Wyant Woods Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the failed to provide activities to meet the interest and needs of residents. This affected eleven residents (#16, # 21, #23, #24, #28, #32, #42, #47, #56, #62, and #112) of 30 residents observed for activities and had the potential to affect the 22 additional residents (#29, #73, #90, #103, #104, #107, #113, #114, #119, #120, #132, #136, #137, #138, #139, #142, #145, #150, #151, #152, #209, and #210) residing on the Birch unit. The facility census was 158. Findings include: 1. Review of the facility activity calendar for April 2025 revealed no activities were provided after 4:00 P.M. Further review noted handouts were the only activity provided after 4:00 P.M. Review of Resident Council Meeting minutes dated January 2024 through April 2025 noted residents requested more activities in and out of the facility in January, February, June, July, September, December of 2024 and January and March of 2025. a. Review of the medical record 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 observations, interview, record review, and review of facility policy, the facility failed to ensure residents received proper assistance with personal hygiene and grooming tasks. This affected three residents (#25, #99, and #114) of five residents reviewed for activities of daily living. The census was 158. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 08/11/21 with diagnosis of hypertensive heart and chronic kidney disease, asthma, moderate intellectual disabilities, abnormalities of gait and mobility, arthritis, peripheral vascular disease, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #99 required moderate assistance with personal hygiene. Review of the Plan of Care dated 02/05/25 revealed Resident #99 had a deficit related to Activities of Daily Living (ADL) and required moderate assistance with personal hygiene. Observation and interview of Resident #99 on 04/09/25 at 8:11 A.M. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to maintain infection control standards during medication administration and failed to appropriately clean a glucometer. This affected one resident (#32) of four residents reviewed for medication administration. The facility identified 29 residents who required blood sugar monitoring. The facility census was 158. Findings include: Review of medical record for Resident #32 revealed an admission date of 02/20/14. Diagnoses included type two diabetes mellitus with hyperglycemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #32 had intact cognition. Review of plan of care noted Resident #32 had diabetes. Interventions included to administer medications as ordered and check blood sugars before meals. Observation on 04/07/25 at 11:54 A.M. revealed Licensed Practical Nurse (LPN) #891 preparing medications to be administered to Resident #32. LPN #891 prepared four medications into a medication cup.…

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 interview, the facility failed to discard expired food items timely and appropriately label or date opened and prepared food items. This had the potential to affect all 166 of 167 resident who received food from the kitchen as Resident #151 received nothing by mouth (NPO). The facility census was 167. Findings include: On 10/15/24 from 6:45 A.M. to 7:00 A.M., the initial walkthrough of the kitchen revealed the reach-in refrigerator contained the following: - One container of beans that was not labeled or dated. - One container of mayonnaise that was not labeled with the open date. - One container of sour cream with an expiration date of 10/12/24. - Three plastic wrapped bundles of sliced cheese that were not labeled or dated. - One bag of lettuce that was not labeled or dated. - One plastic tub containing open packages of hot dogs that was not labeled or dated. - Two small containers of a brown substance that were not labeled or dated. - One container of Dannon Light + Fit vanilla yogurt with an expiration date of 10/03/24 and writing in black marker…

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, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to remove a perpetrator of abuse from the facility immediately to ensure all residents were protected from further abuse. This affected one resident (#78) and had the potential to affect 22 additional residents (#61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, and #83) who resided on the secured Hickory unit. The facility census was 167. Findings include: Review of the medical record for Resident #78 revealed an admission date of 12/31/22 and re-admission date of 02/03/23. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following…

