McKinley Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure infection control standards were maintained during medication administration for Resident #50 and during incontinence care for Resident #24. The facility failed to ensure contact precautions were in place for Resident #1. The facility failed to ensure the infection control policy was reviewed annually. Additionally, the facility failed to ensure the Legionella water management program comprehensively assessed risk measures for their elderly population. This had the potential to affect all residents residing in the facility. The facility census was 151.Findings include: 1.Review of the facility's Legionella risk assessment, undated, revealed the facility had a municipal water source. The assessment evaluated the risk of Legionnaires' disease associated with the facility's water systems and supports compliance with the Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and American…

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 personnel file review, review of the facility assessment, and interviews, the facility failed to conduct mandatory training to all staff on the facility's quality assurance and performance improvement (QAPI) program. This affected five out of 11 personnel files reviewed and had the potential to affect all 151 residents residing in the facility. The facility census was 151. Findings include: Review of Certified Nursing Assistant (CNA) #464's personnel file revealed a hire date of 12/23/25. There was no documented evidence that CNA #464 had received QAPI training as required.Review of CNA #465's personnel file revealed a hire date of 01/06/26. There was no documented evidence that CNA #465 had received QAPI training as required.Review of CNA #466's personnel file revealed a hire date of 02/26/26. There was no documented evidence that CNA #466 had received QAPI training as required.Review of Licensed Practical Nurse (LPN) #338's personnel file revealed a hire date of 09/16/25. There was no documented evidence that LPN #338 had received QAPI training as required.Review of Human…

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

Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA) had at least 12 hours of in-service training annually as required. This had the potential to affect all residents residing in the facility. The facility census was 151.Findings include:Review of the employee file for Certified Nursing Assistant (CNA) #325 revealed a hire date of 03/13/25. Continued review of the employee file revealed CNA #325 had not received 12 hours of in-service training annually as required. Review of the employee file for CNA #386 revealed a hire date of 01/15/25. Continued review of the employee file revealed CNA #386 had not received 12 hours of in-service training annually as required. Review of the employee file for CNA #425 revealed a hire date of 03/04/25. Continued review of the employee file revealed CNA #425 had not received 12 hours of in-service training annually as required. Interview on 04/29/26 at 2:26 P.M. with Human Resources Director (HR) #307 verified the CNA's had not completed the 12 hours of in-service training annually as required. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to conduct care conferences at least quarterly as required. This affected nine residents (#6, #62, #65, #66, #74, #75, #119, #138, and #139) of nine residents reviewed for care planning. Facility census was 151. Findings include: 1. Review of Resident #139's medical record revealed an admission date of 09/05/24 and diagnoses including dementia with other behavioral disturbance, depression, anxiety, hypertension, and osteoarthritis. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #139 was cognitively impaired. Further review of Resident #139's medical record for the last twelve months revealed one care conference completed on 07/31/25. Telephone interview on 04/19/26 at 11:20 A.M. with Resident #139's guardian revealed she was concerned Resident #139 had not had a care conference since July 2025. Interview on 04/21/26 at 2:45 P.M. with MDS/Licensed Practical Nurse (LPN) #379 during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy the facility failed to timely notify the responsible party and physician of changes. This affected four residents (#2, #56, #138 and #153) of five residents reviewed for notification of change. Facility census was 151. Findings include:1.Review of Resident #56's medical record revealed an admission date of 01/30/24 and diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type two diabetes, dementia with mood disturbance and chronic kidney disease stage three. Review of an annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and had two or more falls since the previous assessment without injury. Review of a fall investigation dated 12/31/25 at 2:45 A.M. revealed Resident #56 tried to transfer herself from her wheelchair to her toilet and fell to the floor. The report indicated the nurse practitioner (NP) was notified. Under the report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to ensure residents were free of misappropriation of controlled medications. This affected four residents (Residents #1, #3, #47 and #154) of five residents reviewed for controlled substances. The facility census was 151. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 01/20/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure and arthritis. Review of the physician's orders for Resident #1 revealed an order for Oxycodone (opioid medication for pain) 10 milligrams (mg) every four hours dated 03/27/26. The medication was to be administered at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. daily. Review of the Medication Administration Record (MAR) for April 2026 for Resident #1 revealed Oxycodone 10 mg was administered on 04/27/26 at 1:00 A.M., 5:00 A.M., 9:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to implement and follow their policy for allegations of abuse for residents. This affected four residents (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151. Findings include:1. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered on 12/13/25 at 8:15 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 record review, interview, review of self-reported incident (SRI) and review of the facility policy, the facility failed to thoroughly investigate an allegation of abuse, misappropriation and injury of unknown origin for residents. This affected four (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151. Findings include: 1. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected five (Residents #5, #9, #15, #35 and #107) of 48 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 151. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 06/25/25 with diagnoses including multiple sclerosis, dementia and obstructive reflux uropathy (a blockage in the urinary tract that stops urine from flowing). Review of Resident #5's physician's orders from March of 2026 revealed she had an indwelling catheter related to obstructive reflux uropathy dated 12/02/25. Review of the nursing progress notes from 03/01/26 through 03/31/26 revealed Resident #5 had a foley catheter. There was no evidence she had any other indwelling devices. Review of the quarterly modified Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under section H that Resident #5 had an indwelling catheter. It was also documented she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to formulate a complete baseline care plan timely after admission. This affected 22 residents (#2, #3, #4, #9, #12, #15, #48, #50, #53, #56, #62, #81, #91, #95, #98, #100, #107, #113, #117, #139, #154 and #160) of 62 residents reviewed for care plans. Facility census was 151.Findings include:1. Review of Resident #53's medical record revealed an admission date of 08/29/25 and diagnoses including Alzheimer's disease, dementia, depression anxiety and Crohn's disease. Review of a significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severe cognitive impairment. Further review of Resident #53's medical record revealed no baseline care plan could be found. Interviews on 04/22/26 at 9:16 A.M. and on 04/27/26 at 9:28 A.M. with MDS/Licensed Practical Nurse (LPN) #379 revealed she was not responsible for the baseline care plan as floor nurses created this. MDS/LPN #379 verified she was unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to formulate an accurate and comprehensive care plan as required. This affected five residents (#2, #38, #47, #91 and #139) of 62 residents reviewed for care plans. Facility census was 151.Findings include:1. Review of Resident #139's medical record revealed an admission date of 09/05/24 and diagnoses including dementia with other behavioral disturbance, depression, anxiety, hypertension, and osteoarthritis. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #139 was cognitively impaired and received medications including opioids. Review of Resident #139's physician's orders revealed an order dated 07/22/25 for morphine sulfate solution 20 milligrams (mg)/milliLiter (mL), give five mg by mouth every four hours as needed for pain one to 10 and/or dyspnea and an order dated 03/14/26 for admission to hospice services. Review of Resident #139's care plans revealed no care plan was in place…

