Meadowbrook Care Center

2. Observation on 05/07/25 at 10:11 A.M. of the C Hall shower room with LPN #146 revealed there was an area measuring approximately two inches by three inches of brown skid marks of an unidentified substance on the wall by the toilet. Further observation revealed the walls surrounding the entire shower area contained a layer of a brown unidentifiable material where the wall met the floor, measuring approximately two inches up the wall. Interview on 05/07/25 with LPN #146 confirmed the brown skid marks on the wall by the toilet and the brown substance on the walls surrounding the shower and all of the C Hall residents had access to the shower room. This violation represents noncompliance investigated under Master Complaint Number OH00165072 and Complaint Number OH00164179 and Complaint Number OH00161596 and Complaint Number OH00161253 Based on observation and staff interview, the facility failed to ensure adequate lighting in resident rooms. This affected one (Resident #21) of 16 residents reviewed for adequate lighting. The facility also failed to ensure a clean environment. This…

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 4. Review of the medical record for Resident #10 revealed and admission date of 12/15/22 with diagnoses including diabetes, schizoaffective disorder and chronic kidney disease. Resident #10 was hospitalized from [DATE] to 12/13/24 and returned to the facility. Review of the MDS assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for ADLs. Interview on 05/06/25 at 2:25 P.M. with Regional Operations Manager (ROM) #501 confirmed the facility failed to provide a bed hold notice to Resident #10's representative for the resident's hospitalization from 11/14/24 to 12/13/24. 3. Review of the medical record for Resident #06 revealed an admission date of 12/30/21 with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. Resident #06 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the MDS assessment for Resident #06 dated 03/21/25, revealed the resident had mild cognitive impairment and…

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

Based on review of medical records, observation, staff interview and review of the facility policy, the facility failed to serve food portions as planned by the Registered Dietitian (RD). This affected six (Residents #9, #13, #21, #30, #38, #65) of six residents with orders for a pureed diet. The facility census was 89 residents. Findings include: Review of the medical records for Residents #9, #13, #21, #30, #38 and #65 revealed the residents had physician's orders to receive a pureed diet. Observation of lunch being served on 05/07/25 at 11:27 A.M. revealed [NAME] #188 served pureed portions of barbeque ham sandwiches and pureed potatoes for Residents #9, #13, #21, #30, #38, and #65. [NAME] #18 used a four-ounce scoop to plate the pureed barbeque ham sandwiches and a three-ounce scoop for the potatoes. Further observation revealed there was a poster in the kitchen which explained coded measurement indicators on utensils for reference when portioning food. Review of the dietary spreadsheet for lunch on 05/07/25 revealed the barbeque ham sandwich portion should be five and one-half…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident physicians/medical providers of significant weight loss. This affected one (Resident #45) of eight residents reviewed for weight changes. The facility census was 89 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 08/26/24 with diagnoses including chronic obstructive pulmonary disease (COPD), panic disorder, and pulmonary hypertension. Review of the physician's orders for Resident #45 revealed an order dated 10/07/24 for daily weights. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 03/05/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the weight record for Resident #45 revealed the following weights: 187 pounds on 12/04/24, 169 pounds on 12/05/24, 169.5 pounds on 12/06/24. Interview on 05/08/35 at 2:17 PM with Dietician #504 confirmed staff did not notify Nurse Practitioner (NP) #510 of Resident #45's…

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.

