Garden Park Health Care Center

Based on medical record review and staff interview, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASARR) for newly admitted residents. This affected one (Resident #11) of two residents reviewed for PASARR completion. The facility census was 48 residents.Findings include:Review of the medical record for Resident #11 revealed an admission date of 02/12/25 with diagnoses including radiculopathy, schizoaffective disorder, bipolar disorder, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 05/21/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs).Review of the PASARR for Resident dated 01/17/25 revealed the resident's diagnosis of schizoaffective disorder was not included on the PASARR.Interview on 08/06/25 at 8:18 A.M with the Administrator verified Resident #11's diagnosis of schizoaffective disorder was not listed or marked on the PASARR. Interview on 08/06/25 at 9:47 A.M. with Social Services Designee (SSD) #259…

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

Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop a care plan for a hand contractures. This affected one (Resident #31) of 14 residents reviewed for care plans. The facility census was 48 residents.Findings include: Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia.Review of the care plan for Resident #31 initiated 04/07/25 revealed it did not include a care plan for hand contractures.Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/14/25 revealed the resident had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Review of the MDS assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and had no impairment of the upper extremity including…

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

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to update care plans for residents who smoked cigarettes. This affected two (Residents #21 and #18) of four residents reviewed for smoking. The facility census was 48 residents. Findings include: 1.Review of medical record for Resident #21 revealed an admission date of 10/27/24 with diagnoses including multiple sclerosis, subdural hematoma, anxiety disorder, anti-social disorder, and spondylosis. Review of Minimum Data Set (MDS) assessment for Resident #21 dated 10/27/24 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of the smoking assessment for Resident #21 dated 10/27/24 revealed there was a box checked indicating the resident was to be supervised during smoking times. The assessment was unscored and did not indicate if the resident was an independent or supervised smoker. Review of the care plan for Resident #21 dated 11/26/24 revealed the resident was to be supervised during smoking…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide appropriate hand and nail hygiene for dependent residents. This affected one (Resident #15) of four residents reviewed for hand and nail care. The facility census was 48 residents.Findings include: Review of medical record for Resident #15 revealed an admission date of 12/28/23 with diagnoses including included cerebral infarction, diabetes, hypertension, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 02/13/25 revealed the resident had moderately impaired cognition and required staff assistance with bathing and personal hygiene. Observation on 08/06/25 at 8:44 A.M. of Resident #15 revealed the resident communicated via an iPad but had difficulty using the device because his fingernails were too long. The resident's nails also had debris underneath them. Interview on 08/06/25 at 8:47 A.M. with Resident #25 confirmed his nails were too long and staff had not offered to cut them, and the length of the nails made it difficult…

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

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide treatment for a resident contractures. This affected one (Resident #31) of two residents reviewed for limited range of motion and contractures. The facility census was 48 residents. Findings include:Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia.Review of the care plan for Resident #31 initiated 04/07/25 revealed it did not include a care plan for hand contractures.Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/14/25 revealed the resident had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Review of the MDS assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure resident fall prevention interventions were in place as ordered by the physician and per the resident care plan. This affected one (Resident #31) of four residents reviewed for falls. The facility census was 48.Findings include: Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia. Review of the fall risk assessment for Resident #31 dated 04/10/25 revealed the resident had one to two falls in the past three months and was at risk for falls. Review of the fall care plan for Resident #31 dated 06/04/25 revealed the resident had a potential for injuries and falls related to a balance deficit and a history of falls. The intervention of adding a fall mat to the right side of the bed was added to the care plan on 07/16/25. 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 and staff interview, the facility failed to ensure insulin pens were properly labeled and dated upon opening. This affected three (Residents #4, #38, #51) and had the potential to affect 11 facility-identified residents with orders for insulin. The facility census was 48 residents.Findings include: Observation on [DATE] at 4:16 P.M of medication cart #3 revealed it contained an unlabeled insulin pen with as an open date of [DATE]. Interview on [DATE] at 4:17 P.M with Assistant Director of Nursing (ADON) #235 confirmed there was an unlabeled insulin pen with an open date of [DATE] in medication cart #3. Observation on [DATE] at 4:25 P.M of medication cart #2 revealed it contained an open Lantus insulin pen for Resident #4 without an open date, an open Humalog insulin pen for Resident #51 with an open date of [DATE], a Lantus insulin pen for Resident #38 without an open date. Interview on [DATE] at 4:30 P.M with ADON #235 confirmed medication cart #2 contained Resident #4's open and undated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, the facility failed to maintain a clean and safe environment. This affected 36 residents (#01, #02, #03, #04, #05, #06, #078#08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, and #37). The facility census was 45. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses of thoracic spinal fracture with paraplegia, protein-calorie malnutrition and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #24 had no cognitive impairment. Observation during the initial tour on 01/30/25 from 5:30 P.M. to 6:15 P.M., revealed the following: 1) Resident #24's room had dirty linen spread all over the floor; the walls had large areas that needed patched, sanded and painted; the floor tile in the area in front of the closet was stained/dirty with a dark,…

