Vista Center Of Boardman

Based on record reviews and interviews, the facility failed to ensure there was a Registered Nurse (RN) present in the facility eight consecutive hours seven days a week. This had potential to affect all residents. The facility census was 47.Findings include:Record review was conducted of the nursing services staffing schedule and completion of the staffing tool for the date range of 06/22/25 to 06/27/25 with Human Resources Manager (HRM) #807. The facility met or exceeded the minimum staffing requirement of 2.5 hours of direct care per resident per day, however, on 06/25/25 an RN was not on staff for eight consecutive hours that day. Interview on 07/02/24 at 3:30 P.M. with HRM #807 revealed the facility was staffed based on acuity and census numbers. There should be one nurse on each unit and one aide. The DON was full-time, and they were required to have an RN eight hours a day seven days a week. HRM #807 confirmed on 06/25/25 they did not have required RN coverage for this day.This deficiency represents non-compliance identified during investigation of Complaint Number OH00167011.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were reported to the state agency as required. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 10/09/24. Diagnoses included acute kidney failure, cognitive communication deficit, type two diabetes, adult failure to thrive, and depression.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/25 revealed the resident had impaired cognition. The resident required setup or clean up assistance for eating, supervision for oral hygiene, dressing, and bed mobility, and were dependent on staff for showers, toileting hygiene, and personal hygiene.Review of the nurse progress notes dated from 06/05/25 to 07/02/25 revealed on 06/05/25 the resident was ordered Silvadene cream (a cream used to treat burns) one percent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were thoroughly investigated. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 10/09/24. Diagnoses included acute kidney failure, cognitive communication deficit, type two diabetes, adult failure to thrive, and depression.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/25 revealed the resident had impaired cognition. The resident required setup or clean up assistance for eating, supervision for oral hygiene, dressing, and bed mobility, and were dependent on staff for showers, toileting hygiene, and personal hygiene.Review of the nurse progress notes dated from 06/05/25 to 07/02/25 revealed on 06/05/25 the resident was ordered Silvadene cream (a cream used to treat burns) one percent twice a day times 10…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests on the secured unit A. This affected 19 Residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) out of 47 residents observed for physical environment. The facility census was 47. Findings include:Observations made on 07/01/25 at 9:30 A.M. and 07/02/25 at approximately 11:45 A.M. of rooms occupied by Residents' #12, #13, #16, #17 and #18 revealed there were bed bugs present in each room on the secured A unit.An interview on 07/01/25 at 3:33 P.M. with Licensed Practical Nurse (LPN) #811 revealed there were bed bugs found on the secured unit A approximately one week ago and the facility did not treat them until today. The staff caught a few and put them into a container and gave them to the maintenance director and the Director of Nursing (DON).An interview on 07/01/25 at 3:38 P.M. with LPN #830 revealed they caught three bed bugs the morning of 07/01/25 in the room of Resident #12 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 facility policy review, the facility failed to ensure Resident #8 received timely incontinence care and failed to ensure Residents #8, #22, #46 and #47 received staff assistance for showering. This affected four residents (#8, #22, #46, and #47) of five residents reviewed for assistance with Activities of Daily Living (ADL) needs. The facility census was 43. Findings include: 1. Review of Resident #8's medical record revealed an admission date of [DATE]. Diagnoses included epilepsy, muscle weakness, abnormal posture, hemiplegia, hemiparesis right dominant side, aphasia, gastrostomy status, and pseudobulbar affect. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #8 was dependent on staff for all Activities of Daily Living (ADLs) including eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, incontinence care and bed mobility. Review of Resident #8'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 interview, observation, record review and facility policy review, the facility failed to ensure effective infection control techniques were practiced during incontinence care. This affected one resident (Resident #8) out of five residents reviewed for infection control. The facility census was 43. Findings include: Review of Resident #8's medical record revealed an admission date of 04/19/17. Diagnoses included epilepsy, muscle weakness, abnormal posture, hemiplegia, hemiparesis right dominant side, aphasia, gastrostomy status, and pseudobulbar affect. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #8 was dependent on staff for all Activities of Daily Living (ADLs) including eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, incontinence care and bed mobility. Review of Resident #8's care plan dated 03/04/25 revealed the resident was incontinent of bowel and bladder. Goals and interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility documents and policy, the facility failed to provide therapeutic activities as scheduled and on weekends and evenings to meet the needs and preferences of the resident population. This had the potential to affect all 50 residents in the facility. The facility census was 50. Findings include: Review of the facility activity calendars dated October and September 2024 for the Secured Unit A revealed no activities were scheduled after 3:00 P.M. for the month of October. Review of the September 2024 Activity Calendar for Secure Unit A revealed no activities were scheduled past 4:00 P.M. Review of the October 2024 Unit B/C activity calendar revealed no activities were scheduled after 3:00 P.M. each day except for each Wednesday an activity was scheduled for 5:00 P.M. Review of the activity department staffing schedules for September 2024 and October 2024 which listed former Activities Director (AD) #801, former Activities Aid (AA) #800 and AA #536 as the staff 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, interview and review of facility policy, the facility did not ensure a qualified activity director was overseeing the activity department to ensure therapeutic activities were being provided to the residents. This affected all 50 residents living in the facility. The facility census was 50. Findings include: Review of the facility job description for the Activity Director (AD) revealed they must be a qualified therapeutic recreation specialist or an activities professional who was licensed by the state and was eligible for certification as recreation specialist or as an activity professional. Review of the personnel file for the former AD #801 revealed a date of hire of 05/16/23 as the Activities Director and last day worked was 09/16/24. No certification from the Activity Directors Network was available in the file. Interview on 10/16/24 at 2:31 P.M. with the Director of Nursing (DON) revealed there was no Activity Director for the past month. The facility was utilizing the [NAME]…