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 the facility policy, the facility failed to implement effective fall interventions and post fall assessments including neurological checks to ensure resident safety. This affected four residents (Resident #2, #42, #56 and #91) of six residents reviewed for falls. Facility census was 151.Findings include:1. Review of Resident #42's medical record revealed an admission date of 10/28/22 and diagnoses including acute and chronic respiratory failure, type two diabetes, peripheral vascular disease, anxiety and schizoaffective disorder. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had moderate cognitive impairment and rejected care one to three days in the seven day look-back period. Review of a fall risk assessment dated [DATE] revealed Resident #42 was up at lib and at risk for falls. Review of a fall investigation for 08/05/25 at 2:56 P.M. revealed Resident #42 was heard yelling out in her room. Upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician visits were provided as required. This affected five residents (#5, #35, #42, #44, and #53) of 62 residents reviewed for physician visits. Facility census was 151.Findings include: 1. Review of Resident #42's medical record revealed an admission date of 10/28/22 and diagnoses including acute and chronic respiratory failure, type two diabetes, peripheral vascular disease, anxiety and schizoaffective disorder. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had moderate cognitive impairment and rejected care one to three days in the seven day look-back period. Review of the last 12 months of physician visit documentation revealed Resident #42 was seen on 04/24/25, 08/07/25, 09/11/25, 09/25/25 and 03/05/26. Interview on 05/04/26 at 1:55 P.M. with the Director of Nursing (DON) verified there were no other visits to provide regarding Resident #42 and confirmed she was not seen by the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were free of significant medication errors. This affected four (Residents #1, #4, #47 and #117) of 13 residents reviewed for significant medication errors. The facility census was 151. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 01/20/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure and arthritis. Review of the physician's orders for Resident #1 revealed an order for Oxycodone (opioid medication for pain) 10 milligrams (mg) every four hours dated 03/27/26. The medication was to be administered at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. daily. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1's cognition was intact. Review of the Medication Administration Record (MAR) for April 2026 for Resident #1 revealed Oxycodone 10 mg was administered as ordered…

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

Based on observation, interview, record review and review of facility policy, the facility failed to ensure a mechanical soft diet texture was prepared in a form to meet individual resident needs. This affected 29 Residents (#5, #11, #12, #19, #21, #22, #31, #38, #44, #46, #54, #58, #68, #79, #81, #82, #95, #100, #105, #109, #110, #122, #123, #132, #135, #137, #140, #141, and #147) identified as receiving a mechanical soft diet. The facility census was 151.Findings include:Review of the Diet Spreadsheet for the Spring/Summer menu, dated 2024, revealed a mechanical soft diet would receive ground ham and beans, soft chopped greens, cornbread with margarine, and soft chopped fruit cobbler.Review of the recipe for Ground Ham and Beans, dated 2026, revealed ham would be ground before adding it to the recipe.Observations on 04/22/26 from 12:06 P.M. to 2:38 P.M. of lunch tray service revealed there was no ground, mechanical soft ham and beans prepared for the mechanical soft diets. The residents identified during tray line as receiving a mechanical soft texture received the regular texture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to ensure medical records were complete and accurate. This affected four residents (#5, #47, #56, and #100) out of 62 records reviewed. The facility census was 151.Findings include: 1. Review of Resident #56's medical record revealed an admission date of 01/30/24 and diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type two diabetes, dementia with mood disturbance and chronic kidney disease stage three. Review of an annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and had two or more falls since the previous assessment without injury. Review of Resident #56's physician's orders as of 05/04/26 revealed an order dated 04/11/24 for five nursing observations: bowel, bladder, full body, Braden (skin), and fall every evening shift every three months starting on the first [of the month] for one day. Review of Resident…

