Scioto Rehabilitation & Care Center

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #9 received adequate monitoring as ordered by the physician prior to the administration of a cardiovascular medication to ensure the medication was administered only when necessary. This affected one resident (Resident #9) of two residents reviewed for medication administration. Facility census was 109.Findings include:Review of the medical record for Resident #9 revealed an admission date of 08/02/25 with diagnosis including atherosclerotic heart disease, hypertension and atrial fibrillation.On 10/22/25 from 8:54 A.M. to 9:15 A.M. observation of medication administration with Registered Nurse (RN) #10 revealed the RN administered the resident's Metoprolol medication without first checking the resident's heart rate or blood pressure as ordered. Review of the physician's orders revealed an order for Metoprolol Tartrate 25 milligrams (mg) one time a day for hypertension. The order indicated to hold the medication for systolic blood pressure (SBP) less than 100 or heart…

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

Based on observation, record review, interview, and review of facility policy, the facility failed to follow appropriate transmission-based precautions for a resident on contact precautions. This affected one resident (Resident #41) of three residents reviewed for infection control. The facility census was 109.Review of Resident #41's medical record revealed an admission date of 09/23/25 with diagnosis of osteomyelitis. Findings include:An observation on 10/22/25 at 1:19 P.M. revealed Certified Nursing Assistant (CNA) #3 entering Resident #41's room to prepare for incontinence care. A sign was posted outside of the room door to Resident #41's room indicating he was on contact precautions and a cart containing personal protective equipment (PPE) supplies was noted hanging outside the resident's room door. CNA #3 entered the room without donning a gown or gloves.An interview on 10/22/25 at 1:25 P.M. with Licensed Practical Nurse (LPN) #7 verified the resident had contact precautions in place for infection in his blood and CNA #3 did not apply appropriate PPE consisting of gown 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 medical record review, staff interview, observations, and facility policy review, the facility failed to ensure infection control measures were in place including ensuring dirty linen was off the facility hallway floors, ensuring the Glucometer machine was cleaned between resident use, ensuring sterile techniques was used and maintained during trach care and ensuring Enhanced Barrier Precautions were implemented for residents who required this form of precaution. This affected seven (Resident #13, #20, #60, #70, #92, #250, and #275) of the ten residents reviewed for infection control with the potential to affect all residents residing at this facility. The facility census was 91. Findings include: 1.Observations completed on 09/18/2025 at 1:50 P.M. of the facility's hallways revealed on the hallways named [NAME], there was a pile of dirty bed linen laying on the floor outside a resident's room. Interview on 09/18/2025 at 2:00 P.M. with Certified Nursing Assistant (CNA) #56 confirmed there was a pile of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to notify the transfer of Resident #10 to their Power of Attorney (POA). This affected one (Resident #10) of three residents reviewed for transfers and notification to their POAs. The facility census was 91.Findings include : Review of the medical record for Resident #10, revealed an admission date of 08/16/25 and a transfer to the hospital date of 08/27/25. Diagnoses included but were not limited to chronic kidney disease, stage 4, chronic obstructive pulmonary disease, chronic diastolic heart failure, and iron deficiency anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 that suggested cognitive intactness. The resident was assessed to be independent with bed mobility, to require setup or clean-up assistance with toilet hygiene, supervision or touching assistance with transfers, and total dependence on shower/bathe self. This resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, record reviews and facility policies, the facility failed to notify the physician of weight gain for a congestive heart failure resident. This affected one (Resident #10) of three residents reviewed. The facility also failed to ensure non pressure skin alterations were treated per physician orders. This affected two (resident #20 and resident #300) of three residents reviewed. The facility census was 91.Findings include:1.Review of the medical record for Resident #10, revealed an admission date of 08/16/25 and a transfer to the hospital date of 08/27/25. Diagnoses included but were not limited to chronic kidney disease, stage 4, chronic obstructive pulmonary disease, chronic diastolic heart failure, and iron deficiency anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 which suggested cognitive intactness. The resident was assessed to be independent with bed mobility, 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 in on interviews and record reviews, the facility failed to accurately document and treat pressure ulcers for three residents (#20, #60, and #70) out of four residents reviewed for pressure ulcer care. The facility census was 91.Findings include:1.Review of the medical record for Resident #20, revealed an admission date of 08/21/25 and a left against medical advice (AMA) on 09/10/25. Diagnoses included but were not limited to urinary tract infection, acute on chronic systolic heart failure, pneumonia and history of falling. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15 which suggested moderate cognitive impairment. The resident was assessed to require total dependence on bed mobility, transfers, toilet hygiene and shower/bathe self. This resident was also assessed to be frequently incontinent of bowel and bladder functions. This resident was noted to also have a stage 4 (Full thickness tissue loss with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, record review and policy review, the facility failed to implement fall preventions for Resident #30 and Resident #90. The facility also failed to ensure two staff members were used when transferring Resident #30 with a Hoyer lift resulting in a fall. This affected two ( Resident 330 and Resident #90) of three residents reviewed for accidents/falls. The facility census was 91. Findings include:1.Review of the medical record for Resident #90, revealed an admission date of 08/19/25. Diagnoses included but were not limited to encounter for orthopedic after care, displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, and a new diagnosis of displaced fracture of right great toe, initial encounter for closed fracture as of 9/4/25. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 suggested cognitive intactness. The resident was assessed…

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 hospital paperwork review, the facility failed to ensure the medication Gabapentin, Oxycodone, and Tylenol was administered as per physician order for Resident #60. This affected one (Resident #60) of the four residents reviewed for accurate medication administration. The facility census was 91.Findings include: Review of the medical record for Resident #60 revealed an admission date of 06/20/2025 and a discharge date of 07/11/2025. Diagnoses included chronic non-pressure ulcer of the right foot, peripheral vascular disease, and cerebral infarction.Review of Resident #60's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident experienced long and short-term memory impairment and had severely impaired cognition for daily decision-making abilities. Resident #60 experienced disorganized thinking and an alerted level of consciousness. Resident #60 was noted to receive opioids, antiplatelets and anticonvulsants daily.Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, the facility failed to ensure residents medical records accurately reflected current health status, care and treatments including an accurate Advanced Directive (code status), wound notes and assessment completed by a Certified Wound Nurse Practitioner, and ensure staff did not continue to chart on a residents daily health status days after being discharged from the facility. This affected three (Resident #30, #50, and #70) of the ten residents reviewed for accurate medical record information. The facility census was 91. Findings include:1.Review of the medical record for Resident #30 revealed an admission date of [DATE]. Diagnoses included acute respiratory failure, adult failure to thrive, and chronic obstructive pulmonary disease. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities.…