3. Review of the medical record for Resident #43 revealed an admission date of 8/11/24 with diagnoses including diabetes mellitus, bipolar disorder, and Alzheimer's Disease. Review of the MDS assessment for Resident #43 dated 3/12/25 revealed the resident had severely impaired cognition and received insulin. Observation on 05/05/25 at 11:27 A.M. revealed Resident #43 was seated in the dining room with multiple residents who were waiting for lunch to be served. Registered Nurse (RN) #152 approached Resident #43 and told her she was going to check her blood sugar. RN #152 did not obtain consent from the resident. RN #152 then cleansed Resident #43's finger and pierced it with a lancet to obtain a blood sample to perform a blood sugar check. Interview on 05/05/25 at 11:35 A.M. with RN #152 confirmed she checked Resident #43's blood sugar in the dining room in the presence of other residents and did not provide visual privacy during treatment for the resident. This deficiency represents noncompliance investigated under Complaint Number OH00162453. 2. Review of the medical record for…

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

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure hypnotic medications were used with adequate indications for administration and with adequate monitoring. This affected one (Resident #75) of five residents reviewed for unnecessary medications. The facility census was 89 residents. Findings include: Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the use of Ambien, a hypnotic…

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, resident interview, and staff interview, the facility failed to ensure the accuracy of resident Minimum Data Set (MDS) assessments regarding resident dental status and range of motion and mobility. This affected three (Residents #19, #75 and #80) of 21 residents reviewed for MDS accuracy. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and was not coded as edentulous (having no natural teeth.) Observation on 05/05/25 at 11:35 A.M. of Resident #19 revealed the resident was edentulous. Interview on 05/05/25 at 11:36 A.M with Resident #19 confirmed he was edentulous and had been so upon admission 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) was completed within 30 days of being admitted to the facility with a hospital exemption. This affected one (Resident #19) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the hospital exemption from preadmission screening notification for Resident #19 dated 03/22/25 revealed the resident had a mental disability that was not…

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

Based on medical record review and staff interview facility failed to revise Preadmission Screening and Resident Review (PASARR) assessments after a change in resident condition. This affected one (Resident #58) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #58 revealed an admission date of 03/08/22 with diagnoses including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes. Review of the physician's orders for Resident #58 revealed an order dated on 09/11/24 for the resident to begin receiving hospice services. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 02/28/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Interview on 05/08/25 at 9:20 A.M. with Social Worker (SW) #205 on 05/08/25 confirmed the facility should have completed an updated PASARR for Resident #58 when the resident was enrolled in hospice on 09/11/24, but 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 medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive resident care plans. This affected two (Residents #19 and #75) of 21 residents reviewed for care planning. The facility census was 89. Findings include: 1.Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to conduct quarterly care conferences. This affected three (Residents #10, #24, and #81) of four residents reviewed for care planning. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including dementia, schizophrenia, bipolar disorder, and diabetes mellitus type two. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the care conference records for Resident #10 revealed the revealed the facility did not conduct a quarterly care conference for Resident #10 for the first, second, and third quarters of 2024. The only documented quarterly care conference for Resident #10 was on 10/03/24. Interview on 05/08/25 at 11:52 A.M. with the Social Services Director (SSD) #205 confirmed care conferences were to be conducted…

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

Based on medical record review and staff interview, the facility failed to reassess resident nutritional status following hospitalization. This affected one (Resident #81) of two residents reviewed for readmission. The facility census was 89 residents. Findings include: Review of the medical record for Resident #81 revealed an admission date of 12/19/24 with diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 03/26/25 revealed the resident had intact cognition and required minimal staff assistance for activities of daily living (ADLs.) Review of the May 2025 monthly physician's orders for Resident #81 revealed orders for the resident to have low concentrated sugar renal diet with a fluid restriction of 2000 milliliters (ml) per day. Review of hospital records for Resident #81 dated 03/31/25 to 04/11/25 revealed the resident was hospitalized for volume overload and had 44 pounds of fluid removed during the stay hospitalization. Resident #81's hospital admission weight 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.

2. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including osteoarthritis, benign prostatic hyperplasia glaucoma, chronic kidney disease, and intellectual disabilities. Review of the MDS assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired, required supervision with ADLS, and was admitted with two stage III pressure ulcers and one unstageable pressure ulcer. Review of the care plan for Resident #19 dated 04/01/25 revealed the resident was at risk for the development of pressure ulcers related to the disease process, decreased mobility and moisture exposure. Interventions included staff to administer treatments as ordered and monitor for the effectiveness and to follow facility protocols for the prevention of and treatment of skin breakdown. Review of the wound assessment for Resident #19 dated 04/02/25 per WNP #502 revealed upon admission the resident had the following three pressure ulcers: a stage three pressure ulcer to the left buttock which measured 3.5 centimeters (cm) in…

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

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff administered resident tube feedings in a sanitary manner. This affected one (Resident #75) of one residents reviewed for tube feeding. The facility census was 89 residents. Findings include: Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with dysphagia following cerebral infarction, generalized anxiety disorder, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and had a gastrostomy tube. Review of the physician's orders for Resident #75 revealed an order dated 10/24/24 for an enteral feeding two times a day of Jevity 1.5 to be administered via pump at 70 cubic centimeters (cc) per hour 8:00 P.M. to 6:00 A.M. Review of the care plan for Resident #75 dated 11/11/24 revealed the resident required tube feedings related to dysphagia. Interventions included the following: elevate the head of the bed 45 degrees during 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 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 a medication error report, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for medication errors. The facility census was 89 residents. Findings include:Review of the medical record for Resident #200 revealed an admission date of 01/17/25 with diagnoses including chronic diastolic heart failure, anxiety disorder, acute respiratory failure with hypoxia, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease The resident discharged to the hospital on [DATE]. Review of the Minimum Data Set MDS assessment for Resident #200 dated 01/23/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.)Review of the medical record…

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

Based on medical record review, observation, staff interview, and consulting pharmacist interview, the facility failed to ensure insulin pens were properly labeled and stored. This affected three (Residents #65, #39 and #34) of 21 facility- identified residents who received insulin. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 02/18/25 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment for Resident #65 dated 03/25/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #65 revealed an order dated 02/18/25 for the resident to receive insulin lispro per sliding scale. Observation on 05/06/25 at 10:46 A.M. of the A-nursing unit front medication cart revealed the cart contained two insulin lispro pens for Resident #65 that were not dated. Interview on 05/06/25 at 10:46 A.M. with Licensed Practical Nurse (LPN) #260 confirmed the two insulin lispro pens…

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

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide specified foods for residents with physician's orders to be on a renal diet. This affected one (Resident #81) of two residents reviewed for specialized diets. The facility total census was 89 residents. Findings include: Review of the medical record for Resident #81 revealed an admission date of 12/19/24 with diagnoses including end stage renal disease with dialysis, congestive heart failure, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 03/26/25 revealed the resident had intact cognition and required minimal staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #81 revealed the resident was ordered a renal diet with low concentrated sugar and had a fluid restriction of 2000 milliliters (ml) per day. Review of the breakfast meal ticket for Resident #81 dated 05/07/25 revealed the resident was to receive six ounces of apple or cranberry juice 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.

