Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility did not ensure post-fall investigations were accurate and complete to mitigate risk of future accidents for Resident #3. This affected one resident (#3) of six residents reviewed for accidents. The facility census was 76. Findings include: Review of the medical record revealed Resident #3 was admitted [DATE] with diagnoses including multiple sclerosis, muscle weakness, and type II diabetes. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had a moderate cognitive impairment and required supervision with dressing, sit to lying, and sit to standing and independent with chair/bed-to-chair transfers. Review of the care plan revealed Resident #3 was at risk for falls or injury due to a diagnosis of multiple sclerosis. Interventions included bilateral assist bars to aid bed mobility and promote independence and encouraging Resident #3 to use call light for transfers and ambulation. Resident #3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy the facility failed to provide scheduled toileting to promote continence for Resident #20 and failed to ensure Resident #4's received the appropriate care and services to prevent and treat a urinary tract infection (UTI). This affected two resident's (Resident's #4 and #20) out of three reviewed for bowel and bladder. The facility census was 76. Findings include: 1. Review of Resident #20's medical record revealed Resident #20 was discharged from the facility on 05/15/25 and readmitted to the facility on [DATE]. Resident #20's diagnoses included chronic obstructive pulmonary disease, muscle weakness, major depressive disorder and chronic respiratory failure with hypoxia. Review of progress notes for Resident #20 dated 05/23/25 through 06/11/25 did not reveal evidence Resident #20 refused to be assisted to the bathroom for toileting. Review of Resident #20's medical record dated 05/23/25 through 06/13/25 did not reveal evidence a…

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

Based on record review, interview and review of facility policy, the facility did not ensure a significant weight loss was assessed by the dietitian for Resident #285 . This affected one resident (#285) of two residents reviewed for nutrition. The facility census was 76. Findings include: Review of closed medical record for Resident #285 revealed an admission date of 03/14/25 and a discharge date of 04/11/25. Diagnoses included fracture of coccyx, dysphagia (difficulty swallowing), cognitive communication deficit, type two diabetes, chronic diastolic (congestive) heart failure, chronic kidney disease stage four, vascular dementia, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/20/25, revealed Resident #285 was cognitively intact, exhibited no behaviors, was dependent on staff for eating; had no significant weight loss, and was on a mechanical soft and therapeutic diet. Review of the care plan dated 03/21/25 for Resident #258 revealed the resident was at risk for altered nutritional status related to therapeutic diet, mechanically altered diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility policy the facility did not ensure Resident #20 was treated for pain in accordance with physician orders and care planned interventions. Also, the facility did not ensure pain assessments were completed as ordered by the physician for Resident #3. This affected two residents (Resident #20 and #3) out of three residents reviewed for pain. The facility census was 76. Findings include: 1. Observation on 06/05/25 at 1:15 P.M. with Certified Nursing Assistant (CNA) #342 of Resident #20 revealed Resident #20 was laying in bed, had facial grimacing, dark circles under his eyes and his skin was kind of grayish looking. Resident #20 stated he did not feel well, his foot hurt and his Percocet (pain medication) was decreased to twice a day. Observation of Resident #20's right foot and heel revealed the bottom of the heel was very red and when CNA #342 pressed on the reddened area on the heel Resident #20 cried out in pain. Observation on 06/09/25 at 1:57…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and review of facility policy, the facility failed to work collaboratively with the dialysis center to ensure person-centered care consistent with professional standards of practice was provided to Resident #26. This affected one resident (#26) out of one resident reviewed for dialysis. The facility identified one resident (Resident #26) as the only resident in the facility who was receiving dialysis. The facility census was 76. Findings include: Review of the medical record for Resident #26 revealed an admission date of 11/21/23. Pertinent diagnoses included type two diabetes mellitus with diabetic kidney disease and end stage renal disease. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/23/25, revealed Resident #26 was cognitively intact, exhibited no behaviors including rejection of care during the assessment reference period, and was on dialysis. Further review of Resident #26's medical record revealed between 05/07/25 and 06/04/25, the facility had completed a pre assessment on 05/07/25, 05/14/25, 05/19/25, 05/21/25,…

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.