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

Based on observation and staff interview, the facility failed to ensure the facility's dishwasher was maintained in a manner to prevent foodborne illness. This affected 46 residents out of 46 residents that resided at the facility as the facility identified all residents received food from the kitchen. The facility census was 46. Findings include: Observation of the facility's kitchen on 01/08/25 at 12:17 P.M., revealed the facility's dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. Dietary Manager (DM) #502 was observed testing the chemical in the dishwasher and the dishwasher tested at zero parts per million (ppm). Interview with Dietary Manager (DM) #502 on 01/08/25 at 12:17 P.M., verified the dishwasher was 120 degrees Fahrenheit for the wash and rinse. DM #502 confirmed the dishwasher was a low temperature dishwasher and required chemical to sanitize dishes. DM #502 verified the dishwasher was running at zero ppm for chemical sanitizer This deficiency represents non-compliance investigated under Complaint Number OH00161042.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed notify the state mental health authority with a significant change Pre-admission Screening And Resident Review (PASARR) for a resident with a change in their mental health condition. This affected two (#19 and #46) of three residents reviewed for significant change PASARR. The facility census was 46. Findings include: 1. Review of Resident #19's medical record revealed Resident #19 admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's PASARR dated 09/13/23, revealed Resident #19 had no diagnoses of mental disorders. Resident #19 had a diagnosis of opioid dependence. Resident #19 did not have indications of serious mental illness. Review of Resident #19's psychiatric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to develop care plans to address residents' dental needs, medical diagnoses and use of a prosthetic limb. This affected two (#28 and #19) of three residents reviewed for care planning. The facility census was 46. Findings include: 1) Review of Resident #28's medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included necrotizing fasciitis, other complications of amputation stump, chronic viral hepatitis c, carpal tunnel syndrome bilateral upper limbs, type two diabetes mellitus with other specified complication, insomnia unspecified atrial fibrillation, chronic idiopathic constipation, and opioid dependence. Review of Resident #28's care plan from 10/14/24 to 01/08/25, revealed Resident #28 did not have a care plan to address his dental needs. Review of Resident 28's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and had no natural teeth or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to ensure a resident's issues concerning a prosthetic limb were addressed in a timely manner. This affected one (#19) of two residents in the facility that had prosthesis. The facility census was 46. Findings include: Review of Resident #19's medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's progress note dated 04/25/24, revealed a representative from the prosthetic company delivered Resident #19's prosthesis with adjustments made on that date. Review of Resident #19's physical therapy (PT) note dated 05/10/24, revealed Resident #19 was educated on the usage of the left prosthesis, and he was instructed to call the…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to report an allegation of misappropriation of resident funds to the Ohio Department of Health (ODH.) This affected one (Resident #33) of three residents reviewed for misappropriation. The facility census was 47 residents. Findings include: Review of the medical record for Resident #33 revealed an admission date of 01/26/24 with diagnoses including chronic obstructive pulmonary disease (COPD), traumatic compartment syndrome of left lower extremity, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #33 dated 07/06/24 revealed the resident had intact cognition and required supervision with activities of daily living (ADLs.) Review of the progress note for Resident #33 dated 09/01/24 timed at 4:03 P.M. per Licensed Practical Nurse (LPN) #20 revealed Resident #33 reported he had two hundred dollars in his room, and someone had stolen it. LPN #20 documented Resident #33's allegation of misappropriation of money would be reported to…

