Laurels Of West Columbus, The

Based on observation, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to appropriately clean and disinfect a glucometer between resident use. The affected one (Resident #28) of four residents observed for medication administration. The facility identified seven residents who received blood glucose monitoring utilizing the shared glucometer on A Hall. The facility census was 88. Findings include: Observation on 06/04/25 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #155 checked a blood sugar for Resident #33 and proceeded to prepare medications for Resident #28. Resident #28 also needed a blood sugar test prior to administering insulin. There was no observation of cleaning the glucometer and the same glucometer was used for both residents. Interview on 06/04/25 at 6:34 A.M. with LPN #155 confirmed the glucometer was not cleaned between Residents #33 and #29. LPN #155 stated the standard practice was to clean the medication cart, glucometer, and blood pressure cuff when done with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #12 revealed an admission date of 12/20/23. Diagnoses included type two diabetes mellitus, anxiety disorder, depression, osteoarthritis and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 had limited functional range of motion noted on both sides for both upper and lower extremities and was staff dependent for personal hygiene needs. Review of Certified Nursing Assistant (CNA) documentation in the task section of the medical record from 05/01/25 to 05/31/25 revealed Resident #12 was documented to have shower/bath/bed baths on 05/06/25, 05/14/25. 05/17/25, 05/20/25, and 05/24/25. It was documented no shower/bath/ bed bath was provided on 05/10/25 and 05/28/25 and refused on 05/31/25. Interview on 06/03/25 at 10:56 A.M. with Resident #12 stated she has never refused her shower; the aides tell her there were no Hoyer lift pads available to get her up onto the shower bed…

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, medical record review, review of Self-Reported Incident (SRI), and review of facility policy, the facility failed to prevent Resident #76's controlled substances from being misappropriated. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the use of antipsychotic medication was based on a clinically supported diagnosis. This affected one (Resident #81) of five residents reviewed for antipsychotics. The facility census was 88. Findings include: Record review for Resident #81 revealed an admission date of 04/25/25. Diagnoses included bipolar disorder, psychoactive substance abuse, and nicotine dependence. Review of the physician orders dated 04/26/25 revealed Venlafaxine HCL extended release 150 milligrams (mg) to be administered once daily for depression. The physician order dated 04/30/25 revealed Quetiapine Fumarate 200 mg at bedtime for depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact and had no symptoms of depression. Interview with the Director of Nursing on 06/05/25 at 1:40 P.M. confirmed Resident #81 does not have a current diagnosis of depression in the medical record and there was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, policy review, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate Resident #76's missing controlled substances. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent 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 medical record review and staff interview, the facility failed to ensure Resident #28 had a care plan for a diuretic and Resident #81 had a care plan for smoking. This affected one resident (#28) of five residents reviewed for unnecessary medications and one resident (#81) of one resident reviewed for smoking. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #28's physician order dated 04/23/25 revealed an order for Furosemide (a diuretic) 20 milligrams, one tablet by mouth twice a day. Review of Resident #28's plan of care revealed it did not address his diuretic use. Interview on 06/04/25 at 3:20 P.M. with the Director of Nursing (DON) verified the care plan did not address his diuretic use. 2. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received timely and adequate staff assistance with showers and personal hygiene. This affected one (Resident #53) of four residents reviewed for ADL care. The facility identified 24 residents who were dependent on staff for bathing. Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/24/25. Diagnoses included left knee effusion, depression, anxiety disorder, and chronic kidney disease. Review of the care plan dated 04/24/25 revealed Resident #53 has a functional ability deficit and required assistance with self-care and mobility related to altered mobility. Interventions revealed the resident prefers baths at 10:30 A.M., was dependent on staff for bathing, and required partial to moderate assistance with personal hygiene, including shaving. Review of the facility's hygiene guest preferences form dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included non-chronic pressure ulcer of the left heel, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the Wound Care Clinic visit note dated 04/28/25 revealed Resident #26 was to have a follow up appointment with the clinic in one week. There was no evidence in Resident #26's medical record that Resident #26 attended an appointment at the Wound Care Clinic one week after his appointment on 04/28/25. Interview with Resident #26 on 06/05/25 at 11:02 A.M. confirmed they attended appointments at the Wound Care Clinic on Mondays and had missed an appointment on 05/05/25 due to the facility not scheduling transportation to the appointment. Interview with the Director of Nursing (DON) on 06/05/25 at 2:41 P.M. confirmed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interviews, and facility policy review, the facility failed ensure fall interventions were in place for Resident #28 who had a history of falls and failed to document, communicate and follow up on Resident #252's fall. This affected two (Residents #28 and #252) of three residents reviewed for falls. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21 with diagnoses including cerebral palsy and epilepsy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition. Review of the plan of care dated 06/09/21 revealed Resident #28 was at risk for fall related injury and falls related to cerebral palsy, decreased mobility, opioid pain medication use, and psychotropic medication use. Interventions included perimeter mattress to bed, encourage resident to ask for assistance with transfers, visual cue to ask for help with transfers in…

