Majestic Care of Clyde

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of documented staff interviews, review of self-reported incidents, interview, and policy review, the facility failed to report and thoroughly investigate an allegation of abuse and immediately protect residents by removing the alleged perpetrator. This affected Resident #22 and had the potential to affect 22 resident residing on the memory care unit. Additionally, the facility failed to report and thoroughly investigate al allegation of misappropriation of the medication Ozempic. This affected three residents (#42, #39, #49) of five residents reviewed for misappropriation of medication. The facility identified five residents as receiving the medication Ozempic. The facility census was 56. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/14/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, hypertension, and anxiety. Review of the 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.

Based on observation, record review, staff interviews, and policy review the facility failed to provide adequate grooming care for a dependent resident (#45). This had the ability to affect all residents. The facility census was 56. Findings include: Review of Resident #45's medical record revealed an admission date of 03/15/11. Diagnosis included Parkinson's disease, bipolar disorder, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of Resident #45's Minimum Data Set (MDS) regarding a significant change dated 02/28/25 revealed the resident had an intact cognitive function, was dependent on staff for activities of daily living, and was under hospice care. Review of Resident #45's most recent care plan revealed she had an activity of daily living self-care performance deficit related to Parkinson's disease and required a one person assist with all personal hygiene and care. Observation of Resident #45's toenails on 03/12/25 at 4:05 P.M. with Licensed Practical Nurse #427 revealed the residents right foot contained a long toenail on her second toe. 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 review of the medical record, staff and resident interview, and policy review, the facility failed to timely clarify incorrect medication orders before administration and failed to ensure medications were administered per physician orders. This affected two residents (#64 and #42) of five residents reviewed for medications. The facility census was 56. Findings include 1. Review of the medical record for Resident #64 revealed an admission date of 06/06/24. Diagnoses included type two diabetes mellitus, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of the care plan last revised 01/21/25 revealed the resident had diabetes mellitus with an intervention to administer diabetes medication as ordered by the physician. Monitor/document side effects and monitor for effectiveness. Review of the physician orders dated 01/16/25 revealed an order for Ozempic (0.25 milligrams (mg) or 0.5 mg/dose)…

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 food sample, resident interview, staff interview, and policy review the facility failed to assure residents were served food at an acceptable temperature. This affected 20 residents (#32, #34, #35, #37, #38, #39, #40, #42, #43, #44, #46, #47, #50, #51, #52, #53, #56, #58, #61, and #62) who received meal trays on the 200 hall. The facility census was 53. Findings include: Interview with Residents #13 and #15 on 01/21/25 between 11:28 A.M. to 1:35 P.M. revealed meals on the hall trays were served cold at times. The residents stated sometimes they would ask staff to reheat the food, or they ate just ate the food cold. Observation of meal tray service on 01/21/25 on the 200 hall revealed the food cart arrived to the hall at 11:42 A.M. Staff began to serve the trays to residents within two minutes. A test tray was checked for food temperature at 11:51 A.M. with Dietary Assistant #535. The shrimp temperature was 100 degrees Fahrenheit and the french fries were 118 degrees Fahrenheit. The food tasted cold and the shrimp had no flavor. Interview with Director of Nutritional 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.

