Muskingum Skilled Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of concern log, review of self-reported incident, observation, interview, and policy review, the facility failed to timely investigate an allegation of misappropriation of a resident's wallet. This affected one (Resident #41) of three reviewed for personal property. Findings Include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes, obesity, depression, anemia, long QT syndrome, anxiety, pain, peripheral vascular disease, Vitamin D deficiency, restless legs syndrome, gastritis, constipation, occlusion and stenosis, hypomagnesemia, hyperglycemia, hyperlipidemia, and nocturia. Review of the concerns log dated 01/2026 to 05/2026 revealed there were no concerns that were reported in the last five months, including a missing wallet for Resident #41.Interview on 05/05/26 at 11:54 A.M., with Resident #41's wife revealed two or three weeks after…

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 had an individualized trauma informed plan of care. This affected one resident (#28) of four residents reviewed for behaviors.FIndings include: Record review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including personality disorder, depression, generalized anxiety, post-traumatic stress disorder (PTSD), personal history of suicidal behavior, poisoning by benzodiazepines, and sedative, hypnotic or anxiolytic dependence, in remission. Review of Resident #28's psychiatric note dated [DATE] revealed the resident had PTSD and was stable on Zoloft (anti-depressant) and Xanax (anti-anxiety). The resident had PTSD from watching a friend wreck and die on motorcycle when she was younger and it plays back in her head. She had attempted suicide. There was no documented evidence of triggers or individualized intervention. Review of Resident #28's quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure residents who were dependent on staff were provided assistance with personal hygiene and bathing. This affected two residents (#19 and #25) of four residents reviewed for activities of daily living. The facility census was 38. Findings include:1.Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 12/19/23 revealed Resident #19 required assistance with ADLs related to debility and weakness. The goals included to continue to participate in ADLs as able and have no decline in ADLs through review; remain clean, dry, odor free and appropriately dressed through the review; and remain well-groomed and free of odors at all times and will participate in ADL self-care. Interventions included but were not limited to staff to adjust care as needed to meet resident's needs; staff to encourage resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interview, and policy review, the facility failed to ensure alternating air mattresses were on the correct setting to prevent pressure ulcers. This affected one resident (#19) of three residents reviewed for pressure ulcers and interventions. The facility census was 38. Findings include:Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 10/24/21 revealed Resident #19 was at risk for impaired skin integrity related to decreased mobility, periods of bowel and bladder incontinence, bilateral lower extremity edema, oxygen per nasal cannula, history pressure ulcers, and prefers to lay on back. The goals were for excoriation will resolve without complication as occurrence arises and skin will be free of breakdown. Interventions included but were not limited to elevate heels off mattress, heel protectors as tolerated, inspect skin during daily care, lotion…

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 medical record review, review of infection control log, review contingency medication list, and interview the facility failed to ensure an urinalysis was collected timely and antibiotics were administered per order to treat urinary tract infection. This affected one resident (#48) of five residents reviewed for urinary tract infections.Findings include:Closed medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia, anemia, scoliosis, and ulcerated proctitis. Review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always incontinent of urine. Review of Resident #48's alteration in elimination related to incontinent of bowel and bladder dated [DATE] and cancelled [DATE] revealed to administer all treatments per order and monitor for signs and symptoms of urinary tract infections: foul smelling urine, cloudy urine, sediment, decreased output. Notify physician of changes. 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 interview, record review, laboratory test review, review of education material from the Cleveland Clinic, and policy review, the facility failed to ensure appropriate interventions were implemented for a resident with weight loss and compromised nutritional status. This affected one resident (#40) of three residents reviewed for nutrition. The census was 38.Findings include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including hypoglycemia, type 2 diabetes, dysphagia, benign prostatic hyperplasia, heart failure, major depressive disorder, insomnia, hallucinations, osteoarthritis, and mood disorder.Review of Resident #40's care plan initiated 08/09/25 revealed the resident was at risk for alteration in nutrition and hydration related to diabetes, and mechanically altered diet. Goals included the resident will be adequately nourished with no significant weight changes.Review of Resident #40's record revealed an order placed on 09/01/25 for monthly…

