The Laurels Of Gahanna

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of dishwasher sanitation logs, the facility failed to ensure the dietary manager was competent to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 104 of 107 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three-compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified findings at time of the observation.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a build up of dirt. The wall behind the three-compartment sink was chipped. Dietary Manager #130…

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, interview, review of kitchen staffing schedule, review of dishwasher sanitation log,and review of staff personnel file revealed the facility failed to employ sufficient staff to maintain a clean kitchen. Additionally, they failed to ensure staff were competent to ensure the dishwasher was running appropriately and qualified to be a cook. This had the potential to affect 104 residents who consumed food from the kitchen. The facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include:Findings include:1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three-compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified this.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a buildup of dirt. The wall behind the…

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

Based on observation and interview the facility failed to ensure food was served at a palatable temperature. This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth.Findings include: Interview on 08/06/25 from 12:25 P.M. to 12:55 P.M. with Resident #96 and #97 revealed the food was not always hot when it got to them. Interview with Resident #102 revealed the food was often cold and lunch on that day had been cold as well.Observation on 08/06/25 at 12:30 P.M. revealed the last trays being passed on the E Hall, the cart was open and remained open as Certified Nursing Assistant (CNA) #106 passed the trays. She finished the trays at 12:39 P.M.Observation on 08/06/25 at 12:41 P.M. of a test tray with Dietary Manager #130 revealed the stuffed pepper was 119 degrees Fahrenheit (F), the peas were 102 degrees F, and the [NAME] was 103 degrees F. All foods were cold when sampled.Interview on 08/06/25 at 12:41 P.M. with Dietary Manager #130 verified the foods were not at an appropriate…

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, review of dishwasher manual, review of sanitation instructions, and facility policy review, the facility failed to maintain a clean and sanitary kitchen and sanitize dishes in an appropriate manner. This had the potential to affect 104 residents who consumed food from the kitchen. The facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified this at time of observation.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a build up of dirt. The wall behind the three-compartment sink was chipped. Dietary Manager…

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, interview, record review, and review of facility policy, the facility failed to ensure kitchen equipment was in working order and a system was in place to track maintenance requests. This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility also failed to ensure a safe and clean environment when 35 resident rooms had missing transition strips from residents to hallways. This affected 48 residents (#1, #3, #4, #6, #7, #10, #11, #12, #13, #19, #20, #26, #27, #31, #33, #36, #39, #42, #43, #44, #45, #46, #47, #53, #54, #55, #56, #57, #58, #77, #78, #85, #88, #89, #90, #91, #93, #95, #96, #97, #98, #99, #100, #103, #104, #105, #106, and #107) of 107 residents residing in the facility.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed the disposal connected to the dishwasher was being replaced. Dietary Manager #130 reported the disposal had been down for over a month. The three-compartment…

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 facility policy review, the facility failed to ensure call lights were accessible for use. This affected two residents (#32 and #79) of 14 sampled residents. The facility census was 107.Findings Include:1. Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. On 08/08/25 at 10:18 A.M., observation of Resident #32 revealed the resident's call light was laying on the floor at the bottom of the bed out of the resident's reach. Interview with Certified Nursing Assistant (CNA) #203…

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, interview and facility policy review, the facility failed to notify the physician and the resident's family of a new skin impairment. This affected one resident (#79) of three residents reviewed for pressure ulcers. The facility census was 107. Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for all activities of daily living (ADL). Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, review of facility investigation and self-reported incidents (SRI), and facility policy review, the facility failed to ensure Resident #112 was free from verbal abuse. This affected one resident (#112) of one resident reviewed for verbal abuse. The facility also failed to prevent an injury of unknown origin for Resident #79. This affected one resident (#79) of three residents reviewed for injuries. The facility census was 107.Findings include:1.Review of Resident #112’s medical record revealed an admission date of 06/12/25 and a discharge date of 07/18/25, his diagnoses included type two diabetes mellitus, unspecified corneal ulcer, muscle weakness, and gastro-esophageal reflux disease. Review of the facility self-reported incident dated 06/17/25 revealed the facility reported an incident of emotional or verbal abuse due to a resident and staff member arguing over the meal served for breakfast. The resident was Resident #112 and he had no adverse effects from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to ensure an injury of unknown origin was reported to the required state agency. This affected one resident (#79) of three residents reviewed for pressure ulcers. The facility census was 107. Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for all activities of daily living (ADL). Review of the weekly skin and wound evaluation dated 08/07/25 revealed the 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, interview and facility policy review, the facility failed to ensure an injury of unknown origin was investigated. This affected one resident (#79) of three residents reviewed for pressure ulcers. The facility census was 107. Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for all activities of daily living (ADL). Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to appropriately document a transfer and discharge and provide a transfer notice for Resident #108 and #109. This affected two residents (#108 and #109) of five discharge records reviewed. The facility census was 107.Findings include: 1.Review of the medical record for Resident #109 revealed an admission date of 01/15/25 and a discharge date of 04/13/25 with diagnoses including pneumonia, cognitive communication deficit, generalized anxiety disorder, and chronic respiratory failure. Review of Resident #109’s progress note dated 04/13/25 revealed the resident had a fall and hit her head. Emergency medical services were called, and the resident was sent to the hospital. Review of Resident #109’s medical record revealed no transfer or discharge summary was completed and no transfer notice was provided. Interview on 08/07/25 at 1:13 P.M. with the Director of Nursing (DON) verified there was insufficient documentation related 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 medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately for Resident #108 and Resident #109. This affected two residents (#108 and #109) of 19 medical records reviewed. The facility census was 107.Findings include:1.Review of the medical record for Resident #109 revealed an admission date of 01/15/25 and a discharge date of 04/13/25 with diagnoses including pneumonia, cognitive communication deficit,2109 generalized anxiety disorder, and chronic respiratory failure. Review of Resident #109’s MDS assessments revealed the last one completed was on 04/13/25 and indicated ‘discharge return anticipated’. Review of Resident #109’s medical record revealed she did not return to the facility following her transfer to the hospital on [DATE]. Interview on 08/13/25 at 1:05 P.M. with MDS Nurse #215 verified Resident #109’s MDS assessment was not correct, she had not returned to the facility. 2 . Review of the closed medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, open and closed medical record review, interviews and facility policy review, the facility failed to ensure timely accurate comprehensive assessment of pressure ulcers/injury. Additionally, the facility failed to ensure skin interventions were implemented as physician ordered. This affected three residents (#32, #79 and #108) of three residents reviewed for pressure ulcers. The facility census was 107. Findings Include:1.Review of the closed medical record for Resident #108 revealed an initial admission date of 04/26/25 with the latest readmission of 06/13/25 with the diagnoses including but not limited to other mechanical complication of surgically created arteriovenous fistula, acquired absence of other left toes, encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease ,end stage renal disease (ESRD), diabetes mellitus, pressure induced deep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, the facility failed to have orders in place for continuous oxygen use for Resident #26. This affected one resident (#26) of three residents reviewed for oxygen use. The facility census was 107.Findings include:Review of Resident #26's medical record revealed an admission date of 06/18/25 with diagnoses including chronic heart failure, acute respiratory failure, end stage renal disease, diabetes mellitus, and depression. Review of Resident #26's minimum data set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #26's plan of care revealed it did not address his oxygen usage. Review of Resident #26's physician orders from 06/18/25 to 08/06/25 revealed no orders for oxygen.Review of Resident #26's progress note dated 06/18/25 revealed the resident arrived to the facility with oxygen on at two liters.Review of the skilled nursing notes dated 6/20/25, 07/04/25, 07/06/25, 07/07/25, 07/08/25, 07/09/25, 07/11/25, 07/12/25, 07/13/25,…

