anxiety disorder, depression, and bipolar disorder. Review of Trauma Life Events Checklist, dated 07/28/23, revealed Resident #29 had a transportation accident and witnessed a transportation accident, had a serious accident at work, home or during recreational activity, had been physically assaulted and witnessed physical assault, had been assaulted with a weapon and witnessed assault with a weapon, had been sexually assaulted, had experienced other unwanted or uncomfortable sexual experiences, had been held in captivity, had witnessed a sudden…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview the facility failed to ensure Resident #21 wore a hand splint according to physician order. This affected one resident (Resident #21) of one resident reviewed for splint devices. The facility identified three residents (#6, #12 and #21) with orders for hand splints. The facility census was 53. Findings include: Review of the medical record for Resident #21 revealed an admission date of 08/27/23. Diagnoses included chronic pain, hemiplegia and hemiparesis following cerebral infarction (stroke), and anxiety disorder. Review of Resident #21's occupational therapy evaluation and plan of treatment, dated 07/08/24, revealed the resident had been referred to therapy due to increased assist and worsening left upper extremity tone, especially in his hand, and the resident had a functional limitation present due to a contracture. Review of Resident #21's physician orders revealed an order dated 08/16/24 for left resting hand splint to be on in A.M. and removed in P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident #5 and Resident #29 were free from potential accident hazards related to smoking. This affected two residents (#5 and #29) of four residents reviewed for accidents/hazards. The facility identified 29 residents (#4, #5, #6, #10, #11, #13, #15, #16, #17, #18, #21, #23, #29, #31, #32, #34, #38, #40, #41, #43, #44, #45, #46, #48, #49, #50, #51, #56, #156) as smokers. The facility census was 53. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, generalized muscle weakness and need for assistance with personal care. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had intact cognition with hallucinations and delusions but no behavioral symptoms or rejection of care. He was independent with mobility using a walker. Review of the care plan for Resident #5 dated 01/17/25 revealed he 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 observations, interviews, record review, facility policy review , and review of manufacturer's user guide, the facility failed to ensure Resident #21's head strap for the BiPAP ( bilevel positive airway pressure) machine was clean and sanitary and failed to ensure Resident #34's oxygen tubing was dated. This affected two residents (#21 and #34) out of two residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of medical record for Resident #21 revealed an admission date of 08/27/23. Diagnoses included chronic obstructive pulmonary disease (COPD) and cancer lesion. Review of physician orders for Resident #21 revealed an order dated 08/27/23 to replace BiPAP mask, headgear/straps and tubing every night shift every three months. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/13/24, revealed Resident #21 was moderately impaired cognitively, exhibited no behaviors or rejection of care, and was on a noninvasive mechanical ventilator. Review 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.

Based on observation, interview and record review the facility failed to ensure all insulin medications were accurately labeled to ensure safe administration of medications. This affected three residents (Resident #3, #15 and 36) of nine residents reviewed for medication storage. The census was 53. Findings include: 1. Review of the medical record for Resident #3 revealed admission date 06/27/24. Diagnoses included type two diabetes mellitus and depression. Review of the physician orders for January 2025 revealed Humalog (insulin) Kwik Pen 100 units per milliliter (unit/ml) eight units subcutaneous (SQ), three times a day and per sliding scale. Order for Toujeo Solostar (long-acting insulin) 40 units at bedtime. 2. Review of the medical record for Resident #15 revealed an admission date 06/11/24. Diagnoses included type two diabetes mellitus. Review of the physician orders for January 2025 revealed Fiasp pen 100 unit/ml to give per sliding scale. 3. Review of the medical record for Resident #36 revealed an admission date 01/26/23. Diagnoses included type two diabetes mellitus 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 observation, record review and interview the facility did not ensure Resident #9 received pureed food to meet individual needs. This affected one resident (Resident #9) of five residents reviewed for food/nutrition. The facility identified one resident (#9) as receiving pureed food texture. The facility census was 53. Findings include: Review of the medical record for Resident #9 revealed an admission date of 02/14/22 with diagnoses including severe protein-calorie malnutrition, dementia without behavioral disturbance, and oropharyngeal phase dysphagia (difficulty swallowing between the mouth and esophagus). Review of the physician orders for Resident #9 dated January 2025 revealed active orders for a regular diet, mechanical soft with puree meats texture, regular-thin consistency, large portions, and snacks three times a day after meals with a start date of 05/24/23. Observation on 01/22/25 at 1:27 P.M. of Resident #9's lunch meal revealed Resident #9 was served mechanical soft (ground with gravy) Salisbury steak. There was no pureed meat. The meal ticket on Resident #9's…