2. Review of the medical record for Resident #18 revealed an admission date of 02/22/25 with diagnoses including rhabdomyolysis,COPD, and chronic respiratory failure. Review of the MDS assessment for Resident #18 dated 03/06/25 revealed the resident had severe cognitive impairment and required staff assistance with ADLs. Observation on 05/06/25 at 10:59 A.M. revealed Certified Nursing Assistant (CNA) #882 was wearing gloves and entered Resident #18's room Observation on 05/06/25 at 11:00 A.M revealed CNA #882 exited Resident #18's room still wearing gloves and assisted the resident to the dining room. Interview on 05/06/25 at 11:02 AM with CNA #882 confirmed she entered Resident #18's room and she was wearing gloves. CNA #882 confirmed she assisted Resident #18 to the dining room and she was still wearing the same gloves that she was wearing upon entry to the resident's room. This deficiency represents noncompliance investigated under Master Complaint Number OH00165072 and Complaint Number OH00162543. Based on medical record review, observation, staff interview, and review of the…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a residents and/or resident representative received education regarding the benefits and potential side effects of the influenza immunization. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease. Review of the physician order's orders for Resident #10 revealed an order dated 10/24/24 for the resident to receive the influenza vaccine. Review of the Medication Administration Record (MAR) for Resident #10 dated October 2024 revealed on 10/24/24 the resident was documented as having refused the influenza vaccine. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the Coronavirus (COVID-19) vaccine. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease. Review of the immunization record for Resident #10 revealed the resident received a COVID-19 booster vaccine on 06/09/22 prior to admission to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #10 from 01/01/24 to 05/08/25 revealed the resident did not have a COVID-19 vaccine consent or declination form in his chart.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy, the facility failed to ensure their policy regarding abuse was implemented when facility staff found a male and female resident in a bed together. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, malnutrition, anxiety, depression and hypertension. Resident #4 resided on the secured memory care unit. Resident #4 had been deemed incompetent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition, no range of motion impairment of upper and lower extremities and was frequently incontinent of bowel and bladder. The resident required supervision with eating, bed mobility and transfers, moderate assistance for oral and personal hygiene, toileting and dressing and maximal assistance for bathing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to timely report an an alleged incident of abuse. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, malnutrition, anxiety, depression and hypertension. Resident #4 resided on the secured memory care unit. Resident #4 had been deemed incompetent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition, no range of motion impairment of upper and lower extremities and was frequently incontinent of bowel and bladder. The resident required supervision with eating, bed mobility and transfers, moderate assistance for oral and personal hygiene, toileting and dressing and maximal assistance for bathing. Review of the medical record…

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, interview, and policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing high-contact care to residents in Enhance Barrier Precautions (EBP). This had the potential to affect all residents. The facility census was 93. Findings include: Review of the medical record revealed Resident # 46 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type II diabetes, and chronic viral hepatitis C. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 04/26/2024 revealed Resident #46 had Enhanced Barrier Precautions (EBP) secondary to increased risk for potential infection related to Candida Auris. Interventions included educating residents 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 observation, record review, staff interview, and policy review, the facility failed to ensure residents had access to call lights. This affected one (Resident #46) of five residents sampled for call lights. The facility census was 93. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type II diabetes, and chronic viral hepatitis C. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of care plan dated 11/22/2022 revealed Resident #46 had an Activities of Daily Living (ADL) self-care performance deficit related to disease process and required staff assistance to complete ADL tasks. Interventions included encourage the resident to utilize the call light for assistance as needed,…

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, interview, and policy review, the facility failed to ensure residents received wound care as ordered. This affected one (Resident #41) of one resident of two reviewed for wounds. The facility census was 93. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included ataxic cerebral palsy, idiopathic gout, morbid obesity, type II diabetes, chronic diastolic heart failure, unspecified Chronic Obstructive Pulmonary Disease (COPD), and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 06/27/2023 revealed Resident #41 was at increased risk for pressure ulcer development related to disease process. Interventions included, administer medications as ordered, administer treatments as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents received pain medications timely. This affected one (Resident #75) of six residents sampled for medication administration. The facility census was 93. Findings include: Review of the medical record revealed Resident #75 admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, vitamin chronic pain disease, depression, adjustment disorder with depressed mood, pain in right hip, pain in right shoulder, anxiety disorder, and dermatitis. Resident #75 had no recorded diagnosis for Alzheimer's disease or any other form of dementia. Review of Resident #75's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, had no behaviors, did not wander, and did not reject care. Review of care plan dated 03/24/2024 revealed Resident #75 had chronic pain related to arthritis and depression. Interventions included to administer analgesia…

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, interviews, and policy review, the facility failed to ensure residents received medications as ordered and to maintain a medication error rate of less than 5%. This affected two (Residents #41 and #51) of six residents sampled for medication administration. The facility census was 93. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included ataxic cerebral palsy, idiopathic gout, morbid obesity, type II diabetes, chronic diastolic heart failure, unspecified Chronic Obstructive Pulmonary Disease (COPD), and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #41 had physician orders for Cymbalta Delayed Release (antidepressant) 20 mg capsule by mouth once…

