Avenue At Broadview Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and facility policy review, the facility failed to ensure a resident's admission was timely completed and failed to ensure routine assessments were completed as required. This affected three residents (#60, #2, and #61) of six residents reviewed for accuracy of medical records. The facility census was 57. Findings include: 1. Review of the closed medical record for Resident #60 revealed an admission date of 07/12/25 and a discharge date of 07/24/25. Diagnoses included but were not limited to rhabdomyolysis, sepsis, hydronephrosis, dysfunction of bladder, and elevated white blood cell count. Review of the hospital discharge instructions dated 07/11/25 for Resident #60 revealed medication orders for Albuterol 90 micrograms (mcg) inhaler as needed, Amlodipine 5 milligram (mg) oral tablet to be taken by mouth twice a day, Ceftriaxone 500 mg oral tablet to be given by mouth twice daily for ten days. Doxazosin 2 mg oral tablet to be given by mouth twice daily, finasteride 5…

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, review of facility policy and review of hospital records the facility failed to ensure Resident #59's care planned interventions were implemented and physician orders were followed for oxygen therapy. This affected one resident (Resident #59) out of three residents reviewed for oxygen therapy. The facility census was 58. Findings include:Review of Resident #59's closed medical record revealed an admission date of 11/14/24 and diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, obstructive and reflux uropathy, and retention of urine. Resident #59 had a left pneumonectomy in December, 1989. Resident #59 was discharged from the facility on 07/11/25.Review of Resident #59's care plan dated 12/19/24 and revised on 07/24/25 (Resident #59 was discharged from the facility on 07/11/25) revealed Resident #59 had an altered respiratory status and difficulty breathing related to COPD (chronic obstructive pulmonary…

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 closed record review, and hospital paperwork review, the facility failed to ensure they discharged a resident in a safe and orderly manner. This affected one resident (Resident #73) out of five residents reviewed for discharge. The facility census was 72. Findings include: Review of the closed medical record for the former resident (Resident #73) revealed an admission date of 12/03/24 with a hospital stay from 12/03/24 to 12/04/24 and a final discharge date of 12/09/24 where she discharged home with her daughter. Diagnoses included urinary tract infection (UTI), altered mental status, history of pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis. Review of Resident #73 hospital paperwork revealed the resident had some cognitive deficit. Review of Resident #73's Care Plan revealed there was not a 48 hour Care Plan initiated for the resident. Review of Resident #73's progress note dated 12/03/24 at 5:09 P.M. created on 12/04/24 at 10:11 A.M. by…

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 closed record review, the facility failed to ensure there was a baseline care plan put in place. This affected one resident (Resident #73) out of five residents reviewed for care plans. The facility census was 72. Findings include: Review of the closed medical record for the former resident (Resident #73) revealed an admission date of 12/03/24 with a hospital stay from 12/03/24 to 12/04/24 and a final discharge date of 12/09/24 where she discharged home with her daughter. Diagnoses included urinary tract infection, altered mental status, history of pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis. Review of Resident #73 hospital paperwork revealed the resident had some cognitive deficit. Review of Resident #73's Care Plan revealed there was not a 48 hour Care Plan initiated for the resident. Interview on 12/11/24 at 1:50 P.M. with the Administrator revealed she verified there was no baseline care plan in place for Resident #73. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of resident shower sheets, and review of facility policy,the facility failed to ensure residents received showers per facility schedule and preference. This affected one resident (Resident #25) out of five residents reviewed for showers. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admission date of 12/05/24. Diagnoses included sacrum fracture with routine healing, spinal stenosis lumbar region, repeated falls, diabetes mellitus type II, hypertension, atrial fibrillation, and chronic kidney disease. Review of Resident #25's Medicare five-day Minimum Data Set (MDS) 3.0 dated 12/12/24 revealed the resident had intact cognition. Resident #25 required partial to moderate assistance by one staff member for transferring, showers, dressing, and toileting. Resident #25 required setup help only for eating. Review of Resident #25's care plan dated 12/10/24 revealed a care plan initiated related to 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.

