Ayden Healthcare Of Madeira

Based on observation, staff interview, and policy review, the facility failed to ensure handrails on the Memory Care Unit (MCU) were secured to the wall. This had the potential to affect all 20 Residents (#07, #22, #25, #27, #38, #41, #43, #44, #54, #56, #58, #59, #64, #69, #75, #77, #80, #82, #85, and #88) who the facility identified as being independently mobile and residing on the MCU. The facility census was 86.Findings include:Observation on 12/11/25 at 12:55 P.M. on the MCU, revealed the handrail between the nursing station and the hallway leading to the outdoor smoking area was not secured to the wall. The handrail on the right side of the hallway leading to the outdoor smoking area was also not properly secured to the wall.Interview on 12/11/25 at 12:59 P.M. with State Tested Nursing Assistant (STNA) #60 verified the handrails were not secured to the wall.Review of the facility policy titled Resident Environmental Quality, dated 08/2022, revealed the facility should equip corridors with firmly secured handrails.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodations to allow residents appropriate access to handwashing facilities. This affected three resident (Residents #13, #15 and #55) of five residents reviewed. The total facility census was 86. Findings Include:1. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Morbid obesity, Acute and Chronic Respiratory Failure with hypoxia, and Ventral Hernia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or clean-up assistance for personal hygiene. The resident could transfer self and ambulate a few feet independently. The resident used a bariatric wheelchair for mobility.Review of the weight log revealed the Resident #13 weighed 496 pounds on 11/18/25.Interview on 12/09/25 at 8:45 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, interview, and policy review the facility failed to ensure a discharge summary was completed. This affected one resident (Resident #94) out of three residents reviewed for discharged summaries. The facility census was 86. Findings Include:Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified combined systolic (congestive) and diastolic (congestive) heart failure, and venous insufficiency (chronic) (peripheral). Resident #94 had a planned discharge home on [DATE].Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed to require setup or clean-up assistance for eating, setup or clean-up assistance for oral hygiene, setup or clean-up assistance for toileting, setup or clean-up assistance for shower/bathing, setup or clean-up assistance for dressing, and setup or clean-up assistance for personal hygiene. It noted the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop and implement a fall care plan for a resident who was at risk for falls. This affected one (Resident #66) of five residents reviewed for falls. The facility census was 86. Findings include:Review of the medical record of Resident #66 revealed an admission date of 10/09/24. Diagnoses included right hip fracture, chronic obstructive pulmonary disease, hypothyroidism, unsteadiness on feet, depression, cognitive communication deficit, and restless legs syndrome.Review of the Fall Risk Evaluation dated 12/10/24 revealed the resident was at risk for falls.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #66 had severely impaired cognition. The resident was dependent on staff for transfers, toileting and bathing Review of the progress note dated 01/14/25, revealed Resident #66 experienced an unwitnessed fall. The fall occurred in the resident's room when she was walking from her bathroom to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to provide varied activities to meet the needs and interests of residents. This affected three Residents (#15, #13 and #39) of five residents reviewed for activities. The total facility census was 86.Findings Include: Review of the activity calendars for October, November and December 2025 revealed from 9:30 A.M. to 11:30 A.M., there were three activities consisting of exercise, hydration cart, and table games for seven days of the week. Two to three times a week there was a 5:00 P.M. activity. There were no activities listed after 5:00 P.M. There was no religious program listing on Sundays or any other days of the week. Review of activity participation logs of 12/01/25 through 12/10/25 revealed 10 to 20 of the same residents attending all activities. There was no participation in the morning exercise class. There were no one-on-one participation logs provided for December 2025. Record review for Resident #13 revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure care and services were provided as planned and ordered. This affected one (Resident #15) out of three reviewed. The facility census was 86.Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lymphedema, gastro-esophageal reflux disease without esophagitis, and hyperlipemia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of active physician orders revealed Resident #15 was ordered to have lymphedema boots placed on the resident by nursing staff for one hour two times a day for swelling reduction. Review of the October, November and December 2025 Medication Administration Record, (MAR), revealed there were two time slots for documentation for morning and nighttime. The slots did not have a time duration of one hour and there 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 medical record review, resident interview, and staff interview, the facility failed to arrange vision services outside of the facility as requested. This affected one (Resident #04) of one resident reviewed for vision services. The facility census was 86. Findings include:Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident was independent with eating, required substantial/maximal assistance with bed mobility and was dependent with transfers, bathing, and dressing. Interview on 12/08/25 at 3:21 P.M., Resident #04 stated he was unable to see out of his left eye and was unable to get someone in the facility to make him an eye appointment. Review of an Eye Care Chart note dated 07/24/25…

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.

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 weights were completed as ordered. This affected three (Residents #04, #10, and #48) of five residents reviewed for nutrition. The facility census was 86.Findings include:1) Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had intact cognition. Review of weights for Resident #04 revealed the following: On 03/05/25, the resident weighed 163.2 pounds, on 04/18/25, the resident weighed 161.2 pounds, on 05/08/25, the resident weighed 157.4 pounds, on 07/02/25, the resident weighed 144.6 pounds, on 08/06/25, the resident weighed 144.2 pounds, on 09/06/25, the resident weighed 145 pounds, on 10/06/25, the resident weighed 146 pounds, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a resident's gastrostomy tube (G-tube) was taken care of per physician orders. This affected one (Resident #11) out of two residents reviewed for G-tube care. The facility census was 86.Findings include:Review of the medical record of Resident #11 revealed an admission date of 04/15/21. Diagnoses included dysphagia, type 2 diabetes mellitus, dementia with behavioral disturbance, hypertension, and gastro-esophageal reflux disease.Review of physician orders dated 07/30/25 for Resident #11 revealed an order to change the resident's G-tube dressing daily at night shift and as needed (PRN). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. The resident was dependent or required maximum assistance for activities of daily living (ADL). Review of the October and November 2025 treatment administration record (TAR) revealed Resident #11 did not have a G-tube dressing change…

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 interviews, and policy review, the facility failed to ensure oxygen was provided appropriately. This affected one (Resident #44) out of one resident reviewed for oxygen. The facility census was 86.Findings include: Review of the medical record for Resident #44 revealed an admission date of 06/01/21. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder due to known physiological condition, unspecified dementia, unspecified severity with mood disturbance, other seizures, schizophrenia, hyperlipidemia, hypertension, schizoaffective disorder, bipolar disorder, and major depressive disorder.Review of the plan of care initiated on 08/30/25, revealed Resident #44 had altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications/puffers as ordered, encourage resident to keep head of bed elevated to prevent shortness of breath with lying flat, and oxygen as needed per orders.Review of the quarterly…