Based on observation, resident interview, staff interview, and facility policy, the facility failed to serve reasonably palatable food. This affected all residents who received spaghetti with the lunch meal. The facility identified 11 (#3, #10, #14, #17, #22, #29, #30, #31, #41, #46, and #50) residents who did not receive spaghetti. The facility census was 54. Findings include: Interviews on 11/04/24 between 8:33 A.M. and 3:29 P.M. with Residents #17, #18, #26, #31, #35, #42, #50, and #55 revealed concerns for food palatability. Observation on 11/05/24 at 12:03 P.M. revealed the lunch meal test tray included a four ounce spoodle of spaghetti noodles with marinara sauce. The spaghetti appeared appetizing but tasted sour and was gummy in texture. Interview on 11/05/24 with Corporate Dietary Manager #198 verified the spaghetti tasted acidity. Interview on 11/05/24 from 12:07 P.M. with Resident #1 revealed the spaghetti sauce was not good and could not eat it. Interview on 11/05/24 at 12:08 P.M. with Resident #9 revealed the spaghetti was yuck. Interview on 11/05/24 at 12:11 P.M. 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 review of the medical record, observation, and interviews, the facility failed to ensure the memory care unit was maintained in good condition. This affected six (#43, #56, #44, #55, #21, #28,) of seven residents reviewed for environment and had the potential to affect all residents residing in the memory care unit. The facility census was 54. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 10/11/23. Diagnoses included dementia, hypertension, and retinal disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had moderate cognitive impairment. Observation on 11/04/24 at 8:13 A.M. revealed there was an approximate ten inch wide by five inch tall spider web in the resident's window between the window and the screen. Interview on 11/06/24 at 8:54 A.M., the Director of Housekeeping (DOH) #158 verified the spider web in the window. 2. Review of the medical record for Resident #55 revealed an admission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents had access to their call lights. This affected three residents (#21, #40, and #42) in a facility with a census of 54. Findings include: 1. Review of the electronic medical record for Resident #40 revealed an admission date of 12/27/24 with diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, atherosclerotic heart disease, bipolar disorder, retention of urine, anemia, anxiety, insomnia, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #17 was cognitively intact. Resident #40 required assistance with her functional abilities and ambulated with a walker. Observation on 11/04/24 at 8:42 A.M. revealed Resident #40 needed to use the restroom and needed to use the call light to request assistance from…

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, staff interview, and review of facility policy, the facility failed to ensure residents received adequate hygiene and personal care. This affected one (#43) of six residents reviewed for Activities of Daily Living (ADLs). The facility census was 54. Findings include: Review of Resident #43's medical record revealed an admission date of 01/19/23. Diagnoses included vascular dementia, hypertension, and peripheral vascular disease. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and required setup assistance with personal hygiene and oral care. Observation on 11/04/24 at 9:24 A.M. revealed Resident #43's bottom teeth were caked with a white residue. Observation on 11/05/24 at 7:26 A.M. revealed Resident #43's teeth were still had a white buildup of residue. Interview on 11/05/24 at 7:26 A.M., State Tested Nursing Assistant (STNA) #163 verified the buildup on the resident's bottom dentures.…

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, resident interview, staff interview, review of facility records, and review of facility policy, the facility failed to ensure medications were available for administration. This affected affected two (Residents #22 and #56) of two residents reviewed for availability of medications. The facility census was 54. Findings include: Review of the facility electronic medical record for Resident #22 revealed an admission date of 11/14/24 with diagnoses of delusional disorders, hypertension, depression, cognitive communication deficit, muscle weakness, other abnormalities of gait and mobility, paranoid schizophrenia, insomnia, constipation, and anxiety. Review of Resident #22's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #22 was cognitively intact. Observation on 11/05/24 at 6:35 A.M. of medication administration for Resident #22 by Licensed Practical Nurse (LPN) #168 revealed the facility did…

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, resident interview, staff interview, record review, and review of facility policy, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care. This affected one (Resident #17) of four residents reviewed for dental care. The facility census was 54. Findings include: Review of the electronic medical record for Resident #17 revealed an admission date of 12/27/24 with diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, mild protein-calorie malnutrition, hypertension, atherosclerotic heart disease, bipolar disorder, retention of urine, anemia, anxiety, insomnia, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #17 was cognitively intact. Review of the care plan for Resident #17 revealed the facility will coordinate arrangements for dental care, transportation as needed/as ordered.…

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, observations, staff interview, and policy review, the facility failed to report an injury of unknown origin. This affected one (#22) of three residents reviewed for injury of unknown origin. The facility census was 57. Findings include: Review of Resident #22's medical record revealed an admission date of 08/01/22. Diagnoses included Parkinson's disease, neurocognitive disorder with lewy bodies, vascular dementia, and major depressive disorder. Review of the Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was severely cognitively impaired and dependent for all activities of daily living. Review of the skin check assessment, dated 09/29/24, revealed Resident #22 had bruising on the left side of the neck. Review of the physician note, dated 09/30/24, revealed staff noticed a bruise on the left side of his neck and thought was a pustule that drained white material in the center of it. Review of the facility self-reported incidents, dated 09/28/24 through…