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

Based on observation, interview, and facility policy review, the facility failed ensure a clean, sanitary and homelike environment. This affected six residents (#20, #24, #29, #62, #65, and #75) out of 23 residents reviewed for physical environment. The facility census was 151.Findings include: Observation of the facility on 04/21/26 from 2:45 P.M. to 3:55 P.M. with Director of Maintenance (DOM) #399 and Housekeeping Director (HD) #450 revealed the following areas of concern: In Resident #20's room, debris was all over the floor. Resident #20, who was in bed at the time of the observation, stated he could not recall when the floor was last vacuumed. In Resident #24's side of her room, debris including personal care wipes were noted under the resident's bed. In Resident #65's part of the room, a pervasive urine odor was noted. In Resident #75's room, the carpeting had large stained areas and debris was scattered all over the floor. In Resident #29's room, the carpeting had large stained areas that were yellow and red and debris was noted on the floor. Resident #29, who was in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure consent of psychotropic medications were in place for Resident #2. This affected one Resident (#2) of five reviewed for unnecessary medications. The facility census was 151. Review of the medical record for Resident #2 revealed an admission date of 03/02/26 and diagnoses including dementia, generalized anxiety disorder, recurrent major depressive disorder, restlessness and agitation, and suicidal ideations. Review of the physician's order dated 03/12/26 revealed Resident #2 was ordered 2 milligrams (mg) Alprazolam (Xanax) three times per day for recurrent major depressive disorder and generalized anxiety disorder. This medication order was adjusted on 04/22/26 to 2 mg Xanax two times per day for anxiety and 1 mg Xanax at bedtime for anxiety. Review of Consent for Psychotropic Medications assessment dated [DATE] revealed Resident #2 was on 25 mg Zoloft in the morning and 2 mg Xanax three time per day. The assessment indicated the…

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

Based on record review and interview, the facility failed to ensure resident account management authorization's were signed and witnessed when setting up accounts managed by the facility for residents. This affected three (Residents #56, #62 and #154) of five residents reviewed for personal funds. The facility census was 151. Findings include: 1. Review of the medical record for Resident #56 revealed an admission date of 01/30/24 with diagnoses including schizoaffective disorder, dementia, anxiety and depression. Review of the Resident Fund Manage Service authorization and agreement to handle resident funds dated 05/08/24 revealed the facility signed the authorization as they were Resident #56's representative payee. There was no witness to this authorization. Interview on 04/22/26 at 3:22 P.M. with Business Office Manager (BOM) #413 verified the authorization was not witnessed. 2. Review of the medical record for Resident #62 revealed an admission date of 09/05/24 with diagnoses including cerebral infarction (stroke), alcohol induced persisting dementia, anxiety and depression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to report an allegation of abuse and/or misappropriation to the State Agency as required. This affected three (Residents #62, #138 and #154) of fifteen residents reviewed for abuse and misappropriation. The facility census was 151. Findings include:1. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered…

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 review of facility policy, the facility failed to ensure a safe and appropriate discharge for Resident #165. This affected one Resident (#165) of five reviewed for discharge. The facility census was 151. Findings include:Review of the medical record for Resident #165 revealed an admission date of 02/26/25 and discharge date of 07/01/25. Diagnoses include human immunodeficiency virus (HIV) disease, psoriasis, anemia, homelessness, anxiety disorder, recurrent major depressive disorder, and patient's noncompliance with medical treatment and regimen due to financial hardship. Review of Discharge Planning assessment dated [DATE] revealed an anticipated length of stay of three months. Barriers to returning home included health, finances, housing, and lack of support. It was noted Resident #165 had numerous health needs with no finances, support system or housing so discharge would not be considered safe. Review of Social Service History and Initial assessment 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, staff interview, and review of facility policy, the facility failed to ensure Resident #16 was provided a written transfer notice and failed to ensure the Long-Term Care Ombudsman was notified of resident discharges for Residents #16 and #165. This affected two Residents (#16 and #165) of five reviewed for discharge. The facility census was 151. Findings include:1. Review of the closed medical record for Resident #165 revealed an admission date of 02/26/25 and discharge date of 07/01/25. Diagnoses include human immunodeficiency virus (HIV) disease, psoriasis, anemia, homelessness, anxiety disorder, recurrent major depressive disorder, and patient's noncompliance with medical treatment and regimen due to financial hardship. Review of Discharge Planning assessment dated [DATE] revealed an anticipated length of stay of three months. Barriers to returning home included health, finances, housing, and lack of support. It was noted Resident #165 had numerous health needs with no…

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

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed when residents had a significant change. This affected one (Resident #41) of one resident reviewed for PASARR. The facility census was 151. Findings include:Review of the medical record for Resident #41 revealed an admission date of 03/27/25 with diagnoses including dementia with behavioral disturbance, schizophrenia, depression and anxiety. Review of the nursing progress notes for Resident #41 revealed on 10/29/25 at 4:00 P.M. she was in another resident's room pushing the television and pushing the other resident on the ground. The physician was updated and nursing had received a new order to send her for psychiatric assessment. On 10/30/25 at 9:30 P.M. she was discharged to a psychiatric facility. Further review of the medical record revealed no indication a new PASARR was completed with the significant change in mental status for Resident #41. Interview on 04/21/26 at 9:49 A.M. with Social Services Director (SSD) #373 verified a PASARR was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to revise care plans as needed. This affected three residents (#1, #56 and #81) of 62 residents reviewed for care plans. Facility census was 151.Findings include: 1. Review of Resident #56's medical record revealed an admission date of 01/30/24 and diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type two diabetes, dementia with mood disturbance and chronic kidney disease stage three. Review of an annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and had two or more falls since the previous assessment without injury. Review of a physician's order dated 01/20/26 revealed an order for non-slip strips applied to the floor in front of Resident #56's recliner chair. Review of a progress note dated 04/06/26 at 10:43 A.M. revealed the interdisciplinary team met and reviewed the recommendation to encourage [Resident #56]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure blood pressure medications were monitored for safety and effectiveness. This affected one (Resident #35) of seven residents reviewed for monitoring of medications. The facility also failed to ensure to treat resident skin conditions per the physician's order. This affected two (Residents #75 and #100) of three residents reviewed for general skin conditions. The facility census was 151. Findings include:1. Review of the medical record for Resident #35 revealed an admission date of 06/23/17 with diagnoses including schizoaffective disorder, dementia, anxiety, hypertension and chronic obstructive pulmonary disease. Review of the physician's orders for Resident #35 revealed she had orders for blood pressure medications without parameters for monitoring the blood pressure. Resident #35 had an order for Propanolol 10 milligrams (mg) one time a day dated 03/13/24 and Clonidine 0.1 mg one time a day dated 03/13/24. She also had an order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review, the facility failed to ensure skin was assessed appropriately and pressure ulcers were treated timely for residents. This affected one (Resident #41) of three residents reviewed for wounds. The facility census was 151. Findings include:Review of the medical record for Resident #41 revealed an admission date of 03/27/25 with diagnoses including Alzheimer's Disease, dementia, heart failure, hypertension and adult failure to thrive. Review of the braden scale assessment dated [DATE] for Resident #41 revealed she was at moderate risk for skin breakdown. Review of the shower sheet for Resident #41 dated 02/13/26 revealed her skin was intact. Review of the skilled nursing assessment dated [DATE] by Licensed Practical Nurse (LPN) #406 revealed Resident #41 did not have any changes in skin integrity and there was no wound care being performed. Review of the nurse practitioner progress note dated 02/16/26 for Resident #41 revealed there was a right lower…

