Woods Edge Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control techniques were properly maintained during wound care. This affected one (Resident #15) of three Residents reviewed for wound care. The facility census was 75. Findings include:Medical record review for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnoses included hemiparesis/hemiplegia, Alzheimer ' s dementia with associated cognitive and decision-making impairments, peripheral vascular disease, and hypertension. Resident #15 required a guardian for his care. Resident #15 was ordered to be in Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was cognitively impaired and dependent on staff for activities of daily living (ADL). Was assessed to have a stage IV pressure ulcer (a severe,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review medication administration records and controlled drug records, staff interview, and policy review, the facility failed to ensure administration of a narcotic pain medication was documented on the medication administration record. This affected one (#13) of three residents reviewed for medication administration documentation. The facility census was 83. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required supervision with eating and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the census profile revealed Resident #13 transitioned to hospice services on 08/14/24. Review 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 observation, staff interview, and policy review, the facility failed to properly label prepared foods in the refrigerator. This had the potential to affect all residents residing in the facility who receive food from the kitchen. The facility census was 85. Findings include: Observation and interview on 03/18/25 at 8:53 A.M. with Kitchen Supervisor (KS) #43 revealed during a tour of the kitchen, there were two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice that were not labeled or dated inside the refrigerator. KS #43 verified the two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice were not labeled or dated. KS #43 stated they should be labeled and dated. Review of the facilities Dietary/Food Handling policy dated 01/2023 revealed food is to be dated and labeled upon arrival from vendor and/or upon preparation date. This deficiency represents non-compliance investigated under Complaint Number OH00162926.

Based on interview, observations and record review, the facility failed to serve specialized diets as planned by the Registered Dietitian (RD). This affected 15 residents, (#01, #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #69, #72, #77, and #87) of the 89 residents receiving food from the kitchen. The facility census was 90. Findings Include: Review of the physician orders revealed Residents #01 and #69 had diet orders for puree food texture consistency. Residents #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #72, #77, and #87 had physician orders for a mechanical soft food texture consistency. Review of the lunch menu diet spreadsheet revealed the puree texture diet was to be served puree green beans. The mechanical foods texture diets were to be served green beans. Observation on 11/04/24 at 11:40 A.M. of the lunch meal service revealed the puree texture diets of Resident #01 and #69 and mechanical soft texture diets for Residents #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #72, #77, and #87 received no green beans or other like vegetable. Interview on 11/04/24 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 staff interviews, observations and record review, the facility failed to provide adequate supervision to prevent the elopement of one (#59) of the three residents reviewed. The facility census was 90. Findings Include: Review of the medical record for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, dementia, chronic obstructive pulmonary disease (COPD), diabetes, drug abuse, and tobacco use. Review of a physician order dated 01/24/24 for Resident #59, revealed the resident was ordered to be on a secured unit due to vascular dementia and schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 had moderately impaired cognition and was independent for ambulation. The resident resided on a secured behavior unit. Review of the most recent care plan for Resident #59, revealed the resident resided on a secured unit to promote the resident's safety related to cognitive impairment, elopement risk, exit seeking…

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

Based on observation, record review and interview, the facility failed to ensure menus were followed and residents were notified of menu changes prior to the meal. This had the potential to affect 88 of 89 residents. The facility identified one Resident (Resident #33) who did not receive food from the kitchen. The facility census was 89. Findings include: During observations on 06/03/24 between 10:50 A.M. and 11:10 A.M., the menus posted on each unit indicated the residents were to receive turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/03/24 and were to receive a baked pork chop, stuffing, green beans, and a dinner roll for the supper meal on 06/02/24. Review of the menu for the current week had had turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/02/24. Review of the Daily Menu for 06/02/24 listed a baked pork chop, stuffing, green beans, and a dinner roll for supper The menu for 06/03/24 had turkey and rice casserole, green peas, and a biscuit for the supper meal. During an observation on 06/03/24 at 4:44 P.M., the tray…