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, observations, staff interview, and policy review, the facility failed to investigate an injury of unknown origin. This affected one (#22) of three residents reviewed for injury of unknown origin. The facility census was 57. Findings include: Review of Resident #22's medical record revealed an admission date of 08/01/22. Diagnoses included Parkinson's disease, neurocognitive disorder with lewy bodies, vascular dementia, and major depressive disorder. Review of the Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was severely cognitively impaired and dependent for all activities of daily living. Review of the skin check assessment, dated 09/29/24, revealed Resident #22 had bruising on the left side of the neck. Review of the physician note, dated 09/30/24, revealed staff noticed a bruise on the left side of his neck and thought was a pustule that drained white material in the center of it. Review of the facility self-reported incidents, dated 09/28/24 through…

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 interviews, review of the staffing schedule, and review of Benefits Improvement and Protection Act (BIPA) documentation, the facility failed to ensure required Registered Nurse (RN) coverage. This had the potential to affect all 48 residents. Findings include: Review of the staff schedules dated 05/05/24, 05/18/24, 05/19/24, and 05/25/24, revealed there was not a RN working in the facility. Review of the BIPA staffing forms dated 05/05/24, 05/18/24, 05/19/24, and 05/25/24, revealed there was not a RN working in the facility. Interview on 06/26/24 at 7:45 A.M. with the Director of Nursing (DON) verified there was no RN working on 05/05/24, 05/18/24, 05/19/24, and 05/25/24. The DON reported there is typically no RN coverage every other weekend. This deficiency represents non-compliance investigated under Master Complaint Number OH00154702 and Complaint Number OH00154290.

Based on observation, resident interviews, staff interviews, review of the menu, and facility policy, the facility failed to serve palatable meals. This affected 33 (#10, #12, #13, #18, #20, #21, #23, #27, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #40, #41, #42, #43, #45, #47, #48, #49, #50, #51, #53, #54, #55, #56, #58) residents who received the dinner vegetable and one (#10) resident who received the chicken breast. The facility census was 48. Findings include: 1. Review of the dinner menu dated 06/25/24 revealed the meal included two beef tacos in a soft shell, cilantro lime rice, Mexican corn, and seedless watermelon wedge. Observation on 06/25/24 at 5:47 P.M. revealed the Mexican corn was not cooked well and felt tough while chewing. Interview on 06/25/24 at 5:49 P.M. with Corporate Dietary Manager #201 verified the corn was not to palatability standards. 2. Interview on 06/25/24 at 6:17 P.M. with Resident #10 revealed she was so upset because the kitchen provided her a large tough chicken breast for dinner that she could not even stick a fork into. Resident #10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, resident interviews, and facility policy, the facility failed to provide showers to residents dependent upon staff for assistance. This affected three ( #33, #58, and #22) of three residents reviewed for activities of daily living. The facility census was 48. Findings include: 1. Review of the medical record revealed Resident #33 was initially admitted on [DATE] with re-admission on [DATE]. Diagnoses included other secondary parkinsonism, peripheral vascular disease, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, cognitive communication deficit, other idiopathic peripheral autonomic neuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required substantial/maximal assistance with showers/bathing. Review of the most recent care plan revealed Resident #33 requires substantial/max assistance with one staff with showering and to offer a sponge bath…

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, resident interview, and facility policy, the facility failed to have adequate staffing to meet the needs of residents. This affected three (#22, #33, and #58) of three residents reviewed for staffing and activities of daily living. The facility census was 48. Findings include: 1. Review of the medical record review revealed the Resident #22 was admitted on [DATE]. Diagnoses included other speech and language deficits following other cerebrovascular disease, vascular dementia, hypertensive chronic kidney disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely understood and was dependent for showers. Review of the most recent care plan revealed Resident #22 was dependent on staff for bathing, complete showers per schedule and as needed. Resident #22…

