King David Post Acute Nursing & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a change in condition was thoroughly addressed and vital signs were obtained as ordered. This affected two residents (#93 and #278) of three residents reviewed for change in condition. The facility census was 259. Findings include:1. Review of the medical record for Resident #278 revealed an admission date of [DATE] and expired on [DATE] (. Diagnoses included malnutrition, diabetes, spinal stenosis, high cholesterol and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #278 was severely cognitively impaired. She required setup help for eating, substantial or maximum assistance for oral care and was dependent on staff for toileting, showering and personal hygiene. Review of the physician's orders for [DATE] revealed an order for a Do Not Resuscitate Comfort Care Only Arrest (DNRCCA) (order that allows patients to receive all standard medical treatments, including resuscitation, until a cardiac…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure fall interventions were in place and falls were thoroughly investigated. This affected one resident (Resident #259) of three reviewed for falls and orders. The facility census was 259. Findings include:Review of the medical record for Resident #259 revealed an admission date of 09/27/24. Diagnoses included muscle weakness, artificial hip joints, dementia, depression and glaucoma. Review of the care plan initiated 10/09/24 revealed Resident #259 was at risk for falls. Interventions included anticipating the resident's needs, anticipating safety needs and potential hazards, assessing proper footwear and suggesting change if needed, ensuring the resident's call light is within reach and encouraging the resident to use it to call for assistance. A new intervention was added on 11/11/24 to lay the resident down after meals. Review of the care plan dated 10/16/24 revealed Resident #259 had an actual fall.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated when changed and proper signage on the entrance to a resident's rooms indicating oxygen was in use. This affected two residents (#45 and #93) out of two residents reviewed for respiratory needs. This had the potential to affect 16 additional residents (#2, #13, #27, #60, #79, #85, #101, #105, #122, #170, #177, #185, #193, #231, #242, and #272) identified by the facility as using oxygen. The facility census was 259. Findings include:1. Review of the medical record for Resident #93 revealed an admission date of 11/27/23 with diagnoses including acute and chronic respiratory failure with hypoxia (low level of oxygen in body tissues), hypertension, and congestive heart failure (CHF). There was nothing in the medical record to indicate when Resident #93's oxygen tubing was changed. Review of the physician order dated 07/25/25 revealed Resident #93 had an order for oxygen at two liters…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to ensure Resident #7 was provided with reliable transportation to and from dialysis. This affected one resident (#7) of two residents reviewed for transportation. The facility census was 295. Findings include:Review of the medical record for Resident #7 revealed an admission date of 12/27/24. Diagnoses included fracture of the left fibula, acute pain due to trauma, diabetes with diabetic neuropathy, and dependence on renal dialysis. Review of physician order dated 12/28/24 revealed Resident #7 received dialysis on Tuesday, Thursday, and Saturday. The resident must be in the lobby at 9:00 A.M. for pick-up. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #7 dated 01/08/25 revealed the resident was cognitively intact. Resident #7 used a walker and a wheelchair. Transfers were not attempted due to medical…

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, interviews and facility policy review, the facility failed to adequately provide trauma-informed care to Residents #8 and #74. This affected two residents (#8 and #74) out of two residents reviewed for trauma-informed care. This had the potential to affect four residents (#8, #74, #81, and #157) identified by the facility with a diagnosis of post-traumatic stress disorder (PTSD). The facility census was 259. Findings include:1. Review of the medical record for Resident #8 revealed an admission date of 03/12/25 with diagnoses including PTSD (on admission), diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and major depression. Review of the Social Service Initial Evaluation dated 03/14/25 and completed Social Service Designee (SSD) #844 revealed on Resident #8's evaluation under trauma informed care, it asked if the resident reported or if the medical record reflected any history of trauma, and it stated it was unable to be determined.…

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, observation and review of facility policy, the facility failed to ensure medical records were accurate and/or legible. This affected two residents (#8 and #91) out of 44 resident records reviewed for accuracy and/or identifiable information. The facility census was 259. Findings include: 1. Review of the medical record for Resident #91 revealed an admission date of 05/15/25 with diagnoses including dysphagia, moderate protein-calorie malnutrition, adult failure to thrive, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 had impaired cognition and was dependent on staff for eating. She held food in her mouth and cheeks and received nutrition through parenteral feedings (a medical treatment that provides essential nutrients directly into the bloodstream through an intravenous (IV) line). Review of the After Visit Summary revealed Resident #91 was hospitalized from [DATE] to 09/02/25 as she was admitted to the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, and interview, the facility failed to ensure Resident #284 was permitted to return to the facility after being transferred to the emergency room due to an acute change in condition. This affected one resident (#284) of one resident reviewed for hospitalization. The facility census was 283. Findings include: Review of the closed medical record for Resident #284 revealed an admission date of 02/03/22 with diagnoses that included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, amputation, and atherosclerotic heart disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #284 was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #284 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 02/04/22 revealed Resident #284 was expected to remain in the facility for long-term care placement. Review of the physician's orders dated November 2024…

