Wexner Heritage House

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of facility policy, the facility failed to label oxygen tubing for Resident #09, #14, and #44. This affected three of five residents reviewed for respiratory care. The census was 85. 1. Record review of Resident #09's medical record revealed an admission date of 12/31/24. Diagnoses include chronic obstructive pulmonary disease, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, and type II diabetes mellitus with diabetic neuropathy. Review of Resident #09's Minimum Data Set 3.0 (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition and that Resident #09 required oxygen therapy. Review of Resident #09's care plan dated 12/02/25 revealed Resident #09 is prone to cardio-pulmonary complications related to acute on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based record review, staff interview and review of facility policy, the facility failed to ensure physician ordered daily weights were collected timely, this affected one (#54) of residents reviewed for physician orders. The facility census was 85.Review of the medical record for Resident #54 revealed an admission date of 11/18/25 with diagnoses of hypocalcemia, cognitive communication deficit, atrial fibrillation, muscle weakness, chronic combined systolic and diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery with angina, hyperlipidemia, and pulmonary embolism.Review of admission Minimum Data Set assessment dated [DATE] revealed Resident #54 is cognitively intact, has active heart and circulation diagnoses of atrial fibrillation, coronary artery disease, heart failure, and hypertension, and is currently taking an antiplatelet and anticoagulant.Review of care plan dated 11/24/25 revealed the resident has a nutritional problem 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 record review, interview and policy review the facility failed to ensure physician parameters were appropriately followed. This affected three (#04, #08, and #75) of six residents selected for medication regimen review. The facility census was 85. 1. Record review of Resident #04 revealed an admission date of 10/31/25 and readmission of 11/25/25. Diagnoses included but are not limited to osteomyelitis of vertebra, discitis, low back pain, complication of internal fixation device of vertebrae, bipolar disorder, Post Traumatic Stress Disorder (PTSD), depression, gout and chronic pain. Further review of Resident #04 record revealed an order for Hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg), start date 11/25/25, with direction to give two tablets by mouth every four hours as needed for pain, and a second order for Hydrocodone-acetaminophen oral table 5-325 mg, with a start date of 11/25/25, with directions to give one tablet by mouth every four hours as needed for pain. Interview with Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of manufacturer guidelines, and facility policy review the facility failed to remove expired Tubersol tuberculin solution from circulation. This deficient practice had the potential to affect new resident admissions. The facility census was 85.An observation on [DATE] at 9:51 A.M. revealed in the medication storage refrigerator located at the nurses' desk on the first hallway. Inside the refrigerator was an open half-used vial of Tubersol tuberculin solution not labeled with an open date on the storage box or on the vial. Further observation revealed another open half used vial of Tubersol tuberculin solution with an open date [DATE] located on the vial. Both vials of the Tubersol tuberculin solution had an expiration date of 10/2026.A review of the manufacture guidelines for Tubersol tuberculin solution dated 10/2021 revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date.A review of the facility's policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure physician ordered urine screenings were collected timely, this affected two (Resident #36 and Resident #94) out of six reviewed for physician ordered lab results. The facility census was 85. 1. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses including type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis.Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility.Review of care plan dated 12/03/25 revealed Resident #36 is prone to alterations in bowel and bladder function related to impaired strength and endurance, generalized weakness, unsteadiness on feet, right femur fracture/surgery, anemia, constipation, and diuretic use. Interventions include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed ensure one resident had a physician's order for labs obtained. This affected one resident (#12) of five residents reviewed for unnecessary medications. The facility census was 85.Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit.Review of the resident's current physician's orders for December 2025 identified orders dated 08/22/25 lipid panel every 12 months and 09/11/15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure antibiotic stewardship was followed. This affected one (Resident #36) out of four residents reviewed for antibiotic usage. The facility census was 85. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses of type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis.Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility.Review of care plan dated 12/03/25 revealed Resident #36 is prone to alterations in bowel and bladder function related to impaired strength and endurance, generalized weakness, unsteadiness on feet, right femur fracture/surgery, anemia, constipation, and diuretic use. Interventions include assisting with toileting and hygiene, monitoring urine, and obtaining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy review, the facility failed to complete incontinence care appropriately. This affected one resident (Resident #33) observed for incontinence care. The facility census was 76.Findings include:Review of Resident #51's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included severe protein malnutrition, peripheral vascular disease (PVD), acute kidney disease (AKD) and history of falling. Review of the quarterly minimum data set (MDS) assessment revealed her cognition was severely impaired. She required supervision or touching assistance for eating, was dependent on oral hygiene, toileting, bathing/showering, dressing, personal hygiene and turning and repositioning. Resident #51 was always incontinent of bowel and bladder. No falls and no pressure areas were coded on the MDS. On 10/29/25 at 10:35 A.M. observation of incontinence care provided to Resident #51 revealed certified nursing assistant (CNA) #137…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility policy review the facility failed to maintain infection control practices by failing to perform hand hygiene during meal tray service. This affected three of three (Resident #39, #40 and #43) residents observed during meal service. This had the potential to affect all thirteen residents residing on the Yass 2 unit. The facility census was 76.Findings include: 1. Record review of Resident #39's medical record revealed an admission date of 02/07/24. Diagnoses include unspecified dementia, Type II Diabetes Mellitus with chronic kidney disease, Crohn's disease, colostomy status, chronic kidney disease stage III, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, repeated falls and cognitive communicative deficit.Review of Resident #39's Minimum Data Set 3.0 dated 08/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.Observation on 10/29/25 at 12:15 P.M. revealed during tray service certified nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, self-reported incident review, facility investigation review, interviews, and policy review, the facility failed to complete a thorough investigation regarding an alleged sexual assault of Resident #85. This affected one (Resident #85) of three residents reviewed for abuse. The facility census was 84. Findings Include: Review of the closed medical record revealed Resident #85 was admitted on [DATE] with diagnoses that included a urinary tract infection, Parkinson ' s disease, fibromyalgia, and dystonia. The resident was discharged on 09/05/25.The hospital Discharge summary dated [DATE] revealed Resident #85 had a fall and was treated for a urinary tract infection. An admission summary dated [DATE] at 9:00 P.M. revealed Resident #85 had a hematoma to the left lateral scalp, bruising to the right arm, bruising to the left hip, and bruising to the back of the left shoulder. Review of the progress notes dated 09/03/25 and 09/04/25 revealed no evidence of Resident #85 having loose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to complete treatments, provide medications and obtain laboratory testing as ordered by the physician. This affected one (#86) of three residents reviewed for condition change. The facility census was 84. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with diagnoses that included but not limited to acute osteomyelitis to the left ankle and foot, anorexia, sepsis due to Methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open wound on the left foot. The resident was discharged on 09/03/25.a. Review of the Plan of care dated 08/24/25 revealed Resident #86 was at risk for skin breakdown and development of pressure injury related to hospitalization, and left foot wound due to partial second metatarsal amputation. 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 closed record review, interview, and policy review, the facility failed to ensure laboratory testing was completed per physician order. This affected one (#86) of three residents reviewed for condition change. The facility census was 84. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with diagnoses that included but not limited to acute osteomyelitis to the left ankle and foot, anorexia, sepsis due to Methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open wound on the left foot. The resident was discharged on 09/03/25.A comprehensive metabolic panel (CMP) laboratory test dated 08/27/25 revealed Resident #86's potassium level was 4.0 milliequivalents per liter (mEq/L) of blood. The normal reference range for Potassium was 3.5 mEq/L to 5.3 mEq/L.Review of Minimum Data Set (MDS) 3.0 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interviews, the facility failed to ensure Resident #29 and #71 was treated in a dignified manner. This affected two residents (#29 and #71) of three residents reviewed for dignity. The facility census was 72. Findings Include: 1. Review of the medical record for Resident #29 revealed an initial admission date of 06/02/25 with the diagnoses including but not limited to encounter for surgical aftercare following surgery on the digestive system, infarction of spleen, activated protein C resistance, extranodal marginal zone B-cell lymphoma of mucosa associated lymphoid tissue, asthma, chronic kidney disease, hypertension, edema, atrial fibrillation, gout, sarcoidosis, hyerplipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, presence of urogenital implants and other diseases of spleen. Review of the resident admit/readmit screener dated 06/02/25 revealed the resident had no cognitive deficit. The assessment indicated the resident was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and facility policy review, the facility failed to notify Resident #61's primary care physician of an unstageable deep tissue injury (DTI) (Persistent non-blanchable deep red, maroon or purple discoloration, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). This affected one resident (#61) of three residents reviewed for pressure ulcers. The facility census was 72. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/28/24 with the diagnoses including but not limited to COPD, symbolic dysfunction, nicotine dependence, pressure induced deep tissue damage to left heel, dysphagia, hyperlipidemia, hypertension, retention of urine, history of traumatic brain injury, constipation and gout. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, interview and facility policy review, the facility to ensure the required information was provided to the receiving provider and the transfer was documented in the resident's medical record. This affected one resident (#42) of three residents reviewed for transfers. The facility census was 72. Findings Include: Review of the closed medical record for Resident #42 revealed an initial admission date of 12/02/22 with the diagnoses including but not limited to dementia with behavioral disturbances, symbolic dysfunctions, abnormal posture, violent behavior, repeated falls, diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, overactive bladder, obesity and depression. The resident was discharged to an acute care hospital on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the progress note dated 06/03/25 at 12:29 P.M. revealed the nurse assessed the resident and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and facility policy review, the facility failed to residents with indwelling medical devices utilized enhanced barrier precautions (EBP) as required. This affected one resident (#39) of three residents reviewed for incontinence. The facility census was 72. Findings Include: Review of the medical record for Resident #39 revealed an initial admission date of 07/26/22 with the latest readmission of 02/10/23 with the diagnoses including but not limited to dementia with behavioral disturbances, dysphagia, chronic pulmonary edema, adult failure to thrive, hepatic failure, gastrostomy status, pressure ulcer of sacral region stage IV, disorders of lung, hypertension, depression, hyperlipidemia and osteoarthritis. Review of the plan of care dated 10/07/22 revealed the resident was prone to alterations in bowel and bladder function related to weakness, decreased mobility, non-ambulatory status, dementia, history of urinary tract infection, incontinence of bowel 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 interviews, record reviews, and facility policy review, the facility failed to ensure weekly skin assessments were accurate and completed as well as treatment orders being in place and timely for two ( Resident #21 and #41) out of three residents reviewed for skin breakdown. The facility census was 85. Findings include: 1. Review of the medical record for Resident #21, revealed an admission date of 12/2/22. Diagnoses included but were not limited to unspecified dementia, cognitive communication deficit, overactive bladder, depression, and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of the resident is rarely/never understood. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the physician's order for Resident #21 dated 01/21/25 at 10:36 A.M. revealed cleanse area under right breast with wound cleanser,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility investigation report review, staff interview, and facility policy review, the facility failed to report an allegation of resident abuse to the State agency as required. This affected one resident (#46) of two resident investigative reports reviewed. The census was 83. Findings Include: Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, unspecified cirrhosis of liver, chronic obstructive pulmonary disease, type II diabetes, dependence on supplemental oxygen, dependence on renal dialysis, dysphagia, muscle weakness, hypotension, pneumonia, end stage renal disease, dementia, hypertensive heart and chronic kidney disease, congestive heart failure, atrial fibrillation, cognitive communication deficit, atherosclerotic heart disease, thrombocytopenia, hyperlipidemia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, and facility investigation review, this facility failed to ensure a resident with a Do Not Resuscitate Comfort Care (DNRCC) code status did not receive life saving measures or cardiopulmonary resuscitation (CPR) after a cardiac arrest. This affected one (Resident #3) of the one resident reviewed for appropriate code status. The facility census was 96. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, cirrhosis of the liver, and viral hepatitis B. Review of Resident #3's code status revealed a signed document dated [DATE] indicating a Do Not Resuscitate Comfort Care code status. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital documents review, staff interview, and facility policy review, this facility failed to obtained ordered urine samples for testing due to cloudy urine. This affected one (Resident #196) of the five resident reviewed for care and treatment to prevent hospitalization. The facility census was 96. Findings include: Review of the medical record for Resident #196 revealed an admission date of 11/04/2022. Diagnoses included end stage renal disease, Urinary tract infections, and the need for assistance with personal care. Review of the annual Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #196 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #196 was noted to have an impairment to her bilateral upper extremities and was dependent on staff for toileting and personal hygiene. Resident #196 required the use of an indwelling catheter for urine elimination and 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, interview, observations, and facility policy review, this facility failed to maintain infection control measures while completing catheter care. This affected one (Resident #196) of the one resident observed for catheter care. The facility census was 96. Findings include: Review of the medical record for Resident #196 revealed an admission date of 11/04/2022. Diagnoses included end stage renal disease, Urinary tract infections, and the need for assistance with personal care. Review of the annual Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #196 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #196 was noted to have an impairment to her bilateral upper extremities and was dependent on staff for toileting and personal hygiene. Resident #196 required the use of an indwelling catheter for urine elimination and was always incontinent of bowel movements. Observation…

