Liberty Nursing Center Of Colerain INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to routinely monitor the dialysis access site. This affected one Resident (#15) of two residents reviewed for dialysis. The facility census was 66. Findings include: Review of the medical record for Resident #15 revealed an admission date of 03/02/23. Diagnoses included end stage renal disease (ESRD), type two diabetes mellitus with diabetic chronic kidney disease, dependent on renal dialysis, chronic pain syndrome, hypertension, anorexia, hyperkalemia, depression, and unspecified dementia, unspecified severity, with agitation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderately impaired cognition. Resident #15 was assessed to require supervision for oral hygiene, toileting, personal hygiene, and transfer, substantial/maximal assistance for bathing, and bed mobility, was independent for eating, and dependent on staff for dressing. Review of the plan of care dated 03/03/23, revealed Resident #15…

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

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the facility incident report, staff interviews and policy review, the facility failed to ensure staff appropriately disposed of an insulin needle after use. This had the potential to affect one (#70) out of three residents reviewed for infection control. The facility census was 61. Findings include: Review of the facility incident report dated 05/05/24 revealed while State Tested Nursing Assistant (STNA) #44 was emptying the trash can in Resident #70 bathroom when she was stuck by a hypodermic insulin needle. The investigation noted the facility was unsure who threw the needle away or who the needle was used on prior to being disposed of in Resident #70's bathroom. Interview with the Director of Nursing (DON) on 07/08/24 at 2:00 P.M. revealed an investigation ensued and all staff were educated to prevent any further incidents following STNA #44's needle stick on 05/05/24. The DON confirmed Resident #70 does not have orders for insulin 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, staff interview and policy review, the facility failed to ensure a resident was provided with appropriate assistance and supervision during bed mobility which resulted in the resident having an avoidable fall from the bed. This affected one (#23) out of four residents reviewed for accidents. Facility census was 61. Findings Include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, mood disorder, dementia, unsteady feet, and lack of coordination. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE] revealed Resident #23 had severely impaired cognition and was required total staff assistance for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Review of plan of care for Resident #23 dated 08/07/23 revealed the resident required total care. Review of Resident #23 plan of care revealed there was an update on 09/21/23 which…

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

Based on record review, staff interview and facility policy review, the facility failed to utilize the services of a registered nurse (RN) for at least eight hours a day, seven days a week as required. This had the potential to affect all 68 residents residing at the facility. The facility census was 68. Finding include: Review of the of the facility staff schedules and time card punches for the month of November 2022 revealed the facility failed to have an RN scheduled on 11/13/22. Interview on 12/01/22 at 9:25 A.M. with the Administrator confirmed the facility failed to meet the requirement of providing RN nurse coverage for at least eight hours in the facility on 11/13/22. The Administrator confirmed the facility provided zero hours of RN coverage on 11/13/22 which had the potential to affect all residents residing in the facility. Review of the facility policy titled, Departmental Supervision, dated 2001, revealed an RN is scheduled daily for no less than eight hours a day.

Based on observations, staff interview, dietary spreadsheet review, and recipe review, the facility failed to ensure consistent portion sizes were served to residents and the facility failed to serve foods as planned on dietary spreadsheets. This had the potential to affect 66 of 66 residents residing in the facility who receive their meals from the kitchen, the facility identified two (#21 and #22) residents who did not receive food from the kitchen. The facility census was 68. Findings include: 1. Observation and interview on 11/29/22 at 11:57 A.M. revealed Dietary Staff (DS) #290 revealed the dietary staff was placing lettuce and ranch dressing into a food processor. DS #290 stated she was preparing pureed salad for the residents who receive pureed diets instead of regular salads for the lunch meal. Interview on 11/29/22 at 12:35 P.M., Dietary Supervisor #375 stated residents on pureed diets always receive pureed salads when salads are on the menu. Further review of the daily menu spreadsheet revealed residents on a pureed diet would receive pureed green beans for the lunch meal.…

