Aristos Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure as-needed (PRN) medications had a designated stop date of usage. This affected one Resident (#30) of three reviewed for as needed medications. The facility census was 53.Findings include: Review of Resident 30's medical records revealed an admission date of 03/02/26. Diagnoses included obsessive-compulsive disorder, schizoaffective disorder and depression.Review of care plan dated 03/03/26 revealed Resident #30 revealed Resident #30 was at risk for behavior/mood changes. Interventions included administer medications as ordered and attempt non-pharmacological interventions to improve sleep.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had intact cognition.Review of Resident #30's physician orders revealed the resident had an order dated 0302/26 for Hydroxyzine (an antihistamine medication used to help control anxiety) 50 milligrams (mg) every eight hours as needed for anxiety. Physician…

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 interview, observation, record review and review of facility policy, the facility failed to ensure a urine culture and sensitivity (a laboratory diagnostic procedure that detects and identifies microorganisms (bacteria or yeast) in a urine sample to diagnose a Urinary Tract Infection (UTI)) was obtained per the nurse practitioner's (NP) recommendation. This affected one Resident (#46) out of three residents reviewed for laboratory services. The facility census was 53. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/21/26 and diagnoses included heart failure, diabetes, acute cystitis (inflammation of the bladder usually caused by infection) with hematuria (blood in urine), acute kidney failure, and malignant neoplasm of the bladder. Review of nursing note dated 03/02/26 at 4:44 A.M. and completed by Licensed Practical Nurse (LPN) #320 revealed Resident #46 expressed concern about blood-tinged urine in her nephrostomy bag with no clots. Resident #46 had…

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 review of the facility policy and procedure, the facility failed to ensure room changes were documented in the resident's medical record. This affected two residents (#22 and #23) of three residents reviewed for room changes. The facility census was 52. Findings include:1. Review of the medical records for Resident #22 revealed an admission date of 09/18/25. Diagnoses included Alzheimer's disease with late onset, dementia, muscle weakness, and residual schizophrenia. Review of the medical record for Resident #22 revealed no documented room changes. Further review of Resident #22's medical record reviewed a room change form uploaded under the miscellaneous tab of the electronic medical record dated 03/05/26 indicating Resident #22 was moving rooms due the roommate needed to be in a room by himself for safety and wellness precautions. The form also indicated Resident #22's guardian was notified and was in agreeance with the move. 2. Review of the medical record for Resident #23 revealed an admission date of 11/18/15. Diagnoses included hemiplegia…

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 staff interview, the facility failed to maintain a clean kitchen and serve food in a sanitary manner. This affected all residents except one resident (#41) who the facility identified as received nothing by mouth. The facility census was 49. Findings include:Observation and interview on 09/22/25 between 8:16 A.M. and 8:34 A.M. with Dietary Manager (DM) #522 revealed on the back wall where the knives hung were various dried splatters of food-like particles. The mounted, large black fan in this area had a moderate amount of dust-like particles. The back wall behind the rack with the hanging clean utensils was moderately dusty and there was a moderate amount of dust-like particles on the side of the reach in cooler next to it. In the back room of the kitchen, there was a rack of dry foods. On the bottom shelf of this rack, there were two large clear containers of flour and sugar both with blue lids. Both blue lids were dirty with debris and dried stains. Observation of the dish machine revealed a moderate amount of a tannish colored, wet…

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, policy review and staff interview, the facility failed to develop and implement baseline care plans for residents. This affected four (Residents #1, #10, #32, and #57) of 22 residents reviewed for baseline care plans. The facility census was 49. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 02/28/25 with diagnoses including adult failure to thrive, chronic kidney disease and diabetes mellitus. Review of Resident #1's electronic medical record and paper chart revealed there was no baseline care plan completed after admission. Interview on 09/24/25 at 10:12 A.M. with Registered Nurse (RN) #569 verified Resident #1 did not have a baseline care plan completed after admission. 2. Review of the medical record for Resident #32 revealed an admission date of 08/07/25 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, and heart disease. Review of Resident #32's electronic medical record and paper chart revealed there was no baseline care plan completed after admission. Interview on…

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

Based on observation, staff interview, and record review, the facility failed to ensure the correct servings for the pureed vegetable were provided to the residents who received a pureed diet. This affected four residents (#4, #15, #17, and #37) who the facility identified who received a pureed diet. The facility census was 49. Findings include:Review of the menu for lunch on 09/23/25 revealed for the puree diet the meal included four ounce serving of pureed carrots.Review of the scoop size sheet indicated the #16 scoop which was a blue handled scoop provided two-ounce servings. Observation on 09/23/25 at 11:50 A.M. of lunch meal service revealed Dietary [NAME] (DC) #526 served the pureed carrots using a blue handled scoop (a two-ounce scoop), giving one scoop on each plate. Observation on 09/23/25 at 12:13 P.M. of the last meal cart completed, completing the end of lunch meal service. Interview on 09/23/25 at 12:15 P.M. with DC #526 verified she used the #16 scoop providing one serving each for the pureed carrots. DC #526 verified the #16 scoop provided two-ounce servings and 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.