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

Based on observation, resident interviews, staff interviews, review of the food substitution list, and facility policy, the facility failed to ensure desired meal substitutions were available. This affected one (#12) of one residents reviewed for preferences. The facility census was 48. Findings include: Observation on 06/25/24 at 5:43 P.M. revealed State Tested Nursing Assistant (STNA) #174 calling the kitchen for Resident #12 who had requested a burger instead of the dinner meal. The unknown kitchen staff on the phone was overheard stating there were no burgers but could offer a peanut butter sandwich. No other alternates were offered. Interview on 06/25/24 at 5:55 P.M. with Resident #12 revealed she does not like tacos and had requested a burger but was offered a peanut butter sandwich instead. Resident #12 stated she did not want a peanut butter sandwich and would skip dinner. Observation of the meal tray revealed Resident #12 did not eat any of the food. Interview on 06/25/24 at 6:30 P.M. with Dietary Manager #162 reported the facility was out of hamburger meat and no…

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

Based on observation, resident interview, and staff interview, the facility failed to ensure the resident's environment was kept clean, sanitary, and homelike. This affected eight (#01, #02, #03, #04, #05, #06, #07, and #09) of 10 residents reviewed for environment. The facility census was 48. Findings include: Observations on 02/06/24 at 10:04 A.M. and on 02/07/24 at 11:31 A.M. of the resident bathroom shared between Resident #01 and Resident #02, revealed the bathroom floor had a black/brown substance on the floor surrounding the toilet bowl. A brown/black substance was also built up inside the toilet bowl. Observations on 02/06/24 at 10:08 A.M. and on 02/07/24 at 11:29 A.M. of the resident bathroom shared between Resident #03 and Resident #09, revealed the bathroom floor had a brown substance on the floor surrounding the toilet bowl. A brown substance was also built up inside the toilet bowl. During an interview on 02/06/24 at 10:10 A.M., Resident #03 reported housekeeping staff cleaned resident rooms on a daily basis, but did not always clean the toilet in the bathroom.…

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, review of the facility's Self-Reported Incidents (SRIs), review of the incident log, and review of the facility policy for abuse, the facility failed to ensure residents were free from abuse. This affected two (#1 and #3) of three residents reviewed for physical abuse. The facility census was 53. Findings include: 1. Closed record review for Resident #2 revealed an admission date of 03/07/22. Diagnoses included heart disease, dementia, schizoaffective disorder, anxiety, depression, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/04/23, revealed Resident #2 was cognitively impaired and did not exhibit physical or verbal behaviors directed toward others. Review of the plan of care, initiated on 07/14/22 and revised on 05/19/23 and 07/20/23, revealed Resident #2 had the potential to be physically aggressive related to dementia, poor impulse control, and has put hands on other residents. 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 review of the facility's Self-Reported Incidents (SRI), staff interview, medical record review, and review of the facility policy for abuse, the facility failed to timely report allegations of physical abuse of residents to the State Survey Agency, Ohio Department of Health (ODH). This affected two (Resident #1 and #3) of three residents reviewed for abuse. The facility census was 53. Findings include: 1. Closed record review for Resident #2 revealed an admission date of 03/07/22. Diagnoses included heart disease, dementia, schizoaffective disorder, anxiety, depression, and cognitive communication deficit. Review of Resident #2's nursing progress notes dated 06/20/23 and timed 10:24 A.M., revealed a loud smacking sound was heard by an state tested nursing aide (STNA). Resident #2 was standing over his roommate (Resident #3) and stated he went after me. The roommate (Resident #3) was sitting on the bed crying out and blood dripping from his nose. Review of Resident #3's medical record revealed an initial…