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, interviews, and policy review the facility failed to administer oxygen to residents as ordered and failed to ensure appropriate use of oxygen. This affected two residents (#19, #15) of five residents reviewed for respiratory care. The census was 38.Findings include: 1.Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 02/26/19 revealed Resident #19 had an alteration in oxygen exchange/perfusion related to chronic respiratory failure and chronic obstructive pulmonary disease. The goal was for lungs to be clear to auscultation and oxygen saturation above 90%, respirations to be unlabored, and show adequate oxygen perfusion. Interventions included but were not limited to evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve and provide oxygen per orders. Review of orders revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure residents with known trauma were provided trauma informed care. This affected two residents (#28 and #36) of four residents reviewed for behaviors. The facility census was 38. Findings include:1.Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD) and depression. Review of a care plan dated [DATE] revealed Resident #36 was at risk for impaired social interaction related to PTSD due to her sister passing away which causes her to be upset. The goals included being free of or have decrease in undesirable behaviors and interactions with others and will have no decreased/personally acceptable level of stress from past trauma. Interventions included but were not limited to encourage deep breathing exercises when she is in a stressful situation; encourage positive communication with others; encourage to participate in activities she enjoys; encourage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, review of infection control log, and review of policies the facility failed to ensure residents were free from unnecessary medications. This affected one resident (#31) of five residents reviewed for urinary tract infections and one resident (#10) of six residents reviewed for unnecessary medications. Findings include: 1. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, acute kidney failure, chronic obstructive pulmonary disease, pneumonia, sepsis, retention of urine, paroxysmal atrial fibrillation, prostatic hyperplasia without lower UTI system, varicose veins, gastro-esophageal reflux disease, edema, obstructive an reflux uropathy, Barrettes esophagus with dysplasia, voice and resonance disorder, laryngeal spasm, foot pain, opioid dependence, ventral hernia, leg pain, hypertension, and anxiety. Review of Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility investigation, review of Medscape drug information, review of policies, job description reviews and interviews the facility failed to prevent a significant medication error. This affected one resident (Resident #41) of three residents reviewed for hospice services. The facility census was 38. Findings include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, diabetes mellitus, asthma, dementia, major depression, long QT syndrome (condition affecting repolarization (relaxing) of the heart after a heartbeat. It results in an increased risk of an irregular heartbeat which can result in fainting, drowning, seizures, or sudden death), insomnia, pain, peripheral vascular disease, occlusion and stenosis of carotid artery. The resident was a full code status, and allergies included Duloxetine, Morphine, and Betadine. Review of Resident #41's orders revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, review of hospice contracts and hospice documentation review the facility failed to ensure hospice plans and visits were maintained at the facility and failed to ensure the facility contactwas identified for hospice service contact. This affected three residents (Resident #41, #47 and #48) of four residents reviewed for hospice services. The facility census was 38. Findings include: 1. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, asthma, dementia, major depression, urge incontinence, anxiety, long QT syndrome, insomnia, pain, peripheral vascular disease, Vitamin D Deficiency restless leg syndrome, gastritis, constipation, occlusion and stenosis of carotid artery, hyperglycemia, hyperlipidemia, nocturia, and hypomagnesemia. Review of Resident #41's hospice contract dated [DATE] revealed the facility shall ensure hospice…