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, interview, and policy review, the facility failed to assess Resident #26's pain, document location of pain with administration of 'as needed' pain medications, and administering pain medications according to orders. This affected one resident (#26) of three residents reviewed for pain. The facility census was 107.Findings include: Review of Resident #26's medical record revealed an admission date of 06/18/25 with diagnoses including chronic heart failure, acute respiratory failure, end stage renal disease, diabetes mellitus, and depression. Review of Resident #26's minimum data set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #26's progress note dated 07/20/25 revealed the resident called emergency medical services for pain in his legs.Review of Resident #26's progress note dated 07/20/25 revealed the resident returned from the hospital with a new order for pain medication. Review of Resident #26's physician order dated 07/21/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to educate Resident #108 upon refusal of dialysis and notify Resident #102's family of his refusal to attend dialysis. This affected two residents (#102 and #108) of three residents reviewed for dialysis. The facility census was 107.Findings include: 1.Review of Resident #108's medical record revealed an admission date of 04/26/25 and a discharge date of 06/24/25 with diagnoses including muscle weakness, end stage renal disease with dependence on dialysis, type two diabetes mellitus, fracture of sacrum, pressure induced deep tissue damage of left heel, pressure ulcer of left ankle, chronic obstructive pulmonary disease, alcohol abuse, and peripheral vascular disease. Review of Resident #108's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #108's plan of care dated 04/26/25 revealed resident was at risk for complications related to dialysis. Interventions included…

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 closed record review, interview and facility policy review, the facility failed to ensure medication was available for administration as physician ordered. This affected one resident (#108) of three residents reviewed for medication availability. The facility census was 107.Findings Include:Review of the closed medical record for Resident #108 revealed an initial admission date of 04/26/25 with the latest readmission of 06/13/25 with the diagnoses including but not limited to other mechanical complication of surgically created arteriovenous (AV) fistula, acquired absence of other left toes, encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease, end stage renal disease (ESRD), diabetes mellitus, pressure induced deep tissue injury (DTI) to left heel, DTI to left ankle, atrial fibrillation, anemia, opioid use, depression, urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interview, and review of the facility policy, the facility failed to provide a care planned fall intervention for Resident #63. This affected one resident (#63) out of four residents reviewed for accidents. The facility census was 102 residents. Findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including weakness, dementia, history of transient ischemic attach and cerebral infarction. Resident #63 had falls in the facility on 09/10/24 and 12/18/24. On 09/10/24, the new fall intervention was to have non-skid strips placed to the floor in front of the resident's bed. The care plan dated 08/31/21, Resident #63 was identified at risk for falls related to gait and balance problems, dementia and obesity. A care planned intervention dated 09/10/24 was to have non-skid strips to the floor in front of the bed. Observations on 01/07/25 at 12:22 P.M. and 2:41 P.M. revealed that 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 closed medical record review, review of the facility investigation, resident and staff interviews, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of sexual abuse reported by one resident (Resident #105). This affected one resident (#105) of three residents reviewed for abuse. The facility census was 105. Findings Include: Review of the closed medical record for Resident #105 revealed the resident was admitted on [DATE], a readmission date on 06/20/24, and a discharge date on 10/11/24. Medical diagnoses included end stage renal disease, bipolar disorder, schizophrenia, dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. Review of Resident #105's census revealed she was admitted to a semi-private room. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #105 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS)…

