Country Club Retirement Ctr IV

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Concern Log, review of the Call Light Audit Report, and interview, the facility failed to ensure staff assistance was provided timely for five dependent residents. This affected five (#7, #10, #23, #37, and #30) of six resident reviewed for activities of daily living (ADL's). The facility census was 46. Findings include:1. Review of the medical record for Resident #7 revealed an admission date of 10/15/25 with diagnoses including acute kidney failure, weakness, acute respiratory failure, depression, diabetes mellitus, and atrial fibrillation. room [ROOM NUMBER] Review of the admission Minimum Data Set (MDS) assessment, dated 10/20/25, revealed Resident #7 had intact cognition and required assistance from staff with ADLs. The MDS indicated the resident required substantial/maximal staff assistance with toileting and was always incontinent of bowel and frequently incontinent of urine. Review of the Care Plan dated 10/21/25 revealed the intervention for assistance from staff…

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 review of the facility assessment, review of the daily staffing schedule, review of the Time Punch Detail Hours Report, record review, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected five (#7, #10, #23, #30, and #37) of six residents reviewed for activities of daily living (ADLs), and had the potential to affect all 46 residents residing in the facility. Findings include: 1.Review of the facility assessment, updated September 2025, revealed the general staffing plan is to ensure sufficient staff to meet the needs of the residents at any given time and is determined based on resident population and census. The staffing plan indicated the average number of certified nursing assistants (CNA) required is five. Staffing is reviewed daily and adjusted to meet the needs of the residents. Review of the Daily Staffing Schedule revealed on 11/08/25 the facility census was 46, between 12:19 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's medication administration policy, and interview, the facility failed to ensure medical records were accurate and complete regarding the administration of controlled substances. This affected five (#9, #19, #23, #4, and #44) of six residents reviewed for medication administration. The facility census was 46. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 06/13/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dementia, heart failure, respiratory failure, and chronic obstructive pulmonary disease. Review of a physician order dated 08/23/25 revealed the order for Hydrocodone-Acetaminophen 5-325 milligrams (mg) one tablet by mouth three times for pain. Review of Resident #9's Controlled Drug Record revealed Hydrocodone-Acetaminophen 5-325 mg one tablet was administered on 11/18/25 at 8:00 A.M.,12:00 P.M. and 7:00 P.M. Review of the Medication Administration Record (MAR) revealed no…

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

Based on medical record review, facility investigation review, facility policy review, and interviews, the facility failed to timely report a suspicion of misappropriation of narcotics. This affected one (#19) of three residents reviewed for misappropriation. The facility census was 46. Findings include:Review revealed there was not a recent Self-Reported Incident (SRI) filed with the Ohio Department of Health (ODH) related to misappropriation. Review of the medical record for Resident #19 revealed an admission date of 11/05/25 with diagnoses including multiple sclerosis, hypertension, major depressive disorder, diabetes mellitus, conversion disorder with seizures, and chronic kidney disease. The Minimum Data Set (MDS) revealed the resident was cognitively intact. Interview on 11/25/25 at 10:54 A.M. with the Director of Nursing (DON) revealed on 11/20/25 she was answering a question regarding a narcotic with Licensed Practical Nurse (LPN) #100 when she opened the narcotic book she noticed several blank entries with the same handwriting indicating Registered Nurse (RN) #126's…