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

Based on medical record review, observation, interview, review of manufacturer's guidelines, and review of the facility policy, the facility failed to ensure medication error rates below five percent (%). This affected three (Residents #21, #26, and #27) of three reviewed for medication administration. The medication error rate was 11.1 % based on 36 medication opportunities and four observed errors. The facility census was 47 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 12/20/22 diagnoses including bipolar disorder, congestive heart failure (CHF), and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 07/09/24 revealed the resident had moderate cognitive impairment and required setup with activities of daily living (ADLs.) Review of the physician's orders for Resident #21 revealed an order dated 08/09/24 for Lantus insulin inject 10 units subcutaneously two times a day for diabetes management and an order dated 09/06/24 for loratadine 10 milligrams (mg) one tablet by mouth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents This affected all 46 residents who resided in the facility. The facility census was 46. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute cerebrovascular insufficiency, peripheral vascular disease, obesity, diabetes mellitus, major depressive disorder, essential primary hypertension, and atopic neurodermatitis. The record Revealed #27 had moderately impaired cognition. Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, epilepsy, essential primary hypertension, depression, insomnia, and pneumonia. The record revealed Resident #25 was cognitively intact. Review of the medical record for Resident #24 revealed the resident was…

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

Based on observations, staff interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all 46 residents who resided in the facility. Findings include: Observation of the kitchen on 07/24/24 at 11:30 A.M. with Dietary Manager (DM) #110, revealed the trash cans located in the kitchen had a build-up of food debris and splatter running down the sides of the container and did not contain a lid. The wall tiles located along the length of the three-compartment sink and extending up the walls contained an unknown black substance which appeared to be consistent with mold. Interview with DM #110 at the same time confirmed the findings in the kitchen. Observation of the tray service line on 07/24/24 at 11:55 A.M., revealed Dietary [NAME] (DC) #109 began the tray line by taking the food temperatures. DC #109 took the food thermometer and placed it directly into the broccoli that measured 270 degrees Fahrenheit (F), then placed the thermometer into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of local Health Department records, and review of facility policy, the facility failed to maintain equipment in safe operating condition. This affected two (#24 and #27) of the five residents reviewed for beds /equipment. The facility also failed to ensure the dishwasher was maintained in working order. This had the potential to affect all 46 residents who resided in the facility. Findings include: 1) Review of the medical record for Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis, asthma, obstructive sleep apnea, bipolar disorder, amnesia, anemia, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 was cognitively intact, was independent with bed mobility and required supervision with transfers. Interview with Resident #24 on 07/23/24 at 12:08 P.M., 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 observation and staff interview, the facility failed to ensure there were secured handrails throughout the hallway on the 200 unit. This had the potential to affect 15 (#22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #25, and #36) independently mobile residents residing on the 200-unit. The facility census was 46. Findings include: Observation of the 200-hall during the initial tour on 07/23/24 at 10:46 A.M. with the Administrator, revealed there were no handrails affixed to the walls in the unit. Interview with the Administrator on 07/23/24 at 10:48 A.M., verified there were no handrails affixed to the walls in the 200-hallway. The Administrator stated they have been remodeling the unit and he wold have to order them. This deficiency represents non-compliance investigated under Master Complaint Number OH00156054, OH00155202, and OH00155184.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a medication regimen review was completed as required by a licensed pharmacist. This affected four (#16, #17, #29, and #44) out of four residents reviewed for medication review. The facility census was 51. Findings include: 1. Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified injury of head, subsequent encounter, unspecified psychosis not due to a substance or known physiological condition, dementia in other diseases classified elsewhere with behavioral disturbance, other asthma, opioid use, unspecified with unspecified opioid-induced disorder, cocaine use, unspecified with other cocaine-induced disorder, and nicotine dependence, unspecified with withdrawal. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/30/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to have properly working call lights in all resident rooms. This affected four (#11, #20, #24, and #31) out of 11 residents residing on the unit. The facility census was 51. Findings include: A chart review revealed Resident #11 was admitted on [DATE] with diagnosis including paraplegia, diabetes, anemia, schizophrenia, altered mental status, adult failure to thrive, and hypertension. Review of the Quarterly MDS dated [DATE] revealed Resident #11 has severe cognitive deficits, requires limited to extensive assistance with activities of daily living, and is occasionally incontinent of bladder, and always continent of bowel. A chart review revealed Resident #20 was admitted on [DATE] with diagnosis including coronary artery disease, fall history, hyperglycemia, hypertension, dementia, peripheral vascular disease, benign prostatic hyperplasia, depression, and heart failure. Review of the Quarterly MDS 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 review of personnel funds documentation, staff interview and policy review, the facility failed to ensure resident fund authorization forms contained an authorized signature. This affected one (#19) out of five resident accounts reviewed. The facility census was 51. Findings include: Review of authorized representative form titled, Resident Fund Management Services, undated, for Resident #19 revealed there was no signature on the authorized representative form. Interview on 09/13/22 at 1:58 P.M. with the facility business office manager (BOM) #450 confirmed Resident #19's form did not contain an authorized signature for the facility to manage the residents funds. Review of the facility policy titled, Deposit Resident Funds, dated April 2017, revealed, Resident personal funds that are held and managed by the facility will be safeguarded.