Based on observation, interview, record review, and review of manufacturer instructions revealed the facility failed to ensure proper administration of insulin was followed. This affected one resident (Resident #52) out of five residents reviewed for medication administration. The facility census was 72. Findings include: Based on review of the medical record for Resident #52 revealed an admission date of 02/01/23. Diagnoses included cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus infection, type II diabetes mellitus insulin dependent, anxiety disorder, heart failure, diabetic retinopathy, and hypertension. Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 dated 10/12/24 revealed the resident had intact cognition. Resident #52 required set up or clean up assistance with eating, oral hygiene, and upper body dressing. They required partial to moderate assistance with personal hygiene, and substantial to maximal assistance with toileting and showers. Resident #52 was dependent on nursing staff for administration of medication including insulin.…

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 staff followed infection control policy and procedures related to hand hygiene and proper use of Personal Protective Equipment when administering medications and when administering medications to residents in Enhanced Barrier Precaution isolation rooms. This affected three residents (Residents #4, #25, and #33) out of five residents reviewed for infection control related to hand hygiene and proper Personal Protective Equipment. The facility census was 72. Findings include: 1. Review of Resident #4's medical record revealed and admission date of 09/12/24. Diagnoses included nontraumatic intercerebral hemorrhage, acute respiratory failure, moderate protein-calorie malnutrition with gastrostomy tube placement, cardiac murmur, and personal history or other infectious and parasitic diseases. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and was dependent on 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, observation and interview, the facility failed to ensure Resident #19's choices were honored with rising out of bed in the morning. This affected one (Resident #19) out of two residents reviewed for choices concerning care. The facility census was 67. Findings include: Review of the medical record for Resident #19 revealed an admission date of 07/03/24 with diagnoses including cerebral infarction (stroke) and difficulty walking. Review of the care plan dated 07/09/24 for Resident #19 revealed he had self-care performance deficit with activities of daily living related to impaired mobility and muscle weakness. Interventions stated Resident #19 required one staff member to dress and assist with personal hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition, staff were able to understand him, he required partial to moderate assistance from staff for toileting, showers and dressing. Resident #19 also needed substantial…

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

Based on record review, observation and interview, the facility failed to ensure standard nursing practices were followed for safe meidcation administration. This affected two (Residents #8 and #44) of six residents observed for medication administration. The facility census was 67. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 07/13/20 with diagnoses including multiple sclerosis. Review of the Medication Administration Record (MAR) for Resident #8 revealed she received Calcium with Vitamin D 600 milligrams, Cranberry 500 milligrams, Lexapro 10 milligrams (anti-depressant) and Lubiprostone 8 micrograms (medication for constipation) in the morning of 11/06/24. Review of the Medication Administration Audit Report dated 11/06/24 revealed Licensed Practical Nurse (LPN) #383 documented that she had administered Resident #8's calcium, cranberry, Lexapro and Lubiprostone at 7:48 A.M. Observation and interview on 11/06/24 at 8:10 A.M. of the medication administration by LPN #383 to Resident #8 revealed she was not using a computer or paper…

