Trotwood Health & Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to ensure Resident #10's medications were administered as ordered and failed to ensure Resident #46's pain medication was timely reordered/available for administration. This affected two (#10 and #46) out of six residents reviewed for medication administration. The facility census was 49. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/30/25 with diagnoses of chronic obstructive pulmonary disease, edema, post-traumatic stress disorder, and essential (primary) hypertension. Review of the care plan dated 05/30/25 revealed Resident #10 is at risk for altered cardiac output related to diagnosis of hypertension with interventions of administer medication as ordered and obtain Vital signs as ordered and as needed (PRN). Notify physician as needed. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. 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 medical record review, observation, resident interview, and staff interview the facility failed to ensure the building and furnishings were in good repair. This affected Resident #43 and the 19 residents residing in the in the 300/400 hall (#2, #3, #8, #10, #11, #14, #18, #21, #23, #28, #32, #37, #39, #41, #42, #43, #44, #45, and #46). The facility census was 47 residents. Findings include: 1.Review of the medical record for Resident #43 revealed an admission date of 02/17/25 with diagnoses including chronic obstructive pulmonary disease and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 05/21/25 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs). Observation on 06/04/25 at 9:10 A.M. of Resident #43's room revealed there was a hole in the wall approximately 18 inches above the baseboard which measured approximately nine inches in diameter. Interview on 06/04/25 at 9:10 A.M. with Resident #43 confirmed the hole in his wall had been there when he was admitted to the facility 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, interview, and facility policy review, the facility failed to provide a clean, homelike environment with working showers. This had the potential to affect all residents. The facility also failed to provide a clean floor for Resident #36. The facility census was 45. Findings include: 1. Interview and observation on 03/26/25 at 9:00 A.M. with Licensed Practical Nurse (LPN) #255 confirmed the 500-hallway shower room was the only shower room used by all residents in the facility. LPN #255 confirmed the first two shower room stalls were not functioning. She confirmed the dirt, debris, and trash scattered all over the floor of the shower room. LPN #255 confirmed the lights in the 500-hall shower room contained multiple brown items that appeared to be bugs. LPN #255 confirmed the bathroom stall had a sign that read, Do Not Use, dated 01/22/25. LPN #255 opened the bathroom stall door next to the shower stall and the toilet had various pieces of colored tape on it. The toilet contained black water.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, the facility failed to administer medications per physicians orders. There were two medication errors out of 31 opportunities resulting in a 6.45 percent (%) medication error rate. This affected two (Residents #40 and #47) of three residents reviewed for medication administration. The facility census was 45. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 09/14/23. Diagnoses included chronic obstructive disease, cystocele, overactive bladder, depression, cognitive communication, and anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 required setup or clean up assistance for meals, and oral care. Resident #40 required supervision or touching assistance for bathing, dressing upper and lower body, toilet hygiene, personal hygiene, and placing shoes on and off feet. Review of physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview, and policy review, the facility failed to ensure medications were stored in a safe manner. This affected one (Resident #19) of one resident observed for medication storage. The facility census was 45. Findings include, Medical record review for Resident #19 revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependent withdrawal, emphysema, anxiety disorder, major depressive disorder, polycythemia, chronic obstructive pulmonary disease (COPD), asthma, hypokalemia, foot drop, irritable bowel syndrome, delusional disorder, acute respiratory failure, acute kidney failure, pleural effusion, and acute respiratory failure with hypoxia. Review of Minimum Date Set (MDS) assessment, dated 03/18/25, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 and this indicated he was cognitively intact. Resident #19 required set up, clean up assistance for meals, and oral care. Resident #19 required supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure a comfortable environment. This affected one (Resident #46) of three residents reviewed for comfortable temperatures. The facility census was 48. Findings include: Review of medical records for Resident #46 revealed the resident admitted to the facility on [DATE]. Diagnoses included psychosis, anxiety disorder, type two diabetes, and schizoaffective disorder bipolar type. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of three, indicating he was severely cognitively impaired. Resident #46 required supervision and touching for meals, personal hygiene, toileting, bathing, placing shoes on and off, dressing upper and lower body, and oral care. Observation on 02/26/25 from 9:53 A.M. through 10:20 A.M. of Resident #46's room revealed the door was open and the temperature was 66 degrees Fahrenheit. There was a heater outside the door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected one (Resident #44) of three residents reviewed for medication administration. The facility census was 48. Findings include: Review of medical records for Resident #44 revealed an admission date on 08/24/21. Diagnoses included chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15 indicating he was cognitively intact. Resident #44 had required extensive bed mobility assistance, one-person physical assist for bed mobility, transfers in bed mobility, and toileting hygiene. Review of the plan of care dated 12/18/24 revealed Resident #44 was at risk for pain related to muscle spasm, post procedural pain, and chronic pain. Interventions included to administer medication as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and review of facility policy, the facility failed to ensure the facility was free from medication error rate less than 5%. A total of 30 opportunities were observed with two errors observed, resulting in a 6.6% medication error rate. This affected one resident (#44) of three residents reviewed for medication administration. The facility census was 48. Findings include: Review of medical records for Resident #44 revealed an admission date on 08/24/21. Diagnoses included chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact. Resident #44 required extensive bed mobility assistance, one-person physical assist for bed mobility, transfers in bed mobility, and toileting hygiene. Review of physician order dated 08/20/24 revealed Resident #44 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, review of the facility census and review of facility policy, the facility failed to ensure air temperatures were maintained within comfortable ranges for residents residing on the secure behavioral unit (100 hall). This had the potential to affect 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents who resided on the secure behavior unit (100 hall). The census was 49. Findings include: Observation of the secure behavioral unit (100 hall) on 01/21/25 from 4:16 P.M. to 4:30 with Maintenance Director (MD) #110 and the Administrator revealed air temperatures were below 71 degrees Fahrenheit (F). A check of room air temperatures revealed room [ROOM NUMBER] was at 43.6 degrees F, room [ROOM NUMBER] was at 55 degrees F, and room [ROOM NUMBER] was at 51.1 degrees F. The air temperature in all 12 rooms ranged from 43.6 F to 55 F. Two portable heating units were present in the hallway. Residents were observed in the secure behavioral unit and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident, staff and physician office staff interviews, the facility failed to provide medically-related social services by failing to provide assistance with a resident's medical appointments to an outside provider. This affected one (#21) of three residents reviewed for medical appointments. The facility census was 51. Findings include Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to congestive obstructive pulmonary disease, chronic pain, hypertension, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed the resident had intact cognition. Resident #21 required set up or clean up assistance for eating, supervision or touching assistance for toileting, bed mobility and transfers. Review of the Resident Appointment Sheet for Resident #21 revealed an appointment for unknown physician on 10/17/24 with a pickup time scheduled for 1:45 P.M. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and pharmacist interviews and policy review, the facility failed to ensure medications were administered according to physicians orders, failed to ensure licensed nursing staff accurately documented the administration of medications in the medical record and failed to ensure medications were re-ordered/available from the pharmacy. This affected two (#52 and #21) of three reviewed for medication administration. The facility census was 51. Findings include 1. Medical record review for Resident #52 revealed an admission on [DATE]. Diagnoses include hydronephrosis, anemia, gastroesophageal reflux disease, benign prostatic hyperplasia, obstructive uropathy, thyroid disorder, anxiety, and schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #52 revealed the resident had impaired cognition. Resident #52 required maximum assistance for eating, toileting, and moderate assistance for transfers and bed mobility. Review of the…