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 record review the facility did not ensure each state tested nurse aide (STNA) received no less than twelve hours of annual in-service education. This had potential to affect all residents in the facility. The facility census was 50. Findings included: Review of personnel file for STNA #551 revealed her hire date was 02/02/22 and her training record in her file labeled, Course Status Report with Totals printed on 10/16/24 revealed STNA #551 had completed one training on 06/04/24 that was on corporate compliance. The training did not include how long the training was as at the bottom of the report it revealed STNA #551 had zero hours of training out of 20.83 assigned. The training record revealed she was assigned a variety of trainings including abuse, dementia care, infection control, fall management, fire safety, resident rights, and elopement prevention but these training were marked on the sheet as not attempted. Interview on 10/17/24 at 12:37 P.M. with Human Resource Manager #525 verified STNA #551 had not completed the required annual training and the…

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

Based on record review and interview the facility did not ensure the dietary manager was qualified to oversee dietary service operations. This had the potential to affect all 50 residents receiving meals from the kitchen, as the facility did not identify any residents who did not eat by mouth (NPO). The facility census was 50. Findings include: Review of Dietary Manager ( DM) #511's employee file revealed no formal certified dietary manager training nor certificate of completion for the SERV Safe course. Interview on 10/16/24 at 11:32 A.M. with DM #511 revealed there was not a full-time dietitian in the facility. A company called Dietary Solution provided the menu but no kitchen oversight. DM #511 stated she had not passed the SERV Safe exam and was not certified as a dietary manager. DM #511 stated she was a cook for the facility starting January 2024 then was promoted in May 2024 to the DM position and had no additional formal training to qualify as the DM. Interview on 10/21/24 at 8:42 A.M. with Dietary Solution [NAME] President of Operations #571 confirmed a registered dietitian…

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

Based on observation, interview and policy review, the facility failed to ensure palatable food was served to the residents. This had the potential to effect 50 residents who received a meals from the facility kitchen. The facility identified there were no residents who did not eat by mouth (NPO). The facility census was 50. Findings include: Interview on 10/15/24 at 9:12 A.M. with Resident #15 revealed if his tray was served last from the cart, his food was often cold which happened quite a bit. He revealed the food was just not very nourishing and he questioned, have you ever had to eat cold food? Resident #15 stated because the hot food was often served cold to him the food was not good. Interview on 10/15/24 at 11:43 A.M. Resident #196 stated the food did not taste good and the food was cold. Resident #196 had his family bring in outside food because he did not like the quality of the facility food. An observation was conducted on 10/16/24 from 11:43 A.M. to 12:51 P.M. with Dietary Manager ( DM) #511 of the lunch tray line and a test tray. The lunch menu consisted of sauce with…

