Franklin Plaza Extended Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate. This affected one (Resident #129) of one resident reviewed for advanced directives. The facility census was 163. Findings include:Medical record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses including type two diabetes, right foot ulcer, weakness, tachycardia, and gastro esophageal reflux. A Brief Interview for Mental Status (BIMS) dated [DATE] revealed a score of 15/15, which indicated Resident #129's cognition was intact. Further review of Resident #129's medical records revealed the electronic medical record and the hard copy chart included conflicting advanced directives. The electronic medical record physician orders dated [DATE] revealed an order for Do Not Resuscitate-Comfort Care (DNR-CC), this specified cardiopulmonary resuscitation (CPR) was not to be initiated in the case of cardiac arrest. The DNR-CC was ordered by 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, interview, record review and review of facility policy, the facility failed to ensure Resident #59 was free from restraint. This affected one (Resident #59) out of one resident reviewed for use of a device/restraint. The facility census was 163. Findings include:Review of the medical record for Resident #59 revealed an admission date of 03/28/24 with diagnoses including schizoaffective disorder, dementia, severe protein calorie malnutrition, bilateral osteoarthritis of the hips, and history of falling. Review of the care plan dated 06/22/23 revealed Resident #59 wandered aimlessly and was disoriented. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book, monitor for fatigue, and document wandering behavior. There was nothing in the care plan regarding tilting her wheelchair back, preventing her from getting up. Review of the care plan dated 06/23/23 revealed Resident #59 was at risk…

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 accurately complete resident assessments. This affected one (Resident #15) of three residents reviewed for resident assessments. The facility census was 163. Findings include:Review of the medical record for Resident #15 revealed an admission date of 09/02/11. Diagnoses included schizoaffective disorder bipolar type, bipolar disorder, anxiety disorder and dementia. Review of the significant change in condition Preadmission Screening and Resident Review (PASRR) identification screen completed on 01/18/22 due to a decline revealed Resident #15 had indications of serious mental illness and within the previous two years had utilized psychiatric services including emergency mental health services and inpatient psychiatric hospitalization due to the mental disorder. Review of the notice of PASRR level II outcome dated 01/24/22 revealed Resident #15 was approved for continued nursing facility services with recommended mental health services and supports put…

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 reviews, interviews and observations, the facility failed to revise care plans for Resident #62 and Resident #63. This affected two (Residents #62 and #63) of two residents reviewed for revision of care plans. The facility census was 163. Findings include:1. Review of the medical record for Resident #62 revealed an admission date of 11/09/23 with diagnoses of malignant neoplasm of prostate, history of falling, need for assistance with personal care, anxiety disorder and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact and had no history of falls. He required substantial assistance for toileting and supervision for showers. He had no recent falls. Review of the Annual MDS 3.0 dated 08/02/25 revealed Resident #62 was cognitively impaired. He required substantial assistance with toileting and set-up for showers. Review of progress note dated 12/26/24, timed for 3:22 P.M. revealed the team…

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, time punch review and review of the facility policy, the facility failed to ensure timely incontinence care was provided. This affected one (Resident #156) out of two residents reviewed for incontinence care. This had the potential to affect 63 (Residents #1, #2, #3, #6, #9, #13, #22, #26, #30, #31, #36, #37, #39, #44, #50, #53, #55, #57, #58, #59, #60, #67, #70, #73, #78, #81, #89, #91, #92, #97, #99, #100, #103, #105, #114, #117, #125, #126, #128, #131, #133, #134, #135, #138, #140, #143, #144, #145, #150, #154, #155, #156, #157, #158, #160, #161, #162, #165, #167, #168, #170, #171, and #174) identified by the facility as incontinent. The facility census was 163. Findings include: Review of the medical record for Resident #156 revealed an admission date of 09/09/22 with diagnoses including congestive heart failure, diabetes, dementia, and adult failure to thrive. Review of the care plan dated 09/26/22 revealed Resident #156 had an activities of daily living…