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

Based on observation, record review and interview, the facility failed to follow proper hand hygiene and management of soiled linens during incontinence care. The affected one (#5) of one resident reviewed for incontinence care. The facility census was 46. Findings include:Review of the medical record for Resident #5 revealed an admission date of 10/21/25. Diagnoses included chest pain, unspecified; atherosclerotic heart disease; essential hypertension; cerebrovascular disease; old myocardial infarction; paranoid schizophrenia; and displaced intertrochanteric fracture of unspecified femur.Review of a care plan for Resident #5 , dated 10/21/25, revealed the resident needed assistance from staff to meet activities of daily living (ADL) needs due to decreased mobility. Staff was to assist resident with incontinent care, toileting, bed mobility, dressing, and laundry.On 11/24/25 at 10:10 A.M., an observation of incontinence care for Resident #5 revealed the Certified Nurse Aide (CNA) #115 failed to maintain infection control while performing incontinence care. After cleansing 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 medical record review, interview, and policy review the facility failed to comprehensively assess residents' urinary incontinence to determine type of bladder incontinence and failed to develop and implement an appropriate treatment plan to maintain and/or restore the residents' bladder function. This affected two residents (#45 and #57) of three residents reviewed for urinary incontinence. Findings include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, difficulty walking, encephalopathy, and chronic obstructive pulmonary disease. Review of Resident #45's record revealed the resident was incontinent of bladder due to unaware of toileting needs at this time. Review of the plan of care dated 11/19/24 revealed to assist the resident to the bathroom per resident request, assist with incontinence care, and assist with pads/briefs/pull ups. a. Review of Resident #45's admission and modification Minimum Data Set (MDS) 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 medical record review, observation, and interviews, the facility failed to ensure a resident's oxygen concentrator alarm was addressed timely. This affected one resident (#45) of three residents observed with oxygen concentrators. Findings included: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including dependence on supplement oxygen, pneumonia, chronic respiratory failure with hypoxia, hypertension, heart disease, chronic obstructive pulmonary disease (COPD), hyperlipidemia, and tobacco use. Review of Resident #45's current orders dated 03/2025 revealed to check oxygen saturation twice daily and continuous oxygen at three liters via nasal cannula. Review of Resident #45's cardiac impairment related to hypertension, coronary heart disease (CAD), and hyperlipidemia and potential for alteration in respiratory function related to COPD plan of care dated 11/19/24 revealed to administer oxygen as ordered. Observation on 03/10/25 at 10:04 A.M., revealed 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 record review, interview, and policy review, the facility failed to notify the resident representative and the physician of a change in health status. This affected one resident (#35) of three residents reviewed for notification of change. The facility census was 51. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and history of Coronavirus (COVID)-19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severely impaired cognition. The MDS further revealed Resident #35 required staff assistance with activities of daily living (ADLs). The resident had no chewing or swallowing difficulties. Review of the admission record revealed Family Representative #500 was listed as the resident's emergency contact. Review of nursing progress note, dated 09/13/24 at 2:08…

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, medical record review, and staff interview, the facility failed to ensure physician's orders were in place prior to the use of a reclining safety and enabling chair. This affected one resident (#34) of one resident reviewed for potential restraint use. The facility census was 51. Findings include: Observation of Resident #34 throughout the annual survey from 09/23/24 to 09/30/24 revealed the resident utilizing a reclining geri chair (a large, reclining, mobile and padded chair that's designed to help people with limited mobility sit and stand comfortably). Review of Resident #34's medical record revealed an admission date of 07/02/21 with diagnoses that included chronic obstructive pulmonary disorder, white matter disease and diabetes mellitus. Further review of Resident #34's medical record including Minimum Data Set (MDS) 3.0 assessment with a reference date of 07/03/24 indicated the resident had a significantly impaired cognition level and no restraints were used. Review of Resident #34's physician's orders revealed no evidence of any physician's order in…

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 and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents accurately reflected a new diagnosis and medications. This affected two residents (#38 and #16) of four residents reviewed for PASRR documents. The census was 51. Findings Include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, dementia, diabetes mellitus, muscle weakness, and asthma. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/31/24, revealed the resident had intact cognition and a diagnosis of dementia. Review of Resident #38's PASRR document, dated 08/29/24, revealed under Section D, no was selected incorrectly indicating there was not a diagnosis of dementia. Review of the diagnosis list revealed Resident #38 was diagnosed with dementia on 06/26/24. During interview on 09/24/24 at 5:29 P.M., Corporate Registered Nurse #201 confirmed Resident #38's PASRR…