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 and staff interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). This affected two (Residents #13 and #19) of the three residents reviewed for medication administration. The facility census was 86. Findings included:1) Record review for Resident #13 revealed this resident was admitted to the facility on [DATE]. Diagnoses included Acute and Chronic Respiratory Failure with hypoxia, Ventral Hernia without obstruction or gangrene, and dependence on respirator (ventilator) status. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was dependent on staff for medication administration. Review of active physician orders for Resident #13 revealed the resident was ordered cetirizine hydrochloride (allergies) 10 milligrams (mg) and spironolactone (potassium-sparing diuretic) 50 mg. Observation 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 interviews and policy review, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #90) out of the two residents reviewed for IV medication. The facility census was 86.Findings Include: Record review for Resident #90 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: Osteomyelitis, Type 2 Diabetes Mellitus with Foot Ulcer, and bipolar disorder. Review of the most Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of the physician orders dated 10/17/25 for Resident #90 revealed the resident was ordered the resident to receive daptomycin (antibiotic used to treat serious infections caused by specific gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) sodium chloride intravenous solution 1000 - 0.9 percent in 100 milliliters (mL)…

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 laboratory (lab) tests were completed as ordered. This affected one (Resident #81) of one resident reviewed for laboratory services. The facility census was 86. Findings include:Review of the medical record of Resident #81 revealed an admission date of 07/21/25. The resident discharged from the facility on 07/27/25 and did not return. Diagnoses included pyogenic arthritis, Methicillin Resistant Staph Aureus (MRSA) bacteremia, anxiety, anemia, and stimulant abuse. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #81 dated 07/27/25, revealed the resident had intact cognition. The resident rejected care and resident required setup/cleanup assistance or supervision with all activities of daily living. Review of the physician orders for Resident #81 dated 07/21/25, revealed an order for the resident to receive for vancomycin (an antibiotic used to treat serious bacterial infections) intravenous solution 1000 milligrams (mg)/200 milliliter (ml). Use 1000 mg intravenously every eight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow up timely on dental recommendations. This affected one (Resident #39) of the five residents reviewed for dental care. The total facility census was 86Findings Include:Record review for Resident #39 revealed this resident was admitted to the facility on [DATE] Diagnoses included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Diabetes mellitus, and Unsteadiness of feet. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require supervision or touching assistance for eating, and supervision or touching assistance for oral hygiene. The resident had a physician order for a regular diet. Review of nursing notes dated 08/19/25, revealed Resident #39 was scheduled for surgical dental appointment. The surgical procedure could not be done due to increase in blood pressure. 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, staff interview, and policy review, the facility failed to ensure residents received three meals a day. This affected one (Resident #19) out of three residents reviewed for meal assistance. The facility census was 86.Findings Include:Observation on 12/10/25 at 2:10 P.M., revealed Resident #19 had not received their lunch at this time.Interview on 12/10/25 at 2:11 P.M., with Resident #19 confirmed they did not receive lunch at this time. Resident #19 stated that they requested a ham sandwich and a bowl of soup from the alternative menu.Interview on 12/10/25 at 2:27 with the Director of Nursing (DON), confirmed Resident #19 did not receive their lunch. Review of the facility policy titled, Mealtimes and Frequency revealed the facility will provide at least three meals daily at regular times. The policy also states lunch will be served daily at 12:30 P.M.This deficiency represents non-compliance investigated under Complaint Number 1264367.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and policy review, the facility failed to ensure rooms provided full visual privacy for each resident. This affected two Residents (#56 and #59) out of two residents reviewed for privacy. The facility census was 86.Findings include: Review of the medical record for Resident #56 revealed an admission date of 07/03/24. Diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified protein-calorie malnutrition, encephalopathy, acute kidney failure, type two diabetes mellitus without complications, and hyperlipidemia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had severely impaired cognition. Resident #56 was assessed to require supervision for eating and bed mobility, partial/moderate assistance for oral hygiene and toileting, and substantial/maximal assistance for bathing, dressing, and personal hygiene.Review of the medical record for Resident #59 revealed an admission date 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 observation, staff interview, and policy review, the facility failed to ensure clean dishes were handled in a sanitary manner. This had the potential to affect all 87 residents in the facility who the facility identified all residents receiving food from the kitchen. The facility census was 87.Findings include:Observation of the kitchen on 07/09/25 at 11:01 A.M., revealed [NAME] #300 loading dirty dishes onto racks and pushing the dirty racks through the dish machine. [NAME] #300 pushed two racks through the dish machine, rinsed her hands with the dish sprayer, and walked over to the other side of the dish machine and began unloading clean dishes from the racks. [NAME] #300 was not observed to wash her hands or complete any hand hygiene when moving between the dirty dishes to the clean dishes. [NAME] #300 then finished unloading the clean dishes from two racks and walked back over to the dirty dishes and began loading more dirty dishes onto a rack. [NAME] #300 pushed another rack through the dish machine and, again, walked over to the other side of the dish machine 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, resident interview, staff interview, and review of the facility policy, the facility failed to provide medications as ordered by physician. This affected one resident (Resident #11) of three residents reviewed for medication administration. The facility census was 94 residents. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/10/24 with diagnoses including osteoarthritis and attention deficit hyperactivity disorder (ADHD). Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 10/15/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #11 revealed an order dated 07/15/24 for Adderall five milligrams (mg) two tablets twice daily. Review of controlled drug administration records for Resident #11 revealed Adderall was not administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. Review of Medication Administration Records (MAR) for Resident #11…

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 interview, staff interview, and review of the facility policy, the facility failed to accurately document medication administration. This affected one (Resident #11) of three residents reviewed for medication administration. The facility census was 94 residents. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/10/24 with diagnoses including osteoarthritis and attention deficit hyperactivity disorder (ADHD). Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 10/15/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #11 revealed an order dated 07/15/24 for Adderall five milligrams (mg) two tablets twice daily. Review of controlled drug administration records for Resident #11 revealed Adderall was not administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. Review of Medication Administration Records (MAR) for Resident #11 dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interviews and policy review the facility failed to develop a complete comprehensive care plan to include activities. This affected three (Resident #9, #13, and #45) out of four residents reviewed for activities. The facility census was 88. Findings include: 1. Record review of Resident #9 revealed an admission date of 07/10/23 with diagnoses of acute and chronic respiratory failure with hypoxia, major depressive disorder, and heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required set-up assistance with eating, and required supervision assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and ambulation. Review of the Activities Initial Review assessment dated [DATE] revealed the resident had interests / hobbies of arts and crafts. Unknown if resident wished to participate in activities while in the facility. 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.

