Astoria Place Of Cincinnati

Based on observation, staff interview, and review of the facility policy, the facility failed to maintain the building in a safe and sanitary manner for residents, staff, and the public. This had the potential to affect all residents in the facility. The facility census was 84 residents. Findings include: 1. Observation on 02/19/26 at 10:47 A.M. of the facility's laundry area revealed there was a pool of water on the floor directly inside the entrance to the dirty linens area of the laundry area which was approximately three feet wide by six feet long and approximately one-eighth inch deep. Further observation revealed water was being released from a pipe located under a sink next to the pool of water. The wall adjacent to the pool of water on the floor was missing drywall from the bottom two inches of the wall which was in contact with the pooled water. The metal studs inside the wall appeared to be rusted. Interview on 02/19/26 at 10:47 A.M. with Laundry Aides (LAs) #710 and #712 confirmed there was pool of water on the floor just inside the entrance to the dirty linens side 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 reviews, interviews, and policy review, the facility failed to conduct quarterly care conferences. This affected five Residents (#03, #06, #07, #61 and #49) of five residents reviewed for care conferences. The facility census was 84. 1) Review of the medical record revealed Resident #03 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, atrial fibrillation, bipolar disorder and anxiety disorder. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #03 had intact cognition. Review of care conferences for Resident #03, as provided by the facility, revealed the only documented care conference for Resident #03 was in the third quarter of 2025. There were no documented care conferences at admission and fourth quarter of 2025. During an interview on 02/19/26 at 11:50 A.M. the Director of Nursing (DON) verified Resident #03 was not provided with an admission care conference or a care conference in the fourth quarter of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and policy review, the facility failed to dispose of expired vaccines. This had the potential to affect the forty-six Residents (#01,#02, #03, #06, #07, #09, #10, #11, #15, #16, #20, #22, #25, #28, #29, #30, #33, #34, #35, #37, #38, #39, #40, #41,#47, #49, #50, #52, #54, #57, #58, #59, #61, #62, #64, #69, #71, #73, #74, #77, #78, #80, #85, #94, #95, and #96) housed in the 100 and 300 halls who the facility identified as receiving vaccines. The census was 84.During a medication storage observation on [DATE] at 4:01 P.M., three 0.5 milliliter (mL) single dose Influenza Vaccine Afluria were found to be expired (expiration date [DATE]). Four boxes each containing ten Pneumococcal Vaccine Polyvalent Pneumovax – 23, single dose 0.5 mL syringes were found to be expired (expiration date [DATE]). During an interview on [DATE] at 4:30 P.M., The Director of Nursing ([NAME]) confirmed all the products in the medication storage room on the first floor are intended for 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 observation, staff interview, and review of the facility policy, the facility failed to provide privacy curtains in resident rooms. This affected five (Residents #30, #96, #10, #80 and #18) of five residents reviewed for privacy. The facility census was 84 residents. Findings include: 1.Observation on 02/17/26 at 11:21 A.M. revealed the room of Residents #96 and #30 only had one privacy curtain which was not adequate to provide visual privacy to either resident. Interview on 02/17/26 at 11:21 A.M. with Certified Nursing Assistant #505 verified the one privacy curtain that was in place was not adequate to provide either Resident #96 or Resident #30 privacy during care. 2.Observations on 02/18/26 at 10:34 A.M. and on 02/19/26 at 8:08 A.M. revealed the room of Residents #96 and #30 continued to have only one privacy curtain in place. Observation on 02/18/26 at 12:15 P.M. with Registered Nurse (RN) #309 revealed there were no privacy curtains in Resident #18's room. Interview on 02/18/26 at 12:16 P.M. 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, staff interviews, record reviews and policy review, the facility failed to provide residents with regular utensils during meals. This directly affected three Residents (#37, #03 and #61) but had the potential to all affect all 84 residents as the facility identified all residents received Meals from the kitchen. The facility census was 84. Findings include: 1) Review of medical record of Resident #37 revealed an admission date of 12/10/25. Diagnoses included chronic obstructive pulmonary disease (COPD), unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, left bundle-branch block, unspecified, unspecified mood disorder, acute kidney failure, unspecified, other toxic encephalopathy, and cocaine abuse. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a cognitive status was not assessed. The resident was independent for eating, oral hygiene, and ambulation, supervision assistance for toileting, bathing,…