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

Based on observation, staff interview, and policy review, the facility failed to ensure staff wore hairnets properly while preparing food. This had the potential to all 66 residents who eat their meals from the facility kitchen. The facility identified two residents (#21 and #22) who did not receive food from the kitchen. The facility census was 68. Findings include: 1. Observation and interview on 11/28/22 at 8:48 A.M. revealed Dietary Staff (DS) #365 in the kitchen food preparation areas preparing the lunch meal. DS #365 was wearing a bouffant cap over her head with long braids hanging out, approximately eight inches beyond the bouffant cap. Interview at the same time, DS #365 stated she put the bouffant cap on that morning when she came to work but didn't put the braids within the cap because they wouldn't fit. 2. Observation on 11/29/22 at 11:48 A.M. revealed DS #295 preparing pureed cake in the food processor. DS #295 was wearing a bouffant cap, however approximately five inches of her bangs across her forehead were not covered by the bouffant cap. Interview on 11/29/22 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 observation, record review, staff interview, and policy review, the facility failed to ensure personal protective equipment (PPE) was worn in a COVID positive resident room and ensure contact precautions were in place for potentially positive symptomatic COVID 19 residents'. This had the potential to affect all 68 residents residing in the facility. In addition, the facility failed to ensure staff practiced proper hand hygiene during meal tray pass. This affected 10 residents (#19, #31, #35, #36 #37, #39, #45, #50, #52, and #54) out of 38 residents who resided on the Blue Hall. The facility census was 68. Findings include; 1. Record review for Resident #275 revealed an admission date of 11/17/22. Diagnoses included Coronavirus 2019 (COVID-19), pneumonia, chronic obstructive pulmonary disease, diabetes mellitus type II, acute and chronic respiratory failure, hypoxia, generalized anxiety disorder, major depressive disorder, insomnia, hyperkalemia, chronic kidney disease, and essential primary…

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, observations, resident and staff interviews, and review of the facility policy, the facility failed to ensure residents were bathed and assisted with getting out of bed per their preference. This affected two (#36 and #325) of two residents reviewed for choices. The census was 68. Findings include: 1. Review of the medical record for Resident #325 revealed an admission date of 11/14/22 with a diagnosis of aftercare following joint replacement surgery. Review of the Minimum Data Set (MDS) for Resident #325 dated 11/21/22 revealed resident was cognitively intact and required physical assistance of one staff with bathing. Resident #325 was coded as negative for rejection of care and under section F resident was coded as very important when interviewed regarding how important it was to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan for Resident #325 dated 11/15/22 revealed the resident had an activities of daily living (ADL) self-care performance deficit…

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 and resident and staff interview, the facility failed to maintain a clean and sanitary environment. This affected one (#71) of one residents reviewed for the physical environment. The facility census was 68. Findings include: Observation on 11/28/22 at 9:39 A.M. revealed Resident #71 lying in bed. A large area, approximately two feet by one foot, of an unidentified dried tan substance below the tube feeding pole was identified directly next to the bed. Interview on 11/28/22 at 10:08 A.M., State Tested Nursing Assistant (STNA) #200 verified the large area of unidentified dried tan substance on the floor next to Resident #71 and it needed to be cleaned. Interview on 11/30/22 at 9:21 A.M., Resident #71 stated, that floor is still a mess. It has been that way for a good while. I think that cord (from the tube feeding pump) is cemented into it. Observations on 11/29/22 at 8:18 A.M., 11/30/22 at 8:06 A.M. and 12/01/22 at 3:09 P.M., the large area of unidentified tan substance remained on the floor near Resident #71's bed.

Based on record review, review of the facility incident log, review of facility self-reported incidents (SRI's), staff interview, and review of the facility policy, the facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH). This affected one (#34) of two residents reviewed for abuse. The census was 68. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of nurse progress note for Resident #34 dated 11/15/22 revealed the aide notified the nurse resident had a bruise to the right inner foot. Nurse assessed resident and noted resident's right ankle and foot were swollen. The attending physician was notified and gave an order for an x-ray to the right foot. Review of nurse progress note for Resident #34…

