Rocky River Gardens Rehab And Nursing Ctr

Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 106 residents receiving food from the facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth (NPO). The facility census was 110. Findings include: Observation of the facility's nourishment refrigerators on 04/09/24 starting at 9:51 A.M. with Food Service Director (FSD) #440 revealed the following: • In the first floor resident refrigerator, there were two expired yogurts dated 03/23/24, two expired yogurts dated 03/26/24 and a half-gallon of milk dated 04/04/24. • In the second floor resident refrigerator, there was an unidentified pink substance on the inside base of the refrigerator and there was frozen popsicle material on the inside base of the freezer. • In the third floor resident refrigerator, there were two containers labeled with Resident #85's room number on it but no date. Interviews with FSD #440 verified the above findings at the time of observation. FSD…

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 resident funds were disbursed as required and in a timely manner after death. This affected one resident (Resident #120) of five residents reviewed for resident funds. The facility census was 110. Findings include: Review of Resident #120's medical record revealed an admission date of [DATE] and diagnoses including paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified, unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known physiological condition and history of COVID-19. Review of a Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #120 expired in the facility. Review of a nurses' note dated [DATE] revealed Resident #120 expired in the facility. Review of Resident #120's resident fund statement revealed as of [DATE], Resident #120 had an ending balance of $1069.28. There was no evidence of final disbursal for review. Interview on [DATE] at 4:25…

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 significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14. This affected one resident (#14) of 25 residents reviewed for MDS assessments. The facility census was 110. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression. Review of the physician orders for Resident #14 revealed the resident was admitted to hospice services on 02/20/24 for dementia with behavioral disturbance. Review of the comprehensive annual MDS 3.0 assessment, dated 03/11/24 for Resident #14 under Section J, Health Conditions, revealed the resident was severely cognitively impaired and did not have a life expectancy of less than six months but was receiving hospice services. Interview with MDS Registered Nurse (RN) #540 on 04/12/24 at 11:50 A.M. confirmed Resident #14 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 accurately complete [NAME] Data Set (MDS) assessments for Resident #5, #14 and #90. This affected three residents (Residents #5, #14, and #90) out of 25 residents reviewed for accurate [NAME] Data Set (MDS) assessments. The facility census was 110. Findings Include: 1. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD), history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5 required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand by assist of staff. Review of Resident #5's signed physician orders for the month of April 2024 revealed orders including fall floor mat to right side of the bed dated 01/21/24, bed in the lowest position dated 01/21/24, and bed against the wall dated 01/21/24.…

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 skin assessment upon admission was timely obtained for the accurate initial assessment of skin impairment for Resident #11. This affected one resident (Resident #11) out of four residents reviewed for pressure ulcers. The facility census was 110. Findings Include: A record review for Resident #11 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, heart failure, peripheral vascular disease (PVD), and Alzheimer's disease. Resident #11 had intact cognition and requires assistance from staff for personal hygiene cares, dressing, and transfers. Review of Resident #11's baseline care plan dated 02/02/24 revealed interventions including use of pressure reducing mattress, pressure reducing cushion in wheelchair, encourage use of appropriate footwear while out of bed, and assess/monitor skin for impairments. A review of Resident #11's admission assessment dated [DATE] revealed Resident #11…

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 policy and procedure, the facility failed to ensure pharmacy recommendations were timely addressed for Resident #90 and #109. This affected two residents (#90 and #109) of five residents reviewed for unnecessary medications. The facility census was 110. Findings include: 1. Review of the medical record for Resident #90 revealed an admission date of 06/24/21. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #90 had impaired cognition. Review of the pharmacy recommendation for Resident #90 dated 10/31/23 was for Divalproex (anticonvulsant) 250 milligrams (mg) twice a day. The pharmacy recommendation documented questioning if a gradual dose reduction (GDR) could be attempted at this time to verify this resident was on the lowest possible dose? If no, please indicate response below. There was a list 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 observation, interview, and record review the facility failed to assess and monitor the use of a necessary antipsychotic medication. This affected one resident (Resident #10) out of five residents reviewed for unnecessary medications. The facility census was 110. Findings Include: Observation on 04/10/24 at 10:15 A.M. revealed Resident #10 resting quietly in bed. Further observations on 04/11/24 at 2:25 P.M. and on 04/12/24 at 11:25 A.M. revealed Resident #10 resting quietly in bed with no behaviors observed. A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with the following diagnoses including Chronic Obstructive Pulmonary Disease (COPD), heart failure, high blood pressure, and Alzheimer's Disease. Resident #10 had impaired cognition and was dependent on staff for all personal hygiene cares, transfers and dressing. Review of Resident #10's signed physician orders dated 04/01/24 revealed an order dated 12/25/23 for the use of antipsychotic…