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, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to ensure staff reported allegations of abuse in a timely manner. This affected one resident (#78) of three reviewed for abuse. The facility census was 167. Findings include: Review of the medical record for Resident #78 revealed an admission date of 12/31/22 and re-admission date of 02/03/23. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder. Review of the behavior care plan, revised 08/27/24, revealed Resident #78 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to appropriately assess and monitor Resident #80's closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. This finding affected one (Resident #80) of three residents reviewed for quality of care. Findings include: Review of Resident #80's hospital progress note prior to facility admission, dated 08/08/24 at 10:36 A.M., revealed the resident had a closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. A closed reduction of the left ankle was completed in the hospital. The left lower extremity was placed in a bulky splint and the toes had minimal edema. Review of Resident #80's medical record revealed the resident was admitted on [DATE] with diagnoses including nondisplaced fracture of the medial malleolus of the left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to maintain proper infection control techniques during wound care and insulin administration. This affected one (#40) of three residents observed for wound care, one (#165) of one resident observed for insulin administration, and had the potential to affected 52 residents (#2, #11, #12, #19, #21, #22, #26, #27, #35, #40, #46, #55, #56, #59,#62, #64, #69, #72, #73, #81, #83,#87, #91,#98, #102, #103, #106, #110, #111, #112, #115, #120, #122, #123, #126, #128, #129, #131, #134, #137, #140, #141, #142, #147, #149, #151, #153, #156, #157, #165 #166 and #169) residing on the Oak and Walnut halls where Registered Nurses #427 and 304 were providing care. The facility census was 170. Findings include: 1. Review of Resident #40's medical records revealed an admission date of 08/26/24. Diagnoses included diabetes and non-compliance with medical treatments. Review of Resident #40's Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure Resident #165's diabetes was managed appropriately by ensuring insulin was administered according to physician orders. This affected one (#165) of four residents observed for medication administration. The facility census was 170. Findings include: Review of Resident #165's medical records revealed an admission date of 08/23/24. Diagnoses included diabetes, developmental delays and schizophrenia. Review of Resident #165's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 had intact cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of Resident #165's current physician orders for September 2024 revealed Resident #165 was ordered Fiasp (fast acting insulin) 15 units before meals. Observation of medication administration on 09/10/24 at 7:56 A.M. for Resident #165 with Registered Nurse (RN) #427 revealed RN obtained Resident #165's insulin pen 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.

Based on personnel file review, interview and review of the facility policy, the facility failed to hire staff free of disqualifying offenses including abuse. This affected three out of five personnel files reviewed and had the potential to affect all 161 residents in the facility. Findings include: Review of personnel files on 07/30/24 at 12:03 P.M. and 4:25 P.M. with the Administrator revealed the following areas of concern: • Review of State Tested Nursing Assistant (STNA) #356's personnel file revealed a date of hire of 03/06/23. Review of STNA #356's background check report dated 03/10/23 revealed a charge dated 03/31/04 for cruelty towards child and child neglect and a charge of aggravated child abuse and cruelty towards child with a note that charge was dropped/abandoned on 07/09/04. Both charges occurred in the state of Florida. • Review of Maintenance Technician (MT) #438's personnel file revealed a date of hire of 06/19/24. Review of MT #438's background check report dated 07/01/24 revealed a charge dated 11/05/18 for possession of drugs (2925.11). • Review of STNA #367'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 personnel record review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR). This affected three out of five personnel files reviewed and had the potential to affect all 161 residents who resided in the facility. Findings include: Review of personnel files on 07/30/24 at 12:03 P.M. and 4:25 P.M. with the Administrator revealed the following areas of concern: • Review of State Tested Nursing Assistant (STNA) #356's personnel file revealed a date of hire of 03/06/23. STNA #356's personnel file lacked evidence she was checked against the NAR prior to 07/30/24. A copy of the NAR ran by the Administrator on 07/30/24 was on top of her personnel file. • Review of Maintenance Technician (MT) #438's personnel file revealed a date of hire of 06/19/24. MT #438's personnel file lacked evidence he was checked against the NAR. • Review of Activity Aide (AA) #307's personnel file revealed a date of hire of 06/19/24. AA #307's personnel file lacked…

