Harrison Pavilion Care Center

Based on review of the medical record review, observation, staff interview, and review of manufacturer's instructions, the facility failed to prime an insulin pen prior to administration. This affected one (Resident #44) of one observed for insulin administration and had the potential to affect two residents on medication cart one on the east hall with physician orders for insulin. The facility census was 79 residentsFindings include:Review of the medical record for Resident #44 revealed an admission date of 10/31/24 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 08/07/25 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs.)Review of the physician's orders for Resident #44 revealed an order dated 11/11/24 Novolog insulin inject subcutaneously per sliding scale.Observation on 09/09/25 at 12:14 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #313 did not prime the Novolog…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to measure correct portion sizes to meet resident nutritional needs. This affected one (Resident #73) of one resident with physician's orders for a pureed diet. The facility census was 79 residents. Findings include: Observation of food preparation on 09/11/25 at 11:02 A.M revealed Dietary Staff (DS) #404 used a spatula to scoop pureed stuffed peppers onto Resident #73's plate. Interview on 09/11/25 at 11:03 A.M with DS #404 confirmed Resident #73 was on a pureed diet, and he used a spatula to plate the pureed stuffed peppers for the resident because he did not have the proper scoop.Observation on 09/11/25 at 11:15 A.M reveled DS #404 used a three-ounce scoop when plating Resident #73's mashed potatoes. Interview on 09/11/25 at 11:20 A.M with DS #404 confirmed he used a three-ounce scoop when plating Resident #73's mashed potatoes, but the recipe called for a four-ounce portion of mashed potatoes. DS #404 confirmed he used the three-ounce scoop, because he did not have a four-ounce scoop 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, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff maintained sterile technique during tracheostomy care. This affected one (Resident #11) of one resident sampled for tracheostomy care. The facility also failed to ensure staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). This affected one (Resident #12) of 13 residents reviewed for EBP. The facility census was 79 residents.Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 06/13/25 with diagnoses including anoxic brain damage, anxiety disorder, tracheostomy status, and schizophrenia.Review of the physician's orders for Resident #11 revealed an order dated 06/14/25 for tracheostomy care every day and night shift and as needed.Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 08/08/25 revealed the had severe cognitive impairment and was dependent on staff with activities of daily living (ADLs), and had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to allow residents who were cognitively intact and were their own persons, the ability to independently sign out of the facility. This affected four Residents (#16, #69, #100 and #400) of the four residents reviewed for resident rights. The facility identified 63 Residents (#02, #05, #06, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #26, #27, #28, #29, #30, #31, #33, #35, #37, #38, #39, #40, #41, #42, #43, #45, #48, #49, #50, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #63, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #78, #79, #80 and #81) as being their own person without a guardian at the facility and was able to sign themselves out of the facility if desired. The facility census was 78. Findings include: 1) Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included ataxia following other cerebrovascular disease, insomnia, atherosclerotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of discharge notices, the facility failed to permit a resident to remain in the facility and not transfer or discharge from the facility without the proper documentation regarding the need for discharge from the facility or the physician. This affected one Resident (#400) of the three residents reviewed for transfers. The facility also failed to allow a resident to remain in the facility for the duration of their discharge notice. This affected one Resident (#100) out of three residents reviewed for transfer or discharge. The facility census was 78. Findings include: 1) Review of Resident #400's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee, schizoaffective disorder and constipation. Resident #400 discharged from the facility on 02/10/25. Resident #400's census information revealed 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 staff interview and record review, the facility failed to ensure a resident's discharge summary included a recapitulation of the resident's stay. This affected one Resident (#400) out of three residents reviewed for transfer or discharge summaries. The facility census was 78. Findings include: Review of Resident #400's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee, schizoaffective disorder and constipation. Resident #400 discharged from the facility on 02/10/25. Resident #400's census information revealed Resident #400 was his own responsible party. Review of Resident #400's medical record from 11/08/24 to 02/12/25, revealed no documentation a discharge notice was given to Resident #400. Review of Resident #400's admission MDS assessment dated [DATE], revealed Resident #400 was cognitively intact, was independent with eating, 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 staff and resident interviews, medical record review, review of Self-Reported Incident (SRI), review of police report, and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#34) resident out of four residents reviewed for abuse. The facility census was 80. Findings included: 1. Review of the medical record for Resident #34 revealed an admission date of 07/19/16 with medical diagnoses of hypertension (HTN), nephrotic syndrome, heart disease, chronic obstructive pulmonary disease (COPD), and schizophrenia. Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #34 was cognitively intact and was independent with eating, toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors. Review of the medical record for Resident #34 revealed a nurse progress note, dated 01/08/24 at 6:00 A.M. with stated Resident #34 reported to the nurse that his roommate, Resident #84,…