Based on observation, interview and record review, the facility failed to effectively implement the facility smoking policy. This affected one (Resident #12) of two residents reviewed for smoking. The facility identified 16 residents who smoke. The facility census was 49. Findings include:Observation on 09/22/25 at 10:38 A.M. with Certified Nursing Assistant (CNA) #504 verified Resident #12 had her cigarettes on her night table. CNA #504 stated Resident #12 was an independent smoker and could have them in her possession. Interview on 09/22/25 at 11:38 A.M. with the Administrator revealed the smoking policy stated the independent smokers must keep their smoking materials locked up. Interview on 09/24/25 at 1:56 P.M. with the Director of Nursing (DON) revealed the wrong smoking policy was presented to the State Survey Agency and provided a second policy and stated the corporate lawyer was working on a new policy. Review of the first facility policy dated 10/28/21 titled Smoking revealed independent smokers must keep their smoking materials in the red lock boxes provided and kept 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) included the resident's mental health diagnosis. This affected one (Resident #46) of two residents reviewed for PASARR. The facility census was 49. Findings include:Record review revealed Resident #46 was admitted on [DATE] to the facility with diagnoses including schizophrenia disorder, panic disorder, and psychosis not due to a substance or known physiological condition. Review of Resident #46's PASARR assessment dated [DATE] revealed the PASARR did not address Resident 46's diagnosis of schizoaffective disorder. Interview with Social Service Designee (SSD) #538 on 09/23/25 at 10:29 A.M. verified Resident 46's PASARR did not address her diagnoses of schizoaffective disorder. SSD #538 stated when she arrived she filled out the PASARR. She stated she did not include a schizophrenia diagnosis because there was no proof that Resident #46 had schizophrenia. SSD #538 stated 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.

Based on record review, policy review, and interviews with staff and hospice provider, the facility failed to ensure the residents were timely assessed when new wounds were identified and failed to ensure the wounds were documented accurately in the facility's records. This affected one (Resident #1) of two residents reviewed for pressure ulcers. The facility census was 49. Findings include:Review of the medical record for Resident #1 revealed an admission date of 02/28/25 with diagnoses including adult failure to thrive, chronic kidney disease, diabetes mellitus, contracture to bilateral knees and hips. Review of Resident #1's nursing evaluations revealed Resident #1 had a weekly skin evaluation on 07/31/25 and had no skin breakdown. There was no skin evaluation from 08/01/25 to 08/22/25. The next weekly skin evaluation was on 08/24/25. Review of the nursing progress notes for Resident #1 for 07/31/25 through 08/19/25 revealed there was no documentation as to skin breakdown to his bilateral heels or ankles. Review of the shower sheets for Resident #1 revealed Resident #1's skin 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 observation, record review, policy review, and staff interview, the facility failed to ensure there were smoking assessments of the resident's capabilities and deficits to determine whether or not supervision is required. This affected two (#15 and #46) of three residents reviewed for smoking. The facility census was 49. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 10/03/24. Diagnoses included major depressive disorder, psychoactive substance abuse, throat cancer, and nicotine dependence. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition and used tobacco. Review of the care plan dated 05/06/25 revealed Resident #15 was at risk for injury related to smoking. Interventions included the resident was an independent smoker. There was no smoking assessment for Resident #15 in the medical record from 10/03/24 to 09/23/24. Observation on 09/22/25 at 11:31 A.M. revealed Resident #15 was outside 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 record review, policy review, and staff interview, the facility failed to ensure pharmacy medication regimen reviews were adequately addressed and followed through in a timely manner. This affected two residents (#13 and #45) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include: Review of the medical record for Resident #45 revealed an admission date of 07/09/25. Diagnoses included acute respiratory failure with hypoxia, pneumonia, non-pressure chronic ulcer of left heel and mid-foot with fat layer exposed, obesity, mild protein calorie malnutrition, and depression. Review of the Consultant Pharmacist Medication Regimen Review (MRR) dated 07/24/25 for a physician recommendation, revealed polypharmacy has been associated with an increased risk of hospital admissions. It has been associated with decreased physical and cognitive capability. High medication burden often increased the potential for drug interactions and prescribing cascades as well. The goal is to reduce medication burden, adverse effects, improved quality of life,…