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, review of the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure proper cleaning of a blood glucose meter while checking resident blood sugar levels. This affected two residents (Resident #127 and #271) and had the potential to affect an additional 28 residents (Resident #5, #31, #36, #46, #49, #51, #58, #61, #81, #85, #92, #116, #124, #145, #148, #152, #163, #186, #195, #230, #242, #245, #254, #261, #272, #273, #275, and #276) who received blood glucose level checks via a glucometer. The facility census was 277. Findings include: 1. Record review for Resident #127 revealed an admission date of 11/13/24. Diagnosis included type two diabetes mellitus with diabetic chronic kidney disease. Review of the physician orders for Resident #127 revealed an order dated 11/15/24 for Humalog solution 100 units/milliliter (ml) (Insulin Lispro) Inject as per sliding scale before meals for diabetes. Observation on 01/14/25 at 8:44 A.M. of a blood sugar assessment via glucometer revealed Licensed…

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

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #138's physician and responsible party was notified of a change in condition. This affected one resident (Resident #138) of three residents reviewed for a change in condition. The facility census was 277. Findings include: Record review for Resident #138 revealed an admission date of 12/02/21. Diagnosis included need for assistants with personal care, stress incontinence, and morbid severe obesity. Observation on 01/13/25 at 11:26 A.M. of incontinent care for Resident #138 provided by Certified Nursing Assistant (CNA) #748 revealed Resident #138 had an open area to the right anterior/medial thigh. The open area was actively bleeding a small amount serosanguinous drainage. No treatment was observed to the area. CNA #748 revealed she worked on Saturday, 01/11/25, and the same open area was there then. CNA #748 wiped off the wound during incontinent care while Resident #138 revealed the area was painful. Observation on 01/13/25 between 11:48 A.M. and 12:29 P.M. of the wound 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.

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 timely assess and provide wound care for Resident #138. This affected one resident (Resident #138) of three residents reviewed for incontinence care. The facility census was 277. Findings include: Record review for Resident #138 revealed an admission date of 12/02/21. Diagnosis included need for assistants with personal care, stress incontinence, and morbid severe obesity. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #138 was cognitively intact. Resident #138 used a wheelchair for mobility, required partial/moderate assistants for toileting hygiene, and dependent for personal hygiene. Resident #138 was frequently incontinent of bowel and bladder. Resident #138 was at risk for pressure ulcers/injuries. Record review of the care plan dated 06/10/24 revealed Resident #138 had potential for impaired skin integrity. Interventions included to provide skin care per facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, review of a video recording, review of the facility investigation report, and review of the facility policy, the facility failed to administer Resident #85 and Resident #155's medications per physician orders. This affected two residents (Resident #155 and #85) of three residents reviewed for pharmacy services. The facility census was 277. Findings include: 1. Record review for Resident #155 revealed an admission of 02/03/22. Diagnosis included unspecified convulsions, atherosclerotic heart disease, and constipation. Review of the quarterly MDS dated [DATE] revealed Resident #155 was cognitively intact. Resident #155 required extensive assistance for bed mobility, transfers, and toilet use. Review of the physician orders for Resident #155 revealed orders for Atorvastatin calcium tablet 40 milligrams (mg) give 1 tablet by mouth in the evening related to atherosclerotic heart disease ordered 11/26/23; scheduled to be given from 7:00 P.M. to 11:00 P.M., Polyethylene Glycol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed physician orders were followed and the medication error rate did not exceed five percent (%). The facility had four medication errors of 30 opportunities for an error rate of 13.33%. This affected three residents (Resident #8, Resident #127, and Resident #271) of nine residents observed for medication administration. The facility census was 277 residents. Findings include: 1. Record review for Resident #8 revealed an admission date of 01/08/25. Diagnosis included Parkinson's, cerebral infarction, and muscle weakness. Review of the Clinical admission assessment completed 01/08/25 revealed Resident #8 was verbal, oriented to person, place, and required cues. Review of the physician orders for Resident #8 revealed Resident #8 had an order dated 01/10/25 for Aspirin 81 milligram (mg) oral tablet give one tablet by mouth in the morning for Parkinson's; scheduled to be given between 8:00 A.M. and 11:00…