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 interviews the facility failed to ensure residents received adequate indwelling catheter care, failed to ensure residents received adequate indwelling catheter education upon discharge, failed to ensure urine was obtained per orders, and failed to ensure bladder assessment was accurate on admission. This affected two (Resident #44 and Resident #45) of three reviewed for bladder impairments. Findings included: 1. Closed record review revealed Resident #44 was admitted to the facility on [DATE] and discharged on [DATE]. The residents' diagnoses included metabolic encephalopathy, pneumonia, severe protein-calorie malnutrition, bladder neck obstruction, hydronephrosis, generalized anxiety, malignant neoplasm of prostate, and depression. He had a history of dysphagia, edema, and heart disease. Review of Resident #44's discharge hospital notes dated [DATE] revealed a foley catheter was placed and would need a chronic foley catheter as he was a poor surgical candidate. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure beds were the appropriate size for residents. This affected one (Resident #39) of one resident reviewed for positioning. The facility census was 46. Findings include: Record review revealed Resident #39 admitted to the facility on [DATE] with diagnoses including syncope and collapse, dementia, hyperlipidemia, and intellectual disabilities. Review of a quarterly Minimum Data Set (MDS) assessment completed on 05/03/24 revealed Resident #39 had moderately impaired cognition and was independent for bed mobility. Observation on 07/08/24 at 9:03 A.M. revealed Resident #39 was laying diagonal in bed with his feet over the edge because the bed was not long enough. Observation on 07/08/24 at 11:13 A.M. revealed Resident #39 was laying diagonal in bed with his feet over the edge. When asked if his bed was long enough, Resident #39 shook his head no. Interview on 07/09/24 at 10:26 A.M. with Resident #39 revealed he was not comfortable in his bed because he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review,interview, and policy review, the facility failed to ensure care conferences were offered in conjunction with minimum data set (MDS) reviews. This affected two (Resident #2 and #39) of two residents reviewed for care conferences. The facility census was 46. Findings include: 1. Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, hypertension, and anemia. Review of a quarterly MDS dated [DATE] revealed Resident #2's cognition remained intact. Review of completed MDS' revealed Resident #2 had quarterly MDS assessments completed on 08/29/23, 11/27/23, 02/26/24, and 05/25/24. Review of Multidisciplinary Care Conference assessments revealed care conferences were held on 08/18/23, 02/28/24, and 04/30/24. There was no record of a care conference because held in conjunction with the MDS completed on 11/27/23. Interview on 07/08/24 at 5:23 P.M. with Resident #2 revealed the resident could not recall having care…

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 observations, the facility failed to ensure pressure ulcer interventions were in place. This affected three ( Resident #36, #26, and #12) of three residents reviewed for skin breakdown. The facility census was 46. Findings include: 1. Review of the medical record for Resident #36, revealed an admission date of 06/12/24. Diagnoses included but were not limited to displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, metabolic encephalopathy, unsteady on feet and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 indicating severe cognitive impairment. The resident was assessed to require setup or clean-up assistance with eating, oral hygiene, substantial/maximal assistance with toilet hygiene, bed mobility, sit to stand and dependent with bed and toilet transfers. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to have fall interventions in place for Resident #3 and #12. This affected two (Resident #3 and #12) out of four reviewed for accidents. Facility census was 46. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included Alzheimer's disease, dementia, type 2 diabetes mellitus, hemiplegia and hemiparesis, depression, and anxiety. Review of plan of care dated 11/06/23 revealed Resident #3 was at risk for falls and potential injury related to impaired vision, psychoactive medication, vertigo, impaired balance, dementia, and syncope. Interventions included low bed and to monitor that the bed was in the low position due to Resident #3 would elevate the bed when playing with the controls. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a brief interview for mental status (BIMS) score of 12 out of 15 which indicated cognitive…

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, policy review, and interviews, the facility failed to notify a resident's family prior to a transfer to another facility. This affected one resident (#22) of four residents reviewed for resident rights. The facility census was 40. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, hypertension, schizoaffective disorder, hypothyroidism, dementia, dysphagia, anxiety disorder, and osteoarthritis. Review of a minimum data set (MDS) assessment completed on 12/04/23 revealed Resident #22 had moderately impaired cognition and was transferred to another facility on 12/04/23. Review of a discharge assessment completed on 12/04/23 revealed the discharge instructions were given to Resident #22. Review of nursing note from 11/30/23 at 8:09 P.M. entered by the Administrator revealed Resident #22's son was spoken with regarding a transfer to a new facility for behavior…