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

Based on observation, interview and policy review, the facility did not ensure food was stored in a manner to prevent contamination and/or food borne illness. The facility also did not ensure the kitchen was maintained in a sanitary manner. This had the potential to affect 50 residents. There were no residents identified by the facility as eating nothing by mouth (NPO). The facility census was 50. Findings include: On 10/15/24 at 8:32 A.M. an initial tour of the kitchen revealed dried noodles and chicken sitting the empty wash bay of the three bay sink. Dietary manager (DM) #511 verified the dried noodles and chicken in this sink at the time of the observation. DM #511 stated the sink was to be cleaned every night and as needed. The initial tour also revealed noodles and white beans in the drain of the dishwasher. DM #511 verified the noodles and white beans in the dishwasher drain. Observation of the dry storage area revealed a dented 113 ounce can of Fancy Midwest Chili Sauce and a dented six-pound 11 ounce can of Manwich. There was a 10-pound bag of pancake mix opened 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 record review, review of the administrator job description and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident which included failure to ensure the Quality Assurance Performance Improvement (QAPI) committee meetings were held to include the medical director or designee and evidence of meetings as required were maintained, failure to ensure a qualified director of activities was employed in the facility and failure to ensure a therapeutic activities program was being developed and implemented for the residents. This had the potential to affect all 50 residents residing in the facility. Findings include: Review of the job description for the facility Administrator, signed on 04/01/24 by the Administrator, revealed the primary purpose of the Administrator was to direct the day-to-day functions of the facility in accordance…

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

Based on record review and interview the facility failed to ensure quarterly Quality Assurance Performance Improvement (QAPI)meetings were conducted and failed to have the designated medical director participate in the QAPI meetings. This had the potential to affect all residents. The facility census was 50. Findings include: Review of the attendance signature sheets for the QAPI members revealed Medical Director #702 was not listed as present during the meetings on 04/30/24, 05/21/24, 06/03/24, 07/17/24, 08/21/24, and 09/20/24. There was also no evidence QAPI meetings were held prior to April 2024. Interview on 10/21/24 at 1:57 P.M. with the Administrator confirmed there was no evidence of the medical director's or designee's attendance at the QAPI meetings as required, and the Administrator stated she could not provide any evidence of QAPI meetings prior to April 2024 when she took over as Administrator at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, staff interview, and policy review , the facility failed to ensure enhanced barriers precautions (EBP) were followed for one resident (Resident #194) of nine residents who were identified by the facility as being on EBP (Residents #6, #12, #21, #26, #34, #35, #193, #194, and #196). The facility also failed to ensure annual tuberculosis (TB) signs and symptoms for employes were completed per the TB risk assessment and policy. This had the potential to affect all 50 residents in the facility. The facility census was 50. Findings include: 1. A review of medical records for Resident #194 revealed an admission date of 10/08/24 with diagnoses included cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, need for assistance with personal care, and ulcerative colitis. Review of physician orders for October 2024 included check placement of gastric…

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

Based on observation, interview and review of facility policy the facility did not ensure a safe, functional and comfortable environment for all residents. This had the potential to affect all 50 residents residing in the facility. Findings include: Observation on 10/21/24 from 11:15 A.M. to 11:27 A.M. with Maintenance Director( MD) #526 revealed the following which were verified by MD #526 at the time of the observation: • Resident #148's side rail was breaking off the bed and able to be pulled off the side of the bed. • A corroded hole in the ceiling leading into the 100 hall was found to be open. MD #526 indicated that the hole was caused by water leaking from the roof and reported that he did not have the necessary materials to repair it. The hole was large enough to allow potential pests such as insects or rodents to enter the hallway in resident occupied areas. • The 100 hall contained a hole measuring 4.5 inches across and 2.5 inches wide with sharp edges exposed. The hole was at the level where a resident passing by could make bodily contact with the sharp edges. MD #526…