Based on review of the Payroll-Based Journal (PBJ) report, record review and staff interview the facility failed to have eight consecutive hours of Registered Nurse (RN) coverage in the facility. This had the potential to affect all 92 residents who resided in the facility. Findings include: Review of the PBJ report for quarter one of the 2024 fiscal year, revealed the facility had a high number of days without RN coverage. Review of the staffing schedules from 01/01/24 to 03/31/24 revealed no RN was scheduled for eight consecutive hours on 02/03/24, 02/04/24, 02/10/24, 02/11/24, 02/17/24, 02/18/24, 03/30/24, and 03/31/24. Review of the daily staffing posting for 02/03/24, 02/04/24, 02/10/24, 02/11/24, 02/17/24, 02/18/24, 03/30/24 and 03/31/24 revealed no documented RN coverage for eight consecutive hours. Interview with the Administrator on 07/16/24 at 10:00 A.M. verified that there was no RN scheduled for eight consecutive hours on 02/03/24, 02/04/24, 02/10/24, 02/11/24, 02/17/24, 02/18/24, 03/30/24, and 03/31/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and resident and staff interviews, the facility failed to ensure perineal care was provided for a resident. This affected one (#38) of three reviewed for incontinent care. The facility census is 87. Findings include Medical record review for Resident #38 revealed an admission on [DATE] with diagnoses including but not limited to congestive heart failure, asthma, hypotension, and neuromuscular dysfunction of the bladder. Review of the comprehension Minimum Data Set (MDS) assessment dated [DATE] for Resident #38 revealed the resident had intact cognition. Resident #38 was not coded with refusals or rejections of care. Resident #38 required set up for meals, dependent for toileting, maximum assistance for transfers and moderate assistance for bed mobility. Resident #38 was coded as incontinent of bladder and bowel. Review of the plan of care for Resident #38 revealed resident required assistance with activities of daily living (ADL) due to hypertension, diabetes,…

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

Based on record review and interview, the facility failed to have a Registered Nurse on duty for two days on the weekends. This affected all residents in the facility. The facility census was 87. Findings include: Review of the time punches and daily schedules the facility did not have a registered nurse on duty on Saturday 01/13/24 and Sunday 01/14/24. Interview with Resident #43 and Resident #66 on 01/18/24 at 10:00 A.M. revealed the facility is short staffed on the weekends. Interview with the Director of Nursing on 01/18/24 at 2:00 P.M. confirmed she did not have a registered nurse on duty for the weekend of 01/13/24 and 01/14/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure residents had reasonable access to menus to meet resident needs, facility failed to have alternate menus, failed to ensure residents were notified of menu substitutions, and failed to prepare meals according to the menu. This directly affected seven (Residents #3, #6 #11, #62, #29, #33 and #56) residents and had the potential to affect all residents who received food from the kitchen. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/24/23, revealed Resident #3 was cognitively intact. During an interview on 01/16/24 at 3:02 P.M., Resident #6 had stated she had no menu, and the food served was a surprise. She and other residents had asked for menus to be printed, but she thought it would be senseless, because they tell you one thing was being served and something else 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, and interview, the facility failed to ensure the food looked appetizing and was palatable. This affected all of the residents in the facility. The census was 87. Findings include: Observation of the lunch tray on 01/22/24 at 12:30 P.M. revealed it was spaghetti with meat sauce and cheese on the top, roll, and Normandy blend of vegetables. The vegetables looked brownish. The roll was sitting on the plate and the juices from the other foods made the roll soggy. Interview with the Dietary Manager #44 on 01/22/24 at 12:35 P.M. agreed the meal looked over cooked. She confirmed the roll was soggy from the juices on the plate.

Based on observation and interview, the facility failed to ensure opened food items were dated, staff wore hair coverings and that food was stored properly in the freezer. This had the potential to affect all residents who received food from the kitchen. The facility census was 87. Findings include: 1. During an observation of the reach in freezer on 01/16/24 at 9:00 A.M., there was opened lettuce, hot dogs, turkey lunch meat, bologna, cheese, left over soup, left over enchiladas, and open tuna salad without dates. Nutritional Juice Drinks 6 ounces without dates (Four orange pineapple, six apple juice, 13 cranberry juice) were taken from their original boxes and placed into the refrigerator without a date on them. 2. During an observation on 01/16/24 at 9:10 A.M., there was a large box of beef on the floor of the freezer. 3. During an observation of the tray line on 01/16/24 at 11:30 A.M, [NAME] #66, and Dietary Aides #26 and #30 were not wearing a covering ot wearing hair on 01/16/24 at 11:30 A.M. during tray line, without covering their facial hair. During an interview on 01/16/24…

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.

Based on record review and interview, the facility failed to implement a quality assurance performance improvement (QAPI) plan. This had the potential to affect all 87 residents residing in the facility. Findings include: During the entrance conference on 01/17/24 at 10:04 A.M., the facility's QAPI plan was requested to be provided. During the course of the survey, the QAPI plan was not received. During an interview on 01/22/24 at 3:01 P.M., the Administrator stated he had been working in the facility since January of 2023 and he didn't have a QAPI plan. He stated he goes over the areas of concerns in the morning meetings with the staff and had nothing documented. Review of the policy titled Quality Assurance Performance Improvement Program, dated 10/01/18, revealed this facility shall develop, implement, and maintain an ongoing, facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.

Based on interview and record review, the facility failed to provide evidence a quarterly quality assessment and assurance (QAA) meeting was held. This had the potential to affect all 87 residents residing in the facility. Findings include: Evidence of the facility's quarterly QAA meetings for the last 12 months were requested. Nothing was provided by the end of the survey. During interview on 01/22/24 a 3:01 P.M., the Administrator said he could provide no evidence QAA meetings were held.

