Edith Lane of Cincinnati

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected two (#42 and #77) of three residents reviewed for call lights. The facility census was 119. Findings Included: Review of the medical record for Resident #42 revealed an admission date of 11/25/2019. Diagnoses included palliative care, schizoaffective disorder, dementia, borderline personality disorder, brief psychotic disorder, type two diabetes, and adult sexual abuse. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with mil;d cognitive impairment. Resident #42 required supervision or touching assistance for eating meals. Resident #42 required partial to moderate assistance for dressing the upper body. Resident #42 required substantial maximal assistance for dressing the lower body, putting shoes on and off, personal hygiene, bathing, 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 medical record review, observation, staff interview, and facility policy review, the facility failed to notify the physician of a resident's significant weight loss. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admission date of 07/31/24. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. Resident #116 required supervision or touching assistance for meals and dressing the upper body. Resident #116 required partial to moderate assistance for personal hygiene, dressing the lower body, placing shoes on and off the feet, and oral care. Resident #116 required substantial to maximal 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 and staff interview, and review of resident lists, the facility failed to ensure residents received follow-up care for audiology services. This affected one (#10) of six residents reviewed for ancillary services. The facility census was 119. Findings include: Review of the medical record revealed Resident # 10 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder bipolar type, unspecified anxiety disorder, unspecified impulse disorder, pseudobulbar affect, and type II diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 10 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #10 had adequate hearing with no hearing aids. Review of the care plan dated 01/30/24 revealed Resident # 10 had potential for inability to understand others related to decline in cognitive status. Interventions included to refer for an audiology evaluation as needed. Review of 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, medical record review, staff interview, interview with local health clinic staff, review of hospital documentation, and policy review, the facility failed to recognize potential hazards related to residents attending community appointments unsupervised an failed to ensure a resident was properly assessed for use of a sit-to-stand lift for transfers. This affected one (#75) of one residents sampled for community appointments and one (#5) of 10 residents reviewed for accidents and hazards. The facility census was 119. Findings include: 1. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] and was discharged on 03/24/25. Diagnoses included unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD), unspecified severe protein calorie malnutrition, unspecified anxiety disorder, unspecified psychosis, mixed adjustment disorder, psychotic disorder with delusion, and alcohol dependence. Review of the most recent Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review, the facility failed to provide timely assistance for a resident who was dependent for incontinence care. This affected one (#5) of one residents reviewed for incontinence. The facility census was 119. Findings Included: Review of the medical record for Resident #5 revealed an admission date of 04/26/16. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Resident #5 required substantial assistance for meals, oral care, dressing the upper body, and personal hygiene. Resident #5 was dependent for putting on and taking off shoes, dressing the lower body, toileting, and bathing. Review of a plan of care dated 01/17/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to monitor weights on a consistent basis and failed to address and implement interventions for a resident with significant weight loss in a timely manner. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admission date of 07/31/24. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. Resident #116 required supervision or touching assistance for meals and dressing the upper body. Resident #116 required partial to moderate assistance for personal hygiene, dressing the lower body, placing shoes on…

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

Based on medical record review and staff interview, the facility failed to obtain laboratory values as ordered by the physician. This affected three (#5, #116, and #118) of 32 resident medical records reviewed. The facility census was 119. Findings Included: 1. Review of medical records for Resident #5 revealed an admission date of 04/26/16. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for a complete blood count (CBC), renal panel, and Dilantin level every February, May, August, and November. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for fasting lipid panel, liver function test, hemoglobin A1C, and prostate specific antigen (PSA) yearly that was due April. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory…

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 and staff interview, and medical record review, the facility failed to serve food in a form to to meet resident needs. This affected one (#28) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included dysphagia oropharyngeal phase, cognitive communication deficit, occlusion and stenosis of the right carotid artery, chronic diastolic heart failure, type two diabetes, atrial fibrillation, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of the physician order dated 11/04/24 revealed Resident #28 was ordered a regular diet with mechanical soft texture and thin liquids. Review of the care plan dated 04/14/25 revealed Resident #28 required monitoring of intakes, weight, skin, laboratory values, medication, diet tolerance, and to serve the diet as ordered. 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 observation, staff interview, medical record review, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions. This affected one (#67) of three residents sampled for enhanced barrier precautions. The facility census was 119. Findings Include: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic viral hepatitis C, type II diabetes, morbid obesity, cannabis and other stimulant dependence, unspecified psychoactive substance abuse, unspecified anxiety and mood disorders, paraplegia, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of a care plan dated 05/08/24 revealed Resident #67 had an indwelling urinary catheter related to a neurogenic…

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

Based on observation, resident and staff interviews and review of facility policy, the facility failed to maintain comfortable air temperatures and failed to provide a homelike environment. This affected 10 (#01, #02, #03, #04, #05, #06, #07, #08, #09, and #10) out of 123 residents that resided at the facility. The facility census was 123. Findings include: Observation of Maintenance Assistant (MA) #631 revealed he was obtaining air temperatures in resident rooms on 01/27/25 at 9:53 A.M. Further observation revealed Resident #02's room was 57.6 degrees Fahrenheit (F), Resident #06's room was 61.7 degrees F, Resident #07's room was 61.8 degrees F and the common shower room on the women's secured unit was 66.5 degrees F. Interview with MA #631 on 01/27/25 at 9:53 A.M. verified the air temperature in Resident #02's room was 57.6 degrees F, the air temperature in Resident #06's room was 61.7 degrees F, the air temperature in Resident #07's room was 61.8 degrees F, and the air temperature in the shower room on the women's secured unit was 66.5 degrees F. MA #631 confirmed the packaged…

