Clovernook Health Care And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of Notice of Medicare Non-Coverage (NOMNC) documents, staff interview and facility policy, the facility failed to ensure the NOMNC was accurately completed. This affected three (Residents #143, #144 and #146) of five residents reviewed for Beneficiary Notification. The facility census was 119. 1) Review of the medical record revealed Resident #143 was admitted to the facility on [DATE] and discharged on 02/23/26. Diagnoses included asthma with acute exacerbation, diabetes mellitus type II and morbid obesity. Review of the census profile for Resident #143 revealed the resident was admitted to the facility on [DATE], transitioned to Medicare Part A on 02/01/26, and was discharged from the facility on 02/23/26. Review of the Minimum Data Set (MDS) Discharge-Return Not Anticipated assessment dated [DATE] revealed Resident #143 had intact cognition. Review of the Skilled Nursing Beneficiary Protection Notification Review completed by the facility revealed Resident #143 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, review of facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report an allegation of a missing item. This affected one (#02) resident of the one resident reviewed for reporting of potential abuse and misappropriation. The facility total census was 119. Record review of Resident #02 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #02 include respiratory failure, hypertension, diabetes, end stage renal disease, obesity, anxiety disorder, dependent on dialysis, cardiac defibrillator, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #02 had intact cognition and was dependent on staff assistance with Activities of Daily Living skill (ADL) and mobility. Review of the facility's Missing Item Report dated [DATE], revealed the Administrator received an allegation of a missing [NAME] pendent with diamonds from Resident #02. 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 staff interviews, record review, review of facility's Self-Reported Incidents (SRI), and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#02) resident of the one resident reviewed for reporting of potential abuse and misappropriation. The facility total census was 119. Record review of Resident #02 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #02 include respiratory failure, hypertension, diabetes, end stage renal disease, obesity, anxiety disorder, dependent on dialysis, cardiac defibrillator, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #02 had intact cognition and was dependent on staff assistance with Activities of Daily Living skill (ADL) and mobility. Review of the facility's Missing Item Report dated [DATE], revealed the Administrator received an allegation of a missing [NAME] pendent with diamonds from Resident…

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

Based on medical record review, observation, staff interview, and resident interview, the facility failed to develop comprehensive care plans for residents regarding pain management and refusal of medications. This affected two (Residents #79 and #3) of three residents reviewed for care plans. The facility census was 119 residents. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of 02/14/26 with diagnoses including acute pyelonephritis, calculus in bladder and kidney, chronic kidney disease, and diabetes mellitus type. Review of the MDS assessment for Resident #79 dated 02/19/26 revealed the resident had intact cognition and required staff assistance with ADLs. Review of the physician's orders for Resident #79 revealed orders dated 02/15/26 for Lyrica give one tablet by mouth two times a day for chronic pain syndrome, hold for sedation and Robaxin give one tablet by mouth four times a day for pain. Review of the care plan for Resident #79 dated 02/16/26 revealed it did not include a care plan regarding pain management. Review of the pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure timely care and treatment for a resident exhibiting a change in condition. This affected one (Resident #141) of 26 residents sampled. Based on medical record review, staff interview, and review of the facility policy, the facility also failed to arrange follow-up medical tests. This affected one (Resident #138) of 26 residents sampled. The facility census was 119 residents. Findings include:1.Review of the medical record for Resident #141 revealed an admission date of 01/13/25 with diagnoses including hypertensive heart disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, diabetes mellitus and a discharge date of 02/11/26. Review of the care plan for Resident #141 dated 01/29/26 revealed the resident had an activities of daily living (ADL) self-care deficit and was a substantial one person assist with bed mobility, dressing, and grooming. Review of the Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure staff assessed residents for smoking safety and implemented safe smoking interventions. This affected one (Resident #126) of four residents reviewed for accidents and hazards. Based on medical record review, observation, staff interview, resident interview, and review of the facility policy the facility also failed to ensure staff maneuvered resident shower chairs in a safe manner to prevent falls. This affected one (Resident #67) of four residents reviewed for accidents and hazards. The facility census was 119 residents. Findings include:1.Review of the medical record for Resident #126 revealed an admission date of 03/20/26 with diagnoses including malignant neoplasm of the lip with status post skin graft. Review of the Minimum Data Set (MDS) assessment for Resident #126 dated 03/26/26 revealed the resident had impaired cognition and required supervision 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.

Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure staff followed residents' fluid restrictions. This affected three (Residents #6, #111 and #29) of three residents reviewed for fluid restrictions. The facility census was 119 residents.Findings include:1.Review of the medical record for Resident #6 revealed an admission date of 06/20/23 with diagnoses including pulmonary hypertension, bradycardia, and heart failure. Review of the Minimum Data Set, (MDS) assessment for Resident #6 dated 02/19/26 revealed the resident had impaired cognition and required maximum assistance of staff for activities of daily living (ADLs.) Review of the nutritional assessment for Resident #6 dated 03/31/26 per the Registered Dietitian (RD) revealed the resident was to be on a 1500 milliliter (ml) fluid restriction with dietary to provide 840 ml and nursing to provide 660 ml. Review of Medication Administration Record (MAR) for Resident #6 revealed on 04/04/26 the resident #6 received 1680 ml of fluid in a…

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

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to routinely assess and document resident pain and monitor the effectiveness of pain medications. This affected one (Resident #79) of three residents reviewed for pain management. The facility identified 33 residents on a pain management program. The facility census was 119 residents.Findings include:Review of the medical record for Resident #79 revealed an admission date of 02/14/26 with diagnoses including acute pyelonephritis, calculus in bladder and kidney, chronic kidney disease, and diabetes mellitus type two. Review of the physician's orders for Resident #79 revealed orders dated 02/15/26 for Lyrica 50 milligrams (mg) give one tablet by mouth two times a day for chronic pain syndrome and hold for sedation and Robaxin 500 mg give one tablet by mouth four times a day for pain. Review of the Minimum Data Set (MDS) assessment for Resident #79 dated 02/19/26 revealed the resident had intact cognition and required staff assistance with activities of daily…

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

Based on medical record review, review of an incident report, staff interviews, and policy review, the facility failed to ensure residents were free from avoidable accidents during transfers with a mechanical (Hoyer) lift. This affected one (#6) out of three residents reviewed for accidents. The facility census was 110.Findings include: Review of the medical record for Resident #6 revealed an admission date of 10/23/23. Diagnoses included unspecified sequelae of cerebral infarction, unspecified protein-calorie malnutrition, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, congestive heart failure, peripheral vascular disease, hyperlipidemia, major depressive disorder, pseudobulbar affect, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Review of the annual Minimum Data Set (MDS) assessment, dated 09/08/25, revealed Resident #6 had severely impaired cognition. Resident #6 was assessed to require substantial/maximal assistance for upper body dressing, and was dependent for eating,…

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

Based on observation, staff interview and review of employee personnel file, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 116 residents who resided at the facility. Findings include: Review of the Admissions Director (AD) #132's personnel file revealed AD #132 was hired as the Activity Director on 11/24/15. AD #132's personnel file had no resume with work experience and no Activity Director certificate. Interview with the Human Resource Manager (HRM) #182 on 01/29/25 at 4:40 P.M. verified the facility did not have verification of AD #132's past work experience and AD #132 did not meet the qualifications of an Activity Director. Interview the Administrator on 02/04/25 at 3:00 P.M. verified AD #132 was not a qualified Activity Director.