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 policy review, the facility failed to to ensure residents received meals as ordered/needed. This had the potential to affect 105 out of 110 residents residing in the facility. The facility census was 110. Findings include: Observation of the kitchen on 03/05/25 from 10:56 A.M. to 11:29 A.M. revealed the following meal temperatures: Hamburger - 200 degrees Fahrenheit (°F), mashed potatoes - 188°F, brown gravy - 195°F, coleslaw - 38°F, mechanical texture ham sandwich - 58°F, and regular texture ham sandwich - 54°F. Observation on 03/05/25 at 11:20 A.M. at [NAME] #310 revealed they served the sandwiches that were above 41°F. Interview with [NAME] #310 on 03/05/25 at 11:25 A.M. confirmed that cold foods should be served at or below 41°F. Further observation and interviews on 03/05/25 from 12:04 P.M. to 12:30 P.M. revealed the following: Meal tickets for lunch indicated the featured meal was a turkey sandwich, tomato soup, creamy coleslaw, crackers, and sherbet. A secondary choice of meatloaf home style, peas & carrots, soup…

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 internet resource, the facility failed to ensure residents who received nutritional support through a Nasogastric (NG) Tube received the proper care including ensuring the proper placement of tubing prior to administration of fluids and/or medication. This affected one (Resident #111) of the five resident reviewed for care with a feeding tube. The facility census was 106. Findings include: Review of the medical record for Resident #111 revealed an initial admission date of [DATE] with a re-entry date of [DATE] and a discharge date of [DATE]. Diagnoses included heart failure, hemiplegia and hemiparesis following infarction affecting the left non-dominant side, dysphasia, and gastrostomy status. Review of Resident #111's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident experienced long and short term memory problems as well as a moderately impaired cognition for daily decision making abilities. Resident #111 was noted 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, staff interviews and review of facility policy, the facility failed to store and prepare food under sanitary conditions. This had the potential to effect 108 of 109 residents in the facility. One resident was identified as not eating by mouth. The facility census was 109. Findings include: Observations on 12/16/24 from 8:22 A.M. to 8:40 A.M. revealed a standing pool of liquid, approximately three feet by three feet on the dietary department floor next to the skilled dining room door. Observations revealed a similar puddle of a similar size in the dish room area. The pool of liquid had a sour smell. Several fruit flies were observed flying over the puddles of liquid. Observations revealed that the wall behind the three-compartment sink and the wall behind the beverage dispenser were dirty with various dried food and beverage stains on them. Interview with Dietary Director #364 on 12/16/24 at 9:14 A.M. confirmed the presence of two large pools of sour-smelling liquids on the floor of the dietary department and the presence of dried food and beverage materials on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Resident Council meeting minutes, staff interviews, review of previous job description, review of the Social Services Designee (SSD) #320's current resume, and review of the job description for Social Services Director, the facility failed to ensure a qualified social worker was on staff due to the facility having over 120 certified beds. The deficient practice had the potential to affect all 109 residents in the facility. Findings Include: Review of the Resident Council Meeting Minutes dated from 06/24/24 through 11/25/24 revealed SSD #320 was introduced as the facility's new social worker. SSD #320 was noted as a Licensed Social Worker (LSW) in the monthly meeting minutes. Interviews on 12/16/24 at approximately 9:00 A.M. and 12/18/24 at approximately 2:00 P.M. with SSD #320 revealed she had earned a Master's degree in Social Work however was not able to pass the State licensing board exam in the summer 2024. SSD #320 confirmed she was not a licensed social worker (LSW) currently and would…

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

Based on observations, staff interviews and review of facility policy, the facility failed to have effective pest control in the kitchen. This had the potential to effect 108 of 109 residents in the facility. One resident was identified as not eating by mouth. The facility census was 109. Findings include: Observations on 12/16/24 from 8:22 A.M. to 8:40 A.M. revealed a standing pool of liquid, approximately three feet by three feet on the dietary department floor next to the skilled dining room door. Observations revealed a similar puddle of a similar size in the dish room area. The pool of liquid had a sour smell. Several fruit flies were observed flying over the puddles of liquid. Fruit flies were also observed on the clean silverware and dishes rack. Interview with Dietary Director #364 on 12/16/24 at 9:14 A.M. confirmed the presence of fruit flies in the dietary department. Review of Sanitation policy dated 2001 and revised October 2008 revealed that all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the environment remained free of accident hazards by providing adequate supervision and assistance devices to prevent accidents for three of three residents (#17, #56, and #163) reviewed for accidents. The facility also failed to ensure a wanderguard alarm (alarm used to temporarily lock an exterior door and sound an audible alarm alerting staff that a resident is close to the door) was functioning for two ( #27 and #87) of two reviewed . The facility census was 109. Findings Include: 1. Resident #17 had an admission date of 12/11/23 with diagnoses including: benign neoplasm of meninges, aphasia following cerebral infarction, peripheral vertigo, dizziness and giddiness, abdominal aortic anurysm without rupture, hypertension, hyperlipidemia, angina, dependence on wheelchair, seizures, nicotine dependence cigarettes, obesity, venous thrombosis and embolism, hemiplegia, and hemiparesis following cerebral infarction affecting right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review the facility failed to ensure medications were not left unattended and the medications and medical supplies were not expired. This had the ability to affect all 29 residents in the 100 unit and three (27, #62, and #88) who lived on the 400 hall who were identified as being cognitively impaired and independently mobile. The facility census was 109. Findings Include: 1. Observation [DATE] at 3:05 P.M. in the medication room on the 100 unit revealed a box of vacutainers 22 gage needles, the box expired in 2023 and REF number on needles did not match the reference number on the box. The individual needles did not have expiration dates on them. The prefilled sodium chloride syringes expired [DATE]. Interview on [DATE] at 2:10 P.M. with licensed practical nurse (LPN) #158 confirmed the expired items were identified during the review of the medication storage room and disposed of the items according to facility protocol. Review of the policy Storage of Medications…

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, resident interviews, staff interviews, medical record review, and review of facility policy, the facility failed to provide dignified living conditions for two residents. This affected two (Resident #49 and #81) residents out of three residents (#49, #81, and #220) reviewed for dignity. The facility census was 109 residents. Findings include: 1. Review of medical record for Resident #49 revealed that she was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, suicidal ideations, obsessive compulsive disorder, and unspecified psychosis not due to a substance or known physiological condition. Review of her Minimum Data Set on 11/20/24 revealed that she had a Brief Interview for Mental Status score of 15, indicative of intact cognitive status. Interview with Resident #49 on 12/16/24 at 10:46 A.M. revealed that on many occasions over multiple days, she observed another resident (Resident #63) in his room across the hallway from her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, the facility failed to give one resident timely access to her social security benefits and failed to ensure one resident was appointed a legal guardian appropriately. The deficient practices affected two residents (Residents #61 and #163) of three reviewed for accommodation of needs. The facility census was 109 residents. Findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses that included epilepsy, hemiplegia and hemiparesis following cerebral infarction, muscle weakness and need for assistance with personal care. Review of her Minimum Data Set 3.0 assessment on 11/12/24 revealed that her Brief Interview for Mental Status score was 15, indicative of intact cognition. Interview with Resident #61 on 12/16/24 at 10:14 A.M. revealed that she did not have access to her social security benefits. Resident #61 stated that she had been asking administration about access to her social security benefits since March 2024 when she was readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure an accurate code status was in place for one resident (Resident #97). The deficient practice affected one resident (Resident #97) of one reviewed for advanced directives. The facility census was 109. Findings Include: Review of the medical record for Resident #97 revealed an admission date on [DATE]. Medical diagnoses included Type II diabetes mellitus with diabetic neuropathy, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, encounter for surgical aftercare following surgery on the digestive system, and other intestinal obstruction unspecified as to partial versus complete obstruction. Resident #97's advance directive was noted as full code. Resident #97's daughter was listed as the resident's Durable Power of Attorney (DPOA). Review of the current physician orders revealed Resident #97 had an order for Full Code dated [DATE]. Resident #97 also had an order to admit to hospice…

