Columbus Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to maintain clean and sanitary bed curtains. This affected one (Resident #45) of three residents reviewed for environment. The facility census was 95 residents.Findings include:Review of Resident #45's medical record revealed an initial admission date of 11/08/24 and a readmission date of 02/20/26. Resident #45's diagnoses included type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, chronic obstructive pulmonary disease unspecified, moderate protein-calorie malnutrition, epilepsy unspecified not intractable without status epilepticus, presence of right artificial shoulder joint, acquired absence of right leg above knee, polyneuropathy unspecified, anemia unspecified, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact. Observation of Resident #45's bed curtain on 03/16/26 at 10:31 A.M. revealed three dark red stains splattered on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policy, the facility failed to provide nail care for Residents #66, and #88 who were dependent on staff for care. This affected two residents (#66 and #88) of seven residents reviewed for activities of daily living. The facility census was 95.Findings include: 1. Review of Resident #66's medical record revealed an admission date 07/25/25. Resident #66's diagnoses included chronic obstructive pulmonary disease unspecified, repeated falls, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, essential (primary) hypertension, dysphagia oropharyngeal phase, alcohol use unspecified uncomplicated, anxiety disorder unspecified, and depression unspecified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 was dependent for putting on and taking off footwear. Observation of Resident #66 on 03/16/26 at 12:22 P.M. revealed long, jagged toenails.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a midline dressing was changed as ordered. This affected one (Resident #53) of one resident reviewed for intravenous access line care. The facility census was 95 residents.Findings include:Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included cellulitis of the left lower limb, chronic diastolic (congestive) heart failure, other specified chronic obstructive pulmonary disease, and obesity class Review of the Minimum Data Set (MDS) assessment, dated 01/05/26, revealed Resident #53 was cognitively intact. Review of Resident #53's Midline Insertion Record completed 02/27/26 at 12:05 P.M. revealed a midline catheter (a vascular access device used for intravenous therapy) was placed in the left cephalic vein (a vein located in the left upper arm) on 02/27/26. Further review of Resident #53's Midline Insertion Record revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to provide timely treatment to maintain Resident's #1 hearing abilities. This effected one resident (#1) of one resident reviewed for hearing issues. The facility's census was 95.Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff supervision for mobility and self care. Review of the medical record of Resident #1 revealed on 03/09/26, he notified staff he was having trouble hearing out of one of his ears and thought something might be stuck in it.Review of the physician orders of Resident #1 revealed on 03/10/26 he 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 staff interview, medical record review, and facility policy review, the facility failed to obtain weekly weights as ordered for Resident #52. This affected one resident (#52) of seven residents reviewed for nutritional issues. The facility census was 95.Resident #52 was admitted [DATE] and has diagnoses that include chronic obstructive pulmonary disease, severe protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident used a wheelchair for mobility and had severe cognitive impairment. Further review of Resident #52's medical record revealed an order for weekly weights written on 12/04/25. Further review of Resident #52's medical record demonstrated there were no recorded weights for the timeframe between 12/17/25 and 01/08/26. Additionally, there were no recorded weights in the medical record for the timeframe between 02/26/26 and 03/17/26. Dietician #370 was interviewed via telephone about 8:35 A.M. on 03/19/26. She stated that…

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 change oxygen tubing as required and failed to ensure the humidifier solution was not empty. This affected one resident (#1) of four residents reviewed for respiratory care. The facility's census was 95.Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff assistance with mobility and self-care assistance. Review of the care plan dated 02/12/26 revealed Resident #1 is dependent on continuous oxygen therapy related to a medical history of shortness of breath and respiratory failure. Observation and interview on 03/16/26 at 11:15 A.M.…

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 interview, and staff interview, the facility failed to provide services to treat a resident's anxiety. This affected one (#65) of one resident reviewed for behavioral health. The facility census was 95. Record review for Resident #65 revealed this resident was admitted to the facility on 01/14 26 with diagnoses including: multiple fractures of the bilateral ribs, anxiety disorder, fracture of the pelvis, fracture of the right lower leg, depression, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require hygiene and mobility assistance from staff.Review of the care plan dated 01/14/26 revealed Resident #65 is at risk of impaired psychosocial well-being. Interventions included a psychiatric mental health consultation and counseling services.Review of the practitioner progress notes of 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 interview, record review, and review of the social service director job description, the facility failed to timely arrange and follow up on guardianship for Resident #78 according to the expert evaluation. This affected one resident (#78) of one resident reviewed for guardianship. The facility census was 95.Findings include: Review of Resident #78's medical record revealed an admission date of 03/22/23 with diagnoses including chronic myeloid leukemia, chronic obstructive pulmonary disease, chronic heart failure, aphasia, dementia, epilepsy, spondylosis, gout, and depression. Review of Resident #78's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #78's hospital social work Discharge summary dated [DATE] revealed the social worker had spoke to the facility about starting guardianship and they were in agreement. Review of Resident #78's statement of expert evaluation completed 03/05/25 revealed it concluded that…