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 admission documents, staff interviews, and review of facility policy, the facility failed to timely implement effective and individualized interventions to address behavioral health concerns. In addition, the facility failed to monitor the effectiveness of interventions once implemented. This affected one (#70) of three residents reviewed for behavioral health services. The facility census was 167. Findings include: Review of the medical record for Resident #70 revealed an admission date of 04/17/24. Further review revealed Resident #70 passed away in the facility on 04/26/24. Resident #70 had diagnoses including left non-dominant side hemiplegia and hemiparesis following cerebral infarction, type one diabetes mellitus, psychosis, anxiety disorder, major depressive disorder, delirium, and insomnia. Further review of the medical record revealed Resident #70 was transferred from another facility. Review of admission documents, which included progress notes from 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 record review of the Payroll Based- Journal (PBJ) Staffing Data Report and staff interview, the facility failed ot meet the required minimum staffing levels to meet the needs of the residents. This had the potential to affect all 163 residents residing at the facility. The facility census was 163. Findings include: Review of the PBJ Staffing Data Report for quarter three 2023, dated 04/01/23 through 06/30/23, revealed a one star staffing rating and excessively low weekend staffing. Interview on 03/12/24 at 2:51 P.M., with Administrator confirmed the PBJ Staffing Data Report for 04/01/23 through 06/30/23 was reported correctly. The facility reported less than sufficient staffing to meet the needs of the residents. The Administrator verified the facility has no evidence of corrective action to fix the low staffing situation. This deficiency represents non-compliance investigated under Complaint Number OH00151062 and OH00151071.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of a video recording, resident interview, staff interview, medical record review, self-reported incident (SRI) review, and policy review, the facility failed to ensure a resident's privacy was maintained, when the resident was video recorded without their permission. During the recording, a staff member was questioning the resident about their opinion on body piercing's. Subsequently the video was posted to a social media website with laughing emojis (small digital image or icon used to express an idea, emotion, etc.) at the bottom of the video. This affected one (#4) of three resident reviewed for privacy. The facility census was 163. Findings include: Review of Resident #4's medical record revealed an admission date of 02/14/2012. Diagnoses included paranoid schizophrenia, dementia, severe psychotic disturbances and with agitation, extrapyramidal and movement disorders, anxiety disorder, delusional disorder, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment 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 medical record review, observation and staff interview, the facility failed to ensure fall prevention interventions were in place as ordered by the physician and per the fall plan of care. This affected two (Residents #15 and #62) of three residents reviewed for falls. The facility census was 164. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 06/05/22 with diagnoses that include Alzheimer's disease with dementia, chronic kidney disease and hypertension. A fall risk assessment completed on 12/28/23 indicated Resident #15 was at high risk for falls. Review of the fall risk plan of care for Resident #15 revealed a new intervention of mat to floor beside open side of bed added on 01/06/24. Review of the physician's orders revealed an order dated 01/08/24 which identified the use of a fall mat to the bedside. Observation on 01/09/24 at 12:00 P.M. revealed Resident #15 lying in bed on her left side with no evidence of any fall mat to the floor beside the bed. On 01/09/24 at 12:02 P.M. Licensed Practical Nurse (LPN) #211 verified there…

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 conduct a thorough investigations when investigating a self-reported incident (SRI) for Resident #7, #53, and #409 and when investigating an injury of unknown origin for Resident #33. This affected four residents (Resident #7, #33, #53, and #409) out of five residents reviewed for abuse. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/14/21. Resident #7's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dementia with agitation, and impulse disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition, required extensive assistance of one staff for bed mobility, transfers, and toilet use. The resident had no behaviors. Review of the medical record for Resident #53 revealed an admission dated of 03/23/22. Resident #53's diagnoses included schizophrenia, impulse disorder, and delusional…

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 residents were supervised during smoking. This affected eight residents (Resident #30, #35, #36, #54, #70, #80, #129, and #133) of nine residents reviewed for smoking. Findings include: 1. Record review for Resident #30 revealed an admission date of 01/26/21. Resident #30's diagnoses included dementia, severe with mood disturbances, psychotic disturbances, need for assistance with personal care, muscle weakness, and nicotine dependence. Record review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired and required supervision with activities of daily living. Record review of the list of residents who smoke and require supervision while smoking revealed Resident #30 required supervision during their smoking breaks. Observation on 12/14/22 at 8:37 A.M. revealed Resident #30 was outside in the courtyard of the secured behavioral unit smoking unsupervised. Interview on 12/14/22 at 8:40 A.M. 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 observation, interview, facility policy review and record review, the facility failed to ensure oxygen tubing was dated to ensure timely replacement. This affected eight residents (Residents #23, #44, #61, #69, #96, #118, #138 and #145) of 15 residents utilizing oxygen therapy. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 01/25/22 and diagnoses including dysphagia, type two diabetes, asthma, vascular dementia with mood disturbance, morbid obesity and major depressive disorder. Review of Resident #69's quarterly minimum data set (MDS) assessment dated [DATE] revealed she did not reject care. Resident #69 was coded as using oxygen. Review of Resident #69's physician's orders revealed an order dated 12/03/22 for oxygen at two liters via nasal cannula [for] as needed dyspnea (shortness of breath) to maintain oxygen saturation at 91% or above. No orders were present regarding changing Resident #69's oxygen tubing as of 12/11/22. Review of Resident #69's December…

