Chillicothe Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and facility policy review, the facility failed to ensure orders were in place for oxygen administration. This affected one resident (#6) out of three reviewed for oxygen administration. The facility census was 80 at the time of survey. Findings Include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder, type II diabetes mellitus with diabetic neuropathy, and hepatic encephalopathy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was mildly cognitively impaired with a BIMS of 08 out of 15, had no behaviors, did not reject care, and did not wander.Observation of Resident #6 on 03/02/2026 at 10:18 A.M. revealed an oxygen concentrator to be running next to Resident #6's bed. Resident #6's oxygen tubing was being changed.Review of Resident #6's physician orders 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 closed record reviews, review of hospital discharge orders, staff interview, and facility policy review, the facility failed to ensure medications were not administered longer than prescribed by the physician. This affected one resident (#103) out of the nine residents reviewed for Clostridium difficile (C-Diff) infections. The facility census was 80.Findings include: Closed record review for Resident #103 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included cellulitis of the right lower limb, anemia, and atrial fibrillation. The resident was discharged from the facility on 01/22/26. Review of the hospital discharge orders, dated 10/30/25, revealed the resident was ordered to receive 100 milligrams (mg) of Doxycycline (an antibiotic medication) twice a day for 9 days.Review of the facility physician order, dated 10/30/25, revealed the resident was ordered to receive 100 mg of Doxycycline twice a day. The order did not contain a stop date.Review of the 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.

Based on record reviews, interviews, and policy reviews, the facility failed to ensure that medications were not left unattended at a resident's bedside. This affected one resident (Resident #31) of 19 residents observed during initial observations. The facility census was 80. Findings include: Review of the medical record for Resident #31 revealed an admission date of 10/07/25. She had diagnoses including congestive heart failure, type II diabetes, and hypertension.Review of the Minimum Data Set 3.0 (MDS) assessment completed on 10/14/25 revealed Resident #31 was cognitively intact.Observation on 03/02/26 at 10:27 A.M. revealed a small cup with multiple medications on Resident #31's bedside table.Interview on 03/02/26 at 10:27 A.M. with Resident #31 confirmed her medications were left on her bedside. Resident #31 confirmed her nurse will usually leave her pills for her in the morning if she is too tired to take her medications.Review of physician's orders revealed Resident #61 was administered the following medications in the 9:00 A.M. medication administration timeframe:…

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 and resident and staff interviews, the facility failed to honor resident meal preferences. This had the potential to affect one (Resident #99) of 78 residents at the facility that receives meals from the kitchen. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80 residents.Observation on 03/03/26 at 12:15 P.M. revealed Resident #99 received lunch meal which included beef tips and mashed potatoes with gravy. Review of Resident #99's meal ticket lists dislikes that included broccoli-cauliflower, asparagus, pork and gravy. Interview on 03/02/26 at 12:15 P.M. revealed Resident #99 waved down surveyor and stated, why give facility list of likes and dislikes if facility is not going to honor preferences. Interview on 03/02/26 Staff #327 confirmed resident beef tips and mashed potatoes were covered in gravy and meal ticket list gravy as a dislike.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and policy review, the facility failed to ensure an accurate medical record. This affected one resident (Resident #61) of 24 residents reviewed for accuracy of medical records. The facility census was 80.Findings include: Review of the medical record for Resident #61 revealed an admission date of 03/20/25 with diagnoses including hemiplegia and hemiparesis affecting his right, non-dominant side, aphasia following cerebral infarction, depression, and high blood pressure. Further record review revealed on admission, his Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had moderate cognitive impairment.Review of the annual Minimum Data Set 3.0 (MDS) assessment completed on 02/09/26 revealed Resident #61 was independently mobile with the use of a manual wheelchair. He required maximal assistance with toileting, showering, dressing, and positioning. Resident #61 had displayed no verbal or physical disruptive behaviors, no rejection of care, and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was immediately notified of a resident's change of condition. This affected one (#120) of three residents reviewed for change of condition. The facility census was 70.Findings include: Medical record review for Resident #120 revealed an admission date of 07/17/25 and was discharged on 07/19/25. Diagnoses included coronary artery disease, hydronephrosis, renal insufficiency, anxiety, depression, atrial fibrillation, and cardiomyopathy. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was moderately cognitively impaired, and was partial to moderate assistance for toileting, bed mobility, and for transfers. Review of the progress note dated 07/19/25 at 12:19 A.M. revealed Resident #120 was yelling and the staff entered the room…