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 interviews, and policy review, the facility failed to ensure weekly weights were obtained for new admissions and as ordered by the physician for residents identified as nutritionally at risk. This affected one (Resident #81) of three residents reviewed for nutrition. The facility census was 88. Findings include: Review of the medical record for Resident #81 revealed an admission date of 04/25/25. Diagnoses included spinal fusion, malignant neoplasm of the cervix, lung, vertebrae, and bone, bacteremia, and acute kidney failure. Review of the initial nutritional evaluation dated 04/29/25 revealed a diet order for a regular diet with oral intake between 75-100%, and no reported chewing or swallowing concerns. No acute nutritional diagnoses were documented at that time. The evaluation recommended monitoring weights. Review of the care plan dated 04/29/25 revealed Resident #81 was at nutritional and/or dehydration risk due to cancer, corticosteriod use, and an obese body mass index. Interventions included encouraging choices within the ordered diet, offering…

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 and record review, the facility failed to ensure the residents received the treatment in accordance with physician orders and professional standards for pain management. This affected three (Residents #23, #28, and #137) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, type two diabetes mellitus, and epilepsy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition. Review of Resident #28's physician order dated 12/19/24 revealed an order for Acetaminophen 325 milligrams (mg) three tablets by mouth every six hours as needed for pain. Non-pharmacological interventions were listed. Review of the plan of care dated 04/03/25 revealed Resident #28 was at risk for pain and/or had acute/chronic pain related to chronic…

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 and record review, the facility failed to timely respond to pharmacy recommendations, failed to provide rationale for declining pharmacy recommendations, and failed to follow through with the pharmacy recommendations and the physician accepting the pharmacy recommendation. This affected three (Residents #14, #23, and #28) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21 with diagnoses including cerebral palsy, type two diabetes mellitus, epilepsy, depression, and anxiety disorder. Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #28's pharmacy recommendation dated 06/25/24 revealed the resident received two or more antipsychotics and the pharmacist recommended considering a gradual dose reduction (GDR). There was no evidence the physician addressed 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 medical record review, observations, staff interviews, facility policy review, Medscape guidance, and review of manufacturer guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors out of 36 opportunities for an error rate of 5.56%. This affected one (Resident #28) of four residents reviewed for medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included type two diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and received insulin medication. Review of the physician orders for Resident #28 revealed an order dated 12/29/24 for Insulin Lispro inject 30 units subcutaneously before meals and an order dated 12/17/24 for Admelog injection (Insulin Lispro) sliding scale coverage. Resident #28 had an additional order…

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 1b. Review of Resident #28's physician reorder dated 03/27/25 revealed an order for Glipizide extended release 20 milligrams (mg) one time a day for diabetes mellitus. This was to be taken 30 minutes before meals. The physician order dated 05/13/25 revealed an order for Ziprasidone 80 mg one capsule by mouth twice a day for bipolar disorder. This was to be taken with meals. Review of Resident #28's Medication Administration Record (MAR) for May and June 2025 revealed the resident's Ziprasidone was scheduled for 6:00 A.M. and 8:00 P.M. and Glipizide was scheduled for 9:00 A.M. Additionally, Resident #28 was not given Ziprasidone on multiple occasions including the evening dose on 05/02/25, 05/13/25, and 05/27/25. He missed the morning dose of 05/03/25 and 05/14/25. Interview on 06/04/25 at 8:25 A.M. and 06/04/25 at 2:54 P.M. with the Director of Nursing (DON) verified Resident #28's Glipizide and Ziprasidone were not scheduled at appropriate times. She reported Ziprasidone was in the facility and she was unsure…