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, review of a facility abuse investigation, staff and resident interviews, and facility policy review, the facility failed to ensure one resident (Resident #26) was treated with dignity and respect. The deficient practice affected one resident (Resident #26) of three reviewed for dignity. The facility census was 96. Findings Include: Review of the medical record for Resident #26 revealed an admission date on 04/04/18. Medical diagnoses included paraplegia, chronic pain syndrome, need for assistance with personal care, and atherosclerotic heart disease of native coronary artery without chest pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #26 was independent with completing Activities of Daily Living (ADLs). Review of a facility investigation dated 06/24/24 revealed Resident #26 was involved in a consensual relationship 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 record review, review of a facility abuse investigation, resident and staff interviews, and facility policy review, the facility failed to report former Licensed Practical Nurse (LPN) #115 to the state Nursing Board for an inappropriate relationship with one resident (Resident #26). The deficient practice affected one resident (Resident #26) of three reviewed for abuse. The facility census was 96. Findings Include: Review of the medical record for Resident #26 revealed an admission date on 04/04/18. Medical diagnoses included paraplegia, chronic pain syndrome, need for assistance with personal care, and atherosclerotic heart disease of native coronary artery without chest pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #26 was independent with completing Activities of Daily Living (ADLs). Review of a facility investigation dated 06/24/24…

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 record review, review of a facility abuse investigation, resident and staff interviews, and facility policy review, the facility failed to complete a thorough investigation of an inappropriate relationship between former Licensed Practical Nurse (LPN) # 115 and one resident (Resident #26). The deficient practice affected one resident (Resident #26) of three reviewed for abuse. The facility census was 96. Findings Include: Review of the medical record for Resident #26 revealed an admission date on 04/04/18. Medical diagnoses included paraplegia, chronic pain syndrome, need for assistance with personal care, and atherosclerotic heart disease of native coronary artery without chest pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #26 was independent with completing Activities of Daily Living (ADLs). Review of a facility investigation dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of shower documentation, review of the shower schedule, resident and staff interviews, and facility policy review, the facility failed to ensure showers were completed as scheduled and per resident preference for two residents (Residents #69 and #79). The deficient practice affected two residents (Residents #69 and #79) of three residents reviewed for showers. The facility census was 96. Findings Include: Review of the medical record for Resident #69 revealed an admission date 10/29/20. Medical diagnoses included cerebral infarction (stroke), multiple sclerosis, and muscle weakness. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #69 required substantial/maximal assistance with bathing or showering. Review of the care plan revised 04/22/24 revealed Resident #69 had a functional deficit and required assistance with self-care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to administer all medications to Resident #100 the evening of admission. This affected one (Resident #100) out of three residents reviewed for medication administration upon admission. Facility census was 98. Findings include: Review of the medical record revealed Resident #100 was admitted on [DATE] and discharged on 08/14/24 with diagnoses that included acute osteomyelitis right ankle and foot, end stage renal disease, type 2 diabetes, ascites, and hemiplegia and hemiparesis. Review of the medication administration record (MAR) revealed Resident #100 did not receive Gabapentin (for pain) 200 milligram (mg), Nifedipine (treat high blood pressure) 90 mg, and Senna (laxative) 8.6 mg the evening of 08/10/24. Gabapentin and Nifedipine was available to be pulled from the facility emergency drug kit, and Senna was an over-the-counter medication that was available. The Medicare 5-day Minimum Data Set, dated [DATE] revealed Resident #100 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 interview and record review the facility failed to ensure residents were free from significant medications errors. This affected one (Resident #100) out of three residents reviewed for insulin administration. The facility census was 96. Findings include: Review of the medical record for Resident #100 revealed an admission date of 08/10/24 and discharge on [DATE] with diagnoses of acute osteomyelitis, altered mental status, end-stage renal disease, type two diabetes mellitus with hyperglycemia requiring long-term use of insulin, ascites, hepatomegaly with splenomegaly, and chronic kidney disease. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment completed on 08/28/24 indicated that Resident #100 was cognitively intact, required assistance with activities of daily living, and had diabetes mellitus. Review of progress notes dated 08/10/24 at 5:39 P.M. revealed Resident #100 was admitted to the facility via emergency medical services. The director of nursing and assistant director of nursing were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, review of manufacturer instructions, review of Medscape guidance on intermittent insulin injections, and pharmacy and staff interviews, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #75) of one resident observed for insulin administration. The facility identified 19 residents who receive insulin. The facility census was 98. Findings include: Review of the medical record for Resident #75 revealed an admission date of 05/16/22. Diagnoses include diabetes mellitus (DM) type two. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively impaired. Review of the physician orders for Resident #75 revealed an order dated 04/14/24 for Insulin Glargine subcutaneous solution 100 unit/milliliter (ml) inject 26 units subcutaneously one time a day for DM. Observation of medication administration 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.

Based on observations and staff interview, the facility failed to ensure garbage and refuse is disposed of properly. This had the potential to affect all 101 residents residing in the facility. The census was 101. Findings include: Observation of the facility parking lot on 05/21/24, at 6:50 A.M. revealed one large garbage dumpster and three large recycling dumpster's located in the back of the building parking lot. The garbage dumpster was separated from the three recycling dumpster's. To the right of the dumpster revealed several broken porcelain tiles in a pile with white powder around each tile. Observation of the area to the left close of the dumpster revealed an extra-large rolling plastic garbage can no lid filled with garbage bags and yellow like refuse stuck to the handle of the can. Directly below the handle was additional yellow refuse. Around the outside of the dumpster there were four scattered used rubber gloves, plastic bottles, used face masks and additional refuse laying on the cement around the dumpster. Tour of the garbage dumpster area on 05/21/24, at 7:10 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and policy review, the facility failed to follow infection control protocols during glucose testing for Resident #35. This affected one (#35) out of three residents observed for glucometer checks and had the potential to affect 10 (#15, #24, #33, #35, #77, #38, #71, #69, #35 and #7) residents that receive blood glucose monitoring (BGM) using a shared glucometer. Additionally, the facility failed to ensure infection control practices were followed during catheter care for Resident #85. This affected one (#85) of one resident observed for catheter care. The facility census was 101. Findings include: 1. Review of medical records for Resident #35 revealed an admission date of 02/23/21. Diagnoses include diabetes mellitus type two (DMII), chronic kidney disease, polyosteoarthritis, cellulitis, and generalized weakness. Review of orders dated 03/20/23 for Resident #35 revealed an order for blood glucose (sugar) monitoring (BGM) twice a day. Orders dated 02/15/23…