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

Based on observation, resident interview, and staff interview, the facility failed to ensure residents had full visual privacy as required. This affected nine (#01, #02, #03, #04, #05, #06, #08, #09, and #10) out of 123 residents that resided at the facility. The facility census was 123. Findings include: Observation of the dining room on the women's secured unit on 01/27/25 at 9:53 A.M. revealed Resident #01, Resident #02, Resident #03, Resident #04, Resident #05, Resident #06, Resident #08, Resident #09, and Resident #10 had their beds in the dining room on the women's secured unit. There were not any privacy curtains or barriers between the residents' beds and the beds could be visualized by the entire room. Interview with Resident #02 on 01/27/25 at 10:00 A.M. revealed it was cold in her room and on the women's secured unit. Resident #02 reported she had to sleep in the dining room on the unit due to the air temperatures. Interview with Resident #08 on 01/27/25 at 10:10 A.M. revealed she had to sleep in the dining room for approximately one week with all the other residents…

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, review of the facility policy, and review of online guidelines per the American Heart Association (AHA), the facility failed to administer cardiopulmonary resuscitation (CPR) per the facility policy and per professional standards of care. This affected one (Resident #132) of three residents reviewed for change in condition. The facility census was 128 residents. Findings include: Review of the medical record for Resident #132 revealed an admission date of [DATE] with diagnoses including multiple sclerosis, dementia, attention-deficit hyperactivity disorder, gastro-esophageal reflux disease, metabolic encephalopathy, morbid obesity and schizophrenia. Resident #132 expired in the facility on [DATE]. Review of the care plan for Resident #132 dated [DATE] revealed the resident's code status was full code. Review of the Minimum Data Set (MDS) assessment for Resident #132 dated [DATE] revealed the resident was moderately impaired for decision making and required staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and review of the facility policy, the facility failed to implement timely care and treatment for trauma wounds. This affected one (Resident #64) of three residents reviewed for skin impairment. The facility census was 129 residents. Findings include: Review of the medical record for Resident #64 revealed an admission date of 11/12/23 with diagnoses including multiple myeloma, chronic respiratory failure, malignant neoplasm of brain, and hypertension. Review of the hospital continuity of care (COC) form for Resident #64 dated 09/09/24 revealed the resident had an order to cover the left lower leg wound with Mepilex border and change every three days and as needed for drainage. Resident #64 was to follow-up with the wound care clinic on 09/13/24. Review of the progress note for Resident #64 dated 09/09/24 at 3:55 P.M. revealed the resident was readmitted from the hospital with an open area to the left leg. Review of the wound clinic progress note for…

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

Based on review of the medical record, staff interview, and review of the facility policy, the facility failed to implement timely care and treatment for pressure ulcers. This affected one (Resident #64) of three residents reviewed for skin impairment. The facility census was 129 residents. Findings include: Review of the medical record for Resident #64 revealed an admission date of 11/12/23 with diagnoses including multiple myeloma, chronic respiratory failure, malignant neoplasm of brain, and hypertension. Review of the admission skin assessment dated for Resident #64 dated 09/09/24 revealed the resident was readmitted from the hospital with an unstageable pressure ulcer to the left lower leg. Review of the wound clinic progress note for Resident #64 dated 09/13/24 revealed the resident had an unstageable pressure ulcer to the left lower leg and orders were given to complete dressing changes daily. Review of the physician's order for Resident #64 revealed an order dated 09/17/24 revealed to cleanse the pressure ulcer to the left lower leg with normal saline, apply Medihoney 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.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was below five percent. The medication error was eight percent (%) with two errors out of 25 medication opportunities observed. This affected one (Resident #61) of three residents reviewed for medication administration. The facility census was 129 residents. Findings include: Review of the medical record for Resident #61 revealed an admission date of 06/07/24 with diagnoses including acute hepatitis C, hypertension, and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 08/19/24 revealed the resident had intact cognition and required partial assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #61 revealed orders dated 06/07/24 for vitamin D3 oral tablet 25 micrograms (mcg) once per day and Entresto 24-26 mg two times per day. Observation on 10/16/24 at 9:50 A.M. revealed Licensed Practical Nurse (LPN) #21 did not administer Entresto 24-26…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of facility Self-Reported Incidents (SRIs), review of facility investigation records, and review of the facility policy, the facility failed to ensure residents were free from abuse. This affected one (Resident #25) of three residents reviewed for abuse. The facility census was 128 residents. Findings include: Review of the medical record for Resident #25 revealed the resident an admission date of 08/02/24 with diagnoses including dementia with other behavioral disturbances, Alzheimer's disease, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 08/09/24 revealed the resident had severely impaired cognition and had physical, verbal, and other behaviors which put the resident and others at significant risk for injury. Review of the care plan for Resident #25 revised on 08/08/24 revealed the resident was verbally combative with staff, hit staff, and head-butted staff.…