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 and record review, the facility failed to ensure physician orders for laboratory work were completed in a timely manner. This affected one (Resident #252) of two residents reviewed for laboratory work. The facility census was 88. Findings include: Review of the medical record for Resident #252 revealed an admission date of 05/15/25. Diagnoses included cerebral infarction, moderate protein-calorie malnutrition, and encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #252 had intact cognition. Review of the physician progress note dated 05/30/25 revealed the physician was notified that Resident #252 made an attempt to bite nursing. The physician planned to obtain a complete blood count (CBC), comprehensive metabolic panel (CMP), Vitamin D level, Vitamin B12, and B-type natriuretic peptide (BNP). Review of the physician orders dated 05/30/25 revealed orders for CBC, CMP, Vitamin D level, Vitamin B12, BNP, and urinalysis with culture and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure the residents received timely follow-up for missing dentures. This affected two (Residents #30 and #51) of three residents reviewed for dental concerns. The facility census was 88. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 05/02/22. Diagnoses included stroke, non-Alzheimer's dementia, malnutrition, anxiety, and depression. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was cognitively intact and did not exhibit behaviors during the review period. Resident #30 was able to feed self independently, required staff maximal assistance with oral hygiene. Resident #30 was on a mechanical soft diet and had no natural teeth or fragments. Review of Resident #30's plan of care revealed an intervention initiated on 08/16/24 to provide dental consults as needed and to provide diet 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 and resident and staff interview, the facility failed to ensure medications were documented in the medical record as administered to the resident and failed to ensure dressing changes and pressure-reducing interventions were documented in the medical record. This affected two (Residents #51 and #137) of 21 residents reviewed for medical record accuracy. The facility census was 88. Findings include: 1. Review of the medical record for Resident #137 revealed an admission date of 05/30/25. On 05/31/25, Resident #137 left the facility the against medical advice. Diagnoses including fifth metacarpal bone displaced fracture, chronic obstructive pulmonary disease, and acute respiratory failure. Review of the admission assessment dated [DATE] revealed Resident #137 had recently been admitted after an open heart surgery with a surgical incision to her sternum. Review of the physician orders dated 05/30/25 revealed an order for Acetaminophen extra strength oral tablet 500 milligrams (mg)…

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 investigation review, staff interview, and facility policy review, the facility failed to complete a thorough investigation in regard to a resident's injury of unknown origin. This affected one (Resident #44) of three residents investigations reviewed. The census was 88. Findings Include: Resident #44 was admitted to the facility on [DATE]. Her diagnoses were displaced bicondylar fracture of left tibia, muscle weakness, need for assistance with personal care, Type II Diabetes, atrial fibrillation, ischemic cardiomyopathy, congestive heart failure, hypertensive heart disease, pulmonary hypertension, obstructive sleep apnea, anemia, insomnia, hypothyroidism, atherosclerotic heart disease, chronic kidney disease, and personal history of trans ischemic attack (TIA). Review of the Minimum Data Set (MDS) assessment, dated 02/11/25, revealed the resident was cognitively intact. Review of Resident #44's progress note, dated 03/15/25, revealed Resident #44 complained of pain in…

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, staff and resident interviews, policy review, and record review, the facility failed to ensure medications were administered to the residents without significant medication errors. This affected one (Resident #15) of three residents reviewed for medication administration. The facility census was 89. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE]. Diagnoses included surgical aftercare following surgery of the skin and subcutaneous tissue, fournier gangrene, and type II diabetes mellitus. Review of Resident #15's medication administration record (MAR) for March 2025 revealed an order dated 03/12/25 for Cefepime (antibiotic) HCL solution, one gram/50 milliliters, use one gram IV every six hours for MDRO (multi-drug resistant organisms) for 14 days. The administration times were 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. On 03/26/25, the 12:00 P.M. dose was documented as administered by Licensed Practical Nurse (LPN) #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 resident and staff interview, record review, review of facility self-reported incident and investigation, and policy review, the facility failed to prevent misappropriation of the resident's controlled substances. This affected two (Residents #67 and #83) of 12 residents reviewed for misappropriation. The facility identified 45 residents who had orders for controlled substances. The facility census was 85. Findings include: 1. Review of Resident #83's medical record revealed an admission date of 08/23/24. Diagnoses included Huntington's disease, chorea (a type of dyskinesia characterized by rapid, jerky, and involuntary body movements) and anxiety. Resident #83 has received hospice care since admission to the facility. Review of Resident #83's admission Minimum Data Set (MDS) assessment, dated 08/30/24, revealed Resident #83 was cognitively intact. Resident #83 had no reported behaviors or rejection of care. Review of Resident #83's physician orders revealed an order dated 08/30/24 for Lorazepam (used to decrease anxiety and a controlled substance) oral solution two…

