Scioto Pointe

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record reviews and staff interviews, the facility failed to ensure Residents #5 and #13's falls were accurately documented in the medical record and failed to ensure Resident #6's wound notes were accurate, and treatment documentation was complete. This affected three residents of 24 residents reviewed for accuracy of medical records and documentation. The facility census was 95.Findings include:1. Review of Resident #5's medical record revealed an admission date of 05/22/17. She had diagnoses that included undifferentiated schizophrenia, vascular dementia with behaviors, and history of cerebral infarction. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment completed on 03/17/26 revealed Resident #5 was cognitively intact and displayed no signs or symptoms of depression, delirium, psychosis, or rejection of care during the review period. Further review of the MDS assessment revealed Resident #5 was independent moving from a sitting to standing position and required supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital documents, observation, Local Health Department (LHD) interview, staff interview, and review of facility policy, the facility failed to have an effective water management and legionella prevention plan and further failed to implement recommended legionella mitigation strategies to prevent the potential spread of Legionella pneumonia. This had the potential to affect all 94 residents residing in the facility. The facility census was 94. Findings include:Review of the medical record for Resident #88 (SR) revealed an admission date of 09/23/21. Diagnoses included cerebral infarct (stroke), diabetes, hemiplegia and hemiparesis, anxiety, cardiac arrhythmia, dysphagia, and weakness. Further review of the medical record revealed the resident was treated for pneumonia at the facility and sent to the hospital on [DATE] for further evaluation and treatment.Review of the hospital lab results, dated 10/03/25, revealed Resident #88 tested positive from a urinalysis test 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.

Based on observation and interviews, the facility failed to ensure sufficient support personnel to carry out the functions of the food and nutrition services. This had the potential to affect all 96 residents residing in the facility. Findings Include: On 06/30/25 observations during the breakfast meal on the 100 hallway revealed the resident's breakfast was served in disposable Styrofoam takeout containers and disposable Styrofoam cups. On 06/30/25 at 12:06 P.M., observation of the lunch meal in the dining room revealed the resident's drinks were served in Styrofoam cups. On 06/30/25 at 12:19 P.M., interview with the Dietary Manager (DM) #111 revealed when the dietary department was short staffed disposable containers and cups are used due to the cooks inability to assist with washing dishes. DM #111 verified the facility did not have sufficient staff for the food and nutrition services. On 06/30/25 at 12:21 P.M., observation of the lunch meal on the 400 hallway revealed the residents were served fluids in Styrofoam cups. On 06/30/25 at 12:23 P.M., an interview with Resident #20…

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

Based on observation and interview, the facility failed to ensure an adequate supply of dishes to serve the residents of the facility. This had the potential to affect all 96 residents residing in the facility. Findings Include: On 06/30/25 observations during the breakfast meal on the 100 hallway revealed the resident's breakfast was served in disposable Styrofoam takeout containers and disposable Styrofoam cups. On 06/30/25 at 12:06 P.M., observation of the lunch meal in the dining room revealed the resident's drinks were served in Styrofoam cups. On 06/30/25 at 12:19 P.M., interview with the Dietary Manager (DM) #111 verified the facility does not have enough dishes to serve the residents and Styrofoam disposable containers/cups are utilized. On 06/30/25 at 12:21 P.M., observation of the lunch meal on the 400 hallway revealed the residents were served fluids in Styrofoam cups. On 06/30/25 at 12:23 P.M., an interview with Resident #20 revealed the dietary department always serves on disposable products. She said she prefers to eat/drink from dishes. She stated once in a while they…

