Summit Acres Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and policy review, the facility failed to comprehensively assess and provide treatment to skin integrity concerns. This affected one resident (#73) of two reviewed for non-pressure skin impairments. The facility census was 84. Findings include: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including cardiac arrhythmia, heart failure, muscle weakness, abnormality of gait and mobility, weakness, retention of urine, right knee pain, benign prostatic hyperplasia without lower urinary tract symptoms, obstructive and reflux uropathy, and reduced mobility. Review of Resident #73's quarterly Minimum Data Set, dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) was 11. The resident had no behaviors or rejection of care. The resident required set up for meals, dependent on staff for toileting, bathing, lower body dressing, and putting on and taking off footwear, and partial to moderate assist…

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, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for residents at risk for or having had pressure ulcers and also failed to ensure a resident's pressure ulcer was comprehensively assessed weekly to monitor for wound healing. This affected three residents (#16, #64, and #73) of four residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE]. She was re-admitted to the facility on [DATE] following a multiple day hospitalization stay. Her diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting her left dominant side, peripheral vascular disease, adult onset diabetes mellitus, reduced mobility, muscle weakness, and dependence on a wheelchair. Review of Resident #16's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing…

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

Based on observation, record review and staff interviews, the facility failed to provide timely contracture management. This affected one resident (#56) of one resident reviewed for contractures. Facility census was 84. Findings include: Review of the medical record for Resident #56 revealed an admission date of 02/28/23 with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, dysphagia following cerebral infarction, difficulty in walking, pain, and adult failure to thrive. Review of a quarterly Minimum Data Set (MDS) assessment completed 04/23/25 revealed range of motion limitation to one side. The resident was dependent upon staff for transfers. Review of occupational therapy discharge summary revealed Resident #56 received occupational therapy from 04/15/25 to 04/23/25. It stated the patient will be further assessed for splinting and palm pad during treatment. Upon discharge from occupational therapy, the resident was tolerating the trial of palm guard, and he demonstrated good rehab potential. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center on the days a resident went out for hemodialysis treatments. This affected one resident (#62) of one resident reviewed for dialysis. Findings include: Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of end stage renal disease, chronic kidney disease- Stage V, status post nephrectomy (removal of a kidney) in 2022, and dependence on hemodialysis. Review of Resident #62's physician's orders revealed the resident had an order in place to receive dialysis every Monday, Wednesday, and Friday. His chair times varied depending on the day of the week. His chair time was 10:30 A.M. every Monday and Friday. His chair time for Wednesday was 8:00 A.M. Review of Resident #62's active care plans revealed the resident had a care plan in place for an alteration in renal function as the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide services to prevent Resident #78 from experiencing triggers related to post traumatic stress disorder (PTSD). This affected one resident (#78) of one resident reviewed for PTSD. The facility census was 84. Findings include: Record review revealed Resident #78 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. Review of Resident #78's comprehensive care plan revealed no care plan or interventions regarding PTSD. Interview on 05/19/25 at 3:26 P.M. with Resident #78 reports she continues to have triggers to loud noises and has flashbacks due to a car accident at age of 16. Interview on 05/19/25 at 2:16 P.M. with Social Services #158 and Regional Director of Social Services and Activities #306, on admission a trauma informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of a drug reference resource, and policy review, the facility failed to ensure a resident received a short acting anti-anxiety medication in accordance with their physician's orders to adequately manage anxiety. This affected one resident (#48) of five residents reviewed for behavioral-emotional care. Findings include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included anxiety disorder and major depressive disorder. Review of Resident #48's physician's orders revealed the resident had an order to receive Xanax (a benzodiazepine used in the treatment of anxiety disorders) 0.5 milligrams (mg) by mouth (po) four times a day (QID). The order originated on 04/23/25 and included specific times for administration that included 8:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. Review of Resident #48's medication administration history from 05/01/25 through 05/21/25 revealed the Xanax 0.5 mg po QID was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of pharmacy recommendation, and interviews the facility failed to implement pharmacy recommendation and physician orders. This affected one resident (#14) of five residents reviewed for unnecessary medication review. Findings include: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia, weakness, fibromyalgia, and Parkinson's disease. Review of Resident #14's pharmacy recommendation undated revealed the resident had received ferrous sulfate 325 milligrams (mg) daily since 2023. Her complete blood count (CBC) was within normal limits on 04/28/25. Recommendation to discontinue ferrous sulfate. On 05/16/25 the physician checked the agree box and wrote an additional comment under the other box to discontinue the monthly CBC. Further review revealed there was a handwritten not authored by the Director of Nursing (DON) dated 05/18/25 that indicated the resident doesn't have monthly CBC and would…