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 and staff interview the facility failed to ensure Pre-admission Screening and Resident Review assessments were completed accurately upon admission to the facility. This affected two residents (#16 and #20) of four residents reviewed for admission assessments. The facility census was 51. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 04/04/24 with diagnoses that included bipolar disorder, chronic kidney disease and hypertension. Review of the Pre-admission Screening and Resident Review (PASRR) completed on 04/05/24 revealed Resident #20 had a prior diagnosis which included a mood disorder. No psychotropic medications were identified as currently prescribed for the resident. Review of Resident #20's admission medication orders on 04/04/24 revealed the use of Lamictal (mood stabilization medication) 25 milligrams two tablets every day. Further review of the PASRR dated 04/05/24 indicated no current use of medications. On 09/24/24 at 1:15…

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 provide timely treatment as ordered by the physician. This affected one resident (#35) of three residents reviewed for change of condition. The facility census was 51. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and history of Coronavirus (COVID)-19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severely impaired cognition. Review of a physician order, dated 09/13/24 at 4:00 P.M., revealed the order for Furosemide 40 milligrams (mg), to be injected intramuscularly (IM) one time a day for swelling, for three days. Review of nursing progress note, dated 09/13/24 at 4:02 P.M., revealed Resident #35 had continued swelling of bilateral legs and was not compliant with elevating her…

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, policy review, and interview, the facility failed to ensure a dependent resident received appropriate services to maintain mobility and prevent further decrease in range of motion. This affected one resident (#9) of two residents reviewed for mobility. The census was 51. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, osteoporosis, chronic kidney disease, chronic obstructive pulmonary disease, tremor, and difficulty walking. Review of the Minimum Data Set (MDS) annual assessment, dated 08/05/24, indicated Resident #9's Brief Interview for Mental Status (BIMS) score was 03, which indicated the resident was severely cognitively impaired. The resident was totally dependent on staff for putting on/taking off footwear, lower body dressing, and transfers. The resident had impairment of both lower extremities. Review of the Care Plan, dated 07/07/23, revealed Resident #9 had the potential…

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 obtain a physician order for oxygen therapy. This affected one resident (#35) of three residents reviewed for respiratory care. The facility census was 51. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and history of Coronavirus (COVID)-19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severely impaired cognition. There were no behaviors or rejection of care. The resident did not receive oxygen therapy. Review of physician orders, dated September 2024, revealed no order for oxygen therapy. Review of nursing progress note, dated 09/13/24 at 2:08 P.M., revealed Resident #35 was sitting up on the side of her bed and stated she was having a hard time laying down as it caused shortness of breath.…

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 and interview the facility failed to ensure laboratory results were performed to ensure adequate monitoring of medication and failed to ensure abnormal laboratory results were addressed appropriately. This affected two residents (#28 and #47) of six resident reviewed for medication review. Findings included: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia and hypothyroidism. Review of Resident #28's cumulative current diagnoses list revealed the resident had hyperlipidemia on admission, however there was no documented evidence of the diagnosis of hypothyroidism. Review of Resident #28's Minimum Data Set (MDS) dated [DATE] revealed the resident had hyperlipidemia however there was no documented evidence of diagnosis of hypothyroidism. Review of Resident #28's medication orders dated 01/10/23 to 09/26/24 revealed on admission the resident was ordered pravastatin 80 milligrams (mg) daily for hyperlipidemia…

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

Based on medical record review, hospital record review, resident interview and staff interview, the facility failed to ensure medications had an appropriate indication for use. This affected one resident (#50) of five residents reviewed for medications. The facility census was 51. Findings include: Review of Resident #50's medical record revealed an admission date of 07/25/24 with diagnoses that included schizophrenia, anxiety, dementia and diabetes mellitus. Review of the medications for Resident #50 revealed on 08/05/24 Depakote (seizure medication and for mood stabilization) 250 milligram (mg) twice daily was prescribed. Further review of the medical record revealed no evidence of any physician or certified nurse practitioner evaluation which indicated a diagnosis of seizure disorder or why the medication was initiated. Review of hospital records prior to transfer to the facility revealed no evidence of any prior seizure disorder or use of Depakote. Review of the Medication Administration Record (MAR) for the months of August and September 2024 for Resident #50 revealed Depakote…

