Beachwood Pointe Care Center

Based on record review and interview, the facility failed to timely reorder medications to avoid missed doses. This affected one resident (Resident #32) of three residents reviewed for pharmacy services. The total census was 105. Findings include: Record review of Resident #32 revealed an admission date of 08/22/23 with diagnoses including schizophrenia, diabetes, and breast cancer. Resident #32 had an order dated 12/13/24 and a previous order lasting from 09/05/23 to 12/13/24 for Verzenio (a medication for breast cancer) 150 milligram tablets to be given twice per day. Review of the December medication administration record revealed she did not receive doses of Verzenio on the mornings of 12/12/23 through 12/14/23. Progress notes on 12/12/24 and 12/13/24 revealed the medication was not at the facility. No physical effect on the resident was noted. Interview with Resident #32 on 01/15/25 at 9:44 A.M. revealed she had no knowledge of missed medications. Interview with Registered Nurse (RN) #202 on 01/15/25 at 9:54 A.M. revealed Resident #32's Verzenio was delivered from an outside…

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 privacy curtains in shared rooms. This affected two (Resident #5 and #82) of six residents reviewed for privacy. The total census was 105. Findings include: Record review of Resident #82 revealed he was admitted on [DATE] and resided in the same room since his admission. Record review of Resident #5 revealed he was admitted [DATE] and resided in the same room since his admission, with a room mate (Resident #82) Observation on 01/15/25 at 3:48 P.M. of Resident #82 and #5's room revealed it had no wall or other barrier between the residents' beds, and no privacy curtain or hooks on which one could be hung. Interview with the Administrator on 01/16/25 at 4:13 P.M. confirmed the above observations. Interviews with Resident #5 and Resident #82 on 01/16/25 from 9:23 A.M. to 9:32 A.M. revealed their room never had a privacy curtain throughout their stay. Both roommates entered the bathroom when changing clothes to preserve their own 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, record review, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a safe and sanitary manner. This had the potential to affect all residents residing at the facility except two residents (Residents #88 and #94) identified by the facility as receiving nothing by mouth. The facility census was 102. Findings include: 1. Observation of the dishwasher on 10/24/24 from 8:38 A.M. till 8:45 A.M. revealed Dietary Aide #605 was actively cleaning breakfast dishes through the dishwasher. Observation of the gauges on the front of the dishwasher revealed the gauges did not move when she ran each cycle: the rinse gauge was set at 152 degrees Fahrenheit (F), and the sanitizer gauge was set at 154 degrees F. There was a back gauge on the dishwasher which also did not move that was at 156 degrees F during all cycles. Interview on 10/24/24 at 8:43 A.M. with Dietary Aide/Cook #604 verified during all three cycles, the three gauges did not move from the start of the cycle to the end. She revealed she was unsure how they…

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

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure residents had a clean, comfortable, home-like environment due to a pervasive urine odor, the first-floor central bathroom was not maintained in a clean, sanitary manner, and failed to ensure door thresholds (a strip of wood, or metal forming the bottom of the doorway entering a room) were not missing. This affected all 40 residents on the first floor (#2, #5, #7, #12, #15, #16, #18, #21, #27, #28, #29, #32, #33, #35, #38, #39, #44, #46, #48, #50, #52, #53, #56, #57, #60, #63, #66, #68, #69, #70, #72, #76, #85, #86, #88, #91, #93, #95, #100, and #101). In addition, the facility failed to ensure door thresholds were not missing and the hallway handrail was not broken resulting in sharp edges on both sides which affected 37 residents on the second floor (#1, #3, #9, #13, #17, #19, #20, #22, #25, #26, #30, #31, #34, #42, #43, #45, #47, #49, #55, #58, #59, #61, #62, #73, #74, #75, #77, #78, #79, #80, #81, #92, #94, #97, #98, #99, and #102). The facility census was 102. Findings…

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, Ohio Department of Health Gateway review, and review of the facility abuse policy, the facility failed to implement their abuse policy including investigating and reporting Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to investigate and report Resident #104's daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admission date of 10/10/24 and she was discharged the same day against medical advice (AMA) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, Ohio Department of Health Gateway review, and review of the facility abuse policy, the facility failed to report Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to report Resident #104's daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admission date of 10/10/24 and she was discharged the same day against medical advice (AMA) to home. Her diagnoses included Alzheimer's disease, hypertension, and major…

