Continuing Healthcare Of Cuyahoga Falls

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to investigate an injury of unknown origin for Resident #18. This affected one (Resident #18) of three residents reviewed for investigation. The facility census was 55. Findings include:Review of the medical record of Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. Review of the nursing progress note dated 01/05/26 at 6:38 P.M. by Licensed Practical Nurse (LPN) #602 for Resident #18 revealed during breakfast an aide had noted he had swelling to the right side of his face. She stated she assessed him and noted his right top eye lid was swollen, resident cheeks were swollen and reddened. LPN #602 asked 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 interview, record review, and policy review, the facility failed to ensure Resident #56's immediate discharge was documented accurately and included in the medical record. This affected one resident (Resident #56) of one resident reviewed for discharge. The facility census was 55. Findings Include:Resident #56 was admitted to the facility on [DATE] with diagnoses including vascular dementia severe without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol induced persisting dementia, anxiety disorder, restlessness and agitation, and generalized anxiety disorder. The resident was transported to the hospital on [DATE] with no information regarding if the resident was admitted , transferred, or discharged .Review of the physician's orders for Resident #56 revealed on 01/29/26 and order was written for Depakote 125 milligrams (mg) (an anticonvulsant used as a mood stabilizer) three capsules given three times a day for vascular dementia, 02/01/26 an order was written for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments were accurately completed. This affected three (Residents #18, #42 and #48) of seven residents reviewed for assessments. The facility census was 55. Findings include:1. Review of the medical record for Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of the fall risk assessment dated [DATE] for Resident #18 revealed he had fall in the previous three months. Review of the fall investigation dated 12/11/25 at 5:00 P.M. for Resident #18 revealed he was observed laying on the floor next to his bed. Resident #18 had attempted to transfer from the wheel chair to the bed without staff assistance and fell on the floor. He had no injuries noted on the investigation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, 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 and interview, the facility failed to ensure dependent residents received showers as scheduled. This affected one (Resident #18) of three residents reviewed for showers. The facility census was 55. Findings include:Review of the medical record of Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of Resident #18's care plan dated 06/07/22 revealed he had self-care deficit with his activities of daily living and needed total assistance of one staff member for bathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. He needed substantial to maximum assistance from staff for showers and bathing. Review of Resident #18's showers under the task section of the electronic record and shower sheets provided by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure to audiology services and intervention were implemented properly. This affected two (Residents #21 and #32) of three residents reviewed for audiology services. The facility census was 55. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/01/23 with diagnoses including diabetes mellitus, hypertension, depression and anxiety. Review of the care plan dated 01/04/22 for Resident #21 revealed she had a communication problem related to a mild hearing deficit and had bilateral hearing aids. Staff were to assist the resident with inserting and removing hearing aids and consult audiology as indicated. Review of Resident #21's physician orders revealed she had an order dated 08/06/25 for staff to insert hearing aids every morning and remove them at night. Her hearing aides were to be stored in the medication cart. Review of the nursing progress notes for Resident #21 revealed on 12/01/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received pain medications as ordered. This affected one (Resident #21) of one reviewed for pain management. The facility census was 55. Findings include:Review of the medical record for Resident #21 revealed an admission date of 05/01/23 with diagnoses including diabetes mellitus, hypertension, depression and anxiety. Review of the care plan dated 01/04/22 for Resident #21 revealed she had alteration in comfort related to arthritis. Staff were to administer medications as ordered. Review of the physician's orders for Resident #21 revealed an order for Tramadol 50 milligrams (mg) three times a day for pain dated 12/27/25. Review of the narcotic logs for Resident #21 for February 2026 revealed she had utilized her last Tramadol 50 mg pill on 02/13/26 at 6:00 P.M. and had not received another Tramadol 50 mg pill until 02/17/26 at 2:00 P.M. Review of the Medication Administration Record (MAR) for February 2026 revealed Resident #21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy review, and job description review, the facility failed to ensure Resident #21 and Resident #32 received ancillary services timely. This affected two residents (Residents #32 and #21) of four residents reviewed for medically related social services. The facility census was 55. Findings Include:1. Resident #32 was admitted to the facility on [DATE] with diagnoses including a right ilium fracture, a motor vehicle accident with injuries, chronic obstructive pulmonary disease (COPD), major depressive disorder, acute pain due to trauma, bipolar disorder with psychotic features, anxiety disorder, history of malignant carcinoid tumor of bronchus and lung, malignant neoplasm of the bladder, and a urostomy (a surgical opening created in the abdominal wall to divert urine outside the body when the bladder is removed, commonly due to cancer or injury). Review of the physician's orders for Resident #32 revealed an order dated 02/13/26 for audiology to evaluate and treat. 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 observation, interview, and record review, the facility failed to ensure Resident #32's medical record accurately reflected ostomy care. This affected one resident (Resident #32) of one resident reviewed for ostomy care. The facility census was 55. Findings Include:Resident #32 was admitted to the facility on [DATE] with diagnoses of a motor vehicle accident with multiple fractures, chronic obstructive pulmonary disease, major depressive disorder, bipolar disorder with psychotic features, obstructive and reflux uropathy, anxiety disorder, artificial openings of urinary tract status, malignant neoplasm of bladder, and history of malignant carcinoid tumor of the bronchus and lung. Review of the physician's orders dated 09/12/25 revealed Resident #32 was to have urostomy care on day shift every three days. Staff are to remove the bag and wafer, cleanse the site with normal saline, observe for any abnormalities of the skin/ostomy, apply skin prep to the stoma border, allow the areas to dry, then apply a new…

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, review of the facility menus, interview with staff, and review of facility policy, the facility failed to follow the lunch menu for the residents. This affected all 63 residents in the facility who received their meals from the dining room. The facility census was 63.Findings Include:Review of the menu for 02/25/26 revealed the facility was to serve a corn dog, cheesy mashed potatoes, mixed vegetables, white bread and yellow cake for lunch.Observation of meal service on 02/25/26 at 11:40 A.M. revealed [NAME] #130 was serving corn dogs, regular mashed potatoes, mixed vegetables and vanilla pudding. There was no cheese in the mashed potatoes, no bread was given to the residents and they did not have yellow cake.On 02/25/26 at 12:15 P.M. an interview with [NAME] #130 revealed she did not make the mashed potatoes cheesy and there was not a reason why she did not. She stated they did not have the yellow cake, so they were serving pudding instead and verified they forgot to give the residents bread.On 02/25/26 at 4:15 P.M. an interview with Corporate Dietary Manager…