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 record review, review of care plan, and staff interviews, the facility failed to properly develop comprehensive care plans. This affected two residents (#33 and #6) of two residents reviewed for care plans. The facility census was 101. Findings include: 1. Review of medical record for Resident #33 revealed an admission date of 04/16/24. Diagnoses include diabetes mellitus type two, bipolar disorder, neuropathy, atherosclerotic heart disease, gout, chronic pain, and edema. Review of the care plan on 05/28/24 8:59 A.M. for Resident #33 dated 04/16/24 revealed diabetes mellitus type two and bipolar disorder diagnoses not included in care planning. Interview on 05/28/24 at 10:41 A.M. with the Director of Nursing (DON) confirmed the care plan did not address Resident #33's diabetes or bipolar disorder diagnoses. 2. Review of the medical record for Resident #6 revealed an initial admission date on 12/12/22 and a readmission date to the facility on [DATE]. Medical diagnoses included hemiplegia and hemiparesis…

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, interviews, observations, and policy review, the facility failed to ensure residents were seen by a podiatrist when needed. This affected three residents (#41, #75 and #89) of three residents reviewed for foot care. The census was 101. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 11/08/23 with diagnoses of cerebral infarction, weakness, soft tissue disorder, and diabetes type II. Review of Resident #41's plan of care dated 4/23/24 revealed interventions to refer to podiatrist/foot care. Observation and interview on 05/20/24 at 02:09 P.M. with Resident #41 revealed her toenails on both feet were long, thick, and curled around each toe. Resident #41 revealed she could not wear socks because they are too irritating to her toes. Interview and observation on 05/22/24 at 4:15 P.M. of Resident #41's feet with Licensed Practical Nurse (LPN) #650 confirmed Resident #41 is a diabetic and should have been referred to a podiatrist to care for her toes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interviews, the facility failed to ensure staff consistently implemented a resident's indwelling urinary catheter care. This affected one (#85) out of one residents reviewed for indwelling catheter care. Facility census was 101. Findings include: Review of the medical record for Resident #85 revealed an initial admission date on 06/08/23 and a readmission date on 04/22/24. Diagnoses include infection and inflammatory reaction due to indwelling urethral catheter (04/22/24), urinary tract infection (04/22/24), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (06/08/23), neuromuscular dysfunction of bladder (06/08/23), and retention of urine (06/08/23). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required total dependence on staff to complete toileting. Resident #85 had an…

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 ensure a residents pain medication was available and administered as physician ordered. This affected one (#85) out of three residents reviewed for medication administration. Facility census was 101. Findings include: Review of the medical record for Resident #85 revealed an initial admission date on 06/08/23 and a readmission date on 04/22/24. Medical diagnoses included infection and inflammatory reaction due to indwelling urethral catheter (04/22/24), urinary tract infection (04/22/24), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (06/08/23), neuromuscular dysfunction of bladder (06/08/23), and retention of urine (06/08/23). Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had impaired cognition and scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #37 required setup or clean-up assistance from staff…

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

Based on observations, medical chart review, policy review, and staff interviews, the facility failed to ensure a medication error rate of less than 5%. Four medication errors out 33 medication administration observations resulted in an error rate of 12%. This affected two residents (#35,and #159) of four residents (#35, #71, #159, and #73) observed for medication administration. The facility census was 101. Findings include: 1. Review of medical records for Resident #35 revealed an admission date of 02/23/21. Diagnoses include diabetes mellitus type two (DMII), chronic kidney disease, polyosteoarthritis, cellulitis, and generalized weakness. Review of orders dated 03/20/23 for Resident #35 revealed an order for blood glucose (sugar) monitoring (BGM) twice a day. Orders dated 02/15/23 for Resident #35 revealed order for Lantus Solution 100 unit/milliliter (ml) (Insulin Glargine) 65 units twice a day for DMII. Observation on 5/22/24 at 7:35 A.M. of Nurse #667 revealed Nurse #667 entered the room of Resident # 35 without completing hand hygiene. Further observation revealed Nurse #667…

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

Based on observation, medical records review, policy review, and staff interview, the facility failed to prime an insulin pen prior to administration, resulting in a significant medication error. This affected one (Resident #35) of four residents observed for medication administration. Facility census was 101 Findings include: Review of medical records for Resident #35 revealed an admission date of 02/23/21. Diagnoses included diabetes mellitus type two (DMII), chronic kidney disease, polyosteoarthritis, cellulitis, and generalized weakness. Review of physician orders dated 03/20/23 for Resident #35 revealed an order for blood glucose (blood sugar) monitoring twice a day. Orders dated 02/15/23 for Lantus Solution 100 unit/milliliter (ml) (Insulin Glargine) 65 units twice a day for DMII. Observation on 05/22/24 at 7:35 A.M. revealed Registered Nurse (RN) #667 administered 65 units of Lantura Soluation from the insulin pen to Resident #35 without priming the insulin pen prior to administration. Interview on 05/22/24 at 7:45 A.M. with RN #667 confirmed the insulin pen was not primed…

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 policy review, the facility failed to maintain appropriate infection control procedures during medication administration for Resident #10. This affected one (Resident #10) of three residents reviewed for medication administration. The facility census was 111. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, end stage renal disease, and type II diabetes mellitus. Review of the Medicare five-day Minimum Data Set (MDS) assessment revealed Resident #10 was cognitively intact. Observation on 02/02/24 at 8:35 A.M. revealed Licensed Practical Nurse (LPN) #154 was lifting the medication cards out of the medication cart and putting the medications into her bare hand before placing the medication in the medication cup. LPN #154 revealed she was getting medications ready to administer to Resident #10. LPN #154 verified she should probably be wearing…

