Eastbrook Healthcare Center

Based on observation, interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (%). Six medication errors occurred within 31 observed opportunities for error resulting in an error rate of 19.35% . This affected three residents (Residents # 241, #41, and #58) of nine residents observed during medication administration. The facility census was 88. Findings include: 1. Review of the medical record for Resident #241 revealed an admission date of 09/26/23 with diagnoses including sepsis due to other specified staphylococcus, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, depression, dependence on renal dialysis, and anemia. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 04/27/24 revealed Resident #241 had intact cognition. Further review of the MDS revealed Resident #241 had no insulin-related order changes and had received an insulin injection seven of the seven days during the look-back period. Review of the physician orders revealed an order dated 04/22/24 for…

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

Based on staff interview, review of personnel files and review of the facility abuse prevention policy and procedure, the facility failed to implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property This had the potential to affect all 91 residents residing in the facility. Findings include: Review of a list of faciliy new hires since 06/06/23 revealed 40 non State Tested Nursing Assistants (STNA) and non licensed nurses were hired. Review of the personnel files for Licensed Practical Nurse (LPN) #217 and LPN #313 revealed no evidence they were screened using the State of Ohio Nurse Aide Registry. Interview with the Administrator on 10/17/23 between 11:30 A.M. and 11:45 A.M. revealed he was checking all staff against the nurse aide registry but there was no documented evidence of when the check was completed and what staff the check was completed for. Interview on 10/17/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #15, #26, #49 and #50 were supervised while they were smoking and failed to ensure Resident #15 was wearing a smoking apron while smoking. This affected four residents (#15, #26, #49 and #50) reviewed for smoking safety and had the potential to affect all 33 residents (Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95) who smoked in the facility. The facility census was 91. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 03/29/23 and diagnoses included necrotizing fasciitis, acquired absence of left leg above the knee, type two diabetes mellitus without complications, arthritis due to other bacteria left hip and arthritis due to other bacteria right wrist. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment…

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, interview, record review and review of facility policy the facility failed to ensure Resident #67's right knee skin impairment was accurately documented to include wound type in the medical record. This affected one resident (Resident #67) out of three residents reviewed for wounds. The facility census was 91. Findings include: Review of Resident #67's medical record revealed an admission date of 06/21/23 and diagnoses included immersion foot, left foot (an injury caused by cold exposure to tissue not resulting in freezing), schizophrenia and type two diabetes mellitus without complications. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required supervision of one staff member for bed mobility, limited assistance of one staff member for transfers and locomotion off the unit, and Resident #67 was not steady but able to stabilize without staff assistance for walking. Resident #67 used a…

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

Based on observation, interview, record review, and facility policy review the facility did not ensure insulin was dated after it was opened and/or failed to ensure the insulin was labeled with the resident's name after it was pulled from the contingency box. This affected three residents (#44, #45 and #59) out of nine residents who had orders for insulin on the C North medication cart. This had the potential to affect 20 residents (#6, #9, #14, #16, #27, #29, #30, #32, #35, #44, #45, #47, #50, #52, #55, #59, #60, #74, #80, and #85) who had orders for insulin at the facility. Findings included: 1. Review of the medical record for Resident #44 revealed an admission date of 04/14/23 with diagnoses including diabetes, chronic obstructive pulmonary disease, and heart failure. Review of the August 2023 physician orders revealed Resident #44's orders included: Novolog FlexPen 100 units per milliliter (ml) inject 35 units subcutaneously (SQ) before meals and Ozempic pen-injector 2 milligram (mg) per 1.5 ml inject 0.25 mg SQ every seven days in the morning. Observation on 08/18/23 at 9:06…

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 the services of a Registered Nurse (RN) were maintained for at least eight hours a day, seven days a week. This had the potential to affect all 85 residents currently residing in the facility. Findings include: Review of the schedule from 03/02/22 through 03/08/22 revealed there was no RN scheduled to work for eight consecutive hours on 03/05/22 and 03/06/22. This was verified by Manager (MNGR) #300 on 03/09/22 at 4:30 P.M.