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 review of the facility abuse policy, the facility failed to investigate Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to investigate Resident #104 daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admission date of 10/10/24 and she was discharged the same day against medical advice (AMA) to home. Her diagnoses included Alzheimer's disease, hypertension, and major depression. Review of the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure timely incontinence care was provided to Residents #1, #7, #15, and #48. This affected four residents (#1, #7, #15, #48) out of five residents reviewed for incontinence care. This had the potential to affect 52 residents (#1, #3, #4, #6, #7, #8, #10, #13, #14, #15, #19, #23, #24, #26, #29, #30, #33, #37, #38, #41, #42, #43, #45, #46, #48, #52, #54, #55, #58, #59, #60, #64, #65, #66, #69, #70,#72, #73, #74, #75, #81, #82, #85, #88, #89, #91, #93, #96, #95, #99, #102, and #103) identified by the facility as incontinent. The facility census was 102. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 02/23/24 with diagnoses including spastic hemiplegia affecting the right dominant side, hypertension, and osteoarthritis. Review of the care plan dated 07/18/24 revealed Resident #15 had bladder incontinence related to the aging process. Interventions included…

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, interview, Facility Assessment review, the facility failed to ensure they maintained sufficient and competent staff on the first floor on 10/28/24. This affected three residents (#1, #7, and #15) out of seven residents reviewed for staffing. This had the potential to affect 40 residents (#2, #5, #7, #12, #15, #16, #18, #21, #27, #28, #29, #32, #33, #35, #38, #39, #44, #46, #48, #50, #52, #53, #56, #57, #60, #63, #66, #68, #69, #70, #72, #76, #85, #86, #88, #91, #93, #95, #100, and #101) residing on the first floor. The facility census was 102. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 02/23/24 with diagnoses including spastic hemiplegia affecting the right dominant side, hypertension, and osteoarthritis. Review of the care plan dated 07/18/24 revealed Resident #15 had bladder incontinence related to the aging process. Interventions included checking Resident #15 every two hours and as needed, monitoring for signs 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 record review and interview the facility failed to employ a qualified dietary manager to carry out the functions of the food service department. This had the potential to affect all 94 residents receiving food from the facility kitchen. The facility identified three residents (#8, #91 and #201) who received nothing by mouth. The facility census was 97. Findings include: Review of Dietary Manager (DM) #574's employee file revealed no formal certified dietary manager training and documentation for the SERV Safe course revealed DM #574 had not passed the course. Interview on 07/15/24 at 8:50 A.M. with DM #574 revealed she had been the dietary manager for about four months. DM #574 stated she completed a SERV Safe course prior to starting as the dietary manager, did not pass the course and did not have any additional formal training to qualify her as the DM. Interview on 07/22/24 at 9:10 A.M. with Dietitian #664 confirmed she only worked at the facility seven to ten hours per week so she was not full-time in the facility. Interview on 07/22/24 at 1:42 P.M. with 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, observation, interview and review of facility policy the facility did not ensure the pureed menu was followed for residents requiring a pureed diet. This affected three residents (#38, #71 and #350) of three residents who required pureed diets. The facility census was 97. Findings include: Review of the medical record for Resident #38 revealed an admission date of 04/24/24. Diagnoses included but were not limited to congestive heart failure, hypertension, renal insufficiency, and diabetes mellitus. Resident #38's diet order was a regular pureed diet with thin liquids. Review of the medical record for Resident #71 revealed an admission date of 01/31/22. Diagnoses included but were not limited to hypertension, hyperlipidemia, and dementia. Resident #71's diet order was a regular pureed diet with thin liquids. Review of the medical record for Resident #350 revealed an admission date of 07/15/24. Diagnoses included but were not limited to chronic bronchitis, chronic obstructive pulmonary disease, type II diabetes mellitus, and chronic kidney disease. Resident…