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, interview, and facility policy review the facility failed to ensure staff wore Personal Protective Equipment (PPE) appropriately while the facility was in a COVID-19 outbreak and failed to ensure appropriate PPE was available outside of Resident #64's room who was on isolation for COVID-19. This had the potential to affect all 97 residents who did not have an active diagnosis of COVID (Resident #64 had an active diagnosis of COVID-19). The facility census was 98. Findings included: Observation on 10/04/23 at 8:10 A.M. of signage on the main entrance door which read COVID POSITIVE Effective 09/16/23, Social distances and masking are recommended at all times. Some areas require PPE for visitations. Please see the nurse for guidance. 1. Observation on 10/04/23 at 8:11 A.M. of Certified Nursing Assistant (CNA) #103 in the dining room not wearing her N-95 mask properly. It was covering her neck and chin, and her nose and mouth were exposed. Interview on 10/04/23 at 8:25 A.M. with CNA #103 verified she was not wearing her N-95 mask properly while in the dining room…

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 interview, resident record review, and facility policy review the facility failed to update care plans to meet resident needs. This affected three residents (#29, #79, and #83) of three residents reviewed for pressure ulcers. The facility census was 98. Findings included: 1. Review of Resident #29's medical record revealed an admission date of 08/23/23 with diagnoses including complex lesion at T7-T10 levels of thoracic spinal cord, fusion of spine, thoracic region, abnormal posture, generalized muscle weakness, neuromuscular dysfunction of the bladder, Paraplegia, and need for assistance with personal care. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/29/23, revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, and transferring and ambulation did not occur. The assessment indicated the resident did not have any pressure ulcers but was risk for developing a pressure ulcer/injury. Further review revealed skin and ulcer/injury treatment included a pressure reducing device…

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, interview, resident record review and facility policy review the facility failed to ensure a resident who had a Stage 3 (involving full-thickness skin loss potentially extending into the subcutaneous tissue layer) coccyx pressure ulcer was turned regularly and the treatment order was followed. This affected one resident (#29) of three residents reviewed for pressure ulcers. Findings included: Review of Resident #29's medical record revealed an admission date of 08/23/23 with diagnoses including complex lesion at T7-T10 levels of thoracic spinal cord, fusion of spine, thoracic region, abnormal posture, generalized muscle weakness, neuromuscular dysfunction of the bladder, paraplegia, and need for assistance with personal care. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/29/23, revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, and transferring and ambulation did not occur. The assessment indicated the resident did not have any pressure ulcers but was 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.