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 facility policy review, the facility failed to notify one resident's (#81) family of a room change. This affected one of 29 sampled residents. The facility census was 109. Findings Include: Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24, diagnoses include but were not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review…

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 interviews, and resident interviews, the facility failed to provide written transfer notices and inform residents or their families of their rights regarding hospitalization for three (Residents #41, #76, and #106) out of three residents reviewed for hospitalizations. The facility census was 109. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 01/05/24 with a re-entry date of 08/18/24. The resident was diagnosed with multiple chronic conditions, including pleural effusion, chronic sinusitis, dependence on respirator, chronic diastolic heart failure, cirrhosis of liver, chronic kidney disease stage IIIB, type II diabetes mellitus with diabetic neuropathy, morbid obesity, chronic respiratory failure with hypoxia, venous insufficiency, dependence on wheelchair, hypokalemia, obstructive sleep apnea, cardiomegaly, dependence on supplemental oxygen, hypothyroidism, acquired absence of left leg below knee, chronic pain, presence 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 record review, staff interviews, and resident interviews, and facility policy, the facility failed to provide a bed hold notice to inform residents or their families of their rights regarding the retention of their room and bed during hospitalizations for two (Residents #41 and #76) out of three residents reviewed for hospitalizations. The facility census was 109. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 01/05/24 with a re-entry date of 08/18/24. The resident's diagnoses included pleural effusion, chronic sinusitis, dependence on a respirator, chronic diastolic heart failure, cirrhosis of the liver, chronic kidney disease stage IIIB, type II diabetes mellitus with diabetic neuropathy, morbid obesity, chronic respiratory failure with hypoxia, venous insufficiency, dependence on a wheelchair, hypokalemia, obstructive sleep apnea, cardiomegaly, dependence on supplemental oxygen, hypothyroidism, acquired absence of the left leg below the knee, chronic pain, presence of urogenital implants, lymphedema, and 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 observation,record review, interview, and Resident Assessment Instrument (RAI) manual review the facility failed to conduct an accurate assessment of each resident's functional capacity. This had the potential to affect two residents (#27, and #87), reviewed for accurate, comprehensive assessments, and the facility failed to timely complete a comprehensive assessment for one (#220) of four reviewed for accurate, comprehensive assessments. The facility census was 109. Findings Include: 1. Resident #27 had an admission date of 11/07/19 with diagnoses including: Coronary artery heart disease, hypertension, hypercholesterolemia, orthostatic hypotension, hyperlipidemia, type two diabetes, age related physical debility, major depressive disorder, need for assistance with personal care, dizziness and giddiness, anxiety disorder, bipolar disorder, history of falling, vitamin deficiency, and dementia with behavioral disturbance. Observation on 12/19/24 at 10:25 A.M. revealed Resident #27 in his bed. There was 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 record review and staff interview, the facility failed to ensure an accurate significant change Minimum Data Status (MDS) 3.0 assessment was completed for two residents (Residents #97 and #163). The deficient practice affected two residents (Residents #97 and 163) of two reviewed for significant change MDS assessments. The facility census was 109. Findings Include: Review of the medical record for Resident #97 revealed an admission date on 08/14/24. Medical diagnoses included Type II diabetes mellitus with diabetic neuropathy, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, encounter for surgical aftercare following surgery on the digestive system, and other intestinal obstruction unspecified as to partial versus complete obstruction. Review of the hospice admission Orders/Initial Plan of Care, dated 11/05/24, revealed Resident #97 was admitted to hospice services with the diagnosis of cerebral atherosclerosis. Review of the current physician orders revealed 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 observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#163) received assistance with meals. This affected one resident of four residents reviewed for activities of daily living (ADL). The facility census was 109. Findings Include: Review of the medical record for Resident #163 revealed an initial admission date of 09/23/24 with the latest readmission of 12/01/24, diagnoses included but were not limited to gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope and collapse, repeated falls, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. Review of the plan of care dated 10/12/24 revealed the resident had a self-care performance deficit related to CVA with hemiparesis. Interventions included requires extensive to dependent assistance to reposition and turn in bed, requires extensive assistance 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 observations, resident interviews, staff interviews and review of facility policies, the facility failed to treat and monitor conditions for two residents within professional standards of practice. This affected two (Residents #85 and #87) of twenty-nine residents reviewed during the survey. The facility census was 109 Residents. Findings include: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included hematuria, acquired absence of kidney, chronic heart failure, chronic kidney disease stage III and obstructive and reflux uropathy. Physician orders were silent for diuretics and treatments for edema. Review of Minimum Data Set on 10/29/24 revealed that resident had a Brief Interview Mental Status score of 13, indicative of intact cognition. Review of Resident #85's weights revealed that within thirty days, he had gained 24.6 pounds, indicative of a 11.1% significant weight gain in thirty days. He weighed 211 pounds on 11/14/24, and he weighed 234.6 pounds on 12/04/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure one resident (#81) received podiatry care. This affected one resident of 29 sampled residents. The facility census was 109. Findings Include: Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24, diagnoses included but were not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit.…

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

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 behaviors and side effects for two residents (#9, #81) who received psychotropic and anticoagulant medications. Additionally, the facility failed to complete an abnormal involuntary movement scale (AIMS) when resident #9 was started on an antipsychotic medication. This affected two residents of five residents reviewed for unnecessary medications. The facility census was 109. Findings Include: 1. Review of the medical record for Resident #9 revealed an initial admission date of 01/25/22 with the latest readmission of 04/24/24 with the diagnoses including but not limited to diabetes mellitus, cirrhosis of liver, chronic kidney disease, morbid obesity, hypertension, congestive heart failure, chronic obstructive pulmonary disease, dysphagia, dependence on supplemental oxygen, hyperlipidemia, retention of urine, major depressive disorder, anxiety disorder, atrial fibrillation, obstructive sleep apnea, anemia,…