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

Based on observations, interview, and review of facility policy, the facility failed to maintain a safe sanitary kitchen. This affected all 63 residents who ate their meals from the facility kitchen. The facility census was 63.Findings Include: Observations of the kitchen with Corporate Dietary Manager #128 on 02/25/26 at 10:10 A.M. revealed the following concerns:a. There were two 50-gallon trash cans with no lids on them. b. The utensil drawer with the scoops and ladles had a red, sticky substance spilled down inside the drawer with the scoops and ladles laying in it.c. The stainless stain shelf under the steam table had food and a yellow liquid spilled on it.d. There were three three-tiered red food carts which were soiled with food debris and a white liquid dried on them.e. Two-large tubs of rice crispy cereal were not labeled as to when they were opened.f. Two five-pound packages of semi frozen tubes of hamburger were in the stainless stain sink soaking in warm water.g. The dry storage had several pieces of cardboard and paper littering the floor.h. In the refrigerator there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, interview with the staff, and review of the facility policy, the facility failed to knock on the door before entering the room of Resident #26. This affected one resident (Resident #26) of five residents observed during medication administration.Findings Include:Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive and post-traumatic stress disorder.Observation on 02/25/26 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #133 prepared the medication for Resident #26 at the medication cart in the hallway and then walked right into his room without knocking on the door. An interview at this time with LPN #133 verified she had not knocked on the door or waited for a response before entering the room 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 the bathroom of Resident #10 was maintained in a safe, comfortable manner. This affected one resident (Resident #10) of eight residents observed for environment.Findings Include:Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, severe protein calorie malnutrition, peripheral vascular disease, hypertension, depression, chronic kidney disease, and left eye blindness.Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #10 had moderately impaired cognition, no psychosis, and no behaviors. The assessment stated the resident required setup or clean-up assistance for toileting and she was occasionally incontinent of urine and always continent of bowel.Observation on 02/25/26 at 11:10 A.M. revealed in the bathroom of Resident #10 there were two softball size holes in the wall where the baseboard was missing under the sink…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview, the facility failed to ensure accurate acquiring, receiving, dispensing, and administering of Resident #32's eye drops. This affected one resident (Resident #32) of three reviewed for administering medication per physician's orders.Findings Include:Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included heart failure, protein-calorie malnutrition, nontraumatic subdural hemorrhage, Wernicke's encephalopathy, macular degeneration, cataracts, diverticulosis, alcohol abuse, fatty liver, hypothyroidism, pancreatitis, and adrenal gland disorder.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #32 had intact cognition.Further review of the medical record revealed Resident #32 had cataract surgery on 02/25/26.Review of the post operation orders dated 02/25/26 revealed Resident #32 was to start Prednisone 1.0 percent (%) ophthalmic drops with instructions to administer four drops in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, interview, and review of facility policies, the facility failed to maintain appropriate infection control while administering medication to Resident #21 and #26 and failed to ensure feces-soiled linens were properly contained during care for Resident #20. This affected three residents (Resident #20, #21, and #26) of eight observed for infection control and medication administration.Findings Include:1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, visual loss, mood disorder, psychosis. Prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive and post-traumatic stress disorder.Observation of medication administration on 02/25/26 at 9:00 A.M. revealed Agency Licensed Practical Nurse (LPN) #133 popped an Amlodipine 5 milligram (mg) tablet out of the card into her bare hand and placed the tablet into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure timely and accurate documentation of COVID-19 outbreak identification and reporting. Residents tested positive for COVID-19 between 01/02/26 and 01/03/26; however, documentation reflected delays in notifying residents' responsible parties until 01/06/26 and the county health department until 01/07/26. This affected three residents (#11, #60 and #64) who tested positive for COVID-19 and were not timely notified, 24 residents (#1, #6, #7, #9, #12, #14, #17, #19, #20, #22, #26, #27, #31, #34, #37, #38, #43, #45, #48, #53, #55, #59, #62, #63) who were neither tested nor had documented outbreak notification. The facility census was 63.Findings include: A review of Resident #60's clinical record revealed an admission date of 09/12/25 with diagnoses including dementia with psychotic disturbance, restlessness, agitation, schizophrenia, malnutrition, anxiety, delusional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure meals were served per the dietitian approved menu. This finding affected seven (Residents #14, #21, #22, #27, #40, #44 and #57) residents and had the potential to affect all residents who eat meals in the facility. The facility census was 65.Findings include:1. Review of Resident #14 medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, altered mental status and anxiety disorder. The resident resides on the secured memory care unit (SMCU).Review of Resident #14's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #14's Mini Nutritional Assessment form dated 08/22/25 revealed the resident was at risk for malnutrition and had a weight loss between 2.2 pounds and 6.6 pounds.Review of Resident #14's physician orders revealed an order dated 08/26/23 for a regular diet, regular texture with a regular/thin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure sufficient supervision and intervention was implemented to prevent Resident #11's from eloping, failed to ensure Resident #71 was transferred with staff assistance in a safe and dignified manner, and failed to ensure proper smoking procedures were implemented for five residents (#32, #34, #42, #48 and #52). This finding affected one (Resident #56) of three residents reviewed for elopement; one (Resident #71) of three residents reviewed for transfers; and five residents (#32, #34, #42, #48 and #52) of 17 smokers who reside in the facility. Facility census was 65.Findings include:1. Review of Resident #11's medical record revealed the resident was admitted on [DATE] with diagnoses including alcohol abuse, depression and anxiety. Resident #11 resides on the secured memory care unit (SMCU). Review of Resident #11's admission Elopement assessment dated [DATE] revealed the resident was at a moderate risk of elopement. 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.

Based on observation, interview, and review of facility policy, the facility failed to ensure the safe handling, transport, and separation of laundry to minimize the risk of exposure to contaminated items. This had the potential to affect all 65 residents who resided in the facility at the time of the survey.Findings include: Observation on 12/03/25 from 9:19 A.M. to 9:32 A.M. revealed one open laundry cart containing bags of soiled linen and one trash can labeled for placement of resident personal laundry. The observation revealed no bins or carts marked for laundry from isolation rooms or laundry that was heavily soiled with blood or bodily fluids. Further observation revealed one box of vinyl exam gloves sitting between two washing machines and no other personal protective equipment (PPE) was observed readily available for rinsing or sorting laundry. Interview on 12/03/25 at the time of the observation between 9:19 A.M. and 9:32 A.M. revealed Laundry Aide #859 verbalized not knowing whether there were any gowns, masks, goggles/face shields, or rubber gloves for handling and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to ensure resident advance directives matched across paper and electronic medical records (EMR). This affected four residents (#8, #12, #32, #42) of four residents reviewed for advance directives. Facility census was 65.Findings include: 1.Review of Resident #12's medical record revealed an admission date of [DATE] and diagnoses including hemiplegia and hemiparesis following cerebral infarction, bilateral cataracts, seizures, unspecified protein-calorie malnutrition. Review of Resident #12's paper medical record on [DATE] revealed a bright yellow sheet indicating he had an advance directive of full code (where a patient has chosen to receive every possible life-saving treatment in the event of a cardiac or respiratory arrest. This means that if a patient's heart stops or they stop breathing, medical professionals will initiate immediate life-saving measures such as cardiopulmonary resuscitation (CPR)). 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 review of medical records, facility policies and interviews the facility failed to ensure resident weights were recorded and monitored to ensure nutritional needs were met. This affected four residents (Residents #5, #38, #59, and #63) of five reviewed for nutrition. The facility census was 65.Findings include:1.Review of the medical record for Resident #5 revealed an admission date of 12/19/24. Diagnoses included but were not limited to schizoaffective disorder, unspecified dementia, adult failure to thrive, type II diabetes and unspecified severe protein-calorie malnutrition.Review of the 09/23/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed a Brief Interview of Mental Status (BIMs) of 8 which indicated moderate cognitive impairment. Resident #5 was noted to have require supervision with activities of daily living (ADLs) including meals. Resident #5 was noted to be on a physician prescribed weight gain program with a mechanically altered diet.Review of physician orders for Resident #5 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility policy review and facility assessment review, the facility failed to ensure adequate staffing was provided for the memory care unit. This affected 20 residents (Residents #5, #11, #14, #19, #21, #22, #24, #31, #36, #38, #40, #41, #44, #46, #54, #57, #59, #61, #63 and #65) of 20 residents on the memory care unit. The facility census was 65. Findings include:Observation on 12/03/25 at 6:56 A.M. on [NAME] unit (memory care unit) revealed no staff present after completing a tour of the unit. Two residents were observed sitting on chairs sleeping in the common area and another resident was noted sitting in a chair sleeping by herself in the kitchen area. All other residents were observed to be in their rooms in their beds. Interview on 12/03/25 at 7:02 A.M. with Licensed Practical Nurse (LPN) #817 revealed she was just coming on shift and had not seen any of the night staff walking onto the unit and had not gotten report yet and confirmed staff should have been on the unit.…

