Gardens Of Euclid Beach

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to ensure medical record documentation included weekly skin assessments as ordered and care planned for Resident #1, #3, #7, #9, #29, #44, #45, #49, #53, #63, and #69, and failed to ensure the change of condition and subsequent death of Resident #76 was documented in the medical record. This affected 12 Residents (#1, #3, #7, #9, #29, #44, #45, #49, #53, #63, #69 and #76) of 22 residents reviewed for complete resident records. The facility census was 53. Findings include:1.Review of the medical record for Resident #3 revealed an admission date of [DATE]. Diagnoses included but were not limited to end stage renal disease with dependence upon renal dialysis, type two diabetes mellitus with retinopathy, morbid obesity, hemiplegia and hemiparesis. Review of the [DATE] physician order for Resident #3 revealed an order for a weekly skin assessment to be completed every Monday. Review of the [DATE] quarterly Minimum Data Set (MDS)…

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 a catheter drainage bag was placed in a privacy bag to maintain dignity. This affected one resident (Resident #27) of three residents (Residents #4, #5 and #27) identified with urinary drainage systems. The Facility census was 53. Findings include:Review of medical records for Resident #27 revealed a date of admission of 05/07/25. Significant diagnoses included other mechanical complication of other urinary catheter, obstructive and reflux uropathy, and neuromuscular dysfunction of the bladder. Significant orders included indwelling foley catheter, change foley catheter every 28 days and as needed, empty foley catheter every shift, monitor urine for color, clarity, and odor, and consult urology for catheter change every 28 days. Review of the admission minimum data set 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact. The assessment also noted an indwelling urinary catheter. Review of the care plan 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 interview, record review, and facility policy review the facility failed to ensure the physician was notified of resident changes in condition. This affected two residents (#13 and #85) of 22 residents reviewed for change in condition. The facility census was 53.Findings include:1.Review of the closed medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, asthma, hemiplegia/hemiparesis after a stroke affecting the left nondominant side, congestive heart failure, atrial fibrillation, rectal cancer, and heart disease. Review of the physician's orders for Resident #13 revealed an order written on [DATE] for the resident to be a full code (perform all life saving interventions). An order was written on [DATE] to admit to hospice with a terminal diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. Hospice was to be notified of all changes, falls, medication errors, equipment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility did not ensure Resident #55's care plan was revised to include physician ordered oxygen therapy. This affected one resident (#55) of 22 residents reviewed for care plans. The facility identified three residents (#5, #39 and #55) who required oxygen therapy. The facility census was 53.Findings included:Review of the medical record for Resident #55 revealed a date of admission of 04/25/25 with diagnoses including emphysema and asthma. Review of Resident #55's physician orders revealed an order dated 05/23/25 for oxygen at two liters per minute via nasal cannula. Review of the quarterly minimum data set 3.0 assessment dated [DATE] revealed Resident #55 was cognitively intact. The assessment also revealed oxygen therapy in use. Review of the care plan, date initiated 04/29/25, revealed Resident #55 had emphysema and chronic obstructive pulmonary disease. Interventions included keep the head of the bed elevated for shortness of breath 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, observation and interviews, the facility failed to ensure Resident #29 was provided corrective lens and vision care appointments per physician orders. This affected one resident (Resident #29) of one resident reviewed for vision services. The facility census was 53.Findings include:Review of the medical record for Resident #29 revealed an admission date of [DATE] with diagnoses including diabetes mellitus with proliferative diabetic retinopathy with bilateral macular edema.Review of the [DATE] quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated severe cognitive impairment. Resident #29 was noted under Section B to have adequate vision with corrective lenses. Review of the care plan for Resident #29 which was last reviewed on [DATE] revealed impaired visual function related to hypertension and diabetes. Interventions listed were to arrange consultation with an eye care practitioner 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.