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 facility policy review, the facility failed to ensure insulin pens were dated when opened. This affected three residents (#26, #49 and #192) of three residents reviewed for insulin use. Findings include: Observation on 05/19/25 at 8:15 A.M. of the unit short B medication cart revealed opened insulin containers with no open dates for the following medications: Resident #49 one Lantus long-acting insulin pen with the dispensed date of 05/06/25, Resident #192 one Lantus long-acting insulin pen with the dispensed date of 05/04/25. Interview on 05/19/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #186 verified insulin pens were not dated when opened in the unit short B medication cart. Observation on 05/19/25 at 8:32 A.M. of the unit 2 medication cart revealed opened insulin pens with no opened dates for the following medications: Resident #26 one Lantus long-acting insulin pen with the dispensed date of 03/27/25 and Resident #26 one Insulin Lispro pen with the dispensed date of 11/27/24. Interview on 05/19/25 at 8:32 A.M. with Registered Nurse…

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 facility's contracted dental company's visit list, resident interview, and staff interview, the facility failed to ensure a resident, who consented to receive dental services while in the facility, received those services to replace a broken lower denture plate. This affected one resident (#32) of three residents reviewed for dental services. Findings include: Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included moderate protein-calorie malnutrition, stroke without residual deficits, adult failure to thrive, and legal blindness. Review of Resident #32's payer status in the electronic medical record revealed the resident was admitted to the facility on [DATE] under Ohio Medicaid (MCD). His payer status did not change until 04/18/25, when he was changed to Hospice MCD. Review of Resident #32's clinical admission documentation dated 01/10/25 revealed the resident had the use of an upper denture that was in fair…

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 facility's infection control log, staff interview, and policy review, the facility failed to ensure residents were not treated with antibiotics for urinary tract infections, unless the residents met criteria for treatment. This affected two residents (#63 and #91), who were noted on the monthly infection control logs for the past three months to receive antibiotics without meeting criteria for treatment. Findings include: 1. Review of the facility's infection control log for March 2025 revealed Resident #63 received treatment for a urinary tract infection (UTI) between 03/07/25 and 03/13/25. She was ordered to receive Levofloxacin (an antibiotic used to treat various bacterial infections to include UTI's. The infection control log included columns to indicate if a McGeer's criteria (a set of standardized definitions used for surveillance of healthcare associated infections in long term care facilities and could be used retrospectively to assess the appropriateness of antibiotic prescribing) was completed and if the resident met criteria for treatment. 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, review of the facility's related investigation, observation, staff interview, employee file review, and policy review, the facility failed to ensure a resident was free from staff to resident sexual abuse and another resident was free from neglect when the resident was left on a bed pan for fourteen (14) hours. This affected two residents (#44 and #46) of four residents reviewed for abuse/ neglect. Findings include: 1. Review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a traumatic brain injury, dementia with behavioral disturbances, pseudobulbar affect, restlessness and agitation, mood disorder, hemiplegia and hemiparesis affecting his right dominant side, contractures of the right upper extremity, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #44's annual Minimum Data Set (MDS) assessment completed on 01/08/25 revealed the resident had adequate hearing and unclear speech.…

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 facility's related investigation, observation, staff interview, review of employee files, and policy review, the facility failed to ensure allegations of staff to resident sexual abuse and resident neglect were reported to the State survey agency as required. This affected two residents (#44 and #46) of four residents reviewed for abuse/ neglect. Findings include: 1. Review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a traumatic brain injury, dementia with behavioral disturbances, pseudobulbar affect, restlessness and agitation, mood disorder, hemiplegia and hemiparesis affecting his right dominant side, contractures of the right upper extremity, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #44's annual Minimum Data Set (MDS) assessment completed on 01/08/25 revealed the resident had adequate hearing and unclear speech. He was rarely/ never able to make…

