Canal Winchester Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility nutrition policies, the facility failed to ensure one ( Resident #66) did not experience a significant weight loss and failed to ensure one ( Resident #92's) fluid restriction was followed. This affected two of seven residents (#14, #36, #44, #66, #92, #10, and #10) reviewed for nutrition. The facility census was 112.Findings include: 1. Review of Resident #66's electronic medical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, anxiety disorder, stage three chronic kidney disease, type two diabetes mellitus, muscle weakness, personal history of neoplasm of the large intestine, and acquired absence of other specified of the digestive tract amongst other diagnoses. Further review of Resident #66's electronic medical record revealed a Brief Interview for Mental Status (BIMS) score of eight (dated 11/08/25), suggesting…

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 follow physician orders for oxygenation therapy for Resident #06 and continuous positive airway pressure, (CPAP) use for Resident #36. This affected two residents, (Residents #06 and #36) of four residents reviewed for respiratory care. The facility census was 112.Findings Include:1.Record review for Resident #06 revealed this resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction, diabetes mellitus, chronic respiratory failure with hypoxia, anxiety, depression, congestive heart failure and choric obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require mobility and self-care assistance. Review of the care plan dated 01/02/26 revealed Resident #06 has altered respiratory status and breathing 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 medical record review and staff interview, the facility failed to timely and thoroughly address all pharmacy recommendations. This affected two (Residents #7 and #3) of five residents reviewed for pharmacy recommendations. The census was 112.Findings Include:1. Resident #7 was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure, non-displaced intertrochanteric fracture of left femur, disorder of muscle, acute pulmonary edema, other acute osteomyelitis, cardiomyopathy, hypokalemia, peripheral vascular disease, congestive heart failure, atrial fibrillation, chronic kidney disease (stage IV), atherosclerotic heart disease, hypo-osmolality and hyponatremia, Type II Diabetes, ischemic cardiomyopathy, anxiety disorder, shortness of breath, depression, obesity, insomnia, muscle weakness, hypertension, edema, and umbilical hernia. Review of his minimum data set (MDS) assessment, dated 01/19/26, revealed he was cognitively intact. Review of Resident #7 pharmacy recommendation, 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 observations, medical record review, staff interview, and facility policy review, the facility failed to ensure transmission based precautions and personal protective equipment usage were followed as required. This had the potential to affect 21 (Residents #44, #15, #22, #27, #122, #137, #61, #138, #89, #13, #24, #114, #62, #58, #23, #115, #56, #38, #126, #90, and #66) of 112 residents in the facility. Also, the facility failed to use proper hand hygiene after administering medications and performing wound care treatment. This affected two (Residents #73 and #91) of six residents reviewed for infection control practices. The census was 112.Findings Include:1. Observations on 02/09/26 at 7:05 P.M. revealed Certified Nursing Assistant (CNA) #116 was in Resident #61's room with a mask around their chin. CNA #116 did not have any other personal protective equipment (PPE) on while in the resident's room. Resident #61's room door was observed and had two signs on her door; one for droplet isolation…

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 and staff interview, the facility failed maintain a safe environment free of hazardous chemicals for one (Resident #97) of 17 residents on the 300 hall way. The census was 112. Findings include:Review of Resident #97's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertension, hyperlipidemia and atrial fibrillation. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively impaired, used a walker and wheelchair for mobility, and had no behaviors. The facility identified Resident #97 as being cognitively impaired, independent with ambulation and mobility, and residing on the 300 hallway.Observation on 02/11/2026 at 11:03 A.M. of the 300 hallway revealed residents up and about the hallways and a container of microdot minute wipes (clean and disinfectant wipes) on top of both medication carts stored on the 300 hallway.Review of the microdot minute wipe…

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 review, staff interviews, and review of facility policy, the facility failed to provide care and services to prevent falls. This affected two residents (Resident #15 and Resident #120) out of five residents reviewed for falls. The facility census was 100 residents.Findings include: 1. Review of the medical record revealed Resident #120 was admitted to the facility on [DATE] and had diagnoses that included pulmonary hypertension, dementia and spondylosis. The resident was discharged home from the facility on 10/10/25. Review of Resident #120's admission assessment on 09/27/25 revealed that she was at risk for falls and she was to have two-person assistance with bed mobility. Review of Resident #120's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #120 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. She was assessed as needing touch assistance for mobility and transfers. Review of Resident #120's baseline care plan…