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 and pain specialist staff interviews, the facility failed to ensure a pain specialist appointment was scheduled and failed to effectively manage a resident's pain. This affected one (#84) resident out of three residents reviewed for pain management. The facility census was 80. Findings included: Review of the medical record for Resident #84 revealed an admission date of 11/11/23 with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of 02/13/24. Review of the medical record for Resident #84 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. Review of the medical record for Resident #84 revealed a Nurse Practitioner (NP) note, dated 01/18/24, which revealed Resident #84 stated his current pain management was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policies, the facility failed to follow infection control guidelines when administering medications. This affected one (#70) out of three residents reviewed for medication administration. The facility census was 80. Findings included: Review of the medical record for Resident #70 revealed an admission date of 03/19/08 with medical diagnoses of depression, diabetes mellitus (DM), hypertension (HTN), chronic obstructive pulmonary disease, dementia, and schizoaffective disorder. Review of the medical record for Resident #70 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #70 had moderate cognitive impairment and was independent with eating, bed mobility and transfers. Review of the medical record for Resident #70 revealed a physician order dated 11/27/21 for metformin 500 milligram (mg) one tablet by mouth daily for DM, an order dated 01/13/22 for metoprolol 25 mg one tablet by mouth daily 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interview, the facility failed to ensure medications administered intravenously (IV) were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 26 current residents (#3, #4, #10, #13, #14, #15, #18, #25, #30, #31, #34, #35, #37, #41, #42, #44, #46, #50, #56, #63, #66, #67, #69, #78, #79 and #81) and twelve discharged residents (#85, #86, #88, #89, #90, #91, #92, #93, #94, #95, and #96) identified by the facility who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 26 current residents (#3, #4, #10, #13, #14, #15, #18, #25, #30, #31, #34, #35, #37, #41, #42, #44, #46, #50, #56, #63, #66, #67, #69, #78, #79 and #81) and twelve discharged residents (#85, #86, #88, #89, #90, #91, #92, #93, #94, #95, and #96) identified by the facility who received IV fluids from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices,, and interview, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 26 current residents ( #3, #4, #10, #13, #14 #15, #18, #25, #30, #31, #34, #35, #37, #41, #42, #44, #46, #50, #56, #63, #66, #67, #69, #78, #79 and #81) and twelve discharged residents (#85, #86, #88, #89, #90, #91, #92, #93, #94, #95, and #96) identified by the facility who received IV fluids from the unlicensed source. The facility census was 80. Findings include: 1. Record review for Resident #3 revealed the resident admitted to the…

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

Based on observation, interview, and policy review, the facility failed to store and prepare food in a safe manner. This had the potential to affect 82 residents who received food from the kitchen. The facility census was 83. Findings include: During observation of the kitchen refrigerator on 09/25/23 at 9:21 A.M., there was a plastic container in the refrigerator with sliced cucumbers with no label of the contents, only a date; a block of cheese, opened, with no label or date; a large plastic container of what appeared to be mushrooms with a date, however, no label to confirm what it was; a large bag of peppers with no label or date; a large plastic container of what appeared to be juice located on a shelf in the refrigerator with no label or date. Next to the large container of juice was another large plastic container with a large clump of unknown food inside it. Dietary Manager (DM) #82 stated at the time of the observation it was juice with fruit and that was what was left of the fruit. It did not contain a label or date. There were two large plastic containers containing flour…

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

Based on observation, resident interview, staff interview and policy review, the facility failed to ensure residents were provided a dining room to eat their meals. This had the potential to affect 82 of 82 residents that receive meals from the dining room. The facility identified one (Resident #19) who did not receive his meals from the kitchen. The facility census was 83. Findings include: Observation of the dining meals throughout the week of the annual survey revealed the residents did not utilize the facility dining room. Review of Resident #07's medical record revealed an admission date of 06/13/23, with diagnoses including: diabetes mellitus 2, essential primary hypertension, hyperlipidemia, osteoarthritis, insomnia, anxiety disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obesity, and osteoarthritis. Review of quarterly MDS assessment for Resident #07 revealed he was cognitively intact. Further review of the MDS assessment revealed he was independent from the need of assistance with his meals. Interview on 10/02/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interview, and review of the policy, the facility failed to ensure residents were invited to their care plan meetings. This affected four (#18, #28, #47, and #233) of four residents reviewed for care conferences. The facility census was 83. Findings include: 1. Review of Resident #18's medical record revealed she an admission date of 09/25/20, with diagnoses including: anemia, coronary artery disease (CAD), hypertension, gastroesophageal reflux disease (GERD), diabetes mellitus 2 (DM2), hyponatremia, hyperlipidemia, anxiety disorder, depression, asthma, respiratory failure, and schizophrenia. Review of Resident #18's care conferences revealed her last completed care conference was 12/09/21. Review of the annual Minimum Data Set (MDS) assessment, dated 08/11/23, revealed Resident #18 was cognitively intact. Further review of the MDS assessment revealed she required limited assistance from staff with bed mobility, transfers, and toilet use. Resident #18 required…