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 medications were administered timely for two residents (#101 and #103) of two residents reviewed for timely administration of medications. The facility census was 95.Findings include:1.Review of Resident #103's medical record revealed an admission date of 03/04/26 with diagnoses of major depressive disorder, borderline personality disorder, disorientation, unspecified mood disorder, suicidal ideations, unspecified convulsions, personal history of other mental and behavioral disorders, conversion disorder with seizures or convulsions, anxiety disorder, dysphagia, uninhibited neuropathic bladder, and fibromyalgia. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #103's physician orders active on 03/15/26 revealed the following orders: Aprepitant oral capsule 125 milligrams (mg) one time a day for nausea and vomiting, Cariprazine oral capsule…

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 record review, interview, and facility policy review, the facility failed to follow parameters for blood pressure medication. This affected one resident, Resident #58, of six reviewed for unnecessary medications. The facility census was 95.Findings include: Review of Resident #58's medical record revealed an admission date of 02/09/26 with diagnoses of, but not limited to, type two diabetes, atrial fibrillation, and hypertension. Review of the Brief Interview for Mental Status (BIMS) dated 02/09/26 revealed a score of 12 indicating the resident was cognitively intact. Review of Resident #58's orders on 03/17/26 revealed an order for propranolol hydrochloric acid (HCl) 20 milligram (MG) oral tablet with direction to give on tablet by mouth two times a day for hypertension. Further review of the order revealed parameters for the medication to be held if the resident had a systolic blood pressure of less than 110. Review of Resident #58's Medication Administration Record (MAR) revealed propranolol HCl 20MG was administered to the resident on the following days with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policy, the facility failed to store medications appropriately when found at Resident #45's bedside. This affected one resident (#45) of one resident observed for medication storage. The facility census was 95 residents.Findings include:Review of Resident #45's medical record revealed an initial admission date of 11/08/24 and a readmission date of 02/20/26. Resident #45's diagnoses included type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease unspecified, epilepsy unspecified not intractable without status epilepticus, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact. Observation of Resident #45's bedside table on 03/16/26 at 10:31 A.M. revealed a medication cup resting on the edge of the resident's bedside table outside the reach of the resident. The medicine cup contained five unidentified pills. Interview with Resident #45…

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, resident representative interview, staff interview, and review of facility policy, the facility failed to notify the resident's representative of a resident's change in care. This affected one (Resident #21) of four residents review for notification of change. The facility census was 98. Findings include: Review of the probate court of guardianship record dated 05/22/19 revealed Resident #21 has a court appointed guardian pertaining to person only, due to incompetency. Review of the medical record for Resident #21 revealed an admission date of 11/01/21. Diagnoses included dementia, traumatic brain injury, and cognitive communication deficit. Review of the care plan dated 08/21/22 revealed Resident #21 has liver disease related to liver cirrhosis and interventions included to report abnormal findings to medical provider and resident/resident representative. Review of the Minimum Data Set (MDS) 3.0 assessment completed 01/01/25 revealed Resident #21 had no cognitive impairment. Review of the progress notes dated 01/08/25 revealed Resident #21 was found with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with hematology oncology department, interview with pharmacist, staff interviews, record reviews, and review of facility policy, the facility failed to ensure consistent continuity of care between outside providers including implementing physician orders from outside provider and timely communication and follow up with outside provider. This affected two (Residents #46 and #55) of three residents reviewed for quality of care. The facility census was 98. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 04/22/23 with diagnoses including chronic myeloid leukemia and dementia. Review of the physician orders dated 04/23/23 revealed imatinib mesylate (chemotherapy) oral tablet 400 milligrams (mg) one tablet by mouth in the morning for leukemia. Review of the encounter summary from the hematology clinic dated 10/04/25 at 12:01 P.M. revealed no recommendations to change Resident #55's medications. Review of the progress note dated 01/09/25 revealed…

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

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). This affected two (#64 and #80) of four residents observed for medication administration. There were 29 opportunities with four medication errors for a medication error rate of 13.7%. The facility census was 98. Findings include: 1. Review of Resident #64's medical record revealed an admission date of 09/19/24, with diagnoses of: anoxic brain damage, muscle weakness, dysphagia, cognitive communication deficit, insomnia, chronic obstructive pulmonary disease, and encounter for attention for gastrostomy. Review of a physician order dated 09/19/24 revealed an order for aspirin low dose 81 milligram (mgs) tablet chewable, give one tablet via percutaneous endoscopic gastrostomy tube (PEG) (a feeding tube that is surgically inserted through the abdominal wall and into the stomach) one time a day and an order for Guaifenesin Extended Release (ER) tablet 12 hour, 600 mgs, give one tablet via PEG tube every 12 hours for cough.…

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

Based on observations, medical record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living was provided with the necessary services to maintain good personal hygiene. This affected one of five sampled residents (Resident #57). The facility census was 96. Findings include: Review of the medical record for Resident #57 revealed an admission date of 06/11/21 and diagnoses including dementia, protein-calorie malnutrition, and dysphagia (difficulty swallowing). Review of a Minimum Data Set assessment completed 06/09/24 revealed a brief interview for mental status score of three, indicating severe cognitive impairment. It also stated the resident required substantial/maximal assistance with personal hygiene. Review of the plan of care initiated 06/30/21 and revised on 07/27/24 revealed Resident #57 had an activity of daily living self care performance deficit as evidenced by requires assistance with activities of daily living related to dementia, decreased mobility, and contractures of bilateral lower extremities.…