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

Based on observation, interview, and record review the facility failed to maintain a medication administration error rate of less than 5%. The facility had 37 opportunities for medication error with two medication errors occurring resulting in a medication error rate of 5.41%. This affected one resident (Resident #46) out of four residents observed for medication administration. The facility census was 110. Findings Include: Medication administration observation on 04/11/24 at 7:25 A.M. revealed Licensed Practical Nurse (LPN) #476 preparing morning medication for Resident #46. LPN #476 placed the tablets into a medication pouch to be crushed and poured into a medication cup. LPN #476 took a soft gel capsule of Omega 3 Fish Oil and placed it in a separate pouch to crush and pour the liquid into the medication cup. The soft gel was crushed with a small amount of the liquid being poured into the medication cup. LPN #476 then took a soft gel capsule of B Vitamin Complex and placed it in a separate pouch to crush and pour the liquid into the medication cup. The soft gel was crushed 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 record review, interview, and review of policy and procedure, the facility failed to ensure accurate documentation of a resident's weight in the medical record. This affected one resident (#107) of three residents (#41, #114, and #107) reviewed for nutrition. The facility census was 110. Findings include: Review of the medical record for Resident #107 revealed an admission date of 08/23/23. Diagnoses included chronic kidney disease, diabetes mellitus with diabetic nephropathy, protein-calorie malnutrition, and dementia with behavioral disturbance. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #107 had impaired cognition, weighed 175 pounds (lbs.), had no significant weight changes, and did not receive a specialized diet. Review of the weights and vitals summary for Resident #107 revealed: • 08/23/23 174.4 lbs. on standup scale • 10/01/23 172.3 lbs. on standup scale • 12/15/23 176.2 lbs. while in wheelchair • 01/17/24 175.2 lbs. on standup scale • 02/08/24 174.7…

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

Based on observation, staff interview, and review of a company price quote document, the facility failed to maintain the parking lot in a safe manner. This had the potential to affect all 110 residents residing in the facility. The facility census was 110. Findings include: Observation of the front and back parking lots of the facility on 12/15/23 between approximately 8:30 A.M. and 9:30 A.M. revealed several potholes and significantly damaged pavement in both parking lots. Observation of the front side portion of the parking lot revealed an area measuring 27 feet and four (4) inches long by 13 feet and eight (8) inches wide near a storm drain that had multiple sunken areas with standing water and areas of cracked pavement. Additional observation of the front side parking lot revealed a pothole measuring approximately 26.5 inches long by 22.5 inches wide by approximately three (3) inches deep down to a pebble base, and an area of sunken and broken pavement measuring five (5) feet and 5 inches long by 34.5 inches wide. Observation of the back side parking lot revealed a pothole…

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 each resident's Gradual Dose reduction (GDR) recommendations from the pharmacist was followed up by their physician. This affected four (#3, #30, #24, and #69) of the five residents reviewed for unnecessary medications. The facility identified 31 residents on psychotropic medications. The facility census was 103. Findings include: 1. Record review for Resident #69 revealed an admission date of 03/31/20. Diagnosis included schizophrenia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact. Resident #69 had a diagnosis of schizophrenia and received antipsychotic medication. Review of the care plan dated 04/12/23 revealed Resident #69 used psychotropic medication related to schizophrenia. Interventions included to consult with the pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly. Review of the Consultant Pharmacist Recommendation to Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of policy, the facility failed to ensure a resident's advanced directives were accurately recorded throughout the medical record. This affected one (#35) of three residents reviewed for advance directives. The facility census was 103. Findings include: Record review for Resident #35 revealed an admission date of [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was severely cognitively impaired. Resident #35 required supervision of one-person physical assistants for bed mobility, transfers, ambulation, and toileting. The MDS included bathing itself did not occur. Resident #35 received hospice care. Review of the care plan dated [DATE] revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included to allow patient or…