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 interviews, staff interviews, record review, and policy review, the facility failed to provide a home like environment in maintaining resident's rooms in good condition. This affected four (#03, #21, #36, and #233) of 83 residents residing in the facility. The facility census was 83. Findings include: 1. Review of Resident #03's medical record revealed an admission date of 03/19/08, with diagnoses including atrial fibrillation, gastroesophageal reflux disease (GERD), diabetes mellitus 2, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment, dated 07/12/23, revealed Resident #03 had severely impaired cognition. Further review of the MDS assessment revealed he required supervision assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Observation on 10/03/23 at 10:11 A.M., revealed Resident #03's bathroom entry wall was busted with exposed dry wall, the window seal had a cracked edge with pieces missing, the air conditioning unit was broken with the facing hanging off, all along with the wall…

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, grievance report review, spread sheet review, email communication review, policy review, resident interviews, staff interviews, Registered Dietician interview, the facility failed to ensure residents were provided with adequate portion sizes and substitutes according to the approved menus/spreadsheets. This had the potential to affect 82 of 82 residents who were served food from the kitchen. The facility identified one resident (#19) did not receive food from the facility kitchen. The facility census was 83. Findings include: Review of the facility form titled, Grievance/Complaint Report, dated 07/03/23 revealed Resident #40 stated he was, getting small portions, and would like more protein. Interview on 09/25/23 at 1:53 P.M., with Resident #7stated the facility only provides small portions of food. Resident #7 stated he will ask for more food and staff will tell them they are out of food. A follow up interview with Resident #07 on 10/02/23 at 3:44 P.M., revealed the facility had an issue in the kitchen over the weekend and was unable to utilize the facility…

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

Based on observation, staff interview, and policy review, the facility failed to provide a home like environment by maintaining shower rooms and ensuring there was enough plates and silverware to serve meals. This had the potential to affect up to 50 of 83 residents who reside in the faciltiy. Excluding Resident #19, who does not receive food and a total of 59 residents who do not utilize the shower rooms. The facility census was 83. Findings include: 1. Observation on 09/26/23 at 9:24 A.M., of the shower room located by the central services room revealed the air vents contained large amounts of fuzzy dust and dirt hanging off them in a fringe- like manner. The shower room contained black sludge like substances around the bottom of the shower room walls and on the floor of the shower room. The shower room had busted tile with exposed wall. Interview on 09/26/23 at 9:24 A.M., with State Tested Nurse Aide (STNA) #83 confirmed the air vents in the shower room located near the central supply room had fuzzy, dust and dirt hanging off the vents. STNA #83 confirmed the shower contained 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, resident interview, and staff interview, the facility failed to ensure a resident was provided the assistance to obtain a pair of shoes. This affected one (#64) of 24 residents sampled during the annual survey. The facility census was 83. Findings included: Review of Resident #64's medical record revealed an admission date of 12/14/22. His diagnoses included atherosclerotic heart disease, essential tremor, intellectual disabilities, osteoarthritis, cervical disc degeneration of the cervical region, intervertebral disc degeneration of the lumbar region, chronic pain syndrome, ischemic cardiomyopathy, personal history of traumatic brain injury, occlusion and stenosis of the bilateral carotid arteries, hypothyroidism, type II diabetes, with diabetic neuropathy, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and needed supervision for activities of daily living. Review of Resident #64's podiatry visit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to complete a Significant Change Pre-admission Resident Review (PASARR) for Resident #24. The facility failed to complete a PASARR review for Resident #63 in a timely manner following the expiration of the Hospital Exemption Notification System ([NAME]) approved stay at the facility. The facility failed to ensure Resident #70's PASARR was completed correctly by failing to identify mental health diagnoses. This affected three (#24, #63 and #70) of three residents reviewed for PASARR. The facility census was 83. Findings include: 1. Record review for Resident #24 revealed he was admitted to the facility on [DATE]. His diagnoses included antisocial personality, major depressive disorder, schizoaffective disorder, insomnia, bipolar disorder, depression, and altered mental status. Review of quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #24 was cognitively intact. The MDS assessment revealed he required extensive 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.

Based on record review, resident interview, staff interview, and policy review, the facility failed to complete a thorough investigation to identify the root cause of the fall during a Hoyer lift transfer. This affected one (#47) of three residents reviewed for falls. The facility census is 83. Findings include: Review of Resident #47's medical record revealed an admission date of 05/09/23, with diagnoses including: heart failure, hypertension, Diabetes Mellitus 2, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/23, for Resident #47 revealed she was cognitively intact. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #47 was totally dependent on staff for assistance with transfers and toilet use. Resident # 47 was independent with eating. Review of nursing progress notes for Resident #47 revealed a nursing note created on 06/21/23 at 7:09 P.M. and effective for 06/21/23 at 11:15 A.M. revealed, the resident stated the Hoyer lift tipped while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview and observations, revealed the facility failed to ensure pain medications were available and provided timely to a resident to maintain pain management. This affected one (#1) of one resident reviewed for pain management. The facility census was 83. Findings include: Review of Resident #1's medical record revealed an admission date of 04/23/07, with diagnoses including age-related osteoporosis and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of physician's orders dated 09/18/23 for Voltaren (diclofenac sodium) gel 1%, apply two grams (g) topically to wrist and arm every day and night shift. Observation and interview on 09/25/23 at 11:08 A.M., revealed Resident #1 was noted to be shaking her left forearm, wrist, and hand. Resident #1 stated that she had arthritis and it hurt. Resident #1 reported that she told the nurse, and she was given pain medication, but it still…

