Arc At Cincinnati

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to provide activities of daily living (ADL) assistance for dependent residents. This affected one (#56) of four residents reviewed for ADLs. The census was 92.Findings include:Review of the medical record revealed the facility admitted Resident #56 on 10/13/23. Diagnoses included legal blindness and multiple sclerosis. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the resident required substantial/maximal assistance for personal hygiene. Review of Resident #56's care plan included a focus area, revised 12/11/24, which indicated the resident had an activities of daily living (ADL) self-care deficit related to needing extensive to dependent assistance with ADLs and mobility. Interventions directed staff to assist the resident with 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.

Based on medical record review, observation, staff interview, resident representative interview, and policy review, the facility failed to ensure a residents tube feeding was administered according to physician orders. This affected one (Resident #06) of one resident reviewed for tube feedings. The facility census was 92.Findings Included:Review of the medical record revealed the facility admitted Resident #06 on 10/28/22 and readmitted the resident on 04/11/23. Diagnoses included persistent vegetative state, unspecified severe protein-calorie malnutrition, and gastrostomy status. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #06 was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident had a feeding tube and received 51 percent or more of their total calories via tube feedings and 501 cubic centimeters (cc) or more of fluid per day via the tube. Review of Resident #06's Care Plan included a focus area initiated 11/10/25, indicating the resident required tube feeding…

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, resident interview, staff interview, and policy review, the facility failed to provide respiratory care in accordance with physician's orders for one (Resident #35) of four residents reviewed for respiratory care. The facility census was 92. Review of the medical record for Resident #35 revealed an admission date of 12/20/2020. Diagnoses inlcuded chronic respiratory failure with hypercapnia (abnormally elevated carbon dioxide levels in the blood); chronic diastolic (congestive) heart failure; chronic obstructive pulmonary disease (COPD), unspecified; shortness of breath; and morbid (severe) obesity with alveolar hypoventilation. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #35's care plan, initiated 10/15/2025, indicated the resident had shortness of breath related to COPD, asthma, chronic respiratory failure, and history of hypoxia. An…

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 there was ongoing communication with dialysis providers. This affected two (Resident #05 and #68) of two residents reviewed for dialysis. The facility census was 92. Findings Include:1. Review of the medical record revealed Resident #05 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, and end stage renal disease (ESRD). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/25, revealed Resident #05 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident received dialysis while they were a resident at the facility. Review of Resident #05's Care Plan Report included a focus area revised on 08/22/25, indicating the resident needed hemodialysis related to ESRD. Interventions directed staff to…

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

Based on medical record review, staff interview, and facility policy review the facility failed to ensure medications were administered as ordered, resulting in significant medication errors. This affected three (#56, #100, and #101) of six residents reviewed for medications. The census was 92.Findings include:1. Review of the medical record revealed the facility admitted Resident #56 on 10/13/23. The resident had a diagnoses of allergic rhinitis. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/03/25, indicated Resident #56 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Review of Resident #56's care plan included a focus area, revised on 09/30/24, that indicated the resident had multiple chronic conditions and severely impaired vision affecting his independence and ability to care for himself. An intervention directed staff to administer medications as ordered. Review of Resident #56's order summary report included a physician's order dated 07/10/24 for the corticosteroid…

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 provide routine dental services for one (Resident #45) of one resident reviewed for dental services. The facility census was 92.Review of the admission record revealed that the facility admitted Resident #45 on 07/30/2024. According to the admission record, Resident #45 had a medical history that included traumatic subdural hemorrhage with loss of consciousness, cerebral infarction (stroke) due to unspecified occlusion or stenosis of an unspecified cerebral artery, and aphasia (a language disorder from brain damage that impairs speaking understanding, reading, or writing). Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2025 revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #45 had moderate cognitive impairment. The MDS indicated Resident #45 had difficulty communicating some words or finishing thoughts but was able to be understood if given time. The MDS revealed the resident may miss some parts or 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, interview, and facility policy review, the facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for one (Resident #39) of 37 sample residents. The facility census was 92. Review of an admission Record indicated the facility admitted Resident #39 on 03/14/2025. According to the admission Record, the resident had a medical history that included unspecified pain, low back pain, and chronic pain syndrome with opioid dependence. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received scheduled pain medication and had pain occasionally over the last five days of the assessment period that occasionally limited their participation in rehabilitation therapy sessions and day-to-day activities. Review of Resident #39's Care Plan Report, included a focus area revised 11/10/2025, that indicated the resident was at risk…

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 facility policy review, the facility failed to maintain a current hospice plan of care for one (Resident #03) of one resident reviewed for hospice services. The facility census was 92. Review of the admission Record indicated the facility admitted Resident #03 on 01/20/2022. According to the admission Record, the resident had a medical history that included metabolic encephalopathy, type II diabetes mellitus, emphysema, and non-pressure chronic ulcer of the right lower leg. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2025, indicated Resident #03 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #03 received hospice services. Review of Resident #03's Care Plan Report, included a focus area initiated 04/01/2025, that indicated the resident had a terminal condition and received hospice services that began 03/31/2025. The care plan included the name of the hospice company, address, and phone…

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 facility policy, the facility failed to conduct post-fall investigations. The affected one (Resident #3) of three residents reviewed for falls. The facility census was 91 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/27/23 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and schizoaffective disorder.Review of the progress note for Resident #3 dated 10/02/25 revealed the resident was found on the bathroom floor and was not responsive.Review of the medical record for Resident #3 revealed it did not include an investigation of the resident's unwitnessed fall on 10/02/25.Interview on 10/29/25 at 10:45 A.M. with the Director of Nursing (DON) confirmed the facility did not conduct a past fall investigation for Resident #3's unwitnessed fall on 10/02/25. Interview on 11/03/25 at 9:55 A.M. with the Executive Director (ED), the Assistant Director of Nursing (ADON), and Registered Nurse (RN) #1 confirmed the facility should…

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 properly notify residents/resident representatives of room changes. This affected one (Residents #194) of three residents reviewed for room changes. The facility census was 94 residents.Findings include: Review of the medical record for Resident #194 revealed an admission date of 09/04/15 with diagnosis including dementia, spinal stenosis, injury of cervical spine, neuromuscular dysfunction, bipolar disorder, history of opioid abuse and alcohol abuse and a discharge date of 07/31/25. Review of Minimum Data Set (MDS) assessment for Resident #194 dated 06/20/25 revealed the resident was cognitively impaired and was dependent on staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #194 revealed it did not include documentation of the room changes for the resident 06/03/25, 06/05/25 and 06/19/25 regarding the reasons for moves nor of notification to the resident and resident’s representative of the moves. Interview on 08/18/25 at 1:17 P.M. with the Administrator…