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

Based on review of nursing schedules and staff interview, the facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 52 residents. Findings include: Review of nursing schedule dated 06/16/24 revealed there was no RN scheduled. Interview on 07/17/24 at 9:43 A.M. with the Director of Nursing (DON) confirmed the facility did not have an RN work on 06/16/24.

Based on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 32(#01, #02, #03, #05, #06, #08, #09, #10, #12, #17, #18, #19, #22, #23, #27, #29, #30, #31, #32, #35, #36, #37, #41, #42, #44, #46, #47, #49, #50, #51, #53, and #54) of the 52 residents observed for environment. The facility census was 52. Findings include: 1. Observation of the secured Memory Care Unit (MCU) on 07/08/24 at 10:20 A.M. with State Tested Nursing Assistant (STNA) #341, revealed a very dirty, upswept, light brown laminate wood floors that were 80 percent (%) stained with black coloring throughout the middle of the hall. The entire floor had food crumbs scattered throughout the halls, soda cans and other trash debris in the floor. Interview with STNA #341 on 07/08/24 at 10:28 A.M., verified the environmental conditions of the secured MCU. 2. Observation of Resident #44's room on 07/08/24 at 11:40 A.M., revealed the resident's room felt warm. Interview with Resident #44 at the same 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 medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents did not have access to knives, razors, and smoking materials and smokers were supervised while smoking. This affected Residents #50, #29, #48 and #107. The facility identified 28 Residents (#01, #03, #04, #07, #09, #16, #18, #19, #20, #21, #22, #24, #27, #30, #31, #34, #35, #37, #38, #40, #41, #42, #44, #48, #50, #51, #53, and #54) who smoked. The facility census was 52. Findings include: 1. Review of the medical record of Resident #50 revealed an admission date of 09/14/23. Diagnoses included alcoholic cirrhosis of liver with ascites, chronic obstructive pulmonary disease, anxiety, hypertension, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition and was independently mobile. Review of the Smoking Assessment for Resident #50 dated 06/12/24 revealed the resident needed 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, staff interview, and review of the dishwasher manual, the facility failed to ensure the dishwasher was functioning to clean and sanitize dishes appropriately. This had the potential to affect 51 of 52 residents in the facility. The facility identified one resident (#15) who did not receive food from the kitchen. The facility census was 52. Findings include: Interview on 07/11/24 at 8:51 A.M. with Dietary Supervisor (DS) #502 confirmed she had called for the dishwasher to be serviced on 07/08/24 and the sanitizer concentration levels had read 0 parts per million (ppm) for a few weeks. DS #502 further confirmed the dishwasher remained in use during the time the sanitizer levels read 0 ppm. DS #502 stated the sanitizer level should be at 50 ppm for safe use. Observation on 07/11/24 at 9:00 A.M. revealed there was a sign on the dish machine indicating the sanitizer level should be 50 ppm for proper use. Observation on 07/11/24 at 9:01 A.M. revealed DS #502 tested the sanitizer level with a test strip and the test strip did not change color indicating the machine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with wounds and indwelling medical devices were placed in enhanced barrier precautions (EBP). This affected five (#14, #15, #16, #28, and #33) of five residents reviewed for EBP. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/20/22 with diagnoses including congestive heart failure, osteomyelitis, alcohol dependence, open wound right ankle, systemic lupus, schizoaffective disorder, major depressive disorder. Review of the quarterly Minimum Data Set (MDS) for Resident #14 assessment dated [DATE] revealed the resident had intact cognition, refused care daily, and required supervision or touching assistance with activities of daily living (ADLs.) Review of the non pressure skin grid for Resident #14 dated 07/05/24 revealed the resident had an unstageable vascular ulcer to his right lower extremity. Review of…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations. This affected five (Resident #2, #5, #16, #33, and #47) of five residents reviewed for vaccinations. The facility census was 52 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 08/25/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #5 revealed an admission date of 11/06/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #16 revealed an admission date of 04/16/24. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #33 revealed an admission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were provided with dignity and respect. This affected two (#17 and #33) residents of the five residents reviewed for dignity and respect. The facility census was 52. Findings included: 1. Review of the medical record for Resident #33 revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes, schizophrenia, candidiasis, cerebral infarction, and overactive bladder. Review of the plan of care dated 05/06/24, revealed Resident #33 had an indwelling catheter related to obstructive and reflux uropathy. Interventions included change catheter bag as needed, document urine output, observe catheter for any kinks, and staff to provide catheter care every shift. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had Brief Interview Mental Status (BIMS) of 15 which indicated he was cognitively intact. Observation of Resident #33 in his bed on…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a resident's weight loss. This affected one (Resident #40) of two residents reviewed for nutrition. The facility census was 52. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/13/23. Diagnoses included type two diabetes, emphysema, hypertensive heart disease, hyperlipidemia, peripheral vascular disease, congestive heart failure, anxiety, major depressive disorder, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 06/20/24 revealed the resident had intact cognition, weighed 151 pounds, and had experienced a significant weight loss. Review of the medical record for Resident #40 revealed the following weights: 179.6 pounds on 12/04/23, 167.7 pounds on 02/01/24, 172 pounds on 03/06/24, 164.2 pounds on 04/01/24, 151.4 pounds on 06/07/24. Resident #40 experienced a weight loss of 15.7 percent (%) in six-month period and an 11.9 % weight loss in a three month…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and Guardian interview, observations, review of emergency room (ER) records, review of witness statements, review of Self-Reported Incidents (SRI's) and review of the facility policy, the facility failed to provide adequate supervision to prevent resident-to-resident sexual abuse. This affected two (#29 and #43) of the ten residents reviewed for abuse. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction, seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident interview, staff interviews, review of witness statements and policy review, the facility failed to timely implement their abuse policy during allegations of staff-to-resident verbal abuse. This affected one (#18) of the 10 residents sampled for abuse. The facility census was 52. Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified bipolar disorder, unspecified hemiplegia affecting left dominant side, unspecified anxiety disorder, uncomplicated opioid dependence and marijuana abuse, and unspecified Chronic Obstructive Pulmonary Disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact, had verbal behaviors, did not wander, and occasionally rejected care. Review of a witness statement dated 07/17/24 and authored by State Tested Nurse Aide (STNA) #360, revealed she went into Resident #18's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, observation, review of witness statements, review of the facility policy, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate allegations of sexual abuse. This affected one (#29) of the ten residents reviewed for abuse. The facility census was 52. Findings included: Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction, seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had a court appointed Guardian. Review of a behavior note for Resident #29 dated 03/08/24 at 2:30 A.M. 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 resident interviews, staff interviews, review of the medical record, and policy review, the facility failed to hold quarterly care conferences with residents and/or resident's representatives. This affected three (#29, #49 and #51) of the three residents sampled for care conferences. The facility census was 52. Findings include: 1. Review of medical record for Resident #29 revealed the resident was admitted on [DATE]. D diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction (heart attack), seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had a court appointed Guardian. Review of the Minimum Data Set (MDS) assessment for 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 medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide services to maintain resident vision. This affected one (Resident #46) of eight residents sampled for vision services. The facility census was 52 residents. Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/02/23 with diagnoses including type two diabetes, unspecified visual loss, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the physician orders for Resident #46 revealed an order dated 03/21/24 for the resident to be referred to an ophthalmologist for decreased vision. Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 04/09/2024 revealed the resident had moderately impaired cognition, had highly impaired vision, and had no corrective lenses. Review of care plan for Resident #46 dated 06/06/2024 revealed the resident had an alteration in visual function related to low vision abilities. Interventions included to obtain eye exam consultations to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure dietary supplements were administered per the physician's order. This affected one (#106) of two residents reviewed for nutrition. The facility census was 52. Findings include: Review of the medical record of Resident #106 revealed an admission date of 06/02/24. The resident transferred to the hospital on [DATE] and did not return. Diagnoses included acute gastroenteritis and colitis, post-traumatic stress disorder (PTSD), major depressive disorder, cerebral infarction, adult failure to thrive, colon cancer, diabetes mellitus, emphysema, mild protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 had adequate short and long-term memory. The resident required supervision or touching assistance for eating, weighed 103 pounds, had no known significant weight changes, and received a mechanically altered diet. Review of the physician orders for Resident #106 dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications as ordered. This affected one (#39) of four residents reviewed for pain. The facility census was 52. Findings include: Review of the medical record of Resident #39 revealed an admission date of 08/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD), constipation, insomnia, hypertension, pain, emphysema, anxiety disorder, major depressive disorder, polycythemia vera, alcohol dependence with withdrawal delirium. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. The resident did not display behaviors during the assessment period. Review of the physician orders for Resident #39 dated 10/23/23 revealed the resident was ordered to receive Celebrex 100 milligrams (mgs) two times a day for pain. Physician orders dated 10/24/23, revealed Aspirin 81 mgs daily for prevention, folic acid 1 mg daily for supplement, omeprazole…

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

Based on medical record review, resident interview, and staff interview, the facility failed to obtain radiology services per physician's order. This affected one (Resident #107) of one reviewed for constipation. The facility census was 52 residents. Findings include: Review of the medical record of Resident #107 revealed an admission date of 06/17/24 with diagnoses including humerus fracture, major depressive disorder, low back pain, chronic bronchitis, suicidal ideations, nicotine dependence, age-related osteoporosis, and hypocalcemia and a discharge date of 07/11/24. Review of the Minimum Data Set (MDS) assessment for Resident #107 dated 06/25/24 revealed the resident had intact cognition and required partial/moderate assistance for transfers. Review of the medical record revealed Resident #107's last bowel movement was a medium, formed stool on 07/04/24. Review of a progress note for Resident #107 dated 07/08/24 timed at 9:56 P.M. revealed the resident complained of lower abdominal pain and stated he had not had a bowel movement in five days. The physician was notified and…

