Altercare Of Canal Winchester Post-Acute Rc

Based on review of concern tracking logs, policy review, record review, staff interview, and resident interview, the facility failed to make prompt efforts to resolve complaints/grievances by resident/family members. This affected three residents (Residents #31, #55, and #93) of three residents reviewed for concerns and had the potential to affect all residents of the facility due to the lack of policy/procedure and system in place. The facility census was 57. Findings include: Review of facility Concern Tracking Logs revealed the logs listed the date, resident name, nature of concern, department, and date of resolution. The log did not give specifics of the nature of the concerns. Three residents (Residents #31, #55, and #93) were chosen for review of logged concerns as follows: a. On 03/02/26 it was noted that a concern for Resident #31 was submitted regarding response time. The date of resolution was 03/02/26. No further specifics were documented. Review of the record for Resident #31 revealed an admission date of 12/04/25. Review of a Minimum Data Set assessment completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, staff interview and review of facility policy, the facility failed to report an injury of unknown origin to the State in a timely manner. This affected one resident (#88) out of five residents reviewed for abuse. The facility census was 57 residents. Findings include: Review of a closed medical record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses that included metabolic encephalopathy, need for assistance with personal care, disorientation and cognitive communication deficit. Review of Resident #88's admission skin assessment dated [DATE] revealed that Resident #88 was admitted to the facility with bruising to his bilateral upper extremities, dry scaly skin to his bilateral lower extremities below the knee, and a cancerous lesion that was removed prior to admission on his upper left back area. Review of Resident #88's Minimum Data Set comprehensive assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 08,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility policy review, the facility failed to execute a timely discharge for a resident. This affected one resident (#41) of eight residents reviewed for the discharge process. The facility's census was 57.Findings include:Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Parkinson's Disease, hypertension, coronary artery disease and dementia Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 08. This resident was assessed to be require supervision or touching assistance, along with his walker or cane, for mobility. Review of the nursing progress notes in Resident #41's medical record revealed on 12/09/25 he was identified as being a high fall and high elopement risk. Review of the nursing progress notes in Resident #41's medical record revealed on 10/21/25, 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 observations, record review, staff interview, resident interview, policy review, and family interview, the facility failed to comprehensively assess residents in the areas of activities and dental status. This affected two residents (#6, #13) of 37 residents reviewed for accuracy of assessments. The facility census was 57.Findings include:1. Review of the record for Resident #6 revealed an admission date of 02/28/25 and diagnoses including hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and aphasia (impaired speaking). He received all of his nutrition through a gastrostomy tube (feeding tube leading into the stomach). Review of a Minimum Data Set assessment completed 01/23/26 revealed the resident had short and long term memory problems, had a feeding tube, and was dependent upon staff for mobility, including transfers. Review of an admission activity assessment completed 03/09/25 revealed the resident's previous occupation was a cook. It stated he was not active in religion. It stated participation…

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, staff interview and facility policy review, the facility failed to develop baseline plans of care that included the interventions necessary to properly care for residents within 48 hours of admission. This affected three (Residents #84, #86 and #93) of 37 residents reviewed for plans of care. In addition, the facility failed to ensure that a summary of the baseline plan of care was provided to the resident or representative. This affected one (Resident #93) of 37 residents reviewed for plans of care. The census was 57.Findings include:1. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare, fall with fracture (at home), pain, dementia, osteoarthritis, high blood pressure, and gastroesophageal reflux disease (GERD). No Minimum data Set (MDS) 3.0 assessment was completed because she was a new admission. Further review of Resident #84's medical record on 04/08/26 revealed no baseline plan of care 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 resident record reviews, staff interviews and review of the facility policy, the facility failed to develop comprehensive care plans for three residents. This affected three (Residents #6, 10, and 88) out of thirty-seven resident records reviewed for comprehensive care plans. The facility census was 57 residents.Findings include:1. Review of a closed resident record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia, cognitive communication deficit, chronic obstructive pulmonary disease, and end stage renal disease. Review of the Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed that Resident #88 had a Brief Interview for Mental Status Score (BIMS) of 08 out of 15, indicating moderate cognitive impairment. Resident #88 was assessed as being incontinent of bladder and not having a catheter present. Resident #88 was assessed as not having pressure ulcers present on admission. Review of Resident #88's comprehensive 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 medical record review and staff interview, the facility failed to ensure required plan of care meetings were held with residents and resident representatives. This affected one (Resident #4) of 37 resident records reviewed for care plans. The facility census was 57. Findings include:A review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #4 had moderately impaired cognition. She required supervision or touching assistance for eating, personal hygiene, and turning/repositioning; partial to moderate assistance for oral hygiene and toileting; and substantial to maximal assistance for bathing/showers. She was occasionally incontinent of urine and frequently incontinent of bowel.Review of the care conference documentation for 2025 and 2026 revealed only two documented conferences: 05/22/25 and 09/11/25. There was no care conference in 2025 before 05/22/25 and no care conference in 2026.During an interview on 04/08/26 at 2:32 P.M., Social Service Coordinator (SSC) #208…