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 menu spreadsheet review, the facility failed to follow the menu as written. This affected three residents (Residents #38, #95 and #459) observed out of eight residents receiving pureed meals. Findings include: Review of a menu for week two, corresponding to 12/11/22 to 12/17/22 revealed the dinner meal on 12/12/22 included breaded fish on a bun with broccoli florets, tater tots and deluxe fruit salad. Review of a spreadsheet for Dinner Day Nine, Week Two-Monday corresponding to 12/12/22 revealed residents on a pureed diet were to receive a #8-scoop of pureed breaded fish, a #10-scoop of pureed broccoli florets, a half-cup of mashed potatoes, a #16-scoop of pureed dinner roll/bread and a #10-scoop of pureed sliced peaches and pears. Observation of the dinner trayline on 12/12/22 starting at 4:45 P.M. revealed pureed fish, pureed broccoli, mashed potatoes and gravy were noted on the steamtable. Canned fruit was noted on carts adjacent to the steamtable. No pureed bread was observed during dinner trayline. Tray service started at 5:09 P.M. for the…

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

Based on observation, interview and recipe review, the facility failed to ensure pureed foods were prepared in an appropriate manner that preserved its nutritional value. This affected eight residents (Residents #23, #38, #45, #95, #108, #123, #154 and #459) receiving a pureed diet. Findings include: Observation of puree preparation on 12/12/22 starting at 4:18 P.M. revealed Dietary Aide (DA) #543 placed 15 breaded fish filets into the food processor. DA #543 blended the food, then added water by the tablespoon. When DA #543 deemed the puree complete, 10 tablespoons of water had been added. The mixture was tasted and was thick, salty and lacked flavor. Interview with DA #543 at the time of observation indicated she followed the recipe by adding water. No recipe was out and available during the puree preparation observation. Interview on 12/12/22 at 4:32 P.M. with Dietary Manager (DM) #555 revealed she would have added milk to thin the puree instead of water. DM #555 tasted the puree when requested and agreed the mixture had no flavor as prepared. Interview on 12/12/22 at 4:34 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 observation, interview, policy review, record review and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) to prevent the further spread of COVID-19. This had the potential to affect all 16 residents (Residents #27, #29, #31, #38, #42, #59, #62, #66, #69, #90, #95, #105, #107, #120, #122 and #138) residing on the [NAME] unit. The facility census was 153 residents. Findings include: Review of Resident #42's medical record revealed an admission date of 08/22/22 and diagnoses including intermittent explosive disorders, peripheral vascular disease, unspecified dementia, constipation, quadriplegia, sepsis and schizoaffective disorder bipolar type. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #42 had severe cognitive impairment and was totally dependent on two staff for bed mobility and transfer. Review of Resident #42's current physician's orders revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents were treated with dignity and respect at all times. This affected three residents (Resident #3, #9, and #23) of 42 reviewed for dignity. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/18/15. Resident #9's diagnoses included schizoaffective disorder, dementia and gastro-esophageal reflux disease (GERD). Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 could not complete a mental status assessment. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. Interview and observation on 12/12/22 at 9:46 A.M. revealed Resident #9's bedroom door closed. The resident was lying in bed with a sheet covering him. He stated staff often entered his room without knocking or introducing themselves and did not wear nametags. He revealed he would like to get out of bed and get dressed for the day. Interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure call lights were in reach. The affected two residents (Resident #19 and Resident #37) out of nine residents reviewed for accommodation of needs. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 06/09/2019. Resident #19's diagnoses included multiple sclerosis, dementia, epilepsy and paraplegia. Review of the quarterly Minimum Data Set (MDS assessment dated [DATE] revealed Resident #19 had moderately impaired cognition. She required extensive assistance of two people for bed mobility and toilet use, extensive assistance of one person for dressing, eating and hygiene and was totally dependent on two staff for transfers. Review of the care plan dated 09/21/22 revealed the resident had a self-care performance deficit. Interventions included assistance with locomotion and tasks that caused frustration. She also used a mechanical lift for transfers with interventions to ensure her call bell…