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 interview, the facility failed to ensure Resident #169 was assisted with toileting as needed. This affected one (Resident #169) out of five residents reviewed for activities of daily living. The facility had a census of 67. Findings include: Review of the medical record for Resident #169 revealed an admission date of 10/31/24 with diagnoses including multiple fractures of the pelvis, muscle weakness and difficulty in walking. Review of the nursing progress note dated 10/31/24 revealed Resident #169 was alert and oriented to person, place and time. Review of the nursing skilled assessment dated [DATE] revealed Resident #169 was incontinent of bladder and needed one person to physically assist with toileting. Review of the care plan dated 11/01/24 for Resident #169 revealed she was incontinent of bowel and bladder. Interventions included to check on her and change her on care rounds and as needed. Interview on 11/05/24 at 8:04 A.M. with Resident #169 revealed staff had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure an anchoring device for Resident #51's suprapubic catheter was implemented to prevent accidental pain or injury from excessive tension to the suprapubic catheter. This affected one (Resident #51) of one resident reviewed for catheters. The facility census was 67. Findings include: Review of the medical record revealed an admission date of 04/18/24 with diagnoses including urinary tract infection (10/10/24) and obstructive and reflux uropathy (when the urine cannot flow normally due to a blockage). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #51 had intact cognition and had an indwelling catheter. Observation on 11/05/24 at 2:17 P.M. of Resident #51's suprapubic catheter care by Certified Nursing Assistant (CNA) #307 revealed his catheter had no anchoring device to hold the catheter in place from pulling. Resident #51 stated it caused pain when he repositioned in the bed as it tugged on the…

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

Based on record review, observation and interview, the facility failed to ensure Resident #36's head of the bed was elevated safely per the physician's order, during continuous enteral feedings. This affected one (Resident #36) of three residents reviewed for enteral feedings. The facility census was 67. Findings include: Review of the medical record for Resident #36 revealed an admission date of 03/24/24 with diagnoses including chronic respiratory failure, heart failure, dysphagia (difficulty swallowing) and gastrostomy status (enteral feeding tube). Review of the physician's order for Resident #36 revealed she had an order to keep the head of her bed at least 30 degrees while feeding dated 03/25/24. Observation on 11/04/24 at 1:54 P.M. of Resident #36 revealed her head of the bed was almost completely flat while the continuous enteral feed was running at 50 milliliters. Resident #36's bed did not have a degree measure device on the side of the bed to allow staff to know the exact degree of placement of the head of the bed. Interview on 11/04/24 at 2:03 P.M. with Licensed…

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

Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (Resident #22) of five residents (Residents #13, #22, #38, #51, and #62) reviewed for drug regimens. The facility census was 67. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/12/22. Diagnoses included but were not limited to Alzheimer's dementia, hemiplegia and hemiparesis and bipolar disorder. Review of the 08/24/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #22 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #22 was noted to receive antipsychotics, antidepressants, anticonvulsants and opioid. Last noted General Dose Reduction (GDR) was attempted on 06/22/23. Last GDR contraindicated was on 02/15/24. Review of physician orders for Resident #22 revealed an order for Lamictal 100 milligrams (mg) at bedtime dated 03/13/24. This order was noted to be discontinued 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 routine monitoring for behaviors and side effects for psychotropic medications. This affected three residents (#22, #38 and #51) of five residents reviewed for unnecessary medications. Facility census was 67. Findings include: 1. Review of Resident #38's medical record revealed an admission date of 03/02/23 and diagnoses including acute and chronic respiratory failure with hypoxia, dependence on respirator [ventilator] status, tracheostomy status, quadriplegia, depression, adjustment disorder with depressed mood, insomnia and anxiety. Review of Resident #38's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was cognitively intact and received antianxiety and antidepressant medications. Review of Resident #38's physician orders as of 11/06/24 revealed an order dated 03/22/24 for Busprione hydrochloride oral table, 10 milligrams (mg) give two tablets by mouth two times a day related…