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, resident interview, record review, review of facility self-reported incidents and investigation, and policy review, the facility failed to ensure a thorough investigation was completed following a substantiated instance of staff to resident misappropriation of controlled substances. This affected two (Residents #67 and #83) of 12 resident records reviewed for medication administration. The facility census was 85. Findings include: Review of a facility self-reported incident (SRI) tracking number 252230, initiated 09/24/24, revealed on 09/23/24 the Director of Nursing (DON) returned to the facility due to the behavior of a floor nurse, Registered Nurse (RN) #399. A urine screen was completed on-site with the nurse's verbal consent and was positive for cocaine, benzodiazepines, and opioids. Following RN #399's removal from the building, a narcotic count was completed on RN #399's assigned medication cart and it was determined multiple controlled medications were missing for Residents #83 and #67. An investigation was initiated. The local police…

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 and family interview, record review, and facility procedure review, the facility failed to implement post-operative drain care for one (Resident #89) of three residents reviewed for drain care. The facility identified two residents with post-operative drains. The facility census was 85. Findings include: Review of the closed medical record for Resident #89 revealed an admission date of 08/28/24. Medical diagnoses included cholangiocarcinoma (cancer of the bile ducts), surgical aftercare following surgery on the digestive system, intrahepatic bile duct carcinoma, and bacteremia. Resident #89 was hospitalized from [DATE] to 09/12/24. Resident #89 discharged from the facility on 09/26/24. Review of Resident #89's five-day Minimum Data Set (MDS) assessment, dated 09/19/24, revealed the resident had intact cognition. Resident #89 was recorded as receiving surgical wound care. Review of Resident #89's hospital After Visit Summary (AVS), dated 08/28/24, revealed the resident admitted 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 resident and staff interviews, review of facility policy, and record review, the facility failed to ensure residents were safely transferred, falls were documented in the facility's incident and accident log and resident medical record, and the facility completed thorough fall investigations to determine the root cause analysis. This affected two (Resident #47 and #72) of three residents reviewed for falls. The facility census was 85. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 04/20/24. Diagnoses included hemiplegia and hemiparesis, respiratory failure with hypoxia, vascular disease, muscle weakness, and contracture of the left hand. Review of the progress note dated 08/12/24 revealed a stated tested nursing assistant (STNA) notified the nurse that Resident #47 was lowered to the floor by staff. The STNA stated the resident was being transferred from bed to wheelchair when the resident started to shuffle feet and was lowered to the floor. 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, resident interview, staff interview, record review, and policy review, the facility failed to provide suprapubic catheter site care as ordered for Resident #46. This affected one (Resident #46) of three residents reviewed for indwelling urinary catheters. The facility identified 12 residents who had indwelling urinary catheters. The facility census was 85. Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted to the facility on [DATE]. Review of Resident #46's care plan, dated 06/16/23, revealed the resident was at risk for urinary tract infections and catheter-related trauma, and had an indwelling suprapubic catheter. Listed interventions included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review, and facility procedure review, the facility failed to transcribe physician's orders for and provide intravenous site care for Resident #46's central venous access upon her hospital return. This affected one (Resident #46) of three resident records reviewed for intravenous access devices. The facility only identified one resident with intravenous access. The facility census was 85. Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted ot the facility on 10/10/24. Review of Resident #46's Minimum Data Set (MDS) annual assessment, dated 08/22/24, revealed Resident #46 had intact cognition. Resident #46…

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

Based on staff interview, record review, and policy review, the facility failed to ensure records of controlled medications were properly maintained. This affected two (Resident #83 and #88) of 12 residents whose records were reviewed for medication administration. The facility identified 45 residents with orders for controlled medications. The facility census was 85. Findings include: 1. Review of Resident #83's medical record revealed an admission date of 08/23/24. Medical diagnoses included Huntington's Disease, chorea (a type of dyskinesia characterized by rapid, jerky, and involuntary body movements), epilepsy, and anxiety. Resident #83 has received hospice care since admission to the facility. Review of Resident #83's physician's orders revealed an order dated 08/30/24 for Lorazepam (a benzodiazepine used to decrease anxiety, controlled substance) oral solution 2 milligrams (mg) per milliliter (ml), give 0.75 ml (1.5 mg) by mouth four times daily for anxiety. Resident #80 also had an order dated 08/23/24 for Morphine Sulfate (opioid analgesic, controlled substance) oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #46) of 12 residents' records reviewed for medication administration. The facility census was 85. Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) annual assessment, dated 08/22/24, revealed Resident #46 had intact cognition. Resident #46 had no recorded behaviors or rejection of care. Review of Resident #46's hospital Discharge summary, dated [DATE], revealed Resident #46 was treated in the hospital for 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 medical record review, staff interview, and policy review, the facility failed to ensure the medical record was maintained as an accurate depiction of resident care. This affected one (Resident #88) of 12 residents reviewed for medical record accuracy. The facility census was 85. Findings include Review of the medical record for Resident #88 revealed an admission date of [DATE] and discharge date of [DATE] (death). Review of the physician orders dated [DATE] revealed an order for Morphine Sulfate Solution 10 milligram (mg) per 6.0 milliliter (ml) with instructions to give 0.25 ml by mouth every two hours as needed (PRN) for pain. Resident #88 was receiving hospice services. The Medication Administration Record (MAR) dated 09/2024 revealed on the day of his death ([DATE]), Resident #88 received Morphine PRN dose one time at 11:22 A.M. Review of the narcotic sheet for Morphine PRN revealed the only entry from the date of death ([DATE]) was documented at 1:00 P.M. Review of the progress notes 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.