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

Based on observation, record review and interview, the facility failed to ensure recipes were followed and that the food was visually appealing. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive meals from the kitchen. The facility census was 89. Findings include: Review of the menu for the current week revealed the residents were to receive an open-faced turkey sandwich with gravy, roasted potatoes, and a California vegetable blend for lunch on 06/03/24. Review of the daily menu for 06/03/24 revealed the residents were to receive an open faced turkey sandwich with gravy, mashed potatoes, and a California vegetable blend. Review of the recipe revealed the open faced turkey sandwich was to consist of a slice of toast with three ounces of sliced turkey, mashed potatoes on top of the turkey, and turkey gravy over the sandwich. During observations on 06/03/24 between 12:10 P.M. and 1:00 P.M., residents on all units received a piece of white bread with a chopped meat with a reddish-brown gravy served on top with…

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

Based on observation, interview and policy review, the facility failed to ensure employees wore hair nets while preparing and serving food and beverages. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive food from the kitchen. The facility census was 89. Findings include: During an observation on 06/03/24 at 4:28 P.M., Dietary Aide (DA) #415 was standing at the juice machine in the kitchen, pouring drinks, in preparation for the dinner meal. DA #415 was not wearing a hairnet. During interview at the time of the observation, Dietary Supervisor (DS) #405 verified DA #415 was not wearing a hairnet and told DA #415 to go put a hairnet on. During an observation on 06/03/24 at 4:29 P.M., DA #415 put a hairnet on, however his braids were not fully covered. During observation on 06/03/24 at 4:34 P.M., Dietary [NAME] (DC) #430 was standing at the steam table stirring the food that would be served for the dinner meal. DC #430 was wearing a hairnet, however her braids were sticking outside of the hairnet, not fully…

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 residents were fed in a safe and dignified manner. This affected one (Resident #64) of one resident reviewed for dignity. This had the potential to affect all 89 residents in the facility. Findings include: During an observation on 06/03/24 at 12:21 P.M., State Tested Nursing Assistant (STNA) #300 was standing in the hallway at the nurse station on the 400-hall feeding Resident #64. Resident #64 was seated in a reclining geri-chair facing away from the nurse station. STNA #300 was standing behind Resident #64, reaching around him and putting food into his mouth. There was a cart containing trays for the lunch meal approximately three feet away from the resident's geri-chair. There was no chair in the vicinity for STNA #300 to sit on. During an interview at the time of the observation, STNA #300 verified she was standing to feed Resident #64 and was not facing him as she fed him. STNA #300 stated she was standing to feed Resident #64 because the cart was in her way. STNA #300 did not say why she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a resident's compression stockings were applied as ordered to treat edema. This affected one (Resident #80) of three residents reviewed for edema. The facility census was 89. Findings include: Review of the medical record revealed Resident #80 was admitted on [DATE]. Diagnoses included nerve root and plexus disorder, wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia. Resident #80 had a physician order 05/24/24 to apply compression wraps to bilateral lower extremities, on in the morning, off at night. During an observation on 06/03/24 at 12:27 P.M., Resident #80 had swelling in her legs and was not wearing any compression hose. During interview at the time of the observation, Resident #80 stated she asked for compression hose, however had not been provided with any. During an observation on 06/03/24 at 5:04 P.M., Resident #80 was…

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

Based on record review, interview and policy review, the facility failed to ensure residents were seen by the physician as required. This affected one (Resident #80) of three residents reviewed for physician visits. The facility census was 89. Findings include: Review of the medical record of Resident #80 revealed an admission date of 03/27/24. Diagnoses included nerve root and plexus disorder, wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/02/24, revealed the resident had moderately impaired cognition. Review of facility physician, physician assistant (PA), and nurse practitioner (NP) visits revealed Resident #80 was seen by the physician on 03/29/24, physician assistant on 04/05/24, and the nurse practitioner on 05/24/24 and 05/30/24. During an interview on 06/04/24 at 10:52 A.M., the Director of Nursing (DON) verified Resident #80 was not seen by the physician as required. The DON verified residents…