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 review of facility policy, the facility failed to ensure sufficient interventions were in place to maintain resident nutritional status. This affected three Residents (#2, #41, and #110) of seven reviewed for nutrition services. The facility census was 151. Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 03/02/26 and diagnoses including dementia, adult failure to thrive, generalized anxiety disorder, heart failure, need for assistance with personal care, and suicidal ideations. Review of weight dated 03/02/26 revealed Resident #2 weighed 184.0 pounds and was weighed in a wheelchair. Review of weight dated 03/12/26 revealed Resident #2 weighed 175.0 pounds and was weighed while standing. Review of weight dated 03/13/26 revealed Resident #2 weighed 173.0 pounds and was weighed while standing. Review of physician's order dated 03/13/26 revealed order for regular diet with regular texture and thin liquids. 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 observation, interview, record review and review of the facility policy, the facility failed to maintain oxygen tubing in a hygienic manner and per standards of practice. This affected three residents (Resident #11, #32 and #42) of four residents reviewed for respiratory care. Facility census was 151.Findings include:1. Review of Resident #11's medical record revealed an admission date of 03/07/14 and diagnoses including lupus, chronic respiratory failure, type two diabetes, depression, dementia with other behavioral disturbance and anxiety. Review of an annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment and displayed inattention and disorganized thinking. Review of Resident #11's physician's orders revealed an order dated 02/25/26 for oxygen at two liters as needed to maintain oxygen saturation above 88. Call nurse practitioner if oxygen saturation is below 88. Observation on 04/19/26 at 5:20 P.M. with the Director of Nursing (DON) revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to provide comprehensive pre and post dialysis monitoring. This affected one resident (#160) of one resident receiving dialysis at the facility. Facility census was 151. Findings include: Review of Resident #160's medical record revealed an admission date of 04/17/26 and diagnoses including end stage renal disease, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, dementia and Alzheimer's disease.Review of Resident #160's physician orders as of 04/21/26 revealed an order dated 04/17/26 for dialysis: length of treatment time 3.25 hours, type of dialyzer (blank), parameters of dialysis delivery system: electrolyte composition of dialysate (blank), blood flow rate (blank), dialysate flow rate (blank), anticoagulation (blank) target weight (blank); an order dated 04/17/26 for dialysis: check access site for bruit and thrill, record/report abnormalities immediately every shift record + or = and notify…

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, review of facility policy and job descriptions, the facility failed to ensure residents received sufficient and appropriate social services to meet the residents psychosocial and emotional needs. This affected one resident (Resident #138) of 21 reviewed for social services needs. The facility census was 151. Findings include:Review of the medical record for Resident #138 revealed an admission date of 11/25/24 and diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and essential hypertension. Resident #138's son was listed as a resident representative. Review of the plan of care dated 12/03/24 revealed Resident #138 had mood problem related to dementia with agitation. Interventions included administer medications as ordered, encourage resident involvement with activities of interest as tolerated, meet with resident one on one to encourage resident to verbalize feelings, concerns…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available to administer to residents per the physicians' orders. This affected one (Resident #35) of 13 residents reviewed for medications. The facility census was 151. Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/23/17 with diagnoses including schizoaffective disorder, dementia, anxiety, hypertension and chronic obstructive pulmonary disease. Review of the physician's orders for Resident #35 revealed she had orders for Latanoprost eye drops for glaucoma, one drop in both eyes at bedtime dated 03/13/24; Quetiapine 300 milligrams (mg) at bedtime for schizoaffective disorder dated 03/13/24; Restoril 7.5 mg at bedtime for insomnia dated 03/19/25; and Artificial Tears eye drops three times a day for irritated eyes dated 01/12/25. Review of the Medication Administration Record (MAR) dated from October 2025 through April 2026 for Resident #35 revealed Latanoprost eye drops were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to ensure dental services were provided timely for residents. This affected one (Resident #12) of six residents reviewed for dental services. The facility census was 151. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/07/26 with diagnoses including diabetes mellitus, hypertension, chronic pain and unspecified protein-calorie malnutrition. Review of the dental visits dated from 04/20/25 through 04/20/26 revealed Resident #12 had not been seen by the dentist including visits dated 02/19/26 and 04/07/26. Review of the physician's orders for Resident #12 revealed an order to be seen by the dentist dated 02/09/26. Resident #12 also had an order for Orajel 2x Toothache and Gum Mouth/Throat dated 03/20/26. The nursing staff were to apply to affected tooth every eight hours as needed for tooth pain. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she 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 record review, interview, and facility policy review, the facility failed to ensure coordination of care with hospice services for residents to ensure safe and person-centered care. This affected one (Resident #1) of two residents reviewed for hospice services. The facility census was 151.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/20/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure and chronic pain. Review of the care plan dated 04/05/24 for Resident #1 revealed the care plan had not been updated to reflect he was receiving hospice services or end of life care.Review of the hospice enrollment form dated 03/31/26 revealed Resident #1 was admitted to hospice for chronic respiratory failure.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was receiving hospice services.Review of the facility's general hospice binder revealed Resident #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 and interview the facility failed to ensure that medications and showers were accurately documented. This affected two residents (#24, #31) of two residents reviewed for accurate and complete medical records. The facility census was 156. Findings include: 1. Review of the medical record for Resident #24, revealed an admission date of 06/13/25. Diagnoses included: other fracture of upper and lower end of left fibula sequela, diabetes, morbid obesity, hypertension, attention-deficit hyperactivity disorder, anxiety disorder, major depressive disorder, diabetic ulcer, methicillin resistant staphylococcus aureus infection, and idiopathic neuropathy. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. No behaviors were observed during the look back period. The resident was assessed to require a wheelchair for mobility and to be independent with all activities of daily living. Review of Resident…