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

Based on observation and interview the facility failed to ensure the kitchen's hood filters were free from grease and dust. This had the potential to affect all 91 residents who consumed food from the kitchen. The facility identified two residents (#46 and #48) who ate nothing by mouth. The facility census was 93. Findings include: Observation on 02/26/24 at 8:55 A.M. of the kitchen revealed the filters in the hood which was over the stove tops where food was cooked had a thick build up of grease and dust. Interview on 02/26/24 at 8:55 A.M. with Dietary Manager (DM) #70 verified the observation. DM #70 reported maintenance was responsible for cleaning the hood and he believed they did it twice a year. Interview on 02/28/24 at 1:26 P.M. with [NAME] President of Operations #66 and Culinary Operations Support #67 reported maintenance cleaned the hoods twice a year. Interview on 02/28/24 at 1:55 P.M. with Maintenance Director #130 revealed the hood received maintenance twice a year, however, the kitchen should have been cleaning the filters in between. He reported based on what he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident/ responsible party interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed for bathing and other personal hygiene related care. This affected seven (Resident #4, #20, #42, #82, #245, #248, and #253) of nine residents reviewed for activities of daily living (ADL's). Findings include: 1. A review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included difficulty walking, unsteadiness on her feet, and need for assistance with personal care. She did not have diabetes mellitus listed as a known diagnosis. A review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was able to make herself understood and was usually able to understand others. She was cognitively intact and was not noted to have displayed behaviors during the seven days of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 02/26/24 at 2:47 P.M., an observation of Resident #253's room noted there was an intravenous (IV) bag (500 milliliters) of 0.9% Sodium Chloride and tubing hanging from an IV pole against the wall across from his bed. The IV tubing still had the IV catheter attached at the end of it and the IV catheter was exposed and noted to have dried blood in it. The resident's Power of Attorney (POA), who was in the room at the time of the observation, revealed the resident was given IV fluids about three days ago and the IV bag and tubing had been hanging there since then. He indicated there was blood still in the end of the tubing in the IV catheter. A review of Resident #253's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included vascular dementia, syncope and collapse, presence of a right artificial knee joint, and aftercare following joint replacement surgery. A review of Resident #253's physician's orders revealed an order for 0.9% Sodium Chloride with instructions to use 500…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop comprehensive care plans for Resident #30, Resident #59, and Resident #82. This affected three residents (#30, #59, #82) of 27 residents reviewed for comprehensive care plans. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 10/31/23 with diagnoses including spinal stenosis, osteoporosis, cord compression, chronic respiratory failure, type two diabetes mellitus, chronic pain syndrome, ankylosing spondylitis of spine, and gout. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition. Review of Resident #30's plan of care last reviewed 02/12/24 revealed discharge plans were not indicated in the care plan. Interview on 02/26/24 at 3:08 P.M. with Resident #30 revealed he did not plan on staying in the facility long term. Interview on 02/29/24 at 4:14 P.M. with Social Service Designee #4 verified Resident #30's care plan did not include his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review the facility failed to sufficiently identify and provide activities of interest to Resident #3, specifically on the weekend. This affected one resident (#3) of one resident reviewed for activities. The facility census was 93. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's activity assessment dated [DATE] revealed she found it somewhat important to listen to music, do things with groups of people, and go outside. She did not find it important to read books, participate in religious services or keep up with the news. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #3's plan of care dated 06/19/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure Resident #4's weights were monitored and addressed timely related to cardio-pulmonary complications and failed to ensure Resident #245's surgical wound and anemia was monitored and properly treated. This affected two residents (Resident #4 and Resident #245) of three residents reviewed for quality of care. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including chronic pulmonary embolism, anemia, heart failure, need for assistance with personal care, and adult failure to thrive. Review of MDS completed on 01/24/24 revealed Resident #4 was cognitively intact, had impairment to bilateral upper extremities, required moderate assistance for oral hygiene, maximum assistance for bathing, maximum assistance for dressing, and maximum assistance for personal hygiene. Resident #4 discharged from the facility on 02/12/24. Review of orders revealed an order dated 01/19/24 to obtain Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's 802 matrix, review of the wound physician's wound evaluations, staff interview, and policy review, the facility failed to ensure a resident's wound on his buttocks was properly assessed and classified to identify it as a pressure ulcer as indicated by the wound physician and not moisture associated skin dermatitis as indicated by the facility's wound nurse. This affected one (Resident #249) of three residents reviewed for pressure ulcers. Findings include: A review of Resident #249's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following CVA (stroke) affecting the right dominant side, aphasia (difficulty with speech), difficulty walking, unsteadiness on his feet, and the need for assistance with personal care. A review of Resident #249's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not marked as having any pressure ulcers at the time the MDS assessment 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 observation, interview, and record review the facility failed to follow occupational therapy recommendations and physician orders for splints. This affected two residents (#3 and #42) of four residents reviewed for position and mobility. The facility census was 93. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. Review of Resident #3's plan of care dated 10/14/22 revealed the resident was at risk for or prone to the development of contractures related to pain and immobility. Interventions included providing positioning and splinting to affected joints as ordered and therapy to evaluate and treat as ordered. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure padded side rails were implemented as ordered for Resident #46 with a history of epilepsy. This affected one resident (Resident #46) of six residents reviewed for accident hazards. The facility census was 93. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/03/2020 with diagnoses that included epilepsy, functional quadriplegia, and stenosis of larynx. Review of the most recent Minimum Data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #46 has a diagnosis of epilepsy, is severely cognitively impaired and is dependent on two person staff assist for personal care. Review of physician orders for Resident #46 revealed an order dated 01/05/2020 for seizure precautions padded side rails every shift. Review of Resident #46 care plan dated 01/22/24 revealed a problem of seizure activity with an intervention of padded bilateral side rails as ordered. Observations of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations, the facility failed to timely order and initiate treatment for urinary tract infections (UTI's) for Resident #63 and failed to timely order and initiate appropriate treatments for Residents #22's catheter and Resident #82's nephrostomy tube. This affected three residents (Resident #22, #63, and #82) of three residents reviewed for catheter and urinary tract infections. The facility census was 93. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of 01/26/2024 with diagnoses that included urinary tract infection, acute kidney failure, presence of urogenital implants (control urine leakage). Review of the most recent Medicare 5 day Minimum Data set (MDS) 3.0 assessment completed on 02/01/24 revealed Resident #63 was cognitively intact, has an indwelling catheter and was frequently incontinent. Review of Resident #63's undated document supplied from OhioHealth Urology Physicians revealed peri-urethral estrogen cream…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to develop and implement a comprehensive, effective and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as ordered, and/or to recognize and address significant/severe resident weight loss. This affected four residents (#19, #22, #23, and #59) of seven residents reviewed for nutrition. The facility census was 93. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/23/23 with diagnoses including protein-calorie malnutrition, encephalopathy, retention of urine, dementia, type two diabetes mellitus, adult failure to thrive, systemic lupus, depression, dysphagia, and cognitive communication deficit. Review of Resident #22's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 11/12/23, revealed the resident had moderately impaired cognition. The MDS reflected Resident #22 weighed 180…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review the facility failed to ensure Resident #59 was capable of completing his own tracheostomy care and that tracheostomy care was completed as ordered. This affected one resident (Resident #59) out of one resident reviewed for tracheostomy care. Findings include: Review of the medical record for Resident #59 revealed an admission date of 09/07/20. Diagnosis included tracheostomy status, gastrostomy status, diabetes, and malignant neoplasm at the base of the tongue. Review of Resident #59's quarterly MDS assessment revealed the resident was cognitively intact and had a tracheostomy. Review of Resident #58's medical record revealed no evidence Resident #59 was assessed and determined to be competent to complete his own tracheostomy care. Review of Resident #59's February 2023 physician orders revealed an order to remove stoma vent twice daily to clean, and an order to suction the resident's stoma and keep clean of dried secretions as needed. The facility nurses were signing the order indicating they were removing the stoma vent twice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview, the facility failed to ensure their contracted pharmacy provided pharmaceutical services to ensure medications were available for administration as ordered by the physician. This affected one resident (Resident #85) of two residents reviewed for antibiotic use. The facility census was 93. Findings include: A review of Resident #85's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a peritoneal abscess, post-procedural complications and disorders of the digestive system, bariatric surgery status, peritoneal adhesions (post-procedural and post-infection), and perforation of the bile duct. A review of Resident #85's physician's orders revealed she had an order to receive Zosyn 4.5 Grams (Gm) intravenously (IV) every eight hours for a peritoneal abscess. The order had been in place since the resident's admission into the facility. A review of Resident #85's medication administration record (MAR) for February…