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure forms indicating advance directives were accurately completed. This affected two (#13 and #47) out of three residents reviewed for advance directives. The facility census was 51. Findings include: 1. Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, unspecified dementia with behavioral disturbance, vitamin d deficiency, muscle weakness, and other abnormalities of gait and mobility. Review of the signed Do Not Resuscitate (DNR) Comfort Care form dated 05/24/22 revealed the box for DNR Comfort Care (CC) was checked. Review of the current physician orders revealed an order dated 05/26/22 for DNRCC Arrest. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 06/06/22, revealed Resident #13 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of three out 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 medical record review, observations, resident and staff interviews and policy review, the facility failed to provide a safe, clean, and homelike environment for residents. This affected three (#05, #08 and #23) out of three residents reviewed. The facility census was 51. Findings include: 1. Record review for Resident #05 revealed he was admitted to the facility on [DATE]. His diagnosis included paranoid schizophrenia, history of Coronavirus Disease 2019 (COVID-19), hyperlipemia, vascular dementia, psychotic disturbance, constipation, epileptic seizures, and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] for Resident #05 revealed he had intact cognition. Further review of the MDS assessment revealed Resident #05 was independent and required no assistance from staff with bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and eating. Interview on 09/06/22 11:25 A.M. with Resident #05 revealed he had a concern with the gazebo outside 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 medical record review and staff interview, the facility failed to ensure a significant change assessment was completed following discharge from hospice services. This affected one (#47) resident out of three residents reviewed for hospice services. The facility census was 51. Findings include: Review of the medical record for Resident #47 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, unspecified acquired deformity of left hand, anorexia nervosa, bulimia nervosa, other specified anxiety disorders, disorganized schizophrenia, vitamin d deficiency, chronic viral hepatitis c, and personality disorder. Review of the discontinued physician orders revealed an order dated 04/14/21 for admission to Hospice for Resident #47, which was discontinued on 03/19/22. Review of the plan of care, initiated 04/27/21 and resolved 03/18/22, revealed Resident #47 had a decline in condition and received hospice services. Interventions included allow resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed as required following admission to the facility. This affected one resident (#44) out of three residents reviewed for PASARR. The facility census was 51. Findings include: Review of the medical record for Resident #44 revealed he was admitted to the facility on [DATE]. Diagnoses included malignant neuroleptic syndrome, unspecified severe protein-calorie malnutrition, adult failure to thrive, subsequent encounter for suicide attempt, muscle wasting and atrophy, paroxysmal tachycardia, dietary folate deficiency anemia, catatonic schizophrenia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, major depressive disorder, and autistic disorder. Review of the Hospital Exemption from Preadmission Screening Notification, dated 07/08/21 revealed Resident #44 was admitted to the facility from the hospital. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to develop appropriate care plans based on resident needs. This affected three (#25, #16 and #44) out of three residents reviewed for care plans. The facility census was 51. Findings include: 1. Review of the medical record for Resident #44 revealed he was admitted to the facility on [DATE]. Diagnoses included malignant neuroleptic syndrome, unspecified severe protein-calorie malnutrition, adult failure to thrive, suicide attempt, subsequent encounter, muscle wasting and atrophy, paroxysmal tachycardia, dietary folate deficiency anemia, catatonic schizophrenia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, major depressive disorder, and autistic disorder. Review of the nursing progress note dated 08/06/21 revealed Resident #44 contacted a suicide hotline using a tablet. The note indicated the police called and notified the Assistant Director of Nursing (ADON). Resident #44 was placed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to provide adequate supervision while residents were smoking. This affected three (#16, #23, and #25) out of three residents reviewed for smoking. The facility census was 51. Findings include 1. Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified injury of head, subsequent encounter, unspecified psychosis not due to a substance or known physiological condition, dementia in other diseases classified elsewhere with behavioral disturbance, other asthma, opioid use, unspecified with unspecified opioid-induced disorder, cocaine use, unspecified with other cocaine-induced disorder, and nicotine dependence, unspecified with withdrawal. Review of the plan of care, dated 04/01/22, revealed the resident had the potential for injury related to smoking. Interventions included advise resident to wear smoking apron while smoking if indicated, complete…

