Arbors At Carroll

Based on record review, interview, and facility policy review, the facility failed to ensure dietician recommendations were implemented timely and orders were followed. This affected 2 (Residents #12 and #74) of six residents reviewed for nutrition. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/06/10. Medical diagnoses included chronic kidney disease, dysphasia, muscle weakness, major depressive disorder, cognitive communication deficit, anemia, gastro-esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #12's care plan dated 10/31/23 revealed the resident was at risk for altered nutritional status related to therapeutic diet, and medical diagnosis that include hypertension, peripheral vascular disease, depression, cognitive communication deficit, anemia, and GERD. A listed goal included for Resident #12 to receive and tolerate his diet, and to maintain weight with no further significant changes. Care planned interventions included to periodically obtain the resident's weight,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected two residents (#73 and #43) of two residents reviewed for trauma informed care. The facility census was 96. Findings include: 1. Review of Resident #73's medical record revealed an admission date of 02/28/24. Medical diagnoses included fracture of the left radius, chronic obstructive pulmonary disease, systemic lupus, major depressive disorder, muscle weakness, dysphasia, cognitive communication deficit, and post traumatic stress disorder (PTSD). Interview on 12/09/24 at 10:55 A.M. with Resident #73 confirmed that she had witnessed a family suicide, and was triggered by gun shots and loud noises. Resident #73 stated she had not been involved in care planning related to her PTSD diagnosis, but she used coloring and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected one resident (Resident #81) of two residents reviewed for pain management. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admission date of 03/15/24 with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's plan of care dated 02/23/24 revealed Resident #81 was at risk for pain related to comorbidities. Interventions included but were not limited to administering medications as ordered, offering non-pharmacological interventions to relieve pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure medication parameters were in place and followed for Resident #34, #69, and #79, who received blood pressure medication. This affected three residents (#34, #69, and #79) of six residents who were reviewed for medication administration. The facility census was 96. Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 07/26/24 with diagnoses including cerebral infarction, type two diabetes mellitus, acute respiratory failure, osteomyelitis, cognitive communication deficit, anxiety disorder, osteoarthritis, and hypertension. Review of Resident #69's quarterly Minimum Data Set (MDS) 3.0 dated 11/22/24 revealed he had intact cognition. Review of Resident #69's plan of care dated 07/17/24 revealed the resident had impaired cardiovascular status related to hyperlipidemia and hypertension. Interventions included observing and reporting to the physician any signs of hypertension, administering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and review of facility policy, the facility failed to complete laboratory testing as ordered by the physician for Resident #81. This affected one resident (#81) of two residents reviewed for hydration. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admission date of 03/15/24 with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's laboratory results dated [DATE] revealed her potassium was high at 5.6 milliequivalents (mEq) per liter (L). Review of Resident #81's progress note dated 12/4/24 revealed her potassium was 5.6 mEq/L on her laboratory results. The Certified Nurse Practitioner (CNP) gave 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.

Based on observation, staff interview, and facility policy review, the facility failed to ensure dietary spreadsheets were followed and all food items on the spreadsheets were offered to the residents according to their needs on a level three dysphagia diet. This affected 14 residents, (Residents #6, #10, #14, #17, #31, #33, #48, #59, #61, #64, #66, #72, #85, and #89) the facility identified as having physician orders for a level three dysphagia diet, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an a level three dysphagia diet should receive ground ham steak with gravy, soft rice pilaf with gravy, chopped soft broccoli and cheese sauce, and pudding. Observation of tray line for the lunch meal on 02/07/24 at 11:55 A.M. with [NAME]…

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, review of the pureed ham recipe and facility policy, the facility failed to ensure pureed foods were prepared to the appropriate pureed consistency. This affected nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add…