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

Based on observation, record review, review of drug manufacturer's instructions, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5 percent (%). The facility had two medication errors out of 35 opportunities resulting in a medication error rate of 5.71%. This affected two residents (#248 and #397) of four residents reviewed for medication administration. The facility census was 93. Findings include: 1. Review of Resident # 248's medical record revealed an admission date of 12/29/2023. Diagnoses included osteomyelitis of the vertebra (sacral and sacrococcygeal region), aphasia following a cerebral infarction, unspecified severe protein-calorie malnutrition, and Parkinson's disease. Review of Resident #249's February 2024 physician orders revealed an order for Ceftazidime Intravenous (IV) Solution (antibiotic) Reconstituted 2 grams with instructions to use two grams intravenously three times a day related to osteomyelitis of the vertebra. The order was scheduled to be completed at 6:00 A.M., 2:00 P.M., and 10:00 P.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.

Based on interview, observation, and record review the facility failed to dispose of expired medication for Resident #47. This affected one resident (#47) of four residents reviewed for medication administration. The facility census was 93. Findings include: Review of the medical record for Resident #47 revealed an admission date of 10/05/2023 with diagnoses including end stage renal disease, type two diabetes mellitus with long term use of insulin, and adult failure to thrive. Review of the most recent Minimum Data set (MDS) 3.0 assessment completed on 01/10/24 revealed Resident #47 was cognitively intact and required a hypoglycemic medication to decrease blood sugars. Review of physician orders revealed an order with a start date of 01/05/24 for Lantus Subcutaneous Solution 100 unit/milliliters (Insulin Glargine) for diabetes at bedtime. Review of the Medication Administration Record for February 2024 revealed Resident #47 received his ordered dose of Insulin Glargine on 02/27/24 at 9:00 P.M. and his blood sugars were being monitored appropriately and were controlled within a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, review of tray tickets, and review of diet descriptions the facility failed to ensure Resident #3 was served a puree diet as ordered. This affected one resident (#3) of nine residents reviewed for food/nutrition. The facility identified nine residents ( #59, #3, #31, #50, #250, #254, #27, #263, #23) ordered a pureed diet. The facility census was 93. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed they were rarely or never understood. She was on a mechanically altered diet. Review of Resident #3's physician order dated 10/30/23 revealed they were to receive a regular diet with dysphagia puree texture and nectar thick liquids.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure food allergens were not served to Resident #261, and failed to ensure Resident #1, who had a physician identified lactose intolerance, was not served lactose containing foods. This affected two residents (#261 and #1) of nine residents reviewed for food/nutrition. The facility census was 93. Findings include: 1. Review of the medical record for Resident #261 revealed an admission date of 08/30/22 with a readmission date of 02/23/24, and diagnoses included acute pancreatitis, chronic obstructive pulmonary disease, end stage renal disease and dependent on renal dialysis, chronic heart failure, and osteoporosis. Review of Resident #261's in-progress comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed they had intact cognition. Review of Resident #261's allergy list revealed a mild fish allergy added on 08/30/22. Observation on 02/28/24 at 1:15 P.M. revealed State Tested Nursing Assistant (STNA) #114…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, medical record review, and policy review the facility failed to provide thickened liquids as ordered for one resident (#19). This affected one resident (#19) of nine residents reviewed for food/nutrition. The facility identified six residents (#3, #50, #19, #55, #263 and #42) who required thickened liquids. The facility census was 93. Findings include: Review of the medical record for Resident #19 revealed an admission date of 01/16/19 with diagnoses including encephalopathy, type two diabetes mellitus, dysphagia, dementia, depression, osteoporosis, heart failure, and repeated falls. Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. She was on a mechanically altered diet. Review of Resident #19's physician order dated 11/22/23 revealed she was to receive nectar consistency liquids. Observation on 02/29/24 at 12:37 P.M. revealed Resident #19 in her room with her meal. She was noted to have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview, the facility failed to ensure resident records were complete and accurate regarding medications received and the proper location of wounds. This affected three residents (Resident #30, #46, and #85) of 25 residents reviewed for complete and accurate records. The facility census was 93. Findings include: 1. A review of Resident #85's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a peritoneal abscess, post-procedural complications and disorders of the digestive system, bariatric surgery status, peritoneal adhesions (post-procedural and post-infection), and perforation of the bile duct. A review of Resident #85's physician orders revealed she had an order to receive Zosyn 4.5 Grams (Gm) intravenously (IV) every eight hours for a peritoneal abscess. The order had been in place since the resident's admission into the facility. A review of Resident #85's medication administration record (MAR) for February 2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, thhe facility failed to maintain infection control during Resident #60's dressing change, failed to ensure Resident #380's Foley catheter bag remained off the floor, failed to ensure proper hand hygiene with personal care and meal service, and failed to properly wear personal protecitve equipement related to prevention of COVID-19 transmission. This had the potential to affect all 80 residents residing at the facility at this time. Findings include: 1. Observation on 02/28/22 from 11:44 A.M. through 12:03 P.M. of meal trays being delivered to residents residing on the Nutis hall revealed State Tested Nursing Assistant (STNA) #106 went in and out of residents rooms to deliver residents meal trays along with preparing residents meal trays with out washing hands or using hand sanitizer. STNA #106 was observed delivering meal trays to (8) eight different residents (Resident #09, #25, #278, #52, #69, #66, #39, and #2). Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, observations, and facility policy review, the facility failed to serve food at an appetizing temperature. This affected Resident #24 with the potential to affect all 24 residents residing on the [NAME] Avenue hall (Resident #17, #24, #26, #28, #30, #31, #34, #35, #36, #38 #40, #49, #50, #51 #57, #60, #68, #73, #229, #427, #428, #429, #430, and #432). Findings Include: Review of the facility census, revealed Resident #17, #24, #26, #28, #30, #31, #34, #35, #36, #38 #40, #49, #50, #51 #57, #60, #68, #73, #229, #427, #428, #429, #430, and #432 resided on [NAME] Avenue hall. Observation on 02/28/22 at 12:38 P.M. revealed the lunch meal trays arrived to [NAME] Avenue hall and the door to insulated cart with the trays was left open until it was closed at 12:54 P.M. by housekeeping so she could pass with the linen cart, and State Tested Nursing Assistant (STNA) #109 passed the last tray at 1:02 P.M. (24 minutes after trays arrived to the hall). Observation on 03/02/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, medical record review, and facility policy review, the facility failed to provide proper assistance with toileting to ensure Resident #24 was treated with respect and dignity at all times. This affected one resident (Resident #24) of two residents reviewed for dignity. Findings include: Review of the medical record for Resident #24 revealed an admission date of [DATE] with diagnoses including but not limited to cord compression, constipation, pain in right shoulder, UTI, hyperkalemia, hyperosmolality and hypernatremia, difficulty walking, spinal enthesopathy thoracolumbar region, repeated falls, weakness, spinal stenosis thoracolumbar region, hypertension (HTN), morbid obesity, major depressive disorder, muscle weakness, anxiety disorder, and urge incontinence. Review of Resident #24's admission assessment dated [DATE] revealed the resident's bladder incontinence was unknown but revealed the resident was wet three to four times per week with small amounts of urine.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interviews, review of care conference notes, and facility policy review, the facility failed to conduct quarterly care conferences for Resident #36. This affected one resident (Resident #36) of one resident reviewed for care conferences. Findings include: Review of the medical record for Resident #36 revealed an admission date on 07/14/21. Medical diagnoses included cerebral infarction (stroke), chronic viral Hepatitis C, dyspnea (shortness of breath), localized edema, type II Diabetes Mellitus with diabetic chronic kidney disease, blindness in unspecified eye, morbid obesity, muscle weakness, long term use of insulin, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #36 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required…