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 and policy review, the facility failed to ensure a safe, functional and homelike environment for the residents. This affected three Residents (#10, #49 and #80) of four resident rooms reviewed for a safe, functional and homelike environment. The facility census was 84. 1) Review of the medical record of Resident #10 revealed an admission date of 12/28/25. Diagnoses included acute kidney failure with tubular necrosis, rhabdomyolysis, encephalopathy, abnormal levels of other serum enzymes, and cocaine abuse. Review of the admission Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #10 was cognitively intact. Observation of Resident #10's room on 02/17/26 at 12:39 P.M. revealed the door to the resident's bathroom did not close completely, thus not providing privacy for the resident while using the bathroom adjacent to his sleeping quarters. This was a semi-private room shared with Resident #80. Interview with Resident #10 at the same time expressed…

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 review of Minimum Data Set (MDS) assessments, review of medical record, and staff interview, the facility failed to ensure a significant change assessment was completed for one (Resident #02) of one resident reviewed for significant change assessments. The facility census was 84.Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident with aphasia, diabetes mellitus type II, post-traumatic stress disorder, hypertension and epilepsy. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required supervision for eating, toileting, bed mobility and transfers, and moderate assistance for bathing and dressing, and was independent for oral and personal hygiene. Review of Hospice progress note dated 01/14/26 at 5:27 P.M. revealed Resident #02 was…

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

Based on observation, staff interviews, and facility policy review, the facility failed to provide a discreet cover for a resident's catheter bag and ensure appropriate placement of catheter bag. This affected one (Resident #94) of two residents reviewed for catheter care. The facility census was 84. Review of the medical record of Resident #94 revealed an admission date of 02/16/26. Diagnoses included acute hematogenous osteomyelitis, left ankle and foot, complete lesion at T1 level of thoracic spinal cord, neuromuscular dysfunction of bladder, borderline personality disorder, antisocial personality disorder, paraplegia, schizoaffective disorder, and acquired absence of right leg above knee. The admission Minimum Data Set (MDS) assessment for Resident #94 was still in progress. A Brief Interview for Mental Status (BIMS) revealed Resident #94 was cognitively intact. Observation on 02/18/26 at 10:44 A.M. revealed Resident #94 was present in the main lobby with his catheter bag sitting on his lap and not covered. During an interview on 02/18/26 at 10:44 A.M., Resident #94 acknowledged…

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 the facility policy, the facility failed to implement nutritional recommendations made by the Registered Dietitian (RD) for a resident with weight loss. This affected one (Resident #03) of three residents reviewed for nutrition. The facility census was 84.Findings include:Review of the medical record revealed Resident #03 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, atrial fibrillation, bipolar disorder and anxiety disorder.Review of weights for Resident #03 revealed on 08/03/25 Resident #03 had a documented weight of 221 pounds and on 02/01/26 Resident #03 had a documented weight of 189.8 pounds. This represented a 14.12 percent (%) weight loss in six months.Review of RD progress note for Resident #03 dated 10/15/25 authored by RD #600 revealed Resident #03 was ordered to receive double portions for all meals.Review of weights for Resident #03 revealed on 11/04/25 Resident #03…

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 review of the medical record, staff interviews, review of Self-Reported Incidents (SRI), review of staff time punches, and policy review, the facility failed to follow abuse policy relating to alleged abuse by staff. This affected one (Resident #15) of three reviewed for abuse. The facility census was 78.Findings include:Review of the medical record for Resident #15 revealed an admission date of 10/09/23. Diagnoses included diffuse traumatic brain injury, vascular dementia, mood disorder, and major depressive disorder.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident#15 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was independent with activities of daily living (ADL). Interview with Resident #15 on 12/08/25 at 10:06 A.M. revealed he was verbally abused on 12/05/25 by two staff members (Certified Nursing Assistant [CNA] #13 and CNA #15), who were working on the current shift. When the surveyor…

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 review of the medical record, review of Self-Reported Incidents (SRI), review of emergency room (ER) records, staff interviews, and review of facility policy, the facility failed to report an allegation of abuse to the state agency. This affected one (Resident #79) of three residents reviewed for abuse. The facility census was 78.Findings include:Review of the medical record for Resident #79 revealed an admission date of 06/12/25 with a discharge date of 10/06/25. Diagnoses included dementia, type II diabetes mellitus (DM II), and bipolar disorder.Review of the ER records dated 08/28/25 at 7:01 P.M., revealed Resident #79 was admitted to the ER related to a reported sexual assault. The ER notes indicated Emergency Medical Services (EMS) were called to the facility for a hyperglycemic related incident. When EMS arrived, they found the resident shaking and sweating and stated his roommate fondled him the bathroom. The resident denied any active pain to his genitals, chest, abdomen, or limbs. The hospital…