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 the resident funds accounts, review of the surety bond, interview, and review of the facility policy, the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This had the potential to affect 20 residents identified as having resident fund accounts (Residents #3, # 4, #5, #7, #9, #10, #11, #12, #13, #20, #21, #23, #25, #26, #27, #31, #32, #33, #38, and #39). The facility census was 50. Findings include: A review of resident fund account for the facility dated 10/17/24 revealed a total amount of 98,931.82 dollars. A review of resident fund accounts revealed Resident #26 made a deposit of 101,801.07 dollars on 06/04/24. Resident #26 had a total of 91,442.68 dollars in the resident fund account on 10/17/24. A review of an email dated 09/26/24 from Business Office Manager (BOM) #533 revealed the active surety bond did not cover the amount in resident fund accounts. A review of the document by Merchants Bonding Company, bond number OH5329260, revealed an effective date of 08/01/24. 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, interview, and review of the facility policy, the facility failed to ensure Resident #31's advance directives in the medical record and physician orders matched. The facility also failed to ensure the nurse had knowledge of which code status to follow. This affected one resident (#31) out of four residents reviewed for advance directives and had the potential to affect all 50 residents residing in the facility. Findings include: Review of the medical record for Resident #31 revealed an admission date of [DATE] with diagnoses including obstructive pulmonary disease with exacerbation, acute respiratory failure with hypoxia, seizure disorder, dementia, and schizophrenia. Review of the undated Do Not Resuscitate (DNR) Comfort Care form completed by Nurse Practitioner #701 revealed Resident #31 code status was DNR Comfort Care. This form was in the miscellaneous section of Resident #31's electronic medical record. Review of the nursing note dated [DATE] at 10:30 A.M. authored by Former…

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, review of the Ohio Department of Health Gateway, and review of the facility abuse policy, the facility failed to report an allegation of resident-to-resident abuse within 24 hours to the state agency after Resident #38 threw a cup of hot coffee on Resident #144 . This affected one Resident (#144) out of one resident reviewed for abuse and had the potential to affect all 50 residents residing in the facility. Findings included: 1. Review of the medical record for Resident #38 revealed an admission date of 07/08/24 and his diagnoses included psychosis, dementia, and malignant neoplasm of colon. Review of the care plan dated 07/26/24 revealed Resident #38 had a behavior problem related to verbal outbursts, exit seeking, and history of physical aggression. Resident #38's wife had an order of protection in place through the sheriff's office due to physical aggression. Interventions included administering medication per order, intervening and redirecting the resident as needed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure accurate care plans were in place for Residents #19 and #148. This affected two residents (#19 and #148) of four residents who were reviewed for care plans. This had the potential to affect all 50 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/10/23 with diagnoses including dementia with behavioral disturbances, adult failure to thrive, and other signs and symptoms involving cognitive function. Significant orders included Depakote sprinkles oral capsule delayed releases (used to treat manic or mixed episodes associated with bipolar disorder) 125 milligrams (mg), 125 mg two times daily for behaviors and 250mg daily at bedtime for behaviors. There was also an order stating Do Not Resuscitate Comfort Care Arrest (DNRCCA) meaning life saving measures until the heart stops beating. Review of the care plan dated 09/01/24 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 review of the facility policy, the facility failed to ensure timely and accurate care plans for Residents #34 and #35. This affected two residents (#34 and #35) of four residents who were reviewed for care plans. This had the potential to affect all 50 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 05/08/24 with diagnoses including atrial fibrillation, multiple sclerosis (MS), diabetes mellitus type two, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of the care conferences revealed Resident #34 had an admission care conference on 05/13/24. The next documented care conference was dated 06/03/24. At that meeting, Resident #34 had a change in discharge plans from short-term care to long-term care placement. Review of the care plan dated 08/11/24 revealed Resident #34 was to be discharged home. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to provide oral care for Resident #194, who had hemiplegia and hemiparesis affecting the right dominant side and required supervision or touching assistance for oral hygiene. This affected one resident (#194) of one resident reviewed for activities of daily living (ADL) care and had the potential to affect all residents except seven residents (#4, #10, #12, #23, #32, #33, and #36) identified by the facility as independent with oral care. The facility census was 50. Findings include: Review of the medical record for Resident #194 revealed an admission date of 10/08/24 with diagnoses including cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, need for assistance with personal care, and ulcerative colitis. Resident #194 had a physician's order to provide oral care every shift. Review of the care plan dated 10/08/24 revealed Resident #194 required assistance with ADL care related 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 3. A review of medical records for Resident #195 revealed an admission date of 10/01/24. Significant diagnoses included mixed simple and mucopurulent chronic bronchitis and heart failure. Significant orders included bumex (a water pill for fluid retention) 0.5 milligrams, give one tablet by mouth in the morning for fluid retention for seven days dated 10/07/24 and weekly weights times four weeks then monthly. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #195 was cognitively intact. A review of weights revealed on 10/02/24 Resident #195 weighed 174.5 pounds. On 10/03/24 Resident #195 weighed 201.6 pounds. There was no reweigh noted. On 10/08/24 Resident #195 weighed 187.0 pounds. There was no reweigh noted. On 10/15/24 Resident #195 weighed 185 pounds. Review of the dietary assessment note dated10/07/24 revealed on 10/03/24 Resident #195 weighed 201.6 by standing scale. The assessment also revealed this was a gain of five percent or more in the last month without being on a weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #15 received culturally competent trauma-informed care including the identification of triggers, and interventions to assist with the management to eliminate or mitigate re-traumatization of the resident. This affected one resident (#15) out of two residents reviewed for Post Traumatic Stress Disorder (PTSD). The facility census was 50. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/30/24 with diagnoses including PTSD, bipolar disorder, major depression with severe psychotic symptoms, and hypertension. Review of admission Packet- V12 dated 07/30/24 revealed under trauma, Resident #15 was asked if he experienced trauma in his life, and he answered yes. The assessment asked if he had any triggers that reminded him of the trauma, and he answered yes. In the additional comments section, it had listed PTSD/ Vietnam war. Review of the undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of medical records for Resident #19 revealed an admission date of 04/10/23 with diagnoses including dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbances, adult failure to thrive and other signs and symptoms involving cognitive function. Physician orders included Depakote sprinkles oral capsule delayed releases 125 milligrams (mg), give 125 mg two times daily for behaviors and 250 mg daily at bedtime for behaviors. There were no orders for depakote levels to be drawn. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had a moderate cognitive deficit. The MDS also revealed verbal behaviors occurring one to three days in the seven day look back period. Review of the care plan dated 09/01/24 revealed Resident #19 had a behavior problem related to profanity, refusals of care and yelling out. Interventions included administer medication as ordered and monitor for effectiveness of medication and potential side…