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

Based on observations, resident interviews, family interviews, staff interviews, record review and facility policy review, the facility failed to provide an ongoing activity program based on resident preferences to create opportunities for a meaningful life. This affected one (Resident #6) of 37 sampled residents. The facility census was 57.Findings include:Review of the medical record for Resident #6 revealed an admission date of 02/28/25 with diagnoses including hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and aphasia (impaired speaking). He received all of his nutrition through a gastrostomy tube (feeding tube leading into the stomach). Review of an admission activity assessment completed 03/09/25 revealed Resident #6's previous occupation was a cook. He was not active in religion. Participation barriers included mobility and physical endurance. His general activity preferences included music and watching television. The assessment was completed with the resident. The focus of programming would be 1:1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a resident with a pressure ulcer received the necessary care and treatment as ordered to promote healing, prevent infection, and prevent new ulcers from developing. This affected one resident (#93) of six residents reviewed for pressure ulcers. The facility census was 57.Findings include: Review of the record for Resident #93 revealed an admission date of 01/24/26 and diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease. The resident was transferred to the hospital on [DATE] due to a change in condition and did not return to the facility. The clinical admission assessment with an observation date of 01/24/26 stated the resident had impaired short and long term memory and was oriented to self only. It indicated the resident was incontinent of bowel and bladder and was at moderate risk of skin…

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, observations, staff interview, and facility policy review, the facility failed to ensure fall interventions were in place. This affected one (Resident #4) of two residents reviewed for falls. The census was 57Findings include: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included aphasia, high blood pressure, major depression, insomnia, anemia, cerebral infarction, anxiety and history of embolism.Review of the quarterly MDS assessment dated [DATE] revealed her cognition was moderately impaired. She required supervision or touching assistance for eating, personal hygiene and turning and repositioning, partial to moderate assistance oral hygiene, toileting, substantial to maximal assistance for shower/bathing. Occasionally incontinent of urine and frequently incontinent of bowel. Review of the fall plan of care dated 05/21/21 revealed the resident was at risk for falls due to confusion/altered mental status, history of falls,…

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, staff interview and policy review, the facility failed to The facility failed to ensure accurate and timely monitoring of Resident #93's weight, resulting in an undetected and unevaluated significant weight loss. This affected one (Resident #93) of four residents reviewed for nutritional status. The facility census was 57.Findings include:Review of the record for Resident #93 revealed an admission date of 01/24/26 and diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease. Review of the admission assessment on 01/24/26 revealed Resident #93 refused to be weighed. Diet ordered: low concentrated sweets, mechanical soft diet with nectar thickened liquids. Review of the physician's order dated 01/24/26 revealed an order for weekly weights for four weeks. No evidence of further attempts to obtain weights until 02/05/26.Review of the physician's order dated 01/28/26 revealed the diet was changed to pureed with honey thickened liquids.…

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, staff interview and policy and procedure review, the facility failed to appropriately check for placement of the gastrostomy tube prior to administration of medication. This affected one (Resident #6) of four residents observed for medication administration. The facility census was 57.Findings include:Review of Resident #6's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hemiplegia, high blood pressure, dysphagia following cerebral infarction and aphasia. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed short- and long-term memory problems. Resident #6 was dependent on staff for bathing and personal hygiene and received enteral feedings via a gastrostomy tube (tube placed through the abdominal wall into the stomach). Observation on 04/13/26 at 8:31 A.M. revealed Licensed practical Nurse (LPN) #256 checked for placement by flushing the gastrostomy tube with 30 cubic centimeters (cc) of water 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.