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 review of the medical record, review of Self-Reported Incidents (SRI), review of emergency room (ER) records, staff interviews, and review of facility policy, the facility failed to complete a thorough investigation for an alleged sexual abuse allegation. This affected one (Resident #79) of three residents reviewed for abuse. The facility census was 78Findings include: Review of the medical record for Resident #79 revealed an admission date of 06/12/25 with a discharge date of 10/06/25. Diagnoses included dementia, type II diabetes mellitus (DM II), and bipolar disorder.Review of the ER records dated 08/28/25 at 7:01 P.M., revealed Resident #79 was admitted to the ER related to a reported sexual assault. The ER notes indicated Emergency Medical Services (EMS) were called to the facility for a hyperglycemic related incident. When EMS arrived, they found the resident shaking and sweating and stated his roommate fondled him the bathroom. The resident denied any active pain to his genitals, chest, abdomen,…

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 review of the medical record, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed during incontinence care. This affected one (Resident #46) of three reviewed for incontinence care. The facility census was 78.Findings include:Review of the medical record for Resident #46 revealed an admission date of 04/29/24. Diagnoses included type II diabetes mellitus (DM II), anxiety disorder, bipolar disorder, and functional urinary incontinence.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and dressing, and partial assistance with transfers. Review of Section H (bowel and bladder), revealed Resident #46 was frequently incontinent of bowel and bladder.Observation on 12/08/25 at 1:38 P.M.,…

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

Based on observation and staff interview, the facility failed to ensure medications were properly stored. This had the potential to affect all 18 residents residing on the 200 unit (Residents #17, #25, #30, #101, #102, #103, #104, #105, #106, #107,#108, #109, #110, #112, #113, #114, #115, #116). The facility census was 75 residents. Findings include:Observation on 10/21/25 at 9:33 A.M. of the 200-unit medication cart revealed it contained 18 cups of loose pills labeled with the respective names of all of the residents residing on the unit. Interview on 10/21/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #505 confirmed she had prepulled all of the medications for the morning med pass for Residents #17, #25, #30, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #112, #113, #114, #115, #116.Interview on 10/21/25 at 9:45 A.M with the Director of Nursing (DON) confirmed nurses and qualified medication assistants (QMAs) should not pull all the residents' medications at once. Each resident's medication should be prepared, administered, and signed off, before proceeding 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, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to report an allegation of sexual abuse to the Ohio Department of Health (ODH) in a timely manner. This affected one resident (Resident #45) of three residents reviewed for abuse. The facility census was 75 residents.Findings include: Review of the medical record for Resident #45 revealed an admission date of 01/09/20 with a diagnosis of paraplegia and a discharge date of 04/10/25. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 02/04/25 revealed the resident had intact cognition. Interview on 10/20/25 at 4:00 P.M with [NAME] #246 confirmed sometime in early April 2025 they reported to the previous Administrator that Housekeeping Supervisor (HS) #902 and Resident #45 were having a sexual relationship. Interview on 10/21/25 at 3:23 P.M with Social Worker (SW) #208 confirmed sometime in April 2025 she reported to the previous Administrator that she believed HS #902 and Resident #45 were having a sexual…

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 policy, the facility failed to prevent misappropriation of residents' personal property. This affected two (Residents #12 and #13) of three residents reviewed for residents' rights. The facility census was 75 residents.Findings include: Review of the medical record for Resident #12 reveled an admission date of 07/11/25 with diagnoses including anxiety disorder, infective endocarditis, human immunodeficiency virus (HIV), hepatitis C, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 07/18/25 revealed the resident was cognitively intact and was independent with activities of daily living (ADLs).Review of the medical record for Resident #13 revealed an admission date of 3/04/25 with diagnoses including spondylosis, depression, and diabetes mellitus.Review of the MDS assessment for Resident #13 dated 06/06/25 revealed the resident had mild cognitive deficits and required extensive staff assistance with ADLs.Interview on 08/11/25 at 2:49 P.M. with the…