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 provide timely care for surgical incision staple removal for Resident #103 and Resident #109. The facility also failed to obtain physician ordered daily weights for Resident #83. This affected two residents (#103 and #109) of three residents reviewed for wound/incisional care and one resident (#83) of three residents reviewed for implementation of physician orders. The facility census was 108. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 08/15/22 with diagnoses including fractured femur, sick sinus syndrome, attention deficit hyperactivity disorder (ADHD), mood disorder, cerebral infarction with associated hemiplegia and hemiparesis, anxiety disorder, depression, dependence on wheelchair, presence of pace maker, presence of artificial hip joint (left), and presence of cerebrospinal fluid (CSF) draining device. Review of progress notes for Resident #103 revealed Resident #103 had surgery…

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

Based on observation, medical record review, skin assessments and interviews, the facility failed to ensure skin breakdown prevention interventions were in place. This affected one resident (#103) of one resident reviewed for pressure ulcers. The facility census was 108. Findings Include: Review of the medical record for Resident #103 revealed an initial admission date of 08/15/22 with the latest readmission of 04/26/25 with the diagnoses including but not limited to nondisplaced intertrochanteric fracture of left femur, sick sinus syndrome, anemia, mood disorder, contracture of muscle, multiple sites, attention-deficit hyperactivity disorder, overactive bladder, cerebrovascular accident with left sided hemiplegia, anxiety disorder, insomnia, depression, adult failure to thrive, osteoarthritis, constipation, personal history of traumatic brain injury and hypertension. Review of the plan of care dated 12/07/22 revealed the resident was at risk for pressure ulcer formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure timely notification to the resident and medical practitioner regarding a change in the resident's condition and need to alter the resident's treatmet plan. This affected one resident (#98) of nine residents reviewed for notification. The facility census was 104. Findings include: Review of Resident #98's medical record revealed an admission date of 12/10/19, a re-entry date of 01/28/25 with diagnoses including cerebral infarction, neuropathy, anxiety and major depression. Review of Resident #98's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 15/15 indicating the resident had intact cognition. Review of Resident #98's progress note dated 03/27/25 at 2:43 P.M. revealed the resident was having lower back pain and facility staff notified the nurse practitioner and obtained orders to get an x-ray and to give Tylenol 500 milligrams two tablets three times daily as needed for pain. 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.

Based on interview and medical record review the facility failed to develop a comprehensive resident centered pressure ulcer prevention care plan for one resident (#107) of five reviewed for prevention of alterations in skin integrity. The facility census was 104. Findings include: Review of Resident #107's medical record revealed an admission date of 02/23/25, a discharge date of 03/12/25 and diagnoses including diverticulitis of the intestine with perforation and abscess, influenza, colostomy status, bladder disorder, rheumatoid arthritis, anxiety, unspecified disorder of psychological development and unspecified intellectual disabilities. Review of Resident #107's admission minimum data set (MDS) revealed a brief interview for mental status score of 12 indicating the resident was moderately cognitively impaired. Further review of Resident #107's MDS revealed the resident to be at risk for pressure ulcers, to be receiving a surgical wound care and to be using a pressure reducing mattress. Review of Resident #107's care plan revealed no care plan in place to prevent the development…

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, staff interview, and facility policy review, the facility failed to follow proper infection control and isolation precaution procedures. This affected four (Residents #18, #77, #80, and #81) of four residents reviewed for infection control procedures. The facility census was 102. Findings Include: Observations on 02/20/25 from 10:30 to 10:40 A.M. revealed Resident #77 and Resident #80 had personal protective equipment (PPE) carts in front of each of their rooms. But there were no signs outside of their doors indicating if they were actually on isolation precautions or what type of isolation precautions they were on. Interview with Licensed Practical Nurse (LPN) #103 on 02/20/25 at 10:35 A.M. confirmed Residents #77 and #80 were on contact/droplet isolation precautions for being diagnosed with influenza. The nurse confirmed there should have been signs outside the door, indicating the type of isolation precautions the residents were on as a safety mechanism for staff…