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, the facility failed to ensure resident meals were palatable. This had the potential to affect 261 of 261 residents who received meal trays from the kitchen with the exception of three residents (#99, #182, #204) who the facility identified as receiving no food by mouth (NPO). The facility census was 264. Findings include: Interview on 10/16/24 at 10:15 A.M. with Resident #7 revealed the resident had concerns the food was not good and was not hot when served. Interview on 10/17/24 at 9:00 A.M. with Dietary Director (DD) #858 during tour of the kitchen and kitchenettes revealed the dishwasher was currently not being utilized for the cleaning and sanitizing of dishware for residents. DD #858 revealed all residents were served on disposable dishware and plastic silverware. DD #858 stated the facility was currently waiting for additional parts (timeframe for parts to arrive was not provided) to fix the dishwasher after it had not reached the required temperatures of at least 180 degrees Fahrenheit. DD #858 revealed the dishwasher 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, review of the job descriptions, review of the employee handbook, and interviews, the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administrative staff failed to ensure staff did not sleep while on duty, failed to ensure staff did not have and/or utilize phones for personal use in resident care areas of the facility and failed to ensure the kitchen dishwasher was utilized timely after repairs to ensure meals were not served on disposable plates resulting in food being served from the kitchen that was not palatable. This affected 15 residents (#95, #7, #87, #36, #103, #199, #205, #126, #54, #243, #118, #89, #226, #190 and #188) and had the potential to affect all 264 facility residents residing in the facility which included 35 residents who resided on the Beachwood Pavilion unit and 55 residents who resided on the Euclid Pavilion unit. The facility…

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

Based on observations, staff interviews, and review of the employee handbook, the facility failed to ensure residents were free from potential neglect when staff were sleeping while on duty. This had the potential to affect all 35 residents (#17, #27, #35, #47, #56, #62, #70, #76, #83, #92, #98, #102, #109, #120, #129, #131, #142, #143, #147, #150, #151, #161, #163, #165, #198, #213, #219, #221, #229, #231, #232, #233, #236, #246, #250) residing on the Beachwood Pavilion unit and the potential to affect all 55 residents (#3, #4, #11, #13, #18, #19, #20, #34, #36, #37, #42, #46, #54 #63, #66, #84, #86, #91, #94, #95, #99, #101, #103, #110, #113, #119, #123, #124, #126, #128, #133, #154, #156, #158, #160, #166, #168, #169, #172, #179, #181, #185, #187, #194, #199, #201, #202, #205, #210, #218, #227, #234, #238, #252, #262) residing on the Euclid Pavilion Unit. The facility census was 264. Findings include: Observation on 10/20/24 at 6:21 A.M. of the Beachwood Pavilion unit nursing station revealed Licensed Practical Nurse (LPN) #1001 was seated at the nursing station desk. The…

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

Based on observation, record review, review of the facility policy, review of the Centers for Medicare and Medicaid (CMS) directive related to Enhanced Barrier Precautions (EBP) and interview, the facility failed to develop and implement an effective infection control program to ensure enhanced barrier precautions (EBP) were maintained while wound care was performed for Resident #67. This affected one resident (#67) of three residents reviewed for wound care. The facility census was 264. Findings include: Review of the medical record for Resident #67 revealed an admission date of 06/21/24. Diagnoses included multiple sclerosis, cognitive communication deficit, Crohn's disease, unspecified severe protein calorie malnutrition, Parkinson's disease, major depressive disorder and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 10/01/24 revealed Resident #67 had intact cognition and was dependent on staff for activities of daily living. Resident #67 had an indwelling urinary catheter, and two unhealed Stage II pressure…

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, staff interview and review of facility policy, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner. This had the potential to affect all residents except two (#105 and #193) who received nothing by mouth and 34 residents (#2, #8, #24, #30, #40, #46, #54, #64, #76, #78, #111, #116, #131, #132, #136, #138, #140, #150, #154, #155, #159, #177, #185, #195, #216, #221, #222, #225, #226, #232, #249, #255, #265 and #269) who resided on the [NAME] nursing unit. The facility census was 276. Findings include: Observations on 09/24/25 from 10:49 A.M. to 11:36 P.M. of the nursing unit kitchenettes with Dietary Manager (DM) #597 revealed the following: • Euclid pavilion 1 nursing unit kitchenette had food spillage on the bottom shelf of the refrigerator. The meat and dairy microwaves were dirty with various dried food splatter inside. Further observation revealed food crumbs on the counters and on the two toasters. • Euclid pavilion 2 nursing unit…

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, review of the dishwasher temperature log, service manager interview, and review of the manufacturer's brochure for the facility's dishwasher, the facility failed to ensure the dishwasher reached the minimum required temperature for proper dish sanitization. This had the potential to affect all but three residents (Residents #113, #203, and #293) who received meals prepared and served by the facility. The facility census was 288. Findings include: Observation on 09/11/24 from 2:04 P.M. to 2:15 P.M. of kitchen staff washing dishes using the M-iQ Flight-type Conveyor Warewasher revealed the dishwasher exhibited two error codes throughout the observation: 1) Rinse 1 Warning 701, low temperature, and 2) Warning 710, air gap tank under-run minimum. Further random observations revealed the final rinse temperature reading did not rise above 150 degrees (°) Fahrenheit (F), averaging 144 °F. At 2:15 P.M., Director of Dietary Services #500 removed the facility's thermometer from the dish conveyor belt, which displayed a temperature reading of 157.7 °F…