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 funds were disbursed in a timely manner for Resident #209 after death as required. This affected one resident (Resident #209) of five residents reviewed for resident funds. Findings include: Review of Resident #209's closed medical record revealed an admission date of [DATE] and diagnoses including moderate protein-calorie malnutrition, dementia without behavioral disturbance, hypertension, alcohol abuse, delusional disorders, major depressive disorder and peripheral vascular disease. Review of an annual minimum data set (MDS) assessment dated [DATE] revealed Resident #209 was cognitively intact. Review of a nurses' note dated [DATE] revealed Resident #209 passed away at 6:15 P.M. Review of a closed account summary report from [DATE] to [DATE] revealed Resident #209 expired on [DATE]. Review of Resident #209's quarterly statement for [DATE] through [DATE] revealed a balance of $1760.36 on [DATE] and the account was closed on that date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide shaving assistance to Resident #50 and nail care to Resident #103 timely. This affected two residents (Residents #50 and #103) of four residents reviewed for activities of daily living (ADL). Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 08/31/17. Resident #50's diagnoses included metabolic encephalopathy, type two diabetes mellitus, and paranoid schizophrenia. Review of care plan dated 05/27/21 revealed Resident #50 had a self-care performance deficit and required assistance with activities of daily living. Interventions included to provide assistance with personal hygiene and bathing. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment. Resident #50 required extensive one-person physical assistance for bed mobility, transfers, and personal hygiene; supervision of one person for dressing; supervision 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 observation, interview, and record review, the facility failed to change a unsecured sterile dressing utilized to prevent infection at a peripherally inserted central catheter (PICC) line site for Resident #53. This affected one resident (Resident #53) of one resident reviewed for care of PICC line dressings. Findings include: Record review for Resident #53 revealed an admission date of 08/24/16. Resident #53's diagnoses included dementia severe with psychotic disturbances. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 12 showing mild cognitive impairement. Resident #53 required limited assistance for bed mobility and extensive assistance for transfers. Record review of the care plan for Resident #53 revealed no care plan for the care of the PICC line. Record review of the physician orders for Resident #53 revealed an order for vancomycin hcl (antibiotic) intravenous solution reconstituted 750 milligrams…

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 #94's restorative program and splint devices were implemented to assist with range of motion. This affected one resident (Residents #94) of three reviewed for restorative services. Findings include: Review of the medical record for Resident #94 revealed an admission date of 02/21/20. Resident #94's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia without behavioral disturbance, and vascular dementia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #94 had intact cognition, required extensive assistance of two staff for bed mobility and toilet use, required total dependence of two staff for transfers, and supervision of one staff for eating. The assessment also indicated the resident was impaired on one side for both upper and lower extremities. Review of the plan of care for Resident #94 dated 10/31/22 revealed the resident 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 record review and interview, the facility failed to ensure Resident #9 urine and bowel restorative program was implemented as ordered. This affected one resident (Resident #9) of three reviewed for restorative services. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/18/15. Resident #9's diagnoses included schizoaffective disorder, dementia and gastro-esophageal reflux disease (GERD). Review of Resident #9's bowel assessment dated [DATE] revealed a scheduled toileting program would be initiated. Review of Resident #9's care plan dated 10/25/22 revealed the resident was incontinent of urine and bowel. Interventions included checking for incontinence, establishing voiding patterns and referring to restorative toileting. Review of the quarterly MDS assessment dated [DATE] revealed the resident could not complete a mental status assessment. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize and address Residents #3, #140, and #459's significant weight loss. This affected three residents (Resident #3, #140, and #459) of eight residents reviewed for weight loss. Findings include: 1. Review of the medical record for Resident #140 revealed an admission date of 07/15/20. Resident #140's diagnoses included hemiplegia and hemiparesis, weakness, atrial fibrillation, and obstructive sleep apnea. Review of Resident #140's weight as of admission was 147.2 pounds on 07/22/22. Resident then weighed 131.3 pounds on 11/04/22. This reflected a weight loss in three months of 10.8 percent (%). Resident #140's weight on 12/02/22 revealed 143.2 pounds. Review of the medical record for Resident #140 revealed only one nutritional assessment was completed on 07/29/22 in which the Dietician #556 recommended a regular diet with thin liquids. Review of physician's order dated 10/29/22 for Resident #140 revealed an order for a regular diet with thin…