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

Based on observation and staff interview the facility failed to provide a safe, sanitary and comfortable environment for resident in the resident rooms, hallways and bathrooms. This had the potential to affect all 96 residents residing in the facility. Findings include: 1. Review of the Resident Council Minutes from 04/22/25 revealed the residents requested more deep cleaning in their rooms. Also, Resident #32 had requested repairs to bed, blinds and her sink and toilet leaked. 2. Review of the Resident Council Minutes from 05/27/25 revealed Resident #82 reported a hole under her sink in the bathroom and Resident #32 reported again her sink and toilet were leaking leaking as well as Resident #7's sink was leaking. 3. Review of the Resident Council Minutes form 06/24/25 revealed Resident #82 again reported a hole under her bathroom sink. 4. On 06/30/25 at 10:53 A.M., observation of Resident #89's room revealed multiple areas of dry wall patches on the bathroom door and the room door handle was loose making the door difficult to close. 5. On 06/30/25 at 11:30 A.M., observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, policy review, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity when indwelling urinary catheter collection bags were not covered when the residents were in bed and left visible from the hallway. Additionally, the facility also failed to ensure residents received non-disposable dishes during scheduled meals. This affected one resident (#31) of one resident reviewed for indwelling urinary catheters and one resident (#20) of five residents interviewed during the lunch meal. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 07/19/16 with the latest readmission of 05/10/25 with the diagnoses including but not limited to Parkinson's disease with dyskinesia, polyneuropathies, constipation, obstructive and reflux uropathy, hypertension, chronic kidney disease, chronic pain syndrome, hydrocele, psychotic disorder, restless leg syndrome, mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive plan of care in the area of elopement risk and activities of daily living (ADL). This affected two residents (#48 and #98) of 15 sampled residents. The facility census was 96. Findings Include: 1. Review of the closed medical record for Resident #98 revealed an initial admission date of 06/18/24 with the latest readmission of 04/25/25 with the diagnoses including but not limited to chronic obstructive pulmonary disease, heart failure, diabetes mellitus, asthma, senile degeneration of brain, acute respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic pain, bipolar disorder, chronic pain syndrome, pure hypercholesterolemia, disorganized schizophrenia, morbid obesity, osteoarthritis, psychosis, hypertension, mood disorder, gastro-esophageal reflux disease, other symbolic dysfunction, depressive episodes and epilepsy. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure those residents who were at risk for elopement were assessed and/or physician ordered interventions were implemented to prevent possible elopement from the facility. This affected three residents (#48, #53 and #68) of three residents reviewed for elopement. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date of 12/13/24 with the latest readmission of 05/28/25 with the diagnoses including but not limited to chronic obstructive pulmonary disease, hypertension, obstructive sleep apnea, chronic respiratory failure, congestive heart failure, diaphragmatic hernia, delusional disorder, sepsis, dependence on supplemental oxygen, schizoaffective disorder, bipolar type, psychosis, and urinary incontinence. Review of the plan of care, not dated revealed the resident was independently mobile, resident expresses a desire to leave facility unattended and at risk…

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, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent potential infection. Additionally, the facility also failed to implement Enhanced Barrier Precautions (EBP) during a dressing change. This affected one resident (#31) of one resident reviewed for indwelling urinary catheter care and one resident (#11) of two residents reviewed for wounds. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 07/19/16 with the latest readmission of 05/10/25 with the diagnoses including but not limited to Parkinson's disease with dyskinesia, polyneuropathies, constipation, obstructive and reflux uropathy, hypertension, chronic kidney disease, chronic pain syndrome, hydrocele, psychotic disorder, restless leg syndrome, mood disorder, tachycardia, psychosis, developmental disability, gout, anemia, mood disorder, benign prostatic hyperplasia (BPH),…

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, resident, and Guardian interviews, Sexual Assault Nurse Examiner (SANE) interview, record review, review of a facility Self-Reported Incident (SRI), review of facility investigation, and policy review, the facility failed to initiate a timely investigation of alleged staff to resident sexual abuse. This affected one (Resident #80) of three residents reviewed for abuse. The facility census was 91. Findings include: Review of the medical record for Resident #80 revealed an admission date of 04/26/22. Medical diagnoses included paranoid schizophrenia, anxiety, depression, type II diabetes mellitus, chronic kidney disease, insomnia, chronic pain, and chronic obstructive pulmonary disease (COPD). Review of Resident #80's Quarterly Minimum Data Set (MDS) assessment, dated 06/26/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #80 had no signs or symptoms of depression, no hallucinations, and no delusions. Review of Resident #80's interdisciplinary progress notes, dated 08/01/24 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 observation, staff and resident interview, record review, and policy review, the facility failed to document an allegation of staff-to-resident sexual abuse and record follow-up action taken in Resident #80's medical record. This affected one (Resident #80) of three residents reviewed for abuse. The facility census was 91. Findings include: Review of the medical record for Resident #80 revealed an admission date of 04/26/22. Medical diagnoses included paranoid schizophrenia, anxiety, depression, type II diabetes mellitus, chronic kidney disease, insomnia, chronic pain, and chronic obstructive pulmonary disease (COPD). Review of Resident #80's Quarterly Minimum Data Set (MDS) assessment, dated 06/26/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #80 had no signs or symptoms of depression, no hallucinations, and no delusions. Review of Resident #80's interdisciplinary progress notes, dated 08/01/24 to 09/03/24, revealed no mention or description of an alleged staff-to resident sexual abuse incident…