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

Based on observation, interview, and record review the facility failed to ensure call lights were accessible. This affected one resident (#25) of 156 residents residing in the facility. The facility census was 156. Findings Include:Review of the medical record for Resident #25 revealed admission to facility on 09/06/24 with diagnoses including unspecified dementia, anxiety, depression, schizophrenia, morbid obesity, and left lower leg Tri malleolar (ankle) fracture. The most recent Minimum Data Set (MDS) quarterly assessment completed on 09/23/25 revealed Resident #25 had delusional and disorganized thinking, used a walker to navigate facility, and required supervision or light touching with activities of daily living and grooming or bathing. A Brief Interview for Mental Status (BIMS) assessment completed on 09/23/25 revealed Resident #25 had moderate cognitive deficit (forgetful and distractable). Further record review revealed Resident #25 was a high fall risk and had two recent falls at the facility on 10/28/25 and 09/23/25. Observation and interview on 11/05/25 between 1:40 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.

Based on review of the facility menu, review of resident council meeting minutes, observation, staff interview and resident interview, the facility failed to ensure menus were prepared in advance and updated periodically and failed to ensure residents received the correct portion sizes based on the menus. This had the potential to affect all 154 residents who resided in the facility. Findings include: Review of the Resident Council Meeting Minutes dated 12/31/24 revealed the food committee meeting was not held on this day due to the absence of the Dietary Manager. The council voted to reschedule the food committee meeting as soon as possible. Review of the facility menu (in January 2025) revealed the facility was utilizing the menu for spring and summer 2024. The date on the top of the menu for 01/13/25, revealed the menu was to be used for 07/22/24. It was also noted that residents were supposed to receive eight ounces of spaghetti and meat sauce. Observation on 01/13/25 at 12:00 P.M. revealed Dietary Aide (DA) #202 had utilized a regular-non measurable serving spoon to place one…

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

Based on observation and staff interviews, the facility failed maintain a sanitary kitchen and food storage areas and failed to ensure infection control was maintained while serving the lunch meal. This affected all residents who resided in the facility, as the facility identified all residents as receiving kitchen services. The facility census was 154. Findings Include: 1. Observation of the facility kitchen on 01/13/25 from 9:20 A.M. through 9:40 A.M. revealed the facility kitchen floors were scattered with torn sugar packets, pieces of old discarded food, crumbs, and dark sticky substances were covering parts of the floor. Several walls were noted to have dried up liquids that were previously splashed from food or drinks. Observation of the facility's chemical dishwasher revealed the top to be covered with dust, an abundance of what appeared to be crumbs from food, two dirty wash cloths, and a dried-up dirty sponge. The kitchen also had a large light with the name echo lab used to kill gnats and directly under the echo lab light, the facility was noted to have soup bowls on 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 observation, interview, and record review the facility failed to ensure a clean, sanitary, and homelike environment for residents. This affected one resident (Resident #72) out of three residents reviewed for quality of care and treatment. The facility census was 154. Findings include: Review of the medical record for Resident #72 revealed an admission date of 11/26/24. Diagnoses included diabetes mellitus type one, acquired absence of the left leg below the knee, major depressive disorder, and noninfectious gastroenteritis. Review of Resident #72's care plan dated 01/07/25 revealed the resident displayed behavioral symptoms not directed toward others as evidenced by defecating on the floor and in the trash can instead of utilizing the bedside commode that was provided for him. Review of Resident #72's Minimum Data Set assessment dated [DATE] revealed the resident required supervision and touch assistance for toileting hygiene and showering and bathing. The assessment indicated the resident utilized 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 observation, resident interview, staff interview, and review of pest control customer service reports, the facility failed to eradicate cockroaches from Resident #72's room. This affected one resident (#72) out of three residents reviewed for pest control. The facility census was 154. Findings include: Review of the medical record for Resident #72 revealed an admission date of 11/26/24. Diagnoses included diabetes mellitus type one, acquired absence of the left leg below the knee, major depressive disorder, and noninfectious gastroenteritis. Review of Resident #72's care plan dated 01/07/25 revealed the resident displayed behavioral symptoms not directed toward others as evidenced by defecating on the floor and in the trash can instead of utilizing the bedside commode that was provided for him. Review of Resident #72's Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact required supervision and touch assistance for tilting hygiene and showering and bathing. The…