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

Based on observation, record review and interview, the facility failed to ensure palatable food temperatures were consistently served to residents. This finding had the potential to affect all 55 residents who reside in the facility and were provided meals from the kitchen. Findings include: Review of the Food Temperature Log form dated 12/15/24 to 12/21/24 revealed no evidence food temperatures to ensure food safety and palatability were obtained for breakfast, lunch and dinner on 12/15/24, dinner on 12/16/24, dinner on 12/17/24, breakfast, lunch and dinner on 12/18/24, 12/19/24, 12/20/24 and 12/21/24. Review of the Food Temperature Log form dated 12/22/24 to 12/28/24 revealed no evidence food temperatures to ensure food safety and palatability temperatures were obtained for breakfast, lunch and dinner on 12/22/24, 12/23/24, 12/24/24, 12/25/24, dinner on 12/26/24, breakfast, lunch and dinner on 12/27/24 and 12/28/24. Observations on 01/06/25 at 11:49 A.M. revealed [NAME] #870 obtained temperatures of the carrots, rice, breaded fish, mashed potatoes and hamburger patties 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, record review and interview, the facility failed to ensure the menus and spreadsheets were followed as planned. This finding affected Residents #9, #13, #27 and #44 and had the potential to affect all 55 residents residing in the facility. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left toe, other muscle spasm and peripheral vascular disease. Review of Resident #9's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #9's physician orders revealed an order dated 12/07/24 for a regular diet, regular texture, regular thin consistency; and an order dated 12/12/24 for a mighty shake two times a day for supplement. Review of the Menus and Spreadsheets for 01/07/25 revealed the lunch meal consisted of chicken pot pie, tossed salad, wheat bread, applesauce cake, choice of dressing, margarine and coffee or tea. 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, record review and interview, the facility failed to ensure Residents #9 and #44's mighty shake nutritional supplements were provided as ordered. This finding affected two (Residents #9 and #44) of four residents reviewed for meals. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left toe, other muscle spasm and peripheral vascular disease. Review of Resident #9's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #9's physician orders revealed an order dated 12/07/24 for a regular diet, regular texture, regular thin consistency; and an order dated 12/12/24 for a mighty shake two times a day for supplement. Review of Resident #9's Individual Nutrition Recommendations/Response form dated 12/10/24 revealed the resident was ordered four ounces of might shake twice daily with breakfast and lunch, a multivitamin with…

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 interview, the facility failed to ensure Resident #27's medication was available and administered as ordered. This finding affected one (Resident #27) of four residents reviewed for medication administration. Findings include: Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic dependence, lumbar degenerative disc disease, anxiety and depression. Review of Resident #27's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #27's hospital Discharge Orders form revealed an order to take Acamprosate Calcium (helps people who were dependent on alcohol to abstain from drinking it) 333 milligrams (mg) enteric coated (EC) one tablet by mouth three times daily for 10 days. Do not crush, chew or split. The last dose was administered 11/09/24 at 7:57 A.M. Review of Resident #27's hospital discharge Medication Administration Report (from 11/07/24 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, record review and interview, the facility failed to ensure a mediation error rate of 5% or less. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. This finding affected two (Residents #27 and #53) of four residents reviewed for medication administration. Findings include: 1. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis, lumbar degenerative disc disease, anxiety and depression. Review of Resident #27's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #27's physician orders revealed an order dated 11/10/24 for vitamin D3 (cholecalciferol) 50 mcg (micrograms) or 2000 international units (IU) give by mouth one time a day for vitamin D deficiency. Observation on 01/06/25 at 8:00 A.M. with Licensed Practical Nurse (LPN) #821 of Resident #27's medication administration revealed eight…