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, review of the Self-Reported Incident (SRI), review of the facility investigation, and review of the facility policy for abuse, the facility failed to complete a thorough investigation related to an allegation of physical abuse to a resident. This affected one (#1) of three residents reviewed for abuse. The facility census was 53. Findings include: Review of the medical record for Resident #1, revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, vascular dementia, anxiety, and wandering. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/01/23, revealed Resident #1 was cognitively impaired with no exhibited behaviors. Review of Resident #1's nursing progress notes dated 07/31/23 and timed 9:55 A.M., revealed Licensed Practical Nurse (LPN) #225 noted dark purple/red bruising to both ears with a laceration behind the right ear, smaller bruises on face and head, and bruises to left back along rib cage. When…

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 resident and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected five (Residents #22, #31, #34, #39 and #48) and had the potential to affect all 55 residents residing in the facility. Findings include: During the resident council meeting on 06/01/22 at 3:30 P.M., Resident #22, #31, #34, #39 and #48 stated they were not receiving mail on Saturdays. During interview on 06/01/22 at 4:48 P.M., Activities Director #377 stated activity department staff were in charge of passing out mail on the days they worked. The activity staff worked every other Saturday. Resident mail was not always delivered on Saturdays and sometimes there was mail to be passed out on Monday mornings.

Based on record review and interview, the facility failed to have Registered Nurse (RN) coverage of eight hours per day, seven days per week. This affected all residents in the facility. The facility census was 55. Findings include: Review of the staff schedule from 05/01/22 through 05/31/22 revealed there was no RN coverage on 05/16/22, 05/21/22, 05/27/22, 05/29/22, 05/30/22. The RN coverage was less than eight hours per day on 05/08/22, 05/13/22, 05/15/22, and 05/22/22. During interview on 06/02/22 at 7:54 A.M., the Director of Nursing confirmed there was inadequate RN coverage on the above dates.

Based on observation, interview and policy review, the facility failed to thaw food in a safe manner. This had the potential to affect all 53 residents who received food from the kitchen. The facility identified two residents who did not receive food from the kitchen. The facility census was 55. Findings include: During observation on 06/01/22 from 7:26 A.M. through 8:25 A.M., a strainer containing raw diced pork in clear plastic packaging was in the sink with warm water running over it. During interview on 06/01/22 at 8:31 A.M., Dietary Manager #316 stated raw meat was normally thawed in a refrigerator but staff had forgotten about the pork and were running it under warm water to expedite the thawing process. Review of the facility policy titled Food Safety, dated September 2019, revealed staff would be aware of proper food handling and storage procedures and thawing would be completed by refrigeration, in a microwave oven, during the cooking process, or under cold running potable water.

Based on observation, interview and record review, the facility failed to ensure residents on the secured memory care unit, were provided activities to meet their interests and meet their psychosocial needs. This affected all 22 (Residents #1, #2, #5, #7, #10, #11, #12, #13, #14, #15, #17, #19, #23, #24, #25, #27, #30, #32, #36, #48, #49, and #257) who resided on the secured memory care unit. The facility census was 55. Findings include: Review of Resident #1, #13, and #19's current activity assessments and corresponding documentation revealed residents were not receiving individualized activities. Review of the May 2022 participation logs revealed no evidence any of the residents participated in any type of activity, including individual or group activities. Observations made from 05/31/22 through 06/02/22 during the annual survey, revealed no organized activities nor any type of individual activities available for any of the residents on the memory care unit. During interview on 06/01/22 at 1:41 P.M., State Tested Nurse Aide (STNA) #343 stated activities staff rarely came to 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, interview and policy review, the facility failed to document pharmacy medication regimen reviews in the resident's medical records. This affected five (Residents #19, #36, #37, #50, and #51) of five residents reviewed for medications. The current census is 55. Findings include: 1. Record review revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included brief psychotic disorder, breast cancer, diverticulosis, depression, cognitive deficit, and alcohol dependence. Review of Resident #50's care plans dated 03/2022 revealed a focus for psychotropic medication use. Interventions included the resident will receive the lowest therapeutic medication dosage to facilitate maximum functioning and well being, assess for side effects, attempt gradual dose reduction every six months per protocol, carry out the medication management regimen as prescribed, report changes, complications to the doctor. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE]…