Based on observation, record review, clinical nursing assistant orientation program staff sign off review, interview and facility policy review, the facility failed to ensure appropriate supervision was provided for residents requiring supervision while smoking and failed to ensure residents did not have smoking items in their personal possession. This affected two residents (Resident #45 and #49) of three residents reviewed for smoking. The facility identified 26 residents (Residents #4, #5, #6, #7, #12, #13, #14, #15, #17, #18, #22, #26, #40, #41, #43, #44, #45, #49, #50, #51, #52, #53, #54, #60, #61, and #63) who smoked. The facility census was 53. Findings include:Observation on 08/18/25 at 2:25 P.M. of the outside smoking area revealed three residents (Resident #45, #49 and #60) smoking outside without supervision. At the time of the observation, the Administrator confirmed residents were without staff supervision and stated he did not know if those resident's required supervision, but if they required supervised smoking, a staff member should have been present. 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 record review, observation, interview and facility policy review, the facility failed to ensure oxygen tubing was dated as changed weekly for equipment management and infection control. This affected two residents (Resident #39 and Resident #55) of three residents (Residents #5, #39 and #55) identified by the facility as utilizing oxygen. The facility census was 53. Findings include:1. 1. A review of the medical record for Resident #39 revealed a date of admission of 06/28/23. Significant diagnosis included acute respiratory failure with hypercapnia (a buildup of carbon dioxide in the bloodstream). Significant orders included oxygen at four liters per minute at bedtime and as needed to keep oxygen level above 92 percent, change oxygen tubing every Tuesday for respiratory equipment management and infection control. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. The assessment also revealed oxygen therapy in use. Review of the care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure monthly pharmacy reviews were completed for two residents (Residents #4 and #53) of five reviewed for unnecessary medications. The facility census was 53. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 09/08/23. Diagnoses included hemiplegia and hemiparesis affecting the left non-dominant side, type II diabetes mellitus, history of suicidal behavior, alcohol abuse and cocaine abuse. Review of the physician order dated 01/29/25 for Resident #53 revealed an order for Sertraline Hydrochloride (an antidepressant) 75 milligrams (mg) mg by mouth one time a day for depression. Review of the physician order dated 04/01/25 for Resident #53 revealed an order for Depakote sprinkles (an anticonvulsant) capsule delayed release 125 mg, give one capsule by mouth two times a day for mood stabilization. Review of the physician order dated 05/02/25 for Resident #53 revealed an order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician ordered labs were completed timely as required. This affected one resident (Resident #53) of 22 residents reviewed for physician orders. The facility census was 53. Findings include:Review of the medical record for Resident #53 revealed an admission date of 09/08/23. Diagnoses included hemiplegia and hemiparesis affecting the left non-dominant side, type II diabetes mellitus, history of suicidal behavior, alcohol abuse and cocaine abuse. Review of the physician order dated 11/21/23 for Resident #53 revealed an order for a BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) to be completed every three months with no further directions specified. Review of the medical record for Resident #53 revealed no evidence of a BMP or CBC being completed on 07/15/25 as ordered. Review of the care plan last reviewed on 07/23/25 for Resident #53 revealed resident at risk for adverse effects related to use of psychoactive medications 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, staff interviews, facility policy review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected one resident (#21) and had the potential to affect fifteen residents (#5, #9, #17, #18, #19, #22, #23, #26, #29, #32, #33, #35, #40, #42, #44) who resided on the Sycamore Unit (rooms 202 through 213). The facility census was 57. Findings include: Review of the medical record for Resident #21 revealed an admission date of 06/17/21 with diagnoses including type II diabetes, hemiplegia and hemiparesis following cerebral infarction, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #21 was alert and oriented to person, place, and time. Review of the care plan dated 10/31/23 revealed Resident #21 had signs and symptoms of coronavirus (COVID-19) positive…

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 maintain a sanitary environment and failed to perform repairs in a timely manner. This affected 16 residents (Resident #24, Resident #42, Resident #36, Resident #56, Resident #32, Resident #14, Resident #52, Resident #43, Resident #38, Resident #3, Resident #23, Resident #8, Resident #26, Resident #19, Resident #18 and Resident #33). The facility census was 60. Findings include: A tour of the facility on 08/15/23 from 11:30 A.M. to 1:00 P.M. revealed the following findings on the second floor of the facility: -The elevator metal door frame on the first floor and second floor of the facility had paint chipped with the metal beneath the paint exposed. Inside the elevator the back wall had gouges in the wall and the floor of the elevator had ground in black stains. - On the second floor of the facility the dining room entrance windows had bubbling paint around the windows and the molding along the base of the room and the heating vents were broken, loose and not attached to the wall. - There was water damaged flooring by the ice…