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

Based on medical record review, staff interview review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary psychotropic medications when the facility failed to monitor a residents laboratory (lab) work in response to the use of a psychotropic medication. This affected one (#25) out of five residents reviewed for unnecessary medications. Facility census was 51. Findings include Record review for Resident #17 revealed an admission date of 05/10/21. His diagnosis included, sleep apnea, diabetes mellitus 2, hypoxemia, enchephalopathy, anxiety disorder, dementia, mood disturbance, paranoid schizophrenia, seborrheic dermatitis, dysphasia, major depressive disorder, and gastro-esophageal reflux disease. Review of the quarterly MDS assessment, dated 07/14/22, revealed Resident #17 was cognitively impaired. Further review of the MDS assessment revealed Resident #17 required limited assistance from staff with bed mobility. However, Resident #17 required extensive assistance from staff with transfers, personal hygiene, and toilet use. He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and policy review, the facility failed to maintain an effective pest control program regarding the presence of gnats in a resident's room. This affected one (#23) out of one resident reviewed for effective pest control. The facility census was 51. Findings include: Record review for Resident #23 revealed was admitted to the facility on [DATE]. His diagnosis included cerebral infarction, chronic obstructive pulmonary disease, history of COVID-19, dysphasia, insomnia, hyperlipidemia, diabetes mellitus 2, major depressive disorder, suicidal ideation, schizophrenia, bipolar disorder, and essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #23 was mildly cognitively impaired. Further review of the MDS assessment revealed he was totally dependent on staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #23 required supervision from staff with eating. Interview on…

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

Based on observation and staff interview, the facility failed to ensure proper disposal of smoking materials. This had to potential to affect all 56 residents residing in the facility . Findings include: Observation on 12/26/19 between 1:15 P.M. and 4:45 P.M. revealed in the large smoking area by kitchen cigarette butts were discarded in bushes next to smoking patio and on the ground next to the smoking area. Cigarette butts were too numerous to count. There were also noted were multiple signs revealing, do not throw cigarette butts on the ground. Observation on 12/26/19 between 1:15 P.M. and 4:45 P.M. revealed cigarette butts discarded on the ground outside first floor exit by food warmers, employee smoking area, and also noted were cigarette butts and ashes in the trash can. Interview with Maintenance Director (MD) #2 at time of the observations above confirmed the findings.