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, observation and review of facility documents, the facility failed to maintain a sanitary kitchen. This had the potential to affect all of the residents residing in the facility with the exception of Resident #18. The facility census was 45 residents. Findings include: Interview on 06/27/24 at 7:33 A.M. with the Director of Nursing (DON) confirmed the Kitchen Manger (KM) was sent home due to poor work performance. The DON confirmed when the KM was not present in the building, the cook working was in charge of supervision of the staff in the kitchen. Observation on 06/27/24 at 8:15 A.M. of the kitchen revealed the following concerns: - Dried liquid spills on the storage shelving under the juice and coffee dispenser. - The flooring throughout the kitchen was sticky with grease build-up and dried food/liquid under the cooking equipment and food preparation tables. - There were three food carts with three shelves on wheels in the kitchen with dirt, grease, dried liquid and food particles present on the three shelves. - The food preparation area had knives stored…

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 medical record review, review of a notification of termination of services letter to a physician, review of a notification letter to residents of the change in the Medical Director and rounding physician, review of notification letter to residents of their transfer of physician, review of doctor election form, review of eLicense.ohio.gov website, staff interview, physician interview, Ombudsman interview, resident interview, and review of facility policies, the facility failed to discuss the need for alternative physician services with residents and honor the resident's right to maintain their physician of their choice. This affected and/or had the potential to affect seven residents (#5, #12, #13, #15, #25, #34, and #41) of seven residents who had been receiving services from Physician #1 but were required by the facility to change to a new physician or Physician #2. The facility census was 48. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 07/03/20 with…

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 interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and corrected deficient practice. This affected three of three residents reviewed for choice of physician (#15, #42 and #24) and one (#43) of three residents reviewed for accuracy of documentation. The facility census was 49. Findings include: Review of the facility's survey tracking history revealed the facility had a complaint survey completed on 03/14/24 which resulted in concerns residents were not provided with their physician of choice, and inaccuracy of the medical record in relation to the wound care documentation. Interview on 04/16/24 at 3:16 P.M. with Resident #15 revealed he was previously a patient of Physician #1. He further stated they booted out his previous physician and he was referred to some doctor [Physician #2] who I don't know. During this interview, Resident #15 voiced that his opinion didn't matter because the facility would not allow Physician #1 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.

Based on observation and staff interview, the facility failed to maintain complete medical records in residents medical charts. This had the potential to affect all 48 residents residing at the facility. The facility census was 48. Findings include: Observation on 03/07/24 at 2:31 P.M., with Director of Nursing (DON) revealed a large stack, several inches thick of several resident's information that included: laboratory results, physician progress notes, signed physician orders, and resident monthly summaries. The paper work had various dates from 12/12/24 through 03/05/24. Interview with the DON, at the time of observation, revealed she was unsure why the medical records person had not been filing the resident information in the medical records timely. DON confirmed there were records unfiled from 12/12/24 through 03/05/24 that potentially could affect the care and treatment of all residents. This deficiency represents noncompliance investigated under Complaint Number OH00150880.

Based on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This finding had the potential to affect all 54 residents residing in the facility. Findings include: Review of the staffing schedules from 12/24/23 to 12/30/23 with Human Resources (HR) #811 revealed no evidence of registered nurse (RN) coverage on 12/25/23 for at least eight hours as required. Interview on 01/29/24 at 10:07 A.M. with HR #811 confirmed the facility did not have RN coverage of at least eight hours on 12/25/23. This deficiency represents non-compliance investigated under Complaint Number OH00149612.