Based on observation and interview the facility failed to ensure medications were secured, not expired and medications carts did not contain loose unidentifiable medications. This had the potential to affect all 85 residents currently residing in the facility. Findings include: 1. Observation on 03/07/22 at 8:37 A.M. revealed Licensed Practical Nurse (LPN) #502's medication cart contained an unidentified white powder in the top drawer, a bottle of ibuprofen with an expiration date of 02/22, and 22 unidentifiable loose pills in various compartments of the medication cart. Further observation revealed Resident #24's Humalog insulin pen had an open date of 01/10/22, Residents #70, #19, #49 and #229's insulin pens did not have an open date and Resident #22's insulin had an unreadable open date. Interview with LPN #502 confirmed the observations and stated expired medications should be discarded and insulin pens were to have a date of open due to insulins expired 30 days after opening. 2. Observation of the medication storage room on 03/07/22 at 1:00 P.M. with LPN #209 revealed various…

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 interview the facility failed to employ a designated person to serve as director of food services who meets qualifications. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Findings include: Observation of the kitchen during the initial tour on 03/07/22 at 6:58 A.M. revealed one staff member in the kitchen who was identified as functioning dietary manager. Initial tour was completed with Dietary Manager #259 and findings were reviewed. Interview on 03/07/22 during initial tour of kitchen with DM #259 revealed DM #259 had signed up for ServSafe program (food safety training and certification courses) on 03/04/22. DM #259 indicated they were not a certified dietary manager (CDM) and did not meet any of requirements to serve in such position. Interview on 03/08/22 at 7:59 A.M. with Registered Dietitian (RD) #294 revealed she covered the facility two days per week and did not work full…

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 resident and staff interview the facility failed to ensure foods were served at a palatable temperature and were visually pleasing. This affected six (Residents #5, #39, #66, #74, #435 and #438) of six residents reviewed for food and had the potential to affect and additional 71 residents who received meals prepared by the kitchen. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Findings include: 1. Interview with Resident #66 on 03/07/22 at 8:44 A.M. revealed the facility served food that was bland, tasteless and always cold. 2. Interview with Resident #435 on 03/07/22 at 9:05 A.M. revealed the food is never hot. 3. Interview with Resident #438 on 03/07/22 09:20 A.M. revealed the food tastes like dog food. 4. Interview with Resident #39 on 03/07/22 12:08 P.M. revealed the food tastes terrible and it always served cold. 5. Interview with Resident #74 on 03/08/22 at 7:01 A.M. revealed the food is awful and the color of the meat served was questionable. Resident…

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

Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #259 on 03/07/22 at 6:58 A.M. revealed a dishwashing area with two backed up sinks filled with approximately three to five inches of orange colored liquid and old food floating within. Observed dust and food residue coating the top of the dish machine. Observation of the dish machine cycle revealed adequate level of sanitizing chemicals, however, the temperature gauge was not in working order. DM #259 indicated it had been broken for a while and they did not know the actual temperature the dish machine was reaching. The floor and walls by the dish machine were covered with a dark colored food residue and food particles. Observed an uncovered trash can…

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 properly dispose of garbage and refuse in the dumpster. This had the potential to affect all 85 residents currently residing in the facility. Findings include: Observation on 03/10/22 at 11:45 A.M. revealed dirt, debris, used gloves, and pop cans laying on the ground between two dumpsters. An old truck tire was sitting outside the dumpster enclosure. Interview on 03/10/22 at 12:10 P.M. confirmed findings with Dietary Manager #259. Dietary Manager #259 indicated maintenance will be made aware for cleanup. Review of facility policy Food-Related Garbage and Refuse Disposal dated October 2017 revealed outside dumpsters provided by garbage pickup service will be free of surrounding litter.