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 facility policy, the facility failed to appropriately monitor resident blood pressures. This affected one (Resident #10) of 15 residents reviewed for blood pressures. The facility census was 94 residents. Findings include:Review of the medical record for Resident #10 revealed an admission date of 06/19/23 with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 06/17/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.)Review of the progress note for Resident #10 dated 05/21/25 at 9:31 A.M. revealed the resident's blood pressure was 91/40. There was no documentation of rechecking the blood pressure and/or of physician or provider notification of the low blood pressure reading. Resident of the progress note for Resident #10 dated 07/01/25 at 8:29 A.M. revealed the resident's blood pressure was 203/99. There was 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 observations, staff interviews, and policy review, the facility failed to ensure the resident's electronic medical records (EMR) which contained private and confidential health information were secured and kept confidential. This affected one (#17) of the four residents reviewed for privacy of medical records. The facility census was 92. Findings include: Review of the medical record for Resident #17 revealed an admission date of 06/21/23. Diagnoses included diabetes mellitus type two (DM II), vascular dementia, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Observation on 03/27/25 at 8:15 A.M., revealed Registered Nurse (RN) #30 left Resident #17's EMR with private and confidential health information open and facing the hallway in plain view for other staff and residents to see while he administered medications 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 observations, staff interviews, and policy review, the facility failed to ensure controlled substances were accounted for and signed out after administration. This affected one (#80) of four residents reviewed for medication administration. The facility census was 92. Findings include: Review of the medical record for Resident #80 revealed an admission date of 11/29/18. Diagnoses included cerebral infarction, generalized anxiety disorder (GAD), peripheral vascular disease (PVD), and chronic respiratory failure. Review of the physician order dated 07/09/24 revealed Resident #80 was ordered Lorazepam (controlled substance [schedule IV] used for anxiety) 0.5 milligrams (mg), give one tablet by mouth two times a day for GAD. Review of the physician order dated 07/09/24 revealed Resident #80 was ordered Modafinil (controlled substance [schedule IV] used for excessive sleepiness associated with narcolepsy and/or obstructive sleep apnea) 100 mg, give one tablet by mouth one time a day for supplement. 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 observations, staff interviews, and policy review, the facility failed to ensure medication error rate was less than five percent. This affected one (#80) of four residents reviewed for medication administration. The facility census was 92. Findings include: Review of the medical record for Resident #80 revealed an admission date of 11/29/18. Diagnoses included cerebral infarction, generalized anxiety disorder (GAD), peripheral vascular disease (PVD), gastroesophageal reflux disorder (GERD) and chronic respiratory failure. Review of the physician order for Resident #80 dated 07/09/24 revealed the resident was ordered Stress B/Zinc Oral tablet (B-Complex with Vitamin C & Vitamin E plus Zinc), give one tablet by mouth in the morning for supplement. Review of the physician order dated 07/09/24 revealed Resident #80 was ordered Famotidine oral suspension reconstituted 40 milligrams (mg) per five milliliters (ml), give 2.5 ml by mouth in the morning for GERD. Review of the Annual Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review, the facility failed to ensure infection control practices were followed during medication administration and failed to ensure Enhanced Barrier Precautions (EBP) were followed during a resident's dressing change. This affected three (#11, #17, and #80) residents of the four reviewed for infection control practices. The facility census was 92. Findings include: 1) Review of the medical record for Resident #11 revealed an admission date of 09/21/23. Diagnoses included diabetes mellitus, cerebral infarction, vascular dementia, and major depressive disorder. Review of the care plan dated 09/27/24, revealed Resident #11 had a potential for skin breakdown related to impaired mobility, diabetes, incontinence, and impaired cognition. Interventions included barrier ointment applied after incontinent care, instruct and assist the resident in shifting weight in wheelchair frequently, monitor nutritional status, a pressure reduction mattress with a low-air loss…

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, staff interview and review of facility policy, the facility failed to ensure they discharged a resident in a safe and orderly manner. This affected one (#90) resident of the five residents reviewed for discharge. The facility census was 87. Findings include: Review of the closed medical record for Resident #90, revealed an admission date of 01/12/25. Diagnosis included surgical after-care for knee, bipolar and schizophrenia. Resident #90 was discharged to a homeless shelter on 01/16/25 per his Caseworkers request then immediately returned to the facility after the homeless shelter refused to accept the resident due to his behaviors during previous stays. Resident #90 was discharged again on 01/17/25 with Caseworker #500 and taken to hospital where he had been recently discharged . Resident was listed as his own person and did not have a Guardian. Review of a statement by the Administrator dated 01/09/25, revealed the management staff were informed Resident #90 was being admitted as…

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 phone system was maintained in a safe and functional manner. This had the potential to affect all 84 residents residing in the facility. The facility census was 84. Findings include: Observations from 11/13/24 to 11/19/24 revealed 15 attempts to reach facility personnel on the facility phone system. No personnel answered the phone and the following message was received, Hello, you have reached the ARC of Cincinnati. It is our pleasure to serve you today. Please leave a message and we will be happy to return your call as soon as possible. Thank you and have a good day. There was no option to transfer to an individual, department or nursing unit. Attempts to reach facility staff were unsuccessful on the following dates and times: 11/13/24 at 9:01 A.M., 9:02 A.M., 9:06 A.M., 9:47 A.M., 10:12 A.M., 10:42 A.M., 12:43 P.M. and 2:14 P.M.; 11/14/24 at 9:13 A.M.; 11/15/24 at 9:09 A.M. and 10:12 A.M.; 11/19/24 at 10:39 A.M., 10:42 A.M., 12:54 P.M., 12:56 P.M. and 1:35 P.M. Phone interview on 11/18/24 at 12:45 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 observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two Residents (#32 and #75) who did not receive food from the facility's kitchen. The facility census was 84. Findings include: Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included hypertension, osteoarthritis, unspecified dementia, peripheral vascular disease and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #73 had intact cognition and was always incontinent of bowel and bladder. The resident required no assistance with eating. Review of the dinner menu for 11/04/24 revealed the residents received chili mac, cornbread, salad and peaches. Observation of meal line service on 11/04/24 from 4:55 P.M. to 5:11 P.M., revealed the dinner meal consisted of chili mac, cornbread, salad, green beans, and carrots. Cooking…