Based on record review, interview and policy review, the facility failed to address concerns brought forth by the Resident Council in a timely manner. This directly affected 15 residents who attended the resident council meetings and had the potential to affect all residents. The census was 87. Findings include: Review of resident council meeting minutes dated 01/26/23 documented the residents were concerned about the availability of a substitute menu. When they call down to the kitchen they are told the items aren't available and that additional portions had been thrown away. The minutes dated 03/23/23 documented the residents stated they would like a weekly menu. The minutes dated 04/20/23 documented he residents complained they weren't seeing their concerns reviewed in a timely manner and not seeing resolutions to the concerns. The residents were not pleased with the quality of food presentation and not knowing what the daily meals are going to be. The residents complained of the taste of the food and receiving unwanted items and don't think the diet orders are being followed.…

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

Based on observation, interview, and policy review, the facility failed to ensure the environment and resident equipment were in good repair. This affected four (Residents#5, #27, #29, and #33) of five reviewed for environment. The census was 87. Findings include: 1. During an observation on 01/16/24 at 11:29 A.M., Resident #5's room had splashes of a yellowish substance on the right side of the toilet. Two light globes at the top of the mirror in the bathroom had thick dust on them and the bulb was burnt out in the left light. There were multiple holes in the wall behind the sink in the bathroom. The privacy curtain in the room was soiled with a black and yellow substance. 2. During an observation on 01/17/24 at 7:46 A.M., Resident #27's window blinds were not in place properly and were missing slats. 3. During an observation on 01/16/24 at 1:44 P.M., Resident #29's bedroom floor had stains. The lights in the bathroom were covered with dust. The tile next to the right side of the toilet was coming up from the floor. The wallpaper was coming off the wall going into the bathroom, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure residents had complete and accurate care plans and failed to ensure that care plans were implemented. This affected six (Residents #22, #29, #33, #76, #336, and #82) of twenty-four residents sampled for care plans. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and had diagnoses including unspecified cerebral infarction with hemiplegia and hemiparesis affecting the left dominant side, paranoid schizophrenia, type II diabetes, unspecified chronic obstructive pulmonary disease, type II diabetes, and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/03/23, revealed Resident #22 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #22 had impairment on one side which caused functional limitation in range of motion. Review of the care plan dated 01/16/24…

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, observation, interview and policy review, the facility failed to ensure residents smoked in designated areas and failed to ensure smoking materials were kept secured. This affected four (Residents #45, #33, #336 and #76) of five residents reviewed for smoking. The facility identified 62 residents who smoked. The facility census was 87. Findings include: 1. Record review for Resident #45 revealed an admission date of 01/08/18. Medical diagnoses included traumatic brain dysfunction. There was not a current smoking assessment. The last smoking assessment in Resident #45's record was dated 04/12/21. Review of the annual Minimum Data Set (MDS) assessment, dated 12/01/23, revealed Resident #45 was severely cognitively impaired. Review of the care plan for Resident #45 dated 12/01/23 revealed the resident was at risk for injury related to smoking. Intervention was to provide supervision at all times for smoking. Smoking items are to be kept at the nursing station. Review of the progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure staff were not assigned to residents who specified they did not want that caregiver and failed to ensure residents received their phone calls. This affected two (Residents #26 and #336) of two residents reviewed for resident rights. The census was 87. Findings include: 1. Record review revealed Resident #26 was admitted on [DATE] with diagnoses including multiple sclerosis and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of a facility Self-Reported Incident (SRI), #242077 dated 12/12/23, documented the facility received an anonymous letter from a church in the community alleging possible abuse or neglect of Resident #26. When staff spoke with Resident #26 she said there were two staff members she didn't want to care for her because of personal reasons. During an interview on 01/17/24 at 2:31 P.M., Resident #26 stated she did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a new Preadmission Screening and Resident Review (PASRR) when a new mental health diagnosis was given. This affected two (Residents #33 and #45) of six reviewed for PASRR. The facility census was 87. Findings include: 1. Review of the record for Resident #33 revealed he was admitted [DATE] with diagnoses including schizophrenia (08/08/22), bipolar disorder, anxiety disorder, and panic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Review of the medical record revealed a PASRR was completed on 07/20/20. However, a new PASRR was not completed for Resident #33 after the diagnosis of schizophrenia was added 08/08/22. 2. Review of the record for Resident #45 revealed he was admitted [DATE] with diagnoses including dementia with psychotic disturbance, delusional disorder (10/28/21), major depression and anxiety disorder. Review of the MDS dated [DATE] revealed Resident #45 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, interview, and policy review, the facility failed to ensure residents received quarterly care conferences. This affected two (Residents #6 and #62) of three residents sampled for care conferences. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident # 6 was admitted to the facility on [DATE] and had diagnoses including unspecified cerebral palsy, COPD, type II diabetes, (03/14/13) unspecified bipolar disorder, unspecified hallucinations, contracture to unspecified joint. unspecified major depressive disorder, and other chronic pain. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 6 was cognitively intact, had no behaviors, did not wander, and did not reject care. Record review revealed there were only two care conferences held in 2023 for Resident #6 on 04/25/23 and 07/28/23. 2. Review of the medical record revealed Resident # 62 was admitted to the facility on [DATE] and had diagnoses including…

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 showers were given. This affected two (Residents #29 and #33) of two reviewed for activities of daily living. The census was 87. Findings included: 1. Record review for Resident #29 revealed an admission date of 03/24/23. His medical diagnoses included cerebrovascular accident, diabetes, hypertension, and heart failure. Review of progress notes dated 09/01/23 through 01/18/24 revealed no refusals for showers. Review of quarterly MDS dated [DATE] revealed Resident #29 was cognitively intact. There was no care plan for bathing or showers in his record. Review of the documentation for Resident #29 revealed since 11/14/23 revealed Resident #29 had received six showers out of 20 opportunities. During an interview on 01/16/24 at 1:44 P.M., Resident #29 stated he gets showers but he goes a little longer than he would like to in between showers. He stated there wasn't enough aides on nights to give him a shower and he has voiced it to 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 record review and interview, the facility failed to ensure a pressure ulcer was monitored when hospice took over the care of the resident. This affected one (Resident #27) of two residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers in the facility. The census was 87. Findings include: Record review for Resident #27 revealed an admission date of 02/22/23. His medical diagnoses included traumatic brain disorder, cerebrovascular accident (CVA), non-Alzheimer's dementia, malnutrition, and schizophrenia. Review of the initial pressure ulcer assessment dated [DATE] documented a pressure injury wound to the right trochanter measured seven centimeters (cm) by 6.5 cm by two cm with 100 percent granulation tissue. There was moderate exudate and and the peri-wound was normal and the wound had no signs of infection. Review of the inial pressure ulcer assessment dated [DATE] documented a pressure injury to the coccyx that measured 2.7 cm by 1.5 cm by one cm with 100…