Based on observation, record review and staff interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and data related to the issues was being monitored to determine if the plan of correction was being implemented as written and corrections were being sustained, and to determine if revisions were necessary. This had the potential to affect eight residents (Residents #3, #18, #22, #23, #26, #28, #43, and #48) who were receiving wound care treatments. The facility census was 49. Findings include: Review of the facility's survey tracking history revealed the facility had a complaint survey completed on 01/30/24 which resulted in concerns wound care was not being completed as ordered for one resident with a pressure ulcer and inaccuracy of the medical record in relation to the wound care documentation. Review of the facility's written plan of correction (POC) revealed the facility had an approved plan in place, including: Wound care education to facility nurses 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, interview, medical record review, and review of facility policy, the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to appropriate standards of care to decrease the risk of infection, and the record accurately reflected care that was provided. This affected one resident (#26) out of three residents reviewed for wound care. The facility census was 49. Findings include: Review of the medical record for Resident #26 revealed an admission date of 04/19/23 with diagnoses including chronic obstructive pulmonary disease (COPD), blindness in the right eye, chronic systolic (congestive) heart failure, type two diabetes mellitus, essential hypertension, stage two chronic kidney disease, and acquired absence of the left leg below the knee. Review of the annual Minimum Data Set (MDS) assessment completed on 01/26/24 revealed Resident #26 had intact cognition and had no known wounds at the time the MDS assessment was completed. Review of the physician orders revealed an order for wound care of the left distal leg…

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, record review and interview, the facility failed to ensure Resident #44's pressure ulcer wound care was completed as ordered and failed to ensure the accuracy of Resident #44's medical record. This finding affected one (Resident #44) of one resident reviewed for pressure wounds. Findings include: Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including essential hypertension, chronic kidney disease and hypothyroidism. Resident #44 was admitted with a stage four pressure wound (wound which extends below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) to the coccyx (gluteal cleft) identified as full thickness and a unstageable (unable to stage pressure wound due to necrosis) pressure wound of the right, upper buttock identified as full thickness. Review of Resident #44's Clinical admission form dated 01/19/24 revealed the resident had a buttocks (generalized) pressure wound which measured 2 centimeters (cm)…

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, medical record review, and policy review the facility failed to ensure a complete and accurate medical record for one resident (#43) of three residents reviewed for wound care. The facility census was 49. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/19/24 with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, stage three chronic kidney disease, type two diabetes mellitus, stage four pressure ulcer of sacral region, unstageable pressure ulcer of right buttock, pressure-induced deep tissue damage of other site, unstageable pressure ulcer of other site, and pressure-induced deep tissue damage of left heel. Review of the Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #43 had intact cognition and the presence of one stage four and two unstageable pressure ulcers, which were present on admission to the facility. Review of physician orders revealed Resident #43 had the following wound care orders to his right upper buttock: From 01/30/24 to 02/05/24 cleanse…

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 interview the facility failed to implement a safe discharge including the provision of medications for Resident #49. This affected one (Resident #49) of three residents reviewed for discharge planning and implementation. The census was 46. Findings include: Review of the medical record for Resident #49 revealed an admission date of 08/18/23 and discharge date of 09/11/23. Diagnoses included unspecified severe protein-calorie malnutrition, depression, anxiety disorder, and multiple myeloma not having achieved remission. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/24/23, revealed the resident had intact cognition. Review of the nurse progress note dated 09/11/23 revealed Licensed Practical Nurse (LPN) #102 was unable to provide medications upon discharge due to Resident #49 leaving the building without notifying LPN #102. Interview on 10/07/23 at 10:29 A.M. with the Administrator revealed Resident #49's discharge summary and medications were completed upon discharge. The LPN who discharged Resident #49 did not provide medications…