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 facility policy review, the facility failed to follow proper hand hygiene protocols during pureed food preparation. This had the potential to affect all nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of laboratory test results, review of McGreer's criteria for infections, and facility policy review, the facility failed to follow antibiotic stewardship policies and procedures prior to starting antibiotic treatment for two residents (Residents #43, and #84). The facility also failed to ensure laboratory test results were received prior to starting antibiotic treatment for one resident (Resident #11). The deficient practices affected three residents (Residents #11, #43, and #84) of seven residents reviewed for infections and antibiotic use. The facility census was 88. Findings Include: Review of the medical record for Resident #11 revealed an initial admission date on 06/08/21 and a readmission date on 10/23/23. Medical diagnoses included schizoaffective disorder, chronic obstructive pulmonary disorder (COPD), other irritable bowel syndrome, other disorders of urea cycle metabolism, delusional disorders, overactive bladder, urinary tract infection, and severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident interview, and staff interview, the facility failed to comprehensively assess Resident #84's dental status. This affected one resident (#84) of 27 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and hemiplegia. Review of a nursing admission assessment dated [DATE] revealed it stated Resident #84 does not use dentures or partials and edentulous was not marked. Review of an initial nutrition assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Review of an admission Minimum Data Set (MDS) assessment completed 08/11/23 revealed Resident #84 was not edentulous and did not have broken or loose dentures. Review of a quarterly MDS assessment completed 11/20/23 revealed Resident #84 had a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and facility policy review, the facility failed to provide showers as scheduled to Resident #46. The deficient practice affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required partial to moderate assistance from staff for showering or bathing and for tub or shower transfers. Review of shower documentation dated December 2023 revealed Resident #46 was scheduled to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and facility policy review the facility failed to ensure timely treatment was initiated urinary tract infections. This affected two residents (#43 and #84) of six residents reviewed for antibiotic use/urinary tract infections. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed Resident #84 received the last dose of an antibiotic and stated she feels a little better but not all the way. The resident continued to be slightly confused at times. The nurse updated the nurse practitioner who said it was okay to get another urine culture if needed in the morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed greater than 100,000 Proteus Mirabilis. The bacteria 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.

Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #39 received treatment to maintain vision abilities. This affected one resident (#39) of one resident reviewed for communication/sensory abilities. The facility census was 88. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 with diagnoses including end stage renal disease, diabetes, and psychosis. Record review revealed the resident went out of the facility three times weekly for dialysis. Review of an annual Minimum Data Set (MDS) assessment completed 01/01/24 revealed Resident #39 had a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition (a score of 8-12 = moderately impaired cognition and a score of 13-15 = intact cognition). It stated the resident had impaired vision with no corrective lenses. A quarterly MDS on 10/01/23 also indicated impaired vision with no corrective lenses. Review of a vision consult report dated 04/27/23 revealed Resident #39 was scheduled to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer to Resident #19's nose caused by his glasses. This affected one resident (#19) of four residents reviewed for pressure ulcers. The census was 88. Findings Include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cerebral infarction, anxiety disorder, diverticulitis, major depressive disorder, cognitive communication deficit, hyperlipidemia, contracture of left hand, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 01/01/24, revealed Resident #19 was cognitively intact. The assessment noted the resident was at risk for pressure ulcer development. Review of Resident #19's physician orders, dated 11/27/23, revealed 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.

Based on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #85 received services to prevent decrease in range of motion and to maintain or improve mobility. This affected one resident (#85) of three residents reviewed for positioning/mobility. The facility census was 88. Findings Include: Review of the medical record for Resident #85 revealed an admission date of 06/07/23 with diagnoses including cerebral infarction (stroke) with hemiplegia and hemiparesis (muscle weakness/paralysis). Review of a quarterly Minimum Data Set (MDS) assessment completed 12/12/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #85 had impairment in range of motion on one side, upper and lower. The resident was dependent upon staff for transfers. Review of a physical therapy discharge summary revealed Resident #85 received physical therapy from 10/26/23 to 01/16/24. It stated the resident had significant mobility deficits with increased weakness. The resident had resided at home prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of fall investigations, and facility policy review, the facility failed to complete neurological checks following unwitnessed falls for Resident #17. The deficient practice affected one resident (#17) of two residents reviewed for falls. The facility census was 88. Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 08/07/23 and a readmission date of 09/21/23. Medical diagnoses included Alzheimer's disease, history of falling, and type II diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was rarely or never understood. Per staff assessment, Resident #17 had moderately impaired cognition. Resident #17 required partial to moderate assistance from staff with transfers and used a walker or a wheelchair for mobility. Review of the fall investigations for Resident #17 revealed the resident had unwitnessed falls on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of facility policy and staff interviews, the facility did not ensure all physician ordered nutritional interventions to prevent weight loss were consistently implemented for Resident #53. This affected one resident (Resident #53) of five residents reviewed for nutrition. The facility census was 88. Findings Include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, acute respiratory failure, cardiomyopathy, dysphagia, muscle weakness, hypertension, polyneuropathy, anxiety disorder, depression, and hypotension. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/05/23, revealed she had no cognitive impairment, was dependent on staff for eating, had no significant weight changes and received nutrition by mouth with a mechanically altered diet and nutrition through a feeding tube. Review of Resident #53's current…