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

Based on observation, interview, record review and policy review, the facility failed to provide incontinence care in a manner to prevent urinary tract infection. This affected one (Resident #11) resident reviewed for incontinence. The facility identified 45 residents who were incontinent. The facility census was 87. Findings include: Review of the medical record for Resident #11 revealed an admission date of 02/12/19. Diagnoses included diabetes mellitus type II, spondylosis, post menopausal bleeding, hypertension, anxiety disorder, morbid obesity due to excess calories. Review of the Minimum Data Set (MDS) assessment for Resident #11, dated 10/27/23, revealed the resident had intact cognition. The resident required the assistance of two persons for activities of daily living and was totally dependent for transfers. The resident had no pressure ulcers. During an interview on 01/22/24 at 10:30 A.M., Resident #11 stated she had a urinary tract infection about a month ago. During an observation of incontinence care for Resident #11 on 01/22/24 at 10:30 A.M., State Tested Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered. This affected three (Residents # 18, #45, and #29) of six residents sampled for medication administration. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] and had diagnoses including unspecified anxiety disorder, major depressive disorder, unspecified ankle contracture, unspecified pain, and hereditary spastic paraplegia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/02/23, revealed Resident #18 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #18 had an indwelling urinary catheter. Review of the medical record revealed Resident #18 had physician orders for medications including cranberry capsule 425 milligrams (mg) by mouth once daily; ferrous sulfate 300 mg/5 milliliters (ml), give 5 ml by mouth once daily; loratadine 10 mg by mouth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside. This affected one (Resident #43) out of 21 residents the nurse administered medications to. The facility census was 87. Findings include: Review of Resident #43's medical record revealed he was admitted to the facility on [DATE] with a diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type II, morbid obesity, peripheral vascular disease, chronic atrial fibrillation, and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 10/20/23, revealed Resident #43 was cognitively intact. During an observation on 01/16/24 at 10:30 A.M., there was a cup of medications at Resident #43's bedside. During an interview at the time of the observation, Resident #43 stated he has trouble taking all of the medication at once. He asked the nurse to leave the medication and he would take it later. During an interview on 01/16/24 at 10:45 A.M., Nurse #77…

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

Based on observation, record review and interview, the facility failed to ensure dental services were provided to residents. This affected two (Residents #33 and #73) four residents reviewed for dental services. The facility census was 87. Findings include: 1. Medical record review for Resident #33 revealed an admission date of 07/23/20. Diagnoses included traumatic spinal cord dysfunction. Review of a visit for the dentist on 08/24/23 revealed the resident was seen in his room. The recommendation was to bring the resident to the clinic. There was moderate plaque, calculus, and gingivitis. Recommended staff assistance with daily oral care, brushing two times a day to decrease bacterial load. Review of quarterly Minimum Data Set (MDS) assessment, dated 12/14/23, revealed Resident #33 was cognitively intact. During an interview on 01/16/24 at 2:08 P.M., Resident #33 stated he was supposed to visit the dentist office and it hasn't been set up yet. He said the staff told the dentist he refused to go, but they didn't get him up out of bed to go to the dentist. He denied he had pain 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 observation, record review and interview, the facility failed to provide a resident with adaptive equipment at meals. This affected one (Resident #62) resident. The census was 87. Findings include: Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] and had diagnoses including dysphagia following cerebrovascular disease, unspecified asthma, unspecified dementia, left wrist flexion deformity, type II diabetes, and seizures. Review of the care plan, dated 04/16/21, revealed Resident #62 was at risk for decline in activities of daily living (ADL) function as evidenced by need for assistance with ADL's. Interventions included adaptive equipment including built up spoon/fork utensils, and plate guards. Review of most recent Minimum Data Set (MDS) assessment, dated 12/08/23, revealed Resident #62 had severely impaired cognition. The resident had no functional impairment or limitation in range of motion. Review of the medical record revealed Resident # 62 had physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review, the facility failed to implement appropriate infection control measure for residents in transmission-based precautions. This affected two (Residents #48, and #27) of four residents sampled for infection control. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, chronic obstructive pulmonary disease, chronic viral hepatitis B, and chronic viral hepatitis C. Review of the most recent Minimum Data Set (MDS) assessment, completed on 11/03/23, revealed Resident #48 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of progress notes dated 01/14/24 at 5:37 P.M. revealed Resident #48 had a red rash under the right breast which was associated with pain. The nurse called the on-call provider and passed it on to the night shift nurse in report. On 01/14/23 at 10:51 P.M. the night shift…

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, observation, and staff interviews, the facility failed to prepare an adequate amount of food to serve all the residents and failed to follow the prepared menu. This had the potential to affect all residents residing in the facility. The facility census was 87. Findings include: Review of the lunch menu dated 12/27/23 revealed lunch service included spaghetti with meat sauce, Caesar salad, garlic buttered dinner roll, Oreo fluff, choice of milk, and beverage of choice. Observation of the lunch service tray line on 12/27/23 at 12:05 P.M. through 1:05 P.M. revealed [NAME] #26 was serving spaghetti with meat sauce and ran out of spaghetti with five trays remaining and had to serve hot dogs or hamburgers as an alternative even though an alternative meal was not requested. During tray line observation, a regular salad had replaced the Caesar salad, and a garlic butter dinner roll was supposed to be served but was not available to be put on the trays. Interview on 12/27/23 at 1:19 P.M. with Resident #21 reported that she would have preferred to have spaghetti but…

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, observation and staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect all residents residing in the facility. The facility census was 87. Findings include: Observation of the kitchen on 12/27/23 at 12:05 P.M. and during tray line for lunch service revealed the Kitchen Manager (KM) #29, two Dietary Aides (#27 and #28) and [NAME] #50 were not wearing any hair nets. [NAME] #50 was not wearing a hair net to cover his beard and was observed assisting with the preparation of lunch. Interview with KM #29 at the same time verified the kitchen staff were not wearing hairnets and should be covering all hair with hairnets. Review of the Hair Restraints Policy (dated 11/05) revealed hair restraints shall be worn by all dietary employees while on duty to cover all their hair.