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 reviews, interviews, facility policy review and review of facility staff training, the facility failed to provide trauma-informed care to Residents #17 and #28. This affected two (Residents #17 and #28) out of two residents reviewed for trauma-informed care. The facility reported nine Residents #2, #4, #17, #18, #28, #74, #93, #117 and #119) who had trauma-related diagnoses. The facility census was 163. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 03/20/25 with diagnoses of schizoaffective disorder depressive type, bipolar disorder and chronic post-traumatic stress disorder (PTSD). Review of Resident #17's hospital transfer dated 03/10/25 indicated the resident had PTSD with a history of cocaine and alcohol abuse. Resident #17 was a poor historian and not forthcoming with information. Review of the admission Minimum Data Set (MDS) assessment completed 03/27/25 revealed Resident #17 had no cognitive impairment and PTSD. Review of Resident #17'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, interviews and job description review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #26. This affected one (Resident #26) of two residents investigated for medically related social services. The facility census was 163. Findings include:Review of the medical record for Resident #26 revealed he was admitted on [DATE] with diagnoses of schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia, alcohol dependence with alcohol-induced persisting amnestic disorder, bipolar disorder, delusional disorders, paranoid personality disorder, hearing loss, legal blindness. Pertinent orders for August 2025 in the medical record included Risperdal Oral Tablet 0.5 milligrams (mg) (Risperidone) give 0.5 mg (antipsychotic) by mouth two times a day for schizophrenia, Advanced Directives: Do Not Hospitalize, no percutaneous endoscopic gastrostomy (PEG) tube…

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, interviews, review of diet spreadsheets, and review of facility policy, the facility failed to ensure residents on a controlled carbohydrate diet (CCD) diet with regular or mechanically altered consistency, liberalized renal diet with a regular or mechanically altered consistency, or a renal diet with a regular or mechanically altered consistency received the appropriate food items at meals. This affected 44 residents (#5, #7, #8, #16, #23, #24, #26, #30, #49, #51, #54, #56, #59, #61, #66, #70, #71, #72, #78, #80, #83, #85, #88, #91, #92, #93, #99, #101, #105, #108, #110, #112, #121, #125, #127, #130, #132, #139, #142, #143, #149, #151, #153, #156) the facility identified as being on a CCD with regular or mech soft consistency, two residents (#24, #109) the facility identified as being on a liberal renal diet with regular or mechanically altered consistency, and four residents (#65, #70, #84, and #87) the facility identified as being on a renal diet with regular or mechanically altered consistency out of 158 residents receiving meals from the kitchen. 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, interview, and record review, the facility failed to ensure palatable meals were served to the residents. This affected two residents (#112 and #129) out of three residents reviewed for food/nutrition. The facility census was 162.Findings include: 1.Review of the medical record for Resident #112 revealed an admission date of 03/04/25. Diagnoses included type two diabetes mellitus, injury of head, hypertension (high blood pressure), and adult failure to thrive. Review of physician orders revealed an order dated 03/10/25 for CCD (carbohydrate controlled diet), regular Texture, thin liquids. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/11/25, revealed Resident #112 was cognitively intact, had no significant weight changes, and was prescribed a therapeutic diet. Review of Resident #112's care plan, dated 03/10/25, revealed the resident had altered nutritional status related to diabetes mellitus and hypertension. Interventions included diet per physician order.Further review of Resident #112's medical record revealed a progress note 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 Based on observation, interview and record review the facility failed to ensure appropriate infection control techniques were used for residents on enhanced barrier precautions. This affected two residents (#14 and #147) of two observed for infection control precautions. The facility census was 162.Findings include:1. Review of Resident #14's medical records revealed an admission date of 06/09/22. Diagnoses included cerebral palsy, tracheostomy and gastrostomy.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had no cognition score due to being rarely understood. Resident #14 was dependent for eating, toileting and personal hygiene. Review of the care plan dated 05/20/25 revealed Resident #14 required Enhanced Barrier Precautions (EBP) related to feeding tube and tracheostomy. Interventions included utilize gown and gloves during high contact care that included care of feeding tube and/or trach.Review of current physician orders for July 2025 revealed Resident #14 was on EBP…