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, resident interview, staff interview, and review of the employee handbook, the facility failed to ensure staff did have personal conversations, which included yelling into their phones, in resident rooms. not talk on their phone in resident care areas of the facility. This affected one (#294) out of four residents observed for staff -to-resident interactions. The facility census was 288. Findings include: An observation on 09/09/24 at 3:50 P.M. revealed Licensed Practical Nurse (LPN) #301 entered Resident #294's room to check on him and provide care as needed. LPN #301 was standing next to Resident #294's bed yelling in a very loud voice while talking on her personal cellular phone. After a few minutes LPN #301 exited Resident #294's room without speaking to Resident #294. LPN #301 continued to talk/yell loudly on her phone directly outside of Resident #294's room for a few more minutes. An interview with Resident #294 on 09/09/24 at 4:05 P.M. revealed he was startled by the way LPN #301 was yelling on the phone and wasn't sure why she was upset. Resident #294…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to maintain wheelchairs and durable medical equipment in a clean and sanitary manner one (#120) out of three residents who used a wheelchair for mobility. The facility census was 288. Findings include: Review of the medical record revealed Resident #120 was admitted on [DATE] and re-admitted on [DATE]. Diagnoses included traumatic brain injury, cerebral infarction (stroke) with right sided hemiplegia and hemiparesis, cognitive communication deficit with dementia, brain cancer, hydrocephalus with cerebrospinal fluid drainage device, seizures, congestive heart failure, depression, hypothyroidism, and pulmonary eosinophilia. An observation on 09/12/24 at 7:45 A.M. revealed Resident #120 was assisted up to his wheelchair by State Tested Nursing Assistant (STNA) #303. Resident #120's wheelchair had dried liquid substances and dried food/debris coating both the lower foot rest and leg rests of the wheelchair. STNA #120 applied both 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 observation, record review, staff interview, resident interview and review of facility policy, the facility failed to ensure pressure ulcer treatments were provided as ordered for one (#105) out of three residents reviewed for wounds. The facility census was 288. Findings include: Review of the medical record revealed Resident #105 was admitted on [DATE]. Diagnoses included chronic osteomyelitis with draining sinus of the left femur, pain, depression, vitamin deficiency, chronic kidney disease, prostate cancer, anorexia, and monoclonal gammopathy. A review of Resident #105's Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and was frequently incontinent of bowel and bladder. Review of Resident #105's wound assessment, dated 09/05/24, revealed a left heel stage III pressure ulcer currently measuring 0.3 centimeters (cm) long by 0.3 cm wide by 0.2 cm. deep. Resident #105's physician order dated 08/27/24 revealed to clean the left heel ulcer with normal saline, pat dry, pack the wound…

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 facility policy review the facility failed to ensure staff treated Residents #68 and #126 with respect and dignity. This affected two residents (#68 and #24) of ten residents reviewed for dignity and respect. The facility census was 276. Findings include: 1. Review of Resident #68's medical record revealed an admission date of 06/21/24 with diagnoses including multiple sclerosis, suprapubic cystostomy, a surgical connection between the bladder and abdomen to drain urine, Crohn's disease, malnutrition, Parkinson Disease, fracture of the right patella, (the knee bone) and tibia (shin bone), and neuromuscular bladder, disfunction of the bladder due to nerve injury. Review of Resident #68's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and dependent on staff for eating, toileting, bathing, and personal hygiene. Review of Resident #68's care plan dated 07/02/24 revealed the resident had impaired functional…

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 notify Resident #281 or the resident's representative before a transfer to another room. This affected one resident (#281) of three residents reviewed for room changes. The facility census was 276. Findings include: Review of the closed medical record for Resident #281 revealed an admission date of 05/07/25. Diagnoses included multiple fractures of the pelvis, difficulty walking, muscle wasting and atrophy, diabetes, and cognitive communication deficit. The resident was discharged to an assisted living facility on 05/28/24. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #281 had impaired cognition. Review of the medical record revealed Resident #281 was transferred from Heights Pavilion Second Floor H133 to Heights Pavilion Second Floor H230 as of 05/15/24. (The resident's room was changed after dinner on 05/14/24). Review of the communication with family/power of attorney (POA) note on 05/15/24 at 9:21 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation the facility failed to provide wound care according to physician's orders for Resident #68. This affected one resident (#68) of three residents reviewed for wound management. The facility census was 276. Finding include: Review of Resident #68's medical record revealed an admission date of 06/21/24 with diagnoses including multiple sclerosis, suprapubic cystostomy, a surgical connection between the bladder and abdomen to drain urine, Crohn's disease, malnutrition, Parkinson disease, fracture of the right patella (the knee bone) and tibia (shin bone), and neuromuscular bladder, disfunction of the bladder due to nerve injury. Review of Resident #68's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and had two stage IV pressure ulcers. (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). Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to provide routine indwelling urinary catheter care and failed to have indwelling urinary catheter care orders in place for Resident #68. This affected one resident (#68) of three residents reviewed for indwelling urinary catheters. The facility census was 276. Findings include: Review of Resident #68's medical record revealed an admission date of 06/21/24 with diagnoses including multiple sclerosis, suprapubic cystostomy, a surgical connection between the bladder and abdomen to drain urine, Crohn's disease, malnutrition, Parkinson's disease, fracture of the right patella (the knee bone) and tibia (shin bone), and neuromuscular bladder, and dysfunction of the bladder due to nerve injury. Review of the physician's orders revealed an order dated 06/21/24 to record output from the suprapubic catheter every shift. This order was discontinued on 07/30/24. An order dated 06/22/24 stated to change and date the indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed prevent a significant medication error when Resident #38, who was being treated for chronic pain, did not receive pain medication as ordered by the physician. This affected one resident (#38) of four residents reviewed for medication administration. The facility census was 276. Findings include: Review of Resident #38's medical record revealed an admission date of 11/22/23 with diagnoses including multiple myeloma, anxiety, dementia, type II diabetes, and depression. The record revealed the resident was receiving hospice services. Review of the facility's pain documentation tab revealed the following: • On 06/01/24, Resident #38 had a pain score of zero, on a scale of zero to ten, indicating no pain. • On 06/20/24, Resident #38 had a pain score of one, indicating mild pain. • On 07/01/24, Resident #38 had a pain score of zero, indicating no pain. • There was no documented evidence of pain monitoring for Resident #38 from 07/01/24…