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 laboratory contract, the facility failed to ensure prothrombin time (PT) and international normalized ratio (INR) laboratory tests were completed timely as ordered for one resident (Resident #84). The deficient practice affected one resident (Resident #84) of two reviewed for anticoagulant medications. The facility census was 109. Findings Include: Review of the medical record for Resident #84 revealed an admission date on 06/20/24. Medical diagnoses included atrial fibrillation (A-Fib), heart failure, hypertension, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and a personal history of venous thrombosis and embolism. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 had impaired cognition and scored a ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the Medication Administration Record (MAR) dated November 2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure a complete and accurate medical record for one (#81) of 29 sampled residents. The facility census was 109. Findings Include: 1. Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24 with the diagnoses including but not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe…

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, resident interviews, staff interviews and review of facility policy, the facility failed to follow infection control policies for two residents. This affected two (Residents #85, and #164) of five (Resident #10, #81, #85, #163, and #164) residents reviewed for infection control. The facility census was 109 residents. Findings include: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included hematuria, acquired absence of kidney, chronic heart failure, chronic kidney disease stage III and obstructive and reflux uropathy. Physician orders were silent for diuretics and treatments for edema. Review of Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview Mental Status score of 13, indicative of intact cognition. Review of physician orders revealed he had orders to cleanse the nephrostomy site on his right flank, apply triple antibiotic ointment and apply a clean covered dressing daily on every night shift. Review of the Treatment Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe manner. This affected one (#108) out of 22 residents who smoke in the facility. The facility census was 113. Findings include: Review of Resident #108's medical record revealed the resident was admitted on [DATE] with diagnoses that included bipolar disorder, nicotine dependence, and anxiety disorder. Review of Resident #108's safety evaluation for smoking on 09/19/24 revealed the resident was an independent smoker, which meant that she did not need supervision while she was smoking. Review of Resident #108's current care plan revealed nursing was to keep all smoking materials in a designated area. Observation on 09/25/24 at 5:06 A.M. revealed Resident #108 left her room with a cigarette and a lighter in her right hand. The resident then exited the building into a secured courtyard. Interview on 09/25/24 at 7:00 A.M. with Resident #108…

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 complete wound assessments accurately to reflect the residents current wound condition. This affected one (Resident #207) of the three residents reviewed for skin management and breakdown prevention. The facility census was 95. Findings include: Review of the medical record for Resident #207 revealed an initial admission date of 03/17/23 and a re-entry date of 04/14/23. Diagnoses included disease of the circulatory system, chronic kidney disease, and acquired absence of the left leg below the knee. Review of the weekly skin observation completed for Resident #207 dated 11/17/23 revealed there were no current skin issues noted. Continued review revealed no additional weekly skin observations were completed since 11/17/23. Review of Resident #207's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating a moderately impaired…

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, X-ray result review, staff interview, and facility policy review, the facility failed to ensure weekly skin observations were completed on residents at risk for skin breakdown. This affected one (Resident #207) of the three residents reviewed for skin management and breakdown prevention. The facility census was 95. Findings include: Review of the medical record for Resident #207 revealed an initial admission date of 03/17/23 and a re-entry date of 04/14/23. Diagnoses included disease of the circulatory system, chronic kidney disease, and acquired absence of the left leg below the knee. Review of the weekly skin observation completed for Resident #207 dated 11/17/23 revealed there were no current skin issues noted. Continued review revealed no additional weekly skin observations were completed since 11/17/23. Review of Resident #207's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating 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, hospital record review, X-ray result review, staff interview, and facility policy review, the facility failed to ensure residents being transported with the facility's van was properly secured to prevent falls and to report incidents immediately after they occur. This affected one (Resident #231) of the three residents reviewed for falls. The facility census was 95. Findings include: Review of the medical record for Resident #231 revealed an admission date of 12/14/23 and a discharge date of 01/25/24. Diagnoses included orthopedic aftercare following a motor vehicle accident resulting in concussion, multiple fractures of the left and right ribs, muscle weakness, and reduced mobility. Review of Resident #231's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #231 was noted with impairment to one lower…

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, medication administration observation, staff interview, and review of facility Medication Administration policy, revealed the facility failed to ensure hand hygiene was completed between care for each resident during medication administration. This affected two (Resident #129 and #139) of the three residents reviewed during medication administration. The facility census was 95. Findings include: 1. Review of the medical record for Resident #129 revealed an initial admission date of 12/13/23 and a re-entry date of 12/25/2023. Diagnoses included acute respiratory failure, heart failure, and osteoarthritis. Review of Resident #129's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident had an intact cognition for decision making abilities. Observation on 02/02/24 at 9:10 A.M. of Registered Nurse (RN) #92 administering medication for Resident #129 revealed infection control concerns. RN #92 was observed pulling the scheduled medication for Resident #129…

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 weekly menus, review of substitution log, review of food committee minutes, and facility policy review, the facility failed to ensure menus provided a variety of foods according to resident preferences. This had the potential to affect all 74 residents who received meals from the kitchen. The facility did not have any residents who were unable to eat by mouth (NPO). The census was 74. Findings include: Interview on 10/23/23 at 12:30 P.M. with Resident #50 revealed he did not like the facility's food and it was the same food over and over. Interview on 10/24/23 at 11:39 A.M. with Resident #39 revealed the facility did not offer a variety of foods or food choices. Resident #39 stated the facility would serve tuna salad one day and then will have it again later the same week. Review of the food committee minutes, dated 08/17/23, 09/21/23, and 10/19/23, revealed residents requested to change up the snacks offered in the evenings and requested several food items be…

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 ensure foods were properly dated and were discarded when appropriate. This had the potential to affect all 74 residents who received food from the kitchen. The facility did not have any residents who were unable to eat food by mouth (NPO). The census was 74. Findings include: Observation on 10/23/23 at 3:12 P.M. of the foods stored in the cooler revealed a large gallon jug of italian dressing that was approximately 75% used and had a delivery date of 06/26/23 on the lid with no open date. There was also a large container of yellow salad mustard that was approximately 25% used and had an open date of 07/12/23 and a use by date of 08/12/23. Additionally, there was a large container of coleslaw dressing that was approximately 25% used and had a delivery date of 08/06/23 with no open date. Finally, there was a large bottle of white vinegar that was approximately 80% used and had a delivery date of 02/28/23 with no open date. Interview with Dietary Manager (DM) #300 at the time of the observation…

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

Based on medical record review, observation, staff interview, and facility policy, the facility failed to ensure residents were assisted with meals in a dignified manner. This affected one (Resident #18) of one resident reviewed for dignity. The facility census was 74. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/17/21 with diagnoses including type two diabetes mellitus, moderate protein-calorie malnutrition, hepatitis C, aphasia, depression, anxiety, cognitive communication deficit, need for assistance with personal care, and hypertension. Review of the comprehensive Minimum data Set (MDS) 3.0 assessment, dated 09/27/23, revealed Resident #18 had severe cognitive impairment. Review of the plan of care, dated 01/11/22, revealed Resident #18 had impaired activity of daily living function related to diagnoses, hemiplegia affecting the left side, impaired cognition, and incontinence. Interventions included assisting with meal intake, including the resident in treatment plan, anticipating needs for resident care, assisting with…