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

Based on record review and interview, the facility failed to ensure Resident #15 was offered a care conference meeting quarterly or as needed. This affected one resident (Resident #15) of one reviewed for care conference meetings. The census was 65. Findings include: Review of the medical record for Resident #15 revealed and admission date of 02/12/25. Diagnoses included acute congestive heart failure, anxiety disorder and pyogenic arthritis. Review of the Minimum Data Set (MDS) 3.0 screen revealed assessments were done on 02/12/25, 02/18/25, 05/21/25, 8/21/25 and 11/20/25. Review of the quarterly MDS Set 3.0 dated 11/20/25 revealed she was cognitively intact. Review of the Care Plan meeting assessments revealed they were dated for 7/23/25, 5/27/25, 3/25/25 and 2/25/25. Review of the 07/23/25 form revealed Resident #15 attended. Interview on 12/03/25 at 4:50 P.M. with Social Service Designee (SSD) #924 verified the facility missed at least one care conference meeting with Resident #15 stating Resident #15's last care conference was 07/21/25. SSD #924 stated she had been covering as…

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

Based on medical record review, interview, review of the United States (U.S.) Food and Drug Administration (FDA) latest approved labeling information for Zyprexa, and review of facility policy, the facility failed to ensure antipsychotics were prescribed only as indicated and the resident was monitored appropriately for potential side effects. This affected one Resident (Resident #9) of seven residents who were reviewed for unnecessary medications. The facility census was 65. Findings include:Review of the medical record for Resident #9 revealed an admission date of 09/05/25. Pertinent diagnoses included Alzheimer's disease, unspecified dementia, severe, with agitation, mild depressive disorder, single episode, post-traumatic stress disorder (PTSD), altered mental status, and other symbolic dysfunctions (a variety of language and cognitive impairments).Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 09/10/25 revealed Resident #9 had severely impaired cognition and mild depression with no behaviors, wandering, or rejection of care. Further review of the MDS…

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 policy review the facility failed to ensure comprehensive care plans were completed for one resident (Resident #63) of six reviewed for care plans. The facility census was 65.Findings include:Review of the medical record for Resident #63 revealed an admission date of 09/12/25. Diagnoses included but were not limited to dementia with psychotic disturbance, unspecified protein-calorie malnutrition, paranoid schizophrenic, anxiety disorder, delusional disorders and paranoid personality disorder.Review of the 09/25/25 admission Minimum Data Set (MDS) 3.0 for Resident #63 revealed a Brief Interview of Mental Status (BIMs) score of 13. Review of Activities of Daily Living (ADLs) revealed Resident #63 was noted to require set up for eating and bathing, supervision for toileting, dressing, personal hygiene and transfers.Review of the comprehensive care plan dated 10/15/25 for Resident #63 revealed no evidence of a nutrition care plan or an activities of daily living (ADL) care plan. Phone interview on 12/03/25 at 2:00 P.M. with Registered Dietitian (RD)…

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, interviews, and facility bathing policy, the facility failed to ensure bathing was provided and documented for one independent resident (Resident #61) of three reviewed for bathing. The facility census was 65.Findings include:Review of the medical record for Resident #61 revealed an admission date of 06/13/24. Diagnoses included but were not limited to paranoid schizophrenia, vascular dementia, schizoaffective bipolar type disorder, adult failure to thrive, unspecified protein-calorie malnutrition, and Alzheimer's dementia. Under the shower task, Resident #61 was scheduled to have Tuesday and Saturday night bathing.Review of the 10/30/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #61 revealed a Brief Interview of Mental Status (BIMs) of nine which indicated moderate cognitive impairment. Review of the Activities of Daily Living (ADLs) for Resident #61 revealed resident was independent for bathing.Review of the care plan for Resident #61 revealed it was last reviewed on 10/31/25. Resident #16 was noted to have an ADL self-care performance deficit…

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

Based on record review, interviews, and facility bathing policy, the facility failed to ensure bathing was provided and documented for two dependent residents (Residents #14 and #63) of three reviewed for bathing. The facility census was 65.Findings include:1.Review of the medical record for Resident #14 revealed an admission date of 08/26/23. Diagnoses included but were not limited to vascular dementia, altered mental status transient cerebral ischemic attack, anxiety disorder and unspecified protein-calorie malnutrition. Review of the shower task revealed showers were scheduled for Sunday and Wednesday night shift.Review of the 11/21/25 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #14 revealed a Brief Interview of Mental Status (BIMs) of three which indicated severe cognitive impairment. Resident #14 was noted to be dependent upon staff for bathing.Review of the care plan last for Resident #14 last reviewed on 11/26/25 revealed she required staff assistance with bathing.Observation on 12/01/25 at 11:52 A.M. revealed Resident #14 dressed and sitting with two other…

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 review of the facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two residents (#6 and #10) of five residents reviewed for unnecessary medications. Facility census was 65.Findings include: 1.Review of Resident #6's medical record revealed an admission date of 02/17/23 and diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, depression, anemia, anxiety, heart failure and hypertension. Resident #6 signed on hospice services as of 10/30/25. Review of Resident #6's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and reported frequent, moderate pain. Resident #6 received hospice services. Review of Resident #6's physician orders as of 12/03/25 revealed an order dated 07/21/25 for diclofenac sodium external gel 1% apply to knees topically every six hours as needed for pain. No dose was specified in the order.…

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, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 28 medications were administered with two errors for a medication error rate of 7.14%. This finding affected two (Residents #11 and #49) of six residents observed for medication administration. Findings include:1. Review of Resident #11's medical record revealed the resident was admitted on [DATE] with diagnoses including alcohol abuse, depression and anxiety.Review of Resident #11's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #11's physician orders revealed an order dated 11/17/25 for Sertraline (Zoloft) antidepressant, give 75 milligrams (mg) by mouth in the morning for depression.Observation on 11/19/25 at 8:03 A.M. with Licensed Practical Nurse (LPN) #817 of Resident #11's medication administration revealed two medications were administered with one error. LPN #817 administered 25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure foods were provided per preference. This affected one resident (#42) of seven residents observed at meals and reviewed for nutrition. Facility census was 65.Findings include:Review of Resident #42's medical record revealed an admission date of 09/24/25 and diagnoses including heart failure, unspecified protein-calorie malnutrition, Wernicke's encephalopathy and alcohol abuse. Review of Resident #42's medical record as of 12/03/25 revealed a pnysician's order dated 09/24/25 for a regular diet with no lactose and double portions. Review of Resident #42's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact and was independent with eating. Review of a nutrition assessment dated [DATE] revealed Resident #42 was ordered a regular diet and ate independently. Review of nurses' notes from 09/24/25 through 12/02/25 did not mention food preferences including double portions at…