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, interviews, record reviews, and facility policy, the facility failed to ensure their smoking policy was followed for the independent smokers. This affected three independent smoking residents (#42, #98, and #104) reviewed for smoking but had the potential to affect an additional 12 residents (#12,#17, #32, #36, #65, #93, #97, #99, #128, #146, #151, #153) the facility identified as being independent smokers. The facility identified 30 residents (#5, #11, #12 ,#17, #19, #25, #32, #36, #42, #49, #51, #64, #65, #66, #71, #81, #82, #89, #93, #97, #98, #99, #100, #104, #107, #109, #128, #146, #151, #153) as being smokers. The facility census was 162. Findings include: Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure the smoking policy was being implemented in the facility. This affected three residents (#42, #98, and #104) of three residents reviewed for smoking. The facility identified a total of 30 residents (#5, #11, #12 ,#17, #19, #25, #32, #36, #42, #49, #51, #64, #65, #66, #71, #81, #82, #89, #93,…

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 timely order Resident #62 ileostomy and catheter care to ensure treatment was in place. This affected one resident (Resident's #62) out of three reviewed for catheter and ostomy care. The facility census was 167. Findings include: Review of Resident #62's medical record revealed an admission date of 10/19/24 and diagnoses included benign neoplasm of the cecum, schizoaffective disorder, depressive type, and obstructive and reflux uropathy. Review of Resident #62's progress notes dated 10/19/24 at 3:31 P.M. revealed Resident #62 was admitted to the facility with 28 staples to the abdomen and a JP drain to the left side of his abdomen. Resident #62 had a suprapubic catheter and ileostomy bag. Review of Resident #62's physician orders dated 10/19/24 through 11/04/24 did not reveal orders for the care of Resident #62's suprapubic catheter or ileostomy. Review of Resident #62's Medication Administration Record (MAR) and Treatment Administration…

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 appropriate care and services were followed for Resident #158's PEG (percutaneous endoscopic gastrostomy) tube per physician orders. This affected one resident (Resident #158) out of three reviewed for appropriate care for PEG tubes. The facility census was 167. Findings include: Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's physician orders dated 10/16/24 revealed enteral feed order, every night shift for routine care cleanse around stoma site with normal saline, apply DCD (dry clean dressing), four by four, monitor stoma and surrounding skin for irritation every shift. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief…

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 #158's tracheostomy was properly cared for to keep the surrounding tissue clean. This affected one resident (Resident #158) out of three residents reviewed for respiratory care. The facility census was 167. Findings include: Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed due to resident was rarely, never understood. Resident #158 was dependent for all ADL's. Resident #158 received oxygen therapy, suctioning and tracheostomy care. Review of Resident #158's physician orders dated 10/16/24 revealed orders for trach care every shift and as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure medications were administered in accordance to current nursing standards of practice. This affected two residents (Resident #4 and Resident #158) out of four residents reviewed for medication administration. The facility census was 167. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 10/19/24 and diagnoses included unspecified fracture of the shaft of the right fibula, subsequent encounter for closed fracture with routine healing, type two diabetes with diabetic neuropathy, and shortness of breath. Review of Resident #4's physician orders dated 10/19/24 revealed orders for Fluticasone Proprionate Diskus inhalation aerosol powder breath activated 100 mcg per ACT, one puff orally two times a day for SOB (shortness of breath). Review of Resident #4's Medication Administration Record (MAR) revealed on 11/06/24 at 9:00 A.M., Licensed Practical Nurse (LPN) #400 signed…