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 medications were stored in a secure manner and medications where labeled with residents' names and date opened. This affected three residents (#48, #15 and #51) and had the potential to affect all 58 residents in the facility who received medications from medication carts 1, 2, 3 and 4. Findings include: 1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included ataxia, muscle weakness, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48 was alert and oriented to person, place, time and required a one-person assist for activities of daily living. Observation on 04/04/23 at 8:18 A.M. of Resident #48's bedside table revealed two unidentified white pills, circular in shape, sitting in a small plastic cup. Interview on 04/04/23 at 8:18 A.M. with Resident #48 revealed she was provided the pills by overnight…

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 maintain a safe and sanitary environment for residents. This affected five residents (#10, #16, #21, #54 and #164) of 58 residents residing in the facility. Findings include: 1. On 04/04/23 from 9:45 A.M. to 10:05 A.M. environmental observations revealed the following concerns: Resident #10 had approximately 10 strips of clothing/fabric hanging over the electrical outlet and the baseboard heating unit of the room. The base baseboard molding located by Resident #16's headboard was peeled back and hanging from the wall. There was also a drywall patch behind the headboard that needed sanding; the drywall plaster was uneven and spread haphazardly over the patch. Observation of Resident #21 and #54's room revealed the baseboard heater did not have a cover over the heating elements. On 04/04/23 at 1:38 P.M. interview with the Administrator and Maintenance staff verified the above findings. 2. On 04/03/23 at 10:37 A.M. Resident #164's privacy curtain was observed to have dark brown stains and splatter marks on the left bottom…

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 implement safe and responsible smoking practices and policies. This affected one resident (#48) of one resident reviewed for smoking and had the potential to affect all 58 residents residing in the facility. Findings include: 1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included ataxia, muscle weakness, and unspecified mood disorder. Review of a smoking safety screen assessment. dated 12/19/22 revealed Resident #48 was safe to smoke without supervision upon admission. Further review of the assessment revealed Resident #48 required supervision to smoke during assigned smoke breaks, although she was an independent smoker. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48 was alert and oriented to person, place, time, and required one-person assist for activities of daily living. Review of the care plan dated 04/01/23 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 record review and interview the facility failed to ensure Resident #48 was treated with respect and dignity. This affected one resident (#48) of one resident reviewed for resident rights. The facility census was 58. Findings include: Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included ataxia, muscle weakness, and unspecified mood disorder. Review of a progress note dated 02/14/23 at 12:05 P.M. revealed Resident #48 requested assistance regarding Social Security benefits from Former Social Services (FSS) #900. FSS #900 changed the time for Resident #48 to meet with her and Resident #48 became verbally aggressive. FSS #900 informed Resident #48 she was disrespectful, and her behavior was unacceptable. Review of a progress note dated 02/15/23 at 11:00 A.M. revealed Resident #48 went to FSS #900's office and asked if they were going to continue to work on her Social Security benefits by stating are we going to make the call or what. FSS #900 told…

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 Resident #48 was screened for services and placement in the nursing facility. The facility also failed to notify the appropriate State agency (the Ohio Department of Mental Health) when two residents (#4 and #48) with a level two mental illness had a significant change in condition. This affected two residents (#4 and #48) of two residents reviewed for Pre-admission Screen and Resident Review (PASARR). The facility census was 58. Findings include: 1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included ataxia, muscle weakness, and unspecified mood disorder. Review of a PASARR evaluation dated 01/04/23 revealed Resident #48 had a level two mental illness. In addition, the PASARR result notice dated 01/04/23 revealed a referral was made for a level two evaluation. Further review of Resident #48's hard chart and electronic medical record (EMR) revealed no level two evaluation results.…

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 #48 received timely assistance with applying for Social Security benefits from social service staff. This affected one resident (#48) of one resident reviewed for resident rights. The facility census was 58. Findings include: Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included ataxia, muscle weakness, and unspecified mood disorder. Review of a progress note dated 02/14/23 at 12:05 P.M. revealed Resident #48 requested assistance regarding Social Security benefits from Former Social Services (FSS) #900. FSS #900 changed the time for Resident #48 to meet with her and Resident #48 became verbally aggressive. FSS #900 informed Resident #48 she was disrespectful, and her behavior was unacceptable. Review of a progress note dated 02/15/23 at 11:00 A.M. revealed Resident #48 went to FSS #900's office and asked if they were going to continue to work on her Social Security benefits by stating…