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, resident interviews and staff interviews, the facility failed to ensure care plans reflected resident needs. This affected three (#57, #14, and #252) of 32 resident records reviewed. The facility census was 103. Findings include: 1. Review of Resident #57 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), protein calorie malnutrition (PCM), muscle weakness, gait abnormalities, lack of coordination, and need for assistance for personal care. Review of Resident #57's physician orders revealed the resident was to have behaviors assessed every shift. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 04/01/23, revealed the resident had intact cognition. Review of nurses notes for Resident #57 dated 05/18/23 at 9:27 P.M., revealed a temporary agreement was made with the Director of Nursing (DON) to move him to a first-floor room. This decision was made after the resident went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of policy, the facility failed to provide bathing/showers for two dependent residents. This affected two (#35 and #73) of three residents reviewed for bathing/showers. The facility census was 103. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/17/22. Diagnoses included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances. Review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self-care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff. Review of the quarterly Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interviews, and policy review, the facility failed to timely assess newly identified skin areas and seek new treatment. This affected one (#80) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 103. Findings include: Review of the medical record for Resident #80 revealed an initial admission date of 05/10/22 and a recent readmission on [DATE]. Diagnoses included but were not limited to unspecified hydro nephrosis, neuromuscular dysfunction of bladder, unspecified severe protein-calorie malnutrition, anoxic brain damage, dysphagia, need for assistance with personal care, and quadriplegia. Review of 04/15/23 quarterly Minimum Data Set (MDS) assessment for Resident #80 revealed severe cognitive impairment. Resident #80 was noted to need extensive assist of one for bed mobility, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. Resident #80 was noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of policy, the facility failed to ensure monthly and weekly weights were completed and monitored for residents. This affected two (#73 and #3) of three residents reviewed for weight loss. The facility census was 103. Findings include: 1. Review of Resident #73's medical record revealed an admission date of 07/22/20 and a readmission date of 02/24/23. Resident #73's diagnoses included catatonic schizophrenia, psychotic disorder with delusions due to known physiological condition, severe protein-calorie malnutrition and immune effector cell-associated neurotoxicity syndrome, grade unspecified (neuropsychiatric syndrome that can occur following administration of certain types of immunotherapies). Review of Resident #73's care plan dated 07/27/20 and revised 06/01/23 included Resident #73 was at risk for impaired nutritional status related to mental status, medical diagnosis of hypertension, malnutrition and vitamin B deficiency, shellfish allergy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of policy, the facility failed to ensure physician orders included the time frame intravenous fluids were to be administered and the percentage of the solution to be administered. This affected one resident (#73) of three residents reviewed for physician orders. The census was 103. Findings include: Review of Resident #73's medical record revealed an admission date of 07/22/20 and a readmission date of 02/24/23. Resident #73's diagnoses included catatonic schizophrenia, psychotic disorder with delusions due to known physiological condition, and immune effector cell-associated neurotoxicity syndrome, grade unspecified (neuropsychiatric syndrome that can occur following administration of certain types of immunotherapies). Review of Resident #73's physician orders dated 10/06/22 at 2:00 P.M., revealed per a telephone order from the Nurse Practitioner to insert a peripheral intravenous (IV), insert midline, two liters normal saline bolus. The order did not specify…