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 staff donned appropriate PPE (Personal Protective Equipment) when providing care for Resident's 62 and #158 and failed to ensure enhanced barrier precautions were implemented for Resident #62 timely. This affected two residents (Resident's #62 and #158) of three residents reviewed for infection control. The facility census was 167. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 10/19/24 and diagnoses included benign neoplasm of the cecum, schizoaffective disorder, depressive type, and obstructive and reflux uropathy. Review of Resident #62's progress notes dated 10/19/24 at 3:31 P.M. revealed Resident #62 was admitted to the facility with 28 staples to the abdomen and a JP drain to the left side of his abdomen. Resident #62 had a suprapubic catheter and ileostomy bag. Review of Resident #62's care plan dated 10/24/24 included Resident #62 was at risk 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 observation and staff interview, the facility failed to ensure facility garbage and refuse was maintained in a sanitary condition. This had the potential to affect all 157 residents residing in the facility. The facility census was 157. Findings include: Observation of the facility's outside dumpster area with Dietary Manager (DM) #529 on 06/03/24 at 3:30 P.M. revealed multiple plastic trash bags full of refuse were on the sides of the dumpster, multiple used Styrofoam food containers were on the ground outside the dumpster area, and various other pieces of miscellaneous debris were noted on the ground outside the dumpster area including, plastic gloves, straws, disposable masks, and various food particles. Interview with DM #529 at the time of the observation on 06/03/24 verified the above findings. This deficiency represents an incidental finding discovered during the course of the complaint investigation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide reasonable accommodations during meals for Resident #128 with visual impairments and failed to provide appropriate length beds for Resident's #5 and #140. This affected three (Resident's #128, #5 and #140) of eight residents reviewed for reasonable accommodation of needs. The facility census was 169. Findings include: 1. Review of the medical record revealed Resident #128 was admitted to the facility on [DATE] with diagnoses including legal blindness, as defined in United States of America and primary open-angle glaucoma, bilateral, indeterminate stage. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #128 had intact cognition and required supervision for eating. Review of the plan of care dated 06/10/20 revealed Resident #128 had impaired visual function related to blindness in right and left eye. Interventions included to adapt environment to the residents individual needs 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 record review, observations, and interview the facility failed to date and/or change supplemental oxygen tubing in a timely manner. This affected two (Resident's #27 and #38) of 12 residents reviewed for oxygen therapy. The facility census was 169. Findings Included: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition. Review of physician order dated 04/13/22 revealed Resident #27 was to receive supplemental oxygen via nasal cannula every shift for shortness of breath. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and encephalopathy, unspecified. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #38 had intact cognition. 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 observations, interviews, and record reviews the facility failed to date opened insulin vials to ensure purity and potency. This affected four (Resident's #1, #41, #80 and #122) of 29 residents reviewed for insulins. The facility census was 169. Findings include: Review of the medical record for Resident #1 revealed an admission date of 02/12/22 with diagnosis including diabetes mellitus. Review of the physician's orders revealed an order dated 07/26/22 for Lantus Solostar solution pen. Review of the medical record for Resident #41 revealed an admission date of 05/02/22 with diagnosis including type two diabetes mellitus. Review of the physician's orders revealed an order dated 07/05/22 for a Basaglar KwikPen and an order dated 07/17/22 for NovoLog solution. Review of the medical record for Resident #80 revealed an admission date of 11/23/20 with diagnosis including type two diabetes mellitus. Review of physician's orders revealed an order dated 11/23/20 for a Lantus Solostar solution pen. Review of medical record for Resident #122 revealed an admission date of 06/22/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain infection control standards when serving food. This affected one (Resident #20) of 20 residents observed for dining. The facility census was 169. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, monoplegia of upper limb, and cerebrovascular disease affecting unspecified side. Observations on 07/25/22 at 12:46 P.M., Nurse Aide Trainee (NAT) #735 was observed handling Resident #20's ham sandwich with bare hands. Interview immediately after the observation, NAT #735 verified touching the sandwich with her bare hands. Interview on 07/26/22 at 5:00 P.M., the Director of Nursing (DON) stated staff should be wearing gloves when touching food. Interview on 07/27/22 at 11:20 A.M., the DON stated staff received training related to hand hygiene during tray pass. Review of training signature sheet verified the training was completed.