Based on interview and resident record review the facility failed to ensure resident records were complete and accurate. This affected two residents (#29 and #83) of three residents reviewed for pressure ulcers. The facility census was 98. Findings included: 1. Review of Resident #29's medical record revealed an admission date of 08/23/23 with diagnoses including complex lesion at T7-T10 levels of thoracic spinal cord, fusion of spine, thoracic region, abnormal posture, generalized muscle weakness, neuromuscular dysfunction of the bladder, paraplegia, and need for assistance with personal care. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/29/23, revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, and transferring and ambulation did not occur. The assessment indicated the resident did not have any pressure ulcers but was risk for developing a pressure ulcer/injury. Further review revealed skin and ulcer/injury treatment included a pressure reducing device for his bed. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, and policy review, the facility failed to ensure there was enough staff to provide showers and turning and repositioning for residents. This affected three (#15, #61, #207) of three residents reviewed for showers and one (#47) of four residents reviewed for pressure ulcers, with the potential to affect all 106 residents. Findings include: 1. Medical record review for Resident #5 revealed an admission date of 02/19/16. Medical diagnoses included diabetes, peripheral vascular disease (PVD), and Chronic Obstructive Pulmonary Disease (COPD). Review of care plan dated 01/14/20 for Resident #5 revealed she required activities of daily assistance for bathing with one-person staff assistance. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was not assessed for cognition. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. She was total dependence for bathing with one-person physical assistance.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and policy review, the facility failed to ensure the dining room stayed open even when there was an outbreak of COVID-19. This had the potential to affect all 98 residents who consumed food from the kitchen. The facility identified there were eight residents who could not eat anything by mouth. Findings include: Medical record review for Resident #5 revealed an admission date of 02/09/18. Medical diagnoses included diabetes, peripheral vascular (PVD)disease and chronic obstructive pulmonary disease (COPD). Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was not assessed for cognition. Review of infection control logs for COVID-19 revealed there were five residents with COVID-19 on 12/21/22 and on 01/06/23 there was one who came from the hospital with COVID-19. Observation of dining room on 01/08/23 from 8:30 A.M. to 9:00 A.M. at breakfast and at 12:30 to 1:00 P.M. for lunch revealed there wasn't any residents in the dining room for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, resident council minutes, and policy review, the facility failed to ensure Resident Council Concerns were addressed in a timely manner. This affected seven (#5, #33, #41, #42, #53, #69, and #207) of seven residents reviewed for resident council. Findings include: 1. Review of Resident council minutes dated 08/16/22 revealed the residents complained about name badges not being worn or turned around so you couldn't see the name of the employee. On 09/13/22 the residents complained about when will the dining room would reopen, showers not being completed or offered and said the name badges were still an issue. On 10/11/22 revealed the showers needed to be worked on, and name badges were still an issue. On 11/15/22 the name badges and showers were still an issue. On 12/13/22 showers and name badges were still an issue. Observation of dining room on 01/08/23 from 8:30 A.M. to 9:00 A.M. at breakfast and at 12:30 to 1:00 P.M. for lunch revealed there wasn't any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family and staff interviews, medical record review and policy review, the facility failed to ensure residents were dressed in personal clothes and received showers as scheduled. This affected four (#5, #41, #63, and #207) residents out of the five residents reviewed for activities of daily Living (ADL). This had the potential to affect all the residents. The facility census was 106. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of 03/05/2020 with medical diagnoses of right sided hemiparesis following cerebral infarction, diabetes mellitus (DM), dysphagia, aphasia, hypertensive chronic kidney disease, hyperlipidemia, chronic kidney disease stage 3, and benign prostate hypertrophy. Review of the medical record for Resident #63 revealed a quarterly Minimum Data Set (MDS), dated [DATE] which indicated Resident #63 was rarely/never understood and required extensive staff assistance for bed mobility and dressing. The MDS stated Resident #63 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 medical record review, staff interview and policy review, the facility failed to ensure a individualized care plan was initiated for residents who used psychotropic medications. This affected two residents (#15 and #75) of five residents reviewed for unnecessary medications. The census was 106. Findings include: 1. Medical record review for Resident #75 revealed she was admitted on [DATE]. Medical diagnoses included metabolic encephalopathy, cerebrovascular accident, and Non-Alzheimer's dementia. Review of admission minimum Data Set (MDS) dated [DATE] revealed Resident #75 was severely cognitively impaired. Her functional status was extensive assistance for bed mobility, transfers, and eating. She was a total dependence for toilet use. Review of physician orders dated 11/26/22 revealed Escitalopram Oxalate 5 milligram (mg) to give one tablet by mouth one time a day for depression. Review of care plans for Resident #75 revealed there was not a care plan for depression and no interventions in the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and family interviews, medical record review and policy review, the facility failed to apply Resident #63's splints to maintain range of motion as ordered. This affected one resident (#63) out of two residents reviewed for range of motion. Findings include: Review of the medical record for Resident #63 revealed an admission date of 03/05/2020 with medical diagnoses of right sided hemiparesis following cerebral infarction, diabetes mellitus (DM), dysphagia, aphasia, hypertensive chronic kidney disease, hyperlipidemia, chronic kidney disease stage 3, and benign prostate hypertrophy. Review of the medical record for Resident #63 revealed an Activity of Daily Living (ADL) care plan dated 03/26/21 that stated Resident #63 had a contracture to right hand and decreased ROM to bilateral upper and lower extremities. The care plan revealed interventions that included Resident #63 was dependent upon staff for dressing, bathing, and transfers and staff to encourage/assist with left and 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, medical record review, and staff interview, the facility failed to ensure Resident #15's enteral feed and flush was was dated and failed to position Resident #15 properly in bed to prevent aspiration. This affected one resident (Resident #15) out of eight residents on enteral feedings. Findings include: Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE] with a diagnosis of heart failure, respiratory failure, lack of coordination, dysphagia following nontraumatic intracerebral hemorrhage, attention and concentration deficit following nontraumatic intracerebral hemorrhage, memory deficit following nontraumatic intracerebral hemorrhage, epilepsy, chronic obstructive pulmonary disease, anxiety, depression, pressure ulcer of sacral region, stage III, attention to gastrostomy. Review of the physician orders dated 12/06/22 revealed orders for Osmolite 1.2 at 80 milliliters (ml) per hour times 20 hours per percutaneous endoscopic gastrostomy (PEG) or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a Artificial Manual Breathing Unit (AMBU) bag was in the room for a resident who had a tracheostomy. This affected one (#70) of one resident resident reviewed for tracheostomy. The census was 106. Findings include: Medical record review for Resident #70 revealed he was admitted on [DATE]. Medical diagnoses included malignant neoplasm of the oropharynx. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. Observation on 01/08/23 at 9:58 A.M. revealed there was not an AMBU bag in his room. Interview with Licensed Practical Nurse (LPN) #241 on 01/08/23 at 12:06 P.M. revealed there was not an AMBU bag in Resident #70's room and with the resident having a tracheostomy he should have one in case of an emergency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to assess a resident for risk of entrapment. This affected one (#63) resident of one resident reviewed for side rails. Findings include: Review of the medical record for Resident #63 revealed an admission date of 03/05/2020 with medical diagnoses of right sided hemiparesis following cerebral infarction, diabetes mellitus (DM), dysphagia, aphasia, hypertensive chronic kidney disease, hyperlipidemia, chronic kidney disease stage 3, and benign prostate hypertrophy. Review of the medical record for Resident #63 revealed a quarterly Minimum Data Set (MDS), dated [DATE] which indicated Resident #63 was rarely/never understood and required extensive staff assistance for bed mobility and dressing. The MDS stated Resident #63 was dependent upon staff for transfers, bathing, toileting, and eating. Review of the medical record for Resident #63 revealed no documentation to support a physician order for the ½ side rails to bilateral side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (#27) of one resident reviewed for medications left at the bedside. Findings include: Medical record review for Resident #27 revealed an admission date of 10/05/22. Medical diagnoses included spinal stenosis and atrial fibrillation. Review of evaluations since 10/06/22 revealed there was not one for self administration for medications. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively intact. Observation on 01/19/22 at 11:09 A.M. revealed Resident #27 had a medication cup full of medications and a medication cup full of a red liquid substance. Resident #27 stated the staff want him to take his medications in a hurry and he doesn't want to do that, so he told the nurses to leave the medications and he will take them at his leisure. Interview with Licensed Practical Nurse (LPN) #368 on 01/10/22 at 9:18 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and policy review, the facility failed to provide meals at an appetizing temperature. This affected two (#42 and #53) residents out of the three residents sampled for meals. This had the potential to affect 98 residents who received meal trays, as the facility identified eight residents (#3, #7, #15, #63, #67, #70, #76, #258) received nothing by mouth. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date 09/05/19 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertension, epilepsy, hyperlipidemia, depression, unspecified dementia, constipation, and atrial fibrillation. Review of the medical record for Resident #42 revealed a quarterly Minimum Data Set (MDS) dated [DATE] which indicated Resident #42 had moderately impaired cognition and required extensive staff assistance for bed mobility, transfers, toileting, and dressing. The MDS stated Resident #42 required supervision 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 resident and staff interviews, observations, and record review, the facility failed to deliver meal trays timely. This affected two (#42 and #53) residents out of the three residents sampled for meals. This had the potential to affect 98 residents who received meal trays, as the facility identified eight residents (#3, #7, #15, #63, #67, #70, #76, #258) received nothing by mouth. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date 09/05/19 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertension, epilepsy, hyperlipidemia, depression, unspecified dementia, constipation, and atrial fibrillation. Review of the medical record for Resident #42 revealed a quarterly Minimum Data Set (MDS) dated [DATE] which indicated Resident #42 had moderately impaired cognition and required extensive staff assistance for bed mobility, transfers, toileting, and dressing. The MDS stated Resident #42 required supervision with set-up for eating 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 record review, observation, and interview, the facility failed to maintain appropriate infection control procedures during the treatment of Resident #22's wound. This affected one resident (Resident #22) out of four reviewed for wound care. Findings include: Record Review of Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including encephalopathy, lupus, muscle weakness, dementia, Alzheimer's disease, chronic kidney disease, heart failure, polyneuropathy, insomnia, GERD, COVID-19, depression, anxiety, osteoarthritis, atrial fibrillation, cardiac pacemaker, pressure ulcer stage 4, abnormal posture, cognitive communication deficit, dysphagia, seizures, anemia, obesity, fibromyalgia, hypotension, cardiomyopathy, anticoagulant use, gastrostomy, and left shoulder pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert to name, place, and time and able to make her needs known. Review of current physician orders revealed this…