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

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received follow up care to dental visits. This affected two (Residents #46 and #49) of three residents sampled for dental care. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 10/02/23 with diagnoses including type two diabetes, unspecified visual loss, unspecified chronic obstructive pulmonary disease, and chronic kidney disease. Review of care plan for Resident #46 dated 10/02/2023 revealed the resident was at risk for oral /dental problems related to having natural teeth. Interventions included the following: administer medications as ordered, assist with lip balm for dry/cracked lips, arrange for dental care/transportation as needed, observe/report dental abnormalities, assist with oral care as needed. Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 04/09/2024 revealed the resident had moderately impaired cognition. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure resident records adequately reflected resident status. This affected one (Resident #107) of one resident reviewed for constipation. The facility census was 52 residents. Findings include: Review of the medical record of Resident #107 revealed an admission date of 06/17/24 with diagnoses including right humerus fracture, major depressive disorder, low back pain, chronic bronchitis, suicidal ideations, nicotine dependence, age-related osteoporosis, and hypocalcemia and a discharge date of 07/11/24. Review of the Minimum Data Set (MDS) assessment for Resident #107 dated 06/25/24 revealed the resident had intact cognition and required partial/moderate staff assistance for transfers. Observation on 07/15/24 at 9:00 A.M. revealed Resident #107 was not in his room and was unable to be located by the Surveyor. Review of the medical record for Resident #107 revealed it did not include documentation of resident's location.…

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

Based on medical record review, observation, and staff interview, the facility failed to ensure residents had functioning call lights. This affect three (Residents #2, #47, #53) of three residents reviewed for call lights. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 08/25/23 with diagnoses including schizophrenia, dementia, chronic pulmonary disease, and delusional disorder. Review of care plan for Resident #2 dated 05/06/24 revealed that the resident was at risk for falls and interventions included keeping the call light within reach. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/16/24 revealed the resident was cognitively intact and required supervision with light touch assistance for transfers, bathing, meals, personal hygiene, dressing, and oral care. Observation on 07/08/24 at 10:05 A.M. through 10:35 A.M. revealed Resident #2 was in bed and the call light was sounding. There was no call light cord in the resident's room for the resident to summon assistance and…