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 adequate catheter care for residents with an indwelling urinary catheter. This affected one (Resident #57) of three residents reviewed for urinary catheter use. The facility census was 128 residents. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/13/24 with diagnoses including extradural and subdural abscess, hepatitis C, paraplegia, congenital malformation of the brain, psychoactive substance abuse, hypertension, depression, sepsis, chronic pain, chronic migraine without aura. Review of physician's orders for Resident #57 revealed an order dated 08/15/24 for staff to straight catheterize the resident as needed every eight hours. If the resident has not voided, reinsert indwelling catheter. There were no physician orders for foley catheter care. Review of the nurse progress note for Resident #57 dated 08/17/24 timed at 7:22 P.M. revealed the nurse changed the resident's indwelling urinary catheter 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 medical record review, review of hospital discharge record, observation, resident interviews and staff interview the facility failed to provide needed and timely therapy services to residents. This affected one (Resident #57) of three residents reviewed for therapy services. The facility census was 128 residents. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/13/24 with diagnoses including extradural and subdural abscess, hepatitis C, paraplegia, congenital malformation of the brain, psychoactive substance abuse, hypertension, depression, sepsis, chronic pain, chronic migraine without aura. Review of hospital discharge records for Resident #57 dated 08/13/24 revealed per hospital therapy notes, the resident was required to wear a thoracic-lumbar-sacral orthosis (TLSO) due to a recent thoracic spine surgery conducted while the resident was in the hospital. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated 08/20/24 revealed the…

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

Based on record review, observation, resident interview, and staff interview, the facility failed to provide an operational call light system which would allow for residents to alert staff of their individual needs. This affected one (Resident #57) of five residents reviewed for functioning call lights. The facility census was 128 residents. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/13/24 with diagnoses including extradural and subdural abscess, hepatitis C, paraplegia, congenital malformation of the brain, psychoactive substance abuse, hypertension, depression, sepsis, chronic pain, chronic migraine without aura. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated 08/20/24 revealed the resident had minimal cognitive impairment and was dependent on staff for all care. Observation on 08/27/24 at 11:45 A.M. revealed Resident #57's call light was not operational. There was no bell or alternative device for Resident #57 to use in order to summon staff assistance. Interview on 08/27/24 at 11:45 A.M. with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received therapy services as evaluated by the therapy department and ordered by the physician. This affected one resident (#900) out of three residents reviewed for therapy services. The facility census was 126. Findings include: Review of Resident #900's medical record revealed the resident admitted to the facility on [DATE]. Diagnoses including muscle weakness, malignant neoplasm of right kidney, mixed hyperlipidemia, hypertension, syncope and collapse, type two diabetes mellitus without complications and hypothyroidism. Resident #800 discharged from the facility on 05/26/24. Review of Resident #900's physician order dated 04/16/24, revealed an Occupational Therapy (OT) evaluation was completed, and an order was put in place to treat the resident up to five times in thirty days. Review of Resident #900's physician order dated 04/16/24, revealed Resident #900 was to ordered to receive Physical Therapy (PT) five times over four weeks…

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,review of the weather via website www.timeanddate.com, and facilities policy review, the facility failed to maintain a comfortable environment for 40 Residents in Building One when temperatures were below 71 degrees Fahrenheit for 15 hours. This affected all residents in Building One, (Residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#27,#28,#29,#30,#31,#32,#33,#34,#35,#36,#37,#38,#39 and #40). The total facility census was 140. Findings include: Review of facility temperature logs for Building One revealed no recorded temperatures for Building One housing 40 residents, (Residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#27,#28,#29,#30,#31,#32,#33,#34,#35,#36,#37,#38,#39 and #40) for 01/17/24 6:15 P.M. through 01/18/24 at 10:00 A.M. Review of temperature log dated 01/18/24 at 10:00 A.M. revealed in the Building One the temperature was 55.5 degrees Fahrenheit and at 11:00 A.M. the temperature was 57.5 degrees Fahrenheit.…

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

Based on observation, record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents had the right to have use of a telephone where calls could be made in privacy. This affected three residents (#30, #74, and #125) of three residents reviewed for resident rights. The facility census was 136 residents. Findings include: 1. Review of the medical record for Resident #125 revealed an admission date of 08/15/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and epilepsy. Review of the Minimum Data Set (MDS) assessment 3.0 dated 07/14/23 for Resident #125, revealed the resident was cognitively intact and required supervision with activities of daily living. (ADLs.) Observation of the first floor [NAME] Unit on 09/07/23 at 10:10 A.M., revealed there was a telephone at the nurse's station and at the reception desk. Both telephones were open to the common area for residents, staff, and visitors and did not allow for privacy with phone calls. Interviewwith Licensed…