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

Based on observations, staff interviews, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all but one resident (#17) who facility identified as not receiving food from the kitchen. The facility census was 86. Findings include: Observation of the kitchen on 03/25/24 at 8:50 A.M. with the Admissions Director (AD) #60 revealed Kitchen Aide (KA) #55 was not wearing a hair net while working in the kitchen. Interview with AD #60 at the same time verified KA #55 was not wearing a hairnet while working in the kitchen. Observation of the kitchen on 03/26/24 at 9:03 A.M. with Kitchen Director (KD) #56 revealed KA #54 was wearing a hairnet; however, KA #54's hair hung down and extended outside of the hair net. Interview at the same time with KD #56 verified KA #54's hair hung down and outside of the hairnet. KD #56 verified Resident #17 was the only resident who did not receive food from the kitchen. Review of the 01/01/23 facility policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and review of facility policy, the facility failed to provide a clean, sanitary, and homelike environment. This affected one (#15) resident of the three residents reviewed for environment. The facility census was 86. Findings include: Record review for Resident #15, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, schizoaffective disorder, constipation, diabetes mellitus, and chronic back pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 revealed the resident had significant cognitive deficits and required supervision with activities of daily living (ADLs). Interview with Resident #15 on 03/25/24 at 2:00 P.M. revealed there were bugs in his room all the time. Observation at the same time revealed four roaches crawling on the floor and one roach was crawling up the wall. Resident #15 killed them all. Interview with Licensed Practical Nurse (LPN) #66 on 03/25/24 at 2:30 P.M. reported there…

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

Based on record review, staff interview, and review of the policy, the facility failed to conduct a timely post-fall investigation. This affected one (#76) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/23/22, with diagnoses including: chronic obstructive pulmonary disease (COPD), acute kidney failure (AKF), dementia without behavioral disturbance, and hypertension. Review of the fall risk assessment for Resident #76 dated 05/28/23 revealed resident was at risk for falls. Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 07/01/23 revealed resident was cognitively impaired and required supervision and set up help with activities of daily living (ADLs.) Review of the nurse progress note for Resident #76 dated 07/25/23 revealed the resident had an unwitnessed fall and was found in his room lying on the floor perpendicular to his bed. Resident #76 reported he had fallen but couldn't state when the event had occurred. Resident #76 was sent to the…

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

Based on the staffing punch detail, review of the schedule, and staff interview, the facility failed to ensure there was Registered Nurse (RN) coverage for eight consecutive hours, seven days each week. This had the potential to affect all residents. The facility census was 79. Findings included: Review of the staffing punch details for the two weeks prior to survey revealed there was no RN coverage on 01/28/23 and 01/29/23. Review of the schedule during the week of survey revealed there was no RN scheduled on 02/07/23. An interview was conducted with the Administrator on 02/09/23 at 12:40 P.M. She verified there was no RN working on the 01/28/23, 01/29/23, and 02/07/23. She stated when there was a need for a nurse at times the Director of Nursing (DON) would come in, but the DON did not work those days. The Administrator stated they had one full time RN and two as needed RNs on staff.