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

Based on staff interview, resident interview, observations, and facility policy review, the facility failed to promote and facilitate resident self-determination through support of resident choice of meals. This affected one resident (Resident #427) of three residents reviewed for choices. Findings include: Review of the medical record for Resident #427 revealed an admission date of 02/16/22. Diagnoses included orthopedic aftercare following a surgical amputation, type two diabetes, morbid obesity, chronic systolic heart failure, hypertension, muscle weakness, difficulty walking, and long-term use of insulin. Review of Resident #427's plan of care dated 02/18/22, revealed the resident had a nutritional problem or potential nutritional problem related to increased protein needs due to wound healing. Interventions included provide and serve his diet and supplements as ordered. Review of the admission Minimum Data Set (MDS) assessment, dated 02/22/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no…

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

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to obtain a physicians signature and authorization of Resident #60's preferred code status. This affected one resident (Resident #60) of one resident reviewed for advance directives. Findings include: Review of the medical record for Resident #60 revealed an admission date of 12/28/21. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, stage two chronic kidney disease, type two diabetes (DM II), bilateral osteoarthritis of the knees, neuromuscular dysfunction of the bladder, cord compression, morbid obesity, left hand contractures, chronic diastolic heart failure, generalized anxiety disorder, major depressive disorder, dependence on supplemental oxygen, obstructive sleep apnea (OSA), long term use of insulin, hyperlipidemia, gastro-esophageal reflux disease (GERD), gout, and muscle weakness. Review of the plan of care dated 12/29/21 revealed Resident #60 was prone to cardio-pulmonary complications 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 interview, observation, medical record review, and facility policy review, the facility failed to ensure Resident #36 received assistance to be bathed according to schedule. This affected one resident (Resident #36) of four residents reviewed for activities of daily living (ADL's). Findings include:Review of the medical record for Resident #36 revealed an admission date on 07/14/21. Medical diagnoses included cerebral infarction (stroke), chronic viral Hepatitis C, dyspnea (shortness of breath), localized edema, type II Diabetes Mellitus with diabetic chronic kidney disease, blindness in unspecified eye, morbid obesity, muscle weakness, long term use of insulin, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #36 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #36 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 2. Review of the medical record for Resident #36 revealed an admission date on 07/14/21. Medical diagnoses included cerebral infarction (stroke), chronic viral Hepatitis C, dyspnea (shortness of breath), localized edema, type II Diabetes Mellitus with diabetic chronic kidney disease, blindness in unspecified eye, morbid obesity, muscle weakness, long term use of insulin, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the plan of care dated 07/15/21 revealed Resident #36 was at risk for signs and symptoms of hypo/hyperglycemia and diabetic complications related to diagnosis of Type II Diabetes Mellitus with neuropathy. Resident #36 was prone to elevated blood sugar in the evening and low blood sugar in the morning. Interventions included administer diabetic medication as ordered. Review of the physician's orders for Resident #36 revealed the resident had an order for Lantus Solution 100 unit/milliliter (mL) with instructions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to schedule an ophthalmology consult appointment timely for Resident #36. This affected one resident (Resident #36) of one resident reviewed for ancillary services. Findings include: Review of the medical record for Resident #36 revealed an admission date on 07/14/21. Medical diagnoses included cerebral infarction (stroke), chronic viral Hepatitis C, dyspnea (shortness of breath), localized edema, type II Diabetes Mellitus with diabetic chronic kidney disease, blindness in unspecified eye, morbid obesity, muscle weakness, long term use of insulin, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the plan of care dated 07/15/21 revealed Resident #36 was prone to impaired vision related to blindness to left eye. Interventions included to identify factors affecting visual function including physiological,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #27's interventions to promote wound healing and prevent pressure ulcer development were in place at all times. This affected one resident (Resident #27) of seven residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #27 revealed she was admitted on [DATE] with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, type two diabetes mellitus with diabetic neuropathy, aphasia following cerebral infarction, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic kidney disease, and major depressive disorder. Review of the physician order dated 01/13/22, revealed Resident #27 was to wear Prevalon boots to her bilateral lower extremities at all times. Review of a physician order dated 01/09/22 revealed HydraGuard moisture barrier was to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #37's interventions were implemented to reduce the resident's risk of contracture and skin break down related to left sided weakness. This affected one resident (Resident #37) of one resident reviewed for limited range of motion. Findings include: Record review for Resident #37 revealed this resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, solitary pulmonary, chronic respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, dysphagia oropharyngel phase, cognitive communication deficit, aphonia anxiety disorder, facial weakness following cerebral infarction, paroxysmal fibrillation, atrial flutter hypertension major depressive disorder recurrent, acute post hemorrhagic anemia, cardiomyopathy, gastrostomy status muscle weakness and speech disturbances . Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/13/22, 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, interview, and record review, the facility failed to follow ordered fall prevention measures for Resident #30. This affected one resident (Resident #30) of six residents reviewed for falls. Findings include: Review of the medical record revealed Resident #30 admitted on [DATE] with diagnoses including cerebral infarction, type two diabetes mellitus, gastro-esophageal reflux disease without esophagitis, atherosclerotic heart disease, encephalopathy, and history of falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #30 had moderately impaired cognition. Resident #30 had one fall without injury since the previous assessment. Review of the progress note dated 10/01/21, revealed Resident #30 was found on the floor in her room. The immediate intervention was a floor mat to protect from injury. Review of the plan of care dated 12/07/21, revealed Resident #30 was prone to falls related to her diagnoses, impaired strength, and poor endurance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #24 received appropriate treatment and services to maintain or restore bowel and bladder function. This affected one resident (Resident #24) of one resident reviewed for bowel and bladder incontinence. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/29/21 with diagnoses including but not limited to cord compression, constipation, pain in right shoulder, UTI, hyperkalemia, hyperosmolality and hypernatremia, difficulty walking, spinal enthesopathy thoracolumbar region, repeated falls, weakness, spinal stenosis thoracolumbar region, hypertension (HTN), morbid obesity, major depressive disorder, muscle weakness, anxiety disorder, and urge incontinence. Review of Resident #24's admission assessment dated [DATE] revealed the resident's bladder incontinence was unknown but revealed the resident was wet three to four times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, the facility failed to timely address Resident #67's weight loss. This affected one resident (Resident #67) of four residents reviewed for nutrition. Findings include: Record review for Resident #67 revealed this resident was admitted to the facility on [DATE] with diagnoses including infection of amputation stump, left extremity, pressure ulcer of left buttock stage 1, history of falling, type 2 diabetes mellitus, and depression. Review of the care plan, dated 01/11/22, revealed Resident #67 was at nutritional risk for significant weight loss, and altered nutrition needs related to diagnosis. Interventions included monitor for changes in nutritional status and report to dietitian and physician as indicated, obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated, provide and serve supplement as ordered, weight per order/facility protocol and alert physician to any significant loss or gain. Review of…