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 employee record review and staff interview, the facility failed to provide annual evaluations to State Tested Nursing Assistants (STNA's). Additionally, the facility failed to provide the annual 12 hours of in-services to STNA's. This had the potential to affect all 121 residents residing in the facility. This had the potential to affect all 121 residents residing in the facility. The in-house facility census was 121. Findings include: 1. Review STNA #95's employee record revealed STNA #95 was hired on 10/15/19 and had no annual evaluations. Further review of STNA #95's employee file revealed it contained no documentation regarding the required annual 12 hours of in-services. Interview on 11/22/22 at approximately 2:00 P.M. with Regional Human Resources Business Partner (RHRBP) #205 verified STNA #95 did not have an annual evaluation. RHRBP #205 verified STNA #95 did not have the required annual 12 hours of in-services. 2. Review of STNA #132's employee record revealed STNA #132 was hired on 10/15/19 and had no annual evaluations. Further review of STNA #132's employee file…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy/procedure review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. In addition, the facility failed to maintain food storage in a clean, safe, and sanitary manner. This had the potential to affect all 121 residents. The facility census was 121. Findings include: On 11/14/22 at 9:35 A.M. revealed a tour of the kitchen was completed with the Dietary Director (DD) #108. During the observation the following concerns were observed and the concerns below were verified by the DD #108. a) In the refrigerator there was a stainless-steel rectangular container with cooked apples without a date or a use by date. b) In the refrigerator there was a large bowl of salad without a date or a use by date. c) In the refrigerator there were six egg omelets in plastic without a date or a use by date. d) In the refrigerator there was a smoked ham in a plastic bag without a date or a use by date. e) In the refrigerator there…

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, the facility failed to provide a safe, clean comfortable and homelike environment. This affected 45 Residents (#3, #6, #7, #10, #11, #12, #13, #22, #25, #32, #35, #37, #38, #39, #43, #45, #46, #55, #61, #63, #64, #66, #69, #73, #74, #76, #77, #78, #81, #84, #85, #88, #89, #93, #98, #100, #101, #102, #103, #108, #112, #113, #117, #121 and #325) of 121 residents reviewed for a homelike environment. The facility census was 121. Findings include 1. Observation on 11/14/22 at 11:21 A.M., revealed Resident #22's window curtains on left had brown stains that looked as it was burnt. There was a hole observed in Resident #22's room behind the door with the size of doorknob exposing plaster. 2. Observation on 11/14/22 at 11:53 A.M., revealed Resident #85's window drapes were soiled at the bottom with brown stains covering it. Resident #85's walls near bathroom were stained with coffee drippings dried up on wall. 3. Observation on 11/14/22 at 12:07 P.M., of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and resident representative interviews and policy review, the facility failed to have the quarterly care conferences with residents, the residents representative or with the interdisciplinary team. Additionally, the facility failed to review and revise residents plan of care when there was a change in the residents condition/interventions. This affected six (##13, #88, #101, #57, #97 and #117) out of 37 residents reviewed for care conferences and care planning. The facility census was 121. Findings include: 1. Medical record review revealed Resident #13 was admitted on [DATE]. Diagnoses included but not limited to schizoaffective disorder, cirrhosis of liver, mood disorder, dementia, unspecified psychosis, psoriasis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/22, revealed the resident was moderately impaired and resident required extensive assistance of one staff for bed mobility, transfers, ambulation.…

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

Based on observations, staff interviews and review of the facility policy, the facility failed to ensure hazardous chemicals were securely stored out of the reach of confused and independently mobile residents. This had the potential to affect nine (#57, #58, #21, #6, #54, #23, #40, #71 and #5) residents identified by the facility as cognitively impaired and independently mobile. The facility census is 121. Findings include Observation on 11/14/22 at 1:30 P.M. of the secured unit revealed residents ambulating in the hallways, in and out of rooms and interacting with staff. Observation on 11/14/22 at 1:38 P.M. of unlocked shower room revealed a revealed a container labeled Sani-wipes sitting on a cabinet shelf hanging on the wall. Further review of container revealed a precautionary statement alerting user that product is hazardous to humans and animals. Product causes substantial but temporary eye damage and avoid contact with skin. Additionally, the label revealed an action for first aid was to call poison control. If eye exposure rinse eye for 15 to 20 minutes. If exposure to skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review, the facility failed to ensure residents taking psychotropic medications had documentation for routine monitoring of behaviors and effectiveness of psychotropic medications. This affected five (#19, #42, #90, #6, and #117) of five residents sampled for psychotropic medications. The facility census was 121. Findings include: 1. Review of the medical record revealed Resident #19 admitted to the facility on [DATE] and had diagnoses that included but ere not limited to metabolic encephalopathy, unspecified schizoaffective disorders, type II diabetes, generalized anxiety disorder, unspecified major depressive disorder, unspecified personality disorder, and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #19 was a one-person assist and required supervision with all ADL's. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure medications were prepared properly, labeled, and expired medications were disposed of. This had the potential to affect one resident (#31) whose medications were prepared and not given, four residents (#17, #62, #24, and #106) whose insulin injection pens were not correctly labeled, and two residents (#71 and #77) whose prescribed stock medications were expired. The facility census was 121. Findings include: 1. Review of the medical record revealed Resident #31 admitted to the facility on [DATE]. Diagnoses included unspecified schizoaffective disorder, type II diabetes, borderline personality disorder, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact, had both physical and verbal behaviors, did not wander, and did not reject care. Review of the physician orders revealed Resident #31 had routine medications including amlodipine (can treat high…