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, review of a Self-Reported incident and investigation, review of a soft file, review of resident council minutes, and interview, the facility failed to ensure sufficient staff to provide supervision and timely care. This had the potential to affect all 41 residents. Findings include: 1. Review of resident council meeting minutes on 01/22/24 revealed seven residents (Residents #25, #29, #35, #36, #37, #38, and #39) attended. A concern was addressed regarding a resident or residents believed there should be an extra nursing assistant/floater on the floor for help. The facility's response by the Director of Nursing and the Administrator dated 02/20/24 indicated staffing was reviewed daily. The facility assessment was also reviewed and the facility continued to staff appropriately throughout the building. During an interview on 03/25/24 at 4:17 P.M., the Administrator indicated although the staffing numbers were reviewed, residents were not interviewed further to determine why they believed more staff was needed. The DON was present and provided no other…

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 resident council meeting minutes and interview, the facility failed to ensure resident concerns were addressed. This affected Residents #25, #29, #35, #36, #37, #38, #39, #46 and #47, residents of the B and C hall. The facility identified 25 residents who resided on the B and C halls. The facility census was 41. Findings include: 1. Review of Resident Council Minutes dated 12/20/23 revealed six residents (Residents #29, #36, #38, #39, #46 and #47) attended the meeting. The minutes indicated residents (did not indicate if all residents) reported floors in rooms needed more focus. A resident council concern form indicated the response to the concern was that there was a new maintenance director who was supposed to be starting in December 2023. The form was signed as the issue being resolved and was dated on 12/20/23 as being reviewed by Admissions Director #109 and Maintenance Director #138. No other resolution or remedy was noted. During an interview on 03/25/24 at 4:17 P.M., the Administrator stated, pending the new maintenance director being hired, there was 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 observations and interview, the facility failed to maintain a clean and sanitary environment. This affected Residents #5, #8, #9, #10, #11, #12, #13, #14 and #15 whose rooms were randomly viewed for cleanliness. The census was 41. Findings include: During random observations of residents' rooms and bathrooms on the secure unit, Maintenance Director/Housekeeping Supervisor #138 verified the following: 1. The bathroom between Resident #11 and #12 and the adjoining unoccupied room had a dirty floor. Multiple tile had yellow and brown stains. 2. Resident #14 and #15's room had stained floor tile around the edge of the room and closet. The bathroom they shared with Resident #13 had stained floor tiles especially around the toilet and edges of the room. 3. Resident #9's bathroom shared with an unoccupied room had tiles that were stained. Maintenance Director #138 stated the tile would likely need replaced. 4. Resident #10's floor was dirty under the bed. Tiles were stained with the heavier stains around/under the heater. The bathroom tile between Resident #10 and Resident #8'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 record review and interview, the facility failed to ensure allegations of sexual abuse were reported to the State Survey agency. This affected two (Residents #15 and #43) of seven residents reviewed for abuse. The facility census was 41. Findings include: Review of Resident #15's medical record revealed diagnoses including severe major depressive disorder with psychotic symptoms, cognitive communication deficit and generalized muscle weakness. A history and physical dated 08/22/23 indicated Resident #15 was a poor historian. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired (with a Brief Interview of Mental Status score of 10 out of possible 15). Nurse Practitioner (NP) #154 documented on 03/05/24 she was notified by nursing that Resident #15 inappropriately touched a female resident. An ongoing investigation was occurring. During an interview on 03/19/24 at 8:13 A.M., the Administrator identified the female resident referred to 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 medical record review and interview, the facility failed to revise a care plan to include and address sexually inappropriate behaviors. This affected one (Resident #15) of seven residents reviewed for abuse. The facility census was 41. Findings include: Review of Resident #15's medical record revealed diagnoses including severe major depressive disorder with psychotic symptoms, cognitive communication deficit and generalized muscle weakness. A history and physical dated 08/22/23 indicated Resident #15 was a poor historian. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired. Nurse Practitioner (NP) #154 documented on 03/05/24 she was notified by nursing that Resident #15 inappropriately touched a female resident. An ongoing investigation was occurring. There was no indication Resident #15's plan of care was updated regarding inappropriate sexual behaviors or interventions to prevent such behavior in the future. During an interview on…