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

Based on record review, observation and interview, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #40) out of one resident reviewed for improperly stored medications. The facility census was 67. Findings include: Review of the medical record for Resident #40 revealed an admission date of 02/21/24 with diagnoses including depression, anxiety and respiratory failure. Review of the physician's orders revealed Resident #40 had an order for Guaifenesin 600 milligrams two times a days for cough. There was no indication that Resident #40 could self-administer her medication or keep the medication at bedside. Review of the Medication Administration Record (MAR) for November 2024 for Resident #40 revealed Licensed Practical Nurse (LPN) #371 had documented that she had administered Resident #40's Guaifenesin the morning of 11/05/24. Observation and interview on 11/05/24 at 8:27 A.M. revealed Resident #40 had an orange liquid medication in a medication cup on her tray table. She stated it was her cough medication the nurse had left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and policy review, the facility failed to ensure Resident #25's bedside commode was emptied in a timely manner. This affected one (Resident #25) of three residents reviewed for physical environment. The facility census was 65. Findings include: Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #25 was alert and oriented to person, place and time and required supervision or touching assistance for toileting. Review of the care plan dated 08/20/24 revealed Resident #25 was at risk for bladder incontinence and had a self-care performance deficit with interventions including provide incontinence care with care rounds every shift and toilet assistance of one staff member. Observation and interview on 09/30/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #38's incontinence care was completed timely. This finding affected one resident (#38) of three residents reviewed for incontinence care. The facility census was 69. Findings include: Review of Resident #38's medical record revealed the resident was admitted on [DATE] with diagnoses including multiple sclerosis, varicose veins, and difficulty in walking. Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was always incontinent of urine and frequently incontinent of bowel. Review of Resident #38's physician orders revealed an order dated 03/18/24 for a mechanical lift for all transfers every shift. Observation on 09/10/24 at 5:15 A.M. with State Tested Nursing Assistant (STNA) #832 and STNA #849 of Resident #38's transfer from the power wheelchair to the bed using a Hoyer mechanical lift did not reveal concerns.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure medications were administered in a safe manner. This affected one resident (#58) of five residents reviewed for medication administration. The facility census was 66. Findings include: A review of medical records for Resident #58 revealed an admission date of 07/09/24. Significant diagnoses included, osteomyelitis of vertebra, sacral and sacrococcygeal region, sepsis due to methicillin resistant staphylococcus aureus, diabetes mellitus type two, paraplegia, hypertension, and gastroesophageal reflux disease. Significant orders included oxybutynin five milligrams (medication to treat overactive bladder) by mouth daily, Topamax 25 milligrams (anticonvulsant) daily, zinc sulfate 220 milligrams (supplement) daily, melatonin three milligrams (hormone to aide in sleep) at bedtime, gabapentin 100 milligrams (anticonvulsant and nerve pain medication) two times daily, vitamin C 500 milligrams (supplement) two times…

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 interviews the facility failed to conduct a thorough investigation and implement interventions to assist in preventing further skin impairment for Resident #63. This affected one (Resident #63) of three residents reviewed for skin conditions. The facility census was 62. Findings include: Review of the medical record for Resident #63 revealed an admission date of 04/17/24 with diagnoses including adult failure to thrive, altered mental status, congestive heart failure, dementia, anxiety and depression. Review of the nursing skin assessment dated [DATE] revealed Resident #63 had a new skin tear to her left medial wrist that measured 2.4 centimeters (cm) by 2.0 cm by 0.1 cm. The physician and family were notified and a new order was received for treatment. There was no documentation as to how Resident #63 obtained the skin tear. Review of the nursing skin assessment dated [DATE] revealed Resident #63 had a new skin tear to her left anterior lower leg that measured 1.5 cm by 0.6 by 0 cm.…