Based on review of Resident Council Minutes, resident and staff interviews, the facility failed to inform and explain the resident's rights at monthly resident council meetings. This had the potential to affect 14 Residents (#1, #11, #13, #14, #18, #30, #38, #40, #44, #45, #46, #54, #55, and #56) who attend Resident Council Meetings. The facility census was 56. Findings include: Review of the Resident Council minutes from 08/19 through 12/19 revealed no evidence any resident rights were discussed at the Resident Council Meetings. Interview on 12/27/19 at 3:30 P.M. with Residents #1, #11, #13, and #18 who regularly attend the monthly resident council meetings revealed they did not recall ever being informed or anyone explaining to them about their rights at the monthly meetings. Interview on 12/27/19 at 3:40 P.M. with the Activity Director #137 confirmed she had not informed or explained any of the resident rights at the monthly resident council meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed properly document resident requested Advanced Directives. This had the potential to affect one resident (#25) of 24 reviewed for advanced directives. The facility census was 56. Findings include: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia with chronic pain, liver cell carcinoma (cancer), cirrhosis of liver, and osteoarthritis. Review of physician orders revealed Resident #25 was admitted to hospice services on 11/16/19 for diagnosis of liver cancer. Review of the Electronic Health Record (EHR) revealed a physician order dated 11/20/19 for Resident #25 to be a Do Not Resuscitate Comfort Care (DNR CC) for Advanced Directives. Review of Resident #25 Hard Medical Chart revealed, on the outer binder of the medical record the resident was noted to be a full code status. Inside the medical record revealed the first form was undated, titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, the facility failed to provide privacy for residents. This affected three residents (#25, #53, and #43) of 24 reviewed for privacy. The facility census was 56. Findings include: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including; dementia with chronic pain, liver cell carcinoma (cancer), cirrhosis of liver and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired with no noted behaviors. Observation and interview on 12/26/19 at 10:59 A.M. Resident #25 revealed the resident was in a room shared with another resident, however there was no noted privacy curtain. Resident #25 revealed he would like to have privacy, however he did not ever remember a time when they had a curtain in the room. Interview on 12/27/19 at 6:18 P.M. with Corporate Nurse (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and review of facility policy, the facility failed to maintain a clean and homelike environment. This affected four Resident's rooms (#16, #18, #20, and #210) of 24 observed. The facility census was 56. Findings include: 1. Observation on 12/27/19 at 5:48 P.M. of room [ROOM NUMBER] revealed the resident's wall paper was noted pulled back from the wall exposing large sections of green paint underneath, with thick blue tape noted to be attached in a manor to hold up the wall paper. 2. Observation and interview on 12/27/19 5:50 P.M. of room [ROOM NUMBER] revealed Resident 53's curtain was held up with screws, no curtain rod, and one of the sections had come loose and was left half hanging. Interview with the resident revealed it had been like that for a while and they were supposed to re-hang the curtain, however had not done so. 3. Observation and interview on 12/26/19 at 11:03 A.M. with Resident #25 residing in room [ROOM NUMBER] revealed the light above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to complete Significant Change Minimum Data Set (MDS) assessments for residents following a qualifying status. This affected two Residents (#3 and #25) of 15 residents reviewed for significant changes. The facility census was 56. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including cellulitis, hypertension, cerebral infarction, and epilepsy. Further review of the medical record revealed Resident #3 was transferred to the local hospital on [DATE] due to respiratory failure, hypoxia, septic wound and cellulitis. Resident #3 was readmitted to the facility on [DATE] at 6:15 P.M. from the local hospital with bilateral above the knee amputation. Review of the Discharge Return Anticipated MDS dated [DATE] revealed Resident #3 required only supervision assistance with bed mobility and transfer, limited assistance with dressing, and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to transmit the thirty day and quarterly Minimum Data Set (MDS) assessments for one Resident (#1) of 24 residents reviewed. The facility census was 56. Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/02/19 with diagnoses including type two diabetes mellitus and cerebrovascular infarction (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #1's cognition was intact. Review of the clinical MDS tracking revealed the 30 day MDS dated [DATE] and the quarterly MDS dated [DATE] showed incomplete and had not been transmitted. Interview on 12/28/19 at 3:30 P.M. with the Assistant Director of Nursing (ADON) #104 confirmed the 30 day and quarterly MDS assessments for Resident #1 had not been transmitted within the required seven days.