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 the abuse policy and procedure, the facility failed to develop and 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 and failed to obtain reference checks. This affected six employee files (Licensed Practical Nurse (LPN) #103, LPN #301, Director of Admissions #54, Housekeeping Assistant #82, Human Resource Director (HRD) #100 and the Administrator) of eleven personnel files reviewed for screening against the State of Ohio Nurse Aide Registry and four employee files (LPN #301, State Tested Nurse Aide (STNA) #35, STNA #151 and Floor Technician #83) of eleven personnel files reviewed for reference checks. This had the potential to affect all 112 residents residing in the facility resulting in substandard quality care. Findings include: Review of eleven personnel files revealed six staff were not checked against 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 and interview, the facility failed to ensure staff washed their hands between handling soiled floor mats and clean steam table pans. This had the potential to affect 105 residents out of a census of 112. Residents #27, #47, #61, #65, #69, #86 and #106 did not receive receive meals from the kitchen. Findings included: During the dinner tray line observation on 10/05/19 at 5:25 P.M. Staff #66 was noted to pick-up two debris laden rubber floor mats off of the floor and take them to the back of the kitchen near the dirty dish area. He then sprayed the mats down and put them back near the tray line. The mats still contained debris. He then placed three clean steam table pans beneath the steam table onto a stack of other clean pans without first washing his hands. This observation was verified with the Dietary Manager (DM) at the time of the observation. The DM removed the pans and placed them in the dirty dish area.

Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 112. Findings include: Review of the facilities sign-in sheet for the QA meeting minutes for the meetings held in June 2019, July 2019, August 2019 and September 2019 revealed no evidence the medical director attended the meetings. Interview with the Administrator on 10/09/19 at 3:25 P.M. verified the medical director did not attend the QA meetings as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure appropriate hand washing was performed during care of a resident on isolation precautions, personal protective equipment was properly disposed of, proper signage was posted regarding the need for isolation precautions, and biohazardous waste was properly disposed of. This affected one (Resident #43) of one resident reviewed for isolation precautions and had the potential to affect all 112 residents currently residing in the facility. Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia and a Clostridium Difficile (a highly contagious bacteria) infection of the stool. A Minimum Data Set Assessment 3.0 (MDS) dated [DATE] revealed she had severe cognitive impairment, and needed extensive assistance for most activities of daily living including toileting. She was totally dependent on staff for transfers and eating. Review of physician orders dated 09/24/19 revealed Resident #43 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, interview and record review, the facility failed to ensure the comprehensive assessment was coded correctly for Resident #48 for vision, Resident #34 for medications, Resident #115 for discharge location, Resident #12 for refusal of care and Resident #5 for life expectancy. This effected five of 35 Residents (#5, #8, #12, #14, #16, #23, #26, #27, #34, #37, #43, #48, #51, #57, #58, #61, #64, #66, #75, #78, #79, #82, #92, #97, #99, #103, #104, #107, #108, #109, #111, #113, #115, #163 and #313) reviewed for assessment accuracy. The facility census was 112. Findings include: 1. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including psychosis, symbolic dysfunction, abnormality of gait, altered mental status, insomnia and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the residents vision was adequate, and she had no corrective lens. Interview on 10/06/19 at…

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

Based on observation and staff interview the facility failed to ensure the envionment was manintained in a clean manner and in good repair for all residents. This affected 27 (Residents #9, #10, #11, #12, #22, #34, #35, #55, #56, #57, #58, #61, #62, #65, #68, #69, #80, #86, #87, #93, #96, #97, #98, #99, #112, #163 and #365) of 112 residents currently residing in the facility. Findings include: An environmental tour was conducted on 10/09/19 between 9:45 A.M. and 10:33 A.M. with Housekeeping Supervisor (HSK) #6 and Maintenance Director (MD) #15. The following concerns were observed and verified during the tour by HSK #6 and MD #15; • The room belonging to Residents #10 and #93 contained a stained privacy curtain. • The room belonging to Residents #56 and #62 contained multiple holes in the walls. • The rooms belonging to Residents #69 and #97 contained tube feeding poles with a significant amount of dried and caked on tube feeding liquid. • The room belonging to Resident #99 contained bed sheets with large stains of unknown substances. • The rooms belonging to Residents #9, #65, #68…