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 review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. This had the potential to affect all 47 residents residing in the facility. The census was 47. Findings include: Review of the facility undated document titled, Legionella Water Management Plan, revealed the plan lacked any information about how the facility would intervene when control measures were not met, failed to address ongoing monitoring of the plan's effectiveness, and no documentation of preventative measures or testing of the water system besides temperature monitoring to maintain the water system free of Legionella bacteria. Interview with Maintenance Director (MD) #945 on 09/11/23 at 9:02 A.M. verified the lack of information in the facility's Legionella water management plan. Review of the CDC webpage revealed guidance under the title of, Overview of Water Management Programs, 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 observation, staff interview, interview with a water service representative, review of an emergency water supply contract, and review of water company recommendations, the facility failed to ensure an adequate usable emergency water source was available for use in the event of a service disruption. This had the potential to affect all 47 residents residing in the facility. The facility census was 47. Findings include: Observation of the facility's emergency water supply with Maintenance Director (MD) #945 on 09/11/23 at 9:02 A.M. revealed twenty five-gallon plastic water jugs in the facility's basement. The jugs were coated in dust and dirt. Eleven of the bottles had delivery date stickers of 09/25/17, and nine of the bottles had delivery date stickers of 08/27/13. Interview with MD #945 on 09/11/23 at 9:02 A.M., during observation of the facility's emergency water supply, verified the dates and the condition of the water jugs, and verified there was no other emergency water source available at the facility at the time of the observation. Continued interview with MD #945…

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 facility policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 46 out of 47 residents who ate meals from the facility's kitchen. One resident (#39) was identified as received nothing by mouth. The facility census was 47. Findings include: Observation of the tray line on 08/24/23 from 11:15 A.M. through 12:09 A.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment. Observation and interview on 08/24/23 at 12:15 P.M. revealed the meal cart with meals was parked in front of the dining room. Interview with Licensed Practical Nurse (LPN) #101 stated meal trays were not passed due to the facility had four agency Stated Tested Nursing Assistants (STNAs) working the floor. LPN #101 stated they do not know the meal tray delivery routine. Observation of test tray and interview on 08/23/23 at 12:30 P.M. with Dietary Manager (DM) #115 revealed the ham was 102…

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, observation, staff interview, and facility policy review the facility failed to ensure a homelike environment that was free of pests. This affected five Residents (#18, #30, #32, #41 and #47) of 47 residents residing at the facility. Findings include: Review of the pest control service documentation from 05/11/23 through 08/08/23 revealed the facility was previous treated for flies, gnats, ants, and mice. Review of the maintenance log dated 06/01/23 through 08/23/23 - revealed no pest issues. Interview on 08/23/23 at 8:30 A.M. with Resident #47 stated she had gnats flying around her orange juice cup this morning. Observation on 08/23/24 at 12:30 P.M. of Resident #41's room revealed there were five small flies sitting on the countertop next to a used washcloth. At this time the Director of Nursing (DON) verified the finding. Interview on 08/23/23 at 3:30 P.M. with Resident #39, roommate to Resident #47, stated gnats were flying around Resident #47's breakfast this morning. Interview on 08/23/23 at 3:55 P.M. with the Maintenance Director (MD) #114 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of facility self-reported incidents (SRIs), and facility policy review the facility failed to ensure Resident #47 was free from staff to resident verbal abuse. This affected one resident (47) of two self-reported incidents reviewed for abuse. Findings include: Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including adjustment disorder with mixed anxiety and depression, anxiety disorder, bipolar, major depression disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition and required extensive assistance with activities of daily living. Review of facility SRI tracking number 238135 dated 08/15/23 revealed Resident #47 reported a nightshift male State Tested Nursing Assistant (STNA) #111 was using inappropriate language. STNA #111 was as needed (PRN) help. During the investigation, the Director of Nursing (DON) was notified that STNA #112 was also…