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 medications were properly stored and dated when opened to prevent use after expiration. This had the potential to affect all 93 residents residing in the facility. Findings include: 1. Observation on [DATE] at 12:02 P.M. of the unit A medication storage room refrigerator revealed one open tuberculin multi dose vial without an open date. On [DATE] at 12:05 P.M. interview with the Director of Nursing (DON) verified the tuberculin did not have an open date and therefore staff would not know when to discard it once it was expired. Review of the tuberculosis (TB) assessment facility plan revealed all new admissions were receiving either a one step of two step Mantoux to test for exposure of tuberculosis. Review of the Tuberculin package insert revealed a pierced vial should be discarded after 30 days from opening. 2. On [DATE] at 12:09 P.M. observation of the top drawer of the medication cart revealed a plastic medication cup full of…

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

Based on observation, record review and staff interview the facility failed to store, label, and date food properly to prevent contamination and food borne illness. This had potential to affect 90 of 90 residents residing in the facility who received meal trays from the kitchen, with the exception of Resident #53, #287, and #337 who received nothing by mouth. The facility census was 93. Findings include: On 01/27/20 at 9:00 A.M. an initial tour of the kitchen revealed the following: An open bag of lettuce was in the refrigerator that did not have a date on it. Items stored in the freezer, including a bag of chicken tenders, a bag of hamburger patties, a bag of waffles, a bag of bacon strips and a bag of pre-made biscuit dough were opened and not dated. Interviews with the Dietary Manager (DM) on 01/27/20 at 9:15 A.M. and 9:20 A.M. verified the bag of lettuce in the refrigerator had been opened and did not have a date on it. The DM also verified each of the above listed items in the freezer were being stored opened and undated. Review of the facility policy titled, Date Marking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to ensure Resident #75 was provided dignity related to the use of an indwelling urinary catheter. This affected one resident (#75) of two residents reviewed for catheters. Findings include: Review of the medical record for Resident #75 revealed an admission date of 07/31/19 with diagnoses including depression, anxiety, diabetes mellitus, hypertension, fibromyalgia and spinal stenosis. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had moderate cognitive deficits and use of an indwelling urinary (Foley) catheter. Review of physician's orders dated January 2020 revealed the resident had an indwelling catheter for acute kidney injury and renal calculi. Observation on 01/27/20 at 11:04 A.M. of Resident #75 revealed she was resting in bed with her door open. The resident's Foley catheter bag was exposed to the hallway and there was no dignity bag or cover present. Interview on 01/27/20 at 11:46…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to honor Resident #13's right to change rooms. This affected one resident (#13) of one resident reviewed who requested a room change. Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE]. His diagnoses were epilepsy, obstructive and reflux uropathy, muscle weakness, altered mental status, chronic kidney disease, bacteruria, low back pain, hypertension, dementia, atherosclerotic heart disease, type II diabetes, and other abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/28/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Interview with Resident #13 on 01/28/20 at 8:18 A.M. revealed he wanted to change rooms. He stated he told the nurse about this a while ago, but they were not doing anything about it. He stated he wanted to change rooms because his roommate was loud, his hallway/unit was loud,…

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 Resident #74 received clean bed linens and was provided with pillow cases. This affected one resident (#74) of 26 residents reviewed for homelike environment and dignity. Findings include: Review of the medical record for Resident #74 revealed an admission date of 12/18/19 with diagnoses including hemiplegia, migraines and epileptic seizures. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 was cognitively intact. Observation on 01/27/20 at 11:27 A.M. revealed Resident #74's bed had dried blood observed on the sheets and two areas of black marker stains on the sheets. Her pillow had no pillow case and there was no pillow case located on the bed or in the room. Interview on 01/27/20 at 11:27 A.M. with Resident #74 revealed the dried blood on her sheet was from when she scratched her arm four days ago. She stated she had no idea how the black marker stains were on the sheets and stated she…