Based on observation, review of the dishwasher manufacturer's recommendations, review of facility policy, and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, dishware was properly sanitized, and food was stored to prevent contamination. This affected 77 residents who received food from the kitchen. Resident #5 and #54 received no food by mouth. The facility census was 79. Findings include: Observation of the kitchen on 02/06/23 at 11:05 A.M. revealed lunch food items were on the steam table in the kitchen next to a wire that went from the ceiling to the steam table. The wire was observed to have a fuzzy brown debris on it. There was a red fire blanket on the wall next to the stove which had brown debris on the top of it. Observation of the ceiling above the steam table revealed the ceiling to have a large circular area where the paint was visibly chipping from the ceiling. Observation of the toaster in the kitchen revealed a fan with gray debris to be sitting on top of the toaster pointing towards the steam table area. Observation 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 observation, review of orders for dietary products, and staff interview, the facility failed to ensure residents were not served on disposal plates. This affected 24 (#2, #6, #12, #13, #15, #16, #21, #23, #26, #28, #34, #39, #40, #41, #49, #50, #51, #60, #61, #64, #67, #68, #69 and #75) residents out of 77 residents that received meals from the facility kitchen. The facility census was 79. Findings include: Observation of tray line in the kitchen on 02/08/23 at 11:32 A.M. revealed Dietary [NAME] #77 to serve food items on Styrofoam plates for the second floor men's unit. The plates were then covered with additional Styrofoam plates and placed on the meal cart. Interview on 02/08/23 at 11:32 A.M. with Dietary [NAME] #77 and Dietary Supervisor #77 revealed the kitchen had ran out of regular plates and plate covers and had to serve the second floor men's unit their meals on Styrofoam plates with Styrofoam plates covering the top of the plates. Dietary Supervisor #77 stated the plates and plate covers were back ordered and the facility had not had enough plates to serve all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided Notice of Medicare Non Coverage (NOMNC) to inform the resident of the right to an expedited review of a services termination or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) to inform the resident of the potential liability for a non covered stay. This affected three (#24, #233, and #234) out of three residents reviewed for beneficiary notices. The facility census was 79. Findings include: 1. Review of the Resident #24's medical record revealed an admission to the facility on [DATE]. Diagnoses included iron deficiency anemia, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, spondylosis, osteoarthritis, and major depressive disorder. Review of Resident #24's payer source documentation revealed Resident #24 was on Medicare Part A from 11/04/22 to 11/22/22. Resident #24's payer source was changed to Medicaid on…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide daily activities of daily living (ADL) in the form of hair care, hygiene, dressing, and getting out of bed for one (#27) out of 23 residents reviewed. The facility census was 79. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/14/21. Diagnoses included encephalopathy, gout, Alzheimer's Disease, hypertension, insomnia, dementia, and diverticulosis of intestine part. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/16/22, revealed the resident had severely impaired cognition. The resident was dependent for bathing and required extensive staff assistance for hygiene, dressing, and transfers. Review of the plan of care dated 08/04/22 revealed the resident had behaviors of refusing adequate personal hygiene (bathing, changing clothing, oral care, verbal, and physical aggression towards staff during care. Interventions included anticipate and meet resident's needs. Observation on 02/06/23 at…

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

Based on observations, record review and staff interviews, the facility failed to ensure residents were provided activities. This affected two (#27 and #46) out of three residents reviewed for activities. The facility census was 79. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 12/14/21. Diagnoses included encephalopathy, gout, Alzheimer's Disease, hypertension, insomnia, dementia, and diverticulosis of intestine part. Review of Resident #27's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/16/22, revealed the resident's cognition was severely impaired. Section F on MDS Activities revealed it was somewhat important to Resident #27 to have books, newspapers, and magazines to read, somewhat important to listen to music, somewhat important to do favorite activities. Review of the plan of care dated 08/04/22 revealed the resident was refusing adequate personal hygiene (bathing, changing clothing, oral care, verbal, and physical aggression towards staff during care. Interventions included anticipate and meet resident'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.

Based on observations, medical record, resident and staff interviews, the facility failed to ensure a resident was served a meal to accommodate her food preference. This affected one (#14) of one resident reviewed for meal preferences and allergies. The facility census was 79. Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/23/20. Diagnoses included asthma, schizophrenia, cerebral aneurysm, hypertension, dementia, personality disorder and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/22, revealed the resident had intact cognition. The resident required limited assistance with one person for physical assist for eating. Review of the admission Nutritional Assessment, dated 09/29/20, revealed the resident requests excess beverages often-prune juice, cranberry juice, and Lactaid milk. The resident was obsessed with health and bowels in the past. Likes most foods however periods of changing food preferences and dislikes. The resident drinks Lactose free milk. Review of the plan of care dated 09/13/22…