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

Based on medical record review and interview, the facility failed to address recommendations for deep vein thrombosis (DVT) prophylaxis with the attending physician or Nurse Practitioner (NP) for one (Resident #21) of three residents reviewed for implementation of consultant recommendations/orders. The facility census was 41. Findings include: Review of Resident #21's medical record revealed diagnoses including fracture of the right lower leg, diabetes mellitus, generalized muscle weakness, difficulty walking, chronic pain, and osteoarthritis. Review of documentation from an orthopedic appointment dated 03/13/24 indicated Resident #21 had non-weight bearing on the right lower extremity. Instructions included due to non-weight bearing status on the right lower extremity, a recommendation was made for 325 milligrams of aspirin to be administered twice a day. Review of progress notes and orders revealed no evidence the recommendation was discussed with the attending physician or provided to the physician/nurse practitioner. Further review of the medical record revealed the resident did…

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, policy review, and interview, the facility failed to ensure oxygen was provided in accordance with physician orders. This affected one (Resident #39) of three residents reviewed for oxygen use. The facility census was 41. Findings include: Review of Resident #39's medical record revealed diagnoses including heart failure, generalized anxiety disorder, and cognitive communication deficit. Review of physician orders revealed on 11/27/23 an order was written to initiate oxygen at two liters per minute via nasal cannula to maintain an oxygen saturation of 92% every shift and wean as tolerated. On 03/18/24 at 12:04 P.M., Resident #39 was observed sitting in the wheelchair in her room with oxygen running via concentrator set at four liters per minute (LPM). On 03/18/24 at 12:18 P.M., Licensed Practical Nurse (LPN) #115 verified Resident #39's oxygen concentrator was set at 4 LPM. LPN #115 stated Resident #39's oxygen saturations had been dropping two to four weeks prior to the survey and the oxygen was increased. LPN #115 stated oxygen…

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 a soft file, and interview the facility failed to maintain complete and accurate medical records. This affected three (Residents #21, #42, and #43) of 15 residents reviewed. The census was 41. Findings include: 1. Review of Resident #15's medical record revealed diagnoses including severe major depressive disorder with psychotic symptoms, cognitive communication deficit and generalized muscle weakness. A history and physical dated 08/22/23 indicated Resident #15 was a poor historian. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired. Nurse Practitioner (NP) #154 documented on 03/05/24 she was notified by nursing that Resident #15 inappropriately touched a female resident. An ongoing investigation was occurring. During an interview on 03/19/24 at 8:13 A.M., the Administrator identified the female resident referred to in the progress note for Resident #15 on 03/05/24 as Resident #43. When asked if 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 and interview, the facility failed to ensure clean and sanitary condition of the ice machine located downstairs by the elevator which provided ice for resident consumption. This had the potential to affect all residents in the facility excluding Resident #12, #22 and #39 who the facility identified as receiving nothing by mouth. The facility census was 50. Findings include: Observation made on 09/11/23 at 12:42 P.M. with Laundry Aide (LA) #802 of the ice machine located downstairs by the elevator revealed on the ice guard inside of the ice machine there was a moderate and thick build-up of pink biofilm containing specks of a black, mold-like substance . Laundry Aide (LA) #802 confirmed the finding during the observation. Interview on 09/11/23 at 1:00 P.M. with the Maintenance Director (MD) #804 revealed the ice machine was cleaned every three months and was scheduled to be cleaned at the end of September. MD #804 confirmed there was a visible black mold-like substance and a thick, pink biofilm present inside the ice machine and this ice machine provided ice to…