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 facility policy review, the facility failed to store, prepare and serve foods under sanitary conditions and to prevent the potential for food born illness. This had the potential to affect 94 residents receiving meals from the facility. The facility identified three residents (#8, #91, and #201) who received nothing by mouth. The facility census was 97. Findings include: 1. Initial tour of the facility kitchen on 07/15/24 at 8:50 A.M. with Dietary Manager (DM) #574 revealed the following concerns which were verified by DM #574 at the time of the observations: In the cooling unit there was a quart of whole milk with a best by date of 07/11/24. The milk had visibly separated and had white chunks floating in it. There were also 12 four-ounce containers of yogurt with an expiration date of 07/10/24. Also in the kitchen was observed multiple (between 10 to 50 of each) individual packets of mustard, mayonnaise, ketchup, French dressing, sugar-free breakfast syrup, reduced-sugar blackberry, strawberry and grape spread, red-hot sauce, BBQ sauce,…

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 maintain resident rooms in a safe, sanitary, and homelike condition. This affected seven residents (Resident #6, #16, #40, #43, #68, #71, and #85 ) of 97 resident rooms observed for physical environment. The facility census was 97. Findings include: During the screening process of the facility annual survey on 07/15/24 and 07/16/24, the following concerns were identified and verified with the Director of Nursing and the Administrator at approximately 7:56 A.M. on 07/16/24. • The rooms for Residents #16, #40 and #43 had chipped wall paint, the window shade and privacy curtains had brown stains and splatter marks. Also, the room for Resident #6 included one inch diameter holes around four bolts in the wall behind her bed. • The room for Resident #71 had a four foot by four foot patch on the wall of bare wall. The room also had chipped wall paint, the window shade and privacy curtains had brown stains and splatter marks. • The room for Resident #68 had no transition between the bathroom and room hallway. The tile floor at 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 interviews and record reviews, the facility failed to ensure care plans reflected resident needs regarding Activities of Daily Living (ADL), hospice, wound care and behaviors. This affected five Residents (#7, #16, #60, #74, and #197) of 25 resident records reviewed. The facility census was 97. Findings include: 1. Review of Resident #16's medical record revealed and admission date of 02/23/24 with diagnoses including spastic hemiplegia, osteoarthritis, hypertension, and hyperlipidemia. Resident #16 required repositioning by staff. Review of Resident #16's care plans revealed no focus area, goals, or interventions for positioning or repositioning the resident. Interview on 07/17/24 at 10:19 A.M. with Licensed Practical Nurse (LPN) #610 revealed Resident #16 went out with family a lot and attended activities. LPN #610 said the aides and nurses needed to reposition her frequently throughout the day because she would slump over in the chair if not repositioned. Interview on 07/18/24 at 11:18 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.

Based on closed medical record review, review of medical record request forms and interview, the facility failed to ensure medical record requests were completed timely for Resident #197. This affected one resident (Resident #197) of one resident reviewed for medical record requests. The facility census was 97. Findings include: Review of the closed medical record for Resident #197 revealed an admission date of 09/09/23 and discharge date of 10/17/23. Diagnoses included but were not limited to complete traumatic amputation at level between right hip and knee, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, cardiomyopathy, unspecified severe-protein- calorie malnutrition. Review of the 11/30/23 fax timed at 2:20 P.M. sent to the medical records department from Resident #197's family attorney revealed a medical records request for Resident #197. Review of the 06/21/24 email sent to the Administrator by Resident #197's family attorney revealed a second medical record request for Resident #197. Interview on 07/17/24 at 9:06 A.M. with Medical Records…

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 closed record review, interview and review of facility policy, the facility did not ensure a STAT (urgent) urinalysis test was obtained according to the physician order delaying treatment of a urinary tract infection (UTI) for Resident #197. This affected one resident (Resident #197) of 25 residents reviewed for physician orders. The facility census was 97. Findings included: Review of the closed medical record for Resident #197 revealed an admission date of 09/09/23 and discharge date of 10/17/23. Diagnoses included but were not limited to complete traumatic amputation between right hip and knee, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease and unspecified severe-protein-calorie malnutrition. Review of the facility admission assessment for Resident #197 completed on 09/09/23 revealed Resident #197 was noted to have an indwelling catheter. Review of the 09/22/23 admission Minimum Data Set (MDS) 3.0 assessment for Resident #197 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #197…

