Laurels Of Athens, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of meal times, and staff interview, the facility failed to ensure a medication that was given to a resident for the treatment of osteoporosis was administered in accordance with the physician's orders and on an empty stomach to increase the absorption of the medication. They also failed to ensure a resident receiving a beta-blocker for the treatment of hypertension had her apical pulse checked prior to the administration of the medication as ordered by the physician with parameters in place to hold the medication if the resident's heart rate was less than 60 beats per minute (bpm). This affected two (Resident #12 and #100) of five residents reviewed for unnecessary medications. Findings include:1. Review of Resident #100's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, and hypertension. Review of Resident #100's active physician's orders revealed the resident had an order…

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 policy, the facility failed to ensure a urinalysis with culture and sensitivity (UA C&S) was obtained per orders. This affected one resident (Resident #8) of one resident reviewed for urinary tract infection (UTI). The facility census was 98. Findings include: Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including spinal stenosis and radiculopathy.Review of a care plan dated 02/09/24 revealed Resident #8 was at risk for incontinence of bladder, skin breakdown, and UTI due to diagnoses of overactive bladder. The goal was for risk of septicemia to be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Interventions included but were not limited to administer medications as ordered, observe for/document for signs and symptoms of UTI and report to physician if indicated.Review of an orders revealed an order dated 10/17/25 for Resident #8 to receive a UA C&S one time only for dysuria (painful…

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 a complete and accurate medical record was maintained. This affected four (#9, #12, #76, and #86) of 30 resident records reviewed for a complete and accurate medical record. The facility census was 98. Findings include:1.Record review revealed Resident #86 admitted to the facility on [DATE] with diagnoses including acute osteomyelitis of right ankle and foot, type II diabetes, and dementia. Review of a care plan dated 03/10/26 revealed Resident #86 was at risk for fall related injury and falls related to history and fear of falling. The goal was to be free from injury related to falls through the review date. Review of a nursing note dated 03/25/26 at 9:03 P.M. by Licensed Practical Nurse (LPN) #336 revealed Resident #86 went to the hospital. The note did not contain additional information. Review of an eInteract Change in Condition assessment dated [DATE] revealed the assessment had been opened but was blank. Review of a fall investigation…

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 policy review, the facility failed to ensure hand hygiene was performed in between glove changes during tracheostomy care, failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor, and failed to ensure shared glucometers were properly disinfected between each use. This affected one (Resident #9) of three residents reviewed for respiratory care, one (Resident #92) of two residents reviewed for indwelling urinary catheters, and had the potential to affect three residents (Resident #19, #28, and #79), who the facility identified as having the use of the shared glucometer on the 700 Hall. Findings include: 1. Review of Resident #9's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failure with hypoxia (low oxygen level in the blood), chronic obstructive pulmonary disease, unspecified asthma, chronic pulmonary edema, and tracheostomy status. 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 inform and obtain consent from Resident #44's guardian before administration of a COVID-19 vaccination. This affected one resident of six sampled for vaccinations. The facility census was 98.Findings include:Review of Resident #44's medical record revealed an admission date of 03/23/21, a re-entry date of 11/18/25 and diagnoses including Alzheimer's disease with late onset, dementia, atherosclerotic heart disease, hypertensive heart disease without heart failure, and a history of falling.Review of Resident #44's consent/declination of COVID-19 vaccination form revealed a consent for the vaccination signed on 04/15/25 by Resident #44's former guardian.Review of Resident #44's immunization record revealed the resident received a COVID-19 vaccination on 04/15/25.Review of Resident #44's guardianship paperwork revealed the resident's nephew became his guardian on 07/10/25.Review of Resident #44's immunization record revealed the resident received a COVID-19…

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, review of meal tickets, review of menus/ spreadsheets to include special diets, and staff interview, the facility failed to ensure menus were followed for residents receiving consistent carbohydrate (CCHO) diets. This affected four residents (Resident #86, #88, #159, and #214) that were observed for tray preparation during tray line for the lunch meal served on 12/11/24. It had the potential to affect 31 other residents (Resident #4, #5, #6, #9, #10, #16, #17, #21, #22, #30, #34, #36, #39, #41, #44, #45, #51, #66, #68, #69, #73, #75, #80, #81, #82, #89, #101, #209, #210, #212, and #215) who were identified by the facility as being on a CCHO diet. Findings include: On 12/11/24 at 11:35 A.M., an observation of the tray line for the lunch meal served revealed dietary staff dipped the trays for the 900 hall first. The residents were receiving beef and noodle casserole, Normandy vegetables, one slice of bread of choice, and two chocolate chip cookies. Four residents (Resident #86, #88, #159, and #214) whose trays were dipped and loaded on the food cart for the 900…