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 a safe, functional, and homelike environment for the residents. This affected 23 (#03, #07, #10, #11, #12, #22, #23 #26, #28, #31, #37, #39, #40, #46, #52, #54, #55, #61, #64, #69, #76, #78 and #84) residents residing in the Fountains Nursing Unit. The facility census was 84. Findings include: Observation of the Fountains Nursing Unit on 11/05/24 from 11:00 A.M. to 11:25 A.M. with Maintenance Director #200 revealed the following: a) Resident #23's room had an area of damaged, brown and black discoloration drywall approximately five feet long and four inches wide directly to the right of the resident's window. a) The therapy gym had six ceiling tiles with brown ring stains. c) The common area outside of Resident #84's room had two ceiling tiles with brown ring stains. d) The common area outside of Residents #64 and #28's room had one ceiling tile broken with a brown ring stain. e) The common area outside of Residents #03 and #55's room had two ceiling tiles with brown ring stains. f) The common area outside 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 record review, staff interviews, review of facilities Self-Reported Incidents (SRIs), and facility policy review, the facility failed to ensure their policy regarding injuries of unknown origins was implemented when a resident was found with injuries. This affected one (#11) of the two residents reviewed for abuse. The facility census was 84. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's disease, restlessness and agitation, peripheral vascular disease and repeated falls. Review of the facility's Incidents and Accidents Log from 08/12/24 to 11/06/24 revealed an incident documented for an injury of unknown origin dated 09/06/24 for Resident #11. The entry was struck out on 11/04/24 by the Interim Director of Nursing (DON). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required 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 record review, staff interviews, review of facilities Self-Reported Incidents (SRIs), and facility policy review, the facility failed to timely report an injury of unknown origin to the state agency. This affected one (#11) of the two residents reviewed for abuse and injury of unknown origin. The facility census was 84. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's disease, restlessness and agitation, peripheral vascular disease and repeated falls. Review of the facility's Incidents and Accidents Log from 08/12/24 to 11/06/24 revealed an incident documented for an injury of unknown origin dated 09/06/24 for Resident #11. The entry was struck out on 11/04/24 by the Interim Director of Nursing (DON). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required was dependent on staff 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, review of the facility incident log, review of facility Self-reported Incidents (SRI's), staff interview, and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown source. This affected one (#11) of the two residents reviewed for abuse and injury of unknown origin. The facility census was 84. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's disease, restlessness and agitation, peripheral vascular disease and repeated falls. Review of the facility's Incidents and Accidents Log from 08/12/24 to 11/06/24 revealed an incident documented for an injury of unknown origin dated 09/06/24 for Resident #11. The entry was struck out on 11/04/24 by the Interim Director of Nursing (DON). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required 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 record review, staff interview, and review of facility policy, the facility failed to ensure a resident's medications were ordered timely upon admission. This affected one Resident (#8601) of three residents reviewed for admissions. The facility census was 84. Findings include: Review of the medical record revealed Resident #8601 was admitted on [DATE]. Diagnoses included malignant neoplasm of unspecified bronchus or lung, hepatic encephalopathy, diabetes mellitus type II, obesity and pleural effusion. The resident was discharged on 08/13/24 after the family took the resident to an appointment and never returned the resident to the facility. Review of a nurse's progress note dated 08/12/24 for Resident #8601, revealed the resident was admitted to the facility from the hospital at 2:34 P.M. via private transport by family. Resident #8601 was alert and oriented and able to comprehend use of call-light, telephone, bed and television controls. A complete head-to-toe assessment was completed which 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a incident report, review of a facility investigation, review of personnel files, observations, resident and staff interviews, and facility policy review, the facility failed to ensure a resident was free from a physical restraint. This affected one (#01) of three residents reviewed for physical restraints. The census was 85. Findings include: Review of the Resident #01's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis of left middle cerebral artery, brain stem stroke syndrome, dysphagia, cognitive communication deficit, need for assistance with personal care, muscle weakness, other abnormalities of gait and mobility, age related physical debility, hypertension and hemiplegia and hemiparesis following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure a resident's fall care plan was updated with current interventions. This affected one (#01) of three residents reviewed for falls. The census was 85. Findings include: Review of the Resident #01's chart revealed Resident #01 admitted to the facility on [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis of left middle cerebral artery, brain stem stroke syndrome, dysphagia, cognitive communication deficit, need for assistance with personal care, muscle weakness, other abnormalities of gait and mobility, age related physical debility, hypertension and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of Resident #01's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and Resident #01 was dependent with oral hygiene, toilet hygiene, showering, upper body…

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 medical record review, facility investigation review, observations, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision during a mechanical lift transfer resulting in a mechanical lift (Hoyer) tipping during a transfer. This affected one (#86) of three residents reviewed for accidents. The census was 83. Findings include: Review of Resident #86 medical record revealed an admission date of 07/22/22. Diagnoses included bipolar, depression, diabetes, and high blood pressure. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #86 had no cognitive impairments. Resident #86 required a mechanical lift and two staff members for transfers. Review of the most recent updated mobility plan of care dated 10/17/23 revealed Resident #86 required a mechanical lift and two staff members for all transfers. Review…

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

Based on observations, staff and resident interviews, record review, review of the facility's policy, and review of the resident council minutes, the facility failed to ensure there was enough staff in dietary to provide dining room services to the residents and maintain a clean and sanitary kitchen. This affected two residents (#17 and #71) and had the potential to affect 88 of 90 residents who received food from the kitchen. Two residents (#13 and #58) did not receive food from the kitchen. Findings include: 1. Review of the Resident Council Minutes dated 05/06/22 revealed the residents complained about the dining room not being open and would like for it to reopen so they can use it for eating, socializing and easier access to meals. There wasn't a response for the complaint. Observation of the dining service on 05/23/22 at 12:49 P.M. for lunch revealed all the residents were eating in their rooms and there was no one in the dining room. Observation of the dining service on 05/24/22 at 12:30 P.M. for lunch revealed all the residents were eating in their rooms and there was no 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 observations, record review, review of the facility's policy, and staff interviews, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 88 residents who received meals in the facility. The facility identified two residents (#13 and #58) as receiving no food from the kitchen. The facility census was 90. Findings include: Observation on 05/23/22 from 9:00 A.M. to 9:15 A.M. with Dietary Manager (DM) #205 during the initial tour of the kitchen revealed the standing dessert refrigerator contained the following items that were not labeled or dated: a large tray with bowls of what appeared to be covered peaches, a large slice of what appeared to be cherry pie, a bowl of what appeared to be macaroni salad, and another container that contained what appeared to be coleslaw. Located next to the dessert refrigerator was a standing fridge that contained a container of whip cream with no label or date. Observation of the large walk-in refrigerator revealed there was a large standing cart with of what appeared to be chopped ham salad 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.