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, financial record review, staff interview, facility policy review, and review of online resources, the facility failed to implement a plan to spend down resident funds when they exceeded the Medicaid allowable limit. This affected 15 (Residents #7, #83, #15, #63, #67, #95, #20, #45, #66, #3, #41, #13, #21, #29, and #26) of 18 residents reviewed for finances. The facility also failed to convey resident personal funds to the resident's authorized representative within 30 days of the resident's discharge from the facility or death. This affected three (Residents #93, #94, and #95) of four discharge resident financial records reviewed. The facility census was 94 residents. Findings Include: 1. Review of the medical record for Resident #7 revealed an admission date of 09/25/15 with diagnoses including type two diabetes, major depressive disorder, and peripheral vascular disease. Review of the monthly financial statements for Resident #7 dated 10/06/23 to 03/31/24 revealed the balance ranged from $2,826.27 to $3,188.11. Review of the resident trust account…

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 appropriately assess and monitor resident behaviors. This affected four (Residents #31, #69, #10, and #16) of five residents reviewed for behavior management. The census was 94. Findings Include: Review of the medical record for Resident #31 revealed an admission date of 01/30/24 with diagnoses including epilepsy, psychosis, major depressive disorder, schizoaffective disorder, suicidal ideations, borderline personality disorder, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 05/10/24 revealed the resident was cognitively intact. Review of the care plan for Resident #31 revealed resident had the following behaviors: suicidal ideations, malingering, socially inappropriate/disruptive behaviors. Resident #31 also had a care plan related to cognitive impairments related to the resident's mental health diagnoses which included the following: psychotic disturbance, mood disturbance, anxiety, schizoaffective disorder bipolar…

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, and review of the facility policy, the facility failed to notify the attending physician of a change in condition. This affected one (Resident #76) of 26 sampled residents. The facility census was 94 residents. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/21/22 with diagnoses including peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder. Review of the nurse progress note for Resident #76 dated 06/10/24 timed at 9:30 A.M. revealed the Director of Nursing (DON) spoke with the resident regarding frequent leaves of absence (LOA) from the facility in which he returned in a state of alcohol intoxication. Further review of the note revealed Resident #76 admitted that he did regularly consume alcohol while on LOA but had agreed not to come back to the facility intoxicated going forward. The DON also discussed concerns with Resident #76 regarding missing medications while on LOA which potentially led to recent seizure activity. 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.

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure that a resident footboards were repaired as needed and in a timely manner. This affected one resident (Resident #91) of three residents reviewed for their environment. The facility census was 94. Findings include: Observation on 06/24/24 at 9:39 A.M., on 06/25/24 at 8:48 A.M. and 06/26/24 at 3:37 P.M. revealed footboard to Resident #91's bed was broken at approximately two-thirds of its length. The sharp, jagged edge of the footboard was approximately three feet from the resident's window. Interview on 06/24/24 at 9:39 A.M. with Resident #91 confirmed the footboard to his bed had been broken for at least a week and a half. Resident #91 further confirmed he told the Director of Nursing (DON) he wanted his footboard to be replaced because he was worried about cutting himself on the jagged edge of the footboard as he passed by his bed. Interview on 06/26/24 at 3:39 P.M. with the DON confirmed Resident #91 had informed him of the broken footboard soon after…