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

Based on observations and staff interviews, the facility failed to provide a comfortable, clean, and homelike environment by not ensuring comfortable air temperatures on 100 Hall. This had the potential to affect 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents residing on the 100 Hall. Additionally, the facility failed to ensure the facility was free of pervasive odors on 500 Hall. This had the potential to affect 10 (#46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) residents residing on the 500 Hall. The facility census was 55. Findings include: Observation on 06/04/24 at 8:26 A.M. of 500 Hall revealed the pervasive urine odor. Observation on 06/04/24 at 1:21 P.M. revealed the air temperature on 100 Hall to feel very warm. The observation revealed multiple residents walking in the hallways and into rooms on the unit. None of the residents observed appeared to be in any distress. The observation revealed one portable air conditioning unit which was pumping cool air on to the unit. Observation with interview on 06/04/24 at 1:24 P.M. with Maintenance #201 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 record review observations, staff and resident interviews, and policy review, the facility failed to ensure the call light was within a resident's reach. This affected one (#47) out of three residents reviewed for call lights. The facility census was 55. Findings include: Review of the medical record for Resident #47 revealed an admission date of 10/02/23 with medical diagnoses of diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, dementia with behavioral disturbances. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #47 had moderately impaired cognition and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. The MDS also noted Resident #47 had highly impaired vision. Observation and interview on 06/04/24 at 10:34 A.M. of Resident #47 revealed the call light was resting on the headboard of Resident #47's bed and was not within her reach or line…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed implement their smoking policy to ensure a resident who smokes was assessed upon admission. Additionally, the facility failed to provide adequate interventions and/or supervision to ensure resident's smoking materials were properly secured per the facility smoking policy. This affected two (#51 and #46) out of three residents reviewed for smoking. The facility census was 55. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/14/24 with medical diagnoses of paraplegia, anxiety, bipolar disorder, chronic hepatitis C, schizoaffective disorder, and congestive heart failure. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #51 was cognitively intact and was dependent upon staff for toilet hygiene, requires substantial staff assistance for bathing and moderate staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#23 and #47) residents out of the three residents reviewed for medications administered as ordered. The facility census was 55. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 08/24/21 with medical diagnoses of COPD, hypertension (HTN), convulsions, anxiety, liver disease, and depression. Review of the medical record for Resident #23 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #23 was cognitively intact and was independent with toileting, bed mobility, transfers, and required supervision with showers. Review of the medical record for Resident #23 revealed physician orders dated 10/23/23 for Celebrex 100 milligram (mg) one capsule by mouth two times per day and for Elavil sleep tablet 25 mg one tablet by mouth at bedtime, orders dated 10/24/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure resident's medications were administered as ordered resulting in two medication errors out of 30 opportunities or a 6.66 percent (%) medication error rate. This affected one (#53) out of two residents observed for medication administration. The facility census was 55. Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/24/17 with medical diagnoses of cerebral infarction, right sided hemiparesis, paranoid schizophrenia, and bipolar disorder. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #53 had moderate cognitive impairment and was independent with eating, toileting, transfers, and bed mobility and required supervision with bathing. Review of the medical record for Resident #53 revealed a physician order dated 09/22/23 for Gabapentin 300 milligram (mg) one tablet by mouth daily,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to obtain laboratory work as ordered. This affected one (#65) out of the three residents reviewed for nutrition. The facility census was 55. Findings include: Review of the medical record for Resident #65 revealed an admission date of 05/06/22 with medical diagnoses of depression, rhabdomyolysis, severe protein calorie malnutrition, dementia, and schizophrenia. Review of the medical record revealed Resident #65 discharged to the hospital on [DATE]. Review of the medical record for Resident #65 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/01/24, which indicated Resident #65 had severe cognitive impairment and was independent with transfers and bed mobility but required substantial staff assistance for toileting hygiene and bathing. Review of the medical record for Resident #65 revealed a physician order dated 04/30/24 for the following blood work to be done: comprehensive metabolic panel (CMP), complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure the call light system was functioning properly. This affected two (#23 and #47) out of the three residents reviewed for call lights not functioning properly. The facility census was 55. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 10/02/23 with medical diagnoses of diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, dementia with behavioral disturbances. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #47 had moderately impaired cognition and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. The MDS also noted Resident #47 had highly impaired vision. Observation and interview on 06/04/24 at 10:34 A.M. of Resident #47 revealed the call light was resting on the headboard of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#26) out of three residents reviewed for elopement. The facility census was 58. Findings included: Review of the medical record for Resident #26 revealed an admission date of 04/25/24 with medical diagnoses of chronic obstructive pulmonary disease, schizoaffective disorder, spinal stenosis, psychosis, and mild neurocognitive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 05/02/24, indicated Resident #26 had moderate cognitive impairment, had delusions, and had verbal behavioral symptoms towards others. The MDS indicated Resident #26 required set-up assistance with eating, moderate staff assistance with toilet hygiene and dressing, and maximum staff assistance with bathing. The MDS indicated Resident #26 required supervision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure proper disposal of medications after a resident was discharged