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 staffing schedule review, time card report review, facility assessment review, policy review and interview, the facility failed to provide registered nurse (RN) coverage daily for a minimum of eight consecutive hours. This affected all 47 residents residing within the facility. Findings include: Review of the Staffing Schedules dated September 2023, October 2023 and November 2023 revealed no evidence a RN was scheduled on 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/15/23, 10/28/23, 10/29/23 or 11/19/23. Review of the staffing Time Card Reports dated 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/15/23, 10/28/23, 10/29/23 and 11/19/23 revealed no evidence a RN worked the required minimum of eight consecutive hours. Review of the Facility assessment dated [DATE] revealed the facility provided a RN for at least eight hours daily. Review of the undated policy: Minimum Staffing Requirements revealed the facility will maintain sufficient staffing to provide, in a timely manner, adequate services and care to meet…

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, review of facility documentation of abuse training, record review, and facility policy review, the facility failed to ensure training was provided to staff following an incident of resident abuse. This affected all 47 residents residing in the facility. Findings included: Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal content. Additionally, the assessment revealed she was always incontinent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, resident record review, review of abuse policy acknowledgement, review of the facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to report an occurrence of abuse and failed to report an occurrence of abuse timely to the state survey agency. This affected two residents (#15 and #17) of three residents reviewed for abuse. The facility census was 47. Findings included: 1. Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, resident record review, review of abuse policy acknowledgement, review of the facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to thoroughly investigate resident abuse. This affected two residents (#15 and #17) of three residents reviewed for abuse. The facility census was 47. Findings included: 1. Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal…

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, facility transfer/discharge documentation, facility bed hold documentation, and facility policy review, the facility failed to ensure residents received appropriate notice of transfer/discharge and bed hold and failed to ensure the Ombudsman was notified. This affected two residents (#17 and #48) of three residents reviewed for transfer/discharge and bed hold notice. The facility census was 47. Findings included: 1. Review of Resident #48's medical record revealed an initial admission date of 07/22/23 and readmitted on [DATE] with diagnoses including Arnold Chiari Syndrome with hydrocephalus, type two diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, stage four (sever), and chronic congestive heart failure. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/01/23, revealed the resident was cognitively intact. Review of Resident #48's progress note, dated 11/02/23 and timed 10:56 A.M., revealed she was complaining…

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, resident record review, and facility policy review, the facility failed to ensure residents had comprehensive care plans developed and implemented. This affected two residents (#17 and #22) of seven residents reviewed for care planning. The facility census was 47. Findings included: 1. Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical, verbal or other behavioral symptoms towards others. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Review of Resident #22's progress note,…