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 change a unsecured sterile dressing utilized to prevent infection at a peripherally inserted central catheter (PICC) line site for Resident #53. This affected one resident (Resident #53) of one resident reviewed for care of PICC line dressings. Findings include: Record review for Resident #53 revealed an admission date of 08/24/16. Resident #53's diagnoses included dementia severe with psychotic disturbances. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 12 showing mild cognitive impairment. Resident #53 required limited assistance for bed mobility and extensive assistance for transfers. Record review of the care plan for Resident #53 revealed no care plan for the care of the PICC line. Record review of the physician orders for Resident #53 revealed an order for Vancomycin hcl (antibiotic) intravenous solution reconstituted 750 milligrams…

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 assure staff were trained and competent on assessment and monitoring of a peripherally inserted central catheter (PICC) line dressings to assure the insertion site was secure and not left exposed. This affected one resident (Resident #53) of one resident reviewed for care of PICC line dressings. Findings include: Record review for Resident #53 revealed an admission date of 08/24/16. Resident #53's diagnoses included dementia severe with psychotic disturbances. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 12 showing mild cognitive impairment. Resident #53 required limited assistance for bed mobility and extensive assistance for transfers. Record review of the care plan for Resident #53 revealed no care plan for the care of the PICC line. Record review of the physician orders for Resident #53 revealed an order for Vancomycin hcl (antibiotic)…

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 foods per preference. This affected one resident (Resident #62) of four residents reviewed for dietary preferences. Findings include: Review of Resident #62's medical record revealed an admission date of 06/09/21 and diagnoses including syncope and collapse, altered mental status, suicidal ideations, anxiety disorder, hypertension, unspecified dementia severe with other behavioral disturbance, unspecified dementia severe with mood disturbance, schizoaffective disorder, delusional disorders, type two diabetes and paranoid schizophrenia. Review of Resident #62's physician's orders revealed an order dated 10/07/22 for regular diet with diabetic condiments. Review of a food preference assessment dated [DATE] revealed Resident #62 received a regular diet. The assessment had food dislikes listed including scrambled eggs. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact, 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 and interview, the facility failed to ensure the resident's medical record was complete and accurate. This affected one (Resident #156) of one resident reviewed for discharge records. Findings include: Review of the closed medical record for Resident #156 revealed an admission date of 10/10/22 and a discharge date of 10/11/22. Resident #156's diagnoses included dementia with agitation, hypertension, and anxiety disorder. Review of the discharge no return anticipated Minimum Data Set assessment dated [DATE] revealed the resident had impaired cognition and had an unplanned discharge to the community. Review of the closed hard chart revealed a form titled discharge: Release from Responsibility for Discharge Against Medial Advice (AMA) Form dated 10/11/22 at 4:05 P.M. and signed by Resident #156's power of attorney (POA). Review of the progress notes revealed no documentation related to Resident #156's discharge. Interview on 12/14/22 at 3:23 P.M. with the Director of Nursing (DON) revealed…

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

Based on observation and interview, the facility failed to ensure soiled linens were handled to prevent cross contamination during transport and failed to ensure the bottled hand sanitizers used on medication carts were alcohol based. This had the potential to affect all residents residing in the facility. The facility census was 167. Findings include: 1. Observation on 11/06/19 at 9:24 A.M. revealed State Tested Nursing Assistant (STNA) #254 carrying a blanket which had a large amount of brown stool to the soiled linen room with half of the blanket dragging on the floor behind the STNA. Interview on 11/06/19 at 9:28 A.M. with STNA #254 revealed she had changed Resident #90's bed and did not bag the soiled linen prior to leaving the resident's room. STNA #254 indicated she should have bagged the linen instead of carrying it down the hall and confirmed she dragged half of the soiled blanket on the flooring when transporting the blanket to the soiled utility room. 2. Observation on 11/04/19 at 11:00 A.M. revealed hand sanitizer bottles on each of the eight medication carts. 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 and staff interview the facility failed to maintain a clean and sanitary environment for its residents. This affected Residents #71, #164, #121, #5, #49, #2, #13, #14, #36, #57, #133, #139, #141, #260, #99, #150, #111, #136, #106, #155, #156, #35, #47, #22, #44, #154, #61, #108, #129, #107, #151, #3, #24, #189 and had the potential to affect all residents. The facility census was 167. Findings include: An environmental tour was conducted on 11/04/19 between 10:00 A.M. and 10:33 A.M. with Housekeeping Supervisor (HSK) #990. The follow was observed and verified at the time of discovery by HSK #990. 1. A very strong urine odor was noted in the room of Residents #71 and #164. 2. The overhead light in the room of Resident #121 did not have a cover. 3. The privacy curtain in the room of Resident #5 was significantly stained. 4. The carpet in Resident #49's room was significantly stained. 5. The rooms of Residents #2, #13, #14, #36, #57, #133, #130, #139, #141, and #260 had ceiling tiles that were water stained. 6. The rooms of Residents #3, #24, #189 had ceiling tiles…