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 facility policy review the facility failed to ensure medications were always secure form unauthorized access. This affected one resident (#162) of 29 residents identified to receive medications on the involved nurse's assignment. The facility census was 276. Findings include: Review of the medical record for Resident #162 revealed an admission date of 06/26/22 with diagnoses including hypertension, heart failure, vertigo, anxiety, syncope, seizures, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #162 had intact cognition and received and antibiotics and an opioid. Review of the physicians' orders for August 2024 revealed afternoon medication orders for Depakote 250 milligrams (mg) (anti-seizure medication) for seizures, Tramadol 50 mg (opioid pain medication), Tylenol 1000 mg (analgesic), gabapentin 10 mg (anticonvulsant and nerve pain medication), and a probiotic capsule (supplement). Observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents received clean silverware with meals. This affected five (Residents #42, #183, #215, #261, and #261) of five residents observed for meal service. The facility census was 266 residents. Findings include: Observation on 07/15/24 at 8:25 A.M. of the dietary cart on the [NAME] unit revealed it contained breakfast trays which had not yet been served to residents. The trays for Residents #42, #183, #215, #261, and #261 revealed the silverware on each of the trays had a translucent yellowish color with occasional small bumps solidified onto the surface. Interview on 07/15/24 at 8:33 A.M with Dietary Manager (DM) #401 confirmed the silverware on the breakfast trays for Residents #42, #183, #215, #261, and #261 was dirty. DM #410 confirmed the dietary staff had been handwashing some dishes due to problems with their dishwasher. Interviews on 07/15/24 at 11:22 A.M. with Resident #75 and at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure call lights were answered in a timely manner and failed to ensure staff was not taking personal phone calls while a resident was waiting for assistance. This affected three residents (#285, #116, and #139) out of five residents reviewed for call light response and had the potential to affect all residents residing in the facility. The facility census was 285. Findings include: 1. Review of the medical record for Resident #285 revealed an admission date of 03/18/14 with diagnoses including Parkinson's disease, diabetes, morbid obesity, urinary incontinence, and heart failure. Review of the care plan dated 06/19/19 revealed Resident #285 was at risk for falls due to anxiety disorder, depression, and decline in functional status. Interventions included be sure the call light was within reach, encourage resident to use it, and promptly respond to all requests for assistance. Review of the care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review the facility failed to ensure to obtain Pedialyte (oral electrolytes) ordered by the physician for Resident #226's resulting in nursing staff having to pay for the product with their own money. In addition, the facility failed to notify the physician when Pedialyte was unavailable, and staff were substituting it with Powerade. This affected one resident (#226) of five residents reviewed for dietary services. The facility census was 285. Findings include: Review of the medical record for Resident #226 revealed an admission date of 06/13/22. Diagnoses included non-infective gastroenteritis and colitis, malignant lung cancer, and autistic disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #226 had intact cognition, no behaviors, and required set-up/clean up help with eating. The assessment also indicated the resident weighed 174 pounds, had no significant weight changes, and did not receive 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 interview, observation, record review, review of manufacture guidelines, facility policy review, and review of the facility Caregiver Safety Tips for use of a mechanical lift (device used to move a resident from one place to another)/ sling revealed the facility failed to ensure Resident #280's mechanical lift sling was properly examined prior to transferring resulting in the sling strap breaking and Resident #280 falling to the floor. The facility also failed to complete a thorough nursing assessment prior to Resident #280 being transferred back to bed, the mechanical lift slings were properly laundered, and a thorough investigation was completed of the incident. This affected one resident (#280) of three residents reviewed for falls. The facility census was 285. Findings include: Review of the medical record for Resident #280 revealed an admission date of 06/28/23 with diagnoses including dementia, hypertension, and hemiplegia affecting her right dominate side. Review of the care plan dated 08/23/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy revealed the facility failed to ensure Resident #285's incontinence care was completed in a timely manner, did not place soiled linen and incontinence briefs (a product that holds urine or bowel movement) on the floor and that Resident #285 did not have two incontinence briefs applied at once. This affected one resident (#285) out of three residents reviewed for incontinence care. This had the potential to affect 50 residents (#20, #23, #26, #37, #38, #47, #48, #57, #60, #67, #72, #89, #91, #95, #119, #133, #135, #136 #138, #143, #150, #151, #155, #160, #169, #171, #189, #193, #195, #210, #213, #216, #217, #219, #221, #222, #233, #238, #246, #247, #248, #254, #257, #264, #274, #275, #278, #280, #282, and #285) on the Fairmount Unit that were identified as incontinent. The facility census was 285. Findings include: Review of the medical record for Resident #285 revealed an admission date of 03/18/14 with and her diagnoses including…