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

Based on observations, medical record review, and staff interview, the facility failed to follow up on dietician recommendations to ensure a resident maintained acceptable parameters of nutritional status, including body weight. This affected one of five sampled residents (Resident #93). The facility census was 96. Findings include: The facility identified two residents as having a significant weight loss in the past 30 days (Residents #93 and #65). Review of the medical record for Resident #93 revealed an admission date of 09/01/23 and diagnoses including malignant neoplasm of the floor of the mouth and protein-calorie malnutrition. The resident received a mechanically altered dysphagia (difficulty swallowing) diet. Review of a Minimum Data Set assessment completed 08/10/24 revealed the resident had a brief interview for mental status score of 15, indicating intact cognition. He was independent with eating and was 70 inches tall (five foot, 10 inches). Record review revealed he weighed 122.4 pounds on 06/13/24 and 07/02/24. On 08/02/24 and 08/07/24 he weighed 123.2 pounds. However,…

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

Based on observations, policy review, medical record review, and staff interview, the facility failed to develop/implement infection control policies to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections. This affected two of five sampled residents (Residents #3 and #57). The facility census was 96. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/08/23 and diagnoses including multiple sclerosis and quadriplegia. Review of wound and skin notes by the wound nurse practitioner on 08/21/24 revealed the resident had a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location) on the left buttock and an Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within…

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 review of staff schedules, review of the facility assessment, staff interview, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight consecutive hours a day. This had the potential to affect all residents residing in the facility. The facility census was 96 residents. Findings include: Review of the staff schedules for the weekends (Saturdays and Sundays) dated from 10/01/23 through 12/31/23 revealed the facility did not have an RN on duty for at least eight consecutive hours a day on 10/15/23, 11/12/23, 11/26/23, 12/09/23, 12/10/23, 12/23/23, and 12/24/23. Review of the facility assessment completed for the facility from 10/01/22 through 09/30/23 revealed the facility would be staffed with six to eight licensed nurses providing direct care per day for 12-hour shifts. Interview on 06/12/24 at 4:26 P.M. with the Administrator confirmed the facility did not have a RN on duty for at least eight consecutive hours a day on the following dates: 10/15/23, 11/12/23, 11/26/23, 12/09/23, 12/10/23, 12/23/23,…

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 employee file review and staff interview, the facility failed to ensure State Tested Nursing Assistants (STNAs) received annual performance reviews and 12 hours of continuing education annually. This had the potential to affect all residents residing in the facility. The facility census was 96 residents. Findings include: 1. Review of STNA #43's employee file revealed a date of hire of 10/25/22. STNA #43's file did not include an annual performance appraisal or documentation of completion of 12 hours of continuing education annually. Review of STNA #94's employee file revealed a date of hire of 01/30/23. STNA #94's file did not include an annual performance appraisal. Review of STNA #96's employee file revealed a date of hire of 01/11/23. STNA #96's file did not include an annual performance appraisal or documentation of completion of 12 hours of continuing education annually. Interview on 06/10/24 at 4:45 P.M. with Human Resources Director (HRD) #110 confirmed STNAs #43, #94, and #96 had not received annual performance reviews. HRD #110 confirmed STNAs #43 and #96 had not…

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 the facility policy the facility failed to ensure loose improperly stored medications were discarded and failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect all 96 residents residing in the facility. Findings include: 1 Observation on 06/05/24 at 10:50 A.M. of the medication cart in the 300-hallway revealed there were eight loose pills in the drawer of the cart below the prepackaged medication cards. Interview on 06/05/24 at 10:50 A.M. with Assistant Director of Nursing (ADON) #77 confirmed there eight loose pills in the medication cart and they should have been discarded. Observation on 06/05/24 at 10:55 A.M. of the medication cart in the 400-hallway revealed there were three loose pills in the drawer of the cart below the prepackaged medication cards. Interview on 06/04/24 at 10:50 A.M. with ADON #77 confirmed there three loose pills in the medication cart and they should have been discarded. Review of facility policy titled Storage of…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure safe and sanitary storage of food items in the kitchen. This affected all residents residing in the facility. The facility census was 96 residents. Findings include: Observation on 06/03/24 at 9:13 A.M. of the refrigerator revealed it contained the following items: a bag of undated shredded cheese, a bag of lettuce undated and left open to air, three pitchers of undated and unlabeled juice. Interview on 06/03/24 at 9:15 A.M. with Kitchen Worker (KW) #25 confirmed the undated and unlabeled food and that the lettuce had been left open to air. KW #25 further confirmed all foods should be labeled and should be dated upon opening and food should be stored in airtight packaging. Observation on 06/03/24 at 9:18 A.M. of the dry storage revealed there were three large, dented cans of tomatoes and two large, dented cans of fruit salad. Interview on 06/03/24 at 9:19 A.M. with KW #40 confirmed the dented cans should not be used and should have been discarded. Review of facility policy titled…

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, review of pest control logs, and review of the facility policy, the facility failed to ensure proper pest control interventions were in place in the kitchen. This affected all residents residing in the facility. The facility census was 96 residents. Findings include Observation on 06/03/24 at 9:13 A.M. revealed there were dozens of gnats in the dry storage area of the kitchen. There was an uncovered bowl of vinegar placed on the shelf near the entrance to the dry storage area. Interview on 06/03/24 at 9:15 A.M. with Kitchen Worker (KW) #25 confirmed the kitchen had a gnat problem which the facility had not treated by a professional pest control company. KW #25 further confirmed the sink near the cooking area had a clog and was slow to drain and the slow drain had not been treated by pest control professionals. Observation on 06/05/24 at 11:55 A.M. revealed during lunch preparation there were gnats flying around the food preparation area. Interview on 06/05/24 at 2:54 P.M. with Maintenance Director (MD) #107 revealed he had not heard of any pest…