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 observations, interview and record review, the facility failed to ensure that the kitchen was clean and sanitary and dish washing protocols were followed to ensure dishes were sanitized. This had the potential to affect 39 of 41 residents receiving food from the kitchen. Resident #31 received no food by mouth (NPO). The facility census was 41. Findings include: Tour of the kitchen on 02/06/23 from 8:30 A.M. to 8:50 A.M. with [NAME] #371 revealed in the reach in freezer, chicken was not wrapped properly, labeled, or dated and frozen veggies were not labeled or dated when opened. In the walk-in refrigerator, turkey was not labeled or dated, and old desserts located on the baker's rack were not covered, labeled or dated. [NAME] #371 verified findings at time of observation. Observation of dish machine on 02/06/23 at 8:50 A.M. revealed the dish machine did not reach proper final rinse temperature (180 degrees Fahrenheit) after several empty racks went through the high temperature dish machine. The final rinse temperature was 150 degrees Fahrenheit (F). Dietary Aide #402 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff followed proper infection control procedures when entering and exiting COVID-19 isolation rooms and failed to ensure proper infection control procedures were used during wound care for Resident #26. This affected nine residents (#9, #14, #23, #26, #29, #137, #139, #237, and #287). The census was 41. Findings include: 1. Review of the medical record for Resident #139 revealed an admission date of 02/07/23 with a diagnosis of COVID-19. Review of the physician's orders for February 2023 identified orders for isolation due to COVID-19 through 02/09/23. Review of the care plan dated 02/07/23 revealed Resident #139 had an actual infection related to COVID-19. Interventions included isolation precautions as ordered, all services to be provided in room while on isolation, and personal protective equipment (PPE) would be worn. On 02/08/23 at 1:05 P.M., observation of Resident #139's room revealed a cart 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.

Based on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected five residents (#13, #27, #28, #138, and #238) rooms of 41 resident occupied rooms and two common areas. This had the potential to affect all 41 residents that resided in the facility. Findings include: 1. Observation on 02/06/23 at 11:12 A.M. revealed there was feces on the toilet and toilet seat of Resident #238. The Director of Nursing verified at time of observation. 2. An environmental tour was conducted with the Maintenance Director on 02/09/23 from 9:32 A.M. through 10:15 A.M. revealed the following: - Wallpaper was peeling in common area near the nurses station. - Resident #13's wall had peeling paint located next to the bed. - Resident #27's wallpaper was peeling and had a hole in the wall. - Resident #28's blinds were broken. - The central shower room had paint peeling from the ceiling. - Resident #138's door frame was cracked and frayed. This deficiency represents non-compliance investigated under Complaint Number OH00139256.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to treat residents with respect and dignity at all times. This affected three residents (#19, #26, #27) out of six residents reviewed for dignity. The facility census was 41. Findings include: 1. Record review for Resident #27 revealed an admission date of 09/16/21 and a readmission date of 12/23/21. Diagnoses included but not limited to adult failure to thrive, anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed the resident had severely impaired cognition. The resident required supervision with one staff for activities of daily living. Review of the physician's orders for January 2023 revealed Resident #27 was ordered a no concentrated sweet with mechanical soft texture diet and regular consistency liquids. Observation on 02/06/23 at 12:00 P.M. revealed Resident #27 was at a table with three other residents (Resident #19, #21 and #29). Resident #27 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 provided adequate feeding assistance to Resident #16. This affected one (#16) of three residents reviewed for activities of daily living. The census was 41. Findings include: Review of the medical record for Resident #16 revealed an admission date of 07/25/16. Diagnoses included paranoid schizophrenia, dementia without behavioral disturbance, anxiety disorder, and major depressive disorder. Review of the physician's orders for February 2023 identified orders for a regular diet with mechanical soft texture. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 required extensive assistance of one staff for eating. Review of the nutrition care plan revised 12/16/22 revealed Resident #16 was at-risk for alteration in nutrition and hydration due to hospice, history of medications that could cause weight changes, paranoid schizophrenia, hallucinations, dementia, hypothyroid, depression, COVID-19, 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 observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed and that a physician's order was in place for oxygen use for Resident #12. This affected one (Resident #12) of one reviewed for oxygen use. The census was 41. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/30/15 and re-admission date of 09/27/22. Diagnoses included acute respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Review of the physician's orders for February 2023 identified orders for a Triology sleep machine to be applied at bedtime and removed upon waking. No orders were identified for oxygen use during the daytime hours. On 02/06/23 at 11:00 A.M., observation of Resident #12 revealed oxygen was in use at 3 liters (L) and the oxygen tubing was not dated. On 02/06/23 at 11:04 A.M., interview with Licensed Practical Nurse (LPN) #501 verified Resident #12 was receiving oxygen at 3 L, the oxygen tubing was not dated,…