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

Based on medical record review, review of personnel records, review of staff statements, resident interview, staff interview, review of facility Self-Reported Incidents, and review of the facility policy, the facility failed to report allegations of verbal abuse to the state agency. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 75 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/20/24 with diagnoses including Alzheimer's disease, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 05/06/25 revealed the resident had no cognitive deficits and required supervision with activities of daily living (ADLs). Review of the personnel file for Business Office Manager (BOM) #58 revealed it contained a disciplinary action form dated 07/24/25 which indicated on 07/22/25 BOM #58 had used vulgar language with another employee. BOM #58 was coached and promised not to do it again. Review of an undated written statement per the…

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

Based on medical record review, review of personnel records, review of staff statements, resident interview, staff interview, review of facility Self-Reported Incidents, and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse/mistreatment of residents. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 75 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/20/24 with diagnoses including Alzheimer's disease, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 05/06/25 revealed the resident had no cognitive deficits and required supervision with activities of daily living (ADLs). Review of the personnel file for Business Office Manager (BOM) #58 revealed it contained a disciplinary action form dated 07/24/25 which indicated on 07/22/25 BOM #58 had used vulgar language with another employee. BOM #58 was coached and promised not to do it again. Review of an undated written statement per…

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, review of maintenance orders, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a safe and homelike environment for the residents. This affected Residents #20 and #21, the following 18 residents residing on the 100- unit (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18), and the following 14 residents residing on the 400-unit (#58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71) and had the potential to affect all of the residents residing in the facility . The facility census was 71 residents. Findings include: 1.Observations on 07/07/25 between 9:20 A.M. revealed the handrail next to elevator on the 100-nursing unit was not safely secured to the wall rendering it non-functional. The handrail was missing an end cap and was secured to the wall on one end by one screw and the other end was dangling. There was an end cap and a corner cap missing from the handrail near…

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 review of the facility policy, the facility failed to implement Enhanced Barrier Precautions (EBP) while providing incontinence and wound care and failed to change gloves and perform appropriate hand hygiene during incontinence care. This affected one (Resident #10) of three residents reviewed for infection control. The facility census was 71 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/22/25 with diagnoses including dementia, hypertension and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 05/05/25 revealed the resident had intact cognition, was frequently incontinent of bowel and occasionally incontinent of bladder, was independent for eating and bed mobility, required set up assistance with oral hygiene, required supervision with toileting, and required moderate assistance with personal hygiene, dressing, bathing, and transfers. Review of the physician's orders for Resident #10 revealed an order dated…

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

Based on observation, record review, interview and policy review, the facility failed to notify residents of changes to the menu in a timely manner. This all residents who accepted food from the kitchen. The facility identified two (Residents ##10 and #18) residents who did not receive food form the kitchen. The facility census was 69. Findings include: Review of the menu titled Week-At-A-Glance Cincinnati Fall-Winter 24-25 Week 3 printed 04/14/25 revealed the lunch menu for Wednesday, 04/16/25 included three ounces beef pot roast, two ounces brown gravy, four ounces mashed potatoes, four ounces glazed carrots, and four ounces pineapple tidbits. Observation of meal preparation on 04/16/25 at 11:32 A.M. revealed dietary staff prepared resident lunch trays with beef patties on wheat bread, mashed potatoes with brown gravy, and glazed carrots. During an interview on 04/16/25 at 11:35 AM, Dietary Manager #92 stated he substituted hamburgers on the lunch menu because the pot roast did not finish cooking in time. He stated he did not notify residents of the substitution but it was ok…