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 shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents that were dependent on staff for personal care received the assistance needed for scheduled showers. This affected one (Resident #66) of four residents reviewed for activities of daily living (ADL's). Findings include: Review of Resident #66's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included surgical aftercare following cardiovascular procedure, presence of coronary artery bypass graft, type II (adult onset) diabetes mellitus, morbid obesity, difficulty walking, muscle weakness, unspecified dementia with behavioral disturbances, bipolar disorder, chronic obstructive pulmonary disease (COPD) major depressive disorder, and congestive heart failure. Review of Resident #66's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a minimal difficulty with hearing and clear speech. She was able to make…

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 staff interview, the facility failed to ensure a resident with the use of supplemental oxygen had a physician's order for the use of oxygen and nebulizer equipment was properly cleaned/ stored when not in use. This affected one (Resident #210) of one residents reviewed for respiratory care. Findings include: Review of Resident #210's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses acute on chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dependence on supplemental oxygen, and sleep apnea. Review of Resident #210's active care plans revealed the resident had a care plan in place for having a potential for difficulty breathing and risk for respiratory complications related to acute on chronic hypoxic respiratory failure, CHF, COPD, asthma, obstructive sleep apnea, oxygen dependence, and being a smoker. The goal was for the resident to display optimal breathing pattern…

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 residents with a diagnosis of dementia had a comprehensive and individualized treatment plan to ensure behaviors, including inappropriate dress when visible to others, were addressed to promote independence and dignity. This affected one resident (Resident #1) of one residents reviewed for dignity. The census was 101. Findings include: Review of Resident #1's medical record revealed an admission date of 06/23/12, a reentry date of 01/25/22 and diagnoses including rheumatoid arthritis, unspecified convulsions, unspecified intellectual disabilities, dementia, hypothyroidism, and anemia. Review of Resident#1's annual Minimum Data Set (MDS) with an assessment reference date of 10/03/24 revealed a Brief Interview for Mental Status (BIMS) score of nine indicating the resident was moderately impaired. Further review of the MDS revealed Resident #1 required supervision or touching assistance with transfers from seated to standing and with ambulation during the look back period. Review of Resident #1's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of a facility self-reported incident, facility investigation review, interviews, and policy review the facility failed to prevent misappropriation of resident narcotics. This affected one Resident (Resident #28) of one resident reviewed for misappropriation. The facility census was 94. Findings included: Review of Resident #28's medical record revealed an admission date to the facility on [DATE] with diagnoses including Alzheimer's, dementia with other behavioral disturbances, aphasia (difficulty understanding what is being said or difficulty formulating speech due to injuries to certain parts of the brain), anxiety, depression, insomnia, and cardiovascular disease. Review of Resident #28's fluctuation in mood plan of care initiated on 12/21/20 and revised on 06/19/24 revealed the resident had fluctuations in mood related to dementia, anxiety, mood disorder, insomnia, and reactive agitation for mood stabilizer. Her anxiety included anxiousness, pacing back and forth…

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 a self-reported incident, review of the facilities investigation for the self-reported incident, observation, interviews, and policy review the facility failed to ensure an allegation of misappropriation of controlled medication was thoroughly investigated. This affected one Resident (Resident #28) of one resident reviewed for misappropriation. Findings included: Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia with other behavioral disturbances, aphasia, anxiety, depression, insomnia, and cardiovascular disease. Review of Resident #28's fluctuation in mood plan of care initiated on 12/21/20 and revised on 06/19/24 revealed the resident had fluctuations in mood related to dementia, anxiety, mood disorder, insomnia, and reactive agitation for mood stabilizer. Her anxiety included anxiousness, pacing back and forth and wringing hands. The resident intervention included administering medication as ordered 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 policy review revealed the facility failed to ensure controlled medication were signed out when administered and medication were properly labeled and packaged. This had the potential to affect all residents residing on 100, 200, 300, and 400 halls. Findings included: 1. Observation on 07/30/24 at 10:45 A.M. of 300 medication cart with Licensed Practical Nurse ( LPN) #151 and the Director of Nursing (DON) revealed Resident #26 had 25 Methadone 5 mg in the blister packet however the control drug record sheet indicated the resident should have 26 Methadone 5 mg. LPN #151 confirmed findings and reported she had administered a Methadone to Resident #26 this morning around 8:00 A.M., however she must have not signed it out on the control drug record sheet. Further observation of 300 medication carts revealed there were two whole pills and 6.5 1/2 tablets lying in the medication cart loose and unpackaged. LPN #151 confirmed the pills were not packaged and labeled and she would dispose of them. 2. Observation on 07/30/24 at 10:55 A.M. of 400 medication…