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

Based on medical record review and staff interview the facility failed to administer psychotropic medications as ordered. This affected one resident (#8) of five residents reviewed for medications. The facility census was 51. Findings include: Review of Resident #8's medical record revealed an admission date of 01/25/24 with admission diagnoses that include chronic obstructive pulmonary disease, mood disorder, depression and anxiety. Further review of Resident #8's medical record revealed on 09/23/24 the psychiatric certified nurse practitioner (CNP) evaluated Resident #8 and increased the dosage of Depakote (medication for mood disorders) from 250 milligrams (mg) twice daily to 250 mg two tablets in the morning and 250 mg every night. Review of Resident #8's Medication Administration Record (MAR) revealed after the increased Depakote order was initiated by the CNP on 09/23/24, the new order was transcribed incorrectly into the medical record medication orders and MAR which resulted in Resident #8 to receive two 250 mg tablets in the morning, 250 mg at night and 500 mg every day. No…

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 and interview the facility failed to ensure a resident received dental care timely for ill-fitting dentures and dentures were readily accessible to the resident. This affected one resident (#21) of two reviewed for dental. Findings included: Medical record review revealed Resident #21 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including dysphagia, needing assistance with personal care, gastro-esophageal reflux, and heart disease. Review of Resident #21's census revealed the resident was admitted on [DATE] and was hospitalized from [DATE] to 09/17/24. Interview and observation on 09/23/24 at 1:30 P.M., with Resident #21 revealed he had sores on his gums related to his upper dentures were ill fitting and his bottom dentures have been missing since he returned from the hospital last week (09/17/24). The resident removed his upper denture to show the surveyor the sores he had on the top gum line and that he had no bottom dentures. 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 infection control log review, medical record review, policy review and staff interview the facility failed to ensure residents had an appropriate indication for the use of antibiotics. This affected three residents (#3, #16 and #44) of eight residents reviewed for antibiotic use. The facility census was 51. Findings include: Review of the facility infection control log for the months of July, August and September 2024 revealed 28 resident infections which did not meet McGeer's criteria (assessment to determine if antibiotics are appropriate to be utilized). Review of the following resident records revealed the following: 1. Review of Resident #3's medical record revealed an admission date of 02/21/24 with diagnoses that included Parkinson's disease, chronic obstructive pulmonary disease and congestive heart failure. Review of the infection control log revealed on 07/17/24 Resident #3 had a urinary tract infection which did not meet McGeer's criteria. Physician's orders on 07/17/24 revealed Resident #3 was prescribed Macrobid (antibiotic) 100 milligrams (mg) twice daily 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 observation, review of the facility's concern log, record review, and interview the facility failed to maintain sufficient levels of staffing to ensure call lights were responded to in a timely manner and to meet the total care needs of all residents. This had the potential to affect all 45 residents residing in the facility. Findings include: 1. Review of the facility's concern log dated 11/01/21 to 10/27/22 revealed a concern, dated 07/28/22 indicating call lights needed to be answered more quickly. The facility response included the Director of Nursing (DON) re-educated staff on call lights and the facility's expectations. During the survey, the following resident concerns related to staffing were voiced: a. On 11/07/22 at 9:45 A.M. interview with Resident #7 revealed a concern that it took a while to receive staff assistance after activating the call light. The resident was unable to provide any specifics or quantify the time. b. On 11/07/22 at 10:06 A.M. interview with Resident #20 revealed concerns there were times she was unable to participate in activities because…

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 and interview the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) Identification Screen was completed to determine if Resident #4 needed specialized services. This affected one resident (#4) of two residents reviewed for PASARR. Findings include: Review of Resident #4's medical record revealed diagnoses including psychosis, generalized anxiety disorder, schizophrenia, and auditory and visual hallucinations. According to the diagnosis list, the schizophrenia diagnosis was present upon admission on [DATE]. Resident #4 had orders for the antipsychotic medication Zyprexa and antidepressant Lexapro. Resident #4 was under the services of a psychiatrist. A PASARR, dated 05/03/22 indicated Resident #4 had no diagnoses of mental disorders listed, no disruption in usual living arrangement over the prior two years, and was not prescribed psychotropic medication in the prior six months. On 11/09/22 at 8:49 A.M. the Administrator verified the PASARR…