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

Based on observation and staff and resident interviews, the facility failed to ensure cinnamon rolls were properly prepared to ensure palatability and an appetizing appearance. This had the potential to affect all residents residing in the facility. The facility census was 150. Findings include: Observation on 03/27/24 at 12:28 P.M. with State Tested Nursing Assistant (STNA) #303 revealed Resident #6 had eaten approximately 10% of his lunch tray. Observation of the uneaten cinnamon roll revealed the roll, still covered with clear plastic, was approximately the size of a 50-cent piece in diameter and the texture was hard and crunchy. During interview on 03/27/24 at 12:29 P.M., STNA #303 revealed residents had complained that they were unable to eat the cinnamon rolls because they were too hard and appeared overcooked. STNA #303 verified Resident #6's cinnamon roll appeared overcooked and was hard throughout. During interview on 03/27/24 at 12:31 P.M. Resident #6 stated he didn't eat his cinnamon roll because it was hard. During interview on 03/27/24 at 12:34 P.M., Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to maintain appropriate infection control precautions when Licensed Practical Nurse (LPN) #320 did not properly dispose of a used insulin syringe with needle. This had the potential to affect 31 residents (#3, #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40) of 31 residents residing on [NAME] Hall. The facility census was 150. Findings include: Observation on 03/27/24 at 12:40 P.M. revealed a used insulin syringe, with the sheath pulled over the needle, lying on the floor approximately five feet from the nursing station. This surveyor continued observation. At 12:45 P.M., the Director of Nursing (DON) confirmed the needle was lying on the floor and then retrieved it, without donning gloves, and walked approximately 20 feet to the location of the medication cart and placed the syringe into the sharps disposal container (rigid,…

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

Based on record review, interview, and policy review, the facility failed to ensure a timely discharge/transfer and failed to provide the resident or resident representative with required documentation upon discharge. This affected one (Resident #1) of three residents reviewed for discharge/transfer. The facility census was 150. Findings include: Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted. a. Review of the medical record revealed the resident's Discharge Planning form, dated 03/06/24 and completed by Social Services Designee #301, revealed there was no resident or resident representative signature. During interview on 03/26/24 at 11:56 A.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 record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected one (Resident #1) of three residents reviewed for discharge. The facility census was 150. Findings include: Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted. Review of the medical record revealed no evidence that the discharge summary was completed at the time of Resident #1's discharge on [DATE]. During interview on 03/27/24 at 10:39 A.M., the DON confirmed…

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

Based on record review and staff interview, the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 150 residents residing in the facility. Findings Include: Review of facility staffing schedules revealed on 01/01/24 there was no evidence the services of a registered nurse (RN) were used for at least eight consecutive hours on this date. The schedule reflected there was no RN scheduled for, or present in the building during this entire day. Interview with the Administrator on 03/02/24 at 3:10 P.M. confirmed the facility did not have a registered nurse scheduled or working on 01/01/24. The facility was unable to provide any evidence to support a registered nurse worked in the facility on this date. This deficiency represents non-compliance investigated under Complaint Number OH00150409.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of the facility menu spread sheets, review of the printed tray cards, and medical record review, the facility failed to ensure proper food portions were served to meet the individual needs of Resident #143 who was ordered double portions, and failed to ensure proper food portions were served to all residents receiving meals from the kitchen. This had the potential to affect all residents receiving meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth. The facility census was 147. Findings include: 1. Observation of the lunch meal trayline on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed [NAME] #419 used one number-eight, gray handled ( four ounce) scoop to dish out the regular and mechanical soft turkey [NAME] and one number-12, green handled (two and two-third ounce) scoop to dish the puree turkey [NAME] and the puree mashed sweet potatoes. Review of facility Fall and Winter…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when a dietary staff member with artificial nails was observed not wearing gloves during tray line. This had the potential to affect 146 residents who received food from the kitchen. The facility identified one resident (#37) as not receiving anything by mouth. The facility census was 147. Findings include: Observation of the tray line on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed Dietary Aide (DA) #432 had long, artificial nails with a three dimensional nail charm attached to the right fourth finger. DA #432 was not wearing gloves to cover the artificial nails and was setting up the trays on trayline for the lunch meal service. Interview with the Administrator on 12/12/23 at 3:38 P.M. revealed gloves should be worn by any dietary employee who has artificial nails, and DA #432 should have been wearing gloves to cover the artificial nails while on tray line. Review of undated facility policy Personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, facility policy review, and interview the facility failed to notify Resident #200's family and physician of changes in the resident's condition. This affected one resident (#200) of three residents reviewed for change in condition. Findings include: Review of Resident #200's hospital documentation dated 09/15/23 indicated the [AGE] year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. The resident was neurovascularly intact, alert and oriented, and able to bear some weight but with pain. Review of Resident #200's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnosis including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. A plan of care, created 09/19/23 revealed Resident #200 was at risk 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 closed record review, job qualification review, and interview the facility failed to ensure Resident #200 was transferred by an employee who was qualified to do so following a fall. This affected one resident (#200) of three residents reviewed for falls. Findings include: Review of Resident #200's closed medical record revealed the resident was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #200 had diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident 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 closed record review, hospital record review, and interview the facility failed to identify and provide the necessary behavioral health care and services to Resident #200 related to a substance abuse disorder to assist the resident to attain or maintain her highest practicable physical, mental and psychosocial well-being following admission for rehabilitation/treatment of a fall with fracture. This affected one resident (#200) of three residents reviewed for safety/falls. Findings include: Review of Resident #200's hospital documentation dated 09/15/23 indicated the [AGE] year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. She had a dog at home, and she did not want to leave the dog alone, so she had insisted on going home with pain medication and a walker. She returned with pain that she was unable…