Based on record review, observation, and staff interview, the failed to ensure employment of a full-time, qualified social worker. This had the potential to affect all 116 residents who resided at the facility. Findings include: Review of the employee file for the most recent Social Worker #575, revealed a hire date of 09/18/24 and a termination date of 12/19/24. Interview with the Administrator on 01/29/25 at 11:13 A.M., verified the facility did not have a qualified social worker available for the residents. The Administrator stated she thought her facility was only licensed for 119 beds.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, staff interview, hospital social worker interview, dialysis staff interview, review of a a job description for a social worker, and review of facility policy, the facility failed to ensure a resident received hemodialysis as ordered by not assisting and coordinating transportation. This affected one Resident (#117) of the two residents reviewed for dialysis. The facility also failed to ensure active and ongoing communication between the facility and the dialysis center was maintained. This affected one Residents (#05) of the two reviewed for receiving dialysis. The facility census was 116. Findings include: Review of the medical record for Resident #117 revealed the resident was admitted to the facility on [DATE]. Resident #117 discharged with a return anticipated (DRA) to the hospital on [DATE] at 1:00 A.M. Diagnoses included end stage renal disease (ESRD), heart failure, dysphagia, and dementia. Review of the physician orders for Resident #117 dated…

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

Based on observation, staff interview and review of facility policy, the facility failed to ensure dented cans were not in circulation for use. Additionally, the facility failed to ensure residents' food items stored in unit refrigerators were labeled and dated and further failed to ensure unit refrigerators were clean and consistently monitored to ensure appropriate food storage temperatures. This had the potential to affect all residents except three (#77, #94 and #100) identified by the facility as receiving no food by mouth. The facility census was 111. Findings include: 1. Observation on 10/21/24 at 10:39 A.M. of the kitchen revealed the canned food rack contained four dented cans, including two six-pound cans of pineapple with dents on the top and bottom of the cans, one six-pound can of mandarin oranges with a dent below the top seal, and a six-pound can of stew vegetables with a dent in the top seal. Concurrent interview with Dietary Manager (DM) #24 verified the findings. DM #24 revealed when she unloaded orders of canned goods, she checked the tops and outside of the cans…

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 medical record review and review of facility policy, the facility failed to ensure dignity was maintained during mobility assistance for Resident #54. This affected one resident (#54) of four residents reviewed for dignity. The facility census was 111. Findings include: Review of Resident #54's medical record revealed an admission date of 06/19/23. Diagnoses included Huntington's disease. Review of the annual Minimum Data Set (MDS) assessment, dated 04/09/24, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident used a manual wheelchair and required substantial/maximal assistance from staff to wheel 50 to 150 feet. Review of the care plan, revised 08/01/24, revealed Resident #54 was at risk for falls. Interventions included may get up in a reclining geri (geriatric) chair. Observation on 10/22/24 at 10:50 A.M. revealed Certified Nursing Assistant (CNA) #1 walked out of Resident #54's room, pulling a mobile reclining…

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 resident fund authorizations and staff interview, the facility failed to ensure resident authorization to establish a Resident Funds Trust Account was witnessed by someone who was not an employee of the facility. This affected two residents (#9 and #73) of six residents reviewed for resident funds. The facility census was 111. Findings include: 1. Review of the resident funds management authorization and agreement, undated, revealed Resident #9 and Business Office Manager (BOM) #25 signed the document. Further review revealed the written authorization revealed no witness signature. 2. Review of the resident funds management authorization and agreement, dated 10/25/23, revealed Resident #73 signed the authorization. The document was also signed by BOM #25. Further review revealed the written authorization revealed no witness signature. Interview on 10/23/24 at 2:33 P.M. with BOM #25 confirmed the authorization forms were not witnessed by someone who was not an employee of the facility.

Based on review of resident fund documents and staff interview, the facility failed to notify residents when available funds were within the $200.00 Medicaid resource limit. This affected one resident (#7) of six residents reviewed for personal funds. The facility census was 111. Findings include: Review of Resident #7's quarterly resident account statements revealed on 04/01/24 the resident's balance was $1,974.44. Further review revealed no evidence Resident #7 was notified he was within $200.00 of the $2,000.00 Medicaid resource limit. Concurrent interview with Business Office Manager (BOM) #25 verified the finding and stated she thought the resource limit was $2500.00, not $2000.00.