Based on record review, staff interview and facility policy review, the facility failed to ensure Resident #93 was provided with adequate pain management. This affected one (Resident #93) of two residents reviewed for pain. The facility census was 57.Findings include:Review of the medical record for Resident #93 revealed an admission date of 01/24/26 with diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, pain in thoracic spine, and peripheral vascular disease. Review of the clinical admission assessment with an observation date of 01/24/26 revealed Resident #93 had impaired short- and long-term memory and was alert only to self. The resident had non-verbal expressions of pain (not specified) and had a pain level of three (scale went from no pain to 10). The frequency of pain was noted to be daily. There was no evidence the resident was offered or provided with any interventions for pain relief. A baseline care plan (part of the clinical admission assessment referenced 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 medical record review, staff interview, and facility policy review, the facility failed to ensure medications were available to be administered for Resident #74. This affected one (Resident #74) resident out of 37 residents reviewed for medications. The facility census was 57.Findings include:Medical record review revealed Resident #74 was admitted to the facility on [DATE] at 7:52 P.M. and discharged to the hospital on [DATE]. Pertinent diagnoses included multiple sclerosis, other osteonecrosis left femur, unilateral primary osteoarthritis left hip, fatigue and post-traumatic stress disorder (PTSD).Review of progress notes revealed on 01/07/26 at 7:52 P.M. Resident #74 arrived at the facility via transport from the hospital with a hip fracture. Review of physician orders for Resident #74 revealed the following orders with a start date of 01/07/26:a. acetaminophen 650 milligram (mg) tablet extended release to be given once a day along with 500 mg of acetaminophen. b. acetaminophen 500 mg to be given…

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 pharmacy recommendations, staff interview, and facility policy, the facility failed to ensure medication regimen reviews were completed monthly for Resident #8 and #11 and failed to follow-up timely on pharmacist's recommendations for Resident #7 and Resident #8. This affected three residents (#7, #8, and #11) of five residents reviewed for pharmacy recommendations. The facility census was 57.Findings Include: 1. Review of Resident #11 's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory disease, multiple sclerosis, dysphagia, hypertension, diabetes mellitus and major depressive disorder. Review of the comprehensive minimum data set assessment dated [DATE] revealed his cognition was intact, evidenced by a Brief Interview for Mental Status (BIMS) score of 14. She was considered dependent for toileting, shower/bathing, dressing, and personal hygiene. Review of the medication regimen reviews (MRR) for Resident #11 revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of pharmacy recommendations, and staff interview, the facility failed to ensure pharmacy recommendations were addressed with an adequate indication for use of the medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 57.Findings include:Review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease, atrial fibrillation, Von [NAME] disease, hemiplegia, hemiparesis, diabetes, depression, anxiety, high blood pressure and cerebral infarction. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He required supervision or touching assistance with eating, setup or clean up assistance with oral hygiene, substantial/maximal assistance for toileting, shower/bathing, dressing, personal hygiene and partial/moderate assistance for turning and repositioning. Review of the pharmacy recommendations 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 and staff interview, the facility failed to ensure residents were free of significant medication errors and that medications were given in accordance with physician's orders. This affected one resident (Resident #83) of 37 sampled residents. The facility census was 57. Findings Include:Review of Resident #83's hospital records (prior to admission to the facility) revealed he was diagnosed with Clostridioides difficile (C. diff), (a bacterium causing severe diarrhea, fever, and colon inflammation often triggered by antibiotic use) on 04/02/26. He was placed on Contact plus precautions in the hospital on [DATE]. Contact plus precautions were noted as enhanced infection control measures used, alongside standard precautions, to prevent the spread of highly contagious pathogens, particularly C. diff. He was started on antibiotic treatment Vancomycin 125 milligrams every six hours for the C. diff on 04/02/26 which was to conclude on 04/15/26. Review of the record for Resident #83 revealed 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 resident medical record review and staff interviews, the facility failed to complete labs as ordered for two residents. This affected two residents (#88 and 90) out of thirty-seven medical records reviewed during the annual survey. The facility census was 57 residents. Findings include: 1. Review of a closed resident record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses that included benign prostatic hyperplasia, cognitive communication deficit, chronic obstructive pulmonary disease, and end stage renal disease. Review of Resident #88's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 08, indicative of moderate cognitive impairment. Resident #88 was assessed as being incontinent of bladder and not having a catheter present. Review of Resident #88's nursing progress notes dated [DATE] revealed that Resident #88 was confused, agitated and restless. Resident #88 complained 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 observations, record review, staff interview, resident interview, and facility policy review, the facility failed to assist Resident #13 in obtaining dental services. This affected one resident (#13) of one resident reviewed for non-Medicaid dental services. The facility census was 57. Findings include: Review of the record for Resident #13 revealed an admission date of 11/06/25 with diagnoses including diabetes, chronic kidney disease, and hypertension. The resident was on a regular diet. Review of a Minimum Data Set (MDS) assessment completed 11/12/25 revealed a Brief Interview for Mental Status score of 14, indicating intact cognition. It further stated the resident had obvious or likely cavities or broken natural teeth. A consent for dental treatment was signed by Resident #13 on 02/16/26. Review of a plan of care dated 03/10/26 revealed a potential for alteration in dental/oral status related to aging process and poor nutrition. The goal was for the resident to be free of dental/oral discomfort,…