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

Based on observation, interview and policy review, the facility failed to ensure the facility was free of gnats. This affected the kitchen area. The facility census was 83. Findings include: During observation during the initial tour of the facility kitchen on 09/25/23 at 9:21 A.M., a large, soiled cookie sheet pan had drain flies flying around the pan. During interview at the time of the observation, Dietary Manager (DM) #82 confirmed the facility has an issue with gnats in the drain. Review of the pest control billing statements revealed the facility had been treated for gnats on 08/14/23. The statement stated the Kitchen has very poor sanitation. Please focus on keeping the dishwasher area clean please. Review of the policy titled Pest Control, dated May 2008, stated, the facility shall maintain an effective pest control program and the building is kept free of insects and rodents. This deficiency represents noncompliance discovered during complaint investigation of Complaint Number OH00146416.

Based on record review, observations, staff interviews, review of facility policy, and review of online guidance per the Centers for Disease Control (CDC), the facility failed to ensure staff wore proper personal protective equipment (PPE) to prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected four (#39, #58, #61 and #80) of five residents reviewed for infection control. The facility census was 81. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/25/20 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) with hypoxia, diabetes mellitus (DM), anxiety disorder, cerebral infarction, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) for Resident #39 dated 08/11/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the physician orders for Resident #39 revealed an order dated 09/08/23 for strict room isolation with all services provided in the room due 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 staff interview, review of facility assessment, and review of facility policy, the facility failed to complete and update the facility assessment. This affected all 79 residents who resided in the facility. Findings included: Review of facility assessment on 11/19/21 at 1:00 P.M. indicated the tool was last updated on 01/28/21. Review of Part one (Resident Profile), section 1.5 (Acuity), example three revealed no documentation for Activities of Daily Livings (ADLs). Review of Part three (Facility Resources Needed to Provide Competent Support and Care for Residents Population Daily); under section 3.2 (Staffing Plan) revealed a blank staffing assessment. Under section 3.8 (Physical Environment and Building/Plant Needs) revealed a blank assessment. During interview with Administrator on 11/19/21 at 4:30 P.M. verified the assessment was not completed and updated. Review of updated facility policy titled Facility Assessment revealed the facility assessment was conducted annually to determine and update the capacity to meet the need of and competently care for our resident…

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

Based on staff interview and record review, the facility failed to ensure the Activities Director was properly certified. This affected all residents who resided in the facility. Facility census was 79. Findings included: During the extended survey review on 11/19/21 at 2:00 P.M. revealed no certification for Activities Director. Interview with Activities Director #29 on 11/19/21 at 3:00 P.M. verified she was not certified as Activities Director. Activities Director #29 stated she was enrolled in the National Certification Council for Activity Professionals and anticipated to complete the course and be certified in February 2022. Review of National Certification Council for Activity Professional documentation indicated Activities Director #29 was enrolled on 10/19/21.