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

Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed for Resident #46. This affected one Resident (#46) of five residents reviewed for unnecessary medications. The facility census was 97. Finding Include: Review of the medical record for Resident #46 revealed an admission date of 10/02/19. Diagnoses included chronic respiratory failure, hypertension, and dementia. The record revealed the last lipid panel ( a blood test used to check the amount of cholesterol in the blood) was completed on 06/22/22. The resident was taking Lipitor (a drug used to lower cholesterol in the blood) Review of the pharmacy recommendation dated 09/20/23 recommended a lipid panel now and annually to monitor Lipitor. The recommendation was signed by the physician on 10/10/23 indicating a lipid panel should be completed as ordered. Review of the laboratory order created on 10/10/23 at 1:43 P.M. revealed an order for a lipid profile panel to be completed on 10/02/24. Interview on 07/17/24 at 2:00 P.M. with the Director of Nursing (DON) revealed the order for…

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

Based on closed record review and interview the facility did not ensure physician ordered treatments were consistently documented in the medical record for Resident #197. This affected one resident ( Resident #197) of 25 resident records reviewed for physician orders. The facility census was 97. Findings included: Review of the physician order dated 09/09/23 for Resident #197 revealed an order to complete a Braden assessment (skin assessment) every week times four weeks. Review of the physician order dated 09/14/23 for Resident #197 revealed an order for catheter care every shift. Review of the physician order dated 09/14/23 for Resident #197 revealed an order for no compression (shrinker, ace wrap) to right above knee amputation. Review of the physician order dated 09/15/23 for Resident #197 revealed an order for treatment to right stump: cleanse with normal saline, apply Betadine and cover with ABD (sterile, padded) bandage as needed and every night shift. Review of the 09/23 Treatment Administration Record (TAR) for Resident #197 revealed no evidence of the Braden assessment…

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

Based on observation, interview and review of facility policy the facility failed to ensure Resident #46 had a functional call light. This affected one resident (# 46) of 24 residents reviewed for call lights. The facility census was 97. Findings Include: Interview with Resident #46 on 07/15/24 at 2:30 P.M. revealed her call light had not been lighting up when she pressed the call button. Observation of Resident #46's call light on 07/15/24 at 2:35 P.M. with the facility's Director of Maintenance (DOM) revealed the call light above the resident's door was not working when activated. The DOM stated he had replaced the bulb several days earlier. The DOM shook the call light above the door, the call light lit up, and the DOM stated it must have been loose wiring attached to the bulb so he would fix it. Review of the undated facility policy titled Call Light revealed resident call lights were to be checked by nursing and maintenance on a regular basis to test if functioning.