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, facility policy review, and staff interview, the facility failed to ensure the residents were being monitoring for side effects while taking antidepressant medications. This affected one (#45) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include:Review of the medical record for Resident #45 revealed an admission date of 07/09/25. Diagnoses included depression. Review of the care plan dated 07/28/25 revealed Resident #45 used antidepressant medication related to depression. Interventions included administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Review of the physician orders for September 2025 revealed active orders for Duloxetine HCl 60 milligram (mg) capsule delayed release particles. Give one capsule by mouth one time a day for depression. There was also an active order for Bupropion HCl ER (XL) oral tablet extended release 24-hour 300 mg. Give one tablet by mouth one time a day for depression. Resident #45's medical record did not have…

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 and interview, the facility failed to ensure effective collaboration of care for a hospice resident. This affected one (Resident #1) of one resident reviewed for hospice services. The facility census was 49. Findings include:Review of the medical record for Resident #1 revealed an admission date of 02/28/25 with diagnoses including adult failure to thrive, chronic kidney disease and diabetes mellitus. Review of the hospice contract with the facility dated 06/17/25 revealed documentation would be provided to the facility including copies of clinical notes after each visit. Review of the hospice binder for Resident #1 revealed two hospice interdisciplinary group reports as well as plan of care dated 08/20/25 and 09/03/25. There was no documentation related to nurse or aide visits from 08/11/25 to 09/23/25 when Resident #1 was admitted to hospice services. Interview on 09/24/25 at 2:09 P.M. with Hospice Nurse #572 verified hospice staff came to the facility twice weekly. She stated all documentation for Resident #1 would be in his own personal binder at the…

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

Based on observation, resident and staff interview, and record review, the facility failed to ensure a clean and sanitary environment and the walls received timely repairs. This affected two (#42, and #45) of 28 residents reviewed for physical environment. The facility census was 49. Findings include: 1.Observation on 09/22/25 at 10:31 A.M. revealed there were dirty linens with feces on them in the corner of the closet in Resident #42's room. At this time, Assistant Director of Nursing (ADON) #539 verified the observation. Review of the facility's undated policy titled Laundry and Bedding, Soiled revealed contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). Leak-resistant containers or bags are used for linens or textiles contaminated with blood or body substances. 2. Observation on 09/22/25 at 2:45 P.M. of Resident #45's room revealed two very large holes in the wall behind the resident's bed. The resident's bed was moved away from the wall. Resident #45 stated it had been that way for about three weeks and was told by…

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 personnel file review, staff timecard review, review of the state board of nursing license verification website, staff interview, and review of facility corrective action, the facility failed to ensure nursing staff providing care and services to residents had an active and unencumbered license to practice through the state authority. This had the potential to affect all 46 residents residing in the facility. The facility census was 46. Findings Include: Review of Registered Nurse (RN) #500's personnel file revealed a hire date of [DATE]. Further review revealed at the time of hire, RN #500 had an active valid nursing license from the Ohio Board of Nursing (OBN). Review of the State of Ohio's elicense verification system (online system used by the public to verify license statuses of numerous healthcare professionals including registered nurses in the state Ohio) at,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to notify Resident #100's emergency contact of a significant change in condition. This affected one of three residents reviewed. The facility census was 43. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including atrial fibrillation, left-side hemiplegia and hemiparesis following cerebral infarction, bilateral hypertensive retinopathy, hypertension, hyperlipidemia, gastrointestinal reflux disease, borderline personality disorder, anxiety, depression, and nicotine dependence. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was alert and oriented with a Brief Interview for Mental Status score of 15/15. Resident #100 was her own responsible party. A family member was listed as the first emergency contact in the medical record. Review of the nurse progress note dated 09/14/23 timed 5:09 P.M. indicated Resident #100…

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

Based on observation and interviews, the facility failed to serve hot and palatable foods. This had the potential to affect all residents, except two (Residents #13 and #35) identified as receiving no food by mouth (NPO). The facility census was 54. Findings include: Observation on 11/07/22 at 3:45 P.M. with Food Service Manager (FSM) #409 revealed the dinner meal consisted of chicken parmesan, noodles, green beans, salad, and red grapes. Temperatures taken prior to the start of tray line revealed that not all hot food items were above 165 degrees Fahrenheit. Temperatures taken with Dietary [NAME] (DC) #450 on 11/07/22 at 3:45 P.M. revealed the chicken parmesan was at 168 degrees Fahrenheit, noodles were at 158 degrees Fahrenheit, and the green beans were at 154 degrees Fahrenheit. This was verified by DC #450 at the time of the observation.