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, record reviews, and resident, family, and staff interviews, the facility failed to ensure the residents received incontinence care timely. This affected two (Resident #34 and #62) of three residents reviewed for incontinence care. The facility census was 67. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 10/25/23. Diagnoses included acute respiratory failure with hypoxia, hemiplegia and hemiparesis, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had memory problems, required one person assistance with toileting, and was incontinent of bowel and bladder. Interview and observation on 01/04/24 at 10:31 A.M. with Resident #34's daughter revealed Resident #34 had not received incontinence care all night and morning. Resident #34's daughter stated Resident #34 was soaked and would need a full linen change with incontinence care. Resident #34's daughter stated the family has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the failed to to provide the required assistance for personal hygiene. This affected one of three residents reviewed, Resident #3. The census was 66. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/11/23. Diagnoses included nondisplaced intertrochanteric fracture of the left femur and secondary malignant neoplasm of the bone. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 had impaired cognition and required substantial/maximum assistance for toileting, showering and personal hygiene. Review of the plan of care for Resident #3 dated 10/31/23 revealed a self-care performance deficit related to impaired mobility, impaired cognition, muscle weakness and history of falls. Interventions included staff to shower resident as scheduled and provide one staff assistance for personal hygiene and toileting. Observation and interview on 11/19/23 at 7:54 A.M. revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview the facility failed to ensure an appropriate sized dressing was applied to a Stage four pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Rolled edges, undermining and/or tunneling often occur. Depth varies by anatomical location). This affected one of three residents reviewed for wounds, Resident #57. The census was 66. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/01/23. Diagnoses included osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region, traumatic subdural hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, tracheostomy status, bipolar disorder, cerebral infarction, mild protein-calorie malnutrition, and gastrostomy status. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain accurate medical records in regards to wound treatments. This affected two of three residents reviewed for wound care, Residents #57 and #59. Census was 66. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 08/01/23. Diagnoses included osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region, traumatic subdural hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, tracheostomy status, bipolar disorder, cerebral infarction, mild protein-calorie malnutrition, and gastrostomy status. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #57 had impaired cognition and was admitted with a stage four pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed.…