Based on observation and interview, the facility failed to maintain a clean, safe, and sanitary environment. This affected Resident #67 and had the potential to affect all 90 residents in the facility. The facility census was 90. Findings include: Observation of Resident #67's room on 04/23/24 at 10:50 A.M. revealed the door was hanging off the close. This was verified during interview with Registered Nurse #200 at time of observation. Observation on 04/23/24 at 11:02 A.M. with State Tested Nursing Assistant (STNA) # 202 of the dining room on the third floor revealed the window shades had food splatter on them and a cabinet door was hanging off. This was verified during interview with STNA #202 at time of observation. Observation of the shower room on 04/23/24 at 11:35 A.M. with STNA #205 revealed the ceiling paint was peeling and there was mold and paper on the floor. This was verified during interview with STNA # 205 at time of observation. Interview on 04/24/24 at 10:09 A.M. with Housekeeping Supervisor #216 revealed the dining room was cleaned before and after breakfast 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 and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions in the first and second floor kitchenettes. This had the potential to affect all 39 residents on the first floor (Resident #4,#6,#7,#11,#14,#19,#20,#24,#29,#30,#33,#35,#37,#38,#41,#42,#48,#50,#51,#53,#55,#56,#57,#61,#64,#66,#71,#72,#74,#79,#81,#85,#87,#88,#90,#95,#97,#102,#103) and 32 residents on the second floor (#1,#2,#3,#12,#18,#21,#22,#28,#31,#34,#36,#39,#40,#44,#45,#49,#52,#54,#60,#62,#65,#69,#75,#77,#80,#82,#83,#84,#86,#92,#96,#99,#100,#101)who received foods from those kitchenettes, as the facility identified Resident #36 and #99, who lived on the second floor, as receiving nothing by mouth (NPO). The facility census was 104. Findings include: Observation on 03/03/24 at 4:30 P.M. of the second floor kitchenette area revealed two trays with dirty dishes and cups of coffee from the lunch meal sitting on the counter. Inside of a refrigerator there was a mint green colored liquid along with a syrup-like substance spilled on the bottom of the inside 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 interview, the facility failed to ensure the baseboard in the first floor kitchenette was safety adhered to the wall in order to prevent a source of moisture entrapment and subsequent growth of mold. This had the potential to affect all 39 residents ((Resident #4,#6,#7,#11,#14,#19,#20,#24,#29,#30,#33,#35,#37,#38,#41,#42,#48,#50,#51,#53,#55,#56,#57,#61,#64,#66,#71,#72,#74,#79,#81,#85,#87,#88,#90,#95,#97,#102,#103) living on the first floor. The facility census was 104. Findings include: Observation on 03/03/24 at 4:45 P.M. of the first floor kitchenette revealed an approximate two feet strip of the baseboard molding close to the floor and below the counter, and a half foot strip of baseboard molding next to the refrigerator was pulled away from the wall causing a gap which contained a build up of a black substance. Interview on 03/03/24 at 4:45 P.M. with State Tested Nursing Assistant (STNA) #644 verified the findings at the time of the observation. Interview on 03/03/24 at 5:00 P.M. with the Administrator verified the finding in the first floor kitchenette.…

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

Based on record review and interview, the facility did not ensure Resident #56 attended a follow-up appointment with an outside provider. This affected one resident (#56) of three residents reviewed for ancillary services. The facility census was 104. Findings include: Review of the medical record of Resident #56 revealed an admission date of 10/18/22. Diagnoses included left lower leg amputation on 12/04/2022, hyperlipidemia and anemia. Review of a progress note dated 01/12/23 stated: Follow up appointment for left stump is scheduled for July 5th 2023 at 10:30 A.M. Review of progress notes and ancillary/consultation services notes for 07/2023 revealed no evidence of an appointment being made on 07/05/2023 and no evidence Resident #56 had refused to go to that appointment. Review of the treatment administration records (TARs) for 01/2023, 02/2023 and 07/2023 revealed no appointment was noted as an order on the TARs. Interview on 03/05/24 at 1:00 P.M. with the Director of Nursing (DON) revealed an appointment for Resident #56's left leg stump exam was to be implemented on 07/05/23…

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

Based on record review, interview and policy review, the facility failed to ensure medications to treat diabetes and to improve glucose control were administered as ordered by the physician. This affected one (Resident #99) of seven residents reviewed for medication administration. The facility census was 97. Findings include: Review of the medical record for Resident #99 revealed an admission date of 11/30/23 with diagnoses including diabetes mellitus and hypertension. Review of the physician's orders for December 2023 revealed Resident #99 had an order for Insulin Glargine to inject 40 units in the evening for blood sugar dated 12/01/23; Insulin Lispro to inject 15 units in the evening with dinner for diabetes and Empagliflozin 10 milligrams (mg) one time a day upon rising for diabetes dated 12/03/23. Review of the Medication Administration Record (MAR) for December 2023 for Resident #99 revealed Basaglar Kwikpen (Insulin Glargine) and Humalog (Insulin Lispro) were not documented as administered, refused or held on 12/04/23, 12/16/23 and 12/19/23 at 5:00 P.M. Resident #99's…

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

Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected four residents (#16, #24, #25 and #44) and had the potential to affect all 105 residents residing in the facility. Findings include: Observation on 08/22/23 at 7:20 A.M. revealed a strong odor of urine at the end of the 100-hall. Observation on 08/22/23 at 7:22 A.M. revealed dirty meal trays and two overflowing trashcans in a common dining area on the 100-hall. Observation on 08/22/23 at 7:30 A.M. revealed dirty meal trays and two overflowing trashcans in a common dining area on the third floor. Observation on 08/22/23 at 7:42 A.M. revealed dirty meal trays from the previous meal and an overflowing trashcan in a common dining area on the second floor. Observation on 08/22/23 at 8:05 A.M. revealed a large amount of tube feed underneath Resident #16's bed and along the baseboards. Resident #16 was not interviewable. Observation on 08/22/23 at 8:12 A.M. revealed Resident #25's wall next to his bed had various areas with brown splatters on it. Resident #25 stated he was not…