Based on observation and staff interview the facility failed to ensure it maintained a clean and sanitary environment. This had the potential to affect all 85 residents currently residing in the facility. Findings include: An environmental tour was conducted on 03/08/22 between 2:15 P.M. and 3:02 P.M. the following was observed and verified by Housekeeping Director #262 in an interview on 03/08/22 at 3:33 P.M. -The baseboard heating boards throughout the facility in the three facility dinning rooms and resident rooms showed various significant levels of scraping, scuffing, rust and paint chipping - In the 3rd floor dinning room the light fixtures above resident eating areas were encased in dust and other debris. A simple light tap of the fixtures would cause significant dust and debris to fall down to the resident eating area -The third floor hand rails showed significant paint chipping and peeling. -The main elevator had significant food stains on the floor of the elevator. -The room belonging to Resident #9 revealed the air conditioner was missing a filter cover. -The room…

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, medical record review, and facility policy review the facility failed to ensure residents' code status (level of medical interventions a resident wishes to have performed in the event they experienced an absence of a heartbeat or breathing) entered in the electronic medical record matched the State of Ohio Do Not Resuscitate (DNR) written documents for three residents (#31, #57, and #67) of nine residents reviewed for advanced directives. The facility census was 85. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of [DATE]. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to accurately code the pre-admission screening and resident review (PASRR) accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected five (Residents #24, #52, #61, #64 and #76) of six residents reviewed for accuracy of PASRR coding of MDS assessments. The facility identified twelve residents as having a level two mental illness. Findings include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bi-polar disorder and major depressive disorder. Review of the level two determination from the Ohio Department of Mental Health dated 03/09/20 revealed Resident #24 had a serious mental illness. Review of the section A of the most recent comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #24 dated 08/17/21 revealed the facility answered no to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual…

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 develop resident specific care plans to address residents individual needs and to implement care planned interventions as required. This affected six (Residents #31, #35, #65, #66, #435 and #436) of 24 sampled residents. The facility census was 85. Findings Include: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, bi-polar disorder and schizophrenia. Review of the care plan initiated 02/01/22 revealed the care plan contained the following information. Resident has potential and desires to be discharged to No destination was noted. Resident is at risk for isolation. No cause of isolation risk was given. Resident is at risk for constipation. The goal for this problem was noted as The resident will pass soft, formed stool at the preferred frequency of (SPECIFY FREQUENCY) through the review date. No frequency was specified. Resident is at risk for skin impairment. The goal for this problem…

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 interview, medical record review, and policy review the facility failed to provide documentation that residents and/or their representatives were provided educational information regarding the risks and benefits, and informed consent/refusal for influenza and pneumococcal vaccinations. This affected five (Residents #12, #13, #67, #429, and #439) of seven residents reviewed for influenza and pneumococcal immunizations. The facility census was 85. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/21/21. Diagnoses included chronic respiratory failure, type 2 diabetes, anoxic (lack of oxygen) brain damage, dysphagia (difficulty swallowing), hypertension, epilepsy, and anxiety disorder. The resident had a legal guardian due to cognitive impairment. Review of the immunization record revealed the resident refused consent for the influenza vaccine with no date documented. There was no documentation regarding the pneumococcal vaccine. Further review of the medical record lacked evidence regarding Resident #12 and/or their…