Based on review of facility document and staff interview, the facility failed to have a Legionella prevention program in place. This had the potential to affect all 90 residents residing in the facility. Findings include: Review of a facility policy titled Legionella Water Management Program, dated July 2017, revealed as part of the infection control and prevention program, the facility has a water management program that is overseen by the water management team. The water management program will have specific measures used to control the introduction and/or spread of Legionella (e.g. temperature and disinfectants). The facility was unable to provide any documentation of any specific measures being completed or any documentation of a Legionella program in place. During an interview on 05/26/22 at 8:24 A.M., the Administrator confirmed there was no documentation of any water quality checks for Legionella prevention. The Administrator confirmed there was not a Legionella program in place.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, review of the resident council minutes, and policy review the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#17, #57, and #71) out of three residents reviewed for dignity and respect during the annual survey. The facility census was 90. Findings included: 1. Medical record review for Resident #57 revealed an admission dated 04/28/21. Diagnoses included cancer, heart failure, coronary artery disease, renal insufficiency, diabetes, anxiety, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact. The resident required extensive assistance for bed mobility, transfers, and toilet use. The resident was independent for eating. She was frequently incontinent of bowel and bladder. Observation of incontinence care on 05/23/22 at 10:05 A.M. revealed upon entrance to the room State Tested Nursing Aide (STNA) #172 said to 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.

Based on medical record review, staff interview, review of the cut letters, and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the facility failed to ensure the resident notice letter was accurately completed. This affected three residents (#41, #79, and #488) out of three residents reviewed for Beneficiary Notification. The facility census was 90. 1. Review of the medical record for Resident #41 revealed an admission date of 03/10/22. Diagnoses included acute kidney failure, muscle weakness, type 2 diabetes mellitus, hyperlipidemia, dementia, major depressive disorder, and generalized anxiety disorder. Review of the cut letter for Resident #41 dated 04/09/22 revealed it was signed on 04/05/22 by the resident. The SNFABN for the Resident was dated 04/09/22 and consent was given by the resident verbally. Option one was checked incorrectly, when it was option three that should have been checked because the resident did not want services. 2. Review of the medical record for Resident #79 revealed an admission date of 12/14/21. Diagnoses included Parkinson's, history…

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, observation, staff interview, and policy review, the facility failed to ensure resident rooms were clean. This affected two residents (#54 and #61) out of 25 residents in the initial pool. The facility census was 90. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 02/01/18. Diagnoses listed included hypertension, obstructive sleep apnea, atrial fibrillation, and congestive heart failure. Observation of Resident #54's room on 05/23/22 at 10:13 A.M., revealed the window sill had a large amount of dirt and debris. A gallon jug of distilled water was on the window sill and covered with dirt and debris. The window screen had a large amount of dirt and debris stuck in it. There were dead ant remains in the corner of the room by his nightstand and on the top of his nightstand. The floor along the wall with the window had a large amount of dirt, debris, and cobwebs. During an interview on 05/24/22 at 12:04 P.M. Housekeeper #216 verified Resident #54's window sill and floor had dirt and debris. Housekeeper #216 also…

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, observation, and policy review, the facility failed to ensure residents or resident representative were notified of a transfer from the nursing facility. This affected two residents (#16 and #69) out of three residents reviewed for transfer notice. The facility census was 90. Findings included 1. Medical record review of Resident #16 revealed an admission on [DATE]. Diagnoses included sepsis, acute cystitis, acute kidney failure, metabolic encephalopathy, protein malnutrition, diabetes type two, hypertension, major depressive disorder, iron deficiency anemia and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Resident #16 required extensive assistance with bed mobility, transfers, and toilet use. Review of the plan of care for Resident #16 dated 11/22/21 revealed the resident admitted with urinary tract infection, risk factors include prostatectomy for prostate cancer, recent…

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 and resident interviews, observations, and policy revivew, the facility failed to provide written bed hold notices to residents or their representatives prior to transfers. This affected two residents (#16 and #69) of three reviewed for hospitalizations. The facility census was 90. Findings include: 1. Medical record review of Resident #16 revealed an admission on [DATE]. Diagnoses included sepsis, acute cystitis, acute kidney failure, metabolic encephalopathy, protein malnutrition, diabetes type two, hypertension, major depressive disorder, iron deficiency anemia and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Resident #16 required extensive assistance with bed mobility, transfers, and toilet use. Review of the plan of care for Resident #16 dated [DATE] revealed the resident admitted with urinary tract infection, risk factors include prostatectomy for prostate cancer, recent catheter…