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 and staff interviews the facility failed to ensure residents were able to control room temperature and failed to maintain sanitary shower rooms. This affected one (Resident #73) of six residents sampled for appropriate room temperature controls. This had the potential to affect all residents on the first floor and in the Women's Secured Unit who used the shower rooms. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included unspecified diastolic congestive heart failure, unspecified bipolar disorder, unspecified anxiety disorder, unspecified noncompliance with medical treatment and regimen, and cellulitis of right lower limb. During an observation on 04/30/25 at 9:06 A.M., the air conditioning unit under the window was actively blowing cold air into the room. The control panel could be opened and had metal switch to turn fan on or off. The dial for the temperature control was missing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the physician was notified of diagnostic results in a timely manner. This affected one (Resident #60) of six residents reviewed for falls. The facility census was 69. Findings include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder bipolar type, major depressive disorder, unspecified anxiety disorder, unspecified protein-calorie malnutrition, unspecified psychosis, and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had verbal behaviors, did not reject care, and did not wander. Resident #60, required supervision/setup assistance for ADLs. Review of the care plan dated 04/17/25 revealed Resident #60 had an unwitnessed fall with shoulder fracture injury related to unsteady gait due to 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 record review, staff interviews, and policy review, the facility failed to report allegations of abuse to the State Agency in a timely manner. This affected two (Residents #64 and #51) of six residents sampled for abuse. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, unspecified schizoaffective disorder, unspecified myelodysplastic syndrome, type II diabetes, unspecified heart failure, unspecified dementia, unspecified psychosis, unspecified bipolar disorder, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had verbal behaviors, did not reject care, and did not wander. Resident # 64 required supervision with all activities of daily living. Review of the care plan dated 06/17/24 revealed Resident #64 wandered into other resident's rooms and took their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure residents received appropriate screening for pre-admission screening and resident review (PASRR) prior to admission. This affected one (Resident #43) of six residents reviewed for PASRR. The facility census was 69. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included paraplegia, uncomplicated opioid dependence, chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, dependent personality disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #43 had no PASRR screening documented in his medical record. During an interview on 05/13/25 at 9:34 AM Social Worker (SW) #135 stated a resident coming from the hospital should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents were reassessed for pre-admission screening and resident review (PASRR) after new mental health diagnoses and new psychotropic medications were ordered. This affected one (Resident #36) of six residents reviewed for PASRR. The facility census was 69. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not assessed for cognition status, had self-directed behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #36 had physician orders for psychotropic medications including (0)Divalproex sodium 250 mg delayed release tablet, 500…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review, the facility failed to ensure residents received quarterly conferences attended by members of the clinical team. This affected three (Residents #36, #51, and #60) of five residents reviewed for care conferences. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not assessed for cognition status, had self-directed behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #36 had a care conference on 12/23/24 with the social worker. There were no additional members of the interdisciplinary (IDT) team represented at this meeting.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to timely treat residents with displaced joints. This affected one (Resident #60) of five residents reviewed for falls. The facility census was 69. Findings include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder bipolar type, major depressive disorder, unspecified anxiety disorder, unspecified protein-calorie malnutrition, unspecified psychosis, and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had verbal behaviors, did not reject care, and did not wander. Resident #60 required supervision/setup assistance for activities of daily living. Review of the care plan dated 04/17/25 revealed Resident #60 had an unwitnessed fall with shoulder fracture injury related to unsteady gait due to her spilling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure residents attended mental heath appointments as scheduled. This affected one (Resident #75) of seven residents reviewed for mental health services. The facility census was 69. Findings include: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] and was never discharged out of the system. Diagnoses included schizoaffective disorder bipolar type, suicidal ideations, other uncomplicated psychoactive substance abuse, antisocial personality disorder, uncomplicated nicotine dependence, uncomplicated alcohol dependence, mild neurocognitive disorder with behavioral disturbance, and mild cognitive condition with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#75 was cognitively intact. Review of hospital records revealed Resident #75 had a telemedicine appointment on 08/24/25 at 10:00 A.M. with UC Psychiatry Bridge Clinic to ensure needs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure medications were given as prescribed. This affected three (Residents #38, #45, and #73) of eight residents reviewed for medication administration. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included unspecified humerus fracture, type II diabetes, unspecified protein calorie malnutrition, essential hypertension, and nontraumatic intracerebral hemorrhage in the brain stem. Resident #38 had physician orders dated 03/26/25 for Carvedilol 25 milligrams (mg) twice daily. 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included unspecified combined congestive heart failure, interstitial lung disease with progressive fibrotic phenotype, type II diabetes, psychotic disorder with delusions, and unspecified dementia with behavioral disturbances. Resident #45 had physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure information documented in the medical record was accurate. This affected three (Residents #19, #60, and #75) of six residents reviewed for accurate documentation. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and was discharged on 04/10/25. Diagnoses included unspecified paraplegia, stage III pressure ulcer to the left heel, chronic pain syndrome. Unspecified protein calorie malnutrition, morbid obesity, unspecified bipolar disorder, and neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 01/28/25 revealed Resident #19 wanted to discharge to home or community. Interventions included encouraging the resident to discuss feelings/concerns about…