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 facility policy, the facility failed to ensure bathroom flooring and resident room doors were maintained in a clean and safe condition. Additionally, the facility failed to ensure linens were changed upon being soiled in a timely manner. This affected eight (#20, #23, #35, #75, #235, #236, and #238) of eight residents reviewed for environment. The facility census was 87. Findings include: 1. Observation on 07/15/24 at 9:40 A.M. revealed the linoleum in the bathroom of Resident #235 and Resident #236 was taped down across the doorway with duct tape, which was dirty and tattered. There was a gap between the edge of the linoleum and the walls which went around the bathroom. Dirt and debris were observed in the gap between the linoleum and walls. 2. Observation on 07/15/24 at 9:50 A.M. revealed the linoleum in the bathroom of Resident #238 and Resident #75 was taped down across the doorway with duct tape which was dirty, tattered, and had a…

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

Based on observation, staff interview and review of facility policy, the facility failed to ensure food was prepared in a manner to prevent food-borne illness. This had the potential to affect all residents residing in the facility, with the exception of two residents (#48 and #237) identified by the facility as having no food by mouth (NPO). The facility census was 87. Findings include: Observation on 07/15/24 at 9:00 A.M. revealed two large, uncooked pork loins in plastic packaging, lying in the sink. The two raw pork loins were submerged in water with the drain plug in place, keeping the water from draining. No water was running into the sink. Dietary Manager (DM) #500 obtained the temperature of the water the pork loins were submerged in with a facility thermometer. The water temperature was 62 degrees Fahrenheit (F). Interview with DM #500 on 07/15/24 at 9:02 A.M. confirmed the two raw pork loins were submerged in standing water, which had a temperature of 62 degrees F. DM #500 confirmed raw meats were only to be thawed under cold running water. Review of the facility policy…

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 and staff interview, the facility failed to ensure resident dignity was maintained during dining experiences. This affected two (#36 and #242) of two residents observed for dining. The facility census was 87. Findings include: 1. Observation on 07/15/24 at 11:59 A.M. revealed State Tested Nursing Assistant (STNA) #54 entered the room of Resident #41, carrying the resident's lunch meal tray. STNA #54 set up the resident's tray and began to feed the resident while standing at the side of the resident's bed. Resident #242, Resident #41's roommate, was sitting in his wheelchair in the room and had not received a lunch meal tray. Interview on 07/15/24 at 12:08 P.M. with Resident #242 confirmed the lunch meal Resident #41 was being fed smelled good. Resident #242 additionally confirmed he was hungry and was still waiting for his lunch meal to be delivered to the room Interview on 07/15/24 at 12:10 P.M. with STNA #54 confirmed residents who required assistance consuming meals received their meal trays first so staff could assist them. While…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were invited to care conferences. This affected one (#23) of one residents reviewed for care conferences. The facility census was 87. Findings include: Review of the medical record for Resident #23 revealed an admission date of 10/04/19. Diagnoses included diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness and agitation and impulsive behavior. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the care conferences dated 12/16/23, 03/08/24 and 05/20/24 revealed no evidence Resident #23 was invited to or attended the care conferences. Interview on 07/16/24 at 9:24 A.M. with Resident #23 revealed she was unaware of any care conferences and had not been invited to any. Resident #23 stated she would have attended had she been invited.…

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 and staff interview, the facility failed to ensure the appropriate records and documentation were completed and sent with the resident upon transfer to the hospital. This affected one (#13) of the three residents reviewed for hospitalizations. The facility census was 87. Findings include: Record review for Resident #13 revealed an admission date of 10/25/23 with diagnoses including chronic respiratory failure, pulmonary disease, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/23/24, revealed Resident #13 was assessed to have mildly impaired cognition. Review of the nurses progress note, dated 03/24/24 and timed 1:34 A.M., revealed Resident #13 experienced a change in condition and was transferred to the hospital. Further review of Resident #13's medical record revealed the facility SNF/NF to Hospital Transfer Form was not completed until 03/25/24, the day after the resident was sent to the hospital. Interview on 07/18/24 at 8:46 A.M. with the Director of Nursing (DON) confirmed the SNF/NF to Hospital Transfer Form,…