from the facility. This affected one (#60) out of three residents reviewed for medication disposition after discharge from the facility. The facility census was 58. Findings include: Review of the medical record for Resident #60 revealed an admission date of 07/10/23 with medical diagnoses of pneumonia, severe protein calorie malnutrition, Human Immunodeficiency Virus (HIV), Hepatitis C, and asthma. Review of the medical record revealed Resident #60 was discharged to the hospital on [DATE] and did not return to the facility. Review of the medical record for Resident #60 revealed an admission Minimum Data Set (MDS) assessment, dated 07/17/23, which indicated Resident #60 was cognitively intact and required supervision with bed mobility, transfers, toileting, and bathing. The MDS indicated Resident #60 required extensive staff assistance with eating. Review of the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff and resident interviews, and facility policy review, the facility failed to ensure a resident's call light was functioning properly. This affected one (#02) out of the three residents reviewed for call lights. The facility census was 58. Findings include: Review of the medical record for Resident #02 revealed an admission date of 08/03/21 with medical diagnoses of chronic respiratory failure, cirrhosis of the liver, cerebral infarction, and anemia. Review of the medical record for Resident #02 revealed an annual Minimum Data Set (MDS) assessment, dated 04/15/24, which indicated Resident #02 had moderate cognitive impairment and required supervision with eating, toilet hygiene, transfer, bed mobility, and bathing. Interview and observation on 05/09/24 at 9:10 A.M. with Resident #02 revealed his call light had not worked for a few weeks. Resident #02 was observed to press his call light button. The observation revealed the call light indication box in Resident #02's room signaled the call light turned on, but the call light located outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews and review of Resident Council Meeting minutes, the facility failed to ensure the 200 Hall shower was in good working condition for resident use. This affected one (#31) out of the residents reviewed for functioning shower and also had the potential to affect nine (#26, #28, #30, #31, #32, #33, #34, #35 and #36) residents who reside on the 200 hallway that utilize the shower room. Additionally, the facility failed to ensure the roof did not leak onto the resident hallway on the 500 hall. This had the potential to affect 10 (#55, #56, #57, #58, #59, #60, #61, #62, #63 and #64) residents who reside on the 500 hallway where the room was leaking. The facility census was 50. Findings include: Observation on 04/11/24 at 7:21 A.M. revealed water was leaking from the ceiling onto the hallway floor, into a large trash can, a small bucket, and onto a large white towel on the 500 Hall. The observation revealed the area of the floor with water was three feet wide by two feet long and there was not a wet floor sign present. Observation on…

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

Based on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected three (#31, #37, and #42) out of the three residents reviewed for medication administration. The facility census was 50. Findings include: 1. Review of the medical record for resident #31 revealed an admission date of 01/20/22 with medical diagnoses of congestive heart failure (CHF), hypertension (HTN), hyperlipidemia, glaucoma in the right eye, and convulsions. Review of the medical record for Resident #31 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/14/24, which indicated Resident #31 was cognitively intact and was independent with bed mobility, required supervision with toilet hygiene and transfers and moderate staff assistance with bathing. Review of the medical record for Resident #31 revealed physician orders dated 02/04/24 for meclizine 12.5 milligram (mg) one tablet by mouth three times per day, carvedilol 3.125 mg one tablet by mouth two times per day, Tylenol extra strength 500 mg two tablet by mouth every eight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview the facility failed to ensure the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect all residents residing in the facility with the exception of two facility-identified residents (#33 and #44) who did not leave their rooms. The facility census was 47. Findings include: Tour of the facility on 01/10/24 at 7:55 A.M. revealed there were portable electric space heaters observed in the facility hallways and common areas which were accessible to residents. The following space heaters were observed during the tour: one small heater on the 100 hall, one small heater between the 100 and the 200 hall, one large heater on the 200 hall, one large heater on the 300 hall, one small heater in the chapel, one small heater in the dining room, one large heater in the lobby. The surface area of the front of the units where the heat was generated were uncovered and could have potentially caused a burn if touched. Interview on 01/09/24 at 9:10 A.M with Maintenance Director (MD) #26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee personnel record review, staff interview, and policy review, the facility failed to test employees for tuberculosis per the facility policy. This affected five (State Tested Nurse Aide (STNA) #104, STNA #131, STNA #128, Licensed Practical Nurse (LPN) #156, and LPN #162) of five employee personnel records reviewed. This had the potential to affect all 50 residents. The census was 50. Findings include: 1. Review of the personnel file for STNA #104 revealed a hire date of 09/27/23. Further review revealed no evidence of STNA #104 having a Mantoux test (a skin test used to screen for tuberculosis) completed. 2. Review of the personnel file for STNA #131 revealed a hire date of 08/14/23. Further review revealed no evidence of STNA #131 having a Mantoux test completed. 3. Review of the personnel file for STNA #128 revealed a hire date of 04/25/23. Further review revealed no evidence of STNA #128 having a Mantoux test completed. 4. Review of the personnel file for LPN #156 revealed a hire date of 06/06/23. Further review revealed no evidence of LPN #156 having a Mantoux…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, staff interview, review of the Activity Director (AD) job description, and review of the facility activity calendar, the facility failed to ensure the activities program was implemented as scheduled. This affected five (Residents #13, #16, #34, #56, #57) and had the potential to affect all the residents in the facility with the exception of the following 29 facility-identified (Residents #2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) who did not participate in activities. The facility census was 51. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 09/07/23 with diagnoses including chronic obstructive pulmonary disease (COPD), catatonic disorder, metabolic encephalopathy, osteoarthritis (OA), congestive heart failure (CHF), and paranoid schizophrenia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident…