Based on observation, record review, interview, policy review, and review of online resources per the Center for Medicare and Medicaid Studies (CMS) and the Centers for Disease Control (CDC) the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent spread of infectious diseases including the Coronavirus 2019 (Covid -19) virus. This had the potential to affect all 79 residents. Furthermore, the facility failed to ensure staff wore personal protective equipment properly to prevent the spread of Coronavirus (COVID-19) and failed to ensure contracted staff had temperature taken and completed a signs and symptom screen for COVID-19 prior to entering the resident area. This had the potential to affect all residents in the facility except for four (#73, #74, #75, #76) residents residing in the facility's COVID-19 unit. The facility census was 79. 1. Observation on 11/15/21 from 08:00 A.M. to 04:30 P.M. revealed the facility listed a sign on Resident #278's door stating she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and review of facility policy, the facility failed to provide dining services for residents in a dignified manner which enhanced their quality of life. This affected seven Residents (#45, #40, #75, #65, #9, #14, #36) out of a total facility census of 79. Findings include: 1. Observation on 11/15/21 at 8:25 A.M. of breakfast being served on the [NAME] Hall revealed the residents were served their hot meals in Styrofoam take out containers, also known as clamshells. The menu specified that residents were served hot or cold cereal, scrambled eggs with ham bits, and toast that morning. Interview on 11/5/21 with [NAME] #45, while touring the central kitchen at 8:38 A.M., affirmed that all residents were served their breakfast in Styrofoam containers this morning. [NAME] #45 sated that Styrofoam was used this morning due to not having enough staff. Observation on 11/15/21 at 5:41 P.M. revealed that residents in the middle and back of [NAME] hall, including 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 record review and staff interview, the facility failed to ensure that when a resident formulated an advanced directive the resident's advanced directive was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected four residents (#22, #40, #74, and #5) of six residents reviewed for Advance Directives. The facility census was 79. Findings include: 1. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses including acute kidney failure, major depressive disorder, absolute glaucoma, diabetes mellitus type 2, dysphagia, mild intellectual disabilities. Review of the quarterly minimum data set (MDS) assessment of the resident dated 09/20/21 revealed the resident was assessed as having moderate cognitive losses, was understood and able to understand, and required the physical assistance of one staff person to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of facility investigation, review of facilities self-reported incidents (SRIs), review of medical records, and review of facilities Abuse Investigating and Reporting Policy, the facility failed to prevent potential further neglect during their investigation with ( Resident #231) when he had committed suicide in the facility. This had the potential to affect 49 Residents (#01, #02, #03, #04, #05, #06, #08, #09, #15, #18, #19, #20, #21, #22, #23, #25, #28, #32, #34, #36, #38, #39, #40, #41, #43, #44, #45, #47, #48, #49, #52, #53, #55, #58, #61, #64, #65, #69, #76, #85, #86, #87, #88, #89, #90, #91, #92, #93, and #94) whom the facility identified as having a history of suicidal ideations/attempts after the suicidal incident [DATE]. The facility census was 79. Findings included: Review of medical record for Resident #231 revealed resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included, but not limited to, Parkinson's disease, dementia with behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a valid Pre admission Screen and Resident Review (PASRR) was in place for three Residents (#24, #29, and #231) out of three residents reviewed for PASRR screenings. The facility census was 79. Findings include: 1. Record review for Resident #24 revealed resident was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, hyperlipidemia, major depressive disorder, asthma, diabetes mellitus 2, respiratory failure, hemiplegia and hemiparesis, pneumonia, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 revealed he was cognitively intact. Further review of the MDS assessment dated [DATE] revealed Resident #24 required extensive assistance from staff for bed mobility, transfers, walking, dressing, and bathing. He did not require any assistance from staff with eating and was totally independent with this task. Review of the Hospital Exemption…

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 chart review, interview, and policy review, the facility failed to provide baseline care plans upon admission. This affected two Residents (#27 and #71) . Furthermore, the facility failed to complete a baseline careplan accurately for one Resident (#231) out of 21 residents reviewed for baseline care plans. The in-house facility census was 79. Findings include: 1. Review of medical record for Resident #27 revealed resident was admitted on [DATE] with diagnoses including rheumatoid arthritis, anxiety, bipolar, dysuria, overactive bladder, anemia, and vitamin D deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 has mild to moderate cognitive deficits, requires supervision with activities of daily living (ADLs), with extensive assistance locomotion, and is continent of bowel and bladder. Review of medical records revealed they were silent related to the admission baseline care plan. 2. Review of the medical record for Resident #71 revealed resident was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Record Review of Resident #77 revealed she admitted to the facility on [DATE]. Her diagnoses included, acute kidney failure, cognitive communication deficit, dysphagia, history of coronavirus (COVID) 19, and acute respiratory failure. Review of her 5-day admission MDS assessment, dated 11/08/21 revealed Resident #77 was cognitively intact and she required supervision assistance from staff with bed mobility, transfers, and supervision assistance with personal hygiene, toilet use, eating, and dressing. Review of the nursing progress notes dated 10/11/21 for Resident #77 had a fall and new fall were listed as bed at lower position and floor mats at bedside. Review of Resident #77's fall care plan revealed the facility initiated encourage resident to allow for needed assistance on 10/07/21, fall mats to the side of the bed while in bed initiated on 10/29/21 and bed in lowest position while in bed initiated on 10/29/21. However, the review of Resident #77's fall care plan did not indicate Resident #77 refused 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, observation, and interview the facility failed to ensure residents were smoking safely. This affected six Residents (#11, #31, #53, #57, #73, and #230) out of 29 residents identified by the facility as smokers. The facility failed to ensure resident safety while moving around in wheelchair affecting one Resident #77, and failed to put non-skid strips in bathroom to prevent falls affecting Resident #29. The in-house facility census was 79. Findings include: 1. Record review of Resident #11 revealed resident was admitted on [DATE] with diagnoses including cerebral infarction, schizoaffective disorder, depression, hypertension, diaphragmatic hernia, hyperlipidemia, insomnia, and dysphagia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had no cognitive deficits, requires extensive assistance with activities of daily living (ADL), and is occasionally incontinent of bowel and bladder. Review of Care Plan dated 10/25/21 revealed Resident #11 is a supervised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review and review of facility policy, the facility failed to ensure the physician personally approved in writing a recommendation for residents being admitted . This affected 21 residents (#12, #14, #15, #17, #22, #24, #27, #29, #33, #37, #40, #42, #71, #74, #76, #77, #78, #81, #229, #231, and #328) of the 31 sampled residents. The facility census was 79. Findings included: 1. Review of medical record for Resident #231 revealed resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included, but not limited to, Parkinson's disease, dementia with behavioral disturbances, major depressive disorder, hypertension, restless and agitation, and psychotic disorder with delusions. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #231 was cognitively intact, had no behaviors, and required limited assistance with activities of daily living (ADLs). Section-D (Resident Mood Interview) indicated resident had feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and interview with facility Medical Director (MD), medical record review and review of facility policy, the facility failed to ensure the physician and Non-Physician Providers (NPP) wrote, signed, and dated progress note at each visit. This affected 25 Residents (#05, #12, #14, #15, #17, #19, #22, #24, #29, #30, #34, #36, #37, #40, #48, #53, #71, #76, #77, #79, #81, #82, #229, #231, and #328) of the 31 sampled residents. Facility census was 79. Findings included: 1. Review of medical record for Resident #231 revealed resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included, but not limited to, Parkinson's disease, dementia with behavioral disturbances, major depressive disorder, hypertension (HTN), restless and agitation, and psychotic disorder with delusions. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #231 was cognitively intact, had no behaviors, and required limited 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.