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

Based on medical record review, staff and resident, and policy review, the facility failed to ensure residents were bathed at their preferred time of day. This affected one (Resident #30) of one resident reviewed for bathing. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/21/23 with diagnoses including hypertension, hypothyroidism, displaced intertrochanteric fracture of right femur (07/01/23), panic disorder, generalized anxiety disorder, major depressive disorder, cerebral aneurysm, fibromyalgia, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed Resident #30 had intact cognition and required substantial or maximal assistance with bathing. Review of the plan of care, dated 07/12/23, revealed Resident #30 had impaired activity of daily living (ADL) function related to requiring assistance to perform or complete ADL self-care with varying self-performance. Interventions included anticipating needs for Resident #30's care, assisting with meal intake,…

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

Based on medical record review, review of a Beneficiary Notice list, review of a SNF Beneficiary Protection Notification Review, staff interview, and facility policy review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage was provided to residents as required. The deficient practice affected one (Resident #8) of three residents reviewed for beneficiary notices. The facility census was 74. Findings include: Review of the medical record for Resident #8 revealed an initial admission date of 05/08/18 and a readmission date of 02/22/23. Medical diagnoses included chronic respiratory failure with hypoxia, malignant neoplasm of bronchus or lung, need for assistance with personal care, muscle weakness, history of falling, and dependence on supplemental oxygen. Review of the Beneficiary Notice list provided by the facility on 10/24/23 revealed Resident #8 was discharged from Medicare Part A services on 05/22/23 and remained in the facility. Review of the SNF Beneficiary Protection Notification Review, completed by the facility, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, review of facility investigation and self-reported incident (SRI), review of witness statements, and policy review, the facility failed to ensure residents were free from abuse and failed to ensure staff intervened in a timely manner during an instance of abuse. This affected two (#15 and #68) of three residents reviewed for abuse. The facility census was 74. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 09/28/19 with diagnoses including dementia, type two diabetes mellitus, chronic kidney disease, hemiplegia and hemiparesis, anxiety, depression, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/02/23, revealed Resident #15 had severely impaired cognition. Review of the progress note for Resident #15, dated 07/05/23, revealed Licensed Practical Nurse (LPN) #139 was called to the front desk by the receptionist. When she arrived, she saw Resident #15…

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 Minimum Data Set (MDS) assessments were accurate. This affected one resident (#45) out of 21 residents reviewed for accurate assessments. The facility census was 74. Findings include: Review of the medical record for Resident #45 revealed an admission date of 11/13/18 with diagnoses including traumatic subdural hemorrhage with loss of consciousness, unspecified convulsions, chronic respiratory failure with hypoxia, aphasia, and diffuse traumatic brain injury with loss of consciousness. Review of the comprehensive MDS 3.0 assessment, dated 08/18/23, for Resident #45 revealed it indicated Resident #45 had an invasive mechanical ventilator. Review of the physician order for Resident #45, dated 05/15/23, revealed an order for a non-invasive vent to be worn at bedtime and as needed. Interview on 10/25/23 at 4:18 P.M. with MDS Coordinator #176 verified Resident #45 did not have an invasive vent and the MDS assessment was marked incorrectly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of Pre-admission Screening And Resident Reviews (PASARR), and facility policy review, the facility failed to complete an updated PASARR when a new mental health diagnosis was given and failed to ensure PASARR's were accurate. The deficient practice affected two (Residents #6 and #39) of two residents reviewed for PASARR. The facility census was 74. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 08/24/16. Medical diagnoses included anxiety disorder, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, and obsessive-compulsive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/25/23, revealed Resident #39 had intact cognition. Review of the PASARR, dated 10/27/21, revealed the screening indicated Resident #39 had mental disorders which included schizophrenia, mood disorder, and anxiety disorder. The PASARR did not include…

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 3. Review of the medical record for Resident #53 revealed an initial admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition. Resident #53 required extensive assistance from staff for activities of daily living (ADL) tasks, and had a laryngectomy which required oxygen use and suctioning. Review of Resident #53's care plan, dated 10/14/23 revealed Resident #53 self-removing his tracheostomy cannulas was not addressed in the care plan. The tracheostomy care plan did not reference Resident #53 self-removing his tracheostomy cannulas. Review of Resident #53's progress notes dated 10/07/23 at 11:00 A.M., 10/07/23 at 3:30 P.M. and 10/08/23 at 1:00 P.M. revealed documentation indicating Resident #53 was self-removing the tracheostomy due 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, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for assistance were provided adequate nail care. This affected two (#18 and #31) of three residents reviewed for activities of daily living (ADL). The facility census was 74. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 12/01/22 with diagnoses including chronic kidney disease, spastic hemiplegia affecting right side with memory deficit, type two diabetes, rheumatoid arthritis, major depressive disorder, anxiety disorder, and contracture of right lower leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/22/23, revealed Resident #31 had severely impaired cognition. Resident #31 required extensive assistance of one person for personal hygiene. Review of the plan of care, dated 10/31/22, revealed Resident #31 had impaired activity of daily living (ADL) function related to requiring assistance to perform ADL's and requiring that tasks be broken…

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 lab test results, review of weekly wound observation evaluations, staff interview, and facility policy review, the facility failed to provide timely treatment following critical lab results and failed to ensure weekly wound observation evaluations were completed accurately. The deficient practice affected two residents (Residents #23 and #67) of nine residents reviewed for skin impairments and lab test results. The facility census was 74. Findings include: 1. Review of the medical record for Resident #23 revealed an original admission date of 09/01/21 and a readmission date of 05/05/23. Medical diagnoses included end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with hypoglycemia, moderate protein-calorie malnutrition, and unstageable pressure ulcer of sacral region. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/05/23, revealed Resident #23 had intact cognition and scored 15 out of 15 on the Brief Interview 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 resident and staff interview, and medical record review, the facility failed to accurately assess a residents hearing and to make a timely referral to an audiologist. This affected one (#30) of one resident reviewed for ancillary services. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/21/23 with diagnoses including hypertension, hypothyroidism, displaced intertrochanteric fracture of the right femur (07/01/23), panic disorder, unspecified hearing loss, generalized anxiety disorder, major depressive disorder, cerebral aneurysm, fibromyalgia, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed Resident #30 had intact cognition. The resident had minimal difficulty hearing. Review of Resident #30's plan of care revealed it did not address Resident #30's hearing loss. Review of the nursing evaluation, dated 06/23/23, revealed Resident #30 had adequate hearing. Review of the consent form, dated 07/20/23, revealed Resident #30 did not decline any…