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 the call system was functioning on a secured unit to allow residents to call for staff assistance. This affected three rooms (#408, #410 and #418) out of 8 rooms with two residents occupying each room reviewed for operational call lights. The facility census was 121. Findings include: Observation on 11/14/22 from 10:00 A.M., to 12:00 P.M., revealed the call light was activated inside room [ROOM NUMBER] where two residents resided. The light inside the room was active, however the light outside of the room was not signaling the light was activated. Registered Nurse (RN) #35 verified the call light findings in room [ROOM NUMBER]. Interview on 11/14/22 at 12:27 P.M., the Licensed Practical Nurse (LPN) Unit Manager #58 and RN #35 reported the residents on the 400 unit came to the nurses station when they need something. Observation on 11/15/22 from 10:29 A.M. to 11:30 A.M., revealed the call lights were activated in room [ROOM NUMBER] and 418…

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

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure privacy was provided during perineal care. This affected one (#97) of one resident reviewed for personal hygiene. The facility census was 121. Findings include: Review of the medical record for Resident #97 revealed an admission date of 06/06/22, with diagnoses including: Parkinson's disease, dementia with behaviors, gout, anxiety disorders, history of falling, hypertension and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #97, dated 10/19/22, revealed a severely impaired cognition. Resident #97 was coded as experiencing behaviors that do not fluctuate. Resident #97 required extensive assist with bed mobility, transfers, eating, and toileting. Review of the plan of care for Resident #97 dated 06/22/22 revealed resident has an activity of daily living (ADL) self care performance deficit related to Parkinson's disease and requires staff assistance for completion of ADL tasks. Interventions include assistance of one to two staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A record review revealed Resident #62 was admitted on [DATE]. Diagnoses include anxiety, hypertensive heart and kidney disease, epilepsy, diabetes, congestive heart failure, atrial fibrillation, and depression. Review of the quarterly MDS dated [DATE] revealed Resident #62 has no cognitive deficits, requires extensive assistance with toileting, transfers, bed mobility, with total dependence with personal hygiene, dressing and is incontinent of bowel and bladder. Review of health status note dated 09/29/22 revealed Resident #62 with complaints of shortness of breath and a headache, upon assessment it was noted Resident #62 was having difficulty breathing with exertion in between communication. Vitals signs as follows: blood pressure 156/62, pulse 26, oxygen saturation 94% on room air, respirations 28 and temperature 98.2 with wheezing noted in bilateral lung upon auscultation. Resident #62 was sent to hospital via stretcher and the Director of Nursing (DON) was informed. Review of health status note 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 medical record review, observation, interview, hospice staff interview, review of the hospice contract, and review of the hospice policy, the facility failed to designate a staff member for the collaboration of care and services. This affected one resident (#57) out of one reviewed for hospice services. This has the potential to affect five residents (#56, #57, #50, #97, #38) the facility identified as hospice clients. The facility census was 121. Findings include: Medical record review for Resident #57 revealed an admission date of 12/08/17. Diagnoses included anxiety disorder, covid-19, urinary tract infection, schizophrenia, hypertension. polyarthritis, major depressive disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had severely impaired cognition. Resident #57 required extensive assistance for bed mobility, transfers, eating, toilet use and bathing. Resident #57 was coded as receiving hospice services. Review of the plan of care for…

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

Based on review of personnel files, review of job description and staff interview, the facility failed to have a Licensed Social Worker (LSW) employed on a full-time basis. This had the potential to affect all 135 residents of the facility. Findings include: Review of the personnel file for Licensed Social Worker (LSW) #352 revealed the LSW was fired on 09/19/19 for not meeting the requirements of her job duties. Review of the personnel file for Qualified Social Worker (SW) #353 revealed the SW quit without notice on 10/04/19. Review of the job description for the Social Services Director revealed the general purpose was to provide for each resident's social, emotional and psychological needs and the continuing development of resident's full potential during his/her stay at the facility and to assist in the planning of his/her discharge. Interview on 10/22/19 at approximately 11:15 A.M. with the Administrator verified that there was no LSW employed at the facility since 10/04/19, and the facility's bed capacity was 199. Subsequent interview with the Administrator at 8:35 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.

Based on review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the facility failed to ensure appropriate plans of action were in place to correct any identified quality deficiencies. This had the potential affect all 135 residents residing in the facility. Findings include: Review of QAPI meeting minutes dated 11/01/17 through 04/30/18 revealed the meeting minutes covered falls, behaviors, and medications. There was no evidence of any sign in sheets for the meetings, nor documentation of any other QAPI meetings being conducted. There was no evidence of any plans of action in place to correct any identified quality deficiencies. Interview on 10/28/19 at 12:25 P.M. with the Director of Nursing (DON) confirmed the facility was unable to find any completed plans of action or evidence of any QAPI meeting since 04/30/18. The DON stated when she began working at the facility less than a month ago she was shown the binder and it was very full at that time, however she was uncertain where the documentation was.