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 facility's related investigation, staff interview, and policy review, the facility failed to ensure an allegation of sexually inappropriate behavior between a resident and a staff member was recognized as possible sexual abuse and investigated as required. This affected one resident (#44) of four residents reviewed for abuse/ neglect. Findings include: Review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a traumatic brain injury, dementia with behavioral disturbances, pseudobulbar affect, restlessness and agitation, mood disorder, hemiplegia and hemiparesis affecting his right dominant side, contractures of the right upper extremity, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #44's annual Minimum Data Set (MDS) assessment completed on 01/08/25 revealed the resident had adequate hearing and unclear speech. He was rarely/ never able to make himself understood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, review of the facility's related investigation, observation, staff interview, and policy review, the facility failed to ensure a resident who entered the facility without any skin breakdown received the care and services to prevent an avoidable pressure ulcer from developing. This affected one resident (#46) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #46's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Lewy Body dementia, Alzheimer's disease, metabolic encephalopathy, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #46's admission MDS assessment dated [DATE] revealed the resident had clear speech and adequate hearing. He was sometimes able to make himself understood and was sometimes able to understand others. His vision was highly…

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 the shower/bathing schedule, review of shower sheets, review of concern log, interviews, and policy review the facility failed to ensure dependent residents received showers per preference. This affected three residents (#17, #52, and #70) of four residents reviewed for showers. Findings include: 1. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, muscle weakness, unsteadiness on feet, diabetes, diabetic neuropathy, anemia, history of falling, and amputation of 4th toe. Review of Resident #17's five-day Minimum Data Set (MDS) dated [DATE] revealed the resident was dependent on staff for showers/bathing. Review of the shower/bath schedule (undated) revealed Resident #17 was scheduled for a shower/bath on 6:00 A.M. to 2:00 P.M. shift on Tuesday, Thursday, and Saturday. Review of Resident #17's shower sheets dated 08/09/24 to 09/09/24 revealed the resident had a complete bed bath on 08/30/24…

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, medical record review, electronic mail (email) communication review, interviews, and review of the facility policy, the facility failed to reasonably accommodate the request of Resident #72's family/responsible party to install an electronic monitoring device (camera of choice) in Resident #72's room. This affected one resident (#72) of five residents reviewed for unnecessary medication use. The facility census was 85. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, cardiac arrhythmia, anxiety, and depression. Review of the demographics sheet for Resident #72 revealed Resident Representative (RR) #500 was power of attorney (POA) and health care decision maker for Resident #72. Review of POA documents for Resident #72 revealed RR #500 was designated as POA on 11/20/15. Review of the care plan dated 02/09/24 revealed Resident #72 had cognitive loss/dementia with trouble sleeping or…

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

Based on observation, interview, and policy review, the facility failed to ensure Resident #16's medical record was maintained in a secure and confidential manner. This affected one (Resident #16) of one resident reviewed for confidentiality of medical records. The facility census was 85. Findings include: Observation on 04/17/24 at 10:05 A.M. revealed a computer monitor, located on the top of a medication cart, displaying Resident #16's confidential health information. There was no staff member utilizing the medication cart at the time of the observation. During interview on 04/17/24 at 10:13 A.M., Regional Director of Nursing (DON) #151 confirmed the computer monitor was displaying confidential medical records and should not be. Regional DON #151 locked the screen to ensure privacy. Review of the facility's policy titled, Medical Record Policy and Procedure, dated 08/16/10, revealed it is the facility's policy to utilize an electronic medical records system. The facility maintains resident and facility privacy and promotes the protection of clinical information within and above…

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, facility investigation review, interview and policy review the facility failed to ensure a thorough investigation was completed regarding a resident elopement. This affected one resident (Resident #74) of two residents reviewed for accidents. The facility census was 85. Findings include: Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, and depression. Resident #74 was admitted to the facility Speret Hall, a secure unit that required a code to enter and exit the unit. Clinical admission documentation dated 02/28/24 at 3:25 P.M. authored by Licensed Practical Nurse (LPN)/Program Director (PD) #128 revealed Resident #74 had short and long-term memory impairment and no mobility limitations. Resident #74's gait and balance were normal. The assessment revealed Resident #74 was not at risk for falls but was at high risk for elopement. An elopement risk observation form dated 02/28/24 authored 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of shower schedules, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, were provided the assistance they required for showers and nail care. This affected three (Resident #26, #41, and #236) of five residents received for activities of daily living (ADL). Findings include: 1. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses include the need for assistance with personal care, weakness, reduced mobility, abnormalities of gait and mobility, cerebral palsy, and adult-onset diabetes mellitus. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and adequate hearing. She was able to make herself understood and was usually able to understand others. She was cognitively intact and was not known to display any behaviors. Review of Resident #26's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of audiology visit reports, resident interview, and staff interview, the facility failed to ensure a resident was seen by an audiologist as requested by the resident and/ or her resident representative. This affected one (Resident #26) of two residents reviewed for ancillary services. The facility census was 85. Findings include: Review of Resident #26's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy and adult- onset diabetes mellitus. Her payer status was private insurance when she was first admitted and was Medicaid (MCD) effective 12/22/23. Review of Resident #26's ancillary service consent form through 360 Care revealed the resident's niece signed the bottom of the consent form under where residents without MCD had the option to consent or decline those services. The consent form was signed on 09/29/23, but the boxes were not checked to indicate whether the niece wanted the resident to receive those services or 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 observation, record review, interview, and policy review, the facility failed to ensure residents received routine, preventative foot care. This affected one resident (#2) of two residents reviewed for ancillary services. The facility census was 85. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart disease, vascular disease, diabetes mellitus, morbid obesity, and weakness. Review of the care plan, initiated on 05/06/21, revealed the resident had an alteration in blood glucose related to the diagnosis of insulin dependent diabetes mellitus with an intervention to observe the feet for potential ulcer formation. Further review of the care plan, initiated on 04/10/24, revealed the resident had an infection of the right great toe. Further review of the medical record revealed Resident #2's last podiatry examination was on 09/14/23. Review of the podiatry progress note dated 09/14/23…