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 the Resident Assessment Instrument (RAI) manual the facility failed ensure a Significant Change in Status Assessment (SCSA) was completed when a resident was admitted to hospice services. This affected one resident (#436) of three residents reviewed for hospice services. The facility census was 90. Findings include: Closed medical record review for Resident #436 revealed an admission on [DATE] with diagnoses that include but not limited to large sacral decubitus ulcer, atrial fibrillation, type two diabetes poorly controlled, congestive heart failure, chronic kidney disease, and chronic abdominal wall surgery with slow healing progression. Review of the Minimum Data Set (MDS) assessment for Resident #436 dated [DATE] revealed resident had intact cognition. Resident #436 required extensive assistance with bed mobility, transfers, toilet use and supervision for eating. Review of the plan of care dated [DATE] revealed the resident was enrolled in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, hospice staff interview, observation, and policy review, the facility failed to ensure accuracy of the minimum data set (MDS) assessments to reflect the resident current health status. This affected two residents (#36 and #65) of two residents reviewed for accurate MDS's. The facility census was 90. Findings include: 1. Review of the medical record for Resident #65 revealed an admission date on 11/01/19. Diagnoses included multiple sclerosis, trigeminal neuralgia, dementia and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #65 revealed the resident's cognition was severely impaired. Resident #65 required extensive assistance with bed mobility, transfers, eating and toilet use. Resident #65 was assessed an incontinent of both bowel and bladder. Resident #65 was coded as receiving hospice services. Review of the physician order dated 12/01/20 revealed an order to admit the Resident #65 to hospice services. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to complete baseline care plans for residents. This affected three residents (#08, #16, and #41) of 19 reviewed in the sample. The census was 90. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 03/10/22. Diagnoses listed included hyperlipidemia, dementia, major depressive disorder, and type II diabetes mellitus, and peripheral vascular disease. Review of Resident #41's baseline care plan dated 03/10/22 revealed it was not complete. the sections labeled initial goals, therapy services, safety, social services, and barriers to resident's discharge/goals contained no information. A section where interdisciplinary teams members who contributed to the baseline care plan would sign had no signatures. No interventions where listed for any care area sections. The section for a written summary of the baseline care plan was blank. 2. Record review for Resident #08 revealed he was admitted to the facility 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 medical record review and staff interview, the facility failed to develop a comprehensive plan of care to include the delegation of hospice services and facility staff services for the hospice resident. This affected one resident (#65) of one reviewed for the development of the comprehensive care plan. The facility census was 90. Findings include Review of the medical record for resident #65 revealed an admission date on 11/01/19 with diagnoses including but not limited to multiple sclerosis, trigeminal neuralgia, dementia and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #65 revealed the resident's cognition was severely impaired. Resident #65 required extensive assist with bed mobility, transfers, eating and toilet use. Resident #65 was assessed an incontinent of both bowel and bladder. Resident #65 was coded as receiving hospice services. Review of the facility plan of care for Resident #65 dated 01/03/21 revealed the resident was receiving hospice…

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 and resident interview the facility failed to ensure resident care conferences were held. This affected one resident (#54) out of five reviewed for care planning of 19 sampled. In addition, the facility failed to update the plan of care. This affected two residents (#08 and #70) out of five reviewed for care planning of 19 sampled. The census was 90. 1. Review of Resident #54's medical record revealed an admission date of 02/01/18. Diagnoses included hypertension, obstructive sleep apnea, atrial fibrillation, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Review of Resident #54's medical record revealed no documentation of a care conference being held in the last year. During an interview on 05/23/22 at 10:11 A.M. Resident #54 stated it had been awhile since his last care conference with staff. During an interview on 05/25/22 at 11:12 A.M. Licensed Social Worker (LSW) #231 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a physician ordered splint was in place. This affected one resident (#36) of one resident reviewed for range of motion of 19 sampled during the annual survey. The census was 90. Findings included: Medical record review for Resident #36 revealed an admission date of 12/15/16. Diagnoses included diabetes, cerebrovascular attack (CVA), and contracture. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively impaired. Resident #36 was extensive assistance for bed mobility, transfers, and toilet use. He was supervision for eating. He had no impairment of his upper extremities. Review of the physician orders dated 04/06/22 revealed Resident #36 was ordered a hand splint placed when out of the bed. Review of the care plan dated 04/23/22 revealed Resident #36 had a activity of daily living (ADL) self-care deficit related to dependent for assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents were safely smoking. This affected three (#32, #51, and #182) of four residents reviewed for smoking. The facility identified there were nine residents who were smokers. The facility census was 90. Findings include: 1. Medical record review for Resident #32 revealed an admission date of 03/08/22. Diagnoses included coronary artery disease (CAD), cerebrovascular disease (CVA) and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. His functional status was limited assistance from staff for bed mobility, transfers, and toileting. Review of the safe smoking evaluation dated 03/14/22 revealed Resident #32 was not alert and oriented to perform safe smoking techniques. He wasn't able to communicate the risks associated with smoking or able to smoke safely. He must be supervised by staff, volunteer, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely implement nutritional recommendations when a resident has severe 12.7% weight loss in one month. This affected one (Resident #70) of three residents reviewed for weight loss. The facility identified one resident with unplanned significant weight loss. Findings include: Record review for Resident #70 revealed an admission date of 10/20/17. Diagnoses included Alzheimer's disease, anemia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #70 was severely cognitively impaired. Review of the nutrition note for Resident #70, dated 05/13/22 revealed she had experienced some weight loss. Resident #70 was on a regular, non-starch polysaccharides (NSP) diet. Resident #70 received an eight-ounce renal supplement two times per day. May weight was 95.7 pounds (lbs.), April weight was 109.8 lbs., February weight was 118.1 lbs., and November weight was 120 lbs. Resident's 70's Body Mass Index…

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, resident interview, and staff interview, the facility failed to have clean and sanitary respiratory supply items for a resident. This affected one (Resident #54) of three residents reviewed for respiratory care. The facility identified eight residents who receive respiratory care. The facility census was 90. Findings include: Review of Resident #54's medical record revealed an admission date of 02/01/18. Diagnoses included hypertension, obstructive sleep apnea, atrial fibrillation, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact. Observation of Resident #54's room on 05/23/22 at 10:17 A.M. revealed a gallon jug of distilled water sitting on his window sill. The jug was open and approximately half full. The outside of the jug was covered in dirt and debris. The jug was not dated. During an interview on 05/23/22 at 10:17 A.M., Resident #54 stated the distilled water jug on the window…

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, resident interview, and review of the facility's policy, the facility failed to routinely assess and document the pain for Resident #63 to monitor the effectiveness of the pain medications. This affected one (Resident #63) of three residents reviewed for pain management. The facility identified 33 residents on a pain management program. The facility census was 90. Findings include: Review of the medical record for Resident #63 revealed an admission date of 10/02/21. Diagnoses included type II diabetes mellitus and delusional disorders. Review of the plan of care dated 03/26/21 revealed Resident #63 had a potential for alteration in comfort related to fibromyalgia, chronic back pain, and polyneuropathy. Interventions included monitoring the need for scheduled analgesics, evaluating the effectiveness of pain interventions, and monitoring/documenting for side effects of pain medications. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/19/22, revealed Resident #63 had intact cognition and had no hallucinations or…

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 medications were administered as physician ordered. This affected two (#65 and #435) of three residents reviewed for medication administration. The facility census was 90. Findings include: 1. Review of the medical record for Resident #65 revealed an admission date on 11/01/19. Diagnoses included multiple sclerosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had severely impaired cognition. Review of the physicians' orders for Resident #65 revealed an order dated 01/03/22 for Copaxone (used to treat relapsing forms of multiple sclerosis) 40 milligrams (mg) per milliliter (ml), inject one ml subcutaneous (sub-q) two times a week on Tuesday and Friday. Review of the medication administration record (MAR) for the month of May 2022 for Resident #65 revealed the medication was not signed off as administered as ordered on 05/03/22, 05/06/22, 05/10/22, 05/13/22, 05/17/22, 05/20/22,…