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

Based on record review, review of the facility incident log, review of facility self-reported incidents (SRI's), staff interview, and review of the facility policy, the facility failed to investigate an injury of unknown source. This affected one (#34) of two residents reviewed for abuse. The census was 68. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnosis of cerebral infarction, dementia, and diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.) Review of nurse progress note for Resident #34 dated 11/15/22 revealed the aide notified the nurse resident had a bruise to the right inner foot. Nurse assessed resident and noted resident's right ankle and foot were swollen. The attending physician was notified and gave an order for an x-ray to the right foot. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the x-ray to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to provide residents with notification of the bed hold policy when the resident was transferred/discharged to the hospital. This affected two (#09 and #61) out of two residents reviewed for bed hold notification. The facility census was 68. Findings include: 1. Record review for Resident #09 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive coronary pulmonary disease (COPD), congestive heart failure, atrial fibrillation, hypertensive heart disease, diabetes mellitus two, anemia, acute kidney failure, obesity, essential primary hypertension, osteoarthritis, and insomnia. Review of Resident #09 quarterly minimum data set (MDS) assessment, dated 10/23/22, revealed she had mildly impaired cognition. Further review of the MDS assessment revealed she required extensive assistance with most activities of daily living including bed mobility, dressing, toilet use, and personal hygiene. She 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 2. Review of Resident #2's medical record revealed an admission date of 03/13/17. admission diagnoses included cerebrovascular disease, morbid obesity, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, depression, and macular degeneration. Review of Resident #2's MDS dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 15 out of 15. Review of the MDS revealed Resident #2 required extensive one-person assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS revealed Resident #2 required supervision with set-up help for eating. Further review of section N revealed the resident received insulin, antidepressants, hypnotics, anticoagulants, diuretics and opioid's. Review of Resident #2's plan of care dated 10/25/22 revealed the resident was dependent on staff for emotional, physical, cognitive, well-being. Review of Resident #2's medical record revealed the last care conference was 07/15/21. Review of the Care Conference note…

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

Based on record review, observation, staff interview, physician and nurse practitioner (NP) interview, and review of the facility policy, the facility failed to ensure a resident with a fracture was examined in a timely manner by a physician or provider. This affected one (34) of two residents reviewed for abuse concerns. The census was 68. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.) Review of the care plan for Resident #34 dated 10/22/22 revealed resident was admitted to hospice for a terminal diagnosis of protein calorie malnutrition. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the aide notified the nurse resident had a bruise to the right inner foot. Nurse assessed resident and noted resident's right ankle…

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, observations, resident and staff interviews, and review of the facility policy, the facility failed to provide nail care for dependent residents. This affected two (#34 and 36) of three residents reviewed for activities of daily living (ADL) care. The census was 68. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the care plan for Resident #34 dated 12/27/21 revealed resident was dependent on staff for most of her ADL's due to left hemiparesis after cerebrovascular accident (CVA) and severely impaired cognition. Interventions included to check nail length and trim and clean on bath day and as necessary, report any changes to the nurse. Review of medical record for Resident #34 revealed resident was last…

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

Based on record review, observation, resident and staff interviews, and review of the facility policy, the facility failed ensure care was provided per the physician's orders. This affected two (#5 and #235) of 18 residents sampled. The census was 68. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 06/17/19 with diagnosis of Parkinson's disease. Review of the Minimum Data Set (MDS) for Resident #5 dated 10/21/22 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's.) Review of orthopedic surgeon visit note for Resident #5 dated 10/04/22 revealed the resident had sustained a fracture to her right wrist during a fall. The surgeon immobilized the wrist in a brace because he did not feel resident would tolerate wearing a cast well. Further review of the note revealed the resident should wear the brace at all times and could remove the brace when showering. Review of physician's orders for Resident #5 revealed an order dated 10/13/22 for the resident to wear a brace…