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 facility self-reported incident (SRI), and staff interview, the facility failed to ensure all residents were treated with dignity and respect. This affected one (Resident #71) of two residents reviewed for dignity. The facility census was 102. Findings Include: Resident #71 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, acute cystitis, hypothyroidism, type II diabetes, vitamin D deficiency, hyperlipidemia, anxiety disorder, atrial fibrillation, lymphedema, chronic obstructive pulmonary disease (COPD), insomnia, chronic kidney disease, myopia, mood disorder, hypertension, depression, bipolar disorder, morbid obesity, and dependent on supplemental oxygen. Review of her Minimum Data Set (MDS) 3.0 assessment, dated 01/13/25, revealed she was cognitively intact. Review of SRI tracking number 256314, dated 01/21/25, revealed Resident #71 reported that Certified Nursing Aide (CNA) #110 made an inappropriate comment to her while…

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 and interviews, the facility failed to ensure Resident #31's call light was answered in a timely manner. This affected one resident (#31) of seven sampled residents. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of [DATE] with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data Set…

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 of photographs, interviews and facility policy review, the facility failed to report an injury of unknown origin for one resident (#51) with facial bruising who was dependent on staff to the required state agency. This affected one (Resident #51) of one resident reviewed for injury of unknown origin. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with the diagnoses including but not limited to cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, stage IV pressure ulcer left ankle, Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated…

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 of photographs, interviews and facility policy review, the facility failed to timely investigate an injury of unknown origin for one resident (#51) with facial bruising who was dependent on staff. This affected one (Resident #51) of one resident reviewed for injury of unknown origin. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with the diagnoses including but not limited to cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, stage IV pressure ulcer left ankle, Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure fall interventions were in place for one resident (#43) with a known fall history. This affected one (Resident #43) of three residents reviewed for falls. The facility census was 72. Findings Include: Review of the medical record for Resident #43 revealed an initial admission date of 05/06/19 with the diagnoses including aphasia, history of falls, chronic kidney disease, dysphagia, constipation, dry eye syndrome, pain, atrial fibrillation, hyperlipidemia, non-traumatic intracerebral hemorrhage, dementia, major depressive disorder, hypertension, aphasia, generalized muscle weakness, gastro-esophageal reflux disease, gastrointestinal hemorrhage, retention of urine and age related nuclear cataract. Review of the plan of care dated 08/23/22 revealed the resident was at risk for falls and had potential for injury related to deconditioning, incontinence, unaware of safety needs, vision/hearing problems, history 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 observation, medical record review and staff interview, the facility failed to ensure Resident #31's oxygen nasal cannula was stored in a sanitary manner. This affected one resident (#31) of seven sampled residents. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the 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 medical record review and staff interview, the facility failed to ensure timely availability of medication for administration for one resident (#31). This affected one (Resident #31) of three resident received for new medication. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to timely obtain a physician ordered laboratory test for one resident (#31). This affected one (Resident #31) of three reviewed for a change in condition. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data…

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, interviews and review of photographs, the facility failed to maintain resident equipment in good repair or a clean and sanitary manner. This affected one resident (#31) of three sampled residents. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident'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 observation and interview, the facility failed to maintain a clean and sanitary environment. This affected one unit (500 unit) of four units. The facility census was 72. Findings Include: On 09/30/24 at 10:00 A.M., observation of Resident #31's carpeting revealed the carpet was stained with black and white spots. Interview with Resident #31 revealed the stains were present on the carpet when she was admitted and had offered to pay to have the carpeting shampooed. On 09/30/24 at 10:20 A.M., observation of room [ROOM NUMBER] (unoccupied) revealed the carpeting was stained black in multiple areas. On 09/30/24 at 10:21 A.M., observation of resident room [ROOM NUMBER] revealed the carpeting was stained black in multiple areas. On 10/03/24 at 10:30 A.M., interview with Licensed Practical Nurse (LPN) #155 verified the stained carpeting in rooms 506, 511,and Resident #31's room. This deficiency represents non-compliance investigated under Complaint Number OH00158259, Complaint Number OH00158032 and Complaint…