Based on observation and staff interview, the facility failed to ensure kitchen was clean and sanitary. This had the potential to affect all 88 residents residing in the facility. The facility census was 88. Findings include: Observation on 10/26/23 at 10:30 A.M. of the facility kitchen revealed directly inside the door was two coffee makers with unknown food/liquid spatters on all sides of the machines and down the sides of the stainless-steel table they were sitting on; coffee grounds were all over the table top; the steam table has unknown splatter marks on all sides of the clear plastic protector and down the sides; the electrical outlets on the floor in front of the steam table were covered with heavy accumulation of unknown splatter marks with one plug was being used with an electrical cord inserted; the floor under steam table has heavy accumulation of unknown dark brown and black substances; three metal stands with three shelves each were noted in the kitchen and had heavy accumulation of unknown dark brown black material on shelves and the lowest shelf was covered with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interviews, the facility failed to administer insulin per sliding scale as ordered resulting in a significant medication error. This affected one (#90) of three residents reviewed for diabetic management/medication administration. The facility census was 88. Findings included: Medical record review for Resident #90 revealed an admission on [DATE] and a discharge on [DATE]. Diagnoses include pneumonia, asthma, shortness of breath, diabetes mellitus with hyperglycemia, vitamin B12 deficiency, major depressive disorder, fibromyalgia, hypertension, hypothyroidism, systemic lupus, rheumatoid arthritis, Sjogren syndrome, acid reflux disease and hyperlipidemia. Review of the completed discharge return not anticipated Minimum Data Set (MDS) dated [DATE] revealed a staff assessment for cognitive skill revealed Resident #90 had modified independence for cognition. Resident #90 was not coded with any behaviors. Resident #90 requires extensive assist for bed mobility, transfers,…

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 and staff interview, the facility failed to maintain infection practices by ensuring staff completed hand hygiene between multiple dressing changes. This affected one (#28) of three reviewed for infection control. Facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission on [DATE]. Diagnoses include intracranial injury without loss of consciousness, malnutrition, encephalopathy, paranoid schizophrenia, dementia with behavioral disturbances, cerebral infarction, schizoaffective disorder bipolar type, osteomyelitis of vertebra,and chronic pain. Review of the Comprehensive Minimum Data Set (MDS) assessment date 02/24/23 for Resident #28 revealed impaired cognition. Resident #28 was coded with verbal behaviors and rejection of care for 1-3 days during the look back period. Resident #28 requires total assist with two or more staff members for bed mobility, transfers, and toileting. Resident #28 requires total assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received adequate post-operative care including failure to arrange for a post-operative surgical visit, assess and monitor the surgical incision, and arrange for or remove staples to the surgical incision. This affected one (Resident #75) of three residents reviewed for quality of care. The facility census was 91. Findings include: Review of the medical record for Resident #75 revealed an admission date of 05/12/23 with a primary diagnosis of displaced comminuted fracture of the right femur. Review of the Resident #75's hospital note by Surgeon #645, dated 05/05/23, revealed on 05/05/23 Resident #75 came to the hospital complaining of right hip pain following a fall sustained while working on fixing a deck. X-rays showed a displaced comminuted fracture of the femur. The surgeon recommended surgical repair of the fracture to be done on 05/06/23 which included an open…

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 resident and staff interviews, observation, record review and review of the facility's policy, the facility failed to address the resident's concerns in a timely manner. This had the potential to affect all 91 residents residing in the facility. Findings include: 1. During the Resident Council Meeting held on 01/07/20 at 1:30 P.M., the residents reported the process was to voice concerns at the meeting, a concern form was sent to the managers and they were to hear back regarding the resolution. They stated they did not feel they got feedback regarding their concerns. They stated they were not sure how to access the grievance process. During an interview on 01/09/20 at 11:35 A.M. with Assistant Director of Nursing (ADON) #144, she stated they discussed the resident concern forms daily at a morning meeting and turned the forms over to the Administrator who delegated who would follow-up on the concerns. She reported residents can turn in the concern forms into any staff or staff who could help them…

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 personnel files, review of the Bureau of Criminal Identification and Investigation (BCI) log, review of the Ohio Attorney General's web site, review of the facility's abuse policy, and resident and staff interviews, the facility failed to implement their abuse policy to ensure employee fingerprints were obtained and sent to the Bureau of Criminal Identification and Investigation (BCI & I) for seven employees. Additionally, the facility failed to implement their abuse policy to ensure the BCI & I results were received within 30 days for four employees. The facility also failed to implement their abuse policy when a resident (Resident #1) voiced concerns of an allegation of misappropriation. This had the potential to affect all 91 residents residing in the facility. Findings include: Review of BCI & I facility log revealed the following: 1. Housekeeper (HK) #137 had date of hire (DOH) on 10/23/19. The BCI & I was completed on 12/13/19 and the results were received on 12/18/19. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and a tray test of food, the facility failed to provide palatable food at an appetizing temperature. This had the potential to affect all residents of the facility except Resident #5 and Resident #29 who ate nothing by mouth. The facility census was 91. Findings include: Interview on 01/06/20 at 2:08 P.M. with Resident #62 revealed the meat did not taste like meat and the eggs were always cold. Resident #56 further revealed they used to be served juice and now only get kool-aid to drink. She revealed her husband brings in soup and crackers for her to eat. Interview on 01/06/20 at 3:43 P.M. with Resident #62's daughter revealed the food was garbage. She revealed one Sunday for dinner the only food served was corn bread and french fries. Observation and tasting of the test tray for the dinner meal on 01/07/20 at 5:20 P.M. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) revealed the meal consisted of chicken nuggets, sweet…

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

Based on review of the Dietician Food Safety and Sanitation Checklist, observations, and staff interview, the facility failed to ensure proper use of gloves, ensure hand washing facilities were available in the kitchen, and failed to date and label opened stored foods. This had the potential to affect all of the residents of the facility except two Residents (#5 and #29) who received nothing by mouth (NPO). The facility census was 91. Findings include: Review of the Dietitian Food Safety and Sanitation Checklist dated 12/24/19 revealed the kitchen and the dish room needed a good cleaning. The checklist revealed the floors needed mopped and cleaned and there were many food items not dated or labeled in the freezer, refrigerator, and the dry storage area. Observation of the kitchen on 01/06/20 at 8:44 A.M. revealed there was no soap or paper towels available at the hand washing area in the main kitchen. Interview with [NAME] #211 at the time of the observation confirmed there was no soap and no paper towels available. Observation on 01/06/20 from 8:44 A.M. until 9:15 A.M. 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.