Based on medical record review, interview, and review of facility policy, the facility did not adequately assess Resident #285 for triggers and effective interventions to prevent the risk of re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (#285) out of one resident the facility identified with a diagnosis of PTSD. The facility census was 76. Findings include: Review of the medical record for Resident #285 revealed an admission date of 05/16/25 with diagnoses including PTSD, anxiety and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 05/22/25, revealed Resident #285 was cognitively intact; wasn't showing little interest or pleasure in doing things and wasn't feeling down, depressed, or hopeless; had rejected care one to three days during assessment reference period, required substantial assistance from staff for showering/bathe self and personal hygiene, was dependent on staff for toileting, required substantial assistance from staff to roll left and right with no other mobility attempted…

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

Based on record review, observation, and interview the facility failed to administer medications as ordered. This affected one (Resident #135) of five residents reviewed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #135 revealed an admission date of 05/29/25. Diagnoses included wedge compression fracture of the lumbar vertebra, malignant neoplasm of the prostate, history of transient ischemic attack and cerebral infarction. Review of the plan of care dated 06/02/25 revealed Resident #135 was at risk for bruising/bleeding related to use of anticoagulant medication. Review of the medication admiration record for June 2025 noted Resident #135 was ordered enoxaparin (lovenox) 0.7 milliliters (ml). The syringes were filled with 0.8 ml, staff were to administer only 0.7 ml. Review of the facilities laboratory results for Resident #135's International Normalized Ratio (INR), a blood test to measure the time it takes for blood to clot noted normal values (0.9-1.2) on 06/02/25, 06/03/25. The INR level on 06/04/25 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, interviews, record review, review of diet spreadsheets, and review of the facility document Mechanical Soft Diet, the facility failed to ensure residents on a mechanical soft diet received the appropriate diet consistency. This affected three residents (#14, #286, and #292) of three residents observed for mechanical soft diets. The facility identified eight residents (#14, #22, #29, #42, #55, #59, #286, and #292) as being on a mechanically altered diet. The facility census was 76. Findings include: 1.Review of the medical record for Resident #292 revealed an admission date of 06/05/25. Pertinent diagnoses included dysphagia (difficulty swallowing), severe protein-calorie malnutrition, and disorder of teeth and supporting structures. Resident #292 had a physician order, dated 06/06/25, for a regular mechanical soft diet with thin liquids and was cognitively intact. Further review of Resident #292's medical record revealed an initial nutrition assessment, dated 06/09/25, which indicated 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 3. Review of the medical record for resident #284 revealed an admission date of 03/29/25. Diagnoses included encounter for orthopedic aftercare related to the displaced fracture of the ulna (one of two bones in the forearm) and right femur (thigh bone) and fracture of lower end of right radius (one of two bones in the forearm), Alzheimer's disease, depression, age related osteoporosis, and other abnormalities of gait and mobility. Review of Resident #284's admission MDS assessment, dated 04/04/25, revealed the resident was severely impaired cognitively; exhibited inattention and disorganized thinking which was present but fluctuated; had functional limitation in range of motion on one side of the upper and lower extremity; was dependent on staff for toileting hygiene, lower body dressing, and personal hygiene; was dependent on staff to transfer the resident from chair/bed to chair and walking ten feet had not been attempted; and was frequent incontinent of bowel and bladder. Further review of Resident #284's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy, the facility failed to ensure residents were either supervised during smoking breaks or residents signed out and left the facility premises prior to smoking independently. The facility also failed to ensure smoking materials, including cigarettes and lighters were kept in a secured area. This affected four residents (#56, #52, #57, and #46) reviewed for smoking and had the potential to affect 12 additional residents (#8, #12, #22, #28, #29, #32, #39, #44, #45, #49, #54, and #65) who were smokers residing at the facility. The facility census was 68. Findings include: 1. Record review for Resident #56 revealed an admission date of 05/14/24. Diagnoses included muscle weakness, difficulty in walking, chronic respiratory failure, heart failure, insomnia, anxiety disorder, and nicotine dependance. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Resident #56 used 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, record review, and review of the facility policy, the facility failed to provide thorough incontinence care for Resident #45. This affected one resident (#45) of one resident observed for incontinence care. The facility census was 68. Findings include: Record review for Resident #45 revealed an admission date of 05/17/23. Diagnoses included diffuse traumatic brain injury, hemiplegia affecting right dominant side, and muscle weakness. Review of the annual Minimum data Set (MDS) assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. Resident #45 required partial/moderate assistance with toileting and substantial maximum assistance with personal hygiene. Resident #45 was always incontinent of bowel and bladder. Review of the care plan dated 06/06/23 revealed Resident #45 was incontinent of bowel and bladder and was at risk for altered dignity, skin breakdown and urinary tract infection (UTI). Interventions included checking and providing incontinence care as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with staff the facility failed to ensure soiled linens were not placed directly on the floor in the room of Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for a safe, clean environment. The facility census was 69. Findings included: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cirrhosis of the liver, ascites, hypertension, mitral valve insufficiency, cardiomegaly, inguinal hernia, acute kidney disease, moderate protein-calorie malnutrition, anxiety disorder, pneumonia, respiratory failure, and muscle weakness. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, edema, atrial fibrillation, hypertension, aortic valve stenosis, anemia, severe protein-calorie malnutrition, seizures, benign prostatic hyperplasia, ischemic optic neuropathy.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the medical record, review of the facility policy and interview with the staff the facility failed to ensure aerosol masks were stored in a sanitary protective barrier while not in use for Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for respiratory care. The facility census was 69. Findings included: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cirrhosis of the liver, ascites, hypertension, mitral valve insufficiency, cardiomegaly, inguinal hernia, acute kidney disease, moderate protein-calorie malnutrition, anxiety disorder, pneumonia, respiratory failure, and muscle weakness. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #25 had intact cognition. Review of the April 2024 physician's orders revealed Resident #25 had an order for ipratropium 0.5 milligrams and albuterol solution for nebulization 3.0 mg.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview with staff the facility failed to maintain a medication error rate of less than five percent. Ten errors occurred within 31 opportunities for error resulting in a medication error rate of 32.2 %. This affected one resident (Resident #5) of four reviewed for medication administration. The facility census was 69. Fining included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included convulsions, encephalopathy, clostridium difficile, temporo-parietal lesion, cognitive communication deficit, dysphagia, cerebral infarction, anemia, hypertension, embolism and thrombosis of the deep veins of the right upper extremity, asthma, aphasia, dysphagia, osteoarthritis, gastrostomy, alcohol abuse and intracerebral hemorrhage. Review of the admission Minimum Data set assessment dated [DATE] revealed Resident #5 had severely impaired cognition and she had a feeding tube. Review of the April physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the medical record, review of the facility policy and interview with staff the facility failed to administer medication as ordered for Resident #5. This affected one resident (Resident #5) of four residents observed for medication administration. The facility census was 69. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included convulsions, encephalopathy, clostridium difficile, temporo-parietal lesion, cognitive communication deficit, dysphagia, cerebral infarction, anemia, hypertension, embolism and thrombosis of the deep veins of the right upper extremity, asthma, aphasia, dysphagia, osteoarthritis, gastrostomy, alcohol abuse and intracerebral hemorrhage. Review of the admission Minimum Data set assessment dated [DATE] revealed Resident #5 had severely impaired cognition and she had a feeding tube. Review of the April physician's orders revealed Resident #5 had order for amlodipine 5 milligrams (mg) one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, photographic evidence and review of policy and procedures, the facility failed to ensure correct medications were provided upon discharge. This affected one (#272) of six residents(#273, #274, #275, #276 and #277) reviewed for discharge planning. Findings include: Review of the closed medical record review for Resident #272 revealed an admission date of 11/17/23 and a discharge to home date of 12/02/23. Diagnoses included but were not limited to osteoarthritis, cognitive communication deficit, glaucoma, dysphagia, type II diabetes mellitus, hypertension, and depression. Review of the 11/24/23 admission Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview of Mental Status (BIMS) score of 12 which suggested Resident #272 had moderate cognitive impairment. Review of the physicians' orders dated 12/02/23 for Resident #272 revealed she was receiving the following medications upon discharge: Acetaminophen 325 milligram (mg) every six hours as needed give two tablets Amlodipine (used to treat high blood pressure and chest pain)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review the facility failed to provide a quarterly care conference for two (Resident #14 and #158) of two residents reviewed. The facility census was 52. Findings include: 1. Record review for Resident #14 revealed an admission date of 04/01/2019. Diagnosis included metabolic encephalopathy, Alzheimer's disease with late onset, dysphagia, gastrostomy status, cerebrovascular disease, and chronic respiratory failure with hypoxia. Resident #14 received hospice services. Review of the medical record revealed the last care conference for Resident #14 was dated 11/23/21 at 2:00 P.M. Interview on 11/28/22 at 11:42 A.M. with Resident #14's Power of Attorney revealed she had not been invited to any care plan conferences for Resident #14. Interview 11/30/22 at 10:17 A.M. with Social Services (SS) #34 confirmed care plan conferences were to be scheduled quarterly. The interdisciplinary team would be invited, the resident, the residents responsible party, and if the resident received hospice services, hospice would also be invited to attend. SS #34 confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide nail care for two dependent residents (Resident #32 and #158) and failed to provide shaving for one resident (Resident #158). This affected two (Residents #32 and #158) of five residents reviewed for activities of daily living (ADL) care. The facility census was 52. Findings include: 1. Record review for Resident #158 revealed an admission date of 06/07/22. Diagnosis included burns involving 40 - 49 percent (%) of body surface with zero to nine % third degree burns, muscle weakness, and schizoaffective disorder. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #158's long and short-term memory were intact. Resident #158 required extensive assistance of two staff for bed mobility, transfers and extensive assistance of one staff for personal hygiene. Resident #158 was always incontinent of bowel and bladder. Record review of the care plan dated 08/29/22 revealed Resident #158 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide wound care for two residents (Resident #158 and #5) of two residents reviewed for non-pressure wounds. The facility census was 52. Findings include: 1. Record review for Resident #158 revealed an admission date of 06/07/22. Diagnosis included burns involving 40 - 49 percent (%) of body surface with zero to nine % third degree burns, muscle weakness, and schizoaffective disorder. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #158's long and short-term memory were intact. Resident #158 required extensive assistance of two staff for bed mobility, transfers, and extensive assistance of one staff for personal hygiene. Resident #158 was always incontinent of bowel and bladder. Resident #158 had second and third degree burns with application of ointments and non-surgical dressings. Record review of the care plan dated 06/29/22 revealed Resident #158 was at risk for skin breakdown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the medical record, and staff interview the facility failed to ensure Residents #27 and #44 had their physician's ordered adaptive devices for eating. This affected two residents (Residents #27 and #44) of 11 residents reviewed for nutrition. The facility census was 52. Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, anemia, sciatica, diabetes, acute respiratory failure, diverticulosis, hypotension, chronic kidney disease, vascular dementia, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and required supervision of eating. Review of the nutritional assessment dated [DATE] revealed Resident #27 was to have a right curved handle spork, a divided dish, and individual (bowl) dishes. Review of the November 2022 physicians' orders revealed Resident #27 had…