Based on staff interview, resident interview, meal schedule review, and menu review the facility failed to provide a substantial snack when 16 hours elapsed between the evening meal and breakfast. This had the potential to affect 43 out of 50 residents that received meals from the kitchen. Nine (Residents #21, #33, #44, #46, #100, #101, #102, #104 and #105) who participated in intense therapy located on the substance abuse (GATE) unit received snacks regularly. Two (Residents #13 and #35) were identified as receiving no food by mouth (NPO). The facility census was 54. Findings include: Observation and interview on 11/06/22 at 4:40 P.M. with Dietary Aide #449 and [NAME] #450 revealed that snacks are made and distributed every night. Observation of the snack tray for Gate Unit revealed nine sandwiches and 12 packages of two-piece graham crackers. For the rest of the building, there was a snack tray with six peanut butter and jelly sandwiches, six deli meat sandwiches and six bags of potato chips. Dietary Aide #449 stated that she delivers the snacks every evening around 6:00 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for Residents #6 and #19. This affected two (Residents #6 and #19) of 54 residents reviewed for call light placement. The facility census was 54. Findings include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, difficulty walking, muscle weakness, dysphagia, and severe morbid obesity. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance of activities of daily living. Review of the care plan dated 10/05/22 for Resident #6 revealed Resident #6 was a risk for falls. Interventions included to have commonly used articles within easy reach such as water, call light, remote control, and telephone. Maintain a clear pathway. Observation of Resident #6 on 11/06/22 at 9:03 A.M. revealed Resident #6 was lying in bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the faciliy failed to be administered in a manner which allowed each resident to maintain their highest level of physical, mental, and psychosocial well-being and to prevent the use of illegal substances/drugs on facility grounds. This had the potential to affect all 54 residents residing in the facility including Residents #49, #303, #29, #37, and #300. Findings Include: 1. On 08/25/19 at 10:30 A.M. interview with Resident #49 revealed she had been a resident in the facility for a few months. During the interview, Resident #49 shared one resident in the facility, Resident #40, had repeatedly offered to supply drugs to the other residents while she had resided here. The resident stated she had told administration about this but no one had done anything to stop it. Resident #49 stated she had come to the facility to become healthy and the resident selling drugs was making it difficult. Interview on 08/26/19 at 5:55 A.M. with Registered Nurse (RN) #902 revealed she worked 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 and staff interview the facility failed to initiate care plans with resident centered interventions in a timely manner after identifying resident concerns. This affected 10 residents (Resident #49, #29, #33, #251, #30, #38, #19, #32, #1, and #37) of 54 residents reviewed for care plans. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including alcohol dependence, nicotine dependence, chronic obstructive pulmonary disease (COPD), heart disease, bipolar disorder, and high blood pressure. The smoking care plan for Resident #49 was initiated on 08/23/19. 2. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, diabetes, heart disease, major depression, nicotine dependence, COPD, substance dependence, and high blood pressure. Review of Resident #29's care plans revealed the smoking care plan was initiated on 08/06/19. A diabetes care plan was created on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop or revise care plans for Residents #29 for activities of daily living, Residents #5 and #19 for dementia care, Resident #43 for dialysis and positioning, and Resident #10 for edema. This finding affected one (Resident #29) of two residents reviewed for activities of daily living, two (Residents #5 and #19) of five residents reviewed for unnecessary medications, one (Resident #10) of one resident reviewed for edema, and one resident (Resident #43) of one resident reviewed for dialysis and positioning. Findings Include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, dysphagia following cerebral infarction and personal history of self-harm. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 07/02/19 comprehensive assessment revealed Resident #19 exhibited moderate cognitive impairment and received psychotropic medications on a routine basis.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain dignity at all times for Resident #10, #15, and #29. This affected three residents (#10, #15 and #29) of three reviewed for dignity. The facility census was 54. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, and low back pain. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed mild cognitive impairment, and a requirement of extensive assistance with one person assistance for dressing, toileting, personal hygiene, and bathing. Observation on 08/25/19 at 12:43 P.M. of Resident #10 revealed resident sitting in a chair next to an unmade bed dressed in a hospital gown. An interview with Resident #10 at the time of the observation revealed Resident #10 was waiting for assistance to wash up and get dressed and have the bed made. Resident #10…