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, resident interview, and facility policy review, the facility failed to assist residents in obtaining dental services. This affected two residents (#10 and #62) of three residents reviewed for dental services. The facility census was 57. Findings include: 1.Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, muscle weakness, hypertension, congestive heart failure, asthma, chronic kidney failure, and chronic obstructive pulmonary disorder. Review of the care conference note for Resident #10, dated 10/29/25, revealed no evidence or mention of Resident #10 declining dental services.Review of the annual MDS assessment dated [DATE], Resident #10 had no natural teeth or tooth fragments.Review of Resident #10's care plan dated 01/14/26 revealed the resident was at risk for oral complications due to him being edentulous. Interventions on the care plan included to encourage resident to wear…

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, resident interview, staff interview, medical record review, and policy review, the facility failed to implement care planned interventions for nutritional supplements for Resident #60 to maximize the healing potential of wounds. This affected one resident (#60) of three reviewed for wounds. The facility census was 63.Findings Include:Review of the medical record for Resident #60 revealed an admission date of 08/28/25. Pertinent diagnoses included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage 4 (severe), acute kidney failure, depression, anxiety disorder, muscle weakness, pressure ulcer of sacral region, unspecified stage; pressure ulcer of left heel, unspecified stage, and obesity.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had moderately impaired cognition. The resident was at risk for developing pressure ulcers and she had three stage 4 pressure ulcers on admission.Review 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.

Based on interview, concern log review, Resident Council Meeting review and record review the facility failed to ensure resident concerns were addressed timely and appropriately. This affected seven residents (#2, #15, 16, #17, #21, #26, #37) who were identified to regularly attend resident council. Facility census was 58.Findings include: 1. Review of Resident Council Meeting Minutes dated 01/15/25 revealed concerns of good staff leaving, snacks and water not being offered, medications administered late, and cold food. It was mentioned cold food was also addressed the previous month (12/24 meeting). There were no concerns documented for January 2025 in the concern log.2. Review of Resident Council Meeting Minutes dated 02/19/25 revealed concerns of care issues with showers and activities of daily living and issues with food and drink.Review of the concern log revealed no mention of other concerns from Resident Council and no resolutions or evidence of follow up was provided.3. Review of Resident Council Meeting Minutes dated 03/19/25 revealed concerns of evening medication…