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 and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected one (#82) of three residents reviewed for resident assessments. The facility census was 87. Findings include: Review of Resident #82's medical record revealed an admission date of 04/26/24 and discharged on 04/27/24. Diagnoses included congestive heart failure, hypertensive heart disease, endocarditis, primary pulmonary hypertension, monothematic aortic valve stenosis, anemia, thrombocytopenia, hyperlipidemia, obesity, benign prostatic hyperplasia, hyperglycemia and anxiety disorder. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment, dated 04/27/24, revealed Resident #82 discharged to a short term general hospital. Review of a progress note, dated 04/27/24 at 1:26 P.M., revealed Resident #82 was transferring to an inpatient hospice facility. Interview on 07/18/24 at 1:17 P.M. with Registered Nurse (RN) #66 confirmed Resident #82 was transferred to an inpatient hospice facility and did not go to the hospital from…

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 the medical record, the facility failed to ensure a new skin impairment was assessed and monitored to promote healing. This affected one (#20) of four residents reviewed for skin assessments. The facility census was 87. Findings include: Review of the medical record for Resident #20 revealed an admission date of 06/15/21. Diagnoses included heart disease, anemia, muscle weakness, dysphasia and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Observation on 07/15/24 at 12:08 P.M. of Resident #20 revealed the resident had a bandage to his left elbow. Concurrent interview with Resident #20 stated, during his shower, he bumped his elbow on the wall and had a small scrape. Resident #20 stated the nurse put a bandage on the area. Further review of Resident #20's medical record, including progress notes and skin/wound assessments, revealed no evidence of an assessment of 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 medical record review and staff interview, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the source of the resident's PTSD and minimize triggers and/or re-traumatization. This affected one (#48) of one residents identified by the facility as having a diagnosis of PTSD/trauma. The facility census was 87. Findings include: Record review for Resident #48 revealed an admission date of 06/27/23. Diagnoses included PTSD, chronic respiratory failure, chronic osteomyelitis, diabetes mellitus type II, chronic obstructive pulmonary disease, cerebrovascular insufficiency, protein-calorie malnutrition, apraxia, hypotension, myocardial infarction, anxiety, pulmonary embolism, spinal stenosis, restless leg syndrome, epilepsy, chronic pain, pseudobulbar affect (causes uncontrollable crying and/or laughing), insomnia, gastroesophageal reflux disease and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 06/05/24, revealed Resident #48 was cognitively intact. Resident #48 had an active diagnosis…

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 pharmacy recommendations, medical record review and staff interview, the facility failed to timely act upon pharmacy recommendations for laboratory values to be drawn. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 87. Findings include: Review of Resident #25's medical record revealed an admission date of of 12/29/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, chronic kidney disease, myocardial infarction, epilepsy, atherosclerotic heart disease of native coronary artery, hypertension, chronic pain syndrome, , major depressive disorder, gastroesophageal reflux disease, fracture of right upper end of humerus and localized edema. Review of the significant change Minimum Data Set (MDS) assessment, dated 06/18/24, revealed Resident #25 was cognitively intact, used a walker to aid in ambulation and was always continent of bowel and bladder. Review of a physician order dated 04/18/23 revealed to give Keppra (anti-seizure medication) oral tablet 500…

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

Based on observation, medical record review and staff interview, the facility failed to ensure medication error rates were not greater than 5% when staff crushed extended release medications for Residents #27 and #46. This affected two (#27 and #46) of five residents reviewed for medication administration. The facility had two errors out of 30 opportunities, for a medication error rate of 6.67%. The facility census was 87. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 04/18/22. Diagnoses included carotid artery syndrome, heart failure, type two diabetes mellitus, atherosclerotic heart disease, atrial fibrillation, hypertensive heart disease with heart failure, anemia and vascular dementia. Review of the Minimum Data Set (MDS) assessment, dated 04/19/24, revealed Resident #27 was severely cognitively impaired, used a wheelchair, had an ostomy and was always incontinent of bladder. Review of a physician order dated 04/20/22 revealed to give metoprolol succinate extended release tablet 24 Hour 50 milligram (mg), one tablet by mouth one time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of dental notes, resident interview and staff interview, the facility failed to ensure dental recommendations were followed-up on timely. This affected one (#23) of one residents reviewed for dental services. The facility census was 87. Findings include: Review of the medical record for Resident #23 revealed an admission date of 10/04/19. Diagnoses included diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness and agitation and impulsive behavior. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. The dental section indicated Resident #23 had no broken teeth. Review of the plan of care dated 05/08/24 revealed Resident #23 was at risk for oral and dental problems. Interventions included to monitor, document and report any problems needing attention. Review of dental notes dated 09/27/23 revealed Resident #23 was seen by the dentist for discomfort.…