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 accurate advance directive information was present throughout the medical record for Resident #13. This affected one (Resident #13) of nine residents reviewed for advance directives. The facility census was 55. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, schizoaffective disorder, and dementia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #13 had severe cognitive impairment and required the extensive assistance of two staff for dressing, toileting, and personal hygiene. Review of the physician orders located in the electronic medical record for Resident #13 revealed an ordered dated [DATE] for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest. Review of Resident #13's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to monitor a resident's hemodialysis port. This affected one (Resident #40) of one resident reviewed for hemodialysis. The facility census was 55. Findings include: Record review revealed Resident #40 was admitted on [DATE] and a readmitted on [DATE]. Diagnoses included end stage renal disease, enterocolitis due to clostridium difficile, recurrent, and metabolic encephalopathy. Resident #40 had no physician order related to care of the hemodialysis port. Review of a progress note dated 03/01/22 revealed Resident #40 received a new hemodialysis port to her left chest. Review of the current care plan revealed Resident #40 required hemodialysis, due to end stage renal disease, three times weekly. Interventions included monitoring the hemodialysis access site for redness, swelling, warmth or drainage. Review of the Pre/Post Dialysis Evaluation assessments from 04/01/22 through 04/30/22 revealed the facility did not evaluate Resident #40's hemodialysis…

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 policy review, the facility failed to ensure residents were offered the influenza and pneumococcal immunizations upon admission. This affected three (Residents #1, #36 and #50) of five residents reviewed for influenza and pneumococcal immunizations. The facility census was 55. Findings include: 1. Record review revealed Resident #1 had an admission date of 02/18/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was not offered the influenza or pneumococcal immunizations. Review of Resident #1's medical record revealed no documentation the resident had been offered or had refused the influenza or pneumococcal immunizations. 2. Medical record review revealed Resident #36 had an admission date of 03/28/22. Review of the admission MDS dated [DATE] revealed Resident #36 had not been offered the influenza or pneumococcal immunizations. Review of Resident #36's medical record revealed no documentation the resident had been offered 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 observations, record review, resident council meeting minutes, resident and staff interviews. the facility failed to ensure prompt resolution of nine resident council members (Resident #10, #19, #27, #29, #35, #38, #47, #53 and #108), concerns of missing clothing. The facility census was 59. Findings include: Review of the resident council meeting minutes, dated 06/18/19, identified concerns by residents of missing clothing. The residents who attended this meeting included Resident #10, #19, #27, #29, #35, #38, #47, #53 and #108. The response form, dated 06/24/19, completed by the Laundry Supervisor (LS) #430 identified the personal resident laundry back up has been caused by increase in isolation rooms. The form identified they were working on getting personals delivered back to the residents. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included morbid obesity, seizures, insomnia and urinary obstruction. Review of the annual Minimum…

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, resident and staff interviews, the facility failed to ensure a resident a resident was afforded the right to choose an appropriate time to receive baths. This affected one (Resident #39) of one residents reviewed for activities of daily living (ADLs). The facility census was 59. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with medical diagnoses included cirrhosis of liver, chronic pain and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/15/19, identified Resident #39 was cognitively intact and required assistance of one person for personal hygiene. Review of the facility shower schedule for the west unit identified Resident #39 was scheduled on the night shift 5:00 P.M. to 5:00 A.M. on Wednesdays and Saturdays. Review of the facility bathing records for 06/2019 revealed staff offered Resident #39 bed baths on 07/01/19 at 1:12 A.M., 06/29/19 at 3:11 A.M., 06/24/19 at 4:59…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected two (Resident #19 and #54) of 18 residents reviewed for advance directives. The facility census was 59. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with medical diagnosis including diabetes mellitus. The admission records identified Resident #19 wished to have a full code status (the use of all life-saving measures if a person's heart or breathing stopped, including cardiopulmonary resuscitation (CPR) resuscitation measures). The record further revealed on [DATE], Resident #19 changed his code status Do Note Resuscitate (DNR). Review of the paper medical chart, on [DATE], revealed the outside of the chart included a Full Code sticker. The physician orders, dated [DATE], continued to state full code status and did not have Resident #19's updated advance directives of DNR.…