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

Based on observation, interview and record review the facility failed to ensure resident foods were stored in a safe and sanitary manner. These practices had the potential to affect the 58 residents receiving food from the kitchen. The facility identified Resident #1, Resident #8 and Resident #26 as receiving nothing by mouth. The facility census was 61 residents. Findings include: Tour of the kitchen and food storage areas starting on 10/07/19 at 8:25 A.M. with Dietary Manager (DM) #100 revealed a pan of pork gravy not labeled or dated in the reach-in cooler in the kitchen. Tour of the resident units and nourishment refrigerators revealed: on Pod D, a sticky substance on the base of the refrigerator; on Pod A, five Chinese takeout containers, a plastic bag with two slices of pizza, cottage cheese, fruit and a dairy beverage not labeled or dated; and on Pod C, a container of soup not labeled or dated. Interview with DM #100 verified the above findings at the time of observation. DM #100 confirmed resident food was to be labeled and dated and nursing staff was responsible for…

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

Based on observation, interviews and review of the facility policy and procedure for medication administration, the facility did not ensure medications were properly secured on the D hall during medication preparation for Resident #26. This had the potential to affect the seven residents in the dining room, Resident #22, #29, #33, #37, #41, #43 and #46. The census was 61 residents. Findings include: Record review for Resident #26 revealed the latest return to the facility was on 02/20/19. Diagnoses included a cerebral infarction or stroke, dysphagia or difficulty swallowing, which required a feeding tube placed in the stomach for nutritional feeding and medication administration. Observation of medication preparation and medication administration was completed on 10/08/19 at 8:51 A.M. with Licensed Practical Nurse (LPN) #500. During the observation, LPN #500 dispensed the following medications into a 30 milliliter (ml) plastic disposable cup for Resident #26 who had a feeding tube. The medications required crushing and mixing with water for administration through the feeding tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide dignified care for Resident #22 who had an indwelling urinary catheter. This affected one of one resident reviewed for dignity. The facility census was 61. Findings include: Resident #22 was admitted to the facility on [DATE]. Admitting diagnoses included healing femur (thigh bone)fractures, chronic kidney disease and dementia. According to the minimum data set (MDS) admission assessment dated [DATE], Resident #22 was cognitively impaired, required extensive assistance for bed mobility and personal hygiene, and was totally dependent on staff for dressing, toileting and bathing, and needed staff supervision with eating. Resident #22 had an indwelling urinary catheter and was frequently incontinent of bowel. On 10/07/19 at 10:07 A.M. Resident #22 was observed in a reclining chair in her room. Her urinary catheter drainage bag was visible from the hallway and was not covered with a privacy cover. Interview with State Tested 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.