Based on observation, interview, and policy review the facility failed to ensure expired medications were properly disposed. This affected one medication room, and four medication carts out of six medication carts reviewed for medication storage. The in-house census was 79. Findings include: Observation on 11/16/21 at 3:05 P.M. through 4:00 P.M. of the medication room with the Director of Nursing (DON) revealed three chocolate ensure plus supplements with expiration date of 02/21, one bottle of fiber heal 15 Grams FIBER with expiration date of 06/21, six bottles of Vitamin B6 100 milligrams (mg) with expiration date of 04/21, four bottles of Vitamin B6 250 mg with a expiration date 07/21, one bottle of fish oil 500 mg with expiration date of 07/21, two bottles of vitamin B12 100 micrograms (mcg) with expiration dates of 08/21 & 09/21, and six bottles of vitamin E with expiration date 06/21. Continued observation with the DON of the East medication cart #1 revealed the following expired medications in cart: calcitrate 200 mg with expiration date 07/21, vitamin B12 100 mcg 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, review of nutrition services agreement, and review of personnel records, the facility failed to employ sufficient staff with appropriate skills and competencies necessary to carry out the function of the dietary department related to food and nutrition services. This had the potential to affect 77 of 79 residents of the facility , excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79. Findings include: An initial tour of the central kitchen was conducted on 11/15/21 at 8:38 A.M. with [NAME] #45. There was no supervisor evident on duty. [NAME] #45 was on duty and reported that Dietary Manager (DM) #48 was on vacation. He stated he had been employed as a cook at the facility for about 4 weeks. During tour of the central kitchen it was observed the kitchen was equipped with a single compartment low temperature dish machine with manufacturer's minimum wash and rinse operating temperatures of 120 Fahrenheit (F), and used a sanitizing agent to sanitize the dishes/silverware etc. with a chemical…

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 and resident interview, review of the dietary staffing schedule, and review of the facility mealtime cart schedule revealed the facility failed to employ sufficient staff with appropriate competencies to effectively carry out the functions of the food and nutrition service department. This had the potential to affect 77 of 79 residents of the facility, excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79. Findings include: Observation on 11/15/21 at 5:52 P.M. of residents being served their evening meal revealed that as of 5:52 P.M. the residents on the back [NAME] hall had not been served. Review of the facility's mealtime cart schedule revealed the time the last cart was scheduled to leave the kitchen for the evening meal, which was the back [NAME] cart, was 5:20 P.M. Interview on 11/15/21 at 5:59 P.M. with the staff person serving as the evening cook, Housekeeping Aide (HA) #37 reported she was picking up i.e. working in the kitchen all week. She reported that she was the cook today, and will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and review of planned menus, the facility failed to follow the planned menus as approved by the Registered Dietitian for residents on mechanical soft and pureed diets, resulting in resident's not receiving all planned menu items necessary to meet their nutritional needs. This directly affected four Residents (#22, #71, #48, and #43) who were on texture modified diets, and had the potential to affect six additional Residents ( #72, #77, #62, #38, #40, #64) with physician's order for texture modified diets; mechanical soft or pureed. The facility census was 79. Findings include: 1. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses including acute kidney failure, major depressive disorder, absolute glaucoma, diabetes mellitus type 2, dysphagia, mild intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment of the resident dated 09/20/21 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, staff and resident interview, review of planned menus, and review of facility policy, the facility failed to provide food that was served at a safe and appetizing temperature. This affected seven Residents (#30, #40, #9, #14, #36, #45, and #75) and had the potential to affect a total of 77 of 79 residents, excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79. Findings include: Observation on 11/15/21 at 8:25 A.M. of breakfast being served on the [NAME] Hall revealed the resident's were served their hot meals in Styrofoam take out containers, also known as clamshells. The menu specified that residents were served hot or cold cereal, scrambled eggs with ham bits, and toast that morning. Interview on 11/15/21 at 11:30 A.M. with Resident #30 revealed that he found the food at the facility to be served cold. He stated that the food was always cold, need seasoning, and that is was served on Styrofoam just about every meal. Interview on 11/5/21 with [NAME] #45, while touring the central kitchen at 8:38 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 observation, staff and resident interview, and review of planned menus, the facility failed to prepare the planned menus as approved by the Registered Dietitian for residents on mechanical soft and pureed diets, to ensure residents received food prepared in a form designed to meet their individual needs per physician orders and the comprehensive plan of care. This directly affected five Residents (#22, #48, #43, #40, and #71) who had physician orders for texture modified diets, and had the potential to affect five additional residents ( #72, #77, #62, #38, and #64) with physician's orders for texture modified diets; mechanical soft or pureed. The facility census was 79. Findings include: 1. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses including acute kidney failure, major depressive disorder, absolute glaucoma, diabetes mellitus type 2, dysphagia, mild intellectual disabilities. Review of the quarterly Minimum Data…