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 call lights were within reach of residents. This affected two residents (#25 and #52) of four residents observed for call lights. The facility census was 105. Findings include: 1. Observation on 08/22/23 at 8:12 A.M. revealed Resident #25's call light was on the floor next to his bed. Interview with Resident #25 at time of observation revealed he was completely paralyzed and was unable to get his call light off the floor. Resident #25 stated his call light was often not within reach and would have to yell out for staff to assist him. Observation on 08/22/23 at 2:04 A.M. with Director of Nursing (DON) confirmed Resident #25's call light remained on the floor. 2. Observation on 08/22/23 at 9:40 A.M. revealed Resident #52's call light was wrapped around her bed rail and on the floor. Observation was confirmed with Registered Nurse (RN) #310. RN #310 stated Resident #52's call light was usually clipped to the resident's pillow. RN #310 attempted to clip the call light to Resident #52's pillow and no clip was on the call…

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 complete and accurate care plans. This affected two residents (#25 and #36) of four residents reviewed for care plans. The facility census was 105. Findings include: 1. Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnoses included quadriplegia and colostomy. Review of Resident #25's care plan dated 07/11/23 did not include colostomy care. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed resident had intact cognition. Resident #25 had a colostomy for bowel elimination. Review of physician orders dated 08/22/23 revealed to provide colostomy care every shift and as needed. 2. Review of Resident #36's medical records revealed an admission date of 06/15/23. Diagnoses included paraplegia and altered mental status. Review of Resident #36's care plan dated 07/10/23 did not include colostomy or urinary catheter care. Interview on 08/22/23 at 2:04 P.M. with Director of Nursing (DON)…

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 and interview the facility failed to ensure residents were turned and repositioned as needed. This affected one resident (#25) of four residents observed for activities of daily living (ADL) care. The facility census was 105. Findings include: Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnosis included quadriplegia. Review of the care plan dated 07/11/23 did not include turning or reposition interventions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 required total dependence on staff for bed mobility, toileting, and personal hygiene. Observation on 08/22/23 at 7:25 A.M. revealed Resident #25 was asleep in bed positioned on his back toward his right side. Interview on 08/22/23 at 8:12 A.M. with Resident #25 revealed he had been asking the staff to get him up into his power wheelchair since it had been repaired on 08/18/23; however, staff had not gotten him up. Resident #25 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure physician orders were in place regarding colostomy care. This affected one resident (#25) of four residents reviewed for physician orders. The facility census was 105. Findings include: Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnoses included quadriplegia and colostomy. Review of Resident #25's care plan dated 07/11/23 did not include colostomy care. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 had a colostomy for bowel elimination. Review of the physician orders dated 08/22/23 revealed to provide colostomy care every shift and as needed. No previous orders were in place regarding Resident #25's colostomy care. Interview on 08/23/23 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #25's physician orders did not contain colostomy care. This deficiency represents an incidental finding of non-compliance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wound dressings were changed and intact. This affected one resident (#17) of two residents observed for wound dressings. The facility census was 105. Findings include: Review of Resident #17's medical records revealed an admission date of 10/18/22. Diagnoses included stage four pressure ulcer (Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) of the sacrum (tailbone), left sided paralysis, muscle weakness, and need for personal care assistance. Review of the care plan dated 07/26/23 revealed Resident #17 had a pressure ulcer related to immobility. Interventions included educate resident on importance of turning and reposition and being compliant with care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Resident #17 required total dependence with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure timely colostomy care was provided to Resident's #17 and #25. This affected two residents (#17 and #25) of two residents observed for colostomies. The facility identified four residents (#17, #25, #36 and #70) with colostomies. The facility census was 105. Findings include: 1. Review of Resident #17's medical records revealed an admission date of 10/18/22. Diagnoses included left sided paralysis, muscle weakness, and need for personal care assistance. Review of the care plan dated 07/26/23 revealed Resident #17 had a colostomy. Interventions include provide colostomy care every shift and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Resident #17 was incontinent of urine and had a colostomy for bowel elimination. Review of current physician order for August 2023 revealed to provide colostomy care every shift. Interview on 08/22/23 at 8:05 A.M. with Resident #17…