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

Based on record review, staff interview, and policy review, the facility failed to ensure a licensed pharmacist completed monthly medication review (MMR). This affected two (#14 and #69) of the five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/01/19, with diagnoses including: hemiplegia, hemiparesis, non-traumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, dysphagia following cerebral infarction, cognitive communication deficit, speech disturbance, major depressive disorder, and chronic kidney disease. Review of Residents #14's medical record from June 2022 through May 2023 revealed no evidence of monthly pharmacy reviews being completed. 2. Review for Resident #69's medical record revealed an admission date of 03/31/20, with diagnoses including: paraplegia, muscle weakness, major depressive disorder, and generalized anxiety. Review of Residents #69's medical record from April 2023 through May 2023 revealed no evidence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, hospice staff interviews and staff interview, the facility failed to coordinate care with hospice services in providing care for residents. This affected two (#35 and #80) of three residents reviewed who received hospice services. The facility census was 103. Findings include: 1.Record review for Resident #35 revealed an admission date of 06/17/22. Diagnosis included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was severely cognitively impaired. Resident #35 received hospice care. Record review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of policy, the facility failed to maintain infection control practiced during a wound dressing change. This affected one (#80) of two residents observed during wound dressing changes. The facility census was 103. Findings include: Record review for Resident #80 revealed and admission date of 05/10/22, with diagnoses including anoxic brain damage, cognitive communication deficit, need for assistants with personal care, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 was at risk for pressure ulcers and had two stage four pressure ulcers. Review of the care plan for Resident #80 dated 06/01/23 revealed Resident #80 had a pressure ulcer or potential for a pressure ulcer developing related to decreased mobility. Interventions included to administer treatment as ordered. Record review of the physician order dated 06/07/23 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 comprehensive assessments were accurate. This finding affected four (Residents #7, Resident #21, Resident #40 and Resident #103) of seven resident records reviewed for Pre-admission Screen - Resident Review (PAS-RR). The facility census was 99. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizophrenia, disease of pancreas and disease of biliary ducts. Review of Resident #7's medical record revealed the Minimum Data Set (MDS) 3.0 assessment, dated 07/15/19, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, unspecified psychosis, major depressive disorder and anxiety. Review of Resident #21's medical record…

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, facility policy review and staff interviews, the facility failed to ensure timely disposition of unused medications. This affected one of three medication storage rooms in the facility. The census was 99. Findings include: Observation of the medication storage room on the second floor was completed on 12/03/19 at 2:42 P.M. with Registered Nurse (RN) #207. The observation revealed there were two large boxes sitting on the floor with medication cards full of discontinued resident medications, none of which were identified as controlled substances. The observation revealed the medications were from a pharmacy the facility used to utilize. RN #207 confirmed discontinued medications should disposed of and documented. RN #207 confirmed the facility switched pharmacies on 09/03/19, and the medications should have been disposed of a long time ago. RN #207 was unable to identify who was responsible to ensure the destruction has occurred. Review of the facilities Discarding and Destroying Medications policy dated October 2014 was completed. The policy identified…

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 dignity was maintained during medication administration. This effected one (Resident #50) of three Residents (#50, #54 and #60) residents observed for glucose testing and insulin administration. The facility census was 99. Findings include: During the lunch observation in the second floor dining room on 12/02/19 at 12:54 P.M. Resident #50 was approached by Licensed Practical Nurse (LPN) #255 for glucose testing. The resident was seated at the dining table with two other Residents (#54 and #60). The residents glucose level was tested. The nurse returned to the medication cart and returned to the resident at 1:03 P.M. with a filled syringe. The resident was instructed to lift her shirt for the injection. Resident #75 who had finished her meal and was wandering the dining room, stood behind Resident #50 with the front of her body almost touching the back of Resident #75's body. Resident #75 watched the administration of the insulin injection, making comments in Spanish of which surveyor did not understand.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, resident and staff interviews, the facility failed to ensure one (Resident #96) of 16 residents whom were interviewed, had the right to self-administer medications. The facility census was 99. Findings include: Review of Resident #96's medical record identified admission to the facility occurred on 07/04/19. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified Resident #96 was cognitively intact and able to make her needs known. The record identified no completed assessments to evaluate Resident #96's ability to self-administer medications. The record identified no evidence Resident #96 was ever asked if she wished to self-administer medications. The record further identified Resident #96 was in the process of discharging from the facility and would be administering her own medications after discharge. Interview with Resident #96 occurred on 12/04/19 at 12:42 P.M. Resident #96 identified she was admitted from home and was self-administering…