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 ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 77 of 79 residents of the facility , excluding Residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79. Findings include: An initial tour of the central kitchen was conducted on 11/15/21 beginning at 8:38 A.M. with [NAME] #45. While touring the kitchen the following was observed: a) The walk-in refrigerator that contained all the facility's refrigerated food, with the exception of milk, lacked an internal thermometer. The exterior thermometer indicated the temperature was 39 degrees Fahrenheit (F). [NAME] #45 affirmed there was no thermometer inside the refrigerator. b) The floor of the walk-in freezer was littered with pieces of what appeared to be a cubed meat product and other frozen food products. c) The milk cooler lacked 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, record review, staff and family/representative interview, and review of facility policy, the facility failed to notify each resident's family/representative when the resident experienced an unplanned significant weight loss. This affected one resident (#78) of 31 residents reviewed. The facility census was 79. Findings include: Review of Resident #74's medical record revealed the resident was admitted to the facility on [DATE], from an acute care hospital, with diagnoses including wedge compression fracture of fifth lumbar vertebra, dementia, cognitive communication deficit, muscle weakness, and acute lymphoblastic leukemia. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairments and required the extensive assistance of one staff person to complete activities of daily living with the exception of eating for which he was assessed as being independent with set-up help only. The resident and no natural teeth 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 staff interview, review of facility investigation, review of facilities self-reported incidents (SRIs), review of medical records, and review of facilities Abuse Investigating and Reporting Policy, the facility failed to report an incident of possible neglect to the State Agency when a resident was found on the floor with a dresser on neck and determined deceased by emergency medical services (EMS). This affected one Resident (#231) of the 31 sampled residents. Facility census was 79. Findings included: Review of medical record for Resident #231 revealed resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnosis included, but not limited to, Parkinson's disease, dementia with behavioral disturbances, major depressive disorder, hypertension, restless and agitation, and psychotic disorder with delusions. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #231 was cognitively intact, had no behaviors, and required limited assistance with activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to properly notify the Ombudsman program of resident hospitalizations. This affected two Residents (#03 and #29) out of five residents reviewed for hospitalization. The facility census was 79. Findings include: 1. Review of the closed medical record for Resident #03 revealed he had an initial admission date of 05/12/11. He was recently admitted to the hospital on [DATE] and then re-admitted to the facility on [DATE]. Diagnoses included acquired absence of right leg above knee, acquired absence of left leg above knee, end stage renal disease, dysphagia, moderate protein-calorie malnutrition, hyperkalemia, nutritional deficiency, type two diabetes mellitus with diabetic peripheral angiopathy with gangrene, acute respiratory syndrome, chronic obstructive pulmonary disease, muscle weakness, dementia without behavioral disturbance, heart failure, peripheral vascular disease, dependence on renal dialysis, and anemia. Review of the quarterly Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to conduct initial or periodic assessments of each resident's activity interests. This affected one Resident (#22) of three residents reviewed for Activities. The facility census was 79. Findings include: Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses including acute kidney failure, major depressive disorder, absolute glaucoma, diabetes mellitus type 2, dysphagia, mild intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment of the resident dated 09/20/21 revealed the resident was assessed as having moderate cognitive losses, was understood and able to understand, and required the physical assistance of one staff person to complete activities of daily living. Review of the resident's electronic medical record revealed no documentation related to activities, activity assessment, or activities progress note since initial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and review of facility policy, the facility failed to ensure residents comprehensive care plans were reviewed and revised. This affected two Residents (#77 and #29) of the 31 residents sampled. The facility census was 79. Findings included: 1. Record Review of Resident #77 revealed she admitted to the facility on [DATE]. Her diagnoses included, acute kidney failure, cognitive communication deficit, dysphagia, history of coronavirus (COVID) 19, and acute respiratory failure. Review of her five-day admission Minimum Data Set (MDS) assessment, dated 11/08/21 revealed Resident #77 was cognitively intact. Further review of the MDS assessment for Resident #77 revealed she required supervision assistance from staff with bed mobility, transfers, and supervision assistance with personal hygiene, toilet use, eating, and dressing. Review of the nursing progress notes dated 10/11/21 for Resident #77 had a fall and new fall interventions were listed as bed at lower position and floor…