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

Based on observation, interview, and resident record review, the facility failed to ensure supervision for a resident while eating as recommended by the speech therapist. This affected one resident (#17) of twelve residents reviewed for quality of care. The facility census was 47. Findings included: Review of Resident #17's medical record revealed an initial admission date of 02/06/23 and a readmission date of 10/03/23 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. The resident needed supervision with setup help only with eating and did not have a swallowing disorder. Review of Resident #17's physician order, dated 09/05/23 to November 2023 revealed a regular diet, regular texture and regular (thin liquid) consistency, no straws. Review of Resident #17's Speech Therapy Treatment Encounter Note, dated 09/11/23, revealed speech therapy discharge completed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to provide appropriate urinary incontinence care. This affected one of one resident (#40) observed for incontinence care. The facility census was 47. Findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dementia, schizoaffective disorder and constipation. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #40 was severely impaired for daily decision-making, required staff to assist with personal hygiene, and was always incontinent of bowel and bladder. Review of the care plan: Alteration in Elimination: No control present with bowel and bladder, dependent on staff for peri-care and toileting needs (revised 04/05/18) revealed interventions including to apply barrier cream to peri area as prevention and provide incontinent care as needed. On 11/28/23 between 11:03 A.M. and 11:31 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 medical record review and interview, the facility failed to ensure physician progress notes were readily available for review. This affected one resident (#17) of three residents reviewed for discharge/transfer/bedhold notice. The facility census was 47. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. Review of Resident #17's Progress Notes revealed she was evaluated at the emergency room on [DATE], 10/03/23 and 10/05/23 for changes in condition. Review of the medical record revealed no physician progress notes for review. On 11/30/23 at 10:23 A.M., interview with Registered Nurse (RN) #182 verified there were no physician progress notes available for review on the medical record. On 11/30/23 at 12:48 P.M., interview with RN #182 verified there was no documented evidence in the electronic or paper medical record of an assessment or progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure physician and nurse practitioner (NP) visits alternated as required. This affected one resident (#17) of three residents reviewed for discharge/transfer/bedhold notice. The facility census was 47. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. Review of the Nurse Practitioner (NP) #184 Progress Note dated 07/28/23, 08/31/23 and 10/12/23 revealed an assessment and treatment plan was documented. Review of the electronic and paper medical record revealed no physician progress notes for review. On 11/30/23 at 10:23 A.M., interview with Registered Nurse (RN) #182 verified there was no evidence the physician evaluated Resident #17 or alternated evaluations/assessments with NP #184. On 11/30/23 at 12:48 P.M., interview with RN #182 verified there was no documented evidence in 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, personnel record review, job description review and interview, the facility failed to ensure nurse staff administering medications were competent in their duties and ensured the medications were administered appropriately. This affected one resident (#8) of four residents observed for medication administration. The facility census was 47. Findings include: Review of State Tested Nurse Aide (STNA) #143's personnel record revealed she was licensed by the State of Ohio as a Certified Medication Aide on 08/17/23. Review of the certified medication aide Job Description signed 08/17/23 revealed essential duties and responsibilities included to report to the nurse the following: a resident refusal of medications, any deviation from the delegated medication administration, any unanticipated resident reaction to the medication administration, or anything that causes concern about the condition of the resident. On 11/28/23 at 7:34 A.M., observation revealed STNA #143 administered oral medications to Resident #8 and offered Miralax (laxative) as ordered to Resident #8.…

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 and resident record review, the facility failed to provide appropriate behavioral care when Resident #22 was presenting with escalating behavioral needs. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 47. Findings included: Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or verbal behavioral symptoms towards others. Review of Resident #22's comprehensive plan of care revealed no care plan regarding aggressive verbal or physical behaviors toward other residents or staff. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, medication insert review, policy review and interview, the facility failed to ensure both rapid-acting and long-acting insulin's were administered timely and inhalation medications were administered without error. This affected two residents (#2 and #39) of four residents. Three errors were observed during 26 opportunities resulting in a medication administration error rate of 11.54%. Findings include: 1. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #39 received daily insulin injections for diabetes mellitus. On 11/28/23 at 7:41 A.M., observation revealed State Tested Nurse Aide (STNA) #143 prepared Resident #39's oral medications. STNA #143 stated she was also a certified medication aide (MA-C) and could not administer insulin and Licensed Practical Nurse (LPN) #136 would come to the unit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility failed to ensure Pre-admission Screenings/Resident Reviews (PASARR) were accurate. This affected two residents (#43 and #49) of three residents reviewed. The facility census was 45. Findings included: 1. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, chest pain, atrial fibrillation, anxiety disorder, and major depressive disorder. Review of Resident #43's PASARR revealed diagnoses of anxiety disorder and major depressive disorder were not screened for level two review for mental health. 2. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, type II diabetes, and chronic kidney disease. Review of Resident #49's PASARR revealed diagnoses of anxiety disorder and major depressive disorder were not screened for level two review 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 review of staffing schedules for May 2022, review of daily nurse staffing postings for 05/28/22 thru 05/29/22, time reports and staff interview, the facility failed to ensure they had Registered Nurse (RN) coverage for eight consecutive hours seven days a week as required. This had the potential to affect all residents residing in the facility. Findings include: A review of the facility's nursing schedule for May 2022 revealed there was not a RN scheduled to work for either the day shift (7:00 A.M. to 7:00 P.M.) or night shift (7:00 P.M. to 7:00 A.M.) on 05/28/22 or 05/29/22. The scheduled identified which nurses were scheduled based on an x being placed across from their names in the boxes for a particular date. The empty box indicated the nurse did not work on those days. There were only two RN's included on the schedule for May 2022 with nine LPN's. A review of the daily nurse staffing posting for 05/28/22 and 05/29/22 revealed there were no RN hours recorded for either the day shift or the night shift on those dates. The daily nurse staff posting indicated the number…