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 physician orders and care plans were in place for the care of intravenous (IV) lines to prevent infection/complications. This affected five of five residents identified by the facility as having IV access, Residents #1, #3, #16, #18 and #57. Findings include: Review of Resident #57's medical records revealed an admission date of 10/01/20. Diagnoses included multiple sclerosis (MS), muscle weakness and cognitive deficits. Review of Resident #57's MDS assessment dated [DATE] revealed Resident #57 had impaired cognition, and required total dependence for bed mobility, transfers, toileting and personal hygiene. Observation of Resident #57 on 09/05/23 at 9:15 A.M. with Licensed Practical Nurse (LPN) #220 revealed Resident #57 had an IV to her left arm with a dressing dated 08/23/23. Interview with LPN #220 at time of observation revealed IV dressings were to be changed every seven days. Review of Resident #57's care plan dated 07/03/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record. This affected two residents (#3 and #19) of two residents reviewed for advanced directives. The facility census was 47. Findings include: 1. Review of the medical record for Resident #3 revealed and admission date of [DATE]. Diagnoses included Parkinson's disease, muscle weakness, and dementia without disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance of one staff for bed mobility, walk in room and corridor and extensive assistance of two staff for transfers. Review of the physician's orders for [DATE] revealed Resident #3 had an active order dated [DATE] for cardiopulmonary resuscitation (CPR) full code. Review of the resident's hard medical chart revealed a signed Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure a resident/or resident representative was provided written notification of a resident transfer to the hospital. The facility also failed to notify the ombudsman of the resident's transfer. This affected two (#30 and #40) of two residents reviewed for hospitalization and had the potential to affect all residents. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #30 required hospitalization from 02/28/22 through 03/03/22 for acute hypoxic respiratory failure due to chronic obstructive pulmonary disease exacerbation. The record identified no evidence the resident or resident representative was provided written notification of the resident's transfer. The facility also failed to notify the ombudsman of the resident's transfer to the hospital.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure bed hold notices were given to residents and/or their representatives upon transfer to the hospital. This affected two (#30 and #40) of two residents reviewed for hospitalization and had the potential to affect all resident. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #30 required hospitalization from 02/28/22 through 03/03/22 for acute hypoxic respiratory failure due to chronic obstructive pulmonary disease exacerbation. Review of the medical record revealed no evidence Resident #30 was given a bed hold notice by the facility as required. On 06/02/22 at 12:22 P.M. the administrator verified the facility was unable to locate a bed hold notice for the resident. 2. Review of closed medical record for Resident #40 revealed an admission date 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 record review and interview, the facility failed to ensure resident care plans were revised to include all fall interventions. This affected one resident (Resident #3) of one resident reviewed for falls. The facility census was 47. Findings include: Review of the medical record for Resident #3 revealed and admission date of 02/16/22. Diagnoses included Parkinson's disease, muscle weakness, and dementia without disturbance. Review of the fall assessment dated [DATE] revealed the Resident #3 was at risk for falls. Reviewed fall investigation dated 03/26/22 at 2:20 A.M. with revealed the resident was found on the floor in room. No injuries noted. Unsure why resident was walking unassisted. All previous interventions were in place. Staff will make every attempt to keep resident safe. Intervention included bed in lowest position and floor mats. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance of one 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 observation, record review, and interview, the facility failed to ensure appropriate nail care was provided for Resident #12. This affected one of one residents reviewed for nail care. The total census was 47. Findings include: Record review of Resident #12 revealed he was admitted to the facility on [DATE] and had diagnoses including tracheostomy status, anoxic brain damage, and metabolic encephalopathy. His last minimum data set assessment on 04/01/22 revealed he had total dependence on staff for hygiene. His care plan noted he was in a persistent vegetative state and his nails were to be checked and trimmed on bath days and as needed. No documentation could be found of any podiatry visits, specific documentation of nail care, or any difficulty maintaining his nails. Observation of Resident #12 on 05/21/22 at 9:26 A.M., at 2:46 P.M., and on 06/01/22 at 1:45 P.M. revealed his hands appeared contracted into fists. His fingernails appeared yellowed, irregular, extended roughly 1.5 centimeters past 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 observation, record review, and interview, the facility failed to ensure appropriate and ordered range-of-motion interventions were provided for Resident #12. This affected one of one residents reviewed for mobility care. The total census was 47. Findings include: Record review of Resident #12 revealed he was admitted to the facility on [DATE] and had diagnoses including tracheostomy status, anoxic brain damage, and metabolic encephalopathy. His last minimum data set assessment on 04/01/22 revealed he had total dependence on staff for hygiene and impairment in bilateral upper extremity range of motion. His care plan noted he was in a persistent vegetative state and made no mention of any need for palm protectors, splints, or any other concerns for range of motion. His therapy screen assessment done 03/30/22 made no mention of any range-of-motion concerns and did not make any recommendation for therapy or any other intervention. He had an order dated 04/26/22 for an abductor pillow to be in place to keep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Foley catheters were maintained in a way to prevent possible infection and trauma. This affected two of two residents reviewed for catheter care (Resident #12 and #23). The total census was 47. Findings include: 1. Record review of Resident #12 revealed he was admitted to the facility on [DATE] and had diagnoses including tracheostomy status, anoxic brain damage, and metabolic encephalopathy. He had orders for a Foley catheter and appropriate care orders in place. Observation of Resident #12 on 06/01/22 at 9:43 A.M. and 1:45 P.M. revealed his catheter tubing had a dependent loop (a loop that held drained urine, potentially increasing the amount of urine retained in the bladder and risking backflow) and the urine collection bag rested on the floor of the room. Interview with the Director of Nursing (DON) on 06/01/22 at 1:50 P.M. on 06/01/22 confirmed the above observations. 2. Record review of Resident #23 revealed she was admitted…

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 paper lab orders were transcribed into the computer orders and acted upon. This affected one of five residents reviewed for unnecessary medications (Resident #23). The total census was 47. Findings include: Record review of Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses including ventilator dependence, Type 2 Diabetes Mellitus, right-sided heart failure, hyperlipidemia, major depressive disorder, and neuromuscular bladder dysfunction. Her medications included Insulin NPH and Insulin Lispro (for diabetes management), atorvastatin (for managing hyperlipidemia), and Vitamin D3 supplements. She had an active order dated 01/17/22 for CBC (complete blood count) and BMP (basic metabolic panel) blood lab draws to be done weekly. Record review of Resident #23's physical chart revealed a paper order dated 02/22/22 saying to stop weekly labs, a paper order dated 03/12/22 to draw a TSH (thyroid stimulating hormone) lab 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.