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

Based on observation, medical record review and staff interview the facility failed to include the use of oxygen for Resident #137 in a baseline care plan. This affected one resident (#137) of two residents reviewed for oxygen use. Findings include: Review of Resident #137's medical record revealed an admission date of 01/17/20 with the admitting diagnoses of malignant neoplasm of bronchus or lung, chronic obstructive pulmonary disease (COPD) and oxygen dependence. Review of the resident's nursing comprehensive evaluation dated 01/17/20 revealed the resident was admitted to the facility from an acute care hospital. The resident was alert and oriented to person, place and time. Her speech was clear. The evaluation indicated the resident was dependent on oxygen at five liters per nasal cannula continuously. Review of the resident's admission orders revealed an order dated 01/18/20 for oxygen at five liters via nasal cannula continuously. Review of the resident's baseline plan of care revealed no plan of care addressing the resident's COPD, malignant neoplasm of the bronchus or lung or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure quarterly care conferences were conducted for Resident #63 and failed to ensure Resident #73's care plan was revised related to hemodialysis. This affected one resident (#63) of one resident reviewed for care conferences and one resident (#73) of three residents specifically reviewed for care plan revisions. Findings Include: 1. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, dysphagia, muscle weakness, unspecified convulsions, hypertension, congestive heart failure, major depressive disorder, hemiplegia and hemiparesis, nontoxic multinodular goiter, personal history of traumatic brain injury, morbid obesity, hyperlipidemia and anemia. Review of Resident #63's medical records revealed a care conference was held on 05/20/19, when the resident was admitted back to the facility from the hospital. Then, she did not have another one until 01/10/20. Even on the care…

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 develop and implement a comprehensive and individualized activity program to meet the total care needs of Resident #8. This affected one resident (#8) of one resident reviewed for activities. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including degenerative disease of nervous system, congestive heart failure, muscle weakness, polymer, recurrent depressive disorder, glaucoma, bursitis of unspecified shoulder, hyperlipidemia, nontoxic goiter, anemia, and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/04/20 revealed a Brief Interview for Mental Status (BIMS) score of eight, which indicated she was moderately cognitively impaired. Review of Resident #8's medical records revealed she was on contact isolation precautions for Vancomycin-Resistant Enterococci (VRE) in her urine. Review of the activity assessment, dated 12/20/19 revealed there…

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 interview the facility failed to ensure physician ordered heel (protectors) boots were provided as ordered for Resident #52. This affected one resident (#52) of six residents assessed for skin alterations. Findings include: Review of the medical record for Resident #52 revealed an admission date of 05/28/19 with diagnoses including chronic pain, depression, restlessness, palliative care, hemiplegia and cerebrovascular disease. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had some moderate cognitive deficits, received hospice services and had no skin breakdown. Review of physician's orders dated January 2020 revealed Resident #52 was to wear foot protectors to both feet every shift for protection. Review of skin assessment dated [DATE] revealed Resident #52 had no skin breakdown. Review of the current plan of care revealed Resident #52 was at risk for impaired skin integrity and pressure injury related to weakness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #63 was offered vision appointments. This affected one resident (#63) of two residents reviewed for sensory appointments. Findings Include: Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, dysphagia, muscle weakness, unspecified convulsions, hypertension, congestive heart failure, major depressive disorder, hemiplegia and hemiparesis, nontoxic multinodular goiter, personal history of traumatic brain injury, morbid obesity, hyperlipidemia and anemia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated she was cognitively intact. Review of Resident #63's medical records revealed she did not have a document which indicated her wishes for vision care. There was a consent for all other ancillary services, but the form used for Resident #63 did not have vision as an option. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to provide an appropriate justification and assessment for the ongoing use of a urinary (Foley) catheter for Resident #75. This affected one resident (#75) of two residents reviewed for catheters. Findings include: Review of the medical record for Resident #75 revealed an admission date of 07/31/19 with diagnoses including depression, anxiety, diabetes mellitus, hypertension, fibromyalgia, and spinal stenosis. Record review revealed the resident had an indwelling urinary (Foley) catheter. Review of a history and physical dated 07/24/19 revealed kidney stone resolved. The resident's active diagnoses did not include any justification for the use of a catheter. Review of Resident #75's care plan revealed she was at risk for urinary tract infections and catheter related trauma due to use of Foley catheter. Review of a physician progress note, dated 09/30/19 revealed Resident #75 continued to have a Foley catheter and had some issues…

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

Based on observation, medical record review and staff interview the facility failed to ensure Resident #137's oxygen tubing and humidified water bottle was dated. This affected one resident (#137) of two resident reviewed for oxygen use. Findings include: Review of Resident #137's medical record revealed an admission date of 01/17/20 with the admitting diagnoses of malignant neoplasm of bronchus or lung, chronic obstructive pulmonary disease (COPD) and oxygen dependence. Review of the resident's nursing comprehensive evaluation dated 01/17/20 revealed the resident was admitted from an acute care hospital. The resident was alert and oriented to person, place and time. Her speech was clear. The evaluation indicated the resident was dependent on oxygen at five liters per nasal cannula continuously. Review of the resident's admission orders revealed an order dated 01/18/20 for oxygen at five liters via nasal cannula continuously. On 01/27/20 at 3:28 P.M. observation of Resident #137's oxygen tubing and humidified water bottle revealed the supplies were not dated. On 01/27/20 at 3:30…

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 and interview the facility failed to maintain a system of records and disposition to ensure all controlled drugs were accurately accounted for and reconciled. This affected one resident (#5) randomly reviewed for narcotic medication reconciliation. The facility census was 93. Findings include: On 01/20/20 at 12:07 P.M. review of the narcotic reconciliation book with Licensed Practical Nurse (LPN) #12 revealed the narcotic count sheet for Resident #5's Ultram, a narcotic pain medication, was 24. However, review of the reconciliation signature page revealed 25 pills should be in the medication card. On 01/20/20 at 12:08 P.M. interview with the Director of Nursing (DON), who was at the medication cart revealed the correct count should be 24. LPN #12 revealed she had crushed one tablet of the medication but did not administer it and failed to verify wasting the medication with another nurse before dispensing another pill. The LPN also verfiied she failed to put her signature on the sheet for dispensing another narcotic pain pill.