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, observation, staff interview, and review of facility policy, the facility failed to ensure staff used appropriate hand hygiene and personal protective equipment (PPE) to prevent the spread of Coronavirus (COVID-19). This had the potential to affect 16 residents (#5, #7, #10, #23, #25, #26, #32, #36, #37, #41, #46, #50, #59, #60, #62 and #77) who resided in the hall where staff delivered meal trays without implementation of appropriate COVID-19 protocols. The facility identified two residents (#3 and #52) as having active COVID-19 infection. The facility census was 79 residents. Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/27/24 with diagnoses including severe persistent asthma, shortness of breath, and COVID-19. Review of the nurse progress note for Resident #52 dated 08/12/24 revealed the resident tested positive for infection with COVID-19 after exposure from an infected family member was reported. The facility implemented…

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

Based on medical record review, review of hospital records, resident representative interview, staff interview, and review of facility policy, the facility failed to ensure appropriate care and services were provided to residents following accidents with injury. This affected one (Resident #99) of three residents reviewed for accidents. The facility census was 79 residents. Findings include: Review of the medical record for Resident #99 revealed an admission date of 07/02/24 with diagnoses including diffuse large B-Cell lymphoma, muscle weakness, viral hepatitis B, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment for Resident #99 dated 07/06/24 revealed the resident had mildly impaired cognition and required partial/moderate assistance with turning from side to side. Review of the nurse progress note for Resident #99 dated 08/03/24 revealed the resident was being changed and assisted with bed mobility and hit her head on the side rail. There was no swelling or redness was noted. The facility did not notify the physician of the incident, nor did they…

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

Based on record review, interview, observation and policy review, the facility failed to ensure food was served at a palatable and warm temperature. The deficient practice affected four residents (#9, #10, #29, and #49) and had the potential to affect all residents who received meals from the kitchen except two residents (#32 and #34) who were identified by the facility as receiving nothing by mouth (NPO). The facility census was 80. Findings include: 1. Review of medical record for Resident #9 revealed admission date of 10/21/22 with diagnoses including diverticulosis of large intestine, dysphagia, and irritable bowel syndrome. Interview with Resident #9 on 04/15/24 at 3:13 P.M. revealed the food was served cold, and they have trouble with keeping temperature. 2. Review of medical record for Resident #10 revealed admission date of 04/19/23 with diagnoses including congestive heart failure, type II diabetes, and morbid obesity. Interview with Resident #10 on 04/15/24 at 11:17 A.M. revealed the food was cold and lukewarm. 3. Review of medical record for Resident #29 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.

Based on observation, interview, and record review the facility failed to ensure food was properly date labeled, clean dishware was clean, and food was held at proper hot holding temperatures. The deficient practice had the potential to affect all residents who received meals from the kitchen except two residents (#32 and #34) who were identified by the facility as receiving nothing by mouth (NPO). The facility census was 80. Findings include: 1. Observation on 04/15/24 at 11:28 A.M. with Dietary Manager #299 revealed three large plastic containers containing iced tea, lemonade, and punch were dated 04/15/24 to 04/25/24. A tub of chocolate pudding was also observed dated 4/13/24 to 5/13/24. Dietary Manager #299 changed the dates on the beverages to 4/15/24 to 4/20/24. Dietary Manager #299 was also observed changing the date on the pudding to an end date of 04/19/24. Interview on 04/15/24 at 11:28 A.M. with Dietary Manager #299 revealed time controlled for safety (TCS) foods are dated for five days at this facility. When questioned on what tells us about how long beverages should be…

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, interview, and facility policy review, the facility failed to ensure the primary care physician (PCP) was notified of elevated blood glucose levels outside of the physician ordered parameters. This affected one resident (#16) of five residents reviewed for unnecessary medications. The facility census was 80. Findings include: Review of the medical record for Resident #16 revealed an initial admission date of 04/05/22 with the latest readmission of 04/05/24 with diagnoses including osteomyelitis, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus, asthma, maple syrup urine disease, dissociative identity disorder, chronic kidney disease, hyperlipidemia, and hypertension. Review of the plan of care dated 08/23/22 revealed Resident #16 was at risk for hypo/hyperglycemia episodes. Interventions included accu-checks as ordered, administer medications as ordered, lab results as ordered with reported to PCP, monitor for signs/symptoms of hyperglycemia and hypoglycemia, monitor for signs/symptoms of infection, and notify physician of abnormal…