Based on review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the facility failed to ensure quarterly QAPI meetings were being conducted. This had the potential to affect all 135 residents residing in the facility. Findings include: Review of QAPI meeting minutes dated 11/01/17 through 04/30/18 revealed the meeting minutes covered falls, behaviors, and medications. There was no evidence of any sign in sheets for the meetings, nor documentation of any other QAPI meetings being conducted. Interview on 10/28/19 at 12:25 P.M. with Director of Nursing (DON) confirmed there was no evidence the facility had sign in sheets for the meetings held between 11/01/17 through 04/30/18, nor was there any evidence of any other QAPI meetings being conducted.

Based on record review and staff interview, the facility failed to issue the Notice to Medicare Provider Non-coverage (NOMNC) form and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) forms when required. This affected five (#40, #41, #42, #239 and #240) of six residents reviewed for Beneficiary Protection Notification Review. The facility census was 135. Findings include: Review of the Beneficiary Notices revealed Resident #40 did not receive a NOMNC and SNFABN notification when services ended on 09/25/19. Resident #40 had skilled days remaining at the time the skilled services ended on 09/25/19. Further review revealed Resident #41, #42, #239 and #240 did not receive the SNFABN forms when skilled services were stopped. Resident #41, #42, #239 and #240 had skilled days remaining at the time skilled services ended and remained in the facility. Interview on 10/23/19 at 2:07 P.M. with Business Office Manager (BOM) #122 verified that the facility was not issuing NOMNC and SNFABN forms. The BOM verified Resident #40 did not receive the NOMNC and SNFABN forms when skilled…

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 policy review, the facility failed to provide notice to the resident and /or resident's representative for the reason for transfer and the resident's transfer notices to the Office of the State Long-Term Care Ombudsman. This affected seven (#11, #34, #40, #41, #42, #48 and #108) of seven residents reviewed for hospitalizations. The facility census was 135. Findings include: 1. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, acute kidney failure, congestive heart failure and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/25/19, revealed the resident had no cognitive deficits. Review of the health status note, dated 09/07/19 at 9:38 A.M., revealed Resident #42 was experiencing respiratory distress and was sent to local hospital and admitted for an urinary tract infection. 2. Record review for Resident #11 revealed the resident was admitted 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 5. Record review for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included influenza, unspecified dementia with behavioral disturbance, psychotic disorder with delusions due to known physiological condition, chronic kidney disease, bipolar disorder, and Parkinson's disease. Review of the quarterly MDS assessment, dated 09/23/19, revealed the resident had a moderate cognitive impairment. Review of the nursing progress notes, dated 08/31/19, revealed Licensed Practical Nurse (LPN) #38 documented the resident was short of breath, had increased weakness, and reduced oxygen saturation levels on room air. The nurse noted that after assessment and notification of the physician, the physical advised LPN #38 to send the resident to the emergency department of a local hospital for evaluation. Resident #108 was transported by emergency medical services to the hospital for evaluation. There was no mention in the medical record that the resident or representative was provided with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and resident and staff interview, the facility failed to ensure oxygen cautionary/safety signs were posted where oxygen was in use and failed to change oxygen tubing every week as ordered by physician. This affected five (#16, #41, #42, #45, and #124) of five residents reviewed for respiratory care. This had the potential to affect 31 residents the facility identified as having oxygen equipment maintained in his/her room. The facility census was 135. Findings include: 1. Review of Resident #41's medical record revealed an original admission date of 03/20/19. Diagnoses included congestive heart failure, hypertension and chronic obstructive pulmonary disease. Review of the physician orders for 10/2019 revealed an order for oxygen at two liters per minutes continuous. Observation on 10/21/19 at 8:30 A.M. revealed Resident #41 in his room with oxygen per a concentrator with an undated nasal cannula in use. His room did not have an oxygen cautionary sign…

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, staff interviews, review of facility policy and review of manufacturer recommendations, the facility failed to discard expired medications and failed to date opened insulin pens. The expired medications affected four residents (#2, #57, #112 and #118) and had the potential to affect all the residents that the facility identified as receiving medications and the insulin had the potential to affect nine residents the facility identified as receiving insulin by pens on the second floor of the [NAME] building. The facility census was 135. Findings include: 1. Review of Resident #112's medical record revealed an admission date of 01/16/14. Diagnoses included diabetes mellitus, hypertension, seizures, schizophrenia, anxiety, and depression. Review of the physician orders for October 2019 revealed an order for Humalog eight units three times per day and Lantus 42 units every bedtime. During medication storage observation on 10/22/19 at 2:38 P.M. of the [NAME] Building second floor medication storage room revealed a Lantus insulin pen and a Humalog…