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

Based on medical record review, resident and staff interviews, the facility failed to ensure two of three sampled residents (Resident #31 and #67) were provided interdisciplinary meetings (care conferences) quarterly with each assessment. The facility census is 99. Findings include: 1. Review of Resident #31's medical record identified admission to the facility occurred on 07/19/18 with medical diagnoses including paraplegia, insomnia, spinal cord injury and anxiety. The record identified a quarterly Minimum Data Set (MDS) 3.0 assessment was completed on 10/07/19. The record identified the most recent care plan meeting occurred on 08/19/19, at which time the resident signed acknowledging attendance. 2. Review of Resident #67's medical record identified admission occurred on 01/16/19 following a stroke. The record identified MDS 3.0 assessments were completed on 10/24/19 and 07/10/19, which identified she was cognitively intact. The record identified the most recent care plan meeting was conducted on 02/04/19, at which time the resident attended. Interview with Resident #67 occurred…

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

Based on medical record review and staff interviews, the facility failed to ensure one (Resident #31) of five residents pharmacy recommendations were completed when approved by the physician. The facility census was 99. Findings include: Review of Resident #31's medical record identified admission to the facility occurred on 07/19/18 with medical diagnoses including paralysis, spinal cord injury, pressure ulcers and anxiety. The record identified Resident #31 was receiving two different Vitamin D supplements. The record confirmed the pharmacy reviewed Resident #31's medications on a monthly basis. The record identified on 08/18/19 the pharmacist made a recommendation to obtain a Vitamin D blood level. The physician reviewed and agreed with the recommendation made by the pharmacist. The record revealed no evidence the laboratory blood test was completed and/or ordered by the nursing staff. Interview with Licensed Practical Nurse (LPN) #208 occurred on 12/05/19 at 8:34 A.M. The interview confirmed Resident #31's pharmacy recommendation, which was approved by the physician on 08/18/19,…

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

Based on medical record review and staff interviews, the facility failed to ensure laboratory testing was completed when ordered by a physician. This affected one (Resident #67) of five residents reviewed for unnecessary medications. The facility census was 99. Findings include: Review of Resident #67's medical record identified admission to the facility occurred on 01/16/19 following a stroke. Resident #67 had additional medical diagnoses including diabetes and anti-coagulant (blood thinning) medication use. The record identified a written paper physician order for dated 10/31/19 to complete guaiac of stool three times and a HgbA1c, which are laboratory tests to identify potential blood in the stool and long term blood glucose levels. The record revealed as of 12/04/19 only one stool guaiac had been completed and no HgbA1c as ordered. Interview with Unit Manager/Licensed Practical Nurse (LPN) #208 occurred on 12/04/19 at 1:19 P.M. The interview confirmed the staff had not completed the ordered HgbA1c and the stool guaiac's that were ordered on 10/31/19.

Based on medical record review and staff interviews, the facility failed to ensure diagnostic testing was completed when ordered by a physician. This affected one (Resident #67) of five residents reviewed for unnecessary medications. The facility census was 99. Findings include: Review of Resident #67's medical record identified admission to the facility occurred on 01/16/19 following a stroke. Resident #67 had additional medical diagnoses including diabetes and history of breast cancer. The record identified a written paper physician order dated 10/31/19 to complete a mammogram. The medical record identified the mammogram had not been completed and/or set up as of 12/04/19. Interview with Unit Manager/Licensed Practical Nurse (LPN) #208 occurred on 12/04/19 at 1:19 P.M. The interview confirmed the staff had not completed or set-up Resident #67's mammogram following the 10/31/19 physician order.

Based on observation, interview and policy review, the facility failed to ensure infection control practice was maintained during blood glucose testing for Resident #60. This effected one of two (Residents #54 and #60) residents observed for glucose testing. The facility census was 99. Findings include: During the lunch observation in the second floor dining room on 12/02/19 at 1:05 P.M., Resident #54 was approached by Licensed Practical Nurse (LPN) #255 for glucose testing. The resident was seated at the dining table with two other Residents (#50 and #60). The residents glucose level was tested, and the lancet was disposed of in a plastic cup. LPN #255 then went around the table to Resident #60, prepped a lancet and without cleansing her hands and changing her gloves, grasped the residents finger in preparation of performing a glucose test. At this time the surveyor stopped the LPN informing her there was a break in infection control and she needed to cleanse her hands and re-glove before performing the glucose testing on Resident #60. The LPN responded oh yeah, verifying she…

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