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, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were secured and stored safely. This had the potential to affect three residents (#45, #53, and #35) who resided on the facility's Blue unit that are cognitively impaired and independently mobile. Additionally, the facility also failed to ensure a resident at risk for elopement did not elope from the facility. This affected one (#61) out of one resident reviewed for elopement. The facility census was 68. Findings include: 1. Observation on 11/30/22 at 8:15 A.M. revealed a large bag of medications from the pharmacy underneath the counter at the Blue unit nurse station. Interview on 11/30/22 at 8:37 A.M., the Director of Nursing (DON) verified the large bag of medications from the pharmacy was underneath the counter, unlocked. The DON confirmed the medications should be locked inside the medication room. 2. Observation on 11/30/22 at 9:23 A.M., on the Blue unit, revealed a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations staff interviews, and policy review, the facility failed to ensure weights were obtained as ordered and according to the facility policy. Additionally, the facility also failed to ensure tube feeding was labeled and a syringe was replaced timely. This affected two (#71 and #36) of two residents reviewed for tube feeding. The facility census was 68. Findings include: 1. Review of the medical record of Resident #71 revealed an admission date of 10/10/22. Diagnoses included acute and chronic respiratory failure with hypoxia, systemic lupus erythematosus, severe protein-calorie malnutrition, oropharyngeal dysphagia, encephalopathy, chronic systolic heart failure, anemia, hypothyroidism, unspecified mood disorder, gastro-esophageal reflux disease without esophagitis, and personal history of transient ischemic attack and cerebral infarction. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to administer oxygen in accordance with a physician's order. This affected one (#36) of eight residents reviewed with orders for oxygen. Additionally, the facility also failed to ensure oxygen tubing was dated upon application. This affected three (#20, #29 and #36) of eight residents reviewed with orders for oxygen. The census was 68. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 10/17/22 with a diagnosis of adult hypertrophic pyloric stenosis. Review of the Minimum Data Set (MDS) for Resident #36 dated 10/24/22 revealed the resident was cognitively intact and required extensive assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 revealed it did not include documentation of oxygen therapy for the resident. Review of the physician orders for Resident #36 revealed there were no orders 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 record review, staff interview and policy review, the facility failed to ensure residents were free from unnecessary psychotropic drugs by failing to appropriately monitor side effects of psychotropic medications. This affected two (#8 and #11) of six residents reviewed for unnecessary medications. The facility census was 68. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 10/23/19. admission diagnoses included diabetes, chronic kidney disease, schizophrenia, arthritis, major depressive disorder, anxiety disorder, fracture of medial malleolus of the left tibia, Alzheimer's disease, heart failure, and peripheral venous insufficiency. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 10 out of 15. Review of the MDS revealed the resident required extensive one-person assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. Resident #8 was independent with set-up for eating. 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.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were administered as physician ordered resulting in two medication errors out of 34 errors or a 5.8 percent (%) medication error rate. This affected two (#19 and #31) of four residents observed for medication administration. The census was 65. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 12/23/20 with a diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure, and anxiety disorder. Review of the Minimum Data Set (MDS) for Resident #31 dated 12/31/22 revealed resident was cognitively intact and required supervision with activities of daily living (ADL's). Review of the January 2023 monthly physician orders revealed an order dated 06/03/21 for Fosamax 70 milligram (mg) tablet to be given once every seven days for osteoporosis. Observation on 01/12/23 at 9:10 A.M. of medication administration per Licensed Practical Nurse (LPN) #841 for Resident #31 revealed Fosamax was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to administer intravenous antibiotics as physician orders for the treatment of a urinary tract infection (UTI) resulting in significant medication errors. This affected one (#21) of six residents reviewed for medications administration. The facility census was 68. Findings include: Review of Resident #21's medical record revealed an admission date of 06/28/18. admission diagnoses included pneumonitis, urinary tract infection, protein-calorie malnutrition, dysphagia following a cerebral infarction, anoxic brain damage, aphasia, dysphagia, and sepsis. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status unable to be completed. Review of the MDS revealed the resident required extensive one-person assistance for bed mobility, dressing, and personal hygiene. The resident required total one-person assistance for eating and toileting. Review of Resident #21's plan of care dated 11/10/22…