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interviews, the facility failed to complete Minimum Data Set (MDS) assessments accurately. This affected four Residents ( #50, #53, #1 and #49) of 24 residents reviewed for accuracy of assessments. The facility census was 56. Findings include: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, heart disease, hemiplegia and hemiparesis affecting the right side, benign prostatic hyperplasia, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 was severely cognitively impaired, and had an indwelling catheter. Observation and interview on 12/27/19 at 11:44 A.M. with Resident #50 revealed the resident was noted with no indwelling catheter. Resident #50 stated he had a catheter in the past, however it had been gone for a long time. Interview on 12/28/19 at 11:41 A.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #50 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely complete a Preadmission Screening and Resident Review (PASARR) Level 1 pre-screening for a newly admitted resident. This affected one Resident (#58) of one resident reviewed for PASARR screenings. The facility census was 56. Findings include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, schizoaffective disorder, hemiplegia affecting non-dominant side, and wheelchair dependence. Further review of the medical record revealed no evidence a PASARR screening had been completed. Review of the admission Minimum Data Set (MDS) assessment for dated 10/17/19 revealed Resident #58 was moderately cognitively impaired, with disorganized thinking behaviors noted. Review of Section E-Behaviors revealed the resident had noted delusions, behavior symptoms not directed towards others however disrupts care or living environment of others, and had rejection 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 medical record review, observation, staff interview, resident interview, interview with dental services consultant, resident guardian interview, and review of the facility policy, the facility failed to follow up on recommendations for dentures for two residents (#25 and #2) of four reviewed for Dental Services. The facility census was 56. Findings include: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, venous insufficiency, chronic pain, and liver cell carcinoma (cancer). Review of local Dental Services note dated 08/10/19 revealed Resident #25 was seen by dental services with recommendations for dentures. It was noted the resident was edentulous and wanted dentures. The plan was for impressions to be made on the next visit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired with no noted behaviors. Review of Section L-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to coordinate care and services for a resident receiving hospice services. This affected one Resident (#25) of one reviewed for hospice services. The facility census was 56. Finding include: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia with chronic pain, liver cell carcinoma (cancer), and cirrhosis of the liver. Review of physician orders revealed Resident #25 was admitted to hospice services on 11/16/19 for the diagnosis of liver cancer. Review of the Hospice documentation book and Resident #25's medical record revealed no documentation for hospice services being provided to the resident, and/or no coordination of care between the facility and hospice center. Interview on 12/28/19 at 11:00 A.M. with the Assistant Director of Nursing (ADON) #104 confirmed the facility records contained no information for hospice services and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interviews, the facility failed to provide appropriate infection control measures while providing resident wound care. This affected one Resident (#25) of two reviewed for skin conditions. The facility census was 56. Findings include: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and liver cell carcinoma (cancer). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired with no noted behaviors. Review of Section M-Skin Conditions revealed the resident was at risk for pressure with no noted pressure, however the resident was noted with open lesion other than ulcers. Review of Resident #25's current physician orders revealed an order to apply skin prep to left dorsal second toe daily, every shift, and to cleanse right dorsal foot with wound wash, cover with alginate with silver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility policy, the facility failed to maintain functional call lights for residents. This affected two rooms (#13 and #203) of 14 observed. The facility census was 56. Findings include: Observation and interview on 12/27/19 at 5:50 P.M. revealed the Resident residing in room [ROOM NUMBER] was yelling out for assistance. The resident had pushed the call light and it was noted to not light up. The Corporate Registered Nurse (RN) #102 confirmed the call light was not functioning. Observation and interview on 12/28/19 at 11:50 A.M. revealed the resident residing in room [ROOM NUMBER] was requesting for assistance. When the resident pressed the call light, it did not light up. Licensed Practical Nurse (LPN) #200 confirmed the call light was not functioning in room [ROOM NUMBER]. Review of facility policy titled, Call Lights dated 12/18 revealed all resident call lights will be functional, in good working order, and responded to timely.