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

Based on review of activity calendar, review of personnel files, staff interview, and review of job description, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 29 residents (#2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) identified by the facility as not participating in activities. The facility census was 51. Findings include: Review of the posted facility activity calendar dated September 2023 revealed there were resident activities scheduled seven days per week. Review of the personnel record for Activities Director (AD) #460 revealed the employee was a State Tested Nursing Assistant (STNA) and had a hire date of 05/24/23. Further review revealed AD #460 had no qualifications to be an AD. Interview on 09/21/23 at 8:59 A.M. with AD #460 confirmed she was hired on 05/24/23 to be the AD for the facility. AD #460 confirmed she developed the activity calendar 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were available for administration as ordered by the physician. This affected one (Resident #14) of four residents reviewed for medications. The facility census was 51 residents. Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/13/23 with diagnoses including diabetes, emphysema, hypertension (HTN), and chronic pain. Review of the Minimum Data Set for Resident #14 dated 09/20/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADLs). Review of the admission physician orders for Resident #14 revealed an order dated 09/13/23 for the resident to receive metformin twice daily for treatment of diabetes. Observation of medication administration on 09/25/23 at 8:49 A.M. for Resident #14 per Licensed Practical Nurse (LPN) #190, revealed metformin was not available 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 medical record review, staff interviews, and review of the facility policy, the facility failed to administer medications per physician orders to a resident. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 52. Finding include: Review of the medical record for Resident #57 revealed an admission date 07/21/23. Resident #57 discharged from the facility on 07/22/23. Diagnoses included infection and inflammatory reaction due to internal right knee prosthesis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact. Review of the medication administration record (MAR) revealed Resident #57 did not receive her medication for dates 07/22/23. On 07/22/23, the MAR had an X in all the squares. There were no licensed nurse's signature on the MAR indicating any medications were administered to Resident #57 during her stay at the facility. All medications were due starting on 07/22/23. Review of the…

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

Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 48 residents residing in the facility. Findings include: Review of the facility staffing records from 10/24/22 to 10/31/22 revealed the facility did not have RN coverage for eight consecutive hours on 10/30/22. Interview on 11/03/22 at 3:51 P.M. with the Administrator verified on 10/30/22, the facility did not have RN coverage for eight consecutive hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, medical record review and policy review, the facility failed to conduct quarterly care conferences. This affected four (Residents #08, #09, #27, and #40) out of the four residents sampled for care conferences. Facility census was 48. Findings include: 1. Review of the medical record for Resident #08 revealed an admission date of 10/18/13 with medical diagnoses of left hemiparesis, hypertensive retinopathy, polyneuropathy, hyperlipidemia, atherosclerotic heart disease, anxiety, and hypertension. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had moderate cognitive impairment. Further review of MDS revealed Resident #08 was dependent on staff for activities of daily living (ADLs). Review of the medical record for Resident #08 revealed a care conference note written by Social Service dated 10/21/22 at 12:00 P.M. The care conference note stated Resident #08's Power-of-Attorney (POA) attended the care conference via phone. Further review of the…

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

Based on record review, staff interview, and policy review, the facility failed to maintain evidence the Quality Assessment and Assurance (QAA) committee held quarterly Quality Assurance and Process Improvement (QAPI) meetings. This had the potential to affect all 48 residents in the facility. Findings include: Review of QAPI meetings revealed meetings were held in September 2022 and May 2022. There was no documentation or evidence of any additional QAPI meetings taking place during 2022 and 2021. Interview on 11/03/22 at 5:45 P.M. the Administrator verified there was no evidence of any additional QAPI meetings. The Administrator stated she held a QAPI meeting when she started working at the facility in September 2022, and was unable to locate any additional QAPI information (with the exception of May 2022), in the available records. The Administrator affirmed QAPI meetings should be held at least quarterly. Review of the facility policy titled, Quality Assurance and Process Improvement (QAPI) Plan, undated, revealed QAPI meetings will be held at least quarterly and a record of all…