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 facility self-reported incident review, record review, policy review, resident interview and staff interview the facility failed to ensure Resident #1 was free from staff to resident verbal abuse. This affected one resident (#1) of three residents reviewed for abuse. The facility census was 150. Findings include: Review of facility self-reported incident (SRI) #237331 revealed on 07/21/23 a verbal altercation occurred between Resident #1 and Licensed Practical Nurse (LPN) #205. The incident was immediately reported to the shift supervisor who notified the facility Administrator and Director of Nursing (DON). The incident was reported to Ohio Department of Health on 07/21/23. Further review of the facility SRI and facility investigation revealed a statement from Resident #1 was obtained on 07/24/23 which indicated LPN #205 entered her room with medications, inhaler, and cup 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 review of personnel files, review of schedules and interview, the facility failed to ensure employees who completed a Nurse Aide Training and Competency Evaluation program successfully completed state testing within the appropriate time frames. This had the potential to affect all 148 residents residing in the facility. Findings include: On 04/25/23 at 10:25 A.M., review of personnel files with Human Resources (HR) Director #520 verified Helping Hand #528 completed a nurse aide training course on 10/26/22. HR #520 stated Helping Hand #528 had taken part of the state test but had not successfully completed both portions of the two part test. HR Director #520 indicated Helping Hand #528 remained on the schedule as a nursing assistant. On 04/25/23 at 2:13 P.M., HR Director #520 provided the name of a second aide, Helping Hand #541 who completed her nurse aide training classes on 11/22/22 but broke her wrist and was off work from January 2023 to 03/22/23 and was still working as an aide. Review of schedules from 03/25/23 to 04/25/23 revealed the following: Helping Hand #528…

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

Based on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect the 147 residents receiving food from the facility. The facility identified Resident #55 as receiving no food by mouth. The facility census was 148. Findings include: Observation of the kitchen during the initial tour on 04/24 23 starting at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns: • The tiled floors were discolored with ground in dirt and wax, giving a darkened appearance. The grout between the tiles was also darkened and needing cleaned. • The microwave was dirty with food spills inside • The dish-machine needed to be wiped down. There were crumbs and dust on top with detergent spills down the sides. • The spice table had dried spills down the side. • The stove top was dusty/dirty, and the knobs of the stove were sticky to touch. • The ice machine had a pink gritty substance on the inside of the lid. • There was a large container of cereal not labeled or dated in dry storage and a bag…

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

Based on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 148. Findings include: Observation of the facility's dumpster area on 04/24 23 at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns: a. Three of six dumpster lids were not closed. b. There was a large bag of trash outside the dumpsters with miscellaneous gloves, papers, and other trash on the ground. DM #519 verified the above findings at the time of observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure call lights were within resident reach. This affected one resident (Resident #76) of 32 residents observed for call light accessibility. The facility census was 148. Findings include: Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, hypertension, type two diabetes mellitus, major depressive disorder, and chronic obstructive pulmonary disease. Observation on 04/24/23 at 10:37 A.M. revealed Resident #76's call light was coiled up and zip tied together, hanging against the wall and out of the resident's reach. Interview at the time of the observation with Resident #76 revealed she did not know how long the call light had been hanging that way. Interview on 04/24/23 at 10:40 A.M. with Licensed Practical Nurse (LPN) #556 confirmed Resident #76's call light was coiled up and zip tied hanging against the wall, out of Resident #76's reach. LPN #556 verified Resident #76 would not…

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

Based on self-reported incident review, medical record review, policy review and staff interview, the facility failed to ensure narcotic medications were not misappropriated by staff members. This affected three residents (Residents #68, #99 and #111) of five residents reviewed for misappropriation. The facility census was 148. Findings include: Review of the facility Self-Reported Incident (SRI) #230289 with a created date of 12/19/22 revealed Licensed Practical Nurse (LPN) #701 alleged Registered Nurse (RN) #658 was possibly misappropriating resident narcotic medications. Further review of SRI #230289 and the facility investigation found that RN #658 misappropriated narcotic medications from Residents #68, #99 and #111. Further review of SRI #230289 revealed RN #658 was also identified in an SRI for another facility in 2017 with the allegation of misappropriation of resident narcotics. The SRI was substantiated and RN #658 was terminated from the other facility 1. Facility investigation determined RN #658 misappropriated three narcotic medications on 12/17/22 from Resident #68.…

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

Based on observation, record review and interview the facility failed to ensure residents received the assistance needed for activities of daily living (ADLs). This affected two residents (Resident #89 and #143) of three residents reviewed for ADLs. The census was 148. Findings Include: 1. Review of the medical record for Resident #89 revealed an admission date of 09/14/22. Diagnoses included the need for assistance with personal care, vitreous hemorrhage (blood in the space between the eye's lens and retina), bilateral cataracts, bipolar disorder, anxiety disorder, major depressive disorder, and diabetes with neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/31/23, revealed the resident had moderately intact cognition, severely impaired vision, and minimally impaired hearing. Behaviors included delusions and verbal behavioral symptoms directed at others. The resident required the extensive assistance of two staff for transfers. The resident was totally dependent for locomotion, dressing, and personal hygiene. The extensive assistance of one staff 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.