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, observation, interviews and facility policy review, the facility failed to ensure nail care was provided for Resident #22 who was dependent on staff. This affected one resident (#22) of three residents reviewed for activities of daily living (ADL). The facility census was 80. Findings include: Review of the medical record for Resident #22 revealed an initial admission date of 10/26/23 with diagnoses including cerebral infarction, chronic kidney disease, chronic obstructive pulmonary failure, anemia, diabetes mellitus, hyperlipidemia, hypertension, depression, insomnia, allergic rhinitis, constipation, pain, and dysphagia. Review of the plan of care dated 01/26/24 revealed Resident #22 had a self-care performance deficit related to ADL, abilities will fluctuate between therapy staff and nursing staff, confusion, fatigue, impaired balance, limited mobility, limited range of motion, and stroke. Interventions included ADL level varies with task and time of day, may provide more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to identify an injury to Resident #35's left great toe and toenail. This deficient practice affected one resident (#35) out of two residents reviewed for general skin conditions. The facility census was 80. Findings include: An observation on 04/15/24 at 12:38 P.M. revealed Resident #35's left great left toe covered with a gauze bandage and secured with a piece of tape. There were no initials, date, or time written on the bandage. An observation on 04/16/24 at 2:26 P.M. revealed Licensed Practical Nurse Unit Manager (LPN UM) #205 removing the gauze bandage from Resident #35's left great toe. There was dark red drainage noted to the gauze bandage. Resident #35's left great toenail was observed to be thick and long curving towards the inside of the foot. There was dried dark red drainage observed on the outside edges of the toenail. The toenail was intact with no evidence of being trimmed or filed recently. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview and facility policy review, the facility failed to ensure pressure reducing devices were in place for Resident #17. This affected one resident (#17) of three residents reviewed for pressure ulcers. The facility census was 80. Findings include: Review of the medical record for Resident #17 revealed an initial admission date of 11/01/23 with the latest readmission of 01/28/24 with diagnoses including but not limited to osteomyelitis left ankle and foot, asthma, dementia, diabetes mellitus, chronic kidney disease, atrial flutter, anxiety disorder, spinal stenosis, convulsions, hypertension, dry eye syndrome, and gout. Review of the plan of care dated 11/24/23 revealed Resident #17 had actual impairment to skin related to fragile skin, incontinence, dementia, diabetes mellitus, chronic kidney disease, weakness, aging process, decreased mobility, decreased safety awareness, need for assistance, and right lateral malleolus was surgical, but documentation…

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, observation, interviews and facility policy review, the facility failed to ensure Residents #16 and #68 individualized fall preventative interventions were in place. This affected two residents (#16 and #68) of five residents reviewed for accidents. The facility census was 80. Findings include: 1. Review of the medical record for Resident #16 revealed an initial admission date of 04/05/22 with the latest readmission of 04/05/24 with diagnoses including osteomyelitis, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus, asthma, maple syrup urine disease, dissociative identity disorder, chronic kidney disease, hyperlipidemia, and hypertension. Review of the plan of care dated 08/23/22 revealed Resident #16 was at risk for falls and potential for injury related to confusion, conditioning, incontinence, poor communication/comprehension, cognitive impairment, diabetes mellitus, asthma, maple syrup urine disease, weakness, aging process, assistance devices and effects 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 observation, interview, record review and facility policy review, the facility failed to have a physician's order for the use of oxygen for Resident #35. This deficient practice affected one resident (#35) out of two residents reviewed for respiratory care. The facility census was 80. Findings include: An observation on 04/16/24 at 12:43 P.M. revealed Resident #35 receiving oxygen via nasal cannula with tubing attached to an oxygen concentrator located at the bedside. The oxygen concentrator was set at four liters, and the oxygen tubing leading to Resident #35 was dated 04/14/24. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Lewy Bodies disorder, Alzheimer's disease, high blood pressure, and chronic obstructive pulmonary disease (COPD). Resident #35 had impaired cognition and was dependent on staff for care. Review of Resident #35's signed physician orders for the month of April 2024 revealed Resident #35 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview and facility policy review, the facility failed to ensure a medication error rate of less than five percent. Twenty-nine opportunities for error were observed with three medication errors made resulting in a 10.34 percent error rate. This affected two residents (#17 and #19) of three residents observed during medication administration. The facility census was 80. Findings include: 1. Review of the medical record for Resident #19 revealed an initial admission date of 05/16/18 with the latest readmission of 02/02/24 with diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, dysarthria and anarthria, dysphagia, atrial fibrillation, hypertension, chronic kidney disease, hyperlipidemia, anxiety disorder, major depressive disorder, dementia, hydrocephalus, gastro-esophageal reflux disease, epilepsy, congestive heart failure, and hypokalemia. Review of the plan of care dated 10/12/22 revealed Resident #19 had gastroesophageal…