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, and staff and resident interviews, the facility failed to ensure a pressure ulcer dressing change was completed per physician orders. This affected one (#93) of three residents reviewed for pressure ulcers. The facility identified four pressure ulcers in the facility. The facility census was 99. Findings include: Review of Resident #93's medical record revealed an admission date of 11/14/23. Diagnoses included neurogenic bladder, peripheral vascular disease, depression, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/21/24, revealed Resident #93 was cognitively intact. Further review revealed Resident #93 required set-up and clean-up assistance for eating, partial/moderate assistance for toileting, and supervision/touching assistance for bed mobility. Additionally, Resident #93 was coded for a stage four pressure ulcer to her sacrum and had a colostomy. Review of the most recent care plan revealed Resident #93 had a pressure ulcer to her sacrum related to immobility. Interventions included to document…

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, medical record review, staff interview and review of facility policy, the facility failed to ensure proper colostomy care was provided. This affected one (#77) of three residents reviewed for colostomy care. The facility identified three residents with colostomies. The facility census was 99. Findings include: Review of Resident #77's medical record revealed an admission date of 03/13/23. Diagnoses included chronic ischemic heart disease, coronary artery disease, renal insufficiency, anxiety, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 03/14/24, revealed Resident #77 was cognitively intact. Further review revealed Resident #77 required substantial/maximal assistance for toileting and partial/moderate assistance for bed mobility and transfers. Resident #77 was coded as having a colostomy. Review of the plan of care, dated 03/20/24, revealed Resident #77 required the use of a colostomy. Interventions included to provide ostomy care per order to prevent odors and keep the ostomy patent. Observation on 05/07/24 at 1:14 P.M. of…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure the attending physician completed resident visits every 60 days. This affected two (#2 and #3) of three residents reviewed for physician visits. The facility census was 99. Findings included: 1. Review of the medical record for Resident #2 revealed an admission date of 01/24/21. Diagnoses included hypertension, hyperlipidemia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/30/24, revealed Resident #2 was severely cognitively impaired. Further review of Resident #2's medical record from 12/01/23 through 05/07/24 revealed no evidence of a physician visit. 2. Review of the medical record for Resident #3 revealed an admission date of 01/13/23. Diagnoses included hypertension, dementia, hyperlipidemia, and traumatic brain injury. Review of quarterly MDS assessment, dated 04/24/24, revealed Resident #3 was severely cognitively impaired. Further review of Resident #3's medical record from 12/01/23 through 05/07/24 revealed no evidence of a…

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

Based on employee file review and staff interviews, the facility failed to ensure they employed a qualified dietary manager. This had the potential to affect all 96 residents who received food from the kitchen. The facility census was 97. Findings include: Review of Dietary Manager (DM) #105's employee file revealed DM #105 was hired on 04/07/23 and was not a certified diet manager or food service director in the state. The Director of Food Service Job Description, signed by the Diet Manger #105 and the Administrator on 04/07/23, revealed the diet manager must be a food service director in the state. Interview on 11/14/23 at 3:08 P.M. Dietary Manager #105 revealed the registered dietitian was part time, a diet technician visits two times a week, and there was no certified dietary manager at the facility. DM #105 verified she was not a certified dietary manager, had not enrolled in a certified dietary manager course or food service director program from the state. DM #105 stated she had no dietary manager orientation training. Interview on 11/14/23 at 3:08 P.M. with the Administrator…