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, staff interview and record review, facility failed to ensure menus and spreadsheets were followed and full meals were provided. This affected five Residents #18, #19, #20, #38 and #57 of five reviewed for nutrition. Facility census was 58. Findings include 1. Review of the medical record for Resident #18 revealed an admission date of 03/11/24. Diagnoses included senile degeneration of the brain, dementia and aphasia. Review of physician orders dated 03/13/24 for regular diet with puree texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) was not preformed and stated resident was rarely if ever understood, indicating impaired cognition. Observation and interview on 07/28/25 from 12:20 P.M. to 12:30 P.M. during tray line observation with Kitchen staff #102 and #181 and Regional Kitchen Manager (RKM) #206 revealed a meal ticket for Resident #57 stating puree cookies for lunch meal 07/28/25. Resident #57's tray was made with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure residents were placed in proper isolation type, with appropriate signage. Facility also failed to ensure staff were knowledgeable to isolation status of residents and failed to wear the correct personal protective equipment (PPE). This affected four Residents #19, #20, #23, and #24 of four reviewed for isolation status. Facility also failed to ensure proper sanitization of the glucometer affecting Resident #12 and ensure infection control was maintained during medication administration affecting Resident #68. Facility census was 58. Findings include 1. Review of the medical record for Resident #19 revealed an admission date of 08/22/24. Diagnoses included obstructive pulmonary disease, muscle weakness, COVID-19, and atrial fibrillation. Review of progress note dated 07/16/25 revealed resident tested positive for COVID-19, resident family contacted. Progress note dated 07/28/25 at 1:54 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews, record review and policy review, facility failed to ensure falls were investigated thoroughly, appropriate interventions were implemented based on the cause of the falls and ensure interventions were in place per the care plan. This affected three Residents #2, #23, and #63 of three reviewed for falls. Facility census was 58. Findings include 1. Review of the medical record for Resident #2 revealed an admission date of [DATE]. Diagnoses included unspecified dementia, muscle weakness, abnormalities of gait, hypertension, diabetes and dysphagia. Review of the Care Plan dated [DATE] revealed interventions for falls prevention including: observe resident safety by looking in room when passing added [DATE]Physical therapy, occupational therapy and speech therapy added [DATE]Pharmacy and Physician to review medication with resident visits added [DATE]report medication side effects added [DATE]encourage resident to use call light for transfer/ambulation…

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 staff interviews, review of employee file and policy review, facility failed to ensure residents were free from significant medication error when Narcotics were not given as ordered and documented for Resident #67 and medications were not given as ordered for Resident #66 upon admission. This affected two Residents #66 and #67 of three reviewed for medications. Facility census was 58. Findings include 1. Review of the medical record for Resident #67 revealed an admission date of [DATE] and expired on [DATE]. Diagnoses included unspecified dementia without behaviors, spinal stenosis, muscle weakness, osteoporosis and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of three indicating significant impaired cognition. Review of the Physician orders revealed an order dated [DATE] to [DATE] for Gabapentin capsule 300 MG with instructions to take one capsule twice daily at 6:00 A.M. and 2:00 P.M. A second order dated [DATE] to [DATE] 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, facility staff interview and policy review the facility failed to ensure appropriate hand hygiene was conducted during medication administration for Resident #105 of three reviewed (#28 and #104), and the facility failed to ensure enhanced barrier precautions were in placed and followed for three (Resident #2, #19 and #104) of three reviewed for EBP. The facility census was 61. Findings include: 1. Review of the medical record for Resident #105 revealed an admission date of 09/14/24 with diagnoses not limited to metabolic encephalopathy, vascular dementia, hypertension, pneumonia and gastro-esophageal disease. Review of Minimum Data Set (MDS) 3.0 assessment completed 09/21/24 revealed Resident #105 was moderately cognitively impaired. Observation of medication administration on 09/24/24 at 7:37 A.M. with Registered Nurse (RN) Supervisor #207 revealed after administering Resident #105's medication, hand hygiene was not performed. RN Supervisor #207 arrived at the nurse's cart,…

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, medical record review, and review of facility policy, the facility failed to ensure Resident #30's needs were addressed in a timely manner when she waited for 29 minutes for her call light to be answered. This affected one resident (#30) of one resident reviewed for call lights. The facility census was 61. Findings include: Review of Resident #30's medical record revealed an admission date of 09/06/22 with diagnoses including acute embolism and thrombosis of unspecified deep veins of right lower extremity, adult failure to thrive, type two diabetes mellitus, hypertension, chronic pain syndrome, and muscle weakness. Review of Resident #30's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. She required substantial or maximal assistance to roll left and right in bed. Interview on 09/25/24 at 10:43 A.M. Resident #30 revealed she was uncomfortable in her current position and wanted someone to pull her up. The call light was triggered at that…