Based on review of the Quality Assessment and Assurance Committee (QAA) records and staff interview, the facility failed to have documentation quarterly meetings were held. This had the potential to affect all 91 residents of the facility. Findings include: Review of the records for the QAA Committee records revealed no documentation of quarterly meetings being held. for the past 12 months. Interview with the Director of Nursing (DON) on 01/09/20 at 10:35 A.M., confirmed the facility binder documenting the monthly QAA meetings could not be found. The DON revealed the Medical Director reported she did attend QAA meetings in September 2019 and November 2019, however there was no documentation of the meetings.

Based on observation, staff interview, and review of facility policy, the facility failed to provide laundry services under proper infection control measures. Additionally, based on facility personnel records review, staff interview, and review of facility policy, the facility failed to ensure five staff (State Tested Nursing Assistants (STNAs) #16, #85, and #95, Licensed Practical Nurse (LPN) # 54, and Registered Nurse (RN) #72) of nine reviewed completed annual tuberculosis (TB) screenings. This had the potential to affect all 91 residents residing in the facility. Findings include: 1. Observation and interview on 01/09/20 at 4:27 P.M. revealed Housekeeping Assistant (HSK) #69 was observed grabbing dirty linens out of bags with her bare hands placing them in the washer, with no personal protective equipment (PPE) on. HSK #69 revealed she usually wore Personal Protective Equipment (PPE), however she was about to leave for the night and just took them off. Further observation of the laundry room revealed towels on the floor around the washing machine. HSK #69 revealed they were 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, observation, and staff interview the facility failed to ensure residents were free of significant mediation errors. There were five medications errors observed out of 27 opportunities observed, resulting in a 18.5 % medication error. This affected three Residents (#15, #90, and #196) of 8 observed during medication administration. The facility census was 91. Findings include: 1. Review of Resident #196's medical record revealed an admission date of 12/28/19 with diagnoses including osteoarthritis of shoulders and knees, chronic obstructive pulmonary disease, major depressive disorder, and adult failure to thrive. Review of Resident #196's January 2020 physician orders revealed orders for Pepcid (ulcers) 20 milligrams (mg) twice a day, and Symbicort (inhaler) 160-4.5 micrograms twice a day. Observation of medication administration on 01/08/20 at 8:22 A.M. with Registered Nurse (RN) #143 revealed she did not have Symbicort or Pepcid in the medication card to administer to Resident #196. 2. Review of the medical record for Resident #90 revealed 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 observation, staff and resident interviews, the facility failed to ensure the resident's wheelchairs and the glove dispensers were in good repair. This affected four (#210, #211, #212, and #216) of 99 resident rooms. The facility census was 91. Findings include: During an environmental observation tour of the 208 to 217 hall conducted on 01/10/20 at 9:29 A.M. with Assistant Director of Nursing (ADON) #144 revealed the following observations: • In room [ROOM NUMBER], the resident's wheelchair armrest was noted to be cracked with visible foam. • In room [ROOM NUMBER], there was a wheelchair armrest cracked with visible foam, and the glove dispenser holder was broken with half on the wall. • In room [ROOM NUMBER], there was a wheelchair armrest cracked with visible foam and the [NAME] dispenser holder in the room was observed broken with pieces noted on the wall, with the gloves sitting on a box underneath. The resident in room [ROOM NUMBER] stated he was unsure of how long the dispenser had been broken,…

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, review of the facility's Self-Reported Incidents(SRI) and review of the facility's policy, the facility failed to report an allegation of misappropriation of resident money to the Administrator and/or designee and the State Survey Agency. This affected one (Resident #1) of four residents reviewed for personal property during the investigation stage of the annual survey. The facility census was 91. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, psychotic disorder due to substance abuse, delusional disorder, chronic pain syndrome and insomnia. Review of the five-day Minimum Data Set (MDS) assessment, dated 11/04/19, revealed the resident was moderately cognitive impaired with no noted behaviors. Review of the facility's SRIs revealed there were no SRI involving Resident #1 for the month of 12/2019. Interviews on 01/06/20 at…

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, and review of the facility's policy, the facility failed to investigate an allegation of misappropriation of resident money. This affected one (Resident #1) of four residents reviewed for personal property during the investigation stage of the annual survey. The facility census was 91. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, psychotic disorder due to substance abuse, delusional disorder, chronic pain syndrome and insomnia. Review of the five-day Minimum Data Set (MDS) assessment, dated 11/04/19, revealed the resident was moderately cognitive impaired with no noted behaviors. Interviews on 01/06/20 at 11:51 A.M. and again on 01/08/20 with Resident #1 stated she had five dollars missing from her room sometime before New Year's day, and she was not sure exactly when. Resident #1 stated she informed the staff of 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, observation, staff and resident interview, and review of the facility's policy, the facility failed to treat and monitor a resident's shin wound. This affected one (Resident #71) of four residents reviewed for skin/pressure wounds during the investigation stage of the annual survey. The facility census was 91. Findings include: Review of the medical record revealed Resident #71 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, peripheral vascular disease and cervical disc disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/29/19, revealed the resident was cognitively intact with no behaviors noted. The resident required supervision with one-person assistance with bed mobility and transfers and supervision with dressing and personal hygiene. Review of the physician orders, dated 12/03/19, revealed a physician order to discontinue the current orders to the right shin, cleanse with normal saline, pat dry, apply non-adherent pad,…

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 resident and staff interviews, observation, review of the facility's policy and record review, the facility failed to ensure resident's practiced safe smoking. This affected two (#33 and #81) of two residents reviewed for smoking. The facility identified 13 residents who smoked. The facility census was 91. Findings include: 1. Record review for Resident #81 revealed he was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, hypertension and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/19, revealed he was cognitively intact and required supervision with eating, dressing and personal hygiene. Review of the care plan revealed the resident had a history of smoking in the community, wanting to smoke at nonsmoking times and being allowed to smoke with supervision in designated areas at designated times. Interventions included securing his smoking materials at the nurse's station or other designated area. Review of the smoking assessment, dated…