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

Based on observation, interview, record review, and review of facility policy the facility failed to ensure oxygen cylinders was secured safely and failed to ensure residents had oxygen signs indicating oxygen was in use upon entrance to their rooms. This affected three residents (#51, #193, and #262) out of four residents reviewed for oxygen use. This had the potential to affect 38 residents (#1, #6, #10, #17, #19, #25, #35, #38, #44, #71, #83, #99, #105, #115, #117, #130, #140, #148, #150, #155, #193, #194, #195, #199, #200, #205, #210, #211, #213, #219, #225, #241, #242, #243, #258, #261, #262, and #283) with orders for oxygen. The facility census was 285. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 02/19/22 with diagnoses including chronic respiratory failure, hypertension, and diabetes. Review of the care plan dated 04/02/24 revealed Resident #51 was on a respiratory program including cough and deep breathing per protocol. Interventions included assess respiratory status, cough and deep breathing exercises, and medications as…

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, review of facility policy and clinical pharmacology guidelines and manufacture insulin pen guidelines, the facility failed to ensure Resident #264's insulin by route of insulin pen (an injection device that can use to deliver a preloaded insulin subcutaneously (under the skin)) was administered in a safe manner according to the guidelines. This affected one resident (#264) out of three residents observed for insulin administration. This had the potential to affect 47 Residents (#4, #5, #14, #17, #34, #55, #57, #65, #66, #68, #75, #87, #89, #91, #93, #101, #102, #107, #117, #122, #123, #128, #136, #138, #144, #147, #156, #160, #177, #183, #187, #188, #189, #203, #206, #212, #224, #228, #234, #253, #255, #264, #274, #277, #279, #284, and #285) that had physician orders for insulin. The facility census was 285. Findings include: Review of the medical record for Resident #264 revealed an admission date of 11/14/22 with diagnoses including hypertension, seizures,…

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 assessments were accurately completed. This affected four (Residents #77, #110, #217 and #281) of 42 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 318. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 04/07/22 with diagnoses including dementia, anxiety and pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had clear speech, understood staff and was able to be understood by staff. Review of section C (assessment for cognition) under sections C0100, C0200, C0300, and C0400 revealed the questions were answered as not assessed which resulted in a dash for the cognitive score for Resident #77. The staff interview section for Resident #77 for cognition was also not assessed. Review of section D (assessment for mood) revealed interview with the resident was not performed and the questions were answered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure medical records were accurate and complete. This affected four residents (#28, #43, #179 and #317) of 42 residents reviewed for accurate medical records. The facility census was 318. Findings include: 1. Review of medical record revealed Resident #28 was admitted to the facility on [DATE] and discharged from the facility on 04/30/24. Medical diagnoses for Resident #28 included unspecified protein-calorie malnutrition, atrial fibrillation, essential primary hypertension, chronic kidney disease stage four, anemia in chronic kidney disease and generalized anxiety disorder. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively impaired. Resident #28 was dependent for eating, toileting hygiene, shower/bathing, upper body and lower body dressing, and personal hygiene. Resident #28 was always incontinent of bowel and bladder. Review of the care plan dated 07/29/22 revealed Resident #28…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure Resident #764's call light was within reach and Resident #666's bed was of a comfortable length. This affected two of three residents reviewed for accommodation of needs, Residents #764 and #666. The facility census was 318. Findings include: 1. Review of the medical record for Resident #764 revealed an admission date of 02/06/24 with diagnoses including difficulty walking, muscle weakness and diabetes mellitus. Resident #764 was discharged from the facility on 05/03/24. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #764 had intact cognition, was dependent on staff for chair to bed transfer, and ambulation was not attempted due to medical condition or safety concerns during the assessment period. Observation and interview on 05/01/24 at 11:36 A.M. of Resident #764 revealed her call light was attached the handrail of her bed and the cord was wrapped around the handrail…