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 observations, interview and record review, the facility failed to honor resident preferences regarding menu choices. This affected three residents (#3, #4, and #6) of three residents reviewed for choices. The facility census was 41. Findings include: 1. Record review for Resident #3 revealed an admission date of 09/04/20. Diagnoses included but not limited to hemiplegia and hemiparesis following cerebral infarction, major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed the resident had intact cognition. The resident required supervision with one staff for activities of daily living except eating which was independent. Review of the physician's orders for January 2023 revealed Resident #3 was ordered a regular diet with no restrictions. Review of the care plan dated 09/10/20 with a revision date of 01/10/23 revealed Resident #3 had a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences. Observation of lunch…

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, record review and interview the facility failed to ensure Resident #12 and Resident #35 were provided a dignified dining experience. This affected two residents (#35 and #12) of 22 residents eating lunch in the dining room. Findings include: 1. The lunch meal was observed on 02/18/20 from 12:25 P.M. through 1:10 P.M. During the observation, Resident #35 was observed sitting at table number 6 which was the table where residents needing staff assistance to eat their meals were seated. State Tested Nursing Assistant (STNA) #710 and #732 were seated. The two STNAs spoke with each other throughout the meal regarding various subjects including their personal life. Resident #35 was not addressed by either STNA throughout the course of the meal. Interview with the Administrator and Registered Nurse (RN) #701 confirmed in an interview on 02/18/20 at 2:30 P.M. STNA #710 and #732 should not have been discussing personal business during the course of Resident #35's meal. 2. Resident #12 was admitted 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, record review and interview the facility failed to ensure Resident #9 was provided adequate assistance with mobility to ensure the resident was properly positioned in her wheelchair. This affected one resident (#9) of one resident reviewed for positioning. Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, spinal stenosis, transient cerebral ischemic attack and dementia. Review of activity of daily living (ADL) progress notes, dated 12/19/2019 revealed bed mobility items documented were provided during wound care treatment/evaluation. Lifted resident's legs into bed (extensive (ext) assist). Assisted resident to turn in bed/chair (ext assist). Placed pillow to assist resident with positioning (ext assist). Assisted resident to a sitting position (ext assist). Review of the annual comprehensive assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance from staff for bed mobility…

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, record review and interview the facility failed to ensure adequate infection control practices were maintained during a dressing change for Resident #4 to prevent the spread of infection and failed to ensure Resident #13's indwelling urinary catheter was maintained in a manner to prevent the spread of infection. This affected one resident (#4) of two residents reviewed for pressure ulcers and one resident (#13) of two residents reviewed for catheters. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility with diagnoses including heart failure, chronic kidney disease with dialysis and contusions of the bilateral lower extremities. Review of the most recent wound notes revealed the resident had vascular wounds to her left anterior shin and right lower leg. She also had pressure areas on the right and left heels. Observation of the dressing change for Resident #4 with Licensed Practical Nurse (LPN) #400 on 02/20/20 at 8:10 A.M. revealed she had cleaned off the table in the resident's room with bleach wipes 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.