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

Based on observations, medical record review, staff interview, and review of the facility list of medications not to be crushed, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 15% and included four medication errors of 26 medication administration opportunities. This affected one resident (Resident #39) of six residents observed for medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 and diagnoses including end stage renal disease and diabetes. The resident received hemodialysis three times weekly. There was no evidence of any physician's orders to crush medications. Observation of medication administration on 02/12/24 at 8:45 A.M. revealed Registered Nurse (RN) #528 preparing medications to administer to Resident #39. The following medications were crushed in applesauce together: Sevelamer 800 milligrams (used to lower phosphorus in the blood of patients receiving kidney dialysis), Ropinirole…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were administered medication in accordance with physician orders and prescribing instructions for use of the medications. This affected two residents (Residents #46 and #297) of six residents reviewed for medication administration. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #297 was admitted to the facility on [DATE] with diagnoses that included arthritis due to other bacteria and left knee bacteremia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #297 was cognitively intact, required moderate assistance for activities of daily living and was receiving intravenous (IV) antibiotics. Review of the discharge information from the hospital dated 12/29/23 for Resident #297 revealed a primary diagnosis of blood stream infection and was ordered to receive intravenous (IV) Vancomycin (medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to provide timely dental care and services for one resident (Resident #46). This affected one resident (Resident #46) of one reviewed for dental services. The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 required assistance from staff which ranged from set up help to maximal assistance to complete Activities of Daily Living (ADLs). Resident #46 had missing or broken teeth. Review of the plan of care revised 12/01/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure residents were free from misappropriation when residents' controlled narcotic pain medication was not misappropriated. This affected 18 residents (#10, #17, #22, #26, #29, #42, #47, #53, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) identified by the facility during their investigation into an allegation of misappropriation as having had their controlled narcotic pain medications misappropriated. Findings include: A review of SRI #240119 revealed an allegation of misappropriation was made known to the facility on [DATE]. The initial source of the allegation was a facility nurse and the alleged perpetrator was identified as Licensed Practical Nurse (LPN) #100. The initial resident/ victim was identified as Resident #53.…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure a resident was free from verbal/ emotional abuse. This affected one (Resident #46) of one residents reviewed for abuse. Findings include: A review of SRI #240024 with a date of discover of 10/10/23 revealed an allegation of emotional/ verbal abuse was made known to the facility. The initial source of the allegation was from Resident #46, who was identified as the resident/ victim. The alleged perpetrator was a staff member and was identified as Licensed Practical Nurse (LPN) #22. Witnesses to the alleged emotional/ verbal abuse included the facility's Director of Nursing (DON), LPN #45, and Activity Director #39. A brief description of the allegation revealed Resident #46 came to the nurses' station and requested cough medicine from the oncoming nurse (LPN #22). LPN #22 informed the resident 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, observation, resident interview, family interview, staff interview, and policy review, the facility failed to ensure residents that were dependent on staff for personal care received the assistance needed to complete oral hygiene care. This affected three residents (#1, #12, and #81) of four residents reviewed for activities of daily living (ADL's). Findings include: 1. A review of Resident #81's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease, adult inset diabetes mellitus, and major depressive disorder. A review of Resident #81's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty with hearing, without the use of a hearing aide, and his speech was clear. He was sometimes able to make himself understood and was sometimes able to understand others. His cognition was severely impaired, but was not known to reject care. He required an extensive assist of two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a closed record review, review of a facility incident report related to a medication error, review of an employee file, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one resident (#84) of three residents reviewed for medication administration. Findings include: A review of Resident #84's closed medical record revealed he was admitted to the facility on [DATE] for short respite stay that was to only be over the weekend. He remained in the facility through 07/31/23, when he was transferred to the emergency room directly from his day program set up through the Ohio Department of Developmental Disabilities. He did not return to the facility as he was re-admitted to the hospital on [DATE]. His diagnoses included cerebral palsy, quadriplegia, seizure disorder, neuromuscular scoliosis of the thoracic region,…

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.