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 dependent residents were assisted with activities of daily living to include showers and nail care. This affected four residents (Residents #16, #26, #35, and #40) of five residents reviewed for activities of daily living. The census was 45. Findings include: 1. Review of Resident #16's medical record revealed an admission date of 04/04/22 with diagnoses including chronic atrial fibrillation, pacemaker, anxiety, and heart failure. Review of the personal and cultural preferences plan of care initiated 04/08/22 revealed the resident preferred to shower on Wednesday and Sunday (twice per week). Review of the Quarterly MDS dated [DATE] revealed the resident had intact cognition and was dependent of one staff with bathing. On 07/05/22 at 10:33 A.M. interview with Resident #16 revealed she was not getting showers and today was the first shower she had in four weeks. The resident stated she maintained cleanliness by wiping off by herself.…

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

Based on record review, interview and policy review the facility failed to ensure residents were afforded the opportunity to make choices about their care. This affected one resident (Resident #16) of six residents reviewed for activities of daily living. The census was 45. Findings include: Review of Resident #16's medical record revealed an admission date of 04/04/22 with diagnoses including chronic atrial fibrillation, pacemaker, anxiety, and heart failure. Review of the admission Packet V11 dated 04/04/22 revealed the resident preferred to receive showers three days per week (Tuesday, Thursday and Saturday) in the evening. Review of the personal and cultural preferences plan of care initiated 04/08/22 revealed the resident preferred to shower on Wednesday and Sunday (twice per week). Review of the Minimum Data Set (MDS) 3.0 dated 04/14/22 revealed the resident was cognitively intact and required extensive assistance of one staff member with transfers, dressing, toilet use and personal hygiene. The resident was dependent of one staff member for bathing/showers. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure advanced directives were accurate and reflected resident wishes. This affected one resident (Resident #16) of two residents reviewed for advanced directives. The census was 45. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE] with diagnoses including chronic atrial fibrillation, pacemaker, anxiety and heart failure. Review of the physician orders dated [DATE] revealed the resident was a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) (permits the use of life saving measures before a person's heart or breathing stops. However, only comfort care may be provided after a person's heart or breathing stops). Review of the Multidisciplinary Care Conference Form dated [DATE] revealed the resident wished to be a full code and the resident/family expectations would be a full code status. Review of the my advance directive is DNR-CCA care plan dated [DATE] revealed intervention including advanced…

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 preadmission screening and resident reviews were completed with a significant change in resident status. This affected one resident (Resident #35) of two residents reviewed for preadmission screening and resident review. The census was 45. Findings include: Review of Resident #35's medical record revealed an admission date of 08/15/03 with diagnoses including multiple sclerosis, major depression, dementia without behavioral disturbance, personality disorder and other specified mental disorders due to known physiological conditions. The last pre-admission screening review dated 08/27/03 revealed the resident had no indications of serious mental illness nor developmental disabilities. Further review of the medical record revealed the diagnosis of schizoaffective disorder depressive type dated 05/16/16 was added. Review of the physician orders revealed the resident received zyprexa (antipsychotic medication) by mouth every evening 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 record review, review of the hospice agreement, review of hospice records, and staff interview, the facility failed to maintain an integrated medical record that included hospice nurse visit notes for the purposes of ensuring continuity of care between entities. This affected one (Resident #50) of one resident reviewed for hospice services. Findings include: A review of Resident #50's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (CHF) and emphysema. A review of Resident #50's physician's orders revealed he was admitted to hospice/ palliative care for the terminal diagnosis of CHF. The order was given on 06/03/22. A review of Resident #50's hospice plan of care revealed the resident was to receive one visit from the hospice nurse bi-weekly (every two weeks). A review of Resident #50's care plans revealed he had a care plan in place for receiving hospice services. The care plan was initiated on 05/27/22. The interventions included 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 closed record review, interview, and policy review the facility failed to ensure pressure ulcer care and interventions were implemented. This affected one resident (Resident #26) of three residents reviewed for pressure ulcers. The census was 45. Findings include: Review of Resident #26's closed medical record revealed an admission date of [DATE] with diagnoses including dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the at risk for impaired skin integrity related to decreased mobility, periods of bladder incontinence, oxygen per nasal cannula, fragile skin, history of pressure ulcers and resident noted to prefer to sit in a chair as opposed to laying in a bed initiated [DATE] with interventions including alternating air mattress to bed, barrier cream/ointment after each incontinence episode as needed; encourage fluids; encourage resident to elevate bilateral lower extremities while at rest; encourage resident to turn and reposition every two hours;…