Based on medical record review, staff interview and policy review, the facility failed to monitor resident weights as ordered by the physician. This affected one (Resident #138) of three residents reviewed for weight loss. The facility census was 148. Findings include: Review of Resident #138's medical record revealed an admission date of 11/12/22 with diagnoses that included Alzheimer's disease with dementia, hypothyroidism and hypertension. Review of the physician's orders dated 11/12/22 revealed to obtain weekly weights for four weeks then monthly. Review of Resident #138's weight records revealed weights were obtained on 11/12/22 and then on 12/02/22. There was no evidence of any additional weights obtained between 11/12/22 and 12/02/22. On 04/27/23 at 11:35 A.M. interview with the Director of Nursing verified weights were not obtained per physician's orders following admission. Review of the facility policy Weight Assessment and Intervention with a revision date of 08/2008 indicated nursing staff will measure resident weight on admission and weekly for three weeks thereafter.…

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

Based on observation and interview the facility failed to maintain the kitchen in a sanitary manner. This affected 166 of 167 residents residing in the facility. Resident #78 was identified as ordered nothing by mouth to eat or drink. Findings include: Observation of the kitchen was conducted during the initial tour on 01/12/20 from 8:30 A.M. to 9:00 A.M. with Dietary Manager #102. The following concerns were observed and verified with Dietary Manager #102 at that time: 1. There was a soiled cleaning cloth hanging on the side of a plastic storage container. Inside the storage container were clean scoops and a zip-lock bag of saltine crackers. The Dietary Manager #102 indicated the container was for resident snacks and verified the soiled cloth should not be there. 2. There was a steel pan with slices of bread covered with plastic wrap which was not dated. Dietary Manger #102 indicated they were drying the bread for bread crumbs but verified the bread should have been dated. 3. There was a drain in front of the ovens with a steel cover which was visibly dirty underneath with food…

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 the residents on the Taft unit with appropriate water containers. This affected Resident #68 and Resident #316 and affected 25 of 26 other residents on the Taft unit, Residents #10, #29, #30, #33, #42, #43, #52, #61, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, and #420. Resident #9 received thickened liquids and was not permitted a water pitcher/cup. The facility census was 167. Finding include: Observation on 01/12/20 from 9:58 A.M. through 11:51 A.M. revealed residents on the Taft unit did not have water pitchers or dedicated cups for water in their rooms. No individual water pitchers or large cups were noted in the common areas. A water pitcher with small clear plastic cups was at the nurse's station for residents to get water. Interview on 01/12/20 at 10:32 A.M. with Resident #68 revealed she saved used pop bottles to put water in for her room. An observation at that time revealed Resident #68 had a pop bottle with water on her over bed table. No water…

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

Based on record review and interview the facility failed to ensure all state tested nurse aides (STNAs) completed twelve hours of in-service education annually. This affected one of three STNA's reviewed who had been employed greater than one year. This had the potential to affect all 28 residents residing on the Taft unit, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420. The facility census was 167. Findings include: Review of the personnel record for STNA #407 revealed a hire date of 04/08/16. There was no documentation found to indicate STNA #407 had received at least 12 hours of continuing education for the last annual period of 04/08/18 through 04/08/19 as required. On 01/15/20 at 1:35 P.M., interview with the Human Resource (HR) Director confirmed STNA #407 did not have any paper documenting of continuing education in the personnel file for the review period. The HR Director said staff also uses the computer based education program called Relias to complete…

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 assess, monitor and treat Resident #20's left lower leg scar and wounds. This affected one out of three residents reviewed for skin issues. Findings include: Resident #20 was admitted on [DATE] with diagnoses including heart disease, traumatic brain injury following a motor vehicle accident, schizophrenia, dementia, morbid obesity and cognitive communication deficit. An interview with Resident #20 on 01/12/20 at 10:41 A.M. indicated he had sustained an injury to his lower left leg and had developed a clot from a car accident in the past. An observation at the time of the interview revealed Resident #20's left lower leg had a large discolored scarred area (approximately 4 centimeters wide by 6 centimeters long) with two scabbed areas on each end of the scar. The scarred skin had skin that was peeling off in powdery flakes. Review of Resident #20's nursing assessments and physician assessments dated 09/01/2019 to 01/13/20 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 observation, record review and interview the facility failed to ensure Resident #47's and Resident #78's pressure ulcer treatments were provided as ordered by the physician. This affected two out of three residents reviewed for pressure ulcers. Findings include: 1. Resident #47 was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral vascular accident (stroke)affecting the non-dominant side, respiratory disease, heart disease, Alzheimer's disease, schizophrenia, anxiety and depression. Review of Resident #47's wound assessment dated [DATE] indicated a stage III pressure ulcer (a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia and presents as a deep crater with or without tunneling or undermining of adjacent tissue) on the left heel measuring 0.5 centimeters (cm) long by 2.0 cm wide and 0.2 cm deep. The wound assessment 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, observation, and interview, the facility failed to ensure insulin vials were dated when opened. This affected one Resident (#110) out of five residents reviewed for insulin storage on the [NAME] unit. The facility census was 167. Findings include: Review of the medical record revealed Resident #110 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of physician orders for January 2020 revealed Resident #110 was ordered Levemir (insulin) 26 units, injected subcutaneously (SQ), at bedtime, Novolog (insulin) 25 units SQ in the morning, 13 units SQ in the afternoon, and 16 units SQ in the evening. Observation on 01/15/20 at 11:06 A.M. of the medication cart on the [NAME] unit revealed open vials of Levemir and Novolog insulin for Resident #110. There were no dates on these insulin vials to indicate the date they were opened. Interview on 01/15/20 at 11:06 A.M. with Registered Nurse #600 verified Resident #110's Levemir and Novolog insulin vials were open and undated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #110's medical record included documentation the resident was provided wine per the physician order. This finding affected one (Resident #110) of thirty-five resident records reviewed for documentation. Findings include: Review of Resident #110's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, diabetes and anxiety. Review of Resident #110's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. Review of Resident #110's physician order dated 05/13/19 indicated the resident may have a glass of wine with dinner once a day as needed and the family was to provide the wine. Review of Resident #110's medication administration record (MAR) from 01/01/20 to 01/15/20 did not reveal evidence the resident received the wine. Interview on 01/12/20 at 12:39 P.M. with Resident #110 indicated she should have wine every…

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.