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

Based on observation and interview, the facility failed to maintain effective pest control on the C-unit for Resident #5, #13, #15, #25, #29, #31, #44, #46 and #49 and failed to maintain effective pest control on the secured unit in common areas which had the potential to affect all 15 residents (#2, #6, #10, #11, #18, #19, #20, #25, #26, #33, #36, #40, #45, #48 and #51) residing on the secured unit. This affected 24 residents of 50 residents living in the facility. The facility census was 50. Findings include: Observations made throughout the survey on 09/11/23 through 09/13/23 of the general facility environment including resident rooms and common areas on all units revealed multiple fruit flies present in resident rooms on the C-unit for Resident #5, #13, #15, #25, #29, #31, #44, #46 and #49. The secured unit common area also had evidence of multiple, live fruit flies buzzing around in the common area. Interview conducted on 09/11/23 at 1:00 P.M. wth the Maintenance Director (MD) #804 and Licensed Practical Nurse (LPN) #805 revealed fruit flies have been an issue in the facility,…

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

Based on observation, staff interview, and facility policy review the facility failed to ensure food was labeled and dated appropriately. This had the potential to affect 46 residents who received meals from the kitchen. The facility identified two (Residents #13 and #250) who received nothing by mouth. The facility census was 48. Findings include: Observation on 09/12/22 at 8:19 A.M. of the kitchen revealed a freezer which contained a bag of frozen rolls, identified by the Dietary Manager (DM) #517 as cinnamon rolls opened and undated, one pie opened and undated, a bag identified by DM #517 as biscuits opened and undated, a half full box of chocolate magic cups opened and undated, three bags of pureed cinnamon French toast opened and undated, two bags of pureed waffles opened and undated, one piece of fish, as identified as by the DM #517 in a Ziploc bag, opened and undated, a half bag of chopped spinach opened and undated, a bag identified as sweet potato fries by the DM #517 dated 05/28/22, a bag of cheddar cheese sauce expired 04/22, four bags of French toast opened and undated.…

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 staff interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was given to two Residents (#255 and #256) upon discontinuation of skilled services and failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form and was given to three Residents (#12, #255 and #256) upon the discontinuation of skilled services. This affected three (Resident's #12, #255 and #256) of three residents reviewed for proper notices of non-coverage. The facility census was 48. Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/02/22. Resident #12 was given a NOMNC on 04/22/22 which stated skilled services would be discontinued on 04/27/22. Review of census records revealed Resident #12 remained in the facility. Further review of the medical record revealed Resident #12 did not receive a SNF ABN as required. Review of the medical record for Resident #255 revealed an admission date of 06/02/22. Resident #255 did not receive a NOMNC or SNF ABN as required. Resident #255 was discharged…