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 interview, the facility failed to notify a resident and/or resident's representative in writing of the reason for the transfer to the hospital. This affected one (Resident #60) of one resident reviewed for hospitalization. The facility identified eight residents who were transferred or discharged to the hospital in the last three months. The facility census was 59. Findings include: Review of Resident #60's medical record revealed an admission date of 01/20/19, and a re-admission date of 03/10/19. Diagnoses included atrial flutter, protein-calorie malnutrition, hemiplegia and hemiparesis, acute kidney failure, anxiety, and sepsis. Review of a nursing progress note, dated 03/01/19, revealed Resident #60 was transferred to the hospital due to a change in condition. Further review of a nursing progress note, dated 03/10/19, revealed Resident #60 returned to the facility. Resident #60 was discharged on 04/13/19. Review of the medical record revealed no documentation of a transfer notice being provided to Resident #60 or to the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to initiate a baseline dialysis care plan within in 48 hours of admission for a resident who was admitted receiving dialysis services. This affected one (Resident #208) of one resident reviewed for dialysis. The facility identified Resident #208 as the only resident in the facility receiving dialysis services. The facility census was 59. Findings include: Review of Resident #208's medical record revealed an admission date of 06/14/19 with diagnoses including acute kidney failure with tubular necrosis, hyperkalemia, diabetes mellitus type II, and dependence on renal dialysis. Resident #208 was sent to the hospital on an emergency transfer on 06/15/19 and returned to the facility on [DATE]. Review of daily nursing assessments, dated 06/15/19 and 06/26/19, revealed Resident #208 was admitted to the facility and was receiving dialysis services. Review an initial care plan, dated 06/26/19, revealed no care plan was initiated to include 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 observations, medical record review, air mattress manufactures instructions and staff interviews, the facility failed to ensure a resident had interventions in place to treat a pressure ulcer. This affected one (Resident #39) of two residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 59. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cirrhosis of liver, fractured right femur and chronic pain. The record identified Resident #39 developed a pressure ulcer to the right heel following surgical intervention from a fractured hip occurring in October 2018. The record identified Resident #39 was to have an alternating air mattress as an intervention and treatment for the pressure area. Observation of Resident #39's air mattress occurred on 06/30/19 at 1:36 P.M. and during the wound treatment on 06/30/19 at 3:47 P.M. The mattress was noted to be on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, physician, resident and staff interviews, the facility failed to assess and effectively treat a resident's continuous pain. This affected one (Resident #39) of three residents reviewed for concerns with pain. The facility identified 57 residents on a pain management program. The facility census was 59. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cirrhosis of liver, fractured right femur and chronic pain. Review of the annual Minimum Data Set (MDS) assessment, dated 05/15/19, revealed Resident #39 was cognitively intact and had constant pain. The assessment identified Resident #39 revealed his pain makes it hard to sleep at night. Review of the daily skilled nursing assessments, dated 06/21/19, 06/22/19 and 06/23/19, revealed the resident's pain assessment only identified he was receiving scheduled pain medications. The assessment did not have any evidence of an actual evaluation 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 medical record review and staff interview, the facility failed to obtain a physician ordered laboratory test for a resident. This affected one (Resident #19) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with medical diagnoses including diabetes mellitus and atrial fibrillation. The record revealed Resident #19 was receiving the blood thinning medication, Coumadin three milligrams (mg.) daily. Review of the laboratory testing records, dated 05/21/19, revealed a Protime (PT) and International Normalized Ratio (INR) level test (used to monitor therapeutic levels of blood clotting) was completed. The PT/INR results were reviewed by the physician on 05/21/19 with a new order, written on the bottom of the test, to repeat the PT/INR testing in one week. Further review of the record identified no evidence the PT/INR was completed again until 06/11/19.…

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.