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 2. Resident #15 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute kidney failure, heart failure, major depressive disorder, hyperlipidemia, type two diabetes mellitus, hypertension, aphasia, and seizure disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of seven out of 15, required extensive physical assistance of two or more persons for bed mobility, transfers, and toilet use. Review of the Morse Fall Scale for fall risk dated 02/21/19 revealed Resident #15 was at high risk for falls with a score of 60, indicated by a score of 45 or higher. Review of the comprehensive care plan revealed no evidence of a fall risk care plan. Review of the Incident Note dated 05/26/19 at 6:43 P.M. revealed the nurse documented being called to Resident #15's room by a nursing assistant, observed the resident on the floor lying on her back. The note documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to have call lights in easy reach for resident. This affected one (#80) out of 88 residents observed. The facility census was 88. Findings include: Review of Resident #80's records revealed an admission date of 08/10/12 with diagnoses including muscle wasting and atrophy. Review of Resident #80's minimum data set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment, and required extensive assistance of one person for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Resident #80 required supervision eating. Review of resident's care plan revealed he was at risk for falls due to impaired balance and should have his call light in reach. Observation on 06/10/19 at 10:16 A.M. Resident #80 was in bed asking for assistance. His call light was noted draped over the wall panel approximately six feet away from resident's bed. Interview on 06/10/19 at 10:29 A.M. Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to provide residents access to their money on weekends. This affected three (#14, #41 and #50) out of nine residents reviewed for personal funds. The facility managed funds for 79 residents. The census was 88. Findings include: 1. Review of Resident #14's records revealed an admission [DATE] and diagnoses included major depressive disorder, dementia, cerebral infarction, schizoaffective disorder, and mood disorder. Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required assistance of one to two people for all activities of daily living (ADLs). Resident #14 authorized the facility to manage their funds. Interview on 06/10/19 at 10:16 A.M. Resident #14 stated she can't get money on weekends. 2. Review of Resident #41's medical record revealed an admission of 06/08/18 with diagnosis including encephalopathy. Review of the MDS assessment 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 medical record review and staff interview, the facility failed to ensure resident's Do Not Resuscitate (DNR) code statuses were documented on a valid form. This affected one (#6) out of 24 residents reviewed during the initial pool screening of the annual survey. The facility census was 88. Findings include: Resident #6 was admitted [DATE] with a reentry date 03/07/19. Diagnoses included metabolic encephalopathy, adult failure to thrive, dementia without behavioral disturbance, dysphagia, atherosclerotic heart disease, chronic respiratory failure, acute kidney failure, essential hypertension, bipolar disorder, chronic obstructive pulmonary disease, chronic pain, hyperlipidemia, diabetes mellitus with diabetic neuropathy, neuromuscular dysfunction of the bladder, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven out of 15, required extensive assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interviews, the facility failed to notify the ombudsman and the resident of the transfer regarding the reasons for the discharges from the facility in writing. This affected three (#29, #41 and #78) out of five residents reviewed for discharge notification. The facility census was 88. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with the following diagnoses paroxysmal atrial fibrillation, hypokalemia, essential hypertension, hypo-osmolality and hyponatremia, muscle weakness, personal history of pulmonary embolism, pressure area of sacral region, dysphagia and other abnormalities of gait. Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and require supervision with bed mobility, eating and toileting. Resident #41 was also independent with transfers, personal hygiene and dressing on the 04/08/19 MDS. Review of Resident #41's progress…