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

Based on medical record review, staff interview and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were timely offered, provided, and educated on pneumococcal vaccinations. This affected three (#23, #25, and #58) of five residents reviewed for vaccination status. The facility census was 87. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 10/04/19. Diagnoses included diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness and agitation and impulsive behavior. Review of the pneumococcal consent dated 09/15/23 revealed Resident #23 consented to the pneumonia vaccine. Further review revealed the vaccine was not administered until 10/02/23. 2. Review of the medical record for Resident #25 revealed an admission date of 12/29/22. Diagnoses included hemiplegia and hemiparesis, cerebral infarct, diabetes and epilepsy. Further review of Resident #25's medical record revealed the resident's family declined 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, staff interview, and policy review the facility failed to ensure residents who received psychoactive medications identified specific target behaviors, reduced the medication when the reduction was not clinically contraindicated, and had not ruled out causes of newly emergent behaviors before administering psychoactive medications. This affected four residents (#04, #45, #46, and #55) of six sampled resident reviewed for unnecessary drugs. The facility census was 75. Findings include: 1. Review of Resident #04's medical record revealed he was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary, schizophrenia, and fall. Review of Resident #04's quarterly Minimum Data Set (MDS) date 04/18/2022 revealed the following. Resident # 04's speech was clear, he made himself understood, he usually understands others, and his cognition was intact. Resident #04 had no indicators of psychosis, no behaviors, did not reject care, and did not wander. Resident #04 required extensive…

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

Based on observation, interview and policy review the facility failed to ensure the glucometer was cleaned effectively between use. This had the potential to affect 12 residents (#27, #49, #17, #32, #35, #53, #20, #28, #215, #07, #25 and #14) of 22 residents residing on the hallway who required blood glucose monitoring. The facility census was 75. Findings include: During an observation on 05/04/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #309 cleaned the glucometer, after use, with an alcohol wipe pad. LPN #309 wiped the glucometer off once over and placed it on top of the medication cart. During an interview on 05/04/22 at 7:51 A.M., with LPN # 309 verified the glucometer was cleaned with an alcohol wipe pad. LPN #309 said she always cleaned the glucometer with an alcohol wipe and was not aware of the facility policy on cleaning/sanitizing glucometers. LPN #309 proceeded to the supervisor for instruction. During an interview on 05/04/22 at 9:44 A.M., with the Director of Nursing (DON) revealed cleaning the glucometer with an alcohol wipe was not standard practice or proper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the [NAME] Nursing Drug book, and staff and resident interview, the facility failed to ensure residents were informed of the indication and side effects of medication to make an informed decision. This affected one resident (#12) of 20 residents reviewed. The facility census was 75. Findings include: Review of the medical record for Resident #12 revealed an admission date of 06/10/18 with diagnosis including peripheral vascular disease, depression, morbid obesity, weakness and chronic pain. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact with behaviors of rejection of care. Resident #12 required extensive assistance of two persons for bed mobility, dressing, toilet use, and personal hygiene. Resident #12 was continent of bladder function and had a colostomy for bowel function. Review of the physician orders for May 2022 revealed on 11/19/20 Resident #12 was ordered and received Cimetidine (an antacid…