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

Based on observation, resident interview, and staff interviews, the facility failed to ensure the dining room was available for accommodate resident preferences. This affected two (Residents #09 and #40) of three residents reviewed for accommodations of needs. The facility's census was 48. Findings include: Interview on 10/31/22 at 12:30 P.M. with Resident #09 revealed the facility did not enough staff to serve meals in the dining room. Interview on 10/31/22 at 12:45 P.M. with State Tested Nurse Aide (STNA) #170 revealed the facility removed an aide from the overall schedule, so there was no staff available to assist with the dining room. Observation with interview on 10/31/22 at 2:09 P.M. of Resident #09 revealed the resident was eating his meal in his room. Resident #09 stated the dining room was open about one month ago and he liked to socialize in the dining room. Resident #09 stated he was informed the dining room was closed due to not having enough staff to watch the residents in the dining room. Interview on 10/31/22 at 1:59 P.M. with Resident #40 stated she was told the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and family interviews, and review of facility policy, the facility failed to notify a resident's representative and resident's physician when resident had a change in condition. This affected one (Resident #35) of the three residents reviewed for notifications. The facility's census was 48. Findings include: Review of the medical record for Resident #35 revealed an admission date of 01/08/14. His diagnoses included, hemiplegia and hemiparesis following a cerebral infarction, peripheral vascular disease (PVD), aphasia, dysphagia, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired. Resident #35 was totally dependent upon staff for all activities of daily living (ADLs). Review of the progress note dated 09/21/22 revealed Resident #35 had a Stage III pressure ulcer (full thickness tissue loss) to his right heel. There was no documentation the resident's representative or physician was notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the facility failed to timely report an allegation of sexual abuse to the state agency. This impacted one (Resident #26) of three residents reviewed for abuse. The facility census was 48. Findings include: Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, high risk bisexual behavior, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions during the assessment period. Review of a nursing progress note dated 09/08/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident and/or resident's representative were notified of the facility's bed hold policy upon being transferred to the hospital. This impacted one (Resident #26) of two residents reviewed for hospitalization. Facility census was 48. Findings include: Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident transferred to the hospital again on 10/14/22 and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, and unspecified mood disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observations, and review of the Resident Assessment Instrument (RAI) version 3.0, the facility failed to develop a significant change Minimum Data Set (MDS) when indicated. This affected three (Residents #1, #34, and #35) of three residents reviewed for MDS completion. The facility census was 48. Findings included: 1. Medical record review for Resident #01 revealed and admission on [DATE] with diagnoses that included, but not limited to, terminal encephalopathy, cerebral vascular attack (CVA/stroke), and seizure disorder. Review of the most recent quarterly MDS assessment dated [DATE] for Resident #01 revealed the resident was severely cognitively impaired and required total care for bed mobility, transfers, toileting and eating. Further review of MDS assessments revealed no significant change MDS was noted when resident was admitted with hospice services. Review of the physician orders dated 09/23/20 for Resident #01 revealed an order for Hospice services. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed following a psychiatric hospitalization. This affected two (Residents #26 and #34) of five residents reviewed for PASARR. The facility census was 48. Findings include: 1. Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions during the assessment period. The resident was assessed has rejecting care daily during 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 interviews the facility failed to provide therapeutic activities to meet the needs and preferences of the resident population. This affected two (Residents #09 and #40) out of two residents reviewed for activities. The facility census was 48. Findings include: 1. Record review for Resident #09 revealed an admission date of 04/22/22. His diagnoses included, transient cerebral ischemic attack, cerebral infarction, essential primary hypertension, diabetes mellitus 2, major depressive disorder, hypoglycemia, hepatitis-C, dysphagia, atrial fibrillation (A-fib), and chronic obstructive pulmonary disease. Review of the minimum data set assessment (MDS) assessment dated , 07/30/22, revealed resident had mildly impaired cognition. Further review of the MDS assessment revealed Resident #09 required limited assistance or supervision for activities of daily living (ADLs). Interview on 10/31/22 at 12:27 P.M. with Resident #09 revealed he only attended bingo because there was not much to do. 2 Record review for Resident #40 revealed an admission date 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 medical record review, staff interview, and policy review, the facility failed to implement physician orders following a pharmacy medication review. This affected one (Resident #31) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Review of the medical record of Resident #31 revealed an admission date of 09/26/13. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus with diabetic polyneuropathy, nicotine dependence, personal history of traumatic brain injury (TBI), bipolar disorder, disorganized schizophrenia, gastro-esophageal reflux disease (GERD), insomnia, pseudobulbar affect, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. The resident was assessed as exhibiting physical and verbal behaviors directed towards others, other behavioral symptoms not directed towards others, and rejection of care one to three days during the assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete laboratory (lab) orders per pharmacy recommendations and physician's orders. This affected one (Resident #8) of one resident reviewed for lab orders. The facility's census was 48. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/18/13 with medical diagnoses of left hemiparesis, hypertensive retinopathy, polyneuropathy, hyperlipidemia, atherosclerotic heart disease, unspecified convulsions, epilepsy, anxiety, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment. Resident #8 was dependent upon staff for bed mobility, transfers, dressing, toileting, and bathing and the resident did not ambulate. Review of Resident #8's physician orders revealed an order dated 01/20/22 for Divalproex Sodium (generic form of Depakote) (mood stabilizer/seizures) tablet 500 milligram (mg) by mouth two times per day and an 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.