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 medications were administered and documented timely. This affected one resident (#45) of three residents reviewed for medication administration. The facility census was 105. Findings include: Review of Resident #45's medical records revealed an admission date of 01/25/19. Diagnoses included chronic pain, muscle weakness, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of the care plan dated 07/18/23 revealed Resident #45 had alteration in comfort related to chronic pain. Interventions included administer medications as ordered. Review of current physician orders for August 2023 revealed Resident #45 was ordered Roxicodone (narcotic pain medication) 30 milligrams (mg) twice daily at 9:00 A.M. and 9:00 P.M. and Roxicodone 5 mg at 3:00 A.M. and 3:00 P.M. Interview on 08/22/23 at 8:53 A.M. with Resident #45 revealed her medications were not always administered…

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 adequate and timely feeding assistance to Resident's #25 and #41. This affected two residents (#25 and #41) of three residents observed for feeding assistance. The facility identified six residents (#25, #34, #41, #78, #90 and #100) who required feeding assistance. The facility census was 105. Findings include: 1. Review of Resident #25's medical records revealed an admission date of 03/23/23. Diagnosis included quadriplegia. Review of the care plan dated 07/11/23 revealed no interventions related to feeding assistance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 required total assistance with eating. Interview on 08/22/23 at 8:12 A.M. with Resident #25 revealed he needed assistance with eating and stated there had been occasions when he had not received a meal or assistance with his meals. Observation on 08/22/23 at 12:37 P.M. revealed Resident #25's lunch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure comprehensive care plans for antidepressant medications were written for Resident #24 and Resident #44 and failed to ensure a care plan to address hemodialysis care was in place for Resident #30. This affected three residents (Resident's #24, #30 and #44) of 24 residents reviewed for comprehensive care plans. The facility census was 87. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 12/17/21 with diagnoses including personality disorder, patient noncompliance with medical treatment, and latent syphilis. Review of Resident #24's March 2022 and April 2022 physician orders and medication administration records (MAR) revealed the resident received Aripiprazole (antidepressant) tablet 5 milligram (mg) three times a day for depression and Quetiapine Fumarate tablet 25 mg one tablet at bedtime (antidepressant). Review of Resident #24's electronic care plan dated 04/04/22 revealed no focus areas, goals, or…

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, interview, and review of manufacture's guidelines, and policy review the facility failed to ensure a medication error rate of less than five percent. Two errors occurred within thirty-three opportunities for error resulting in a medication error rate of 6.06 percent. This affected two (Resident #22 and #292) of six residents observed during the medication administration observation. The facility census was 87. Findings include: 1. Review of Resident #22's medical records revealed an admission date of 02/08/21 with diagnoses including type two diabetes mellitus with diabetic peripheral angiopathy, hypertension, adult failure to thrive, symbolic dysfunctions, severe protein-calorie malnutrition, and malignant neoplasm of colon. Review of the care plan dated 01/27/22 revealed Resident #22 had actual/potential for fluid deficit related to dehydration, diuretic use, electrolyte imbalance, and cancer. Review of the Minimum Data Set (MDS) 3.0 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 and record review the facility failed to ensure Resident #76's splint was applied to the right hand as ordered. This affected one resident (Resident #76) of two residents reviewed for range of motion. The facility census was 103. Findings include: Resident #76 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, aphasia and contracture of muscles at multiple sites. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A Brief Interview for Mental Status (BIMS) score of 00 indicated severe cognitive impairment. A care plan relative to activities of daily living (ADLs) revealed Resident #76 was to wear a right-hand resting splint for six to eight hours daily. Review of the progress notes from 03/05/19 through 05/06/19 revealed only one note mentioning Resident #76's splint. A health status note 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.