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 the Ombudsman was notified Resident #38 was transferred to the hospital. This affected one (Resident #38) of three residents reviewed for hospitalizations. The facility census was 48. Findings include: Review of the medical record for Resident #38 revealed an admission date of 06/22/22. Diagnoses included cerebral infarction, hyperkalemia, chronic kidney disease, encephalopathy, seizures, and anemia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had impaired cognition. He required extensive assistance in most areas of activities of daily living (ADL). Review of a progress noted dated 06/21/22 revealed Resident #38 was transferred to the hospital on [DATE] and admitted with a diagnosis of pancreatitis. Review of a progress note dated 07/18/22 revealed Resident #38 was lethargic and had a high potassium level. The physician was contacted and ordered the resident be sent to the Emergency Department (ED) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to provide medication administration according to facility policy for Resident #40. This affected one (Resident #40) of four residents observed for medication administration. The facility census was 48. Findings include: Review of the medical record for Resident #40 revealed an admission date of 08/17/22. Diagnoses included encounter for other orthopedic aftercare, asthma, and type two diabetes mellitus. Review of the physician's order dated 08/18/22 for Resident #40 revealed azelastine HCL 137 micrograms (mcg)/spray (steroid nasal spray) one spray in both nostrils two times a day for allergies. Review of the physician's order dated 08/22/22 for Resident #40 revealed proair HFA aerosol solution 108 mcg/act (emergency inhaler) two puffs inhale four times a day for shortness of breath and wheezing. The order also for the same date revealed fluticasone propionate suspension 50 mcg/act (inhaler) two sprays in each nostril…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure Resident #16 received interventions after three days of no bowel movement per the bowel protocol and failed to ensure neurological (neuro) checks were completed for Resident #39 after an unwitnessed fall. This affected one of one resident (Resident #39) reviewed for falls and one (Resident #16) of five residents (Residents #10, #14, #16, #28, #39) reviewed for unnecessary medication. The census was 48. Findings include: 1. Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, osteomyelitis of vertebra, morbid obesity, chronic respiratory failure, malnutrition, altered mental state, discitis lumbar sacral region, acquired absence of toes, neuropathy, and heart failure. Medications included Percocet 10-325 milligrams (mg) (opioid pain medication) every eight hours as needed for pain. Review of the quarterly Minimum Data Summary (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to develop and implement comprehensive and individualized range of motion treatment and services for Resident #28 to address contractures/limitations in range of motion to the resident's upper left hand. This affected one (Resident #28) of five residents reviewed for range of motion. The facility census was 48. Findings include: Observation on 09/12/22 at 2:35 P.M. of Resident #28 revealed a contracture (hardened muscles or tissue, leading to deformity and rigidity of joints) to his left hand. Interview with Resident #28 at the time of the observation revealed he could not move his hand and would like to see a hand doctor. Review of the medical record for Resident #28 revealed an admission date of 09/10/20. Diagnoses included diabetes, cerebral infarction, muscle atrophy, transient ischemic attack (TIA), hypoglycemia, and anemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have a physician acknowledge pharmacy recommendations for Residents #10, #14 and #39. This affected three (Residents #10, #14 and #39) of four residents reviewed for unnecessary medications. The facility census was 48. Findings include: 1. Review of the medical record for Resident #10 an admission date of 03/27/20. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had intact cognition. Resident #10 was independent for bed mobility, transfers, dressing, toilet use, and personal hygiene; and independent with set-up help only for eating. Resident #10 was always continent of bowel and bladder. Review of the pharmacy recommendations for Resident #10 dated 07/31/22 and 08/05/22 revealed Resident #10 had been prescribed Ativan (antianxiety medication) 1 milligram (mg) three times a daily which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to provide evidence Resident #10 had an attempted or actual gradual dose reduction of antianxiety medication. This affected one (Resident #10) of four residents reviewed for unnecessary medications. The facility census was 48. Findings include: Review of the medical record revealed Resident #10 had an admission date of 03/27/20. Diagnoses included chronic obstructive pulmonary disorder, chronic respiratory failure with hypoxia, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had intact cognition. Resident #10 was independent with no help for bed mobility, transfers, dressing, toilet use, and personal hygiene; and independent with set-up help only for eating. Resident #10 was always continent of bowel and bladder. Review of pharmacy recommendations for Resident #10 dated 07/31/22 and 08/05/22 revealed she had been prescribed Ativan (antianxiety medication) 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to have a physician's order for Resident #40's emergency inhalation medications to be kept at the bedside. This affected one (Resident #40) of four residents reviewed for medication storage. The facility census was 48. Findings include: Review of the medical record for Resident #40 revealed an admission date of 08/17/22. Diagnoses included encounter for other orthopedic aftercare, asthma, and type two diabetes mellitus. Review of the physician's order dated 08/18/22 for Resident #40 revealed azelastine HCL 137 micrograms (mcg)/spray (steroid nasal spray) one spray in both nostrils two times a day for allergies. Review of the physician's order dated 08/22/22 for Resident #40 revealed ProAir HFA aerosol solution 108 mcg/act (emergency inhaler) two puffs inhale four times a day for shortness of breath and wheezing. The order also for the same date revealed fluticasone propionate suspension 50 mcg/act (inhaler) two sprays…

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.