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

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to administer Resident #60's oxygen per physician orders. This affected one resident (Resident #60) of three residents reviewed for respiratory care. Findings include: Review of the medical record for Resident #60 revealed an admission date of 12/28/21. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, stage two chronic kidney disease, type two diabetes, bilateral osteoarthritis of the knees, neuromuscular dysfunction of the bladder, cord compression, morbid obesity, left hand contractures, chronic diastolic heart failure, generalized anxiety disorder, major depressive disorder, dependence on supplemental oxygen, obstructive sleep apnea (OSA), long term use of insulin, hyperlipidemia, gastro-esophageal reflux disease (GERD), gout, and muscle weakness. Review of Resident #60's plan of care dated 12/29/21, revealed the resident was prone to cardio-pulmonary complications related to COPD. history of respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rational was provided for a denial of Resident #2's pharmacy recommendations. This affected one resident (Resident #2) of five residents reviewed for drug regimen review. Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/21/19. Diagnosis included osteoarthritis, cognitive communication deficit, major depressive disorder, and dementia with behavioral disturbances. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 indication Resident #2 with a severely impaired cognition for daily decision making ability. Resident #2 required supervision from one staff member for bed mobility, transfers, ambulation and toilet use, and set up assistance only for eating. Resident #2 was noted to have impairments to bilateral upper extremities and required the assistance of a walker…

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

Based on staff interview, medical record review, and facility policy review, the facility failed to decrease Resident #60's psychotropic medication per pharmacy and physician recommendations. This affected one resident (Resident #60) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #60 revealed an admission date of 12/28/21. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, stage two chronic kidney disease, type two diabetes, bilateral osteoarthritis of the knees, neuromuscular dysfunction of the bladder, cord compression, morbid obesity, left hand contractures, chronic diastolic heart failure, generalized anxiety disorder, major depressive disorder, dependence on supplemental oxygen, obstructive sleep apnea (OSA), long term use of insulin, hyperlipidemia, gastro-esophageal reflux disease (GERD), gout, and muscle weakness. Review of Resident #60's care plan dated 12/29/21, revealed the resident was prone to mood indicators, at risk for potential adverse side effects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to assist Resident #60 in obtaining urgent dental care. This affected one (Resident #60) of four residents reviewed for dental care. Findings include: Review of the medical record for Resident #60 revealed an admission date of 12/28/21. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, stage two chronic kidney disease, type two diabetes, bilateral osteoarthritis of the knees, neuromuscular dysfunction of the bladder, cord compression, morbid obesity, left hand contractures, chronic diastolic heart failure, generalized anxiety disorder, major depressive disorder, dependence on supplemental oxygen, obstructive sleep apnea (OSA), long term use of insulin, hyperlipidemia, gastro-esophageal reflux disease (GERD), gout, and muscle weakness. Review of Resident #60's Admit/Readmit Screener dated 12/28/21, revealed the resident did not have her own…

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