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 resident interview, record review and staff interviews, the facility failed to ensure Resident #107 had care plan meetings as required. This affected one (Resident #107) of two residents reviewed for care plan meetings. The facility census was 112. Findings include: Review of the medical record for Resident #107 revealed he was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, hypertension, chronic viral hepatitis C, retention of urine and prostate cancer. Resident #107 was interviewed on 10/06/19 at 11:32 A.M. and stated he had not been invited to or participated in any care plan meetings since he was admitted . Further review of the medical record for Resident #107 revealed no documentation that any care plan meetings had been held. Social Worker (SW) #89 was interviewed on 10/08/19 at 10:00 A.M. and stated resident care conferences were held quarterly. SW #89 verified on 10/08/19 at 10:59 A.M. that no care conferences had been held with Resident #107 since his admission…

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 accurate advanced directive information was present throughout the medical record for Resident #12. This affected one of one resident (Resident #12) reviewed for advanced directives. The facility census was 112. Findings include: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Alper's disease (a progressive neurological disorder), paranoid schizophrenia and psychosis. Review of the physician's orders for October 2019 revealed Resident #12 was a full code. Further review of the medical record for Resident #12 revealed a red sheet of paper under the advanced directive tab with do not resuscitate comfort care (DNRCC) printed on it. Registered Nurse (RN) #158 was interviewed on 10/09/19 at 11:24 A.M. and verified Resident #12's code status was DNRCC, and the physician's order for full code was incorrect.

Based on record review and staff interview, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form was given to Resident #73 upon the discontinuation of skilled services. This affected one (Resident #73) of three residents reviewed for proper notices of non-coverage. The facility census was 112. Findings Include: Review of the medical record for Resident #73 revealed Resident #73 was given a Notice of Medicare Non-Coverage (NOMNC) on 09/26/18 indicating skilled services was would be discontinued on 09/28/19. Review of census records revealed Resident #73 remained in the facility. Further review of the medical record revealed Resident #73 did not receive a SNF ABN as required. Interview with Social Worker #89 on 10/08/19 at 10:55 A.M. verified the lack of notice. He stated he was unaware that a SNF ABN form needed to be issued when residents remained in the facility and were discontinued from Medicare services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and physician notes, the facility failed to ensure a care plan was initiated for a resident admitted with a chronic cough. This affected one resident (Resident #64) of 35 residents whose care plans were reviewed. The facility census was 112. Findings include: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Her admitting diagnoses included respiratory failure with hypoxia, major depressive disorder, anxiety disorder, cerebral infarction, tracheostomy and type II diabetes. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance of two staff for most activities of daily living including transfers, toilet use and personal hygiene. Review of the nurse practitioner notes dated 09/10/19 indicated the resident was evaluated for a low grade temperature of 99.1 degrees Fahrenheit (F). The note stated the resident was having a frequent most cough. Per this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents care plans were updated to meet the residents needs. This affected one resident (Resident #43) of 35 residents whose care plans were reviewed. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. His admitting diagnoses included epilepsy, heart failure, hypertension, atrial fibrillation, dementia and Clostridium Difficile (C. Diff), a highly contagious bacteria, in the stool. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. She required extensive assistance for most activities of daily living, including toileting. She was totally dependent on staff for transfers and eating. Review of the physician's orders revealed on 09/24/19 she was diagnosed with C. Diff in her stool, and she was placed on isolation precautions. Review of the resident's plan of care dated 09/30/19 indicated Resident #43 was on contact…

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 ensure a safe and accurate discharge for Resident #313 . This affected one resident (Resident #313) of two residents reviewed for the discharge process. Findings include: Review of the medical record of Resident #313 revealed an admission date of 06/17/19. Her admitting diagnoses included type II diabetes, pneumonia, heart failure, hypothyroidism and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident was alert and oriented. She required supervision of one staff for most activities of daily living, including personal hygiene and toileting. Interview with the Director of Nursing (DON) on 10/06/19 at 9:30 A.M. revealed that residents, depending on their insurance, can be discharged with their medications from the medication cart. She stated the discharging nurse will reconcile the discharge medications against the resident's medication card to make sure the resident is getting the correct…