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 gradual dose reductions were attempted for residents receiving psychotropic medications. This affected one (Resident #65) of three residents reviewed for unnecessary psychotropic medications. The facility identified 62 residents receiving psychoactive medications. The facility census was 90. Finding include: Review of the medical record for Resident #65 revealed an admission date on 11/01/19. Diagnoses included multiple sclerosis, trigeminal neuralgia, dementia and Alzheimer's disease. Review of the plan of care dated 01/03/21 revealed Resident #65 had a potential for side effects related to the use of antidepressants, antianxiety, antipsychotics and anticonvulsants. Interventions included to administer medications as ordered, monitor for side effects and effectiveness, report any changes to the physician, and monitor for any adverse side effects. Review of the psychoactive medication consent/education dated 01/26/21 revealed the potential risk and benefits of psychoactive medication. No specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's policy, observation, and resident and staff interview, the facility failed to properly store the resident's medications. This affected one (Resident #57) of 19 residents observed in the final sample and two medication carts of three medication carts observed for drug storage. The facility census was 90. Findings include: 1. Review of Resident #57's medical record revealed an admission date of [DATE]. Diagnoses included type II diabetes mellitus, pulmonary hypertension, fibromyalgia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was assessed as being cognitively intact. Observation of Resident #57's rooms on [DATE] at 9:03 A.M. revealed there were pills in a medication cup on a nightstand beside Resident #57's bed. Also, there was a bottle of Naproxen (anti-inflammatory) 125 milligrams per milliliter (mg/ml) suspension and a bottle of omega three ethyl [NAME] (vitamin) located on her…

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, hospice staff interview, and review of the hospice contract, the facility failed to collaborate with hospice on a resident's comprehensive plan of care. Additionally, the facility failed to designate a staff member who was responsible for working with hospice to coordinate care provided to the resident by hospice and facility staff. This affected one (Resident #65) of one resident reviewed for hospice services. The facility identified one resident receiving hospice services. The facility census was 90. Findings include: Review of the medical record for Resident #65 revealed an admission date on 11/01/19. Diagnoses included multiple sclerosis, trigeminal neuralgia, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 65's cognition was severely impaired and was receiving hospice services. Review of the physician orders dated 12/01/20 revealed an order to admit Resident #65 to hospice services.…

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, observation, resident interview, staff interview, the facility failed to have a bed in good condition for a resident. This affected one (Resident #61) of 25 residents observed in the initial pool. The facility census was 90. Findings include: Review of Resident #61's medical record revealed an admission date of 04/26/21. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Interview and observation on 05/24/22 at 2:01 P.M. with Resident #61 stated her bed had been broken since admission to the facility. Resident #61 stated she had told staff. Observation of Resident #61's bed revealed her bed was leaning to the right side. The mattress had a tear along the top side of the head of the bed. Interview on 05/24/22 at 8:51 A.M. with Maintenance Director (MD) #226 confirmed Resident #61's bed was leaning to the right and needed replaced or fixed. MD #226 confirmed Resident #61's mattress had a tear in it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, family interview, and staff interview, the facility failed to notify residents and/or their responsible parties in writing of the purpose of the resident's transfer out of the facility. This affected four (#4, #18, #28, and #79) of four residents reviewed for discharge. The census was 125. Findings include: 1. Review of Resident #4's records revealed an admission date of 05/01/19. Diagnoses included congestive heart failure (CHF), sarcoidosis of other sites, edema, type two diabetes, presence of automatic (implantable) cardiac defibrillator, sarcoid myocarditis, and hypertension (HTN). Review of progress notes dated 08/05/19 revealed the resident had a routine cardiology appointment and was sent to the hospital for fluid overload related to CHF by her cardiologist. There was no evidence in the record the resident and/or representative was notified of the reason for the transfer. Interview on 09/12/19 at 4:18 P.M., the Director of Nursing (DON) verified 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 medical record reviews, staff interviews, family interviews, staff interviews and review of facility policy, the facility failed to provide written bed hold information upon transfer to the hospital for four (#4, #18, #28, and #79) out of four residents reviewed for bed hold notices. The census was 125. Findings include: 1. Review of Resident #4's records revealed an admission date of 05/01/19. Diagnoses included congestive heart failure (CHF), sarcoidosis of other sites, edema, type two diabetes, presence of automatic (implantable) cardiac defibrillator, sarcoid myocarditis, and hypertension (HTN). Review of progress notes dated 08/05/19 revealed the resident had a routine cardiology appointment and was sent to the hospital for fluid overload related to CHF by her cardiologist. The record contained no evidence the resident was provided the facility bed hold policy upon transfer. Interview on 09/12/19 at 4:18 P.M., the Director of Nursing (DON) verified Resident #4 did not receive a bed hold notice for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, the facility failed to provide personal care for dependent residents. This affected four (#28, #37, #46, #113) residents of five reviewed for activities of daily living. The facility census was 125. Findings include: 1. Review of Resident #28's medical record revealed an admit date of 07/26/19, with diagnoses including: hypertension, pneumonia, atrial fibrillation, tachycardia, bladder dysfunction, and urinary tract infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed cognitive impairment and extensive assist of one needed for dressing, toileting, and bathing. Review of the care plan dated 07/27/19 revealed self-care deficit with interventions to assist as needed. Observation on 09/10/19 at 11:25 A.M., of Resident #28 sitting in a wheelchair in the facility main dining room eating lunch. Resident #28 was observed with long hairs on her chin. Interview on 09/10/19 at 11:33 A.M. with State Tested Nurse Assistant…

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, facility policy reviews, resident and staff interviews, the facility failed to ensure measures were taking to secure sharps containers from un authorized access. This had the potential to affect three ( #17, #72 and #97) of three residents who were confused and independently mobile in the area. The facility failed to ensure residents were following establish smoking policy. This affected two (#600 and #374) random residents observed smoking. The facility failed to ensure staff was available for residents in the dining room who required supervision while eating. This had the potential to affect 19 (#17, #27, #30, #33, #36, #37, #40, #43, #44, #56, #69, #95, #97, #101, #102, #108, #135, #147, #264) residents who ate in the dining room and required supervision with eating. The facility census was 125. Findings include: 1. Observation during facility tour on 09/09/19 at 10:30 A.M., revealed a medication cart sitting in the main hallway with a biohazard sharps (used needle) container attached. The sharps container was open without a lid and had syringes protruding…