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, facility documentation review, and facility policy review, the facility failed to ensure food was stored, prepared and maintained in a safe and sanitary manner. This had the potential to affect 106 residents who were receiving food from the kitchen (a list provided by the facility revealed Resident #95 received nothing by mouth). The facility census was 107. Findings included: 1. Review of the facility logs titled, Food Temperature Record. dated 07/23/23 through 10/21/23, revealed the facility did not assess the temperature of any of their beverages, including milk, prior to them being served. Further review of the form revealed coffee should be 180 degrees, milk should be 35 degrees, and juice should be less or equal to 40 degrees. Interview on 10/23/23 at 8:55 A.M. with the Dietary Staff #3 verified the facility did not temperature check their beverages, including their milk, prior to it being served. Review of the facility policy titled, Food Temperatures, revised 11/12/21, revealed foods will be maintained at proper temperature to ensure food…

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 ensure equipment was maintained in a safe operating condition. This had the potential to affect 106 residents who were receiving food from the kitchen (a list provided by the facility revealed Resident #95 received nothing by mouth). The facility census was 107. Findings included: 1. Observation on 10/23/23 at 8:35 A.M. revealed the walk-in freezer in the kitchen with a blanket folded in half and lying on the floor in front of the door. An interview at the time with Dietary Staff Staff #3 revealed the seal on the walk-in freezer door had not been working properly and the door didn't close properly. He revealed due to the seal not working, there was ice accumulation in the freezer unit, and he had to chip the ice away every Monday morning. Observation of the interior of the walk-in freezer revealed ice accumulation on the floor, racks, food and mechanical unit. This surveyor walked into the freezer to attempt to read the thermometer and the floor was covered in ice and a safety concern. Interview 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, document review, and facility policy review, the facility failed to ensure residents had access to their money on evenings and weekends. This had the potential to affect all 50 residents (#1, #3, #4, #5, #7, #9, #10, #11, #13, #15, #16, #17, #18, #19, #22, #23, #25, #28, #29, #30, #32, #35, #36, #37, #41, #43, #45, #46, #48, #49, #51, #53, #54, #58, #61, #64, #65, #67, #68, #72, #74, #76, #80, #84, #85, #86, #87, #93, #96, and #105) for whom the facility managed resident personal funds accounts. The facility census was 107. Findings included: Interview on 10/26/23 at 1:34 P.M. with Business Office Manager #86 verified residents only had access to funds Monday through Friday from 9:00 A.M. to 5:00 P.M. She revealed there was no petty cash residents could access on the evenings or on the weekends. Observation on 10/26/23 at 1:40 P.M. of signage in the window of the front office of the facility revealed Banking Hours, Monday thru Friday, 9:00 A.M. to 5:00 P.M. Review of the facility form titled, Trust - Current Account Balances as of 10/26/23 by Posting…

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 ensure puree meals were prepared to the correct consistency for consumption. This had the potential to affect five residents (#21, #28, #40, #54, and #69) who were ordered pureed diets. The facility census was 107. Findings included: Observation on 10/25/23 at 10:45 A.M. revealed Dietary Staff #81 pureeing eight servings of baked ziti. She placed the baked ziti in the robot coup and pureed it for approximately 15 seconds. Dietary Staff #81 looked at and tasted the baked ziti then reported to this surveyor it was ready to be served. As this surveyor was placing her spoon in the pureed baked ziti, Dietary Staff #3 looked at the pureed baked ziti and reported it wasn't ready and needed some beef broth added to it. This surveyor then tasted the pureed baked ziti and found it to be very sticky, gummy, and clung to the roof of the surveyor's mouth like peanut butter, not pudding. Dietary Staff #3 then tasted the pureed ziti and reported it was not quite ready to be served. Dietary Staff #3 gave Dietary…

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 2. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, morbid obesity, difficulty in walking and chronic kidney disease, stage two. Review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/27/23, revealed he was cognitively intact. Review of Resident #26's physician order, dated 08/21/23, identified his advanced directives were do not resuscitate comfort care arrest (DNR-CCA). Review of Resident #26's documentation titled admission Record, dated 07/19/22, and the first form seen in the unit advanced directives binder revealed he was a do not resuscitate comfort care (DNR-CC). Further review of Resident #26's documentation in the unit advanced directives binder and tucked behind the admission Record revealed an Ohio DNR Order Form, dated 08/23/23, which revealed he had chosen DNR-CCA. Interview on 10/23/23 at 2:50 P.M. with Resident #26 revealed he…