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 interview the facility failed to ensure the dining tables on the hickory unit were structurally sound and stable for residents to eat their meals from. This affected four of 19 residents who ate their meals in the Hickory unit, Residents #44, #101, #157, and #365. The facility census was 167. Findings include: During observations of the lunch meal on 11/03/19 at 11:32 A.M. on the Hickory unit. There were two tables sitting adjacent to each other near the window which wobbled severely. Staff attempted to put the edge of one table beneath the edge of the second table in a attempt to prevent the tables from moving. They were unsuccessful in their attempt to stabilize the table. Licensed Practical Nurse (LPN) #309 had asked Resident #44 if she wanted to sit somewhere else and she stated no it was okay. The other three residents were not given an opportunity to move to another table. The tables were observed to continue to rock as the residents tried to eat. Seated at the two tables were Residents #44, #101, #157, and #365. This was verified at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #156's advance directives and physician orders accurately reflected the resident's code status. This affected one (Resident #156) of thirty-two residents whose records were reviewed. Findings include: Review of Resident #156's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia in other diseases classified elsewhere without behavioral disturbance, Parkinson's disease and Alzheimer's disease with late onset. Review of Resident #156's physician orders revealed an order dated 10/01/19 which indicated the resident's code status was DNR comfort care (DNR CC) which would not include chest compressions, resuscitative drugs, cardiac monitoring or anything other than comfort care measures. Review of Resident #156's Ohio DNR Identification Form dated 08/07/19 indicated the resident's code status was Do Not Resuscitate Comfort Care Arrest (DNR CCA) which included life saving measures that…

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 timely assess bruising and immediately report the bruising as an injury of unknown origin to the State Agency. This affected one (Resident #122) of four residents reviewed for general skin conditions. Findings include: Observation of Resident #122 on 11/03/19 at 9:56 A.M. revealed he was in the common dining room on the second floor secured memory care unit. Further observation at this time revealed Resident #122 had multiple dark red/purple bruises to both arms. All bruises were circular but of different sizes and were located on the anterior and posterior surfaces of the arms. There were seven bruises on the right arm and five bruises to the left arm. Resident #122 was unable to explain how the bruising occurred. Review of Resident #122's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia without behavioral disturbance and major depressive disorder.…

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 Residents #24 and #146 and their representatives were notified in writing the reason for the discharge to the hospital in an easily understood language. This affected two (Residents #24 and #146) of five residents whose records were reviewed for hospitalization. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Smith's fracture of the left radius, vascular dementia without behavioral disturbance and Alzheimer's disease. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #24's progress note dated 08/04/19 at 4:28 P.M. indicated the facility received a call from the hospital and the resident was being admitted for possible metabolic encephalopathy. Review of Resident #24's progress note dated 08/07/19 at 8:00 P.M. indicated the resident returned from 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 record review and interview, the facility failed to ensure Residents #24 and #146 and their representatives were notified in writing of the facility policy for bed holds including the reserve bed payment. This affected two (Residents #24 and #146) of five residents whose records were reviewed for hospitalization. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Smith's fracture of the left radius, vascular dementia without behavioral disturbance and Alzheimer's disease. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. The medical record revealed the resident's payor source was Medicaid CareSource Review of Resident #24's progress note dated 08/04/19 at 4:28 P.M. indicated the facility received a call from the hospital and the resident was being admitted for possible metabolic encephalopathy. Review of Resident #24's progress note…

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 Residents #24 and #128's activity care plans included measurable goals and interventions to meet the physical, mental and psychosocial well-being of the residents. This affected two (Residents #24 and #128) of 38 residents whose care plans were reviewed. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, major depressive disorder and insomnia. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem. Review of Resident #24's fall care plan revealed an intervention dated 08/08/19 to encourage participation in activities that promoted exercise, physical activity for strengthening and improved mobility. Further review of Resident #24's medical record and care plans did not reveal an activity care plan that…