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, medical record review and interview the facility failed to ensure Resident #4 and Resident #96, who required staff assistance with activities of daily living received timely and adequate assistance with personal care, including facial hair removal. This affected two residents (#4 and #96) of four residents reviewed for activities of daily living. Findings include: 1. Review of Resident #4's medical record revealed diagnoses including congestive heart failure, psychosis, type 2 diabetes mellitus, chronic atrial fibrillation, atherosclerotic heart disease, depression, schizophrenia, chronic obstructive pulmonary disease, pain, auditory and visual hallucinations, heart failure, macular degeneration, osteoarthritis, and generalized muscle weakness. A care plan initiated 05/30/22 indicated Resident #4 needed assistance from staff to meet activities of daily living needs. Interventions included assisting with meals, ambulation, hair care, incontinence care, oral care, toileting, transfers, bed mobility, dressing, and bathing as needed. The care plan did 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 medical record review and interview the facility failed to ensure adequate monitoring and care for Resident #28 related a diagnosis of diabetes mellitus including clarification of a physician's order for administration of sliding scale insulin. This affected one resident (#28) of five residents reviewed for medication use. Findings include: Review of Resident #28's medical record revealed diagnoses including Alzheimer's disease and diabetes mellitus. Record review revealed on 06/13/22 Resident #28 had a physician order for enteral (tube) feeding at night between 8:00 P.M. and 6:00 A.M., Novolog insulin 15 milliliters to be administered three times a day, and Novolin R insulin four times a day per sliding scale. On 06/13/22, the Novolin R was discontinued and an order was written for Novolog insulin to be administered four times a day per a sliding scale two hours after Resident #28 ate to see if blood glucose levels had gone down with the regular dose administered. The times were listed as 6:30 A.M., 10:30 A.M., 3:30 P.M. and 8:00 P.M. The routine Novolog insulin was…

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

Based on observation, medical record review, and interview the facility failed to ensure Resident #10, who had an indwelling urinary catheter received appropriate services to prevent urinary tract infections. This affected one resident (#10) of two residents reviewed for urinary catheters. The facility identified four residents with urinary catheters. Findings include: Review of Resident #10's medical record revealed diagnoses including obstructive and reflux uropathy (blockage in the urinary tract), Parkinson's disease, and osteoarthritis. A care plan, initiated 09/06/22 indicated Resident #10 had an indwelling urinary catheter related to urinary retention with hydronephrosis (excess urine accumulation in kidney(s) that caused swelling of kidneys) and obstructive and reflux uropathy. The goal was for Resident #10 to be free of infection. Review of physician's antibiotic orders and progress notes revealed Resident #10 was treated for a urinary tract infection beginning 07/29/22 and started treatment for a possible urinary tract infection on 10/04/22 related to (urinary tract…

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

Based on record review and interview the facility failed to implement a comprehensive and effective antibiotic stewardship program to ensure the appropriate use of antibiotics. This affected 19 residents (#18, #14, #17, #28, #149, #29, #46, #150, #3, #40, #45, #299, #35, #39, #20, #196, #12, #5 and #151) and had the potential to affect all 51 residents residing in the facility: Findings Include: Review of the antibiotic stewardship program/infection control log dated 10/2019 to 12/2019 with Licensed Practical Nurse (LPN) #20 revealed: a. In October 2019 there were ten infections. Resident #18 was started on Cipro for a urinary tract infection (UTI) before the culture had returned. The culture indicated the resident was resistance against Cipro and she was switched to Amoxicillin. Resident #14 was treated with Keflex for and unidentified source and did not meet criteria. Resident #17 received Keflex for a UTI without evidence of urine culture. There was no form completed to ensure the resident met criteria. Resident #28 was treated with Daptomycin antibiotic and the culture indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report injuries of unknown origin involving Resident #46 to the State agency as required. This affected one resident (#46) of five residents reviewed for falls. Findings Include: Review of Resident #46's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA) with aphasia (inability to speak). Review of the nurse's note, dated 11/16/19 at 6:45 P.M. and authored by Registered Nurse (RN) #16 revealed the nurse was called to Resident #46's room. The note indicated upon arrival to the room, the resident was observed standing naked, walking away from the doorway with copious amounts of blood noted to the floor surrounding the resident. The resident had facial injuries with excessive amounts of blood on his head, face and chest. Pressure was applied to a large laceration above the resident's right eye and the resident was assisted to a seated position on his bed. The nurse was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview the facility failed to implement a comprehensive and individualized restorative ambulation and transfer program for Resident #46 following the resident's discharge from therapy as recommended. This affected one resident (#46) of four residents reviewed for restorative nursing services. Findings Include: Review of Resident #46's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA) with aphasia (inability to speak). The resident was admitted to the facility from an acute care hospital with a history of falls and inability to ambulate with recommendations for occupational therapy (OT) due to functional mobility, dressing and transfer decline. The resident was also noted to have deficits in strength, balance and coordination affecting his functional mobility and transfer ability requiring physical therapy (PT) at the time of admission. Record review revealed the resident was cognitively…