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 refer a resident with a newly evident mental disorder for a level II resident review with a significant change in status assessment. This affected one resident (#55)of six residents reviewed for pre-admission screening and resident review (PASRR). The facility census was 75. Findings include: Review of Resident #55's medical record revealed he was admitted on [DATE]. Diagnoses included right lower leg fracture, hyperkalemia, paranoid personality, skin picking disorder, restless leg syndrome, depression, type II diabetes, and end stage renal disease. Review of Resident #55's PASRR dated 03/02/2022 revealed no mental illness diagnoses. Review of Resident #55's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #55 was not considered to have a serious mental illness. Resident #55's speech was clear, he made himself understood, he understands, and his cognition was intact. Review of Resident #55's progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with diagnoses of mental disorders or intellectual disabilities were correctly identified during the Preadmission Screening and Resident Review (PASRR) and the facility failed to reassess residents with expired level one determinations. This affected two residents (#02 and #45) of seven residents reviewed during the annual survey for PASARR. The facility census was 75. Findings include: 1. Review of medical record for resident #02 revealed an admission date of [DATE]. Diagnoses included depressive disorder, dementia with behavioral disturbance, dementia without behavioral disturbance, psychosis not due to a substance or known disorder. Resident # 2 was diagnosed with cognitive communication deficit on [DATE]. Review of Resident #02's physician orders revealed an order for risperidone (antipsychotic medication) 0.5 milligrams one tablet by mouth once daily at bedtime for dementia with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure care planned skin alteration prevention interventions were in place and failed to ensure residents edema was being monitored. This affected two residents (#57 and #51) out of the five residents reviewed for edema and skin conditions. The facility census was 75. Findings include: 1. Record review for Resident #57 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute combined systolic and diastolic heart failure, cognitive communication deficit, polyneuropathy, recurrent depressive disorders, cerebral infarction, anxiety disorder, muscle weakness, repeated falls, dysphagia, hemiplegia and hemiparalysis affecting unspecified site, and osteoarthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #57 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10. This 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 observation, medical record review, and staff interview the facility failed to ensure a resident's bed was positioned to prevent the resident from falling out of bed between the bed and the wall. This affected one resident (#04) of three sampled residents reviewed for accidents. The facility census was 75. Findings include: Review of Resident #04's medical record revealed he was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary, schizophrenia, and falls. Review of Resident #04's Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #04's speech was clear, he made himself understood, he usually understands others, and his cognition was intact. Resident #04 had no indicators of psychosis, no behaviors, did not reject care, and did not wander. Resident #04 required extensive assistance two staff for bed mobility, to transfer, and did not walk. Resident #04 had two or more falls with no injury and two or more falls with minor injury. Review of Resident #04's behavior…

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 3. Review of medical record for resident #02 revealed an admission date of 11/25/21. Diagnoses included chronic obstructive pulmonary disease, other recurrent depressive disorders, atrial fibrillation, dementia, muscle weakness, cognitive communication deficit, gastrointestinal hemorrhage, dysphagia, and anemia. Review of Resident #02's weights revealed on 04/07/2022 the resident weighed 158.2 pounds. On 04/27/2022, the resident weighed 149.0 pounds which is a -5.82 % loss. And further review of Resident #02's weights revealed on 01/07/2022 the resident weighed 177.0 lbs. On 04/27/2022, the resident weighed 149 pounds which is a -15.82 % loss. Review of Resident #02's orders revealed an order for ProMod Liquid 30 milliliters by mouth two times daily for wound healing and an order for Dronabinol 2.5 milligrams by two times daily for poor appetite. Review of Resident #02's care plan revealed interventions to administer appetite stimulant as ordered and an intervention to encourage and assist as needed to consume…

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 policy review the facility failed to evaluate a resident's need for an opioid analgesic prior to the administration of the medication. This affected one resident (#265) of one resident's reviewed for pain. The facility census was 75. Findings include: Review of Resident #265's medical record revealed he was admitted on [DATE]. Diagnoses included osteomyelitis, alcohol use, type II diabetes, streptococcal infection, non-pressure chronic ulcer of foot with fat layer exposed, resistance to vancomycin, and altered mental status. Review of Resident #265's admission Minimum Data Set (MDS) dated [DATE] revealed his speech was clear, he made himself understood, understands others, and his cognition was intact. Resident #265 had no behaviors and did not resist care. Resident #265 required supervision of one staff for bed mobility, to transfer, and to walk. Resident #265 received scheduled pain medication, received as needed (PRN) pain medication, and non-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 medical record review, observation, staff interview, and policy review the facility failed to ensure medications were administered without error. There were 38 opportunities for error with three observed errors for a calculated error rate of 7.89 percent. This affected one resident (#17) of three residents observed for medication administration. The facility census was 75. Findings included: Review of the medical record for Resident #17 revealed an admission date of 10/18/18. Diagnoses included glaucoma, macular degeneration and type two diabetes mellitus. Review of the admission assessment dated [DATE] indicated Resident #17 required assistance with medication administration. Review of the physician orders for May 2022 revealed Resident #17 was ordered Artificial Tears instill two drops to both eyes two times daily, Timolol Maleate (a medication to decrease pressure inside the eye) 0.5% instill one drop to both eyes two times daily, Brimonidine (a glaucoma medication) 0.2% instill one drop to both eyes…

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.