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

Based on observation, staff interview and review of the facility policy, the facility failed to store foods safely, and maintain a sanitary kitchen to ensure food service safety. This had the potential to affect 60 of 60 residents who received food from the kitchen. The facility identified two residents (#21, #49) who received nothing by mouth. The facility census was 62 residents. Findings include: Observation on 08/05/24 from 8:19 A.M. through 8:50 A.M. of the facility kitchen and refrigerators on the nursing units revealed the following concerns: There was a four-foot diameter floor fan with gray fuzzy debris blowing from the fan grill across the kitchen area onto the food preparation area, food service area, clean dish storage and food storage areas. The exhaust louvers above the stove cooking surface had gray and blackened debris consistent with the appearance of heavy grease build up. The six ceiling fan louvers throughout the kitchen had a heavy buildup of gray fuzzy debris located over food preparation areas, food service areas and clean dish storage areas. There was a…

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

Based on observation, medical record reveiw, policy review and interview the facility failed to provide a safe, comfortable and clean environment for all residents. This affected 13 residents (#3, #5, #6, #8, #14, #30, #31, 34, #38, #44, #48, #52 and #56) of 19 residing on the women's secured unit. The facility census was 62 residents. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 03/10/23 with diagnoses including schizophrenia, right eye blindness, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 06/03/24 revealed the resident had intact cognition and required limited assist with transfer and was independent with ambulation. Observation on 08/05/24 at 2:22 P.M. revealed the wall adjacent to Resident #38's bed and the walls in the bathroom had handwritten statements with letters that were two to three inches high and covered a wall span of approximately six feet. The verbiage of the handwritten statements were vulgar in nature. Interview on 08/05/24 at 2:25 P.M. with Maintenance…

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, facility policy review and interview, the facility failed to ensure resident bedrooms provided visual privacy for the residents. This affected eight residents (#3, #5, #6, #24, #30, #31, #52, and #56) of 19 women residing on the secured women's unit. The facility census was 62 residents. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 12/06/17 with diagnoses including diabetes, schizophrenia, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 07/09/24 revealed the resident had intact cognition and was independent with mobility. Review of the medical record for Resident #56 revealed an admission date of 06/23/23 with diagnoses including schizophrenia, diabetes, and anxiety. Review of the MDS assessment for dated 06/12/24 revealed the resident had intact cognition and was independent with mobility. Observation on 08/08/24 at 10:37 A.M. revealed Residents #24, #52, and #56 were residing 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.

Based on observation, facility policy review the facility failed to provide a safe, functional, sanitary and comfortable environment. This affected 19 residents (#3, #5, #6, #8, #9, #14, #20, #24, #28, #29, #30, #31, 34, #38, #40, #44, #48, #52 and #56) of 19 residing on the women's secured unit. The facility census was 62 residents. Findings Include: 1. Observation on 08/05/24 at 2:32 P.M. revealed the women's secure unit shower room had a blackened substance, consistent with appearance of mold, at base of shower stall and adjacent walls. The shower exhaust fan did operate and had a gray fuzzy layer covering the surface. There was a shower privacy curtain which was torn three feet from the top and was not attached to the track and was hanging which prevented complete privacy around the shower area from the door entrance. Interview on 08/05/24 at 2:32 P.M. with MA #34 confirmed the main shower room had blackened areas around the base of the shower and on the walls and needed to be cleaned. MA #34 verified the exhaust fan did not operate and needed to be cleaned. MA #34 verified the…

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

Based on observation, medical record review and interview the facility failed to ensure Resident #23 received proper treatment and assistive devices to maintain vision. This affected one resident (#23) of six residents reviewed for vision services. The facility census was 62 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 12/14/22 with diagnoses including chronic obstructive pulmonary disease (COPD), schizoaffective disorder, dementia, and generalized anxiety disorder. Review of the optometry note for Resident #23 dated 11/15/23 revealed eyeglasses were recommended and ordered for the resident. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 06/06/24 revealed the resident was cognitively intact. Interview on 8/06/24 at 9:32 A.M. with Licensed Practical Nurse (LPN) #73 revealed Resident #23 did not have eyeglasses to wear. Observation on 08/06/24 at 1:33 P.M. revealed Resident #23 was not wearing eyeglasses and was squinting to read a clock on the wall of the second-floor men's unit. Interview on 08/06/24…