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #46 and #35) of three residents reviewed for environment. The facility census was 48. Findings include: 1. Observation on 10/31/22 at 10:32 A.M. revealed the wall directly next to Resident #46's bed, which was positioned against the wall, had approximately 10 brown, raised spots of an unidentified substance on the wall, measuring approximately dime to half-dollar size. Further observation revealed the ceiling above the window had a large area, measuring approximately two feet by one foot, with peeling paint, four clusters of black spots, and a grey fibrous material. Interview on 10/31/22 at 10:35 A.M., with State Tested Nursing Assistant (STNA) #135 verified the spots on Resident #46's wall. STNA #135 stated she had not noticed the spots on the wall the last time she worked, three days prior. STNA #135 further verified the condition of the ceiling and stated she thought it was related to something leaking. STNA #135 stated the ceiling had been like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to ensure the facility kitchen was clean and food items were being properly stored. This affected 60 out of 61 residents who receive meals from the facility kitchen. The facility identified one (#47) resident who receive nothing by mouth (NPO). The facility census was 61. Findings include: 1. Tour of dry food storage area on 12/15/19 at 9:22 A.M. with Dietary Manager #459 revealed one bag of chocolate devils cake mix; one bag of powdered sugar; one bag of coffee cake mix; one bag of walnuts and one bag of raisins that was stored in the original plastic packaging. These items were opened and placed into a second plastic storage bag that was undated. Dietary Manager #459 confirmed the observation. 2. Tour of walk in refrigerator on 12/15/19 at 9:49 A.M., with the Dietary Manager #459 revealed an opened 128 ounce tub of banana peppers; a 128 ounce tub of thousand island salad dressing; a 128 ounce tub of teriyaki sauce; a 128 ounce tub of honey mustard salad dressing; a 128 ounce tub of Italian dressing and a 20 ounce bottle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and review of facility policy, the facility failed to maintain the building and equipment in a clean and homelike manner. This had the potential to affect 14 (#2, #14, #20, #24, #27, #30, #35, #39, #40, #46, #51, #55, #58, #60) residents residing in the 100 hall lock unit and three (#23, #53, and #57) residents residing in the unlocked areas out of 61 total residents residing in the facility. Facility census was 61. Findings include: Initial tour of the facility conducted on 12/15/19 throughout the day revealed Resident #53 was observed with an outlet box cover missing and wires exposed behind her bed; Resident #23 was observed with boxes on the floor next to her bed with personal belongings, and Resident #57 was observed with a broken off dresser drawer and his television was noted hanging to the left wall behind is head. Further observation conducted of the locked 100 hall revealed multiple rooms with chipped paint, broken/empty hand sanitizer canisters,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy, the facility failed to securely store medication in locked medication carts. This had the potential to affect 16 (#4, #11, #13, #15, #21, #25, #26, #31, #33, #42, #44, #45, #54, #57, #62, and #63) residents the facility identified as cognitively impaired and independently mobile. The facility census was 61. Findings include: Observation and interview conducted upon entrance to the facility on [DATE] at 8:18 A.M. revealed the medication cart in the 200/300 hall was observed to be left unlocked and unattended by staff. Licensed Practical Nurse (LPN) #301 arrived back to the cart after several minutes, and verified the cart had been left unlocked and unattended, and locked the cart. Observation and interview conducted on 12/16/19 at 4:18 P.M., while walking down the 300 hall with the Director of Nursing (DON) revealed a medication cart was observed to be left unlocked and unattended by staff. DON verified the medication cart was left unlocked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to properly document advanced directives. This affected one (#23) out of 24 advanced directives reviewed during the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Review of the medical record revealed Physician Orders dated [DATE] for Resident #23's code status to be a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, and review of facility policy, the facility failed to implement their abuse policy to ensure the staff thoroughly investigated an allegation of resident to resident sexual abuse. This affected one (#23) out of one reviewed for abuse during the investigation stage of the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, and review of facility policy, the facility failed to thoroughly investigate an allegation of resident to resident sexual abuse. This affected one (#23) out of one reviewed for abuse during the investigation stage of the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, the facility failed to develop the required 48 hour care plans for newly admitted residents. This affected three (#23, #35, and #47) of 17 residents reviewed during the investigation stage of the annual survey. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Further review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews and policy review, the facility failed to conduct and/or include the appropriate staff in the development of resident care plan and care planning conferences. This affected three (#35, #47 and #57) of 17 residents reviewed during the investigation stage of the annual survey. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behaviors, anxiety disorder, major depressive disorder, bariatric surgery, post-traumatic stress disorder, borderline personality disorder, and tobacco use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's preference for routine and activities noted it was very important to the resident to be able to choose her clothes, care for personal belongings, choose between showers/bath, have snacks between meals, choose bedtime, be around animals, use phone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review the facility failed to ensure nail care was provided to a resident who required assistance with personal hygiene. This affected one (#57) reviewed for personal hygiene. The facility census was 61. Findings included: Review of medical record of for Resident #57 revealed an admission date of 01/18/17 with diagnosis that include but limited to chronic breathing disorder, high cholesterol, need for personal assistance, repeated falls, depression, borderline personality disorder, impulse disorder, mental disorder, anxiety, high blood pressure, acid reflux disease, and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed impaired cognition. Resident requires extensive assist for bed mobility, transfers, dressing, personal hygiene and toileting with two staff members. Resident requires supervision for eating. Review of plan of care dated 10/10/18 for Resident #57 needs assistance for completion 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 medication record review, observation, staff, family and resident interviews, the facility failed to provide activities to meet the needs of the residents. This affected three (#14, #24, and #35) out of three residents reviewed for activities during the investigation stage of the annual survey who resided on the locked unit. This facility census was 61. Findings include: 1. Review of the medical record revealed Resident #14 was admitted to the facility with diagnoses including schizophrenia, hepatitis C, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was moderately cognitively impaired, with verbal behaviors occurred one to three days during the lookback period, other behaviors not directed toward others four to six days during the lookback period, and wandering behaviors occurring one to three days during the lookback period. Review of MDS dated [DATE] section F- Preferences for routine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff and resident interviews, the facility failed to ensure residents were afforded with full visual privacy. This affected two (#14 and #35) of two reviewed for Privacy during the investigation stage of the annual survey. The facility census was 61. Finding include: 1. Review of the medical record revealed Resident #14 was admitted to the facility with diagnoses including schizophrenia, hepatitis C, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was moderately cognitively impaired, with verbal behaviors occurred one to three days during the lookback period, other behaviors not directed toward others four to six days during the lookback period, and wandering behaviors occurring one to three days during the lookback period. Review of MDS dated [DATE] section F- Preferences for routine and activities revealed it was very important to-choose clothes 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.