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 a comprehensive fall investigation was completed and interventions were implemented to prevent falls. This affected one resident (Resident #39) of three residents reviewed for accidents. The census was 45. Findings include: Review of Resident #39's medical record revealed an admission date of 02/06/19 with diagnoses including legal blindness and schizoaffective disorder. Review of the physician orders revealed no physician ordered fall prevention interventions. Review of the Fall Risk Evaluation- V2 completed 02/24/22 identified the resident as a fall risk. Review of the Fall Investigation dated 03/07/22 revealed the resident yelled and was observed lying at the foot of her bed with the bedside table extended to it's highest level. The resident had a history of non-compliance with medical recommendations/safety recommendations. The fall followed a pattern similar to the resident's previous falls but no root cause was identified and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review the facility failed to follow infection control guidelines related to incontinence care for a resident at risk for urinary tract infections. This affected one resident (Resident #35) of one resident observed for incontinence care. The census was 45. Findings include: Review of Resident #35's medical record revealed an admission date of 08/15/03 with diagnoses including multiple sclerosis, major depression, dementia without behavioral disturbance and constipation. Review of the alteration in elimination related to no control present with bowel and bladder initiated 03/24/14 with interventions including provide incontinence care as needed; check and change routinely and as needed; monitor for signs and symptoms of urinary tract infection. Review of the risk for infection related to incontinence of bowel and bladder with no sensation of need related to multiple sclerosis causing an increased risk of urinary tract infections initiated 03/24/14 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview the facility failed to ensure comprehensive meal intake documentation was available to adequately monitor resident nutritional status. This affected one resident (Resident #26) of three residents reviewed for nutrition. The census was 45. Findings include: Review of Resident #26's closed medical record revealed an admission date of 12/27/18 with diagnoses including dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD), and sleep apnea. In 2019, macular degeneration and changes in retinal vascular appearance bilaterally was added to her diagnoses list. Review of the potential for alteration in nutrition and hydration related to medical diagnoses, COPD needs higher, nutritional risk, therapeutic diets, history of protein storage depletion, history of significant weight changes implemented 12/27/18 with interventions including obtain food preferences, provide diet as ordered, dietician referral as needed, supplements and weights as ordered.…

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 and facility policy review the facility failed to ensure a resident's oxygen flow rate was set as ordered and failed to provide education to a resident on the risks of increasing the flow rate with a diagnosis of chronic obstructive pulmonary disorder. This affected one resident (Resident #40) reviewed for respiratory care. The facility census was 45. Findings include: Review of the medical record for Resident #40 revealed an admission date of 01/10/22 with diagnoses including acute and chronic respiratory failure with hypoxia, congestive heart failure, malignant neoplasm of left lung, chronic obstructive pulmonary disorder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #40 was cognitively intact, had no impairment to range of motion to bilateral upper extremities and received oxygen therapy. Review of the current physician orders for 07/2022 revealed Resident #40 was to receive oxygen at two-three…

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 policy review, the facility failed to ensure pharmacy recommendations pertaining to gradual dose reduction (GDR) attempts for psychoactive medications were responded to by the physician and/ or psychiatrist to include a resident specific rationale as to why a GDR attempt was contraindicated. This affected two (Resident #7 and #40) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder (MDD) and anxiety disorder. A review of Resident #7's physician's orders revealed the use of Duloxetine HCL (Cymbalta) 60 milligrams (mg) by mouth twice a day for MDD. The order had been in place since 11/17/21. A review of a pharmacy recommendation dated 05/12/22 revealed the facility's contracted pharmacist recommended Resident #7's physician consider a GDR for the use of Cymbalta as the resident had been on Cymbalta 60 mg…