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, review of the facility policy and staff interview, the facility failed to secure resident medications. This had the potential to affect three (#17, #72 and #97) of three residents who were confused and independently mobile in the area. The facility census was 125. Findings include: Observation during facility tour on 09/09/19 at 1:06 P.M., revealed an unlocked treatment cart sitting in the hall near room [ROOM NUMBER]. Registered Nurse (RN) #170 came to the cart within 4-5 minutes and verified the cart was unlocked and contained prescription medications. RN #170 stated she had been using the cart but went to answer a call light forgetting to lock it. RN #170 reported three (#17, #72 and #97) residents who were confused and independently mobile and lived on the hallway containing room [ROOM NUMBER]. Review of Resident #94 revealed an admission date of 04/19/19, with diagnoses including sepsis, hypotension, end stage renal disease, hypertension, and gastrointestinal hemorrhage. Review of…

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

Based on observations, review of facility policy and staff interviews, the facility failed to fail to store food in a safe manner. This had the potential to affect 39 residents (#2, #5, #6, #7, #9, #10, #14, #16, #23, #26, #27, #30, #31, #32, #33, #41, #44, #45, #49, #54, #56, #57, #60, #68, #69, #71, #80, #84, #88, #90, #94, #96, #98, #99, #101, #102, #108, #112, and #266) who resided on the Elm and [NAME] hall. The facility census was 125. Findings include: Observations on 09/09/19 at 1:00 P.M., revealed the refrigerator in the nutrition room on Elm and [NAME] Hall was noted to contain two eight-ounce cans of 2 Call HN (nutritional supplement) that had expiration dates of January 2019 and February 2019. The refrigerator also contained an open 46-ounce box of grape juice dated 08/15/19. The Freezer section contained a individual ice cream serving in a takeout container that was unlabeled and undated. Interview on 09/09/19 at 1:04 P.M. with Licensed Practical Nurse (LPN) #3 verified the findings in the refrigerator and freezer. LPN #3 stated all items should be dated and thrown out…

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, resident interview, and staff interview, the facility failed to maintain the dignity of a resident with a urinary catheter and of a resident who lacked clothing. This affected two (#28, #88) of two residents reviewed for urinary catheters. The facility census was 125. Findings include: 1. Review of Resident #28's medical record revealed an admit date of 07/26/19. Diagnoses included hypertension, pneumonia, atrial fibrillation, tachycardia, bladder dysfunction, and urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 07/29/19, revealed Resident #28 had cognitive impairment and required extensive assist of one staff for dressing, toileting, and bathing. Review of the care plan dated 07/27/19 revealed a self-care deficit with interventions to involve resident in care by offering choices of what to wear. Review of progress note dated 09/05/19 revealed a care conference was held with Resident #28's son attending via phone. Documentation reported needs were discussed, but there was no mention of clothing. Observation on 09/10/19 at 11:25…

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, review of facility policy, and staff interview, the facility failed to follow their policy to report an allegation of abuse to the Administrator and failed to complete and investigation of the allegation. This affected one (#48) of one resident reviewed for abuse. The facility census was 125. Findings include: Review of Resident #48's medical record revealed an admit date of 05/30/19. Diagnoses included convulsions, post-concussive syndrome, corneal ulcer, adjustment disorder with mixed anxiety and depressed mood, intracranial injury, acute respiratory failure, and fractures of femur, scapula, humerus. Review of the Minimum Data Set assessment, dated 07/03/19, indicated Resident #48's mental status was not assessed since the resident was not understood. Resident #48 was dependent for all activities of daily living. Review of the progress note dated 09/08/19 at 5:09 P.M. documented the nurse observed the resident's mother sitting entirely on the resident's pillow at the head of the bed with a very short skirt on. The resident was laying in front of her on 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, review of facility policy, and staff interview, the facility failed to report an allegation of abuse to the Administrator. This affected one (#48) of one resident reviewed for abuse. The facility census was 125. Findings include: Review of Resident #48's medical record revealed an admit date of 05/30/19. Diagnoses included convulsions, post-concussive syndrome, corneal ulcer, adjustment disorder with mixed anxiety and depressed mood, intracranial injury, acute respiratory failure, and fractures of femur, scapula, humerus. Review of the Minimum Data Set assessment, dated 07/03/19, indicated Resident #48's mental status was not assessed since the resident was not understood. Resident #48 was dependent for all activities of daily living. Review of the progress note dated 09/08/19 at 5:09 P.M. documented the nurse observed the resident's mother sitting entirely on the resident's pillow at the head of the bed with a very short skirt on. The resident was laying in front of her on the bed. The mother was massaging his shoulders and arms. When the mother saw 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, staff interview, review of facility policy, the facility failed to investigate an allegation of abuse involving one (#48) of one resident reviewed for abuse. The facility census was 125. Findings include: Review of Resident #48's medical record revealed an admit date of 05/30/19. Diagnoses included convulsions, post-concussive syndrome, corneal ulcer, adjustment disorder with mixed anxiety and depressed mood, intracranial injury, acute respiratory failure, and fractures of femur, scapula, humerus. Review of the Minimum Data Set assessment, dated 07/03/19, indicated Resident #48's mental status was not assessed since the resident was not understood. Resident #48 was dependent for all activities of daily living. Review of the progress note dated 09/08/19 at 5:09 P.M. documented the nurse observed the resident's mother sitting entirely on the resident's pillow at the head of the bed with a very short skirt on. The resident was laying in front of her on the bed. The mother was massaging his shoulders and arms. When the mother saw the nurse passing the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one (#3) out 25 residents reviewed for MDS accuracy. The facility census was 125. Findings include: Review of the record for Resident #3 revealed he was admitted [DATE]. Diagnoses included acute kidney failure, bladder-neck obstruction, traumatic ischemia of muscle, hyperlipidemia, occlusion and stenosis of left carotid artery, peripheral vascular disease, phantom limb syndrome with pain, dementia without behavioral disturbance, hypotension, mood disorder, anxiety disorder, poly neuropathy, heart disease, insomnia and vitamin B-12 deficiency. Review of the comprehensive MDS assessment revealed it was completed on 04/03/19. There was no evidence a quarterly MDS assessment was completed in July 2019. During an interview on 09/10/19 at 12:38 P.M., Registered Nurse #149 verified Resident #3 should have had an MDS assessment completed in July 2019. She reported she missed completing his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately code he discharge location on the Minimum Data Set (MDS) assessment for one (#116) of 25 residents reviewed for accuracy of MDS assessments. The facility census was 125. Findings include: A review of the closed record for Resident #116 revealed she was admitted [DATE] and discharged [DATE]. Her diagnoses included fracture of the right leg, end stage renal disease and dependence on renal dialysis, disorder of phosphorus metabolism, type II diabetes mellitus, and paroxysmal atrial fibrillation. Review of the discharge MDS assessment, dated 06/22/19, revealed the resident had a planned discharge to the acute hospital. Review of a progress note for Resident #116, dated 06/21/19, revealed she was discharged home with home health services. During an interview on 09/11/19 at 4:40 P.M., Registered Nurse #149 verified the progress note was correct regarding Resident #116 discharging home and the MDS documenting she went to the hospital 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, observation, staff interview, and review of facility policy, the facility failed to develop care plans to address medication use and indwelling urinary catheter use. This affected two (#12 and #28) of 25 residents reviewed for care planning. The facility census was 125. Findings include: 1. Review of the record for Resident #12 revealed he was admitted [DATE]. Diagnoses included dementia with behavioral disturbance, bilateral sensorineural hearing loss, hypertension, encephalopathy, and malignant neoplasm of skin. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/19, revealed Resident #12 had severe cognitive impairment. Review of the physician's orders for Resident #12 revealed he was prescribed the antiseizure medication Depakote Sprinkles 500 milligrams four times per day, the antianxiety medication Ativan 0.5 milligrams three times per day, and the antipsychotic medication olanzapine 2.5 milligram in the morning and five milligram at bedtime. Review of the 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.