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 facility policy, and interview, the facility failed to ensure Resident #11's physician and guardian were notified timely following a fall with injury. This affected one resident (#11) of five residents reviewed for falls. The facility census was 63. Findings Include: Review of the medical record for Resident #11 revealed admission date of 09/12/11 with diagnoses including cerebral palsy (CP), schizophrenia, convulsion, moderate intellectual disabilities (ID), borderline personality disorder, type two diabetes mellitus, seizures, psychosis, dementia, peripheral vascular disease, impulse disorder, post-traumatic stress disorder (PTSD), and intermittent explosive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 was rarely understood and was dependent on staff for transfers and mobility. The resident had an unwitnessed fall on 03/11/24 at 6:00 A.M. On 03/11/24 at 3:25 P.M. review of Resident #11's medical record revealed 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 record review, review of facility policy, and interview, the facility failed to ensure adequate assessment and timely care and treatment were provided to Resident #11 following an unwitnessed fall with injury. This affected one resident (#11) of five residents reviewed for falls. The facility census was 63. Findings Include: Review of the medical record for Resident #11 revealed admission date of 09/12/11 with diagnoses including cerebral palsy (CP), schizophrenia, convulsion, moderate intellectual disabilities (ID), borderline personality disorder, type two diabetes mellitus, seizures, psychosis, dementia, peripheral vascular disease, impulse disorder, post-traumatic stress disorder (PTSD), and intermittent explosive disorder. Review of a fall risk assessment dated [DATE] revealed Resident #11 was a high risk for falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 was rarely understood and was dependent on staff for transfers and mobility. Review of the most…

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, resident representative interview, staff interview, and review of facility policy, the facility failed to ensure staff made timely notification of changes in resident condition to the physician and resident representative. This affected one (Resident #78) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of 08/31/22 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) for Resident #78 dated 10/19/23 revealed the resident was cognitively intact. Review of the discharge return anticipated Minimum Data Set MDS assessment for Resident #78 dated 01/04/24 revealed the resident required partial/moderate assistance with toileting. Review of the nurse progress note for Resident #78 dated 01/04/24 timed at 5:44 A.M. per Licensed Practical Nurse (LPN) #205 revealed State Tested Nursing Assistant (STNA) #101 notified the nurse at 3:44 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident banking records, review of review of facility grievance logs, review of facility investigative reports, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (Resident #78) of three residents reviewed for misappropriation. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) for Resident #78 dated [DATE] revealed the resident was cognitively intact. Review of the resident fund account record for Resident #78 revealed the resident withdrew 30 dollars in cash from his account on [DATE]. Review of the discharge return anticipated MDS assessment for 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 review, review of resident banking records, review of review of facility grievance logs, review of facility investigative reports, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of facility policy, the facility failed to ensure allegations of misappropriation were reported to the Ohio Department of Health (ODH) as required. This affected one (Resident #78) of three residents reviewed for misappropriation. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) for Resident #78 dated [DATE] revealed the resident was cognitively intact. Review of the resident fund account record for Resident #78 revealed the resident withdrew $30.00 in cash from his account on [DATE]. 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, review of resident banking records, review of review of facility grievance logs, review of facility investigative reports, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of facility policy, the facility failed to complete a timely and thorough investigation of misappropriation of resident property. This affected one (Resident #78) of three residents reviewed for misappropriation. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) for Resident #78 dated [DATE] revealed the resident was cognitively intact. Review of the resident fund account record for Resident #78 revealed the resident withdrew $30.00 in cash from his account on [DATE]. Review of the discharge return…

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 facility policy, the facility failed to ensure Resident #78 was timely and adequately assessed and provided timely medical intervention following a fall with major injury. This affected one (Resident #78) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of 08/31/22 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #78 dated 10/19/23 revealed the resident was cognitively intact. Review of the discharge return anticipated MDS assessment for Resident #78 dated 01/04/24 revealed the resident required partial/moderate assistance with toileting and had one fall with major injury since the prior assessment. Review of the nursing progress note for Resident #78 dated 01/04/24 timed at 5:44 A.M. per Licensed Practical Nurse (LPN) #205 revealed State Tested Nursing Assistant (STNA)…