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 policy review, the facility failed to ensure medications were properly secured, properly discarded and/or properly labeled. This affected three (#225, #9 and one one unknown resident) residents whose medication were left either unsecured, not properly labeled and not properly discarded. The facility census was 68. Findings include: 1. Review of discharged Resident #225 revealed an admission date of 02/07/20. admission diagnoses included acute posthemorrhagic anemia, gastrointestinal hemorrhage, congestive heart failure, atrial fibrillation, protein calorie malnutrition, dementia, and psychotic disorder. Further review revealed the resident expired in the facility on 11/11/22. Review of Resident #225's Minimum Data Set (MDS) dated revealed the resident required extensive two-person assistance for bed mobility, transfers, dressing, and toileting. The resident required extensive one-person assistance for personal hygiene. The resident 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 observations, staff interview, dietary spreadsheet review, recipe review, and policy review, the facility failed to ensure recipes were followed when preparing pureed foods and also failed to ensure proper consistency of pureed foods in an effort to ensure pureed food items were palatable. This had the potential to affect three (#12, #33, and #71) of 68 residents who received a pureed diet. The facility census was 68. Findings include: 1. Observation and interview on 11/29/22 at 11:57 A.M. revealed Dietary Staff (DS) #290 place lettuce and ranch dressing into a food processor. DS #290 stated she was preparing pureed salad for the three (#12, #33, and #71) residents on pureed diets. When queried, DS #290 stated she did not measure the lettuce before placing it in the food processor and, instead, just used what was left after preparing bowls of salad for residents on regular diets. DS #290 was unable to say how much ranch dressing was added to the food processor. DS #290 pulsed the lettuce and ranch dressing and poured the contents into three bowls. The contents were observed…

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, Centers for Medicaid and Medicare Services (CMS) Submission Report review, policy review and staff interview, the facility failed to submit the annual Minimum Data Set (MDS) assessment within the 14 days after completion of assessments. This affected two Residents (#1 and #2) out of two reviewed for resident assessment. The facility census was 71. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 07/13/18, with diagnoses including methicillin resistant staphylococcus aureus (mrsa) infection, sepsis, cellulitis, urinary tract infection, metabolic encephalopathy, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder, diabetes, morbid obesity, depression, restless legs syndrome, obstructive sleep apnea, hypertension, congestive heart failure, chronic obstructive pulmonary disease, osteoarthritis, chronic gout, acute kidney failure, altered mental status, and enterocolitis. Review of the Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure medications were accurate on the minimum data set (MDS) assessment. This affected one (#34) of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a readmission date of 07/06/18. Diagnosis included chronic obstructive pulmonary disease, congestive heart failure, and dementia. Review of annual MDS assessment dated [DATE] revealed Resident #34 received a diuretic medication for seven days and an antibiotic for three days during the seven day assessment reference dates, 08/10/19 through 08/16/19. Review of Resident #34's medication administration record (MAR) for August 2019 revealed Resident #34 received furosemide, a diuretic medication, 40 milligrams (mg) by mouth daily 08/10/19 through 08/15/19 for a total of six days and did not receive any antibiotic medication 08/10/19 through 08/16/19. 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, policy review and staff interview, the facility failed to reconcile narcotics at the time of administration. This affected one (#42) of six residents observed during medication administration. The facility census was 71. Findings include: Observation on 08/27/19 at 4:46 P.M., with Registered Nurse (RN) #15 of the Blue Hall Medication Cart #1 revealed on Resident #42's tramadol 50 milligrams (mg) narcotic sheet showed total of 22 pills. However, when the sheet was matched to the sleeve of pills there were only 21 tramadol 50 mg actually present. Interview on 08/27/19 during observation with RN #15 verified she had given the tramadol around approximately 2:00 P.M. and forgot to sign it out, at the time she administrated it. Review of the policy titled Controlled Drug Reconciliation Policy dated 11/2017, revealed controlled medications are stored under double lock, and counted at each change of shift by two nurses who sign the change of shift log verifying the count was correct and transferring responsibility. Removal of a controlled medication is recorded on 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 medical record review, policy review and staff interview, the facility failed to have a stop date for the use of as needed (prn) psychotropic medication. This affected one (#62) of five residents reviewed for unnecessary medications. The facility identified 45 residents currently receiving psychotropic medications. The facility census was 71. Findings include: Review of the medical record for Resident #62 revealed an admission date of 08/10/16, with diagnoses including cerebral infarction, hypertension, hyperlipidemia, coronary artery disease, myocardial infarction, vitamin D deficiency, urinary tract infection, benign prostatic hyperplasia, cardiac defibrillator, low back pain, angina, hypercholesterolemia, ischemic optic neuropathy, heart failure, lung disorders, shortness of breath, chronic obstructive pulmonary disease, spinal stenosis, pneumonia, metabolic encephalopathy, respiratory failure, idiopathic hypotension, diabetes, heart failure, chronic pain, depression, mood disorder, and dementia 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.