Country Club Center I

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure a comprehensive COVID-19 vaccination program was implemented related to education and documentation of administration /refusal for four residents (Resident #5, #18, #30, and #65) of five residents reviewed for vaccination status and failed to ensure evidence of staff vaccination and education related to COVID-19 vaccination status was maintained. The facility census was 52.Findings include:Findings include: 1.Review of the medical record for Resident #5 revealed an immunization record which indicated she was administered a Covid-19 vaccination on 01/20/25. There was no consent located on the record and the immunization record did not indicate if the vaccine was administered at another location. Further review of the medical record for Resident #5 revealed a form titled 2024-2025 Formula Covid-19 Vaccine Form. The form was signed by Resident #5 but undated and only her name was written at the top of the form. The health screening 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 observation, interview and record review, the facility failed to maintain the dignity of a resident by leaving her pants pulled down while she was in bed. This affected one resident (#30) of three residents reviewed for dignity. The facility census was 52.Findings include:Review of the medical record for Resident #30 revealed an admission date of 08/22/22. Diagnoses included unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psycho-physiologic insomnia, unspecified mood disorder, weakness, history of falling, muscle weakness and difficulty walking. Review of the Minimum Data Set (MDS) version 3.0, dated 03/13/26, for Resident #30 revealed a Brief Interview for Mental Status (BIMS) score of 7 on a 0-15 scale. A score of 7 would indicate severe problems with thinking and memory. Per the MDS, the resident required a wheelchair for ambulation, and was dependent for all activities of daily living (ADLs). On 03/30/26 at 12:35 P.M., an observation of Resident #30 revealed she was lying in bed. She had on boots to protect her heels on each foot.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and record review, the facility failed to notify residents of a change in Medical Director or provide residents with a choice of physician and failed to ensure a resident had the right to choose how their diabetes mellitus was managed. This affected two residents (#3, #9) . The census was 52.Findings include:Findings include: 1.On 04/01/26, Review of the medical record for Resident #9 revealed the physician of record had changed from 03/31/26. The physician of record on 03/31/26 had been Medical Doctor #750. On 04/01/26, the physician of record was noted to be MD #1122. This was confirmed by the Director of Nursing on 04/01/26 at 12:10 P.M. Review of a document titled Medical Director Agreement dated 01/19/26 and signed by all parties on 02/02/26 revealed MD #1122 would be contracted effective 01/19/26 as the Medical director for the facility. DON #540 confirmed this document on 04/01/26 at 12:38 P.M. and indicated it was effective 04/01/26. Review of an electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and review of electronic communication, the facility failed to provide residents, families, and/or resident representatives with an explanation in advance, in writing, describing why a room or roommate reassignment took place. This affected two residents (#65, #52) of two residents reviewed for room change. The facility census was 52.Findings include:1.Review of the medical record for Resident #65 revealed he was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle and foot, type two diabetes mellitus with foot ulcer, repeated falls, pain in left and right hip and major depressive disorder. Review of a care plan for Resident #65, last updated 03/30/26 revealed a focus of care for behavioral concerns including inappropriate language, yelling out and making growling sounds. The goal was for the resident to have no episodes of inappropriate behavior. Interventions were to include providing support and encouragement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, policy review, and interview, the facility failed to ensure advanced directives were accurately documented per resident wishes. This affected one resident (#28) of three residents reviewed for death. Findings include:Closed medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including a left hip fracture, metabolic encephalopathy, anxiety and heart failure. Review of paper and electronic medical record revealed the following Advanced Directives for Resident #28:a. The electronic Physician Orders revealed Resident #28's was a Full Code starting on [DATE] through [DATE]. b. The paper medical record revealed a signed Full Code form dated [DATE]. c. The paper medical record revealed DNR Comfort Care-Arrest (DNRCCA) form dated [DATE] was signed by the residents spouse, the physician's name was printed on the DNR form but not signed. The date signed indicated the year was '2029'.d. The hospice provider faxed to the facility on [DATE] a DNR Comfort…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, beneficiary notice review, and interview, the facility failed to issue beneficiary notices as required. This affected one resident (#43) of three residents reviewed for liability notices. The census was 52. Findings include: Medical record review revealed Resident #43 was admitted on [DATE] with diagnoses including cerebral vascular accident, hypertension and neurogenic bladder. Resident #43 was discharged from therapy on 01/28/26 and discharged home on [DATE]. Review of the record revealed no beneficiary notice was issued to Resident #43. Review of the Social Service Note/Narrative dated 01/29/26 revealed Resident #43 discharged home on this day with home health services and no medical equipment was needed upon discharge. The resident's son was to transport the resident and was supplied with a medication list, discharge summary, discharge notice and a reminder of scheduled appointments. Review of Resident #43's Occupational Therapy (OT) Notes revealed the following:a. 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, review of manufacturer guideline review, policy review, and interview, the facility failed to ensure psychoactive medications administered had adequate indications for use. This affected one resident (#1) of five residents reviewed for unnecessary medications. The census was 52. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including encephalopathy, generalized anxiety disorder, severe sepsis with septic shock, cystitis, hyponatremia, depression, acute respiratory failure with hypoxia, asthma, pain, diabetes mellitus, pneumonia and insomnia. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact for daily decision-making, had no mood symptoms and no psychosis or behavioral symptoms. Resident #1 was administered antipsychotic medications daily. Review of the electronic Physician Orders dated April 2026 revealed Resident #1 was ordered Abilify 20 (mg) every morning since…