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 review of Resident Council meeting minutes, resident interviews, staff interviews, and facility policy review, the facility failed to timely respond to resident concerns. This affected 16 facility-identified (Residents #3, #8, #13, #17, #22, #26, #30, #38, #42, #43, #44, #46, #51, #52, #74, #79) who attended the Resident Council meetings. The facility census was 96 residents. Findings include: Review of the Resident Council meeting minutes dated 08/08/23 revealed residents voiced concerns related to not receiving clothing back from the laundry and aides not providing showers. There was no response to the concerns provided by the facility. Review of the Resident Council meeting minutes dated 09/12/23 revealed residents voiced concerns related to aides not helping with providing toileting/incontinence care, aides stating they would return and then not returning to provide requested care, call lights not being answered, and insufficient staff on the weekends. There was no response to the concerns provided by the facility. Review of the Resident Council meeting minutes 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.

Based on medical record review, review of Self-Reported Incidents, staff interview, and review of the facility policy, facility failed to ensure resident care plans were updated regarding behavioral changes. This affected one (Resident #81) of two residents reviewed for behaviors. Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility also failed to ensure care conferences were completed for residents. This affected five (Residents #14, #30, #73, #78, #88) of five residents reviewed for care conferences. The census was 96 residents. Findings include: 1. Review of medical record for Resident #81 revealed an admission date of 02/15/24 with diagnoses including altered mental status, cognitive communication deficit, type two diabetes mellitus, and transient ischemic attack (TIA) with cerebral infarction. Review of Minimum Data Set (MDS) assessment for Resident #81 dated 04/15/24 revealed the resident was cognitively impaired. Review of facility Self-Reported Incidents (SRIs) #246403 dated 04/15/24 and #247016…

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, observation, staff interview, resident interview, and facility policy review, the facility failed to ensure residents who were dependent on staff assistance with personal hygiene received routine nail care. This affected five (Residents #14, #20, #24, #50, #92) of seven residents reviewed for activities of daily living (ADLs.) The facility also failed to ensure dependent residents received routine bathing assistance. This affected two (Residents #27 and #92) of seven residents reviewed for ADLs. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 02/18/24 with diagnoses including multiple sclerosis, functional quadriplegia, neuromuscular dysfunction of bladder, major depressive disorder, convulsions, contracture of right hand, contracture of right upper arm, contracture of right ankle and foot, voice and resonance disorder and status colostomy. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 03/28/24 revealed the resident had no cognitive deficit…

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, observation, resident interview, and staff interview the facility failed to ensure splints were placed appropriately and orders for fitting of diabetic shoes were completed timely. This affected four (Residents #20, #24, #14 and #47) of four residents reviewed for range of motion. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 07/14/23 with diagnoses including diabetes mellitus, muscle wasting, atrophy and difficulty in walking. Review of Minimum Data Set (MDS) assessment for Resident #47 dated 04/15/24 revealed the resident was cognitively intact, required supervision with ambulation, and was independent with dressing. Review of the physician visit note for Resident #47 dated 04/29/24 revealed the resident needed to be fitted for appropriate diabetic footwear. Review of the nurse practitioner (NP) progress note for Resident #47 dated 04/30/24 revealed patient had seen specialist at spine and joint regarding leg pain and knees buckling. The doctor ordered the…

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

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to follow infection control practices for residents with dressings to peripherally inserted central catheters (PICC) line site. This affected one (Resident #87) of one resident reviewed for intravenous (IV) therapy. The facility also failed to ensure medications were administered using proper infection control practices. This affected two (Residents #5 and #27) of five residents observed for medication administration. The facility also failed to ensure staff wore proper personal protective equipment (PPE) when providing hands-on care to residents on enhanced barrier precautions (EBP) This affected two (Residents #24 and #43) of 25 facility-identified residents who required EBP. The facility also failed to provide proper wound care in a sanitary manner to prevent cross-contamination. This affected three (Residents #24, #27, and #43) of six residents reviewed for pressure ulcers. The facility census was 96. Findings include: 1. Review of medical…

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, observation, resident interviews and the facility failed to ensure residents were dressed in an appropriate and dignified manner. This affected one (Resident #43) of two residents reviewed for dignity. The facility census was 96 residents. Findings include: Review of the medical record for Resident #43 revealed an initial admission date of 09/20/23 with the latest readmission of 01/25/24 with diagnoses including acute kidney failure, spina bifida, diseases of spinal cord, diabetes mellitus, asthma, severe morbid obesity, hypertensive heart disease with heart failure, congestive heart failure, cerebrospinal fluid drainage device, neuromuscular dysfunction of bladder, urinary incontinence, incontinence of feces, major depressive disorder, anxiety disorder, radiculopathy lumbar region, hydrocephalus and gastroesophageal reflux disease. Review of the plan of care dated 09/29/23 revealed the resident had a self-care deficit related to spina bifida, morbid obesity and refusal of showers. Interventions included the staff would assist the resident with upper…