Based on observation, staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure proper personal protective equipment (PPE) was utilized for residents who required enhanced-barrier precautions (EBP) for open wounds. This affected two (Residents #39 and #41) of three residents reviewed for wound care. The facility identified 23 residents with open wounds. The facility census was 85. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 03/11/22. Medical diagnoses included chronic kidney disease and vascular dementia. Review of Resident #39's Minimum Data Set (MDS) quarterly assessment, dated 07/02/24, revealed the resident had moderately impaired cognition. Resident #39 was at risk for skin breakdown but was noted upon assessment to have no unhealed pressure ulcers. Review of Resident #39's care plan, dated 10/16/24, revealed the resident has an actual impairment to skin integrity related to pressure injury. Resident #39 was listed as having 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 observation, staff interview, and facility policy review, the facility failed to medications were not left unattended and unsecured. This had the ability to affect all 21 residents (#2, #10, #12, #15, #16, #20, #22, #23, #24, #25, #36, #41, #42, #46, #49, #58, #62, #66, #70, #73, #192) who resided on the 200 to 212 hall. The facility census was 89. Findings include: Observation on 02/01/23 at 4:10 P.M. revealed a sleeve of medications left unsecured on the top of the medication cart while the nurse was in another room and the medication cart was not in view. The sleeve of medications contained 30 Tamsulosin (medication used to treat symptoms of an enlarged prostate) tablets and was laying unsecured on top of the medication cart. Interview with the Unit Manager License Practical Nurse #110 on 02/01/23 at 4:10 P.M. confirmed the medications were left unattended and unsecured on top of the medication cart. Review of the facility policy titled Medication/Treatment Cart Use, dated 09/07/22, revealed no medications are kept on top of the cart. The cart must be clearly visible 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 observations and staff interviews the facility failed to ensure walls were in good repair in resident rooms. This had the potential to affect all eight (#7, #10, #22, #31, #41, #44, #45, and #50) residents who resided in rooms #201, #203, #211, #215, #216, #220, #222, and #224. The facility census was 89. Findings include: Observations on 01/30/23 at 11:00 A.M., on 01/31/23 at 10:00 A.M., on 02/01/23 at 3:30 P.M., revealed damaged walls with exposed dry wall behind resident beds and upon entering resident rooms #201, #203, #211, #215, #216, #220, #222, and #224. Interview with the Maintenance Director #123 on 02/02/23 at 10:30 A.M. confirmed the dry wall in rooms #201, #203, #211, #215, #216, #220, #222, and #224 were in need of repair. Review of the facility policy titled, Maintenance Department dated 08/17/21, revealed the department will do on-going monitoring of the facility for areas needing repair and, if needed, will report to the supervisor for approval of the repairs needed.

Based on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure indwelling urinary catheter collection bags were contained in a privacy bag to maintain dignity. This affected two (#5 and #75) of two residents reviewed for catheters. Additionally, the facility failed to ensure residents were dressed in a dignified manner. This affected one (#21) resident out of one resident reviewed for appropriate clothing. The census was 89. Findings include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 05/19/21 with a latest readmission date of 01/28/23. Resident #5's diagnoses included severe morbid obesity, chronic kidney disease, depressive disorder, diabetes mellitus. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment, dated 12/19/22, revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit. The assessment indicated Resident #5 required extensive assistance with toileting. Review of the nursing comprehensive…