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, and review of the facility policy, the facility failed to develop a care plan for residents regarding unsupervised leaves of absence (LOA) from the facility. This affected one (Resident #76) of 26 sampled residents. The facility census was 94 residents. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/21/22 with diagnoses including peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder. Review of the care plan for Resident #76 updated 05/23/24 revealed it did not include documentation of the resident's frequent LOAs from the facility with guidelines to ensure the safety of the resident while out of the building. Review of the nurse progress note for Resident #76 dated 06/10/24 timed at 9:30 A.M. revealed the Director of Nursing (DON) spoke with the resident regarding frequent leaves of absence (LOA) from the facility in which he returned in a state of alcohol intoxication. Further review of the note revealed Resident #76 admitted 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.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to assist dependent residents with activities of daily living (ADL) care. This affected one (Resident #53) of two residents reviewed for ADL care. The facility census was 94 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 07/28/22 with diagnoses including schizoaffective disorder bipolar type, polyosteoarthritis, and chronic pain syndrome. Review of the comprehensive care plan for Resident #53 revealed the resident had the potential for a self-care deficit in grooming related to impaired ability to groom self and a lack of fine motor skills. The goad on Resident #53's care plan was that the resident would be well groomed. The intervention listed was that Resident #53 would be cued and prompted to participate in grooming and that the resident would be assisted to complete the task. Observation on 06/24/24 at 7:59 A.M. and 06/25/24 at 7:50 A.M. revealed Resident #53's chin hairs 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, staff interview and review of the facility policy, the facility failed to monitor residents who had fallen. This affected two (Residents #10 and #63) of four residents reviewed for falls. The facility census was 94 residents. Findings include: 1.Review of the medical record for Resident #10 revealed an admission date of 10/15/18 with diagnoses including cerebrovascular disease, major depressive disorder, weakness, panic disorder, dementia, personality disorder, and disorganized schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/30/24 revealed the resident had moderate cognitive impairment and required substantial/maximal assistance with toilet hygiene, bathing, bed mobility and transfers. Review of the progress note for Resident #10 dated 05/11/24 revealed the resident had a fall without injuries. Further review of the progress notes revealed there was no post-fall monitoring documented for the resident on 05/12/24 and 05/13/24. Review of the progress note for Resident #10 dated 06/16/24 revealed the resident had…

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, and staff interviews the facility failed to ensure residents received oral fluids between meals. This affected one (Resident #13) of 26 residents sampled. The facility census was 94 residents. Findings include: Review of the medical record for Resident #13 revealed an admission date of 04/17/23 with diagnoses including multiple sclerosis, mood disorder, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 06/07/24 revealed the resident was cognitively intact and required partial/moderate assistance with eating and substantial/maximal assistance with bed mobility and was dependent on staff with oral and toilet hygiene. Review of the active care plan for Resident #13 revealed an intervention to encourage good fluid intake at meals and between meals due to at risk for decreased cardiac output and alternated nutritional status. Review of the nutritional assessments for Resident #13 dated 04/01/24 and 06/10/24 completed by the Dietician revealed the resident required 1600-1700 milliliters (ml) 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 medical record review, staff interview, and review of facility policy the facility failed to adequately assess pain for residents who received pain medications. This affected one (Resident #52) of three residents reviewed for pain management. The facility census was 94. Findings: 1.Review of medical record for Resident #52 revealed admission date of 01/26/24 with diagnoses including peripheral vascular disease, major depression, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, type two diabetes, and acute kidney failure. Review of the care plan for Resident #52 dated 02/13/24 revealed the resident had pain or alteration in comfort related to immobility, non-pressure ulcers. Interventions included the following: administer pain medications as per medical doctor orders and note the effectiveness, assess for nonverbal signs of pain, offer non-pharmacological interventions to manage pain such as massage reposition, gentle exercise, breathing and relaxation techniques distraction redirection music therapies or comfort foods. Review of the Minimum…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to monitor resident blood pressure prior as ordered by the physician in conjunction with administration of a diuretic medication. This affected one (Resident #55) of six residents reviewed for medications. The facility census was 94 residents. Findings Include: Review of the medical record for Resident #55 revealed an admission date of 03/28/22 with diagnoses including obsessive compulsive personality disorder, paranoid schizophrenia, polydipsia, and hypoosmolality and hyponatremia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #55 dated 04/05/24 revealed the resident had intact cognition. Review of the physician's orders for Resident #55 revealed an order dated 06/22/24 for Lasix 20 milligrams (mg), hold for systolic blood pressure less than 100. Review of the care plan for Resident #55's revealed the resident was at risk for decreased cardiac output and abnormal lab values related to polydipsia, sodium deficit hyponatremia, with a goal to take Lasix as…

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

Based on medical record review, staff and resident interview, review of the resident's funds account, and review of the facility's policy, the facility failed to ensure the residents were able to get cash from their funds accounts held by the facility. This affected six (#9, #24, #36, #59, #62, and #74) of six residents reviewed for personal funds accounts. The facility identified 80 residents who have personal funds account with the facility. The facility census was 81. Finding include: 1. Medical record review for Resident #9 revealed an admission date of 02/21/20. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/21, revealed she was cognitively intact. 2. Medical record review for Resident #24 revealed an admission date of 03/09/19. Review of the quarterly MDS assessment, dated 07/14/21, revealed he was cognitively intact. Interview with Resident #24 on 10/04/21 at 10:42 A.M. revealed he wasn't able to get cash because the facility denied he could take out cash for any transactions. 3. Medical record review for Resident #36 revealed an admission of 08/04/16.…