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, record review, and policy review the facility failed to report an allegation of misappropriation to the state survey agency in a timely manner. This affected one resident (Resident #21) of three residents investigated for concerns related to abuse (Resident #21, Resident #110 and Resident #217) The facility census was 318. Findings include: Review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses including cognitive communication deficit and major depressive disorder. During interview on 04/30/24, Resident #21 revealed that both she and her niece had discovered unauthorized charges on her bank credit card. Resident #21 indicated she had not initiated the charges. Resident #21 confirmed that her niece had reported the suspicious charges to Unit Manager (UM) #1339. Resident #21 was alert, oriented and able to respond to interview questions appropriately. During interview on 05/07/24 at 2:30 P.M., UM #1339 verified that Resident #21's niece…

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, record review, and policy review the facility failed to thoroughly investigate an allegation of misappropriation. This affected one resident (Resident #21) of three residents investigated for concerns related to abuse (Resident #21, Resident #110 and Resident #217) The facility census was 318. Findings include: Review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses including cognitive communication deficit and major depressive disorder. During interview on 04/30/24, Resident #21 revealed that both she and her niece had discovered unauthorized charges on Resident #21's bank credit card. Resident #21 indicated she had not initiated the charges. Resident #21 confirmed that her niece reported the suspicious charges to the Unit Manager (UM) #1339. Resident #21 was alert, oriented and able to respond to interview questions appropriately. During interview on 05/07/24 at 2:30 P.M., UM #1339 verified that Resident #21's niece had reported an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper infection control measures were maintained throughout a wound care dressing change to promote healing of the wound. This affected one resident (Resident #296) out of eight residents reviewed for wound care. The facility census was 306. Findings include: Review of the medical record for Resident #296 revealed an admission date of 03/21/24 with diagnoses including congestive heart failure, atrial fibrillation, hypertension, acute kidney failure, prostate cancer, and pneumonia. Review of Resident #296's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required substantial assistance by two staff members for bed mobility toileting, and transfers. Review of Resident #296's physician's orders dated for March 2024 revealed orders to cleanse abrasion to right buttock with normal saline, pat dry and cover with foam dressing daily and as needed. Review of Resident #296'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the facility policy the facility failed to ensure residents performed hand hygiene to prevent cross contamination of germs during Resident #16's and Resident #17's medication administration, Resident #23's perineal care and Resident #31's mechanical lift transfer. This affected two residents (Resident #16 and #17) out of six residents observed for medication administration, one resident (Resident #23) out of two residents observed for perineal care and one resident (Resident #31) out of one resident observed for mechanical lift transfer. The facility census was 317. Findings include: 1a. Resident #16 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage, dementia with cognitive communication deficit, heart block and arrhythmia, osteoarthritis, fractured radius, humerus and femur, iron deficiency anemia, mood disorder, anxiety, psychosis, hypothyroidism, and high blood pressure. Resident #16's physician order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure Resident #34's skin treatment was applied to prevent development of skin breakdown. This affected one resident (Resident #34) out of two residents observed for incontinence care. The facility census was 317. Findings include: Resident #34 was admitted on [DATE] with diagnoses including infection/inflammation of cardiac implant device, aortic aneurysm, leakage of aortic graft replacement, dementia, hypokalemia, defibrination syndrome (coagulation disorder), major depressive disorder, hyperlipidemia, high blood pressure, atrial fibrillation/flutter, adult failure to thrive, heart failure, acute kidney failure, diabetes mellitus, stage 2 sacral region pressure ulcer, and hyperosmolality. A review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] for determining risk of skin breakdown revealed she had a risk of developing skin breakdown. Resident #34's physician order dated 12/08/23 to apply Chamosyn ointment 0.45-20 percent (menthol-zinc oxide) topically every shift for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff secured Resident #24's, Resident #29's, and Resident #33's medications. This affected three residents (Resident #24, Resident #29, Resident #33) out of six residents observed for medication administration. Findings include: 1. Resident #29 was admitted on [DATE] with diagnoses including intracerebral hemorrhage with right sided paralysis, hypertension, major depressive disorder, and chronic gastritis. Resident #29's physician order dated 01/11/22 indicated to administer Omeprazole 20 milligram (mg) tablet orally once a day for gastritis and on 01/22/24 indicated to administer 10 milliliters (ml) of cough/chest congestion Dextromethorphan oral syrup 10/100 mg in 5 ml (dextromethorphan-guaifenesin) every 6 hours as needed for cough. An observation on 01/31/24 at 7:00 A.M. revealed Licensed Practical Nurse (LPN) was in the process of administering medications to Resident #29. The medication cart LPN #400 was using was located at…