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

Based on observation and interviews, the facility failed to maintain resident rooms in a safe and sanitary condition. This affected six residents (#18, #20, #22, #24, #55, and #56) of 12 residents observed for environment. The facility census was 56.Findings include:1. Observation on 09/23/25 at 12:08 P.M. of Resident #18 room revealed numerous stains on carpet. Observation and interview on 09/24/25 at 8:19 A.M. with Administrator confirmed above observations.2. Observation on 09/23/25 at 12:33 P.M. of Resident #20 room revealed a strong odor, the toilet was dirty and a bed pan was on the floor with brown stains. Resident's wheelchair was in bathroom with opened boxes of medical equipment placed on top and other various items including a brief.Observation and interview on 09/23/25 at 12:44 P.M. with CNA #354 confirmed the observations.3. Observation on 09/23/25 at 4:37 P.M. of Resident #24 room revealed a chair with numerous stains, floor boards and walls were dirty and dusty, the floor was extremely sticky, various debris on floor, brown stain around the toilet rim, the walls in…

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

Based on record review, observations and interview, the facility failed to provide therapeutic activities in the secured memory care unit to meet the physical, mental and pscyho-social wellbeing of the residents. This affected all 18 residents in the memory care unit. The facility census was 56. Findings include:Observations throughout investigation from 09/23/25 through 10/21/25 on the memory unit revealed activities on the memory care unit not being done as scheduled with memory care residents sitting in common areas with one television on. There was one activity board in the common area but residents were not observed using it. The large common area had multiple single chairs arranged in front of the walls but the space was so large residents could not converse with each other if sitting across from each other. There was a television in the large common area that was never on and only observed the television on in the smaller sitting area. Observation of bingo, magician and musician activities off the memory care unit revealed some memory care residents were taken to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review the facility failed to ensure medications were labeled, unexpired, and stored in an appropriate manner. This had the potential to affect all residents served from two of two storage rooms, two of two treatment carts, and two of three medication carts available for medication storage in the facility.Findings include:1.Observation of the facility medication storage rooms and [NAME] Unit treatment cart on 09/30/25 at 9:51 A.M. to 10:27 A.M. with the Assistant Director of Nursing revealed the following:The medication storage room in the [NAME] Unit contained (1) bottle of Children's Flonase 0.38fl oz expired on 04/2025 and (4) Zyno Medical administration sets (tubing used for intravenous (IV) medication) expired on 01/25/25.The [NAME] treatment cart contained (15) packets Procure triple antibiotic ointment 0.9 grams and an opened (1) DermaRite 4x4 xeroform gauze (medicated gauze used in wound treatment).The medication storage room in the Cascade Unit contained…

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

Based on observation, interview and facility policy, the facility failed to provide food at appetizing temperatures. This had the potential to affect 55 of 56 residents as the facility identified Resident #17 as receiving no food by mouth. Facility census was 56.Findings include:Review of Resident Council dated 06/26/25 revealed complaint that Certified Nursing Assistants (CNA) are only passing their assigned resident trays which results in food sitting for a long time. There was no evidence of the resolution to the council minutes following the June 2025 meeting.Interview on 09/24/25 at 3:32 P.M. with Resident #56 revealed she usually eats meals in her room and food is not always warm.Interview on 09/24/25 at 9:30 A.M. with Resident #55 revealed the dining room is not open so he usually eats in his room and the food is sometimes not warm.A test tray was plated on 09/23/25 at 6:13 P.M. and arrived on the Buckeye Hall at 6:17 P.M. Test tray was completed at 6:34 P.M., after all room trays were served. The food was not at the appropriate temperature. The pasta was 122.4 degrees…

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 policy review the facility failed to ensure appropriate infection control procedures were followed. This affected three residents (Resident #18 Resident #20, and Resident #52) out of three residents reviewed for infection control procedures. The facility census was 56.1.Review of Resident #20's medical record revealed an admission date of 10/01/21. Diagnoses included dementia, dysphagia, psoriatic arthritis, essential hypertension, neuromuscular dysfunction of bladder, anxiety and colostomy. Review of Resident #20's physician order dated 12/16/24 for Enhanced Barrier Precautions (EBP) revealed orders for protective personal equipment (PPE): gloves/gown during high-contact resident care activities. Review of Resident #20 Care Plan dated 04/22/25 revealed resident was at risk for malnutrition and weight loss and required the use of an ostomy. Review of Resident #20 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident required setup or clean-up assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure residents received adequate nutritional and communication assistance. This affected one Resident (#20) of three reviewed for activities of daily living (ADL's). The facility census was 56.Review of Resident #20's medical record revealed an admission date of 10/01/21. Diagnoses included dementia, dysphagia, psoriatic arthritis, essential hypertension, neuromuscular dysfunction of bladder, anxiety and colostomy.Review of Resident #20 Care Plan dated 04/22/25 revealed resident was at risk for malnutrition and weight loss and required interventions including providing assistance with all meals, snacks and supplements. Resident had a communication impairment with interventions that included using communication tools, terms, gestures the resident can understand.Review of Resident #20 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident required setup or clean-up…

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 review of facility policy, the facility failed to ensure Resident #55 blood sugar was monitored appropriately. This affected one resident (Resident #55) of three residents reviewed for quality of care. Facility census was 56. Resident #55 was admitted to the facility on [DATE] and had diagnoses including heart failure, type 2 diabetes, atrial fibrillation (abnormal heart rhythm), and low back pain. Resident #55 had an order dated 06/20/25 for a Dexcom G7 Sensor (a wearable continuous blood sugar monitor) for blood sugars every ten days. Review of the Medication Administration Record (MAR) for 08/01/2025 to 08/31/25 revealed on 08/20/25 Resident #55 did not receive the Dexcom G7 Sensor due to being out of the facility without medications and on 08/30/25 nothing was indicated on the MAR; the entry was blank. Review of the MAR for 09/01/25 to 09/30/25 revealed on 09/09/25 and 09/29/25 Resident #55 did not receive the Dexcom G7 Sensor. Resident #55 was not administered 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 interview and record review, the facility failed to ensure Resident #22 received treatment to maintain vision. This affected one resident (Resident #22) of three residents reviewed for vision. The facility census was 56. Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome of bilateral lacrimal glands and bilateral combined forms of age-related cataract.Review of an annual Minimum Data Set (MDS) 3.0 assessment completed on 08/01/25 revealed Resident #22 was alert and oriented with intact cognition. Further review revealed Resident #22 vision was severely impaired.Record review revealed Resident #22 was seen by the eye care consultant on 03/18/25 and recommended following up with ophthalmologist of facility choice for cataract evaluation.Interview on 09/24/25 at 3:57 P.M. with Resident #22 revealed she is unable…