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, family and staff interview, facility failed to ensure call lights were within reach for one (Resident #88) of one resident reviewed for call lights. The facility also failed to ensure resident choice to go outside when not medically contraindicated. This affected one (Resident #30) of two residents reviewed for dignity and respect. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #88 revealed an admission date of 12/13/23 with diagnoses including hemiplegia and hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness and cognitive communication. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 05/03/24 revealed Resident #88 was cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of care plan for Resident #88 dated 05/06/24 revealed the resident required assistance with ADLs. Interventions include staff to ensure the resident's call light was within reach. Observation on 06/03/24 at 11:20 A.M. revealed Resident #88's call light 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.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure accurate advanced directives and code status were reflected in the resident medical record. This affected two (Residents #14 and #30) of two reviewed for advanced directives. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 11/10/10 with diagnoses including aneurysm, hemiplegia and hemiparesis, convulsions, diabetes, polyneuropathy, and muscle wasting and atrophy. Review of the signed advanced directive paperwork for Resident #14 dated 07/13/20 revealed the resident's code status was do not resuscitate comfort care arrest (DNRCC-A.) Review of physician's orders for Resident #14 revealed an order dated 05/02/23 to change resident's code status to do not resuscitate comfort care (DNRCC.) Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 05/22/24 revealed the resident was cognitively intact. Review of the plan of care for Resident #14 dated 05/23/24 revealed resident's code…

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, staff interview and facility policy review, the facility failed to notify the primary care physician of resident blood glucose level outside of the physician-ordered parameters. This affected one (Resident #27) of one residents reviewed for insulin. Additionally, the facility failed to notify resident representatives of discontinuation of enteral tube feeding. This affected one (Resident #88) of eight residents reviewed for nutrition. The facility census was 96 residents. Findings Include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/15/24 with diagnoses including acute kidney failure, chronic obstructive pulmonary disease, obstructive sleep apnea, severe morbid obesity, diabetes mellitus, gastro-esophageal reflux disease, hypertension, hyperlipidemia, adult failure to thrive, history of malignant neoplasm of prostate and osteoarthritis. Review of the plan of care for Resident #27 dated 05/17/24 revealed the resident had diabetes. Interventions included the following: administer insulin injections 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.

Based on medical record review, observation, resident representative interview, and staff interview, the facility to ensure privacy curtains were kept clean. This affected one (Resident #88) of 31 sampled residents. The facility census was 96 residents. Findings Include: Review of the medical record for Resident #88 revealed an admission date of 12/13/23 with diagnoses including hemiplegia and hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness and cognitive communication. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 05/03/24 revealed the resident was cognitively impaired and required assistance with activities of daily living, (ADLs.) Observation on 06/03/24 at 11:20 A.M. revealed Resident #88's privacy curtain was dirty with brown splatter and food crumbs stuck to it. Interview on 06/04/24 at 9:13 A.M. with Resident #88's representative confirmed the resident's privacy curtain was dirty with splatter and food on it. Observation on 06/04/24 at 4:50 P.M. revealed Resident #88's privacy curtain was dirty with brown splatter and food crumbs…

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 interview, staff interview, review of Pre-admission and Resident Review (PASARR) results letter, and facility policy review, the facility failed to educate, offer, or implement Level II services for residents. This affected one (Resident #39) of two residents reviewed for PASARR screenings. The facility census was 96 residents. Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/06/23 with medical diagnoses including bipolar disorder, depression, dementia, alcohol abuse, anxiety disorder, and post-traumatic stress disorder (PTSD). Review of the PASARR screening for Resident #39 dated 10/24/23 completed prior to the resident's admission to the facility revealed the resident required ongoing case management from a mental health agency, emergency mental health services, and had an inpatient psychiatric hospitalization in the last two years. Review of the Notice of PASARR Level II Outcome letter for Resident #39 dated 10/25/23 revealed the resident was approved with specialized services for nursing…

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, observation, staff interview, resident interview, and review of the facility policy, the facility failed to timely evaluate and treat a rectal fistula, failed to timely schedule an outside gastroenterology (GI) follow-up appointment, and failed to ensure precertification for hospice services was completed. This affected three (Residents #11, #64, and #73) of 31 residents sampled. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date on [DATE] with diagnoses including paraplegia, encounter for attention to other artificial openings of urinary tract, encounter for attention to ileostomy, irritable bowel syndrome, and anal fistula (added on [DATE]). Review of the care plan for Resident #11 revised [DATE] revealed the resident had impaired skin integrity. Interventions included complete at skin risk assessment upon admission, readmission, quarterly and as needed, complete weekly skin checks, and provide…

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 representative interview, and staff interview, the facility failed to ensure timely follow up for ophthalmology (vision) services. This affected one (Resident #88) of one resident reviewed for ophthalmology services. The facility census was 96 residents. Findings include: Review of the medical record for Resident #88 revealed an admission date of 12/13/23 with diagnoses including hemiplegia and hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness and cognitive communication. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 05/03/24 revealed the resident was cognitively impaired. Review of the progress note for Resident #88 dated 04/25/24 revealed the resident returned from a doctor appointment with a referral for ophthalmology services. Review of the facility vision provider list dated July 2023 to June 204 revealed Resident #88 was not seen during any of the visits. Interview on 06/04/24 at 9:36 A.M. with Resident #88's representative revealed they wanted resident to see an ophthalmologist and were…