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 interview, medical record review, and facility policy review, and review of the Centers for Medicare and Medicaid (CMS) guidance the facility failed to provide documentation that residents and/or their representatives were provided educational information including risks and benefits, and informed consent/refusal for COVID-19 vaccinations. This affected three (Residents #67, #429, and #439) of seven residents reviewed for COVID-19 immunizations. The facility census was 85. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 09/15/21 and a discharge date of 03/14/22. Diagnoses included acute and chronic respiratory failure, encounter for attention to tracheostomy (opening in the throat for a breathing tube), type 2 diabetes, hypertension, and pneumonia. The resident was his own responsible party. Review of the immunization record lacked documentation regarding the COVID-19 vaccination. Further review of the medical record lacked evidence regarding Resident #67 receiving educational information including risks and benefits,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to complete a Minimum Data Set (MDS) 3.0 assessment as required upon resident discharge to the hospital. This affected one (Resident #2) of one resident reviewed for MDS accuracy. The facility census was 85. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia and high blood pressure. Review of the progress note dated 09/30/21 revealed Resident #2 was sent to a local acute care hospital due to pulling out his feeding tube. Resident #2 ultimately did not return to the facility and the facility ceased billing the resident for bed hold days on 10/01/21. Review of the MDS data for Resident #2 revealed the last MDS assessment completed was an admission assessment dated [DATE]. No discharge MDS assessment was completed as required. On 03/09/22 at 9:56 A.M. interview with MDS Nurse #218 verified no discharge assessment was completed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure the pre-admission screen and resident review (PASRR) was accurate and reflective of current mental healthcare needs. This affected one (Resident #66) of twelve residents reviewed for PASRR status. The facility census was 85. Findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, schizophrenia and bi-polar disorder. Review of the physicians orders for the current month (March 2022) revealed an order dated 01/29/22 for Resident #66 to receive Quetiapine Fumarate (anti-psychotic medication) 50 milligrams (mg) in the morning and 25 mg in the evening to address depression and behaviors. Review of the PASRR dated 01/28/22 revealed the answer was indicated as no to the question, Does the individual have a diagnosis(es) of any of the mental disorders listed below (schizophrenia was listed as choice) and no to the question, In the past SIX (6) months, has the individual been…

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 medical record review the facility failed to develop a person-centered care plan for Resident #31. This affected one of six residents reviewed for care plan timing and revision. The facility census was 85. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score off 11/15. He required the extensive assistance of one staff…

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 and interview the facility failed to ensure routine turning and positioning for Resident #67 and adequate nail care for Residents #65 and #30. This affected three (Residents #67, #65 and #30) of six residents reviewed who were dependent for activities of daily living care. The facility census was 85. Findings include: 1. Review of Resident #67's medical record revealed an admission date of 09/15/21 with diagnoses that included right and left leg amputations. Review of the care plan dated 09/22/21 revealed the resident had a potential for alteration in comfort and interventions included reposition as needed for comfort. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assistance with bed mobility. Observation on 03/08/22 at 7:18 A.M. revealed Resident #67 was positioned on his back in bed. The resident was non-verbal. Observation on 03/08/22 at 8:25 A.M. revealed #67 remained in bed on his back. Observation on 03/08/22 at 10:09 A.M. revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure heel pressure offloading devices (PODs) were appropriately applied and routine repositioning was completed to promote the healing of existing pressure ulcers for Resident #18 and failed to provide adequate wound care for Resident #66. This affected two (Resident #18 and #66) of four residents reviewed for pressure ulcers. The facility census was 85. Findings include: 1. Review of medical record for Resident #18 revealed admission date of 09/13/17. Diagnoses included type II diabetes mellitus, severe protein calorie malnutrition, mild intellectual disabilities, post-traumatic stress disorder, pressure ulcer of right heel, pressure ulcer of left heel, chronic osteomyelitis of right ankle and foot, and benign neoplasm of colon. Review of Medicare Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required total staff assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and eating.…

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, interview and record review the facility failed to ensure ancillary podiatry visits were provided and adequate foot care was administered to Resident #65. This affected one (Resident #65) of three residents reviewed for ancillary services. The facility census was 85. Findings include: Resident #65 was admitted to the facility on [DATE]. Admitting diagnoses included anemia, mild calorie malnutrition, hemiplegia and hemiparesis, cerebral infarction, atrial fibrillation, absence of left leg above the knee, schizophrenia affect disorder and insertion of gastrostomy tube. Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Functionally, the resident was totally dependent on two staff for transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Observation on 03/08/22 at 9:30 A.M. with State Tested Nursing Assistant (STNA) #235 revealed all five toe nails were thick, yellow colored and some were…