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 ensure Resident #44 was free from significant medication error. This affected one resident (Resident #44) of three residents reviewed for medications. Findings include:Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including multiple sclerosis, epilepsy, seizures, essential hypertension, major depressive disorder, localization-related symptomatic epilepsy and epileptic syndrome with complex partial seizers.Review of the physician order dated 10/30/24 with a revised date of 08/04/25 revealed Resident #44 was prescribed Valtoco 10 milligrams (mg) 1 spray alternating nostrils every 24 hours as needed for seizures.Review of the nurse progress note dated 08/04/25 revealed nurse spoke to Nurse Practitioner (NP) to get a new prescription for the Valtoco seizure medications.Review of the nurse progress notes dated 09/11/25 revealed Resident #44 had a seizure. Nurse notified NP, received an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#112) out of three residents reviewed for insulin administration. The facility identifieid ten residents who required insulin. The facility census was 50. Findings include: Review of Resident #112's medical record revealed an admission date of 02/22/21 with diagnoses including chronic kidney disease, heart failure, type two diabetes mellitus, and protein calorie malnutrition.Review of Resident #112's care plan revised on 08/16/21 revealed the resident was at risk for hypoglycemic (low blood sugar) and hyperglycemic (elevated blood sugar) episodes related to diabetes. Listed interventions included to monitor blood sugar levels as ordered, monitor for signs and symptoms of hypoglycemia and hyperglycemia, and to administer insulin as ordered. Review of Resident #112's physician orders revealed an order dated 06/18/25 for Novolog…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and record reviews, the facility failed to ensure resident refrigerators were monitored for sanitary conditions and that food was maintained at temperatures safe for consumption. This affected 17 (#6, #8, #9, #12, #13, #17, #19, #20, #25, #29, #30, #31, #32, #36, #40, #41 and #45) of 17 residents identified by the facility as having personal refrigerators. The facility census was 49.Findings include: Interview on 07/08/25 at 10:50 A.M. with Resident #12, revealed he was concerned about his refrigerator being safe and the floor surrounding the refrigerator area having a red dried substance. Observation of Resident #12's refrigerator revealed a red, dried substance on the bottom shelf. The thermometer in the refrigerator showed a temperature of 50 degrees Fahrenheit (F). There was food in the refrigerator. Further observation revealed a refrigerator temperature monitoring log for June 2025 hanging on the outside of the refrigerator that had only been completed…

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 #9 revealed an admission date of 10/24/19. Diagnoses included weakness, gastro-esophageal reflux disease without esophagitis, vitamin D deficiency, and age-related osteoporosis without current pathological fracture. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 had intact cognition. Observation on 06/09/25 at 10:35 A.M. in the Resident #9's room revealed an opened store brand bottle of an antacid chewable, with more than 50% gone, sitting on the resident's bedside table. Interview at this time, Resident #9 stated she had a friend bring it in for her. Resident #9 stated they don't have it here and were too busy with other residents. Observation on 06/11/25 at 4:53 P.M. in Resident #9's room the bottle of store brand antacid was no longer on the bedside table. Interview at this time with Resident #9 revealed she still had them but had put the bottle in drawer of her nightstand next to her bed. Observed Resident #9 open the second drawer 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.

Based on observation, record review, interview and review of facility policy, the facility failed to maintain a safe, clean, comfortable and homelike environment for all residents. This affected one resident (Resident #29) of three residents reviewed for environment on the Cascade unit, and had the potential to affect an additional 35 residents (Resident #1, #2, #5, #6, #8, #10, #11, #12, #13, #15, #17, #18, #21, #22, #23, #24, #26, #28, #30, #31, #34, #36, #37, #38, #40, #41, #42, #43, #45, #48, #49, #50, #33, #19,and #32) the facility identified as living on the Buckeye and Memory Care (MC) units. The facility census was 51. Findings include: Record review of the Resident Council Meeting Minutes dated 02/05/25 revealed residents had concerns staff were not making beds or changing sheets, not emptying trash cans or putting bags in the trash cans. Record review of Resident Council Meeting Minutes dated 03/26/25 revealed a concern regarding rooms needing swept more than once a week. Review of the facility cleaning checklist revealed bathrooms were to be swept, and bedrooms were 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, interview, record review and review of facility policy the facility failed to ensure staff performed hand hygiene and implemented proper glove use during medication administration for Resident #6, Resident #13, and Resident #22, and failed to disinfect the glucometer after using it to check Resident #13's blood sugar. This affected three residents (#6, #13 and #22) out of six residents reviewed for medication administration. In addition, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) during wound care for Resident #47. This affected one resident (Resident #47) out of three residents reviewed for wound care. The facility census was 51 Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 04/21/21 with diagnoses including hypertensive heart disease, bipolar disorder, hypothyroidism, benign prostatic hyperplasia, gastroesophageal reflux disease, vitamin D deficiency, chronic pain syndrome, restless leg…

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 review of facility policy, the facility did not ensure facility staff did not neglect Resident #5 when in need of staff assistance to meet care needs. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51. Findings include: Record review for Resident #5 revealed an admission date of 06/01/22 and a readmission date of 01/10/25 with diagnoses including heart failure, cardiomegaly (enlarged heart) with atheroscerotic heart disease, , atrial fibrillation (heart arrhythmia), osteoarthritis, diabetes mellitus, palpitations, insomnia, chronic embolism and thrombosis of unspecified vein and hypokalemia (low potassium level). A review of Resident #5's most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #5 was always incontinent of bowel and bladder. Record review of Resident #5's plan of care initiated on 06/02/2022 revealed Resident #5 had an alteration in elimination 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 record review, interview and review of facility policy, the facility did not ensure an allegation of neglect of Resident #5 was reported to the state agency and administrator as required. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51. Findings include: Review of the medical record for Resident #5 revealed an admission date of 06/01/22 and a readmission date of 01/10/25 with diagnoses including heart failure, cardiomegaly (enlarged heart)with atheroscerotic heart disease, , atrial fibrillation (heart arrhythmia), osteoarthritis, diabetes mellitus, palpitations, insomnia, chronic embolism and thrombosis of unspecified vein and hypokalemia (low potassium level). A review of Resident #5's most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #5 was always incontinent of bowel and bladder. Review of Resident #5's plan of care initiated on 06/02/2022 revealed Resident #5 had an alteration in elimination…

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 review of facility policy, the facility did not ensure an allegation of neglect of Resident #5 was thoroughly investigated and corrective action taken as required. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51. Findings include: Review of the medical record for Resident #5 revealed an admission date of 06/01/22 and a readmission date of 01/10/25 with diagnoses including heart failure, cardiomegaly (enlarged heart)with atheroscerotic heart disease, , atrial fibrillation (heart arrhythmia), osteoarthritis, diabetes mellitus, palpitations, insomnia, chronic embolism and thrombosis of unspecified vein and hypokalemia (low potassium level). A review of Resident #5's most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #5 was always incontinent of bowel and bladder. Review of Resident #5's plan of care initiated on 06/02/2022 revealed Resident #5 had an alteration in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff provided the physician ordered wound treatment during Resident #47's wound treatment procedure. This affected one resident (Resident #47) out of three residents reviewed for wounds. The facility census was 51. Findings include: Review of the medical record for Resident #47 revealed an admission date of 01/13/23 with diagnoses including bullous penphigoid (a rare autoimmune disease that causes blisters or sores on the skin.), morbid obesity, anxiety, depression, insomnia, lymphedema, adult failure to thrive and high blood pressure. Review of a wound assessment dated [DATE] for Resident #47 revealed Resident #47 had severe edema of the lower extremities, and multiple sores and blisters on the thighs, abdominal fold, buttocks, and back. Resident #47's physician order dated 06/25/24 indicated to implement enhanced barrier isolation precautions during resident care tasks. Resident #47 had a stage three pressure ulcer located on the…

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

Based on observation, record review and interview the facility failed to ensure the staff administered medications with a less than five percent error rate. Three errors occurred within 24 opportunities for error resulting in a medication error rate of 12.5 percent. This affected two residents (Resident #13 and Resident #28) out of six resident observed for medication administration. The facility census was 51. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 01/21/25 with diagnoses including chronic respiratory disease including respiratory failure, chronic obstructive pulmonary disease, hypercapnea, hypoxia, high cholesterol, atherosclerotic heart disease, anemia, psychoactive substance abuse, cocaine/cannabis abuse, alcohol abuse, hemophilus influenza and insomnia. A review of Resident #28's physician order dated 04/10/25 indicated to administer 25 milligrams (mg) of metoprolol tartrate orally twice a day. An observation on 04/14/25 at 7:58 A.M. of Registered Nurse (RN) #61 administering medications to Resident #28 revealed RN #61…