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 observation, record review, resident and staff interviews, review of the facility policy, and review of manufacture instructions, the facility failed to ensure Resident #8's continuous positive airway pressure (CPAP) mask was properly cleaned. This affected one (Resident #8) out of three residents reviewed for respiratory care. The facility census was 85. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD) with exacerbation, emphysema, sleep apnea, and anxiety disorder. Review of a plan of care dated 12/28/21 revealed Resident #8 had the potential for impaired gas exchange related to diagnoses of sleep apnea and the use of CPAP (a form of positive airway pressure that is continuously applied to the upper airway collapse, as occurs in sleep apnea and is highly effective in treating sleep apnea) equipment. Interventions for cleaning CPAP equipment…

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, pharmacy review, and interview the facility failed to ensure physician orders were implemented after a pharmacy recommendation and failed to provide rationale for extending as needed psychotropic medication beyond 14 days. This affected one resident (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 85. Findings include: a. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included dementia, alcohol abuse, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 had severely impaired cognition and behaviors (verbal/disruptive sounds) towards others. Review of the monthly pharmacy recommendation dated 08/04/23 revealed a recommendation for Resident #62 to have a gradual dose reduction. The physician wrote an order (no date) on the pharmacy recommendation for Zyprexa (antipsychotic) 2.5 milligram (mg) twice a day to be decreased to 2.5 mg once a day for 14 days 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 a self- reported incident (SRI), facility policy review, and interview, the facility failed to ensure resident medications were not misappropriated by facility staff. This affected one resident (#13) of four residents reviewed for abuse. The facility census was 82. Findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Raynaud's syndrome without gangrene, supraventricular tachycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, insomnia, senile degeneration of the brain, hallucinations, unspecified mood affective disorder, major depressive disorder, anxiety disorder, and tinea unguium. Review of an annual minimum data set (MDS) assessment completed on 10/13/23 revealed Resident #13 had severely impaired cognition. Review of orders revealed Resident #13 was ordered ativan 0.5 milligrams (mg) twice a day for anxiety on 09/06/23, norco 5-325 mg as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to utilize the starter box from the pharmacy to administer the correct medication to a resident when their medication was not able to be located. This affected one resident (#13) of one resident reviewed for medications. The facility census was 82. Findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Raynaud's syndrome without gangrene, supraventricular tachycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, insomnia, senile degeneration of the brain, hallucinations, unspecified mood affective disorder, major depressive disorder, anxiety disorder, and tinea unguium. Review of an annual minimum data set (MDS) assessment completed on 10/13/23 revealed Resident #13 had severely impaired cognition. Review of orders revealed Resident #13 was ordered ativan 0.5 milligrams (mg) twice a day for anxiety on 09/06/23, norco 5-325…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the facility failed to provide oxygen as ordered by the physician. This affected two Residents (#2 and #26) of three reviewed for oxygen. The facility census was 86. Findings included: 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple myeloma not having achieved remission, generalized muscle weakness, shortness of breath, acute respiratory failure with hypoxia, and pleural effusion in other conditions classified elsewhere. Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/18/23, revealed she was cognitively intact and had an active diagnosis of respiratory failure. Further review revealed she received oxygen therapy while not a resident and while a resident. Review of Resident #2's physician order dated, 08/29/23, identified she was to have continuous oxygen at two liters/minute per nasal cannula. The staff were to check placement 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 and staff interview, the facility failed to maintain an accurate medical record related to skin wounds. This affected two residents (#62 and #67) of three residents reviewed. Findings include: Interview 08/30/23 at 11:31 A.M. with the Administrator revealed the facility had an incident when two residents developed maggots in their skin wounds. Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] and a 08/28/23 readmission with diagnoses including acute osteomyelitis of the right femur, paraplegia, weakness, abnormal posture, dysphasia, need for assistance with personal care, osteomyelitis of the sacrum, schizophrenia, bipolar disorder, unspecified psychosis, muscular dysfunction of bladder, reduce mobility, hypertension, insomnia, colostomy, abscess of the left testicle, irritable bowel syndrome with diarrhea, indwelling urinary catheter nephrostomy, delusional disorder, paranoid disorder, and acute kidney failure. Review of the 07/17/23 quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of inservice records, staff interview, and policy review, the facility failed to ensure appropriate infection control standards and practices were followed regarding the use of personal protective equipment (PPE) to help prevent the spread of Covid-19 within the facility. This had the potential to affect all 81 residents that resided in the facility except 22 residents (Resident #2, #5, #11, #13, #20, #23, #26, #29, #30, #31, #32, #50, #51, #55, #60, #62, #68, #70, #71, #74, #75, and #81) who the facility identified as having or have had Covid-19 since their most recent Covid-19 outbreak began on 07/27/23. Findings include: 1. On 08/10/23 at 7:44 A.M., a random observation during the initial tour of the facility noted State Tested Nursing Assistant (STNA) #196 walking in the hallway near room [ROOM NUMBER]. She had a surgical mask with the ear loops behind her ears and the mask portion over her chin. STNA #196's mouth and nose were visible due to not having a mask over…