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 ensure a wound specimen was obtained timely and antibiotic treatment was initiated timely for Resident #29. This affected one resident (#29) of two residents reviewed for non- pressure skin alterations. Findings Include: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including open wound of ankle, anemia, acute embolism and thrombosis of deep veins of right lower extremity, moderate protein-calorie malnutrition, and peripheral vascular disease. Review of Resident #29's wound center orders, dated 10/11/19 revealed new orders to obtain a wound aerobic and anaerobic positive gram stain (to be collected by the facility on 10/11/19). Review of Resident #29's progress notes dated 10/11/19 revealed at 4:00 P.M., the resident returned from the wound center with new orders to obtain a sample from the resident's right lateral ankle and send to the laboratory in the morning. At 4:07 P.M., the specimen was obtained…

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 restorative range of motion services and/or splints were implemented per the plan of care for Resident #3 and Resident #38 and failed to ensure restorative staff were knowledgeable of the types of range of motion exercises to be provided. This affected two residents (#3 and #38) of four residents reviewed for positioning and restorative/rehabilitation. Findings Include: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty walking, and unsteadiness on feet. Review of Resident #3's physical therapy notes, dated 09/30/19 the revealed resident was discharged to skilled nursing facility with recommendations including restorative nursing. Review of Resident #3's occupational therapy notes dated 09/30/19 revealed the resident was discharged from therapy with recommendations for transfer and functional mobility including decrease balance. Review of Resident #3'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, record review and interview the facility failed to ensure Resident #9 received timely dental services. This affected one resident (#9) of one resident reviewed for dental care. Findings Include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, muscle weakness and a history of falling. Review of Resident #9's dental health notes revealed Resident #9 was seen by the dentist on 05/24/19 and a new lower partial was recommended so the resident could chew better. Review of Resident #9's oral status, dated 10/02/19 failed to identify the resident had a broken or loosely fitting partial denture. Review of Resident #9's oral cavity assessment, dated 10/07/19 revealed the resident had some teeth loss, but failed to identify she had a lower partial or the condition of the lower partial. Review of Resident #9's care plan, dated 12/10/19 revealed the resident was at risk for oral…

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

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during a pressure ulcer dressing change for Resident #27 to prevent the spread of infection. This affected one resident (#27) of one resident observed for wound care. Findings Include: Record review revealed Resident #27 was admitted to the facility 05/18/19 with diagnoses including Stage III pressure ulcer to right shoulder and amyotrophic lateral sclerosis. Observation on 12/10/19 from 8:46 A.M. to 9:02 A.M., revealed Registered Nurse (RN) #19 placed supplies (clear trash bag, two alcohol wipes, gauze package, alginate (AG) package, and a foam dressing package) on an uncleaned bedside table. She wiped half of the bedside table with a wet paper towel and placed the clear trash bag over the half of the bedside table. She removed scissors from her pocket and cleansed them with one of the alcohol wipes and then placed them down on the clear plastic bag. The nurse removed the old dressing and performed hand hygiene with soap and water and applied new non-sterile…

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.