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 a facility policy, the facility failed to store food, drink, and meal services items in a safe and sanitary manner. This had the potential to affect all 96 residents who received food from the kitchen. The facility identified one (#1) resident who had orders for nothing by mouth. The facility census was 97. Findings Include: 1. Observation of the kitchen during tour on 11/13/23 from 8:45 A.M. to 9:05 A.M. revealed an unlabeled and undated three gallon pitcher of liquid, a container of sauerkraut dated 11/09/23, and an open container of whole milk with no date in the reach-in refrigerator; an open container of grape jelly with no open date and six bags of rolls with no open or expiration date on the food preparation counter; no thermometer inside the milk cooler; no thermometer in the ice cream freezer and no documentation ice cream freezer temperatures from October and November 2023; there were open containers and bags of french fried onions and pasta with no open dates, boxes of cream of wheat, oats, and rice with no received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, resident interviews, and policy review, the facility failed to ensure residents had a safe, comfortable, and homelike environment. This affected eight (Residents #36, #13, #58, #45, #86, #55, #30, and #78) of eight residents reviewed for environment. Additionally, this affected all residents residing on the Unit B Memory Care Unit (MCU). The census was 97. Findings included: 1. Observation of Resident #36's and Resident #13's room on 11/13/23 at 2:19 P.M. revealed the walls in the room had plaster on them that didn't match the paint, there were scuff marks on the sliding door that went into the bathroom, and the top of the vanity was scarred up and had ink of newspaper imbedded in the top of it. 2. Observation of Resident #58's and Resident #45's room on 11/14/23 at 7:18 A.M. revealed dry wall was missing from the sliding door that went into the bathroom. 3. Observation and interview 11/15/23 at 8:21 A.M. with Resident #86 revealed she was sitting in her room with a jacket…

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 pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications to residents. This affected three (Resident #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the unlicensed company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications. This affected three (Residents #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required 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, observation, and staff interview, the facility failed to provide puree foods per the spreadsheet approved by the dietitian. This had the potential to affect six (Residents #52, #30, #13, #4, #45 and #55) who received puree consistency diets from the kitchen. The facility census was 97. Findings include: Medical record review for Residents #52, #30, #13, #4, #45, and #55 revealed all residents were ordered to receive puree diets. Review of the dinner menu spreadsheet dated 11/14/23 revealed the puree consistency diet was to be prepared with puree carrots and the carrots and the bread was to be pureed separately. The puree carrot portion was four ounces and the puree bread was two ounces. Observation on 11/14/23 at 2:56 P.M. revealed [NAME] #107 prepared puree corn and puree bread together for the vegetable puree. The puree bread was not separated from the puree corn. [NAME] #107 prepared corn, and not carrots as listed on the spreadsheet. The menu spreadsheet and recipe were not used by [NAME] #107. Interview on 11/14/23 at 2:56 P.M. [NAME] #107 verified he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Residents #47, #78, and #87) of three reviewed for medications administered by IV Company #700. The facility identified 22 Residents (#1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order 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 review of the facility's infection control log, staff interview, and review of facility policy, the facility failed to have an affective antibiotic stewardship program. This affected five (#2, #23, #41, #61, and #91) of five residents reviewed on the infection log. The census was 97. Findings include: Review of the facility's infection log for October 2023 revealed Resident #2, Resident #23, Resident #41, Resident #61, and Resident #91 were ordered and received antibiotic medications for suspected urinary tract infections (UTIs). On 10/01/23, Resident #61 had increased confusion with no elevated temperature and was started on an antibiotic. Resident #61 was noted to have a UTI without a urinary catheter. On 10/04/23, Resident #91 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and was started on an antibiotic. On 10/06/23, Resident #2 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and started on an antibiotic. On 10/17/23, Resident #23 had no elevated temperature, but was determined…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure call lights located in resident bathrooms had pull cords and residents would be able to activate if on the floor. This affected four (#29, #31, #89, and #407) of four residents reviewed for call light functionality. The census was 97. Findings include: Observation of four (#29, #31, #89, and #407) resident's bathrooms on 11/14/23 from 3:40 P.M. to 3:45 P.M. revealed the bathroom call lights did not have pull cords to activate the lights. During an interview on 11/14/23 at 3:50 P.M., the Director of Nursing (DON) confirmed Resident #29, Resident #31, Resident #89, and Resident #407's bathroom call lights did not have pull cords. The DON confirmed the four identified residents would not be able to activate the call light if the resident was on the floor in the bathroom. The DON also confirmed the four identified residents were capable of independently activating a call light. Review of the facility policy titled, Answering the Call Light, dated 01/12/20, revealed staff should be sure…