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 that food and beverage items were stored in the resident's snack and beverage utility rooms and in the refrigerators and were labeled and dated to prevent potential cross contamination and ensure only food/beverages used were not spoiled. This had the potential to affect 36 residents located on the Lighthouse unit, and the 33 residents located on the Two [NAME] unit. The facility census was 135. Findings include: Observation of the resident's snack and beverage utility room and the refrigerators on each resident unit were observed with Assistant Dietary Manager (AMD) #173 on 10/22/19 at 4:11 P.M. and the following was observed: 1. In the Lighthouse resident snack/beverage refrigerator, there were multiple open bottles of beverages which had been partially consumed including water bottles, a Gatorade bottle, a bottle of lemonade, none of which were labeled as to who they belonged to or dated as to when they were opened or no longer to be consumed. In addition, there were three beverage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of maintenance/housekeeping work order requests, the facility failed to maintain a safe, sanitary and orderly environment for residents. This had the potential to all 36 residents located on the Lighthouse unit, a secured unit for residents with dementia. The facility further failed to provide a safe area for residents to smoke. This had the potential to affect 27 Residents (#14, #23, #25, #29, #35, #40, #43, #47, #50, #57, #59, #60, #64, #67, #70, #71, #72, #77, #81, #84, #93, #94, #98, #101, #104, #109 and #113) whom the facility identified as smokers and utilized the smoking area. The facility census was 135. Findings include: 1. Observation of the Lighthouse Unit the secured unit with the Maintenance Assistant (MA) #116 on 10/23/19 beginning at 11:00 A.M. revealed in the activity/dining room there were five chairs being used by residents which had ripped arm rests and the top layer of the vinyl seat peeling off exposing the padding below. In the television…

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, resident and staff interview, and review of facility policy, the facility failed to ensure resident's were provided with water pitchers in their rooms in accordance with their needs and preferences. This affected three (#31, #103 and #127) of 35 residents residing on the Lighthouse unit. The facility census was 135. Findings include: 1. Review of Resident #127's current comprehensive plan of care, with a target date of 11/06/19, revealed a plan of care to address the resident's poor food and fluid intake related to failure to thrive. The goal was for the resident to be free of symptoms of dehydration and maintain moist mucous membranes, and to consuming 1800 cubic centimeters (cc) of water/fluids every 24 hours. Interventions included to encouraging the residents to drink fluids of choice and ensure the resident had access to fluids as ordered whenever possible. The facility assessed the resident on 10/01/19 as having fair to good memory and recall. Interview and observation with Resident #127 on 10/22/19 at 9:23 A.M. reported that he did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and physician and staff interview, the facility failed to notify the doctor of a change in condition in a resident's health status. This affected one (Resident #42) of three residents reviewed for pressure ulcers. The facility census was 135. Findings include: Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, congestive heart failure, antibiotic resistance, sepsis, schizoaffective disorder, morbid obesity and cellulitis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/25/19, revealed Resident #42 had no cognitive deficits and was always incontinent of bowel and bladder. Review of the care plan, dated 05/05/17, revealed Resident #42 was at risk for pressure ulcer development related to disease process, decreased mobility and moisture exposure. An observation on 10/21/19 at 2:06 P.M. of Licensed Practical Nurse (LPN) #17 removing a dressing from Resident #42's hip/abdomen area…

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

Based on record review, review of facility's Self-Reported Incidents, resident and staff interviews and review of facility policy, the facility failed to implement their policy when they did not report immediately to the administration Resident #117's allegation of misappropriation. This affected one (#117) of four residents reviewed for abuse. The facility census was 135. Findings include: Review of Resident #117's medical record revealed an admission date of 12/04/17. Diagnoses included anxiety, depressive disorder, stroke and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident had intact cognition. Interview on 10/21/19 at 3:15 P.M. with Resident #117 reported someone had taken forty dollars from her sometime last week. She stated she had told Unit Manager Licensed Practical Nurse (LPN) #142 and her family. Resident #117 pulled a clear plastic jar from her bed linen that had some dollar bills inside and stated that was where she last saw the money. She was unable to provide the day she reported to staff of her missing money.…

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 resident and staff interviews, observation, record review, review of facility's Self-Reported Incidents and review of facility policy, the facility failed to report an allegation of misappropriation to administration immediately. This affected one (Resident #117) of four residents reviewed for abuse. The facility census was 135. Findings include: Review of Resident #117's medical record revealed an admission date of 12/04/17. Diagnoses included anxiety, depressive disorder, stroke and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident had intact cognition. Interview on 10/21/19 at 3:15 P.M. with Resident #117 reported someone had taken forty dollars from her sometime last week. She stated she had told Unit Manager Licensed Practical Nurse (LPN) #142 and her family. Resident #117 pulled a clear plastic jar from her bed linen that had some dollar bills inside and stated that was where she last saw the money. She was unable to provide the day she reported to staff of her missing money. Observation on 10/23/19 at 11:43 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 record review, and resident and staff interview, the facility failed to complete Minimum Data Set (MDS) assessments which accurately reflected each resident's status in regarding to falls, incontinence and pain medication regimen. This affected two (#46 and #127) of 28 residents who were reviewed for accurate MDS assessments. The facility census was 135. Findings include: 1. Record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of one rib unspecified side, encounter for fracture with routine healing 08/27/19. Review of the nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #54 on 08/26/19. LPN #54 documented the resident was heard crying out for help. The resident was across from the nursing station in the dining room laying on the floor on his right side. The resident's pain was rated at a ten on a scale of one (no pain) to 10 (most excruciating pain). LPN #54 noted the resident's grasp could not be assessed due…