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

Based on observation, staff interview, and policy review, the facility failed to ensure a resident's electronic medical record was maintained in a confidential manner. This affected one resident (Resident #7) during a random observation made during the course of the annual survey. The facility census was 107. Findings include: On 10/25/23 at 9:38 A.M., a random observation of a medication administration cart for the 600 hall noted the medication cart to be left unattended in the hallway. There were no staff present at the medication administration cart and no staff in the general vicinity. The medication administration cart had a computer on top of the cart. The computer was on and had Resident #7's electronic medication administration record (eMAR) displayed on the screen. The eMAR included a picture of the resident, her room location, her date of birth , known allergies, her code status, and four of the medications displayed on that page. Among the medications that were shown were Lasix, Ativan, Miralax, and Tylenol Extra Strength. The computer screen remained on displaying 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 ensure personal hygiene and bathing was completed for dependent residents. This affected two residents (#23 and #37) of three residents reviewed for activities of daily living. Findings include: 1. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, peripheral vascular disease, difficulty in walking, muscle weakness and chronic obstructive pulmonary disease. Review of Resident #37's Care Plan: ADL Self Care Performance Deficit revised 03/14/23 revealed the resident required assistance with ADL's, had impaired range of motion of bilateral hands/fingers, and chose to decline personal care at times. Resident #37 had no bathing time preference and preferred activities of daily living to be completed in the afternoon. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was severely impaired for daily decision-making and 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, interview, policy review, and observations the facility failed to ensure fall prevention interventions were in place for two residents with history of falls. This affected two residents (#51 and #76) of four residents reviewed for falls. The facility census was 107. Findings included: 1. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including epilepsy, Alzheimer's disease, neuropathy, osteoarthritis, hydrocephalus, and depression. Review of a quarterly minimum data set (MDS) completed on 10/01/23 revealed resident had intact cognition, had no behaviors, is independent for self-care and indoor mobility, had no impairment to bilateral upper extremities, was impaired to a lower extremity on one side, and was frequently incontinent of bowel and bladder. Review of Resident #76's orders revealed fall interventions including padded bilateral enabler rails, left side of the bed against the wall, low bed with fall mat to the right of the bed, and over…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, resident record review, and facility policy review, the facility failed to ensure a resident had the appropriate enabler bars on his bed and failed to ensure the resident's assessment was accurate for the type of devices used on his bed. This affected one resident (#26) of four residents reviewed for accident hazards. The facility census was 107. Findings included: Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, generalized muscle weakness, and spondylosis without myelopathy or radiculopathy of the lumbar region. Review of Resident #26's plan of care, dated, 05/18/22, revealed he had an activity of daily living (ADL) self-care performance deficit and required assistance with ADL's and mobility related to activity intolerance, decreased endurance and weakness secondary to COPD. One of the interventions identified he was to have bilateral enabler bars 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.

Based on observation, record review, drug information review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had four medication errors out of 31 opportunities resulting in a medication error rate of 12%. This affected two residents (#35 and #36) of three residents reviewed for medication administration. Findings include: 1. On 10/25/23 at 8:25 A.M., a medication administration observation was completed for Resident #35. Registered Nurse (RN) #191 was the nurse that administered the medications to the resident for his 8:00 A.M. medication pass. Among the medications the resident received was Creon ( a medication that contains digestive enzymes to help break down and digest fats, starch, and proteins in food) 12-38-60 two capsules by mouth. The label on the blister card the Creon was dispensed in instructed the nurse to give six capsules by mouth with meals. The nurse woke the resident up to take his medications and he was not noted to have breakfast at the time the medication was given. The nurse 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, record review, interviews and facility policy review, the facility failed to properly store medications when not being administered. This affected one resident (#5) that was observed for medication storage at the medication cart. The facility census was 107. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 03/02/22 with the diagnoses of: Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease and Permanent Atrial Fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require extensive assistance with two plus person physical assist with bed mobility, transfers, and extensive assistance with one-person physical assist with toilet use. Observation on 10/24/23 at 6:41 A.M. of Registered Nurse (RN) #153 revealed Resident #5 had medication tablets in a medicine cup, a patch, and 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 record reviews, observations, interviews and policy review, the facility failed to demonstrate proper hand washing and proper storage of COVID 19 personal protective equipment (PPE). This affected two residents (#5 and #23) of the two residents reviewed for handwashing and proper storage of equipment. The facility census was 107. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 03/02/22 with the diagnoses of: Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease and Permanent Atrial Fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require extensive assistance with two plus person physical assist with bed mobility, transfers, and extensive assistance with one-person physical assist with toilet use. Observation on 10/24/23 at 6:30 A.M. of Registered Nurse (RN) #153 exiting…

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.