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

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected two residents (#45 and #49) of four residents reviewed for falls. The facility census was 74. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 11/13/18 with diagnoses including traumatic subdural hemorrhage with loss of consciousness, unspecified convulsions, chronic respiratory failure with hypoxia, aphasia, and diffuse traumatic brain injury with loss of consciousness. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/18/23, revealed Resident #45 had severely impaired cognition. Review of the physician order, dated 11/14/18, revealed Resident #45 had an order for a fall intervention which included keeping the bed in the lowest position except for during care. Review of the plan of care, dated 11/21/18, revealed Resident #45 had the potential for falls related to a history of falls, incontinence, medication use,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure there were physician orders in place to care for a residents an indwelling urinary catheter. This deficient practice affected one resident (Resident #53) out of two residents reviewed for indwelling urinary catheter care. The facility census was 74. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition and scored 00 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from staff for activities of daily living (ADL) tasks and had an indwelling urinary catheter. Review of the baseline care plan, dated 10/16/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, review of hospital records, and facility policy review, the facility failed to ensure there were physician orders for heated humidified oxygen for a resident who was receiving heated humidified oxygen. The facility census was 74. Findings include: Review of the medical record for Resident #53 revealed an initial admission date of 05/03/23. Resident #53 had multiple hospitalizations which included from 07/31/23 to 09/01/23, from 09/05/23 to 10/06/23, and from 10/08/23 to 10/14/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition. Resident #53 required extensive assistance from staff for activities of daily living (ADL) tasks, and had a laryngectomy which required oxygen use and suctioning. Review of…

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

Based on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to ensure pain medication was administered as ordered. This affected one resident (#30) of two residents reviewed for pain management. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/21/23 with diagnoses including hypertension, hypothyroidism, displaced intertrochanteric fracture of right femur (07/01/23), panic disorder, generalized anxiety disorder, major depressive disorder, cerebral aneurysm, fibromyalgia, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed Resident #30 had intact cognition. Review of the plan of care, dated 07/12/23, revealed Resident #30 had the potential for pain related to a previous left hip fracture and fibromyalgia. Interventions included to ensure Resident #30 was included in the treatment plan, administering pain medications as ordered, assessing the resident for location, onset, origin, intensity, 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 staff interview, medical record review, and review of facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to administering anti-anxiety medications. This affected one resident (#30) of six residents reviewed for unnecessary medications. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/21/23 with diagnoses including hypertension, hypothyroidism, displaced intertrochanteric fracture of right femur (07/01/23), panic disorder, generalized anxiety disorder, major depressive disorder, cerebral aneurysm, fibromyalgia, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed Resident #30 had intact cognition. Review of the plan of care, dated 07/12/23, revealed Resident #30 was at risk for drug related complications related to psychotropic medication use including anti-anxiety and antidepressant medications. Interventions included administering medications as ordered, attempting non-pharmacologic interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to maintain a medication error rate less than five percent (%). There were two medication errors out of 30 opportunity which resulted in a medication error rate of 6.67%. This affected one resident (Resident #53) out of three residents reviewed for medication administration. The facility census was 74. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition. Resident #53 required the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube for supplemental nutrition and medication administration. Review of the signed physician orders, dated October 2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to residents were free from significant medication errors. This affected one resident (Resident #53) out of three residents reviewed for medication administration. The facility census was 74. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition. Resident #53 required the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube for supplemental nutrition and medication administration. Review of the signed physician orders, dated October 2023, revealed Resident #53 had orders for Metoprolol Tartrate 25 milligram (mg), give 12.5 mg (half tablet) twice daily 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 medical record review, resident and staff interviews, and facility policy review, the facility failed to ensure medical records were accurate. This affected two residents (Residents #23 and #30) of 21 residents reviewed whose medical records were reviewed. The facility census was 74. Findings include: 1. Review of the medical record for Resident #23 revealed an original admission date of 09/01/21 and a readmission date of 05/05/23. Medical diagnoses included end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with hypoglycemia, moderate protein-calorie malnutrition, and unstageable pressure ulcer of sacral region. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/05/23, revealed Resident #23 had intact cognition and received dialysis services. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated September 2023, revealed Resident #23 had an order to go to dialysis treatments on Tuesday, Thursday, and Saturday. The MAR indicated Resident #23 completed her dialysis visits 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to follow proper infection control practices during medication administration. This affected one resident (Resident #53) out of three residents observed for medication administration. The facility census was 74. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition and scored 00 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #53 required extensive assistance from staff for activities of daily living (ADL) tasks and required the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube for supplemental nutrition and medication…

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 an emergency room note, review of infection control log, staff interview, and facility policy review, the facility failed to ensure there was appropriate justification for antibiotic use. This affected one (Resident #23) out of six residents reviewed for unnecessary medications. The facility census was 74. Findings include: Review of the medical record for Resident #23 revealed an original admission date on 09/01/21 and a readmission date on 05/05/23. Medical diagnoses included end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with hypoglycemia, moderate protein-calorie malnutrition, and unstageable pressure ulcer of sacral region. Review of the census for Resident #23 revealed the resident was in the hospital from [DATE] to 09/01/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/05/23, revealed Resident #23 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and facility resident council minutes, the facility failed to provide bathing activities to all dependent residents. This affected two (Resident #32 and Resident #70) of three resident's reviewed for activities of daily living. The census was 78. Findings Include: 1. Resident #32 was admitted to the facility on [DATE]. His diagnoses were congestive heart failure, atherosclerotic heart disease, atrial fibrillation, type II diabetes, hypertension, hyperlipidemia, chronic kidney disease (stage III), obesity, schizoaffective disorder, mood disorder, major depressive disorder, anxiety disorder, osteoarthritis, insomnia, nicotine dependence, and chronic obstructive pulmonary disease. Review of his Minimum Data Set (MDS) assessment, dated 07/26/23, revealed he had a mild cognitive impairment. He required one person physical assistance for bathing. Review of Resident #32 shower logs, dated June 2023 to August 2023, revealed he had a total of three…

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 interview the facility failed to ensure meals served to residents were served timely, meals were palatable and met each residents' preference. This affected seven residents (#390, #387, #392, #386, #385, #78, #84 and #37) and had the potential to affect all 97 residents who received meal trays from the kitchen. The facility identified one resident (#76) who received nothing by mouth. The facility census was 98. Findings Include: Review of the facility dining schedules revealed lunch meal trays were scheduled to be served to the [NAME] unit between 12:00 P.M. and 12:30 P.M. On 10/18/21 at 12:29 P.M. interview with Resident #390 revealed she had been admitted to the facility on [DATE]. During the interview, Resident #390 voiced concerns regarding the meals and indicated meals were always late, the food was always cold and she did not always get milk as requested with her meal trays. The resident indicated the lunch meal was to be delivered by 12:30 P.M. but was sometimes not…