Based on observation, policy review, interview, and review of manufacturer's recommendations, the facility failed to ensure dishes were maintained in a clean and sanitary manner. This had the potential to affect 162 who ate meals in the facility's kitchen. Four residents (#11, #50, #128, and #374) received enteral nutrition as their only source of nutrition. The facility census was 162. Findings include: Observations on 06/04/19 at 10:05 A.M. during the operation of the dish machine after the breakfast meal revealed two dish racks went through the dish machine's complete cycle on top of each other. The bottom dish rack had cereal bowls and directly placed on top another rack was filled with plate covers and bottoms. After the double rack went through the complete cycle, there was food on the base of the bowls which was flipped upside down on the dish rack. Interview with Corporate RD #219 at the time of the observation verified there were too many lids on the top rack and the dish machine shoots water from the top and the bottom and the staff is good with taking dirty dishes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure isolation rooms were cleaned properly. This affected one resident (Resident #144) of five residents reviewed for infections and these cleaning practices had the potential to affect all residents residing in the facility. The facility census was 162 residents. Findings include: Review of Resident #144's medical record revealed an admission date of 10/24/18 and diagnoses including severe protein-calorie malnutrition, depression, dependence on renal dialysis, spinal stenosis and mild cognitive impairment. A minimum data set (MDS) assessment dated [DATE] revealed Resident #144 was cognitively impaired and required extensive assistance from staff for activities of daily living. A physician's order dated 06/03/19 revealed Resident #144 was on contact precautions for clostridium dificile (c. diff). Observations on 06/04/19 at 2:19 P.M.; 06/05/19 from 9:28 A.M. to 9:37 AM., 12:36 P.M. and 06/06/19 at 9:10 A.M. and 12:10 P.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.

Based on observations and interviews, the facility failed to ensure resident medications were stored properly in medication carts. This affected three of six medication carts in the facility. The facility census was 162. Findings include: Observation of the medication chart was completed on 06/05/19 at 8:10 A.M. on the Two [NAME] unit with Licensed Practical Nurse #67. The medication cart contained medications for residents on the second-floor west unit. Each resident had separate bubble pack card with a 30-day supply of medication contained on each card. Each medication had its own card. The two large drawers in the middle of the cart were used to store the bubble packed pills and the cards were stored in an upright manner, pulled out as needed and placed back into the drawer after pushing the medication out of the bubble pack card. Both drawers containing the medications, had three holes in the bottom of the front of each drawer. These holes would allow for loose medications to fall to the floor if the medication was small enough to fit through the hole. Each hole was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the advance directive orders were accurate and consistent in the electronic and non-electronic charting. This affected two residents (Resident # 138 and Resident # 324) of 37 residents reviewed for advanced directives. The facility census was 162 Findings Include: 1. Record review revealed Resident #138 was admitted on [DATE] with diagnoses including chronic kidney disease, heart disease, a pressure ulcer located on the base of the spine. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive physical assistance activities of daily living. Review of the hard chart medical record revealed a valid Ohio DNR (Do Not Resuscitate) Identification Form dated 05/20/19 was signed by a physician that confirms a DNR Comfort Care Protocol (DNRCC) was activated. Review of June 2019 signed physicians' order revealed an order dated 05/31/19 for a full code status. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure smokers (#139 and #373) were supervised during smoke break on the secured unit. This affected two out of the four residents (#73, #131, #139 and #373) that smoked on the secure unit. The facility census was 162. Findings include: Review of Resident #139's medical record revealed an admission date of 04/25/19 with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, Wernicke's Encephalopathy, malnutrition and nicotine dependence. Review of an admission comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was assessed to be severely impaired with a Brief Interview of Mental Status (BIMS) of five. The assessment revealed that the resident was independent for most Activities of Daily Living (ADLs). Resident #139's medical record also indicated that a smoking assessment and comprehensive care plan were not completed Review of Resident # 373's medical record revealed an admission date 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.