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, and staff interview, the facility failed to provide residents with physician ordered adaptive equipment during meal time. This affected four (Resident #10, #19, #21, and #22) of four residents reviewed for adaptive equipment. The facility identified 13 residents who utilize adaptive equipment. The facility census was 81. Findings include: 1.) Review of the medical record for Resident #19 revealed an admission date of 10/15/18. Diagnoses included squeal cardiovascular disease, altered mental status, and muscle spasms. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21, revealed the resident with a moderately impaired cognition for daily decision making ability. Resident #19 was noted to require extensive assistance from one staff member for eating. Resident #19 was noted to have impairment to one of her upper and one of the her lower extremities. Review of Resident #19's physician orders for October 2021 revealed for the resident to have a dycem (a non-slip material) to be placed under the resident plate and to 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 record review, staff interview, and observations, the facility failed to provide a resident with adequate assistance with dressing. This affected one (#40) of three residents reviewed for activities of daily living. The facility identified 42 residents who require assistance from staff or were dependent on staff for assistance with dressing. Findings include: Review of the medical record for Resident #40 revealed an admission date of 12/29/16. Diagnoses included schizoaffective disorder, anxiety disorder, obsessive-compulsive behavior, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/21, revealed the resident had moderately impaired cognition for daily decision making ability. Resident #40 required extensive assistance from one staff member for dressing. Review of the nursing progress notes for Resident #40 from 10/04/21 thorough 10/07/21 revealed no documentation related to the resident refusing to change her clothing or complete daily personal hygiene. Observation of Resident #40 from 10/04/21 through 10/07/21 revealed the…

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

Based on observation, medical record review, resident and staff interview, and review of the facility's policy, the facility failed to provide meaningful activities to the residents. This affected two (#38 and #44) of five residents reviewed for activities. The facility census was 81. Findings include: 1.) Review of the medical record for Resident #38 revealed an admission date of 10/27/15. Diagnoses included nicotine dependence, mood disorder, COVID-19, schizophrenia, mood disorder, epilepsy, major depressive disorder, restless leg syndrome, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/21, revealed the resident had intact cognition. She was independent on bed mobility, transfers, eating, toileting, personal hygiene, and bathing. She required supervision for dressing. Review of the care plan, dated 11/24/19, revealed Resident #38 was at risk for decreased participation in activities related to resident refusal. Interventions included to perform activity assessment quarterly and as needed, promote the following activities for 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.

Based on record review, resident and staff interview, observation, and review of the facility's policy, the facility failed to ensure treatment orders were completed per physician orders. This affected one (#45) of one resident reviewed for non-pressure related skin issues. The facility identified one resident with treatment orders for skin tears. The facility census was 81. Findings include: Review of medical record for Resident #45 revealed an admission date of 02/15/17. Diagnoses included Diabetes Mellitus (DM) Type II, dementia without behavioral disturbances, schizoaffective disorder, bipolar disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/17/21, revealed the resident had impaired cognition. Review of the care plan, dated 02/16/17, revealed Resident #45 was at risk for actual/potential alteration in skin integrity related to DM, fragile skin, dry itchy scalp, and right elbow skin tear. Interventions included to provide treatments per physician order, weekly skin assessment for skin irritation, redness, bruises, scratches, open…

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 and staff interview, and observation, the facility failed to ensure the resident received proper treatment to maintain good foot health. This affected one (#1) of one resident reviewed for foot care. The facility census was 81. Findings include: Review of the medical record for Resident #1 revealed an admission date of 05/29/13. Diagnoses included Diabetes Mellitus (DM) Type Two. Review of the care plan, dated 05/30/21, revealed Resident #1 had potential for alteration in skin integrity related to DM, history of tinea unguium (superficial fungal infection), resistant to care/skin interventions, incontinence of urine, and resident was non-complaint with showers and personal hygiene at times. Interventions included to assess the condition of the resident's feet weekly and report abnormal findings to the physician. Keep nails trimmed short and filed smooth. Refer to podiatry for routine and as needed foot care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/16/21, revealed the resident had impaired cognition. She required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the faciliy's policy, the facility failed to ensure a resident's fall was investigated in a timely manner to determine the root cause and to identify any patterns of repeated falls and to evaluate, revise and/or add individualized interventions to the resident's care plan. This affected one (#73) of three residents reviewed for falls. The facility census was 81. Findings include: Review of the medical record for Resident #73 revealed an admission date of 04/08/15. Diagnoses included secondary Parkinsonism, mood disorder, depressive disorder, dementia without behavioral disturbance, schizophrenia, psychosis, and creutzfeldt-[NAME] disease. Review of the resident's undated care plan revealed the resident was at risk for falls as evidence by history of falls with injury, multiple risk factors related to use of psychotropic medications, pain in bilateral knees, weakness, lack of coordination, tremors, dorsalgia, and secondary Parkinsonism. The goal was for no…