Based on observation, medical record review, staff interview, pharmacist interview and review of facility policy, the facility failed to ensure resident's were free from significant medication errors during insulin administration. This affected one resident (#1) of six residents reviewed for medication administration. The facility census was 111. Findings included: Review of Resident #1's medical record revealed an admission date of 08/19/21 and a readmission date of 10/15/21. Diagnoses included type two diabetes mellitus. Review of Resident #1's current physician orders revealed an order for Novolog (rapid-acting) insulin to be administered subcutaneously according to a sliding scale three times a day. Additionally, Resident #1 had an order for Lantus (long-acting) insulin, six units to be administered subcutaneously at bedtime. Review of the Medication Administration Record (MAR) for October 2024 revealed Resident #1's sliding scale Novolog was scheduled to be given each day at 8:30 A.M., 12:30 P.M. and 4:30 P.M., and the resident's Lantus was scheduled to be administered each day…

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, review of the Individual Control Drug Record (ICDR)and review of facility policy, the facility failed to ensure a narcotic medication was accurately labeled to reflect current physician orders. This affected one resident (#367) of six residents reviewed for medication administration. The facility census was 111. Findings include: Review of Resident #367's medical record revealed an admission date of 10/04/24. Diagnoses included chronic pain syndrome. Review of Resident #367's current physician orders revealed an order for oxycodone five milligrams (mg), two tablets every eight hours as needed for pain. Review of Resident #367's Medication Administration Record (MAR), for the timeframe from 10/01/24 through 10/25/24, revealed an order started on 10/05/24 and discontinued on 10/10/24 for oxycodone five mg, one tablet every four hours as needed for pain. The MAR also revealed an order started on 10/10/24 for oxycodone 5 mg, two tablets every eight hours as needed. Review of the ICDR for oxycodone five mg tablets revealed a…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure resident medical records contained complete and accurate information. This affected one resident (#367) of six residents reviewed for medication administration. The facility census was 111. Findings include: Review of Resident #367's medical record revealed an admission date of 10/04/24. Diagnoses included type two diabetes mellitus. Review of the Medication Administration Record (MAR) for October 2024 revealed the transcription of an order, started on 10/09/24 and discontinued on 10/21/24, for Trulicity subcutaneous solution pen injector 1.5 milligrams (mg) per 0.5 milliliters (mL) to be administered subcutaneously weekly on Wednesdays. According to the MAR, on 10/21/24, the resident's Trulicity order was changed to Trulicity subcutaneous solution pen injector 1.5 mg per 0.5 mL to be administered subcutaneously weekly on Mondays. The MAR reflected the resident's Trulicity was scheduled to be given on 10/09/24, 10/16/24 and 10/21/24. The MAR revealed documentation that…