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, staff interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary, food items were dated when opened, there were internal thermometers for reach in freezers and refrigerators, microwaves in the kitchenettes were clean, and cross contamination did not occur when taking the temperatures of food items or when placing lids over the plates of food. This had the potential to affect all residents receiving food from the facility kitchen. The facility identified five residents (#111, #142, #209, #657, and #663) that received no food by mouth. The facility census was 309. Findings include: 1. Observation during the initial kitchen tour on 04/10/23 between 8:45 A.M. and 9:21 A.M. with Assistant Dietary Manager #1408 revealed the following concerns: In the kitchen area the following was observed: • An accumulation of black dust observed blowing from the metal cage of the fan on the wall next to the dairy warmer. • The six ANSUL nozzles above the soup kettle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This affected one resident (#33) of one resident reviewed for choices. The facility census was 309. Findings include: Record review for Resident #33 revealed and admission date of 04/13/18. Diagnoses included heart failure, stage IV pressure ulcer of sacral region (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.), acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), hypertension, diverticulosis, history of blood clots, breast cancer, and osteoarthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had intact cognition. She required two-person extensive physical assistance…

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, record review, and facility policy review the facility failed to ensure fluid restrictions were being monitored for four residents (#98, #232, #233, and #270) out of four residents reviewed for fluid restriction. The facility identified eleven residents (#98, #161, #232, #233, #256, #259, #266, #270, #307, #631, and #651) on a fluid restriction. The facility census was 309. Findings include: 1. Record review revealed Resident #270 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, type two diabetes mellitus without complications, and severe protein calorie malnutrition. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #270 was cognitively intact, required supervision with set up for all activities of daily living (ADL) except required supervision of one person assist for bed mobility and toilet use, and received dialysis. Review of the physician orders for Resident #270 revealed an order dated 12/18/22 for a 1000…

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 staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (#91) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 309. Findings Include: Medical record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, hypertension (high blood pressure), and major depressive disorder. Review of the psychiatric consult note for Resident #74, dated 11/02/22, revealed Resident #91 was given a diagnosis of schizoaffective disorder. This diagnosis was reflected and dated as such throughout Resident #91's medical record. Review of the medical record for Resident #91 revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new diagnosis…

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 facility policy review the facility failed to date or change oxygen tubing for Residents #188 and #255 and failed to have a physician order for oxygen administration for Resident #188. This affected two residents (#188 and #255) of two residents reviewed for oxygen therapy. The facility census was 309. Findings include: 1. Review of Resident #188's medical record revealed an admission date of 12/27/18 with diagnoses including disease of spinal cord, abnormalities of breathing, obstructive sleep apnea, and acute respiratory failure. Review of the Medicare 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #188 was cognitively intact, required limited assistance for bed mobility and transfers. Review of Resident #188's April 2023 physician orders revealed no orders for oxygen administration. Observation on 04/10/23 at 11:08 A.M. of Resident #188 in the room with oxygen administered at four- and one-half liters per minute (LPM) via nasal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #270 was assessed and monitored for complications after hemodialysis treatments and failed to provide proof of ongoing communication and collaboration with the dialysis facility. This affected one resident (#270) of one resident reviewed for hemodialysis. The facility census was 309. Findings include: Record review revealed Resident #270 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, type two diabetes mellitus without complications, and severe protein calorie malnutrition. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #270 was cognitively intact, required supervision with set up for all activities of daily living (ADL) except required supervision of one person assist for bed mobility and toilet use. Resident #270 received dialysis. Review of Resident #270's physician orders revealed an order dated 12/16/22 for dialysis treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure medical records were complete and accurate. This affected one resident (#278) of three reviewed for accurate medical records. The facility census was 309. Findings include: Review of the medical record for Resident #278 revealed an admission date of 03/08/23 with diagnoses including left femur fracture, reduced mobility, hypertension, and edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #278 was cognitively intact. She required extensive assistance of one person for bed mobility, dressing, and hygiene, extensive assistance of two people for transfers and toileting, and limited assistance of one person for eating. Review of the physician's orders for March 2023 revealed Resident #278 was admitted to hospice services on 03/21/23 with a diagnosis of coronary artery disease. Interview on 04/18/23 at 1:13 P.M. with the Director of Nursing (DON) revealed there was no record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used appropriate infection control practices, including hand washing and use of gloves during wound care for Resident #61 and intravenous medication administration for Resident #641. This affected one resident (#61) of six residents reviewed for wounds, and one resident (#641) of two residents reviewed for intravenous medication administration. The census was 309. Findings include: 1. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of chronic osteomyelitis with draining sinus of left femur, non-pressure chronic ulcer of the left thigh with necrosis of bone and non-pressure ulcer of left thigh with necrosis of muscle. Review of the physician orders for Resident #61 revealed an order dated 04/04/23 to instill chlorhexidine (antiseptic) into canals with twelve-inch catheter attached to a normal saline syringe for five minutes; remove catheter; wipe skin 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.