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

Based on medical record review, observation, staff interview and facility policy review, the facility failed to comprehensively assess resident pressure ulcers upon admission/readmission to the facility. This affected three (Residents #24, #27, #43) of six residents reviewed for pressure ulcers. The facility census was 96 residents. Findings include: Review of the medical record for Resident #24 revealed an admission date of 02/18/24 with diagnoses including multiple sclerosis, functional quadriplegia, neuromuscular dysfunction of bladder, stage IV pressure ulcer to left buttocks, major depressive disorder, convulsions, contracture of right hand, contracture of right upper arm, contracture of right ankle and foot, voice and resonance disorder and status colostomy. Review of the nursing admission evaluation for Resident #24 dated 02/18/24 revealed the resident was readmitted to the facility with pressure ulcers to the coccyx, and right and left buttocks. The assessment contained no staging, measurements, description of the wound or exudate present. Review of the assessment contained…

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, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure incontinence care was provided timely and upon request. This affected one (Resident #14) of one resident reviewed for incontinence care. The facility census was 96 residents. Findings include: Review of the medical record for Resident #14 revealed an admission date of 02/01/11 with diagnoses including aneurysm, hemiplegia and hemiparesis, convulsions, diabetes, polyneuropathy, muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 05/22/24 revealed the resident was cognitively intact and required moderate to dependent assistance for personal hygiene and bathing. Review of the plan of care for Resident #14 dated 05/23/24 revealed the resident was incontinent of bowel and bladder with the intervention to check resident every care round for incontinence, toilet upon rising, before and after meals, prior to bedtime and as needed. Review of the progress notes for Resident #14 dated 04/01/24 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.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure oxygen equipment was stored appropriately and oxygen nasal cannula tubing was changed as ordered by the physician. This affected two (Residents #27 and #64) of two residents reviewed for respiratory services. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/15/24 with diagnoses including acute kidney failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), severe morbid obesity, diabetes mellitus, gastro-esophageal reflux disease, hypertension, hyperlipidemia, adult failure to thrive, history of malignant neoplasm of prostate and osteoarthritis. Review of the plan of care for Resident #27 dated 05/17/24 revealed the resident received bilevel positive airway pressure (BiPap) therapy for obstructive sleep apnea. Interventions included to educate resident/representative on the importance of BiPap therapy and encourage resident to use the BiPap. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital staff interview, staff interview, and review of the facility policy, the facility failed to ensure residents were notified in writing of proposed discharge from the facility. This affected one (Resident #10) of three residents reviewed for discharge to the hospital. The census was 97. Findings include: Review of the closed medical record for Resident #10 revealed an admission date of 12/14/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, hypertensive heart, chronic kidney disease and depression. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/22/23 revealed the resident was cognitively intact and required extensive assistance of staff with activities of daily living (ADLs.) Review of the progress notes for Resident #10 dated 11/16/23 to 02/09/24 revealed the resident was transferred to and from the hospital multiple times and each time prior to the hospital transfer on 02/10/24 the resident 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.

Based on observations, staff interviews, resident interviews and policy and procedure review, the facility failed to ensure staff wore personal protection equipment appropriately. This had the potential to affect all 92 residents in the facility. The census was 92. Findings include: Interview on 09/27/21, at 10:45 A.M. with the Director of Nursing (DON) revealed there were eight residents who were newly admitted , unvaccinated, and under quarantine isolation precautions. The interview further revealed Personal Protective Equipment (PPE) is provided outside of the room on the room door or in a cart. Prior to entering the room, staff are to don a N-95 respirator, gloves, face shield, and isolation gown. Prior to exiting the room, staff should doff the PPE and place it in the receptible, then don a surgical mask and clean their face shield. Interview on 09/27/21, at 5:00 P.M. with the DON and the Administrator, revealed the facility received new admissions after they were tested in the hospital. Unvaccinated newly admitted residents were to be under quarantine precautions for 14 days.…

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

Based on observations, review of facility policy, interviews with residents and staff, the facility failed to ensure residents were permitted to eat in the dining room to promote well-being and homelike environment. This affected 87 of 87 residents who received food from the kitchen. The facility identified five residents who do not receive food from the kitchen. The facility census was 92 Findings include: Tour of facility from 09/27/21 through 09/30/21 revealed all residents to be eating in their rooms. The dining room was not observed to be used for resident dining at breakfast, lunch and dinner. Interview on 09/27/21 at 8:36 A.M., with Dietary Aide #114 and [NAME] #160 revealed the dining room was not in use for resident dining. All residents were eating in rooms. Interview on 09/28/21 11:50 A.M., with Interview with Registered Dietitian (RD) #231 reported she has been here a couple of months. RD #231 confirmed residents were not eating in the dining room. RD #231 reported she doesn't like it, but that is how it is during this pandemic. RD #231 reported she does not have…