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

Based on record review, staff interview, review of job description, the facility failed to ensure they employed a qualified Dietary Manager. This had the potential to affect all 115 residents who received food from the kitchen. The facility census was 115. Findings include: Interview on 09/18/24 at 9:14 A.M. with Dietary Manger (DM) #92, revealed she did not have a certified dietary manager certificate, certified food service manager certificate, a national certification for food service management and safety from a national certifying body or at least an associate degree in food service management. Interview on 09/18/24 at 11:14 A.M. with the Regional Director of Operations (RDO) #140, verified DM #92 did not meet the minimum qualifications to be a Dietary Manager. Review of a job description for Director of Food Service revealed the Director of Food Service must be registered as a Food Services Director in the state and will assist in planning, developing, organizing, implementing, evaluating, and directing the Food Services Department, its program and activities. This deficiency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow the physician's order for a resident's pressure ulcer treatment. This affected one (Resident #65) of three residents reviewed for pressure ulcers. The facility census was 106. Findings include: Review of the medical record revealed Resident #65 was admitted on [DATE]. Diagnoses included surgical amputation, cognitive communication deficit, acquired absence of below the knee, type two diabetes mellitus, end stage renal disease, dependent on renal dialysis, and chronic pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively impaired. Resident #65 was dependent on staff for transfers, toileting, bathing, and personal hygiene. Review of the plan of care dated 05/28/24 revealed Resident #65 had pressure ulcer and had potential for pressure ulcer development related to immobility, incontinence, and disease process. Resident #65 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, staff interview, and facility policy review, the facility failed to promptly notify the resident representative when residents tested positive for COVID-19 and/or were exposed to COVID-19 and were placed under isolation precautions. This affected two (Residents #38 and #105) of three residents reviewed for notification of change. The census was 104. Findings include: 1. Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE]. Resident #38's diagnoses included but were not limited to hemiplegia and hemiparesis, hydrocephalus, epilepsy, cognitive communication deficit, dysphagia, dementia, major depressive disorder, and adjustment disorder with anxiety. Review of Resident #38's Minimum Data Set (MDS) assessment, dated 11/27/23, revealed Resident #38 had mild cognitive impairment. Review of Resident #38's medical profile revealed Resident #38's wife was deemed guardian of person. Review of Resident #38's medical record revealed no evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#10, #62, #92, and #97) reviewed for medications administered by a contracted ancillary provider. This affected six current Residents (#5, #50, #57, #67, #74 and #77) and 13 discharged Residents (#84, #85, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96 and #97). The census was 108. Findings include: 1. Record review for Resident #10 revealed he was admitted to the facility on [DATE]. His diagnoses included, osteomyelitis, paraplegia, candidiasis, anemia, and insomnia. Review of the most recent Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four of four Residents (#10, #62, #92, and #97) reviewed for medications administered by a contracted ancillary provider. This affected six current Residents (#5, #50, #57, #67, #74 and #77) and 13 discharged Residents (#84, #85, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96 and #97). The census was 108. Findings include: 1. Record review for Resident #10 revealed he was admitted to the facility on [DATE]. His diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#10, #62, #92, and #97) reviewed for medications administered by a contracted ancillary provider. This affected six current Residents (#5, #50, #57, #67, #74 and #77) and 13 discharged Residents (#84, #85, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96 and #97). The census was 108. Findings include: 1. Record review for Resident #10 revealed he was admitted to the facility on [DATE]. His diagnoses included, osteomyelitis, paraplegia, candidiasis, anemia, and insomnia. Review of the most recent Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility investigation, and policy review, the facility failed to ensure a resident's discharge was safe, orderly and the accurate medications were provided to a resident upon discharge. The facility also failed to implement an effective discharge planning process by failing to confirm home health services needed post discharge were in place prior to discharge. This affected one (#10) of the three residents reviewed for discharges. The facility census was 108. Findings include: Review of the closed medical record for Resident #10 revealed the resident was admitted on [DATE] and discharged home on [DATE]. Diagnoses included, but not limited to, osteoarthritis, diabetes mellitus, left knee replacement, intracerebral hemorrhage, and morbid obesity. Review of the five-day Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #10, revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a discharge summary of recapitulation of resident's stay. This affected one (#10) out of three residents reviewed for discharge rights. The facility census was 108. Findings include: Review of the closed medical record for Resident #10 revealed the resident was admitted on [DATE] and discharged home on [DATE]. Diagnoses included osteoarthritis, diabetes mellitus, left knee replacement, intracerebral hemorrhage, and morbid obesity. Review of the five-day Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #10, revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of the care plan dated 09/15/23 for Resident #10, revealed the resident was admitted in the facility for short term rehabilitation (rehab) and would have a safe discharge to the community after completing rehab with skilled nursing care and therapy. Review of the medical record for Resident #10 with the…