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

Based on observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records during routine medication administration, leaving information visible to the public. This affected two (Resident #104 and #105) out of three residents observed during medication administration. The facility census was 61. Findings include: 1. Review of the medical record for Resident #105 revealed an admission date of 09/14/24 with diagnoses not limited to metabolic encephalopathy, vascular dementia, hypertension, pneumonia and gastro-esophageal disease. Review of Minimum Data Set (MDS) 3.0 assessment completed 09/21/24 revealed Resident #105 was moderately cognitively impaired. Observation of medication administration on 09/24/24 at 7:37 A.M. with Registered Nurse (RN) Supervisor #207 began by reviewing the medication administration record (MAR) for medications to be administered to Resident #105. Resident # 105 required a blood pressure reading prior to administration of her medications which required RN supervisor #207 to obtain a blood pressure…

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

Based on observation, interview and record review the facility failed to provide set up meal assistance to a resident with limited range of motion. This affected one (Resident #213) of three residents who require set up assistance with meals. The facility census was 61. Findings include: Review of the medical record for Resident #213 revealed an admission date of 09/09/24 with diagnoses not limited to osteoporosis, left femur nailing, muscle weakness, need for assistance with personal care, fracture of upper end of left humerus and history of falls. Review of admission Minimum Data Set (MDS) 3.0 assessment completed 09/16/24 revealed Resident #213 had a severe cognitive impairment, required set up assistance with eating and oral hygiene. Review of admission assessment completed 09/09/24 revealed upon admission, Resident #213 presented with left upper extremity edema and expressed a daily pain level of 3 due to fractures in the left femur and humerus. Nutritional assessment indicated Resident #213's nutritional status was probably inadequate, as she rarely consumed a complete meal…

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, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place for Resident #2 and #19 and failed to ensure complete and timely investigations were completed for Resident #2 and #205. This affected three residents (#2, #19, and #205) of five residents reviewed for falls. The facility census was 61. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 08/20/24 with diagnoses including senile degeneration of brain, unspecified fracture of left talus, dislocation of internal left hip prosthesis, unspecified dementia, depression, anxiety disorder, chronic kidney disease, and overactive bladder. Review of Resident #2's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. She had one fall with no injury since admission and one fall with a non-major injury. Review of Resident #2's fall investigation (event) dated 08/23/24 revealed at 7:13 P.M. she had a fall in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #38 had reasonable access to fluids. They additionally failed to ensure Resident #19 was weighed monthly and failed to ensure Resident #2's significant weight change was addressed and that her nutrition status was accurately assessed. This affected three residents (#2, #19, and #38) of six residents reviewed for nutrition and hydration. The facility census was 61. Findings include: 1. Review of Resident #38's medical record revealed an admission date of 04/20/21 with diagnoses including hypertension, muscle weakness, vascular dementia, chronic diastolic heart failure, dysphagia, bipolar disorder, and cognitive communication deficit. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had a severe cognitive impairment. He required set up or clean up assistance with eating. Review of Resident #38's plan of care on 09/23/24 revealed it did not address…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure nonpharmacological interventions were attempted and documented prior to administering 'as needed' anxiety medication. This affected one resident (#2) of five residents reviewed for unnecessary medications. The facility census was 61. Findings include: Review of Resident #2's medical record revealed an admission date of 08/20/24 with diagnoses including senile degeneration of brain, unspecified fracture of left talus (08/23/24), dislocation of internal left hip prosthesis, unspecified dementia, hypertension, depression, anxiety disorder, chronic kidney disease. chronic pain, and overactive bladder. Review of Resident #2's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. Review of Resident #2's plan of care dated 09/06/24 revealed the resident received psychotropic medications including an antidepressant and antianxiety medication. Interventions included physician and pharmacist to review…