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, resident interview, staff interview, and facility document review, the facility failed to provide drinks and meals to residents in a timely/respectful manner. This affected 10 residents (#8, #13, #14, #15, #16, #35, #37, #39, #48, and #67) of 18 residents in the 300 hallway who receive meals by mouth. The facility census was 79. Findings include: Observations on 06/25/23 from 12:10 P.M. to 12:42 P.M. revealed ten residents (#8, #13, #14, #15, #16, #35, #37, #39, #48, and #67) sitting in the 300-hallway dining room with no drinks available or offered to them. At 12:37 P.M., the food cart for the room trays arrived for the 300 hallway rooms, not the dining room. All 10 residents watched meals and drinks be passed to the residents in the rooms. At 12:42 P.M., a cup of water was offered to Residents #14 and #48 after they requested it; no drinks were offered to the other eight residents. It wasn't until 12:46 P.M. that all other residents were asked if they wanted something to…

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

Based on observations, facility document review, resident interview, and staff interview, the facility failed to provide meals in a timely manner. This affected 32 residents (#3, #4, #5, #8, #11, #13, #14, #15, #16, #24, #30, #35, #37, #39, #43, #44, #48, #52, #58, #60, #61, #63, #64, #68, #67, #77, #181, #182, #183, #184, #185, and #186) of 32 residents who receive meals from the 100 and 300 hallways in the facility. The census was 79. Findings include: 1. Observations on 06/25/23 from 12:10 P.M. to 12:37 P.M. revealed multiple residents in the 300-dining room and in their rooms of the 300-hallway, waiting for lunch. Meals were delivered to the 300-hallway rooms, starting at 12:37 P.M. and ending at 12:42 P.M. Observations on 06/25/23 from 12:10 P.M. to 1:12 P.M. revealed ten residents in the 300-hallway dining room, waiting for lunch to be served. Lunch was served at 1:12 P.M. Review of facility mealtimes revealed the lunch mealtimes for the 100-hallway hall trays were supposed to be delivered between 11:40 A.M. to 11:45 A.M. Also, the 300-hallway hall trays were supposed to be…

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

Based on observation, interview, and review of facility policy revealed the facility failed to ensure the kitchen was maintained in a sanitary manner, food was labeled and dated, and residents were not served expired food. This affected Resident #27 and had the potential to affect 77 of the 79 residents residing in the facility. The facility identified two residents (#15 and #34) who ate nothing by mouth. The facility census was 79. Findings include: 1. Observation on 06/25/23 at 9:00 A.M. revealed the following verified concerns: a. Observation of the refrigerator revealed a container of sausage patties with a use by date of 06/23/23, a container of brown gravy with a use by date of 06/24/23, and sloppy joes with a use by date of 06/21/23. This was verified by Dining Services Manager #120 at that time. b. Observation of the dry storage room revealed a large container of thickener dated 04/05/22 and a container of rice with no date on it. Observation of the floor in the room revealed multiple unidentifiable spills were observed across the floor and were noted to be thicker closer to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, activities calendar, and policies, the facility failed to thoroughly assess and care plan activities and failed to ensure activities were available to two cognitively impaired residents (#61 and #68) on the weekends. This affected two residents (#61 and #68) of two residents reviewed for activities. The facility census was 79. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 03/03/22 with diagnoses including chronic obstructive pulmonary disease, pressure-induced deep tissue damage, chronic kidney disease stage three, anxiety disorder, encephalopathy, dementia, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had severely impaired cognition. Review of the plan of care dated 03/02/23 revealed Resident #61 showed no interest in group activity secondary to general weakness and terminal diagnosis. Interventions included providing reading,…