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

Based on observation, record review and interview the facility failed to provide safe food storage, clean production equipment and a clean ice machine in the main kitchen. The had the potential to affect 97 of 97 residents who received meal trays from the kitchen. The facility identified one resident (#76) who received nothing by mouth. The facility census was 98. Findings Include: On 10/18/21 at 8:25 A.M. observations during a kitchen tour revealed two cases of cereal were stored on the floor of the dry storage area. One case of frozen tater tots was stored on the floor of the freezer. At that time, [NAME] #301 verified the foods stored on the floor in dry storage room and freezer. On 10/18/21 at 8:35 A.M. observation in the kitchen revealed a coffee cup was stored inside the sugar bin. The can opener blade and base contained dirty dried on food. The microwave was soiled inside. The ice machine had a black substance on the inside white plastic piece. At the time of the observation, interview with Registered Dietitian #300 verified the cup inside the sugar bin, dirty can opener…

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

Based on observation, facility policy and procedure review and interview the facility failed to provide a trash can with a fitting lid in the main kitchen production area. This had the potential to affect all 97 of 97 residents who receive meal trays from the kitchen. The facility identified one resident (#76) who received nothing by mouth. The facility census was 98. Findings include: On 10/18/21 at 8:25 A.M. observations during a kitchen tour revealed breakfast tray line was in progress. Next to the serving area and food production was a large trash container full of trash with no lid to cover the trash. There was no indication the trash container was in use at the time of the observation. At the time of the observation, interview with [NAME] #301 verified the trash container had no lid. Review of the undated facility policy titled Waste Disposal revealed all waste was to be kept in a leak proof container that was covered when not in use.

Based on record review and interview the facility failed to implement a water management program to ensure appropriate and ongoing surveillance for Legionella. This had the potential to affect all 98 residents residing in the facility. Findings Include: Review of the facility Legionella Environmental Assessment, dated 01/18/21 revealed there was no water safety plan or Legionella prevention program but that the facility was in the process of setting one up. On 10/20/21 at 10:18 P.M. interview with Infection Preventions Licensed Practical Nurse (LPN) #312 revealed all residents with in-house acquired pneumonia, were currently being tested for Legionella. LPN #312 revealed a former resident had tested positive for Legionella in February 2021. LPN #312 shared the local health department was involved and the facility was tested for Legionella at that time. On 10/20/21 at 12:38 P.M. interview with Maintenance Director (MD) #314 revealed facility maintenance staff run water in empty rooms twice per week to help prevent Legionella. MD #314 revealed this was the only Legionella prevention…

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 facility policy and procedure review the facility failed to maintain resident financial records to ensure each resident received funds they were allotted. This affected 26 residents (#87, #88, #89, #90, #74, #6, #92, #30, #43, #93, #94, #95, #18, #96, #97, #40, #8, #98, #99, #100, #101, #102, #103, #31, #104 and #105) of 79 residents identified to be eligible for government assistance funds. The facility census was 98. Findings Include: Review of 79 resident financial statements, for residents who were residing in the facility from 03/01/20 to at least 06/01/20, revealed 26 residents, Resident #87, #88, #89, #90, #74, #6, #92, #30, #43, #93, #94, #95, #18, #96, #97, #40, #8, #98, #99, #100, #101, #102, #103, #31, #104 and #105 did not receive their first government stimulus check of $1200. There was no evidence the facility made an effort to determine why these residents did not receive their stimulus check or to maintain accurate financial accounts for these 26 residents. Interview with Business Office Manager (BOM) #155 on 10/20/21 at…

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 3. Review of the medical record for Resident #4 revealed an admission date of 04/01/21 with diagnoses including heart failure, chronic kidney disease stage three, type two diabetes mellitus with diabetic, chronic kidney disease, hyperlipidemia, hypertension, gout, kidney transplant, major depressive order, chronic respiratory failure and gastro-esophageal reflux disease without esophagitis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21 revealed the resident had intact cognition. The MDS also revealed the resident received scheduled, 'as needed' medications, and non-medication interventions for pain. The resident had occasionally had mild pain in the five days before the assessment. Review of the plan of care revealed no plan of care had been developed and implemented for Resident #4 related to pain. Review of the physician's orders for September and October 2021 revealed orders for Dilaudid tablet two milligrams by mouth every six hours as needed for pain, Colchicine tablet 0.6 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 observation, record review, facility policy review and interview the facility failed to ensure residents, who required staff assistance for activity of daily living (ADL) care, received adequate and timely assistance with toileting/incontinence care and/or grooming, including nail care to maintain proper hygiene. This affected five residents (#4, #37, #70, #71 and #76) of eight residents reviewed for activities of daily living. Findings Include: 1. Review of the medical record for Resident #37 revealed an admission date 01/29/16 and readmission date 06/13/18 with diagnosis including type two diabetes, severe morbid obesity, chronic peripheral venous insufficiency, peripheral vascular disease, heart failure, hypertension, hyperlipidemia, obstructive sleep apnea, major depressive disorder, history of falling, benign prostatic hyperplasia, osteoarthritis, history of other infectious and parasitic diseases, tobacco use, dependence on wheelchair and multiple sclerosis. Review of the quarterly Minimum Data…

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 facility policy review the facility failed to honor the bathing requests/preferences of Resident #11. This affected one resident (#11) of eight residents reviewed for activities of daily living. Findings Include: Resident #11 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, chronic obstructive pulmonary disease (COPD), morbid obesity, congestive heart failure, atherosclerotic heart disease, and hypertensive heart and chronic kidney disease. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/19/21 revealed the resident was cognitively intact. Review of Resident #11's medical record revealed in the last 90 days, the resident did not receive any showers. According to the medical and resident preference records, Resident #11's preference was to take showers, not bed baths as she received. There was no evidence to support the resident was offered a shower, offered to utilize the facility shower chair or any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview facility failed to ensure Resident #70 had the right to formulate an advance directive. This affected one resident (#70) of 26 sampled residents. Findings Include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's, disease, chronic kidney disease, benign cyst of the testis, history of COVID-19, peripheral vascular disease, sacral ulcer, schizophrenia and right side ischium osteomyelitis (dated [DATE]). The outside of the resident's hard chart contained the wording FULL CODE. In addition, review of the resident's electronic medical record indicated the resident was a full code in regard to advance directives. A full code status directed staff to provide cardiopulmonary resuscitative measures for the resident. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #70 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. On [DATE] at…

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, facility policy review and interview, the facility failed to provide a transfer notice for Resident #76 and Resident #62 who were transferred to the hospital. This affected two residents (#76 and #62) of three residents reviewed for hospitalization. Findings Include: 1. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's Disease and a stroke with hemiplegia/dysphasia. Record review revealed on 06/24/21 the resident was transferred to the hospital with congestion and fever and returned 06/27/21. The resident's mother was his representative and was notified of the discharge; however, there was no evidence of a written transfer notice provided to the resident's mother. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/27/21 revealed the resident had severely impaired short and long term memory and decision making skills. On 10/20/21 at 11:06 A.M. Corporate registered nurse (RN) #305…