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 staff interview and policy review the facility failed to ensure one (Resident #42) timely received speech therapy services regarding a change in nutritional condition/status. This affected one of five residents reviewed for nutrition. The facility census was 61. Findings Include: Review of Resident # 42's medical record revealed an admission date of 02/26/24. Further review revealed diagnoses of chronic obstructive pulmonary disease, unspecified, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Dysphagia, oropharyngeal phase, diabetes and encounter for attention to gastrostomy tube. Review of the Minimum Data Set, dated [DATE] revealed Resident #42 had a feeding tube and was receiving a mechanically altered diet. Review of Resident #42's physician's orders revealed an order dated 06/07/24 that read moist mechanical soft (no breads) with nectar thick liquids. Review of Resident #42's nursing progress notes dated 07/23/24 revealed 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported incident (SRI), review of facility investigation, resident and staff interview and policy review the facility failed to prevent the misappropriation of Resident #21's prescribed narcotics. This affected one resident (#21) of three residents reviewed for misappropriation. The facility census was 62. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/30/21 with diagnoses including myasthenia gravis without exacerbation, anxiety disorder, chronic pain syndrome, peripheral vascular disease, and cognitive communication deficit. Review of Resident #21's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, was on a scheduled pain medication regime, and reported no pain during the previous five days. Review of Resident #21's plan of care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility Self-Reported incident (SRI), review of facility investigation, resident and staff interview, and policy review the facility failed to timely investigate an allegation of misappropriation. This affected one resident (#21) of three reviewed for misappropriation. The facility census was 62. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/30/21 with diagnoses including myasthenia gravis without exacerbation, anxiety disorder, chronic pain syndrome, peripheral vascular disease, and cognitive communication deficit. Review of Resident #21's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, was on a scheduled pain regimen and reported no pain during the previous five days. Review of Resident #21's plan of care dated 05/07/24 revealed he had an alteration in comfort or pain related to diagnoses of myasthenia gravis and osteoarthritis. Interventions included reminding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident received timely and physician ordered treatment after a change in condition. This affected one of three sampled residents ( #63). The facility census was 60. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of 02/15/24 and diagnoses including chronic obstructive pulmonary disorder, hypertension, and syncope. The resident was admitted from the hospital after a stay from 02/11/24 to 02/15/24 following a syncopal episode. Upon discharge from the hospital, medication orders included an albuterol inhaler two puffs every four hours as needed for wheezing (used to treat or prevent bronchospasms in individual's with lung diseases). A nursing progress note on 02/19/24 at 2:16 P.M. revealed the physician was in to see Resident #63. Review of a history and physical completed by the physician on 02/19/24 revealed the resident had been seen at the hospital from [DATE] to 02/15/24 for 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.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurately documented. This affected two of three sampled residents (#50, #63). The facility census was 60. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 08/29/23 and diagnoses including chronic pain, paresthesia (a tingling or prickly pins and needles sensation), and fibromyalgia. Record review revealed a physician's order 11/10/23 for Oxycodone (a narcotic pain medication) 5 milligrams every eight hours (scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M.). Review of a Minimum Data Set assessment completed 01/27/24 revealed a brief interview for mental status score of 15, indicating intact cognition. Interview with Resident #50 on 03/04/24 at 11:05 A.M. revealed the weekend before last, the facility ran out of her Oxycodone pain medication. She stated she did not get the medication for 26 hours. She stated that not receiving the medication caused her to have severe pain which she described as a 9…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to maintain a sanitary environment for resident showers. This affected one resident (#64). The facility census was 60. Findings include: Observations of the shower in Resident room [ROOM NUMBER] on 03/04/24 at 1:40 P.M. revealed there were four areas of dried brown material on the floor of the shower that appeared to be bowel movement. Interview with the Director of Nursing on 03/04/24 at 1:40 P.M. confirmed the dried brown material on the floor of the shower in Resident room [ROOM NUMBER]. She stated that there was currently not a resident residing in the this room. She stated the resident who had resided in the room had went to the hospital the previous day (Resident #64). She stated Resident #64 had not used the shower and did not use a bedside commode/bedpan. She stated that if a resident used a bedside commode/bedpan, it should be emptied in the toilet, not the shower. She stated the dried brown material should not be there. This deficiency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to notify a resident's physician of weight gain as ordered. This affected one resident (#13) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hypertension, type II diabetes, chronic obstructive pulmonary disease, hyperlipidemia, and constipation. Additional diagnoses were added on 01/01/24 including encephalopathy and abdominal distention. Review of a quarterly minimum data set (MDS) assessment completed on 10/03/23 revealed Resident #13 had intact cognition, no behaviors, was always incontinent of bowel, and was dependent on staff for toileting assistance. In addition, Resident #13 had an order started on 05/01/22 to record daily weight and if there was a two-pound weight gain in one day or five-pound weight gain in one week notify the physician. Resident #13 gained four pounds on 12/04/23, gained two…