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 ensure a resident advanced directives form was signed by the physician. This affected one (#21) out of two residents reviewed for advance directives. The census was 89. Findings include: Review of the medical record for Resident #21 revealed an initial admission date of 12/24/22 with diagnoses incuding but not limited to Parkinson's disease, adult failure to thrive, and depression. Review of Resident #21's comprehensive Minimum Data Set assessment, dated 12/31/22, revealed the resident had no cognitive deficit. Review of Resident #21's plan of care revealed no care plan addressing the resident's do not resuscitate comfort care (DNRCC) status. Review of Resident #21's physician orders revealed an order dated 01/03/23 for Resident #21 to be a DNRCC. Review of Resident #21's medical record revealed there was no evidence of a DNRCC form signed by the resident's physician. Interview with Licensed Practical Nurse (LPN) #111 on 01/31/23 at 4:07 P.M., verified Resident #21 did not have 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 medical record review and staff interview, the facility failed to ensure a resident indwelling urinary catheter was discontinued/removed as ordered by the physician. This affected one (#5) out of two residents reviewed for urinary catheters. The census was 89. Findings include: Review of the medical record for Resident #5 revealed an initial admission date of 05/19/21 with a latest readmission date of 01/28/23. Resident #5's diagnoses included but were not limited to fracture around internal prosthetic right knee joint, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment, dated 12/19/22, revealed Resident #5 had clear speech, understood others, made herself understood and had no cognitive deficit. The assessment indicated Resident #5 required extensive assistance with toileting. Review of Resident #5's nursing comprehensive evaluation, dated 01/07/23, revealed the resident was readmitted to the facility with an indwelling urinary catheter. Review of Resident #5's physician orders for February…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to monitor resident pain levels and document the effectiveness of non-pharmacological interventions for pain. This affected one resident (#84) out of three residents reviewed for pain management. The facility census was 89. Findings include: Review of the medical record revealed Resident #84 admitted on [DATE] with diagnoses including but not limited to severe protein-calorie malnutrition, cerebral infarction, and Alzheimer's disease. Review of Resident #84's plan of care, dated 12/16/22, revealed Resident #84 was at risk for pain or had pain related to constipation and gastro esophageal reflux disease. Resident #84 reported zero out of ten was an acceptable pain level. Interventions included administering medications as ordered, anticipating residents need for pain relief as needed and respond immediately to any complaint of pain, evaluating characteristics of pain on a scale of zero to ten, and evaluate for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of Medscape, the facility failed to ensure resident medications had appopriate indications for use and were monitored appropriately. This affected two residents (#40 and #84) out of five residents reviewed for unnecessary medications. The facility census was 89. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 02/08/21 with diagnoses which included but was not limited to unspecified dementia without disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. Review of Resident #40's most recent Minimum Data Set assessment, dated 11/11/22, revealed Resident #40 was cognitively impaired with poor memory recall. Review of Resident #40's physician orders revealed Resident #40 had an order dated 07/19/22 for Depakote (an anticonvulsant medication) twice a day for a documented diagnosis of dementia. Interview on 02/01/23 at 12:27 P.M. with the Director of Nursing (DON) verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of prescribing information from the Food and Drug Administration (FDA), the facility failed to ensure an there was an appropriate diagnosis for the use of antipsychotic medications. This affected one (#84) out of five residents reviewed for unnecessary medications. The census was 89. Findings include: Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, metabolic encephalopathy, cerebral infarction, Alzheimer's disease, dysphagia, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Set assessment, dated 01/06/23, revealed Resident #84 had severely impaired cognition. Review of Resident #84's physician order, dated 01/20/23, revealed an order for Olanzapine (Zyprexa) tablet five milligrams (mg), give one tablet by mouth two times a day for dementia and behaviors. Review of Resident #84's physician order, dated 01/27/23, revealed an order…

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 ensure Resident #84's tube feeding and water flushes were documented accurately. This affected one resident (#84) out of one resident reviewed for tube feeding. The facility census was 89. Findings include: Review of the medical record for Resident #84 revealed the resident admitted on [DATE] with diagnoses including but not limited to severe protein-calorie malnutrition, metabolic encephalopathy, cerebral infarction, Alzheimer's disease, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/06/23, revealed Resident #84 had severely impaired cognition. Resident #84 was 65 inches tall and weighed 170 pounds. Resident #84 had gained weight and was not on a physician prescribed weight gain regimen. Review of the physician order, dated 12/06/22, revealed Resident #84 had an order for Osmolite 1.2 (a tube feeding formula) to be administered at 80 milliliters (ml) every hour for 20 hours or until 1600 ml had been…

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.