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 residents were treated with dignity and respect. This affected two (Residents #47 and #44) of two residents reviewed for dignity and respect. The census was 97. Findings included: 1. Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation on 11/14/23 at 11:30 A.M. revealed State Tested Nurse Aide (STNA) #168 was assisting Resident #47 with getting dressed. The resident said, Help me, constantly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected one resident (Resident #33) of eight residents reviewed for advanced directives. The facility census was 97. Findings include: Review of Resident #33's medical record revealed an admission date of 02/08/22. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, acute pulmonary edema, heart failure, psychotic disorder with delusions due to known physiological, dementia, anxiety, and major depression disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was mildly cognitively impaired. Review of Resident #33's paper medical record revealed a Do Not Resuscitate (DNR) Order Form dated 02/09/22 revealing the resident's advanced directive was DNR Comfort Care Arrest. Review of the current physician order dated 08/15/22, located in the electronic medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident received regular care conferences. This affected one (Resident#29) of one reviewed for care conferences. The census was 97. Findings include: Review of Resident #29's medical record revealed an admission date of 12/26/22. Diagnoses listed included prostate cancer, spinal stenosis, major depressive disorder, hypertension, and Parkinson's disease. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact and required extensive assistance with activities of daily living (ADLs). Further review of MDS information revealed quarterly assessments were completed on 04/04/23, 07/04/23, and 09/07/23. Review of social service progress notes revealed a care conference was last held for Resident #29 on 03/16/23. During an interview on 11/15/23 at 10:28 A.M. the Administrator confirmed a care conference was not held for Resident #29 since March 03/16/23. The Administrator confirmed care…

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 a resident's feet were kept clean. This affected one (Resident #47) of four residents reviewed for activities of daily living assistance. The census was 97. Findings included: Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation of Resident #47's feet on 11/13/23 at 10:04 A.M. revealed they were covered with a dark brown substance on the bottom of them. At 10:32 A.M. the Licensed Practical Nurse Unit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to provide incontinence care per standards of care. This affected one (Resident #47) of one resident observed for incontinence care. The facility census was 97. Findings include: Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation of incontinence care for Resident #47 on 11/14/23 at 11:43 A.M. revealed STNA #168 removed a soiled brief from the resident, stood her up on her walker, and took a wet towel and bent the resident over…

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 interviews, resident interview, and review of facility policy, the facility failed to complete a urinalysis as ordered. This affected one (Resident #78) of one resident reviewed for laboratory services. The facility census was 97. Findings include: Review of medical record for Resident #78 revealed an admission date of 03/17/23. Diagnoses included delusional disorders, chronic viral hepatitis C, depression, type 2 diabetes mellitus with hyperglycemia, opioid abuse, other stimulant abuse, vascular dementia moderate with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #78 required staff assistance to complete Activities of Daily Living (ADL) tasks. Resident #78 was occasionally incontinent of bladder. Review of nurse's notes for Resident #78 dated 10/18/23 at 4:18 P.M. revealed the resident was noted with increased behaviors as well as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, and staff interview, the facility failed to revise the care plans when new conditions were identified for two (#33 and #102) out of 26 residents reviewed for care plans. Facility census was 131. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE]. Diagnoses included multiple sclerosis, pseudomonas, anoxic brain damage, chronic respiratory failure, tracheostomy, gastrostomy, epilepsy, dysphagia, tachycardia, altered mental status, and supplemental oxygen. Review of the quarterly Minimum Data Set assessment, dated 11/05/19, revealed Resident #33 had moderately impaired cognitive skills, required total dependence from staff for all activities of daily living. Resident #33 has impairments to bilateral upper and lower extremities. Review of Occupational Therapy (OT) notes, dated 05/30/19, revealed a goal for Resident #33 to tolerate assessment and trial/provision of hand splint for right hand with contractures noted 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.