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 did not ensure food served to Resident #5, #46 and #47 was palatable and attractive. This affected three residents (#5, #46 and #47) of seven residents reviewed for food and nutrition. The facility census was 51. Findings include: An interview was conducted on 04/14/25 at 9:20 A.M. with Resident #47 who revealed she did not like the taste of the facility food. An observation was conducted on 04/14/25 from 12:45 P.M. to 12:57 P.M. of the kitchen tray line for the lunch meal. [NAME] # 112 had placed a shallow pan of meatloaf on the trayline for the meal service. The meatloaf had burnt edges and [NAME] #112 needed to scrape between the pan and the burnt edges of the meatloaf in order to release pieces of meatloaf. Observation of the mashed potatoes on tray line revealed the mashed potatoes were so runny/watery [NAME] #112 had to serve them with a serving spoon instead of a measured scoop. In addition, [NAME] #112 was serving rice that had a clumped, ball-like shape when scooped onto the plate. [NAME] #112 verified the findings at the time…

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 diet order report, and interview, the facility failed to serve food at an appetizing taste and temperature. This had the potential to affect all 59 residents who received meals from the kitchen. The census was 59. Findings include: Observation on 02/04/25 at 1:19 P.M. revealed [NAME] #3 served a test tray consisting of a lemon pepper chicken breast, white rice and cooked peas and carrots from the kitchen tray line and placed the meal tray within the meal cart. At 1:23 P.M., the meal cart was delivered to [NAME] Hills unit (secured memory care unit). At 1:28 P.M., the nursing staff began serving residents meals within the dining room on the secured memory unit. At 1:39 P.M., all residents had been served their lunch tray, and the test tray was tested. Registered Dietitian (RD) #14 used a facility thermometer to take the temperature of the food while the surveyor taste tested the food. RD #14 confirmed the following temperatures: 93.5 degrees Fahrenheit (F) for the chicken…

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, review of the food temperature log, review of the FoodSafety.gov website, review of the diet order report, policy review and interview, the facility failed to store and prepare food in a sanitary manner. This affected all 59 residents who received meals from the kitchen. The census was 59. Findings include: Observation on 02/04/25 at 7:55 A.M. during the initial tour of the kitchen revealed the tiled floor was black and sticky in the kitchen servery and in the kitchen. There were no paper towels in the paper towel dispenser at the handwashing sink in the dish machine room. There was a food temperature log dated the First Week of February hanging on the bulletin board outside of Dietary Manager (DM) #4's office within the kitchen. There was a cardboard box full of four-ounce milk cartons sitting on the floor, an opened plastic bag of hot dogs in a metal pan without a date, and four slices of what appeared to be pie covered with plastic wrap without a date sitting on a tray on a metal food cart within Fridge #1 which was the walk-in refrigerator. At 8:15 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observation, review of the Centers for Medicare and Medicaid (CMS) 802 Matrix form, review of the nursing staff assignment sheets, review of the education in-service attendance record, and interview, the facility failed to ensure sufficient nursing staff to provide appropriate supervision to residents residing on the secured memory care unit. This affected 19 residents (Resident #29, #53, #48, #12, #34, #30, #56, #38, #16, #44, #17, #58, #9, #42, #19, #2, #13, #45 and #20) who resided on the [NAME] Hills unit (the secured memory care unit). Facility census was 59. Findings include: Review of the Daily Assignment Sheet [for nursing staff] dated 01/23/25 revealed Registered Nurse (RN) #9 and Certified Nurse Aide (CNA) #21 were assigned to [NAME] Hills unit (secured memory care unit) from 7:00 A.M. to 7:00 P.M. and CNA #8 was assigned to [NAME] Hills unit from 7:00 A.M. to 3:00 P.M. Review of the Education In-Service Attendance Record dated 01/23/25 timed 7:00 A.M. and 2:30 P.M. revealed RN #9, CNA #21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure all residents in the memory care unit received appropriate dementia care and services. This affected three of three residents (Residents #9, #58 and #12) reviewed for dementia care and had the potential to affect 19 (Resident #29, #53, #48, #12, #34, #30, #56, #38, #16, #44, #17, #58, #9, #42, #19, #2, #13, #45 and #20) residents residing in the memory care unit. Findings include: 1. Medical record review revealed Resident #58 was admitted on [DATE]. Resident #58's date of birth was 01/06/66 and he had diagnoses including cognitive communication deficit, restlessness, agitation, insomnia, hepatic encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), alcohol dependence and homelessness on admit. Review of the Minimum Data Set (MDS) assessment with an initiation date of 01/22/25 revealed Resident #58 had a Brief Interview Mental Status (BIMS) score of 13 indicating he 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.

Based on observation, review of diet order report, policy review, and interview, the facility failed to follow the menu to ensure nutritional adequacy. This affected 12 residents (Residents #1, #3, #9, #15, #19, #24, #25, #41, #42, #48, #51, and #53) who were ordered a mechanical soft diet or a pureed diet. The census was 59. Findings include: Review of the of Week One 2024-2025 for Tuesday [02/04/25] Menu Spreadsheet revealed residents ordered a pureed diet were supposed to receive pureed scrambled eggs, pureed toast and six ounces of pureed hot or cold cereal with beverages for breakfast. Residents ordered a mechanical soft diet were supposed to receive three ounces of ground lemon pepper chicken for lunch. Residents ordered a pureed diet were supposed to receive three ounces of pureed lemon pepper chicken, four ounces of pureed fluffy steamed rice, four ounces of peas and carrots and two ounces of pureed dinner roll for lunch. The menu was signed by a Registered Dietitian (RD). Observation on 02/04/25 at 8:54 A.M. of [NAME] #3 serving breakfast from the steam table in the kitchen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Centers of Disease Control and Prevention (CDC) COVID-19 vaccination guidelines, policy review and interview, the facility failed to offer any 2024-2025 COVID-19 vaccinations to residents. This affected five (Residents #9, #43, #38, #17 and #34) residents reviewed for COVID-19 vaccination. The census was 59. Findings include: Review of the CDC's Interim Clinical Considerations for COVID-19 Vaccines in the United States dated 01/31/25 revealed people ages 65 and older, vaccinated under the routine schedule, were recommended to receive two doses of any 2024-2025 COVID-19 vaccine separated by six months (minimum interval two months) regardless of vaccination history with one exception: unvaccinated people who initiated vaccination with 2024-2025 Novavax COVID-19 vaccine were recommended to receive two doses of Novavax followed by a third dose of any COVID-19 vaccine six months (minimum interval two months) later. Review of the facility's COVID-19 policy revised April…