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 and record review, the facility failed to ensure there was intervention for prevention of functional decline in abilities for Resident #48, who declined in bed mobility, transfers, eating and toileting. This affected one of six (Resident's #5, #48, #75, #99, #109, and #163) reviewed for activities of daily living. The facility census was 112. Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including sarcoidosis, psychosis, symbolic dysfunction, abnormality of gait, difficulty in walking, peptic ulcer, altered mental status, insomnia, dementia with behavioral disturbance, hypertension and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required supervision for bed mobility and toileting, and she was independent with transfers and eating. Review of the 07/31/19 MDS 3.0 assessment revealed the resident required extensive assistance for bed mobility 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 one resident (Resident #75) received nail care of five Residents (#16, #75, #99, #109, and #163) reviewed for activities of daily living (ADL). The facility census was 112. Findings included: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including, hemiplegia and hemiparesis, vascular dementia without behavior disturbance, major depression, other specific joint derangements. Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident required extensive assistance of one staff for personal hygiene. On 10/06/19 at 11:20 A.M. observation of the resident revealed his left arm was contracted at the wrist and elbow. The resident had full use of the right hand. The right hand was noted to have long dirty finger nails. With the contractures of the left hand, the resident would not be able to clean or clip his nails. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #48 was provided with glasses after a vision exam indicated she required them. This effected one of one resident reviewed for vision. Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including psychosis, symbolic dysfunction, abnormality of gait, altered mental status, insomnia and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident's vision was adequate, and she had no corrective lens. Interview on 10/06/19 at 9:38 A.M. with the residents responsible party revealed the resident was admitted with glasses, but they have disappeared. She was unsure if the resident had been seen for vision consult. Review of the resident record revealed the resident was seen for a vision exam on 11/07/18 and had a prescription for glasses. Interview on 10/08/19 at 10:18 A.M. with 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 and record review, the facility failed to ensure Resident #78's right hand splint was applied correctly. This effected one of one resident reviewed for positioning. The facility census was 112. Findings include: Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, hypothyroidism, dysphagia, symbolic dysfunction and cerebral vascular accident. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive impairment and no splinting devices. Review of the physicians telephone orders dated 09/19/19 stated the resident was to wear bilateral resting hand splints at all times. Interview on 10/06/19 at 10:20 A.M. with the residents spouse revealed she thought the splints had been applied by the state tested nursing assistants (STNA's). The surveyor observed the resident was wearing bilateral hand splints, a left elbow…

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 and review of personnel files, the facility failed to ensure performance reviews were completed every 12 months and failed to ensure State Tested Nurse Aides (STNA) completed 12 hours of in-service education every twelve months. This affected two (STNA #131 and #166) of five STNA personnel files reviewed. Findings include: Review of five STNA personnel files revealed two STNA's #131 and #166 had been employed over a year. STNA #131 was hired on 01/09/00 and had no evidence of annual evaluations until this day, 10/09/19. STNA #166 was hired 01/09/13 and had no evidence of annual evaluations. Human Resource Director (HRD) #100 provided a performance evaluation indicating her date of hire was 06/06/19 and was not due for a three month evaluation until 09/02/19. Interview with HRD #100 verified annual evaluations were not completed on 10/09/19 at 4:30 P.M. Review of STNA #166's personnel file had no evidence she was provided 12 hours of in-service education annually. Interview with HRD #100 on 10/09/19 at 4:30 P.M. verified there was no documented evidence of STNA…

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 a residents was discharged with the correct medication. This affected one resident (Resident #313) of three residents reviewed for discharge. The facility census was 112. Findings include: Review of the closed medical record of Resident #313 revealed an admission date of 06/17/19. Her admitting diagnoses included type II diabetes, pneumonia, heart failure, hypothyroidism and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was alert and oriented. She required supervision of one staff for most activities of daily living, including personal hygiene and toileting. Review of the discharge medications revealed she was ordered the following medications: • Amlodipine (medication to treat high blood pressure and chest pain) 10 milligrams (mg) daily • Aspirin (blood thinner) 81 mg by mouth daily • Doxazosin (medication to treat urinary retention and high blood pressure) 2 mg take one tablet by mouth daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review monthly pharmacy recommendations and interview, the facility failed to ensure a gradual dose reduction was attempted for Resident #108. This affected one resident (Resident #108) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #108 was admitted to the facility on [DATE]. Her admitting diagnoses included urinary tract infections, sickle cell trait, gout, vascular dementia, type II diabetes and chronic kidney disease. Review of Resident #108's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. She required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Resident #108 was totally dependent on staff for transfers and locomotion on and off the unit. Review of the medication assessment from the MDS revealed the resident received seven injections of insulin, received an antidepressant seven of seven days, an antipsychotic seven…

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.