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's discharge status was accurately coded on the Minimum Data Sets (MDS) assessment. This affected one (#89) of 21 residents reviewed for accuracy of assessments. The facility census was 88. Findings include: Record review of Resident #89's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses acute kidney failure, hypoxemia, other specified disorder of white blood cells, age related physical debility, unspecified fall, repeated falls, respiratory failure unspecified hypoxia, muscle weakness, other abnormalities of gait and mobility, cognitive communication deficit, hyperkalemia, chronic obstructive pulmonary disease, heart failure, other arthritis, type two diabetes mellitus, atherosclerotic heart disease of native coronary artery without angina pectoris and elevated white blood cells count. Review of Resident #89's discharge MDS assessment dated [DATE] revealed resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop accurate baseline care plans for residents within 48 hours of their admission. This affected three (#41, #57 and #84) of 21 residents reviewed for baseline care plans. The facility census was 88. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with the following diagnoses paroxysmal atrial fibrillation, hypokalemia, essential hypertension, hypo-osmolality and hyponatremia, muscle weakness, personal history of pulmonary embolism, pressure area of sacral region, dysphagia and other abnormalities of gait. Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and require supervision with bed mobility, eating and toileting. Resident #41 was also independent with transfers, personal hygiene and dressing on the 04/08/19 MDS. Review of Resident #41's chart revealed resident did not have a baseline care plan in the 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 medical record review and resident and staff interview, the facility failed to ensure a resident's fall risk care plan was reviewed and revised. The facility also failed to ensure residents were allowed the opportunity to participate in care planning. This affected three (#6, #13 and #15) out of 21 residents reviewed for care planning. The facility census was 88. Findings include: 1. Record review of Resident #13's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; cerebral aneurysm, psychotic disorder with hallucinations due to known physiological, alcohol dependence, hypothyroidism, essential hypertension, unspecified convulsions, unspecified dementia without behavioral disturbance, urinary incontinence, paranoid schizophrenia, epilepsy and gastroesophageal reflux disease without esophagitis. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment and required total dependence 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and resident and staff interview, the facility failed to ensure fall risk interventions were implemented to prevent falls. The facility also failed to transfer a resident based on assessed transfer needs which resulted in a resident having an avoidable fall. This affected two (#13 and #15) of five residents reviewed for falls. The facility census was 88. Findings include: 1. Record review of Resident #13's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; cerebral aneurysm, psychotic disorder with hallucinations due to known physiological, alcohol dependence, hypothyroidism, essential hypertension, unspecified convulsions, unspecified dementia without behavioral disturbance, urinary incontinence, paranoid schizophrenia, epilepsy and gastroesophageal reflux disease without esophagitis. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment and 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 medical record review and staff interview, the facility failed to ensure psychotropic medication ordered on an as needed (PRN) basis was not prescribed for an indefinite period of time. This affected one (#44) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 44 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and required extensive assistance to total dependence of two or more persons for activities of daily living. Review of Physician's Orders revealed an order written 04/22/19 for Ativan 0.5 milligrams by mouth every four hours as needed (PRN) for anxiety. There was no stop date attached to the order. Review of the Pharmacy…

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 documentation of a resident's hospice provider was accurate in the medical record. This affected one (#2) of 21 residents reviewed for complete and accurate medical records. The facility census was 88. Findings include: Record review of Resident #2's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; type two diabetes mellitus without complications, acute hepatitis C without hepatic coma, heart failure, major depressive disorder, encounter for other specified aftercare, other chronic pain, personality disorder, opioid dependence, generalized anxiety disorder, alcohol dependence, unspecified dementia without behavioral disturbance, cyst of epididymis and acute respiratory failure. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact and required limited assistance with personal hygiene. Resident #2 also required supervision 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to ensure a resident was provided with a safe and functional room. This affected one (#27) out of 24 residents reviewed. The facility census was 88. Findings include: Review of Resident #27's medical records revealed an admission date of 02/06/02 with diagnosis of paraplegia and hemiplegia affecting right side. Review of minimum data set (MDS) dated [DATE] revealed resident had moderate cognitive impairment. Resident #27 required limited assistance of one person for eating and locomotion on the unit. Resident required extensive assistance of one person for bed mobility, dressing, and personal hygiene. Resident was totally dependent upon two people for transfers between surfaces and toileting. Observation on 06/10/19 at 10:22 A.M. revealed Resident #27 was lying in his bed, the particle wood headboard of the bed was completely detached and propped up against the mattress of the bed between the two exposed metal support poles that…

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.