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 complete a new pre-admission screening and resident review (PASARR) for Resident #55 who had a new mental diagnosis. This affected one resident (#55) of one reviewed for PASARR. Findings Include: Review of the medical record for Resident #55 revealed an admission date of 08/24/16 with diagnoses including atherosclerotic heart disease, rheumatoid arthritis, craniosynostosis, anxiety disorder, other obsessive-compulsive disorder, major depressive disorder and unspecified hearing loss. Review of the Preadmission Screening/Resident Review Identification Screen, dated 08/25/16 revealed the resident's diagnoses included panic or other severe anxiety disorder. Review of the plan of care, dated 02/27/18 revealed Resident #55 had a mood problem related to her disease processes including insomnia, depressive disorder, psychotic delusional disorder and anxiety. Additionally, the resident experienced crying, agitation, yelling, and made repetitive statements such…

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, facility policy review and interview the facility failed to revise ensure resident care plans were revised to reflect the current status of Resident #81 related to monitoring psychotropic and anti-depressant medications and for Resident #37 related to smoking. This affected two residents (#37 and #81) of 25 residents whose care plans were reviewed. Findings Include: 1. Record review revealed Resident 81 was admitted to the facility on [DATE] with diagnoses including diabetes, bipolar disorder and anxiety/depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed the resident's cognition was intact, she did not ambulate and was dependent on two staff for transfers. Medications ordered for the resident on 10/08/21 included the psychoactive medication, Abilify 15 milligrams (mg) daily for bipolar disorder and antidepressant medications, Trazadone 50 mg daily and Zoloft 10 mg daily. Review of the resident's care plan revealed no mention of the psychoactive 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.

Based on observation, record review and interview the facility failed to monitor areas of skin impairment, failed to complete skin assessments and/or failed to follow physician ordered dressing changes. This affected two residents (#4 and #60) of four residents reviewed for non-pressure skin issues. Findings Include: 1. Review of the medical record for Resident #4 revealed an admission date of 04/01/21 with diagnoses including heart failure, chronic kidney disease stage three, type two diabetes mellitus with diabetic, chronic kidney disease, hyperlipidemia, hypertension, gout, kidney transplant, major depressive order, chronic respiratory failure and gastro-esophageal reflux disease without esophagitis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21 revealed Resident #4 had intact cognition. Review of the physician's orders for October 2021 revealed Resident #4 had an order for percutaneous endoscopic gastrostomy (PEG) tube removal on 10/07/21. Additional orders were noted for removal of gastrostomy tube site covering after 48 hours on 10/09/21 and 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, record review and interview the facility failed to ensure preventative pressure relieving devices were in place as ordered/planned for Resident #4, Resident #70 and Resident #71, who were being treated for pressure ulcers. This affected three residents (#4, #70 and #71) of five residents reviewed for pressure ulcers. Findings Include: 1. Review of the medical record for Resident #4 revealed an admission date of 04/01/21 with diagnoses including heart failure, chronic kidney disease stage three, type two diabetes mellitus with diabetic, chronic kidney disease, hyperlipidemia, hypertension, gout, kidney transplant, major depressive order, chronic respiratory failure and gastro-esophageal reflux disease without esophagitis. Review of the plan of care, dated 09/29/21 revealed the resident had impaired skin integrity related to a pressure ulcer to the right heel. Interventions included applying treatments as ordered, educating the resident of causative factors and elevating the heels in 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 3. Review of medical record for Resident #37 revealed an admission date 01/29/16 and readmission date 06/13/18 with diagnosis including type two diabetes, severe morbid obesity, chronic peripheral venous insufficiency, peripheral vascular disease, heart failure, hypertension, hyperlipidemia, obstructive sleep apnea, major depressive disorder, history of falling, benign prostatic hyperplasia, osteoarthritis, history of other infectious and parasitic diseases, tobacco use, dependence on wheelchair and multiple sclerosis. Review of current care plan, dated 06/14/18 and last updated on 04/09/20 revealed Resident #37 was at risk for injury related to smoking. The care plan was updated on 04/08/20 to reflect the resident had burned himself when smoking. Interventions included nursing was to maintain all smoking materials in designated area. Review of quarterly MDS 3.0 assessment, dated 08/18/21 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. The assessment…

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, facility policy and procedure review and interview the facility failed to ensure accurate and proper monitoring and evaluation of potential weight loss for Resident #59. This affected one resident (#59) of four residents reviewed for nutrition. Findings Include: Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including pneumonia, heart failure, type II diabetes, chronic kidney disease, dehydration, anemia, dementia, muscle weakness, dysphagia, hyperosmolarity and hypernatremia, gout, anxiety disorder, insomnia, constipation, shortness of breath and acute and chronic respiratory failure. Review of Resident #59's medical record revealed the resident's admission weight, dated 09/15/21 was 268 pounds. On 09/19/21 the resident's weight was 268.8 pounds. On 09/20/21 the resident's weight was noted to be 209 pounds, a 59 pound/22.25% decrease in one day. According to her electronic progress note, dated 09/20/21 staff confirmed the weight of 209 pounds.…

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, facility policy and procedure review and interview the facility failed to provide comprehensive care and services to meet the respiratory needs of Resident #3, Resident #60 and Resident #62. The facility failed to ensure oxygen was provided as ordered, oxygen orders were clarified when needed and oxygen equipment was maintained in a clean and sanitary manner. This affected three residents (#3, #60 and #62) of four residents reviewed for respiratory care. Findings Include: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, chronic respiratory failure with hypoxia, morbid obesity, neuromuscular dysfunction of the bladder, retention of urine, heart failure (CHF) and dependence of supplemental oxygen. Review of the care plan, dated 10/04/21 revealed Resident #3 was at risk for altered respiratory status/difficulty breathing related to CHF, COPD with oxygen…

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 and implement a comprehensive and individualized pain management program including adequate monitoring and the development of a pain treatment plan for Resident #70. This affected one resident (#70) of five residents reviewed for pain. Findings Include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, chronic kidney disease, benign cyst of the testes, history of COVID-19, peripheral vascular disease (PVD), sacral ulcer, schizophrenia and right side ischium osteomyelitis (05/06/21). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #70 revealed was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Section J of the MDS revealed the resident was not on scheduled pain medication. On 10/18/21 at 10:40 A.M. interview with Resident #70 revealed he had daily pain and severe arthritis.…

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 interview the facility failed to ensure adaptive meal devices were provided for Resident #70 and Resident #71. This affected two residents (#70 and #71) of six residents identified with adaptive meal equipment. Findings Include: 1. Review of Resident #70's nutritional plan of care revealed an intervention to provide adaptive equipment with meals to allow resident to eat independently. On 10/18/21 during the lunch meal, observation and review of Resident #70's meal ticket revealed the ticket reflected the resident required a plate guard, built up silverware for all meals and send two strawberry milk shakes with each meal. On 10/18/21 at 12:29 P.M. observation of the lunch meal revealed Resident #70 was observed to have a hot dog bun with chopped hot dog and tater tots on a plate. The staff had left Resident #70's tray of food in his room. Resident #70's plate and tray did not have any type of plate guard or any built up silverware. At the time of the meal observation,…

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.