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

Based on observation, interview, and policy review, the facility failed to ensure medication carts and a medication room was locked. This had the potential to affect eight residents (#11, #12, #13, #14, #15, #16, #17, and #18) identified by the facility as independently mobile with confusion, The facility census was 102. Findings include: Observation on 09/13/23 at 5:49 A.M. of the second floor revealed the medication cart was unlocked with no staff present. Interview on 09/13/23 at 5:51 A.M. State Tested Nursing Assistant (STNA) #67 reported the nurse was outside smoking. Interview on 09/13/23 at 5:51 A.M. with Licensed Practical Nurse (LPN) #60 verified the second floor medication cart was unlocked and the nurse using the cart was outside smoking. Observation on 09/13/23 at 5:54 A.M. revealed the medication cart on the first floor was unlocked with no staff around. Additionally, there was a large wad of paper stuck in the door of the medication room, keeping it unlocked. Interview on 09/13/23 at 5:56 A.M. with LPN #21 verified the medication cart and medication room was left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview, and policy review, the facility failed to check orders for as needed medications prior to administrating. This affected one (Resident #17) of six residents reviewed for medication administration. The in-house facility census was 102. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including anxiety disorder, depression, and vascular dementia. Review of the care plan dated 10/31/16 revealed Resident #17 had the potential for altered mood status or psychosocial well-being related to depression, recent non-traumatic cerebral hemorrhage with left hemiparesis. Resident #17 was placed in nursing home due to history of stating he feels that he would be better off dead but has no intent of harming himself. Resident #17 stated again on 11/28/18 feelings of being better off dead with no thoughts 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 staff interview, Ombudsman interview, review of the facility policy, and record review, the facility failed to ensure residents were invited to care conferences and had the opportunity to participate in the development of their care plan. This affected two (#69 and #100) of three residents reviewed for resident care conference or participation in care planning. The facility census was 100. Findings include: 1. Review of Resident #100's medical record revealed Resident #100 admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with hyperglycemia, protein calorie malnutrition, mood disorder due to known physiological condition with major depressive like episode, hypotension, repeated falls, hypertensive heart disease with heart failure, and congestive heart failure. Review of the admission Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were put in place for a resident at high risk for falls and per the resident's plan of care. This affected one (Resident #85) of five residents reviewed for accidents. The facility also failed to ensure resident smoking materials were safely stored and secured. This affected three (Residents #3, #68, and #97) of 18 facility identified residents who smoked. The facility census was 108. Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 08/18/22. Diagnoses included laceration of trachea, fracture of the second cervical vertebra, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was cognitively impaired and required extensive assistance of one to two staff with activities of living (ADLs.) Review of the fall risk assessment dated [DATE] 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 observation, staff interview, and review of the facility policy, the facility failed to ensure expired medications were discarded. This affected the following residents (Residents #33, #34, #36, #72, and #202) of 25 facility identified residents receiving insulin. This had the potential to affect Residents #57, #58, #70, and #85 who resided on the second floor with orders for bisacodyl suppositories. This had the potential to affect Residents #36 and #70 who resided on the second floor with orders for promethazine suppositories. This had the potential to affect all residents on the second floor with the exception of Residents #91 and #94 who the facility identified as having contraindication to receiving tuberculin skin testing solution. The facility census was 108. Findings include: 1. Observation on 09/21/22 at 1:14 P.M. of the second-floor medication room with Registered Nurse (RN) #175 revealed the medication refrigerator contained an open and undated bottle of tuberculin testing solution, a box of bisacodyl suppositories with a manufacturer's expiration 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, resident interview, staff interview, and review of the facility policy, the facility failed to ensure food was served at safe and appropriate temperatures. This had the potential to affect all residents residing in the facility with the exception of five residents (Residents #52, #63, #70, #77 and #92) identified by the facility as not receiving food prepared in the facility kitchen. The facility census was 108. Findings include: Interview on 09/19/22 at 12:42 P.M. with Resident #3 stated the food at the facility was served cold. Interview on 09/21/22 at 11:15 A.M. with Dietary Supervisor (DS) #63 reported she had not heard any complaints about the temperature of the food. Observation of the tray line on 09/21/22 at 12:12 P.M. revealed the food was the following temperatures: baked beans were 151 degrees Fahrenheit (F), hot dogs were 160 degrees F and the potato salad was 40 F. Hot plates were not utilized for the resident's plates as DS #63 stated she did not want the potato salad to get warm. Observation of a test tray on 09/21/22 with DS #63 revealed the hot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident, and resident's representative were notified of resident's room move. This affected one (Resident #85) of 26 residents reviewed for room change notification. The facility census was 108. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/18/22 with diagnoses including laceration of trachea, fracture to the second cervical vertebra, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was cognitively intact. Review of the nursing progress notes for Resident #85 dated 08/18/22 through 09/21/22 revealed they did not include documentation regarding a room move for Resident #85. Review of the facility's binder which included room move forms revealed there was no form documenting notification of room move for Resident #85. Review of the written statement by Admissions Director (AD) #123…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the medical record accurately reflected a resident's advance directive. This affected one (Resident #8) of 32 residents reviewed for advance directives. The facility census was 108. Findings include: Review of the clinical record revealed Resident #8 was admitted to the facility on [DATE]. His diagnoses included hypertensive chronic kidney disease, obstructive and reflux uropathy, chronic kidney disease stage II, and vascular dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment. Review of the electronic record revealed Resident #8 had an order for Do Not Resuscitate Comfort Care Arrest (DNR CC- Arrest) (protocol is activated when the patient experiences cardiac or respiratory arrest), dated 12/10/21. Review of the hard chart revealed Resident #8 had an undated DNR-CC (DNR protocol is activated when the DNR order is issued) signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure residents, who required extensive staff assistance or dependent on staff for activities of daily living (ADL) care, received adequate and timely hygiene care and assistance with meals. This affected three (Resident #18, #28 and #54) of five residents reviewed for ADL. The facility identified 102 residents who required assistance for dressing, 72 residents who required assistance with eating, and all 108 residents required assistance with bathing. The facility census was 108. Finding include: 1. Medical record review for Resident #54 revealed an admission date of 08/08/12. Diagnoses included dementia, hemiplegia and hemiparesis following cerebral infarction, osteoarthritis, cognitive communication deficit, and type II diabetes mellitus (DM). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had impaired cognition and was dependent on staff for personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident who was at nutrition risk and had a unplanned significant weight loss received a timely nutritional assessment and intervention(s). This affected one (Resident #47) of seven residents reviewed for nutrition. The facility identified eight resident with unplanned significant weight loss/gain. The facility census was 108. Findings include: Review of Resident #47's medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, severe protein-calorie malnutrition, diverticulosis, hyperlipidemia, vitamin D deficiency, cerebral atherosclerosis, acute kidney failure, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired and he required extensive assistance for eating. Review of the quarterly nutrition assessment dated [DATE] revealed Resident #47 was on a regular diet with mechanical texture. His…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received medications as physician ordered. This affected one (Resident #85) of five residents reviewed for medications. The facility census was 108. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/18/22 with diagnoses including laceration of trachea, fracture to the second cervical vertebra, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was cognitively intact. Review of the hospital continuity of care form dated 08/18/22 revealed Resident #85 had an order to receive a Lovenox (anticoagulant) injection once daily at bedtime. Review of the admission orders dated 08/18/22 revealed Resident #85 had an order to receive a Lovenox injection once daily at bedtime. Review of the care plan dated 08/29/22 revealed Resident #85 was at risk for developing complications secondary to having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents on as needed anti-anxiety medications had a duration or stop date for the medication. This affected one (Resident #85) of five residents reviewed for unnecessary medications. The facility identified seven residents with orders for anti-anxiety medications. The facility census was 108. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/18/22 with diagnoses including anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was cognitively intact. Review of the physician orders dated 08/24/22 revealed Resident #85 had an order to receive Ativan as needed for anxiety. The physician order did not include a stop date. Review of the care plan dated 08/29/22 revealed Resident #85 used anti-anxiety medications related to anxiety disorder. Interventions included the following: administer anti-anxiety medications 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.