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

Based on observations, staff interviews, review of nursing schedules, review of Self-Reported Incidents (SRI), review of personnel files, review of concern logs, review of resident council minutes, and review of the facility assessment, the facility failed to provide sufficient nursing staff to meet the total care needs of the residents and failed to provide adequate nursing coverage on each shift. This had the potential to affect all 59 resident in the facility. The facility census was 59. Findings include: 1. Review of an SRI, dated 09/17/24, revealed Certified Nursing Assistant (CNA) #600 was found to be sleeping in an empty resident bed and had eaten several bags of snacks and chips. Resident #4 stated an STNA (State Tested Nursing Assistant) came into her room, pulled the privacy curtain and pulled her blind down. CNA #600 then proceeded to lay down in the bed, the other bed in her room (bed B), and ate and drank all night. Resident #4 stated I could hear her crunching all night. CNA #600 was suspended pending the investigation. Review of CNA #600's personnel file revealed 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 observations, resident interviews, staff interviews, job description review, review of resident diet order list, and review of personnel files, the facility failed to ensure adequate and appropriate dietary staff to meet the dietary needs of the residents. This had the potential to affect all residents except one resident (#45) who received nothing by mouth. The facility census was 59. Findings include: Interview on 12/16/24 at 9:00 A.M. with Resident #21 revealed his breakfast meal had not arrived, and he was hungry. Resident #21 revealed his breakfast, lunch, and dinner meal were late daily. Interview and observation on 12/16/24 at 9:10 A.M. with Resident #11 revealed she had not received her breakfast meal. Resident #11 revealed all her meals arrived late every day. Resident #11 revealed her lunch always arrived after 2:30 P.M. and her dinner always arrived after 6:30 P.M. Review of the mealtimes revealed for lunch dining room opened at 11:15 A.M. The tray line began at 12:00 P.M., the [NAME] unit…

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, policy review, resident interviews, and staff interviews, the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect all residents except one resident (#45) who received nothing by mouth. The facility census was 59. Findings include: 1. Observations during the tour of the kitchen on 12/16/24 from 9:33 A.M. to 9:56 A.M., with the Administrator revealed: observed in the walk-in cooler the two light fixtures were heavily dusty, there was a black substance on the ceiling near the fans and on the silver parts around the fan. There was also a black substance/spots on the wall around the door that led to the walk-in freezer; observed on a clean rack on the bottom shelf was a black bucket with plastic cups that were clear colored but were very cloudy. There was a four slotted silverware container with spoons in two of the slots that had water spots and the other two slots were empty with crumbs; the dry storage room floor entry way was heavily soiled; observed 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 observations, resident interviews, family interviews, staff interviews, review of resident council minutes, and policy review, the facility failed to ensure a clean, functional and sanitary environment. This had the potential to affect all 59 residents. The facility census was 59. Findings include: Observation on 12/16/24 at 9:00 A.M of Resident #21 over the bed light revealed a light that was unable to be turned on due to no string or pull cord to operate it. Interview on 12/16/24 at 9:00 A.M., with Resident #21 revealed the light above his bed had not been in working order for 8 weeks and no one would fix it due to electricity concerns and/or hazards. Interview on 12/16/24 at 9:03 A.M. with Licensed Practical Nurse (LPN) #303 revealed housekeeping did not clean the resident rooms or common areas often. LPN #303 revealed housekeeping staff typically swept and mopped the areas that were visible from the hallways. Interview and observation on 12/16/24 at 9:10 A.M., with Resident #11 revealed housekeeping…

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 reviews, observations, review of self-reported incident, review of resident concern log, review of resident council minutes, policy review, resident interview, ombudsman interview and staff interviews, the facility failed to timely and fully address residents expressed concerns with care and treatment and environmental issues. This directly affected eighteen Residents (#9, #10, #11, #19, #27, #30, #31, #32, #40, #47, #48, #49, #52, #54, #55, #56, #58, and #62), with the potential to affect all resident residing on the 300 hall. The census was 59. Findings include: On 12/17/24 from 1:45 P.M. to 2:10 P.M. a resident meeting was held with Resident #32, Resident #40, Resident #47 and Resident #62 attending. The residents revealed concerns with the facility's lack of response to expressed concerns. The residents stated they consistently had issues with call light response times, dietary issues, missing laundry and the turnover of staff. Resident #32 had an issue with his light not working and reported it weeks prior. Resident #40 had voiced concerns about 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 observation, resident interview and staff interview, the facility failed to ensure potentially hazardous chemicals and medicated treatments were kept in a secured area where residents residing in the Memory Care Unit did not have access. This had the potential to affect 14 (#1, #7, #12, #15, #16, #35, #37, #43, #44, #50, #52, #57, #59, and #60) who were identified by the facility as being independently mobile of the 17 residents residing in the Memory Care Unit. In addition, the facility failed to ensure a resident at risk for choking was supervised and monitored during meals. This affected one (#50) of ten residents observed for dining in the memory care unit. The facility census was 59. Findings include: 1. Observation on 12/16/24 at 12:39 P.M. of the Memory Care Unit revealed a large dining area. Next to the dining area was an open kitchenette area with multiple kitchen cabinets. Observation revealed none of the cabinets were secured. Residents were observed sitting in the dining area and wandering…

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

Based on observation, staff interview, and review of policy, the facility failed to ensure medications were stored in a secure manner. This affected six (#4, #25, #27, #40, #41, and #60) and had the potential to affect 19 additional residents (#1, #3, #7, #12, #15, #16, #17, #21, #26, #29, #35, #37, #43, #44, #49, #50, #52, #57, and #59) identified by the facility as being cognitively impaired and independently mobile. The facility census was 40. Findings include: 1. Observation on 12/16/24 at 9:20 A.M., revealed 11 pills left unattended in a medication cup at the bedside table for Resident #41. Certified Nursing Assistant (CNA) #462 was present providing incontinence care for Resident #41. Interview and observation on 12/16/24 at 9:24 A.M., with Licensed Practical Nurse (LPN) #463 confirmed the 11 pills were left unattended in a medication cup at the bedside table for Resident #41 and confirmed the medications were not administered to Resident #41 per the physician orders. 2. Observation on 12/16/24 at 9:36 A.M., revealed four pills in a medication cup left unattended at the…