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

Based on record review, interview and policy review the facility failed to ensure gradual dose reductions were attempted for residents receiving antipsychotic medications. This affected one resident (Resident #22) of five residents reviewed for unnecessary medications. The census was 45. Findings include: Review of Resident #22's medical record revealed an admission date of 11/30/17 with diagnoses including diabetes, depression, schizophrenia and atrial fibrillation, Review of the physician orders revealed zyprexa (antipsychotic medication) 20 milligrams (mg) one tablet by mouth daily written on 01/16/20. The medication was scheduled for administration at bedtime. Review of the pharmacy recommendation dated 04/19/22 revealed the resident has been taking the antipsychotic medication, Zyprexa 20 mg every night at bedtime since January 2020. Please evaluate the current dose and consider a dose reduction. The physician response dated 05/17/22 revealed no change- see psych note and medical record review- 04/20/22. Review of the psychiatry note dated 04/20/22 revealed no evidence a GDR…

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, product instructions for use, staff interview and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had three errors out of 29 opportunities for error for a medication error rate of 10.3%. This affected two (Resident #6 and #44) of three residents observed for medication administration. Findings include: 1. A review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD) and hypertension (HTN). A review of Resident #44's physician's orders revealed the resident had an order to receive Metoprolol Tartrate (a beta blocker used in the treatment of hypertension) 25 milligrams (mg) by mouth (po) twice a day for HTN. The orders included parameters to hold the medication if the resident's systolic blood pressure (SBP) was less than 90 millimeters of mercury (mm/hg) or her pulse was less than 50 beats per minute (BPM). The 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 ensure follow-up occurred related to consultation recommendations and dental extraction aftercare. This affected two residents (Resident #26 and #46) of four residents reviewed for dental services. The census was 45. Findings include: 1. Review of Resident #26's closed medical record revealed an admission date of 12/27/18 with diagnoses including dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the resident is at risk for oral/dental health problems related to having top and bottom partials; staff assistance provided daily with oral hygiene and denture care implemented on 09/21/21 with interventions including encourage application of dental adhesive to assist with eating Review of the Clinical Notes Report dated 12/29/21 revealed the resident needed all of her remaining teeth extracted and referred for dentures. Tooth #10, #11, #24, #25, #26 and #27. No aftercare instructions were noted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure residents received the Influenza and Pneumococcal vaccines when consenting to receive them. This affected two (Resident #7 and #10) of five residents reviewed for immunizations. Findings include: 1. A review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity, adult onset diabetes mellitus, and stage 3 chronic kidney disease. A review of Resident #7's Influenza vaccine consent form revealed the resident consented to receive the Influenza vaccine. The form was dated and signed by the resident on 10/25/21. A review of Resident #7's Immunization Report revealed the resident last received the Influenza vaccine on 10/01/20. There was no documented evidence of the resident receiving the Influenza vaccine after he had consented to receive it on 10/25/21. On 07/12/22 at 10:30 A.M., an interview with the Director of Nursing revealed they did not have any documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure reasons for obtaining a COVID-19 test, date the COVID-19 test was performed, and the results of the COVID-19 test were documented in the resident's medical record as required. This affected one (Resident #31) of one residents reviewed for transmission based precautions related to COVID-19. Findings include: A review of Resident #31's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependence on renal dialysis, hypertension, and morbid obesity. His diagnoses list was updated to reflect he was COVID-19 positive on 06/27/22. A review of Resident #31's physician's orders revealed an order for the resident to be placed in droplet isolation for 10 days due to being COVID-19. The order was given on 06/27/22. A review of Resident #31's nurses' progress notes revealed there was no documentation to show why the resident was tested for COVID-19. The progress notes also…

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.