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 review and revise care plans for three (#79, #88, and #103) of 25 residents reviewed for care plans. The facility census was 125. Findings include: 1. Review of medical records revealed Resident #103 admitted on [DATE]. Diagnoses included cardiac arrest, convulsions, hypertension, type two diabetes mellitus, anoxic brain damage, and tracheostomy. Review of the significant change Minimum Data Set (MDS) assessment, date 08/06/19, revealed Resident #103 had severe cognitive impairment. Review of physician orders revealed on 07/29/19 Resident #103 was admitted to hospice. On 07/30/19 Resident #103's code status changed from Full Code to Do Not Resuscitate - Comfort Care Arrest (DNR-CCA). Resident #103 was receiving hospice services as of . Resident #103's orders revealed the resident received all her nutrition via a tube feeding and was to have nothing by mouth (NPO). Review of the current care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interviews, the facility ensure a resident's code status was consistent through out the medical record. This affected one (#103) of 32 residents reviewed in the initial sample for code status. The facility census was 125. Findings include: Review of medical records revealed Resident #103 admitted on [DATE] with diagnosis including cardiac arrest, convulsions, enterocolitis due to Clostridium difficile (C. diff), multi-drug resistant organisms (MDRO), acute kidney failure, shock, pulmonary embolism, respiratory failure, hypertension (HTN), type two diabetes mellitus (DM2), anoxic brain damage, retention of urine, Methicillin resistant Staphylococcus aureus (MSRA), tracheostomy, and an open wound to left buttock. Review of minimum data set for significant change on 08/06/19 revealed Resident #103 had severe cognitive impairment with moderate hearing difficulty, severe vision difficulty, she was non-verbal, and was rarely/never able to be understood nor could…

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 and staff interviews, the facility failed to ensure an audiology follow-up services for a resident was completed and the resident received services to repair a hearing aide. This affected one (#84) of two reviewed for vision and hearing services. Facility census was 125. Findings include: Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including: respiratory failure, muscle weakness, unsteadiness on feet and unspecified kerato conjunctivitis, gastro-esophageal reflux disease without esophagitis, age-related osteoporosis, chronic obstructive pulmonary disease, abnormal weight loss, glaucoma secondary to both eye disorders, edema, anxiety disorder, hyperglycemia, and chronic kidney disease stage three. Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE] quarterly, minimal difficulty for hearing with hearing aid, clear speech and difficult to make self-understood. Requires limited…

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, observations, resident and staff interviews, the facility failed to monitor Resident #31's meal intakes and ensure the resident received nutritional interventions implemented by the speech therapist and follow two (#67 and #18) resident's fluid restrictions. This affected three (#31, #95, and #18) of six residents reviewed for nutritional and fluid intake. The facility census was 125. Findings include: 1. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, altered mental status, mild cognitive impairment, muscle weakness, dysphagia, oral phase, dementia with behavioral disturbance, edema and chronic obstructive pulmonary disease and hypertension, gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 09/03/19, indicated the resident had severe cognitive impairment, the resident required limited assistance with eating…

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, review of medical record review, resident and staff interviews, the facility failed to ensure resident oxygen tubing was changed on a routine basis. This affected three (#18, #48, and #95) of three residents reviewed for respiratory care. The facility identified eleven residents currently receiving oxygen in the facility. The facility census was 125. Findings include: 1. Review of Resident #18's medical record revealed an admit date of 03/05/19, with diagnoses including: diabetes, dementia, congestive heart failure, kidney failure, and chronic obstructive pulmonary disease. Review a Minimum Data Set (MDS) assessment dated [DATE] indicated cognitive impairment and total dependence on staff for all activities of daily living. Observation on 09/09/19 at 3:19 P.M., revealed Resident #18 lying in bed with oxygen tubing running to her nose. The oxygen concentrator was set at three liters. The tubing revealed no dated. 2. Review of Resident #48's medical record revealed an admit date of 05/30/19,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure accurate medical records were maintained for residents with unclear tube feeding physician orders. This affected two (#15 and #48) of 25 residents whose medical orders were reviewed for accuracy. The facility sample was 125. Findings include: 1. Review of Resident #48's medical record revealed an admission date of 05/30/19, with diagnoses including: convulsions, post-concussive syndrome, corneal ulcer, adjustment disorder with mixed anxiety and depressed mood, intracranial injury, acute respiratory failure, and fractures of femur, scapula, humerus. Review of the Minimum Data Set assessment dated [DATE] indicated mental status was not assessed since resident was not understood and that Resident #48 was totally dependent for all activities of daily living. Review of physician orders for September 2019 revealed undated order for Jevity 1.5 (liquid nutrition) tube feeding at 95 cubic centimeters (cc) per hour via gastrectomy tube for a total…

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.