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, resident representative interview, staff interview, and review of facility policy, the facility failed to ensure resident falls were thoroughly investigated including identification of root cause of the fall, identification of hazards and risks associated with falls and evidence of implementation of appropriate interventions to prevent resident falls. This affected one (Resident #78) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record for Resident #78 revealed an admission date of 08/31/22 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of the care plan for Resident #78 dated 08/31/22 revealed the resident was at risk for falls and injury related to falls. Interventions included the following: review information on past falls and attempt to determine cause of falls, record root cause of falls, alter and remove any potential causes, follow facility fall protocol. Resident #78's fall care plan 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 observation, staff and vendor interviews, review of facility billing/financial information, and review of facility policy, the facility neglected to meet financial obligations for the delivery of care and maintenance to all the residents and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the needs of all 67 residents residing in the facility. Findings include: 1. Review of an itemized invoice statement from Prairie Farms (milk delivery) dated 01/10/24, revealed numerous unpaid balances from 10/19/23 through 12/07/23 which totaled $3,847.32 due. Review of a facility check (number 13089) dated 01/10/24, revealed a payment was made to Prairie Farms in the amount of $3,847.32. An observation of the food storage on 01/16/24 at 8:12 A.M. with the Dietary Manager (DM #30) revealed there were only two gallons of milk in the milk cooler. An interview with DM #30 at the same time, revealed he had to go to the grocery store 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 observation, resident and staff interview and review of facility policy, the facility failed to ensure heating equipment was functional to provide warm temperatures in resident rooms. This affected nine residents (#05, #06, #10, #16, #17, #18, #19, #20 and #26) observed/interviewed related to temperatures in the facility. The lack of preventative/routine maintenance on resident individual room heating units had the potential to affect all 67 residents residing in the facility. Findings include: On 01/16/24 at 8:30 A.M. a tour of the facility revealed there was a slight chill inside the facility. An interview on 01/16/24 at 1:07 P.M. with Resident #06 reported her room was so cold she had to wear her coat, a scarf, and gloves to bed the last couple of nights. An observation at the time of the interview revealed there was cold air coming from around the wall heating unit and it was not functioning. The heating unit had individual controls for the heat and fan. Interview with Resident #05 (the roommate of Resident #06) at the same time, revealed the resident reported the room…

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

Based on observation, resident and staff interview and review of facility policy, the facility failed to provide a comfortable, safe, and homelike environment with (air) temperatures maintained between 71 and 81 degrees Fahrenheit. This affected 30 residents (#01, #05, #06, #07, #08, #09, #10, #11, #12, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #43, #52, #53, #57, #58 and #64) of 67 residents residing in the facility. Findings include: On 01/16/24 at 8:30 A.M. a tour of the facility revealed there was a slight chill inside the facility. An interview on 01/16/24 at 1:07 P.M. with Resident #06 reported that her room was so cold she had to wear her coat, a scarf, and gloves to bed on the night of 01/15/24 through 01/16/24. An observation at the time of the interview revealed there was cold air coming from under the wall heating unit and near the floor in the resident's room and it was not functioning. Interview with Resident #05 (roommate of Resident #06) at the same time, revealed the room was cold and she was buried under her blankets as she slept.…

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 staff interview, observation, and review of the facility policy, the facility failed to ensure resident representatives had reasonable access to communication with residents by telephone. This had the potential to affect all of the residents residing in the facility. The facility census was 71. Findings include: Interview: 12/21/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #131 confirmed she could not hear the phone if it rang in the nurses' station unless she was sitting in the nurses' station. If she was on the floor administering medications or addressing a resident's needs, the phone would ring multiple times and would go unanswered. Observation on 12/25/23 at 6:19 P.M. revealed the surveyor called the facility, and the phone rang 15 times and was unanswered. Observation on 12/26/23 at 5:23 A.M. revealed the surveyor called the facility, and the phone rang 10 times and was unanswered. Observation on 12/26/23 at 6:00 A.M. revealed the surveyor called the facility, and the phone rang 10 times and was unanswered. Interview on 12/26/23 at 10:00 A.M. with 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, resident interview, staff interview and review of policy, the facility failed to provide a homelike environment to residents. This affected one resident, (#2), with the potential to affect all 23 of the 100-hall residents (#1, #3, #11, #12, #13, #16, #17, #20, #23, #27, #31, #32, #36, #40, #42, #43, #47, #53, #55, #56, #58, #69). The current census is 71. Findings include: Record review of Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include cerebral infarction, diabetes, encephalopathy, depression, and non-pressure ulcer of skin. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition, was continent of bowel and bladder, and was a one-person assist for Activities of Daily (ADL). Review of Resident #2's care plans dated 09/2023 revealed a focus for self-care performance requiring limited hands-on assistance with daily hygiene and ADLs. Observation and interview 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.