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 review of resident council meeting minutes and review of facility policy, staff and resident interview, the facility failed to follow up on resident council requests surrounding smoke breaks. This had the potential to affect 25 of 25 residents the facility identified as being smokers. The facility census was 92. Findings include: Interview of Resident #44, during the resident council facility task, on 09/29/21 at 1:42 P.M., Resident #44 reported she was asked by her peers to inquire about the additional smoke break they had requested of the facility. Resident #44 reported the facility provides five smoke breaks throughout the day and indicated prior to COVID-19, the residents received seven smoke breaks throughout the day. Resident #44 reported the Administrator to be aware of the resident request for one additional smoke break to no avail. Review of the facility provided smoking times revealed scheduled smoking sessions are held at 6:30 A.M., 9:15 A.M., 12:45 P.M., 4:00 P.M. and 7:45 P.M. Review of the resident council meeting minutes revealed that on 06/08/21, 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 and staff interview, the facility failed to notify the resident's physician of a significant weight change and failed to notify a physician of a weight change related to edema. This affected three (#3, #41 and #52) of seven residents reviewed for nutrition and one (#59) of one resident reviewed for edema. The facility census was 92. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 07/16/21, with diagnoses including urinary tract infection, repeated falls, chronic obstructive pulmonary disease, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. The resident had a height of 64 inches and weight of 78 pounds. The resident had a significant weight loss while not on prescribed weight loss regimen. Review of Resident #52's weights revealed on 08/03/21 a weight of 77.6 pounds was entered in the electronic medical record (EMR) by…

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 reviews and staff interviews, the facility failed to ensure the pharmacy recommendations were acted on timely. This affected three (#35, #59 and #63) of five residents reviewed for unnecessary medications. The facility census was 92. Findings include: 1. Review of Resident #35's medical record identified admission to the facility occurred on 05/13/21, with diagnosis of Parkinson's disease, multiple sclerosis and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] for admission identified in section H-300 Resident #35 was frequently incontinent of bladder. The following MDS dated [DATE] under section HO-300 identified she had a decline in urinary continence and was now identified as always incontinent of urine. Review of the pharmacy review and recommendation dated 08/23/21 identified no supporting diagnosis and indication for the use of the medication myrbetriq. The report identified if the medication is no longer needed, please discontinue to reduce…

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, review of facility policies and staff interviews, the facility failed to store medications properly and in a manner that deters theft or inappropriate ingestion. This affected three residents (#32, #59, and #71) and had the potential to affect all 41 of 41 residents who reside on the 200 hall and 300 hall. The census was 92. Findings include: 1. Observation on [DATE] at 8:05 A.M. with Licensed Practical Nurse (LPN #49) revealed the following items in the 100 and 400 hallway medication carts. -Resident #71 had a bottle of Lantus, that was unopened and was delivered by the pharmacy on [DATE]. The bottle was not refrigerated and was in a baggie that stated Refrigerate. -Resident #32 had an insulin pen located in the 400 hall cart, however she resided on the 300 hallway. Resident #32's insulin pen was inside a discharged residents baggie. -There were additional bottles of opened insulin that had opened dates placed on the bag holding them instead of the actual bottle. Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain a clean environment for residents. This affected four (#25, #29, #32 and #80) of 22 resident's rooms observed. The facility census was 92. Findings include: 1. Observation on 09/28/21 at 9:55 A.M., of Resident #80's room, revealed the resident utilized a tube feeding for all nutrition and a computer screen that goes across the bed for communication. The observations identified there was dried food debris covering the computer screen. The tube feeding pole and base were observed to have dried substance that appeared to be dried tube feeding. Resident #80 was observed to use the retinal screen for all communication with the facility as she is non-verbal. Interview on 09/30/21 at 7:50 A.M., with the Licensed Practical Nurse (LPN #186) in Resident #80's room, confirmed the communication computer screen had a large amount of dried debris and needed cleaned. The interview further confirmed the tube feeding pole and bases were observed 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 medical record review, facility documents review, and staff interview, the facility failed to notify residents or their representatives in writing as to the reason they were being transferred to the hospital. This affected three (#32, #75 and #87) of three residents who were reviewed for hospitalization. The census was 92. Findings include: 1. Review of Resident #32's medial record revealed she was admitted on [DATE] and transferred to the hospital and admitted on [DATE] and released on 09/24/21. The ombudsman's office was notified; a bed hold letter was sent certified to her representative. However, a letter explaining why she was being transferred to the hospital was not issue to Resident #32 or her representative. 2. Review of Resident #75's medical record revealed he was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. The ombudsman's office was notified he was discharged to the hospital, a bed hold letter was sent certified to his representative. However, a letter…

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 develop a comprehensive care plan to address a resident experiencing delusions. This affected one (#86) of two residents reviewed for mood and behavior. The facility census was 92. Findings include: Review of the medical record for Resident #86 revealed an admission date of 09/10/20, with diagnoses including unspecified protein-calorie malnutrition, legal blindness, dysphagia, rheumatoid arthritis and fixed delusions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. No delusions or hallucinations were indicated. Review of the physician's note dated 09/16/20 revealed when Resident #86 had been in the hospital she had been evaluated by psychiatric services. They initially determined active psychosis; however, this was rescinded. It was determined she had fixed delusions. Review of the Certified Nurse Practitioner note dated 09/23/20 revealed it…

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 interviews, procedure manual review and policy review, the facility failed to provide care and services for pressure ulcer treatments as ordered to promote healing. This affected three (#7, #32 and #71) of five residents reviewed for pressure ulcers. The facility census was 92. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 12/30/19 ,with diagnoses including Parkinson's disease, unspecified dementia without behavioral disturbance, major depressive disorder, gastroesophageal reflux disease and atherosclerotic heart disease. Review of the physician orders dated 08/30/21 revealed an order was written to cleanse the coccyx pressure ulcer with normal saline, pat dry, apply medihoney (honey based product for wound management) and foam dressing daily. Review of the pressure skin grid assessment dated [DATE] revealed the coccyx wound was a stage three and measured 3.0 centimeter (cm) in length, 1.0 cm in width and had a…