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

Based on record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure bowel movements and toileting program were monitored per physician orders and the resident's plan of care. This affected one (#21) of one resident reviewed for bowel incontinence. The facility identified 29 residents who required assistance from staff or dependent on staff for toileting. The facility census was 81. Findings include: Review of medical record for Resident #21 revealed a re-admission date of 12/01/19. Diagnoses included sequelae of cerebral infarction, schizoaffective disorder, constipation, bipolar disorder, and dementia without behavioral disturbances. Review of the care plan, dated 02/22/13, revealed Resident #21 was at risk for alteration in bowel elimination related to medications and potential for occasional bowel incontinence. Interventions included to record bowel movements daily and note the size and consistency and report any abnormalities to the charge nurse. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/14/21,…

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 record review, staff interview, and policy review, the facility failed to ensure Resident #22's weights were performed as recommended and per facility policy and failed to monitor and intervene appropriately for a resident who was at a nutritional risk for weight loss. This affected one (#22) of three residents reviewed for weight loss. The facility identified two current residents with significant weight loss. The facility census was 81. Findings include: Review of the medical record of Resident #22 revealed an admission date of 02/02/18. The resident was hospitalized from [DATE] to 06/24/21 and 07/02/21 to 07/07/21. Diagnoses included diffuse traumatic brain injury with loss of consciousness, dementia with behavioral disturbance, Type II diabetes mellitus (DM), history of COVID-19, cerebral infarction, chronic pain syndrome, abnormal weight loss, major depressive disorder, schizoaffective disorder, oropharyngeal dysphagia, anxiety disorder, epilepsy, and…

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

Based on medical record review, observations, staff interview, and review of the facility's Medication Regimen Review policy, the facility failed to ensure residents receiving psychotropic medication were monitored accurately for adverse reactions. This affected one (Resident #40) of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Review of the medical record for Resident #40 revealed an admission date of 12/29/16. Diagnoses included schizoaffective disorder, anxiety disorder, obsessive-compulsive behavior, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/21, revealed the resident had a moderately impaired cognition for daily decision making ability. Resident #40 was noted to display verbal behaviors director towards others. Review of the physician orders for Resident #40 revealed the follow orders related to mood and/or behaviors: on 03/10/21, Buspirone (antianxiety) 10 mg tablet, give two tablets, three times a day for anxiety. On 08/17/21, Invega Sustenna (antipsychotic) suspension…

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, observation, and staff interview, the facility failed to ensure residents were provided food which met the resident's preference such as not being served pork. This affected one (Resident #54) of four residents reviewed for food preferences. The facility census was 81. Findings include: Review of the medical record for Resident #54 revealed a admission date of 03/02/20. Diagnoses included post-traumatic stress disorder, and dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/20/21, revealed the resident had a moderately impaired cognition for daily decision making ability, and was noted to express verbal behaviors directed towards others. Review of the meal slip, dated 10/05/21 and 10/06/21, stated the resident did not like pork. Review of the facility's monthly menu for October 2021 revealed for lunch on 10/05/21, the facility was serving tacos made with pork meat. On 10/06/21 for dinner, the facility was serving baked pork. Observation on 10/05/21 at 1:20 P.M. of Resident #54's lunch tray 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 record review, staff interview, and policy review, the facility failed to ensure falls were documented in the medical record. This affected one (#73) of three residents reviewed for falls. The facility census was 81. Findings include: Review of Resident #73's medical record revealed an admission date of 04/08/15. Diagnoses included secondary parkinsonism, mood disorder, depressive disorder, dementia without behavioral disturbance, schizophrenia, and psychosis. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/03/21, revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, and toileting. Review of the facility's incident logs from 04/01/21 through 09/30/21 revealed the resident had falls on 04/30/21, 05/02/21, 05/19/21, 07/09/21, 09/02/21, and 09/27/21. Review of the progress notes, dated 04/29/21 through 09/30/21, revealed there was documentation of falls which occurred on 05/19/21, 09/02/21, and 09/28/21. There was no documentation of the resident's falls occurring on…

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