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 the follow physician orders as written. This affected one resident (#12) of 17 resident physician orders reviewed. The facility census was 79. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, morbid obesity, hyperlipidemia, gout, congestive heart failure, muscle weakness, sleep apnea, adjustment disorder, major depressive disorder, chronic kidney disease (stage III), anemia, hypertension, atrial fibrillation, transient cerebral ischemic attack, restless leg syndrome, sciatica, pain, and unsteadiness on feet. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #12's current physician orders revealed the facility was to check her weight every Monday and Thursday and notify the physician if there was a greater than three-pound change. This order 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 and interview the facility failed to ensure accurate documentation and proper treatment for Resident #73's pressure ulcer and failed to ensure Resident #61's treatments for her pressure ulcer were completed and documented in the medical record. This affected two residents (#61 and #73) of four reviewed for pressure ulcers. The facility census was 79. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 03/03/22 with diagnoses including chronic obstructive pulmonary disease, pressure-induced deep tissue damage, chronic kidney disease stage three, anxiety disorder, encephalopathy, dementia, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had severely impaired cognition. She had two unstageable deep tissue injuries (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear). 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.

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 complete weight/nutritional monitoring as needed. This affected two residents (#16 and #55) of seven residents reviewed for nutrition. The facility census was 79. Findings include: 1. Resident #16 was admitted to the facility on [DATE]. Her admitting diagnoses were non-traumatic intracerebral hemorrhage in hemisphere, chronic obstructive pulmonary disease, hemiplegia and hemiparesis, mood disorder, peripheral vascular disease, hypertension, seborrheic dermatitis, insomnia, and dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 05/16/23, revealed she had a significant cognitive impairment. Review of Resident #16 weights, dated 11/01/23 to 06/10/23, revealed the following significant weight changes: 11/01/22 (127.6 pounds) to 12/19/22 (139.4 pounds), which was a 9.2 percent increase. 12/19/22 (139.4 pounds) to 01/17/23 (132.5 pounds), which was a 5 percent decrease. 01/17/23 (132.5 pounds) to 02/13/23…

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 medical record review, staff interview, and facility policy review, the facility failed to provide adequate parameters for physician orders. This affected two residents (#17 and #10) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Resident #17 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney stage IV, type II diabetes, epilepsy, end stage renal disease, nephrotic syndrome, hemiplegia and hemiparesis, anemia, hyperlipidemia, depression, cognitive communication deficit, gout, anemia, insomnia, osteoarthritis, pain, and long-term use of insulin. Review of his Minimum Data Set (MDS) assessment, dated 06/13/23, revealed she was cognitively intact. Review of Resident #17's physician orders revealed an order for Oxycodone HCl 5 milligrams (mg) to be given once every six hours as needed for pain. Also, she had an order for Acetaminophen 325 mg, two tabs every six hours as needed for pain. Neither as needed pain medication had…

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 medical record review the facility failed to ensure Resident #68 was provided with a mechanical soft diet as ordered. This affected one resident (#68) of 17 on a mechanically altered diet. The facility census was 79. Findings include: Review of the medical record for Resident #68 revealed an admission date of 11/19/22 with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, sciatica, dysphagia, cognitive communication deficit, and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had severely impaired cognition. She was on a mechanically altered diet. Review of the physician order dated 05/12/23 revealed Resident #68 had an order for a mechanical soft textured diet. Observation on 06/25/23 between 12:27 P.M. and 12:41 P.M. revealed Resident #68 was served a meal by State Tested Nursing Aide (STNA) #140. Resident #68 was served a whole piece of Salisbury steak, mashed potatoes, green beans,…

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 prevent a catheter bag from lying on the floor causing potential infection control issues. This affected one resident (#73) of two residents reviewed for urinary catheters. The facility census was 79. Findings included: Record review revealed Resident #73 admitted to the facility on [DATE] with diagnoses including osteomyelitis, severe protein-calorie malnutrition, constipation, psoriasis, pressure ulcer of sacral region stage II, discitis of lumbar region, retention of urine, anorexia, benign prostatic hyperplasia without lower urinary tract symptoms, insomnia, pain of bilateral hips, personal history of diseases of the skin and subcutaneous tissue, personal history of urinary tract infections, and presence of urogenital implants. Review of Resident #73's care plan dated 05/22/23 revealed Resident #73's catheter bag should be anchored to prevent tugging or tension on the catheter. On 06/26/23 at 9:50 A.M. an observation was made 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.