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 record review, the facility failed to implement comprehensive person-centered care plans. This affected one (#80) of 26 residents reviewed for care plans. The facility census was 135. Findings include: Review of the medical record for Resident #80 revealed an admission date of 09/02/08. Diagnoses included muscle weakness, polyneuropathy, arthropathy, dementia, congestive heart failure, peripheral vascular disease and dementia. Review of the physician orders, dated 11/09/17, revealed the resident was to have anti-roll backs to his wheelchair for safety with self-transfer. Review of the resident's care plan, last revised on 02/11/19, revealed the resident had an actual fall with no injury. Interventions included anti-roll backs to his wheelchair. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/03/19, revealed the resident had severely impaired cognition and had no behaviors and did not reject care. Observation of Resident #80 on 10/22/19 at 3:10 P.M. revealed the resident was propelling himself in the main hallway 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interview, the facility failed to provide professional standards of care for wound care. This affected one (Resident #42) of three residents reviewed for wound care. The facility census was 135. Findings include: Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, gastric ulcer, diabetes mellitus, sepsis, morbid obesity and cellulitis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/25/19, revealed Resident #42 had no cognitive deficits, required extensive assistance to total dependence on staff for activities of daily living (ADLs) and was always incontinent of bowel and bladder. An observation on 10/21/19 at 2:06 P.M. of Licensed Practical Nurse (LPN) #17 removing a dressing from Resident #42's hip/abdomen area revealed the dressing was wet with a urine odor and soiled with a brown substance. An interview on 10/21/19 at 2:26 P.M. with LPN #17 verified that 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, physician and staff interviews, and record review the facility failed to timely assess a pressure wound. This affected one (#110) of 28 residents reviewed for orders in the initial screening process. The facility census was 135. Findings include: Review of Resident #110's medical record revealed an admission date of 08/22/14 with diagnoses including heart failure, chronic kidney disease, chronic obstructive pulmonary disease, schizophrenia, dementia, diabetes mellitus and peripheral vascular disease. Review of the annual Minimum Data Set (MDS) assessment, dated 09/11/19, revealed the resident had cognitive impairments, no behaviors, and was totally dependence or one to two staff for activities of daily living. The MDS also indicated the resident was at risk for skin breakdown but did not have any. Review of physician orders for October 2019 revealed an order dated 05/16/19 to cleanse the sacrum with normal saline, pat dry, apply calcium alginate with silver (treated material for infected wounds) to wound bed, cover with dry dressing every night shift and as…

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

Based on observation, record review and resident and staff interviews, the facility failed to provide ongoing podiatry care for residents. This affected one (#117) of one resident reviewed for foot care. The facility census was 135. Findings include: Review of Resident #117's medical record revealed an admission date of 12/04/17 with diagnoses including diabetes mellitus, neuropathy, anxiety, depressive disorder, stroke and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident had intact cognition and was totally dependent on two staff for transfers, toileting, hygiene, extensive assist of one to dress, and set up for meals. Review of the care plan, dated 12/05/17, revealed there was a problem of diabetes mellitus with interventions to wash her feet daily with soap and water, dry thoroughly, and may use powder or lotion. Another intervention was to refer to podiatrist for foot care needs. Review of the podiatry note, dated 04/29/19, revealed the resident was to be seen in two to three months for at risk foot care. There was no…

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

Based on observation, record review and staff interview, the facility failed to administer resident's medications with a medication error rate less than five percent. There were two medication errors out of 30 opportunities. The faciliy had a 6.6 percent medication error rate This affected two (#17 and #126) of 10 residents observed for medication administration. The in-house facility census was 135. Findings include: 1. Review of Resident #17's physician orders revealed Depakote (anticonvulsant) 125 mg, seven capsules was to be administered at 9:00 A.M. along with Med Pass 120 milliliters. Observation on 10/23/19 at 9:18 A.M. of Resident #17 receiving medications by Licensed Practical Nurse (LPN) #45 revealed he received seven capsules of Depakote 125 milligrams (mg.). There was no Med Pass administered to the resident. Interview on 10/23/19 at 9:30 A.M. with LPN #45 verified she did not administer Med Pass to Resident #17. LPN #45 reported the Med Pass was not available. 2. Review of Resident #126's physician orders revealed Renvela (phosphate binder) 800 mg. was to be given 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 observation, staff interview, and facility policy review, the facility failed to ensure infection control was maintained during medication administration. This affected two residents (#17 and #101) of ten observed during medication administration. The facility census was 135. Findings include: Observation on 10/23/19 at 9:11 A. M. of Licensed Practical Nurse (LPN) #45 revealed the nurse popped out a Clonazepam (controlled mediation) tablet from a blister card directly into her bare hands before placing it into a medication cup. She then opened individual packs of four other medications, placing three of them into the medication cup. After using a pill crusher she poured the crushed medications onto a blob of pudding and using her bare hands to open capsules, she sprinkled the fourth medication onto the pudding. She then spooned the medications into Resident #101's mouth. The LPN did not perform any hand hygiene and then returned to the cart and began to type on the laptop. LPN #45 then removed medications for Resident #17 from the cart and still using bare hands opened…

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.