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, facility policy and procedure review and interview the facility failed to ensure cold foods were held and served at appropriate temperatures. This had the potential to affect all 78 residents residing in the facility. Findings include: On 09/19/22 at 10:45 A.M. initial tour of the kitchen revealed a walk in cooler containing cold food items including milk and juice. Temperature monitoring was noted to be completed twice a day and documented on a temperature log. No discrepancies were identified and for the month of September 2022, the cooler temperature was documented as less than 41 degrees Fahrenheit. Upon observation, the thermometer in the walk-in cooler was 32-34 degrees Fahrenheit. The facility kitchen provided meal service for residents who resided in the skilled nursing facility and the residential care facility, which were physically located in the same building. On 09/21/22 at 10:30 A.M. observation of the kitchen revealed staff were preparing for the lunch meal. Dietary staff working included [NAME] #147, Dietary Aide #171, [NAME] #112 and Dietary…

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, open and closed record review, interview, resident handbook review and facility policy and procedure review the facility failed to ensure residents were provided the opportunity to exercise their right to smoke according to the facility smoking policy and failed to ensure new admissions were notified of the facility new smoking procedures upon admission. This affected two residents (#12 and #284) of two residents reviewed for smoking. The facility identified seven residents who smoke. The census was 78. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 05/17/21 with diagnoses including malignant neoplasm of the esophagus, gastroesophageal reflux disease, anxiety, protein calorie malnutrition and depression. Review of the plan of care, dated 04/19/22 revealed the resident was unable to smoke without supervision due to Hospice diagnosis, anxiety, depression, nausea and vomiting. Interventions included all smoking materials would be locked up in 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 and interview the facility failed to revise a comprehensive person-centered care plan following a fall for Resident #38. This affected one resident (#38) of three residents reviewed for falls. Findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, repeated falls, diabetes mellitus, and Parkinson's disease. Review of Resident #38's Fall with Injury Event, dated 02/19/22, revealed on 02/19/22 at 7:00 A.M., the resident stated he fell in the bathroom and hit his face on the bathroom sink. The fall was unwitnessed. There was swelling and bruising noted to the resident's right cheek, and pain and swelling of the right shin. The resident was transferred to the emergency room for evaluation. Review of Resident #38's care plan revealed no documentation of fall interventions initiated following the fall on 02/19/22. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 08/10/22 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 observation, record review and interview the facility failed to ensure Resident #59, who required staff assistance with activity of daily living (ADL) care received timely and adequate assistance with nail care to maintain good hygiene/grooming. This affected one resident (#59) of three residents reviewed for ADL care. Findings include: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, weakness, heart failure, need for assistance with personal care, abnormalities of gait and mobility, onychomycosis, and anxiety. Review of the plan of care, initiated 12/01/20 revealed staff would provide ADL assistance as needed to the resident. On 08/16/22 record review revealed a consent to receive podiatry services. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 08/23/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #59 was mildly cognitively impaired. 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, facility policy and procedure review and interview, the facility failed to ensure a pressure ulcer treatment was provided as ordered for Resident #50. This affected one resident (#50) of two residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including schizoaffective disorder, dementia, diabetes mellitus, atherosclerotic heart disease, and history of falling. Record review revealed the resident's skin was intact on admission. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50's Brief Interview for Mental Status (BIMS) score was 99, which indicated the interview was not attempted as the resident was rarely/never understood. There were no behaviors or rejection of care identified on the assessment. The MDS assessment revealed the resident required extensive, two-person assistance with bed mobility, transfers, dressing, eating and toileting. The 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, record review and interview the facility failed to ensure Resident #51, who had a limitation in range of motion/contracture to the left hand was provided a hand roll as ordered by the physician. This affected one resident (#51) of one resident reviewed for range of motion. Findings include: A review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including contracture of bilateral hands, Alzheimer's disease, dementia without behavioral disturbances, osteoarthritis, and rheumatoid arthritis. A review of Resident #51's physician's orders revealed the resident had a order (initiated 07/01/19) to cleanse her left hand with soap and water, dry well, and place a rolled washcloth in the hand every morning. The order indicated for staff to remove the rolled washcloth every night at bedtime. A review of Resident #51's annual Minimum Data Set (MDS) 3.0 assessment, dated 08/12/22 revealed the resident had highly impaired hearing and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, facility investigation review, facility policy and procedure review and interview the facility failed to provide adequate and appropriate supervision/interventions to prevent resident elopements and failed to ensure comprehensive elopement investigations were completed to potentially prevent reoccurrence. This affected two residents (#82 and #285) of two residents reviewed for elopement. Findings include: 1. A review of Resident #82's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, toxic encephalopathy, chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, history of falling, osteoporosis, and dependence on supplemental oxygen. A review of Resident #82's Elopement Risk Observation, dated 06/07/22 revealed the resident was considered a low risk for elopement. Risk…

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, facility policy and procedure review and interview the facility failed to provide appropriate care in a manner to decrease the risk of Resident #78 developing a urinary tract infection. This affected one resident (#78) of one resident observed for incontinence care. Findings include: Review of Resident #78's medical record revealed diagnoses including history of kidney infection and urinary tract infection, bilateral primary osteoarthritis of knees, and cognitive communication deficit. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/28/22 revealed Resident #78 required extensive assistance from staff for toilet use and was frequently incontinent of bowel and bladder. A urologist note, dated 09/12/22 revealed an order for the antibiotic, Macrobid 100 milligrams (mg) twice a day for urinary tract infection prophylaxis. The note indicated associated diagnoses for use of the Macrobid were kidney stone, right ureteral stone, and retained ureteral stent. On 09/22/22…

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, facility policy and procedure review and interview the facility failed to ensure Resident #9 did not receive an antibiotic without an adequate indication for use and meeting criteria for the treatment of a urinary tract infection (UTI). This affected one resident (#9) of five residents reviewed for unnecessary medication use. Findings include: A review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses included dementia, unspecified psychosis, and schizo-affective disorder of the depressive type. The resident was hospitalized between 08/30/22 and 09/02/22. A review of Resident #9's hospital records for her hospitalization between 08/30/22 and 09/02/22 revealed the reason for her hospitalization was bipolar affective disorder. Record review revealed the resident had been started on an antibiotic, Cephalexin (Keflex) 500 milligrams (mg) three times a day beginning 08/30/22. A copy of laboratory testing completed at 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.

Based on record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized immunization program to ensure influenza and/or pneumococcal immunizations were provided to Resident #68 and Resident #231 when indicated. This affected two residents (#68 and #231) of six residents reviewed for influenza and pneumococcal immunizations. Findings include: 1. Review of Resident #68's medical record revealed diagnoses including traumatic brain injury and history of pneumonia. Resident #68's date of birth was 10/26/61. Review of vaccination information indicated Resident #68 received an influenza vaccination in 2017 and 2018. In addition, Resident #68 had received the PCV-13 pneumonia vaccine on 01/31/19 and the PPSV 23 pneumonia vaccine on 01/06/17. A form for acknowledgement of vaccine information included a notation dated 11/09/21 indicating staff spoke with Resident #68's representative to request consent to administer the influenza and pneumonia vaccine and was told the representative would think about it 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.