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

Based on observations, medical record review and staff interview, the facility failed to ensure a resident was wearing a physician ordered hand splint. This had the potential to affect one (#76) of one resident reviewed for assistive devices. The facility census was 92. Findings include: Review of medical record for Resident #76 revealed an admission date of 07/10/20, with diagnoses including cerebral infarction, pulmonary vascular disease, dysphasia, and a contracture to his left hand. Review of Resident #76's medical record revealed on 04/21/21, the physician ordered Resident #76 to wear Left hand splint 7 times per week, staff is to put it on at 8 A.M. and take it off at 2:00 P.M. and check skin prior to donning and after doffing it. Review of Resident #76's plan of care revealed Resident #76 is to wear his splint as the physician ordered. Interview on 09/29/21 at 8:11 A.M., with Resident #76 who is cognitively intact revealed he has had a wrist splint that he should be wearing daily but it has been lost for several months. He reported it to staff but has not received any…

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 reviews, review of policy, resident and staff interviews, the facility failed to ensure residents received a meal prior to leaving for their dialysis appointment and coordinated care with the dialysis center. This affected two (#48 and #75) of two residents reviewed for dialysis. The census was 92. Findings include: 1. Review of Resident #48's medical record revealed she was admitted on [DATE], with the diagnoses of end stage renal disease, hypertensive, long term insulin uses and acute chronic diastolic congestive heart failure. She is cognitively intact. A care plan relative to her medical and psychological needs revealed individualized intervention with measurable goals. She receives dialysis Tuesdays, Thursdays, and Saturdays. Review of Resident #48 physician's orders (09/2021) revealed the facility is to send a packed breakfast with resident to dialysis on Tuesdays, Thursdays, and Saturdays. It is the responsibility of the night shift to ensure resident receives her…

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, policy review, medical record review and staff interviews, the facility failed to ensure resident's medication administration had a medication error rate of less than 5%. The facility was observed to have two medication errors in 35 opportunities for an error rate of 5.7%. This affected two (#32 and #246) of five residents observed for medication administration. The facility census was 92 Findings include: 1. Observation on [DATE] at 7:33 A.M.,of Licensed Practical Nurse (LPN) #154, revealed the nurse was gathering medications for Resident #32, which included scheduled insulin. LPN #154 removed a bottle of Novolog from the medication cart, dated as opened on [DATE] and drew up 14 units of insulin and administered to Resident #32. Review of the policy tilted Pharmacy Insulin Storage form, dated [DATE], identified Novolog can be used for 28 days from the date it was opened. Interview on [DATE] at 10:45 A.M., with LPN #154 confirmed the bottle of Novolog used for Resident #32, was opened…

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, policy review and staff interviews, the facility failed to ensure a resident received his cancer medicine as ordered. This affected one (#75) of five residents reviewed for medications. The census was 92. Findings include: Review of medical record for Resident #75 revealed an admission date of 02/19/2, with diagnoses of mild cognitive impairment and diagnosis of hypertensive heart, chronic kidney disease, chronic diastolic heart failure, malignant neoplasm of unspecified part of right bronchus or lung and type 2 diabetic mellitus. Review of Resident #75's Medication Administration Record (MAR) from 08/2021 to September 2021 revealed Resident #75 has not received the medicine Tagrisso (Osimertinib Mesylate) Tablet 40 milligrams (mg) once a day for cancer since 09/16/21. Review of Resident #75's nurses' progress notes revealed on 09/17/21, the resident's cancer medication (Tagrisso) was not available. The Director of Nursing was notified, and the on-call MD was notified. On 9/23/21, the Resident's oncology doctor was notified about the Tagrisso…

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 and staff interviews, the facility failed to timely obtain physician ordered laboratory test and report the results of the laboratory test to the physician. This affected one (#52) of one resident reviewed for urinary tract infections. The facility census was 92. Findings include: Review of the medical record for Resident #52 revealed an admission date of 07/16/21, with diagnoses including urinary tract infection, repeated falls, chronic obstructive pulmonary disease, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, no delusions or hallucinations were indicated. Review of Resident #52's physician's orders for September 2021 revealed an order dated 09/12/21 to obtain urine for a urinary analysis until 09/12/21 at 11:59 P.M., it was indicated this was completed. An additional order dated 09/13/21 revealed an order for a urinary analysis, basic…

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, observation, and staff interview, the facility failed to provide appropriate adaptive feeding equipment to residents. This affected one resident (Resident #25) of twelve residents with adaptive feeding equipment. The census was 92. Findings include: Review of medical record for Resident #25 revealed an admission date 03/08/21. Diagnoses included sequelae of cerebral infarction, unspecified symptoms and signs involving cognitive functions following cerebral infarction, and dysphagia following cerebral infarction. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 had moderate cognitive impairment and required extensive assistance of one person for eating. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #25 required hand over hand assistance for drinking and self-feeding. Resident #25 required an adaptive cup ([NAME] Cup) in order to enable Resident #25 to grasp the cup more independently. Review of…

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