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

Based on record review, observation and resident and staff interview, the facility failed to ensure a therapeutic diet was was provided to a resident. This affected one (Resident #90) of four residents reviewed for nutrition. The facility identified four residents on a renal diet. The facility census was 91. Findings include: Review of the medical record for Resident #90 revealed an admission date of 09/27/19 with diagnoses including chronic congestive heart failure, diabetes mellitus, and chronic kidney disease stage III. There was no evidence the resident had any physician diet orders. Review of the Minimum Data Set (MDS) assessment, dated 12/11/19, revealed Resident #90 had intact cognition. Interview on 01/06/20 at 2:32 P.M. with Resident #90 revealed she frequently received foods that were not on her diet, such as breads every meal, tomatoes, potatoes, cheese, and salty foods. Interview and observation on 01/07/20 at 1:04 P.M. of Resident #90 receiving her lunch in the dining room revealed a piece of chicken, diced potatoes, and spinach. Her diet ticket listed her diet 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure pharmacy recommendations were completed and those completed were acted on in a timely manner This affected two Residents (#30 and #90) of five reviewed for unnecessary medications. The facility census was 91. Findings include: 1 Review of the medical record for Resident #90 revealed an admission date of 09/27/19 with diagnoses including diabetes, chronic pain, fibromyalgia, major depressive disorder, and hypothyroidism. Review of Resident #90's January 2020 physician orders revealed and order for Citalopram (anti-depressant) 20 milligrams (mg) daily, Duloxetine (nerve pain and anti-depressant) 60 mg daily, Levothyroxine (hypothyroidism) 25 micrograms daily at 8:00 A.M., Elavil (nerve pain and anti-depressant) 25 mg daily dated 11/18/19, and Dulera (inhaler). Review Resident #90's Pharmacy Recommendation dated 03/26/19 revealed to attempt a dose reduction of Citalopram and Duloxetine, or provide 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, staff interview, and review of facility policy, the facility failed to ensure pharmacy recommendations for dose reductions were responded to for one Resident (#90) of five reviewed for unnecessary medications. The facility further failed to discontinue a resident's psychotropic medication following a outside physician visit. This affected one Resident (#1) of five residents reviewed for unnecessary medication. The facility census was 91. Findings include: 1. Review of the medical record for Resident #90 revealed an admission date of 09/27/19 with diagnoses including hypertension, major depressive disorder, fibromyalgia, and hypothyroidism. Review of Resident #90's January 2020 physician orders revealed Citalopram (for depression) 20 milligrams (mg) daily, Duloxetine (nerve pain and depression) 60 mg daily, Levothyroxine (hypothyroidism) 25 micrograms daily, and Elavil (nerve pain and depression) 25 mg daily dated 11/18/19. Review of Pharmacy Recommendations dated 03/26/19 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.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were free of significant medications errors. This affected one Resident (#90) of 19 reviewed. The facility census was census was 91. Findings include: Review of the medical record for Resident #90 revealed an admission date of 09/27/19 with diagnoses including diabetes, chronic pain, chronic kidney disease stage III, and hypothyroidism. Review of January 2020 physician orders revealed orders for blood sugar checks before meals and at bedtime, Humulog insulin 17 units subcutaneously, three times a day, call the physician if blood sugar is above 300, and hold for blood sugar less than 100. Additionally, Metolazone 2.5 milligrams (mg) tablet daily as needed for weight greater than 165 pounds was ordered, as well as an order dated 11/19/19 to weight the resident daily. Review of Resident #90's January Medication Administration Record (MAR) revealed blood sugar checks were not documented at 8 A.M. on 01/01, 01/02, 01/04, and 01/05/20, however the Basaglar…

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 pharmacy information, the facility failed to remove medications when they expired. This affected one Supply Room of one reviewed for expired medications. The facility further failed to date insulin when opening a new vial. The expired medications had the potential to affect two Residents (#8 and #90) of two reviewed for insulin. The facility census was 91. Findings include: Observation of medication storage area on 01/07/20 at 1:35 P.M. revealed the Central Supply room contained four bottles of aspirin 325 milligrams (mg) with an expiration date of 08/19, two bottles of Iron 325 mg with an expiration date of 12/19, on bottle of stress tablets with an expiration date of 08/18, and one bottle of folic acid 400 mg with an expiration date of 04/19. Interview with Central Supply staff State Tested Nurse Assistant (STNA) #150 verified the expiration dates. Medication storage observation on 01/07/20 at 4:02 P.M. of the 400 hall medication cart revealed an open vial of Lantus insulin labeled for Resident #8. The vial did not display 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, resident and staff interview, the facility failed to ensure one resident was provided annual dental care. This affected one resident (#52) of 24 reviewed for dental services. The facility census was 91. Findings include: Review of Resident #52's medical record revealed an admission date of 08/24/17 with diagnoses including heart failure, spinal stenosis and pulmonary edema. Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #52's plan of care dated 11/15/19 revealed the resident was at risk for dental or oral cavity health problems related to assistance with oral care. Intervention included to ensure routine cleaning and check-ups. Review of Resident #52's summary dental report revealed resident was seen for an oral evaluation on 06/06/18. There was no documentation the resident had been seen since 06/06/18. Interview on 01/06/20 at 2:13 P.M. with Resident #52 revealed she had not seen a dentist…

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 speciality diet list, observation, staff interview, resident interview, and review of facility policy, the facility failed to provide foods of similar nutritive value to residents who chose a speciality diet. This affected three Residents ( #79, #37 and #16) of three reviewed who requested a speciality diet. The facility census was 91. Findings include: Review of the facility Specialty Diet listing revealed three Residents (#79, #37 and #16) with Lacto Ovo Vegetarian diet. (diet consists of mostly plant based foods, dairy and eggs). Interview on 01/06/20 at 11:15 A.M. with Resident #79 confirmed being a vegetarian. Resident #79 revealed she often received an over abundance of carbohydrates and very little protein. Observation and interview on 01/07/20 at 4:50 P.M. of the evening tray line revealed Dietary Manager (DM) #350 plated all three vegetarian resident's meals with only sweet potato fries and cole slaw. Observation of the tray revealed no source of protein was placed on the resident's trays. The DM confirmed there was no protein source included 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 observation, staff, resident interview, and review of facility policy, the facility failed to offer snacks to residents. This affected two Residents (#1 and #30), of five residents reviewed for snacks. The facility census was 91. Findings include: 1. Interview 01/09/20 at 1:24 P.M., with Resident #1 revealed facility staff were supposed to offer snacks, however she never receives any. Resident #1 revealed she has seen staff pass by the cart of snacks, however she is never offered any. Resident #1 revealed her family brought in snacks because the facility did not provide them. 2. Interview on 01/06/20 at 12:08 P.M. and again on 01/08/20 at 8:39 A.M. with Resident #30 revealed the facility staff did not provided snacks. Resident #30 revealed the only snacks she receives were brought in from outside the facility. Interview on 01/09/20 at 1:46 P.M. with State Tested Nursing Assistants (STNAs) #9 and #142 revealed snacks were received after dinner and are put on a tray, then they walk around the unit. STNA #9 revealed there were some residents with snacks in there room, so 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.