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 and interview the facility failed to provide adequate care for the use of an indwelling urinary catheter. This affected one (Resident #67) of one resident observed for catheter care. The facility census was 85. Findings include: Review of Resident #67's medical record revealed an admission date of 09/15/21 with diagnoses that included bladder dysfunction. Review of the care plan dated 09/22/21 revealed the resident had an indwelling urinary catheter related to bladder dysfunction but lacked any indication or interventions regarding providing catheter care. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had no recorded cognition score, and required extensive assistance with toileting and personal hygiene. Review of physician orders for March 2022 revealed the resident was to receive catheter care every shift and as needed. Observation on 03/08/22 at 10:12 A.M. of Resident #67 with State Tested Nursing Assistant (STNA) #210 revealed the resident's urinary catheter…

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, interview, record review, and review of facility policy the facility failed to ensure Resident #18 was assessed for nutritional needs and to implement new interventions to address a significant unplanned weight loss and failed to ensure the resident was provided feeding assistance with meals. This affected one of eight residents reviewed for nutritional status. The facility census was 85. Findings include: Review of medical record for Resident #18 revealed admission date of 09/13/17. Diagnoses included type II diabetes mellitus, severe protein calorie malnutrition, mild intellectual disabilities, pressure ulcer of the right and left heel, chronic osteomyelitis of the right ankle and foot, and benign neoplasm of the colon. The medical record indicated Resident #18 was hospitalized from [DATE] to 02/16/22 for altered mental status and sepsis. While hospitalized Resident #18 developed Clostridium Difficile (a bacterial infection that causes severe diarrhea) and Coronavirus. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medications were administered with an error rate of less than 5%. A total of 12 errors out of 27 opportunities observed resulted in a 44.4% medication error rate. This affected one resident (#40) of three (#41, #49 and #40) observed for medication administration. The facility census was 85. Findings include: Review of Resident #40's medical records revealed an admission date of 09/23/21 with diagnoses that included gastrostomy (feeding tube placement), tracheostomy and respiratory failure. Review of care plan dated 09/24/21 revealed the resident required the use of a feeding tube related to dysphasia (difficulty swallowing) and interventions included, check tube for residual (amount of stomach content remaining after administration of feeding solution or medications). Review of the Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition and required extensive total dependence with transfers, toileting and personal hygiene. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #40) of three observed for medication administration. The facility census was 85 Findings include: 1. Review of Resident #40's medical records revealed an admission date of 09/23/21 with diagnoses that included gastrostomy (feeding tube placement), tracheostomy and respiratory failure. Review of care plan dated 09/24/21 revealed the resident required the use of a feeding tube related to dysphasia (difficulty swallowing) and interventions included, check tube for residual (amount of stomach content remaining after administration of feeding solution or medications). Review of the Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition and required extensive total dependence with transfers, toileting and personal hygiene. Review of physician orders for March 2022 revealed resident was to have nothing by mouth (NPO), check for residual 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, taste test and diet manual review the facility failed to prepare pureed foods at the proper consistency. This had the potential to affect two (Residents #280 and #432) of two residents prescribed a pureed diet. The facility census was 85. Findings include: Observation on 03/08/22 at 7:51 A.M. revealed [NAME] #302 was preparing pureed waffles for the breakfast meal. [NAME] #302 was noted to use water as a thinning agent. Taste test of the pureed waffles revealed it was very thick and not smooth with chunks of waffle throughout the mixture. Dietary Manager #259 confirmed the consistency of the pureed waffles. Confirmed with Registered Dietitian #294 thinning pureed foods with water was not an appropriate practice and not according to the recipe on 03/08/22 at 7:59 A.M. Review of a resident diet list revealed Residents #280 and #432 were prescribed a pureed diet. Review of Pureed Bread Products recipe (undated) revealed broth, milk, or juice should be used to thin during processing of pureed bread products including waffles. The recipe indicated to ensure 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 interview, observation, and medical record review the facility failed to ensure accurate documentation was contained in the medical record. This affected two (Residents #31 and #47) of six residents reviewed for accurate documentation. The facility census was 85. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/22, revealed the resident had moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 11/15.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review the facility failed to follow appropriate infection control procedures during provision of incontinence care for Resident #31 and medication administration for Resident #40. This affected one (Residents #31) of three residents observed for personal care and one (Resident #40) of three residents observed for medication administration. The facility census was 85. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral…

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.