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 and interview the facility failed to ensure Residents #40, #300 and #303's advance directives were available in the paper chart and/or in the electronic charting system. This affected three of five residents reviewed for advance directives. Findings include: Review on 08/25/19 of the paper chart and the electronic charts for Residents #40, #300 and #303's medical records confirmed the advance directives were not listed. On 08/25/19 at 1:15 P.M. interview with Licensed Practical Nurse (LPN) #906 verified advance directives were not available in the paper chart or electronic records for Residents #40, #300 and #303.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to timely notify hospice of Resident #9's skin concerns. This finding affected one (Resident #9) of two residents observed for pressure ulcers. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, altered mental status and muscle weakness. Review of Resident #9's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #9's physician order dated 08/27/19 to cleanse the right and left buttock with normal saline, apply zinc and cover with a border gauze dressing every shift and when soiled. Review of Resident #9's progress notes from 08/01/19 to 08/26/19 did not reveal evidence hospice was notified of the resident's skin breakdown. Observation on 08/27/19 at 9:14 A.M. with Hospice State Tested Nursing Assistant (STNA) #907 of Resident #9'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #31's narcotic medications were not misappropriated. This finding affected one (Resident #31) of three residents reviewed for misappropriation. Findings include: Review of Resident #31's self-reported incident (SRI) investigation dated 07/30/19 indicated on 07/29/19 Registered Nurse (RN) #902 reported that a pharmacy card of 38 Percocet (pain medication) belonging to Resident #31 was removed from the narcotic drawer and the count sheet was removed from the narcotic binder. The discontinued narcotic medication had not been administered to Resident #31 since the end of May 2019. The facility was unable to locate Resident #31's Percocet pain tablets. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] and discharged on 08/12/19 with diagnoses including schizoaffective disorder, major depressive disorder and cocaine abuse. Review of Resident #31's Minimum Data Set (MDS) 3.0 assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, unspecified dementia without behavioral disturbance, anxiety disorder. Review of the quarterly MDS 3.0 dated 06/05/19 comprehensive assessment revealed Resident #5 exhibited severe cognitive impairment. Review of Resident #5's medication orders revealed physician's order dated 02/07/19 for aripiprozole 2 mg once a day for schizophrenia, bipolar disorder and depression and a physician's order dated 05/24/19 for Cymbalta capsule delayed release 60 mg once a day for depression. Review of Resident #5's assessments revealed AIMS assessments were not completed by the facility. Interview on 08/29/19 at 8:55 A.M. with Assistant Director of Nursing (ADON) #911 who works as a MDS Coordinator confirmed Resident #5's medical record did not include AIMS assessment for the resident's psychotropic medication use as required. Based on interview and record review the facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide care and services in the areas of dressing and personal hygiene for Resident #10, #15, and #29. This affected three residents (#10, #15 and #29) of three reviewed for care and services. The facility census was 54. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, and low back pain. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed mild cognitive impairment, and a requirement of extensive assistance with one person assistance for dressing, toileting, personal hygiene, and bathing. Observation on 08/25/19 at 12:43 P.M. of Resident #10 revealed resident sitting in a chair next to an unmade bed dressed in a hospital gown. An interview with Resident #10 at the time of the observation revealed Resident #10 was waiting for assistance to wash up 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 record review and interview the facility failed to ensure Resident #43 was assessed and monitored for complications before and after hemodialysis treatments. This affected one (Resident #43) of one resident reviewed for hemodialysis. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, anemia in chronic kidney disease, essential primary hypertension, and type 2 diabetes mellitus without complications. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely cognitively impaired, totally dependent on staff for activities of daily living, and receiving dialysis. Review of Resident #43's physician orders dated 05/10/19 indicated dialysis treatment was ordered for Monday, Wednesday, and Friday, and orders dated 07/30/19 indicated a port to the right chest required daily dressing changes. Review of Resident #43's medical record revealed no pre or post dialysis assessments…

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 documentation was entered into resident records regarding the care provided by the facility. This affected two residents (Resident #49 and #37) of 34 residents reviewed for documentation. The facility census was 54. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including alcohol dependence, nicotine dependence, chronic obstructive pulmonary disease (COPD), heart disease, bipolar disorder, and high blood pressure. Review of the Minimum Data Set (MDS) 3.0 comprehensive quarterly assessment dated [DATE] revealed Resident #49 was cognitively intact, demonstrated no adverse behaviors, and was participating in therapy services. Review of the medical record revealed the resident was discharged from the facility but no documentation was noted as to why or where Resident #49 was transferred. Interview with the Director of Nursing (DON) on 08/28/19 at 11:00 A.M. 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.