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 interview the facility failed to provide professional services while administering medications to residents on therapeutic diet. This affected one Resident #71 out of one resident identified by the facility on thickened liquids. The in-house facility census was 79. Findings include: Review of the medical record for Resident #71 revealed an admission date of 10/13/21 with diagnoses including cerebral infarction, dysphagia, muscle weakness, constipation, encephalopathy, diabetes, hypertension, altered mental status, and magnesium deficiency. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed Resident #71 has mild cognitive deficits, requires extensive assistance with activities of daily living, limited with personal hygiene, and is occasionally incontinent of bowel and bladder. Review of care plan dated 11/02/21 revealed Resident #71 has a swallowing problem related to coughing or choking during meals or swallowing medications. Swallowing assessment result…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to provide each resident an ongoing program of activities designed to support their physical, mental, and psychosocial well-being. This affected one Resident (#22) of three residents reviewed for Activities. The facility census was 79. Findings include: Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses including acute kidney failure, major depressive disorder, absolute glaucoma, diabetes mellitus type 2, dysphagia, mild intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment of the resident dated 09/20/21 revealed the resident was assessed as having moderate cognitive losses, was understood and able to understand, and required the physical assistance of one staff person to complete activities of daily living. Review of the resident's electronic medical record revealed no documentation related to activities, activity…

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, staff interview, and review of facility policy the facility failed to conduct consistent assessments of resident's skin condition per a licensed nurse. This affected three (#40, #70, #78) of three residents reviewed for skin integrity. The facility also failed to conduct regular pressure ulcer risk assessments which affected two (Residents #40 and #70) of three residents reviewed for skin integrity. The facility failed to document a description of impaired skin integrity which required intervention per physician's order which affected one (Resident #78) of three residents reviewed for skin integrity. The facility census was 79. Findings include: 1. Review of the record for Resident #40 revealed an admission date of 09/18/17 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) for Resident #40 dated 11/25/21 revealed resident was cognitively intact and required extensive assistance with activities of daily living (ADLs). Review of pressure ulcer risk assessment for Resident #40…

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 facility policy, the facility failed to ensure each resident's oxygen tubing was dated, documented, and changed weekly per facility policy. This affected one Resident (#30) reviewed for respiratory care, out of 10 residents identified by the facility as receiving oxygen therapy. The facility census was 79. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, alcoholic liver disease, hypertensive heart disease with heart failure, and dementia with behavioral disturbance. Review of a quarterly Minimum Data Set assessment (MDS) of the resident dated 10/08/21 revealed the resident had good memory and recall, and received oxygen during the assessment period. Review of the resident's physicians orders revealed an order for oxygen at two liters per minute via nasal cannula as needed 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 Based on staff interview, record review and review of facility policy, the facility failed to ensure residents medical records were complete and accurately documented. This affected two Residents (#03 and #231) of the 31 sampled residents. Facility census was 79. Findings included: 1. Review of medical record for Resident #231 revealed resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included, but not limited to, Parkinson's disease, dementia with behavioral disturbances, major depressive disorder, hypertension, restless and agitation, and psychotic disorder with delusions. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #231 was cognitively intact, had no behaviors, and required limited assistance with activities of daily living (ADLs). Section-D (Resident Mood Interview) indicated resident had feelings of being down, depressed, or hopeless, and no thoughts of self-harm. Review of psychiatric Nurse Practitioner (NP) #169 progress notes dated…

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

Based on observation, resident and staff interview, record review, and review of facility policy revealed the facility failed to provide each resident with a safe, functional, and sanitary environment which was clean and in good repair. This affected five Residents (#74, #30, #40, #24, and #77) out of 31 sampled residents. The facility census was 79. 1. Observation of the resident sleeping room and bathroom occupied by Resident's #30 and #40 on 11/15/21 at 9:56 A.M. revealed the cover to the baseboard heater in front of the toilet was missing exposing sharp edges of the heating element and there were multiple gnats in the bathroom. The floor behind the head of Resident #30's bed was heavily soiled with food and other debris and his privacy curtain was stained and soiled with a large dark grayish/black in area near the resident's head. Resident #30 confirmed the privacy curtain was soiled. Interview with Resident #40 on 11/15/21 at 4:44 P.M. stated there were gnats in the bathroom he shared with Resident #30 as water has been leaking out of the bottom of the toilet. Observation 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.