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

Based on observations, resident interviews, staff interviews, review of resident diet order list and policy review, the facility did not ensure food was held at appropriate temperatures while on the steam table and served at palatable temperatures. This affected seven residents on pureed (#13, #36 #52) and/or mechanical soft (#4, #15, #19, #50) diets respectively. Additionally, interviews with four residents (#11, #19, #33, #40) voiced concerns that the food was served cold. The facility census was 59. Findings include: Interviews on 12/16/24 from 9:00 A.M. to 3:00 P.M. with Residents #11, #19, #33, and #40 stated the food was served cold. Observation on 12/19/24 at 11:38 A.M., Dietary [NAME] (DC) #407 washed his hands and then obtained food temperatures of the food on the steam table for tray line meal service. Continuous observation revealed the temperature of the ground baked ziti was 120 degrees Fahrenheit (F), pureed baked ziti was 120 degrees F, and the pureed beets were 130 degrees F. Concurrent interview with DC #407 verified the temperatures and stated the items would heat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure physician orders were followed and implemented. This affected two (#46 and #62) of six residents reviewed for physician orders. The facility census was 59. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 11/10/21. Diagnoses included dementia, anxiety disorder, Alzheimer's disease, muscle weakness, and difficulty walking. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required substantial to maximum assistance from staff for transfers. Review of the physician orders for December 2024 revealed active orders to encourage the resident to elevate feet throughout day for every shift for bilateral edema to feet. Interview on 12/16/24 at 1:44 P.M., with Resident #46's family member revealed the resident was recently started on a blood thinner for a blood clot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, and staff interviews, the facility failed to ensure physician ordered pressure relieving devices were in place to prevent pressure ulcers. This affected one (#21) of two residents reviewed for pressure sores. The facility census was 59. Findings include: Review of Resident #21's medical record revealed an admission date of 10/18/22 and re-admission date of 11/19/24, with diagnoses including: displaced fracture of the neck of the right femur, muscle weakness, and aftercare following joint replacement surgery. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was alert with cognition impairment. Review of the MDS assessment revealed Resident #21 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 12/09/24 revealed Resident #21 had a fracture and was at risk for increased pain, limited ambulation, and further injury related to a right femur fracture. Interventions included abductor pillow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of policy, the facility failed to ensure foot care was provided as needed. This affected two (#15 and #41) of two residents reviewed for non-pressure wounds. The facility census was 59. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 08/25/20. Diagnoses included type two diabetes mellitus, idiopathic peripheral autonomic neuropathy, cellulitis of unspecified part of limb, and erythema intertrigo. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #41 was dependent for dressing, toilet use, transferring, putting on and taking off footwear and was unable to walk. Resident #41 had no skin ulcers, wounds, or other skin problems identified at the time of the assessment. Review of the care plan dated 02/24/23 revealed Resident #41 had diabetes mellitus and was at risk for diabetic related complications. Interventions included to use a draw…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, and staff interviews, the facility failed to ensure a resident with limited range of motion from a fractured hip was provided with positioning device to prevent dislocation of hip. This affected one (#21) of six residents reviewed for accidents. The facility census was 59. Findings include: Review of Resident #21's medical record revealed an admission date of 10/18/22 and re-admission date of 11/19/24, with diagnoses including: displaced fracture of the neck of the right femur, muscle weakness, and aftercare following joint replacement surgery. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was alert with cognition impairment. Resident #21 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 12/09/24 revealed Resident #21 had a fracture and was at risk for increased pain, limited ambulation, and further injury related to a right femur fracture. Interventions included abductor pillow 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, staff interview, medical record review, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had three medication errors of 25 opportunities for an error rate of 12%. This affected two (#31 and #32) of four residents reviewed for medication administration. The facility census was 59 residents. Findings include: 1. Review for Resident #31's medical record revealed an admission date of 12/18/20. Diagnoses included muscle wasting, hypocalcemia, and [NAME] syndrome (an immune system illness). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact. Review of the care plan dated 01/06/23 revealed Resident #31 was at risk for constipation related to decreased mobility and medication use. Interventions included to administer medications as ordered. Review of the physician orders for Resident #31 for December 2024 revealed an order for Miralax oral powder 17…

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

Based on observations, medical record review, policy review, resident interview and staff interview, the facility failed to arrange an Maxillary Oral Surgeon consult as ordered. This affected one (#2) of one resident reviewed for dental services. The facility census was 59. Findings included: Review of Resident #2's medical record revealed an admission date of 07/07/22, with diagnoses including: unspecified dementia, gastroesophageal reflux disease, and hypertensive heart disease without heart failure. Review of the quarterly Minimum Data Set (MDS) assessment completed on 10/07/24 revealed Resident #2 had no broken or loosely fitting full or partial dentures or mouth or facial pain, discomfort or difficulty chewing. Review of care plan initiated on 10/02/18, revealed Resident #2 had potential for dental concerns and was at risk for increased pain and infections as evidenced by own teeth, poor dentition, and rejections of assistance with oral hygiene. Interventions included observe for pain, excessive bleeding, et cetera (etc) and report to physician (MD), observe for signs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review, and review of policy, the facility failed to ensure accurate documentation reflecting care and treatment provided. This affected two (#15 and #62) of three residents reviewed for wound care. The facility census was 59. Findings include: 1. Review for Resident #62's medical record revealed an admission date of 10/07/24. Diagnoses included cutaneous abscess of perineum, rectal abscess, Crohn's disease, and rectal fistula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 had medically complex conditions including ulcerative colitis, Crohn's, and inflammatory bowel disease. Resident #62 received antibiotics and received intravenous (IV) medication. Review of the care plan for Resident #62 dated 10/23/24 revealed the resident was on IV - peripherally inserted central catheter (PICC) antibiotics related to peritoneal abscess. Interventions included to observe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of policies, the facility failed to ensure infection control practices were maintained during a sterile peripherally inserted central catheter (PICC) line dressing change. This affected one (#62) of one resident reviewed for infection control with intravenous access care. The facility census was 59. Findings include: Review for Resident #62's medical record revealed an admission date of 10/07/24. Diagnoses included cutaneous abscess of perineum, rectal abscess, Crohn's disease, and rectal fistula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 had medically complex conditions including ulcerative colitis, Crohn's', and inflammatory bowel disease. Resident #62 received antibiotics and received IV medication. Review of the care plan for Resident #62 dated 10/07/24 revealed Resident #62 was to be on Enhanced Barrier Precautions as evidence by a peripherally inserted…

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 facility policy review, the facility failed to ensure call lights were answered in a timely manner and failed to promptly address resident needs. This affected one resident (#14) of three residents reviewed for call light response and had the potential to affect all 60 residents residing in the facility. Findings include: Review of the medical record for Resident #14 revealed and admission date of 03/08/24. Diagnoses included congestive heart failure (CHF), muscle weakness, chronic obstructive pulmonary disease (COPD), depression, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. She was dependent on staff for toileting, showering and dressing, required partial to moderate assistance for personal hygiene and set-up or clean-up assistance for eating and oral hygiene. Review of the care plan dated 03/14/24 revealed Resident #14 had a self-care deficit due to fatigue, CHF,…

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

Based on record review and interview, the facility failed to employ a full-time licensed social worker (LSW) as required. This had the potential to affect all 68 residents in the facility. Findings include: Review of the employee list provided by the facility revealed no LSW listed as being employed at the facility. Interview on 01/29/24 at 9:48 A.M. with the Administrator revealed the facility did not have a full-time social worker. Interview on 01/29/24 at 10:36 A.M. with the Regional Director of Operations (RDO) #200 confirmed the facility was certified and licensed for 122 beds. She confirmed the facility did not currently have a full-time LSW. This deficiency represents noncompliance investigated under Master Complaint Number OH00150251.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure residents and/or their representatives were invited to participate in care conferences as required. This affected three residents (#7, #36, and #43) of three residents reviewed for participation in care planning. The facility census was 68. Findings include: 1. Review the medical record for Resident #7 revealed an admission date of 2/24/21. Diagnoses Included chronic obstructive pulmonary disease (COPD), diabetes, depression, dementia, and anxiety. The resident had a legal guardian. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. He required supervision for showering or bathing and hygiene, set up help for eating, oral hygiene and was independent in toileting. Review of the medical record review the care conference was held for Resident #7 on 01/26/23. Those in attendance included the social worker, activities, and nursing administration. There was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure care conferences were completed as required. This finding affected three residents (#7, #36 and #43) of three residents reviewed for care planning. The facility census was 68. Findings include: 1. Review the medical record for Resident #7 revealed an admission date of 02/24/21. Diagnoses Included chronic obstructive pulmonary disease (COPD), diabetes, depression, dementia, and anxiety. The resident had a legal guardian. Review of the comprehensive Minimum Data Set (MDS) assessment date 01/13/24 revealed Resident #7 was cognitively intact. He required supervision for showering or bathing and hygiene, set up help for eating, oral hygiene, and was independent in toileting. Review of the medical record review the care conference was held for Resident #7 on 01/26/23. Those in attendance included the social worker, activities, and nursing administration. There was no documented evidence in the medical record that the resident…

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