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 staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to perform oral hygiene for Resident #4 and #9, shaving assistance for Resident #9, showers, and nail care for Resident #317 and #322. This affected four residents (Resident #4, #9, #317, and #322) of seven residents reviewed for activities of daily living (ADL's). Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/07/22 wit diagnoses including type 2 diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of Resident #4's physician orders revealed an order dated 02/10/22 for limited assistance of one staff member for oral hygiene. Review of the comprehensive Minimum…

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 staff interview, resident interview, medical record review, and facility policy review, the facility failed to sufficiently staff the facility to provide activities of daily living assistant for Resident #4, #9, #317, and #322. This affected four residents (Resident #4, Resident #9, Resident #317, and Resident #322) of eight residents reviewed for sufficient staffing. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/07/22 wit diagnoses including type 2 diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of Resident #4's physician orders revealed an order dated 02/10/22 for limited assistance of one staff member for oral hygiene. Review of the comprehensive Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident #51's call light was within his reach. This affected one resident (Resident #51) of one resident reviewed for accommodation of needs. Findings include: Review of the medical record for Resident #51 revealed he admitted on [DATE] with diagnoses including atherosclerotic heart disease, type two diabetes mellitus, hyperlipidemia, bipolar disorder, depression, acute embolism and thrombosis of iliac vein, spinal stenosis, aphasia, and intervertebral disc degeneration. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had intact cognition. He required the extensive assistance of two staff for bed mobility and the assistance of two staff for transfers. Review of the plan of care dated 05/04/22 related to activity of daily living functioning revealed Resident #51 needed therapy services related to a decline in prior function of activities of daily living, diagnoses, difficulty…

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 staff interview, observations, medical record review, and facility policy review, the facility failed to identify and treat Resident #4's stage III pressure ulcer. This affected one resident (Resident #4) of two residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #4 revealed the resident was admitted on [DATE] with diagnoses including type two diabetes mellitus without complications, peripheral vascular disease (PVD), reduced mobility, cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, weakness, history of positive for COVID-19 on 01/10/22, chronic atrial fibrillation, iron deficiency anemia, and pneumonia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/14/22, revealed the resident had (intact/ impaired) cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of one to two…

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 staff interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and #46 oxygen (O2) equipment was stored properly and Resident #4's oxygen orders were documented accurately. This affected two Residents (#4 and #46) of three residents reviewed for respiratory care. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 02/19/22 with diagnoses including chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, chronic combined systolic (congestive) and diastolic (congestive) heart failure, acute respiratory failure with hypoxia, obstructive sleep apnea (OSA), other nonspecific abnormal finding of lung field, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/28/22, revealed Resident #46 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of eight out of 15 (moderate impairment). The resident required limited to extensive assistance of one to two or more staff members for all activities of daily living (ADL's).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and resident and staff interviews, the facility failed to provide Resident #8 social services to obtain sufficient clothing. This affected one resident (Resident #8) of one resident reviewed for social services. Findings include: Resident #8's was admitted on [DATE] with medical diagnosis including anxiety, depression, cognition, pain, wheezing, UTI, glaucoma, restless leg syndrome and depression. Resident #8's medical record revealed she did not have family and she had a lawyer for power of attorney. The record identified Resident #8 resided in an apartment prior to falling, going to the hospital and then being admitted at the facility. Review of Resident #8's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she was cognitively intact, with periods of confusion. The MDS indicated it was very important for Resident #8 to take care of belongings. Observation of Resident #8 on 05/23/22 at 12:21 P.M. revealed the resident had a pair of jeans and shirt…

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.