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 #24's skin care plan was revised to include goals and interventions related to the resident's left hand cast. This affected one (Residents #24) of 38 residents whose care plans were reviewed. Findings include: Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Smith's fracture of the left radius, dementia in other diseases classified elsewhere with behavioral disturbance and Alzheimer's disease. Review of Resident #24's MDS 3.0 assessment dated [DATE] confirmed the resident exhibited a memory problem. Review of Resident #24's physician orders revealed an order dated 09/24/19 and discontinued on 11/05/19 to keep the resident's left arm cast clean and dry with non weight bearing to the left hand. Review of Resident #24's medical record and care plans did not reveal evidence a care plan was revised with goals and interventions related to the resident's left arm…

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 the restorative program for ambulation was provided for Resident #97 and restorative program for range of motion was provided for Resident #23. This affected two out of three residents reviewed for restorative programs. Findings include: 1. Resident #97 was admitted on [DATE] with diagnoses including morbid obesity, heart/kidney disease, mental illness and intellectual disability. Resident #97's annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #97 needed supervision for walking in her room and was independent with locomotion using a wheelchair on and off the unit. Resident #97's physician orders dated 10/31/19 indicated a restorative ambulation program. The ambulation program included for one staff to assist Resident #97 to use a front wheeled walker to ambulate up to 50 feet followed with a wheelchair 15 minutes a day six to seven days a week. An interview with Therapy Director #308 on 11/05/19 at 10:25 A.M. indicated…

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 #160's fingernails were clean and manicured and Residents #38 and #160's faces were free of excessive facial hair. This affected two (Residents #38 and #160) of 35 residents observed for activities of daily living. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was moderately cognitively impaired and required extensive assistance for dressing, bed mobility, transferring, toileting and personal hygiene. Review of the medical record revealed Resident #160 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #160 was severely cognitively impaired and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accurate weights were obtained and to verify weights as needed. This affected two residents (Residents #49 and #63) of nine residents reviewed for nutrition. The facility census was 167. Findings include: Review of Resident #49's record revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, anxiety, alcohol dependence with alcohol-induced persisting dementia, slow transit constipation, and functional diarrhea. Review of the quarterly comprehensive assessment dated [DATE] revealed the resident required set-up of his meals by one staff person. Review of physician orders revealed the resident was ordered a regular diet with thin liquids. Further review of the resident's record revealed on 09/05/19 the resident weighed 173.6 pounds. On 10/01/19 the resident weighed 162.8, a loss of 10.8 pounds in one month. There was no re-weigh of the resident after the 10/01/19 weight. Review of Resident #63's record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #55's enteral feedings infused as ordered by the physician. This affected one (Resident #55) of one resident receiving tube feeding in the facility. Findings include: Review of Resident #55's record revealed the resident was admitted on [DATE] with diagnoses including Huntington's disease, bipolar disorder, gastrostomy tube, other chorea, Alzheimer's disease, dementia, vitamin D deficiency, functional quadriplegia, anxiety and abnormal involuntary movements. Review of a physician ordered dated 05/15/19 revealed the order indicated to disconnect the tube feeding solution from 9:30 A.M. to 11:30 A.M. while up in the common area in a chair every day. Review of a physician order dated 05/22/19 revealed the order indicated to infuse enteral tube feeding solution at 60 milliliters continuously for a total volume of 1,320 milliliters in 22 hours. Observation of Resident #55 on 11/03/19 at 9:30 A.M. indicated the tube feeding tube…

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, and interview the facility did not ensure Resident #122's medical record included documentation of two separate resident to resident incidents including assessments and interventions which were completed following the incidents. This affected one (Resident #122) of 39 residents whose records were reviewed. Findings include: Review of Resident #122's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorders and dementia in other diseases classified elsewhere with behavioral disturbance. Review of Resident #122's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #122's medical record and progress notes from 10/17/19 to 11/04/19 did not reveal evidence of any incidents with other residents. Interview on 11/04/19 at 10:10 A.M. with State Tested Nursing Assistant (STNA) #293 indicated Resident #122 and Resident #10 had 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.