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

Based on interview, record review, self-reported incident dash board review, and policy review the facility failed to ensure an allegation of resident to resident physical abuse were reported to the Administrator and State Survey Agency (SSA) as required. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse. The facility census was 52. Findings include: 1.Review of Resident #15's medical record revealed an admission date of 10/22/21 with diagnoses including hypertension, hemiplegia (left side) and hemiparesis following cerebral infarction, major depressive disorder, muscle weakness, chronic pain syndrome, and insomnia. Review of Resident #15's care plan dated 11/01/21 revealed the resident needs assistance from staff to meet activity of daily living (ADL) needs related to decreased mobility, hip fracture, and hemiparesis due to an old cerebrovascular accident. Interventions include assisting the resident with transfers and mobility as needed. Review of Resident #15's quarterly minimum data set (MDS) completed on 01/30/26 revealed Resident #15 was…

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

Based on observation, record review, interview, investigation review and policy review the facility failed to ensure allegations of abuse were thoroughly investigated. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse.Findings include: 1.Review of Resident #15's medical record revealed an admission date of 10/22/21 with diagnoses including hypertension, hemiplegia (left side) and hemiparesis following cerebral infarction, major depressive disorder, muscle weakness, chronic pain syndrome, and insomnia. Review of Resident #15's care plan dated 11/01/21 revealed the resident needs assistance from staff to meet activity of daily living (ADL) needs related to decreased mobility, hip fracture, and hemiparesis due to an old cerebrovascular accident. Interventions include assisting the resident with transfers and mobility as needed. Review of Resident #15's quarterly minimum data set (MDS) completed on 01/30/26 revealed Resident #15 was moderately cognitively impaired. The resident did not exhibit behaviors or indicators of psychosis 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to ensure a comprehensive discharge process and receipt of a bed hold notice upon transfer. This affected two residents (#24 and #63) of six residents reviewed for discharges. The census was 52. Findings include:1. Closed medical record review revealed Resident #63 was admitted on [DATE] with diagnoses including hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene and cardiomyopathy. The resident was discharged from the facility on 03/11/26. Review of the care plan: Discharge Planning dated 03/16/25 revealed Resident #63 was long term placement due to his needs exceeded community resources. There was no evidence the care plan was updated to reflect the facility had been assisting the resident with discharge back to the community reflected on the care plan. The care plan was 'cancelled' on 03/16/26 after the resident was discharged from the facility. Review of the quarterly Minimum Data Set 3.0 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive assessments were completed timely as required. This affected one resident (#43) of 26 residents reviewed for assessments. The census was 52. Findings include: Medical record review revealed Resident #43 was admitted on [DATE] with diagnoses including septicemia, urinary tract infection and hypertension.Review of Resident #43's admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the assessment was not submitted until 12/31/25 at 9:32 P.M.On 04/14/26 at 6:51 P.M., electronic interview with the Administrator verified the above MDS assessment was not completed within the required timeframe due to it was missed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive assessments were accurately completed. This affected three residents (#1, #2 and #55) of 26 residents reviewed for accuracy of assessments. The census was 52. Findings include: 1.Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including a cerebral vascular accident (CVA) with hemiplegia affecting the left nondominant side. Review of the admission assessment dated [DATE] revealed Resident #2's skin was warm and dry, skin color was within normal limits, turgor was normal with no skin issues. Review of the modified admission Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #2 was severely impaired for daily decision-making, was at risk for pressure ulcer development and had a Stage III pressure ulcer that was present upon admission. On 03/31/26 at 9:18 A.M. and on 04/01/26 at 2:22 P.M., interview with the Director of Nursing verified the modified admission MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, pre-admission screening and resident review (PASARR), and interview, the facility failed to notify the appropriate state agency of a newly diagnosed mental illness for evaluation. This affected one resident (#10) of one resident reviewed for PASARR. The census was 52. Findings include:Medical record review revealed Resident #10 was admitted on [DATE] with diagnoses including chronic respiratory failure, congestive heart failure, end stage renal disease and diabetes mellitus. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact for daily decision-making, did not have a serious mental illness requiring a Level 2 screening and/or evaluation, had a diagnosis of a psychotic disorder and received antipsychotic medications. The resident did not have a diagnosis of bipolar disorder, depression or schizophrenia documented on the assessment. Review of the Medical Diagnosis list revealed the following medical diagnoses were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide baseline care plans within the required timeframe to residents. This affected one resident (#50) of 18 residents reviewed for development of care plans. The census was 52. Findings include:Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including diabetes mellitus, emphysema, heart failure, atrial fibrillation, sleep apnea, hypertension and neuropathy. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #50's cognition was intact for daily decision-making. Review of Resident #50's Baseline Care Plan dated 03/12/26 revealed no evidence the resident was provided a copy or signed acknowledgement of the baseline care plan. On 03/30/26 at 12:18 P.M., interview with Resident #50 stated he had not had a care conference or a meeting regarding discharge planning. The resident denied having received any Baseline Care Plans since admission. On 04/09/26 between 7:55 A.M. and 8:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure care plans were reviewed after each assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Further the facility failed to appropriately revise discharge plans of care. The affected two residents (#51 and #63) reviewed for care plan accuracy. The facility census was 52.Findings include: 1.Review of the medical record for Resident #51 revealed an admission date of 11/01/25. Diagnoses included acute systolic congestive heart failure, chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic polyneuropathy, muscle weakness, fall on same level, and benign prostatic hyperplasia. Review of a Minimum Data Set (MDS) assessment version 3.0 dated 03/04/26 for Resident #51 revealed the resident required a wheelchair for mobility, and partial to moderate assistance for bathing/showering. Review of a Minimum Data Set (MDS) assessment version 3.0 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 staff and resident interview, record review, call light audits, and policy review the facility failed to ensure residents were provided care and services to support their activities of daily living. This affected two residents (#24, #63) of twelve residents reviewed for activities of daily living. The census was 52.Findings include: 1. Review of Resident #24's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview review for mental status (BIMS) score of 15 indicating the resident had no cognitive impairments. The resident had no exhibited behaviors. The resident required mobility assistance with a walker and a wheelchair. The resident required maximal assistance for toileting, showering, lower body dressing including footwear, and personal hygiene. The resident required supervision/ touching assistance for toileting and tub / shower transfer. The resident was at risk for developing pressure ulcer/ injuries. Review of Resident #24 care plan dated 09/13/24 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure residents were provided an on-going, comprehensive activity program to meet their preferences. This affected two residents (#2 and #28) of two residents sampled for activities. The census was 52.1.Closed medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including encephalopathy, heart failure, anemia, diabetes and a fractured hip. The resident expired on [DATE].Review of the Activities assessment dated [DATE] revealed activities were to be offered one to three times a week. The resident's activity pursuit and preferences included current the following interests: One-on-One included animals/pets (very important), beauty/barber (very important), exercises (somewhat important), family/friend visit (very important), gardening (important), movies/television (important), cooking (very important), and current events (somewhat important). Small group activity interests included: bingo…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review and interview, the facility failed to develop and implement a comprehensive, individualized and effective pressure ulcer prevention program to prevent the development of a pressure ulcer. This affected one resident (#2) of four residents reviewed for pressure ulcers. The census was 52.Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with hemiplegia affecting left non-dominant side, encephalopathy, chronic systolic congestive heart failure, moderate protein calorie malnutrition, respiratory failure, altered cognitive function, hypothyroidism, vitamin-D deficiency, hyperlipidemia, insomnia, sleep apnea, hypertension, atrial fibrillation, abdominal aortic aneurysm without rupture, chronic kidney disease stage 3, and presence of a prosthetic heart valve. Review of the admission assessment dated [DATE] revealed Resident #2's skin was warm and dry, skin color…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of manufacturer's guideline, policy review, and interview, the facility failed to safely transfer residents while using a mechanical lift, failed to provide staff training on the use of all mechanical lifts, and failed to ensure resident call lights were within reach for a resident at risk for falls. This affected three residents (#30, #55, #11) of three residents reviewed for accidents. The facility census was 52. Findings include: 1.Review of the medical record for Resident #30 revealed an admission date of 03/31/21with diagnoses that included unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psychophysiologic insomnia, unspecified mood disorder, weakness, history of falling, dysphagia oropharyngeal phase, hyperlipidemia, age-related osteoporosis, unspecified osteoarthritis, essential hypertension, major depressive disorder, vitamin D deficiency, muscle weakness and difficulty walking. Review of the Minimum Data Set (MDS) version…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and interview, the facility failed to ensure ordered respiratory care was provided. This affected one resident (#1) of three residents observed for respiratory care. The census was 52. Findings include:Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including malignant right lower lung cancer, obstructive sleep apnea treatment with BiPAP (Bilevel Positive Airway Pressure), paroxysmal atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes mellitus with diabetic polyneuropathy and urinary tract infection. Review of the hospital Discharge summary dated [DATE] revealed Resident #1 was to continue with daily oxygen and nightly BiPAP. Review of the facility form titled N Adv - Clinical admission -V 30 assessment dated [DATE] revealed Resident #1 received oxygen 2 liters per minute via nasal cannula and BiPAP. Review of the modified admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to ensure medications were administered without significant error. This affected one resident (#1) of five residents sampled for unnecessary medications. The census was 52. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including malignant right lower lung cancer, obstructive sleep apnea treatment with BIPAP, paroxysmal atrial fibrillation, asthma, chronic pain, GERD, chronic obstructive pulmonary disease, diabetes mellitus with diabetic polyneuropathy and urinary tract infection. Review of the hospital Discharge summary dated [DATE] revealed the following changes in Resident #1's medication orders were to be implemented upon admission to the skilled nursing facility: Start Betapace (used to treat life-threatening ventricular arrhythmias and maintain normal sinus rhythm in patients with atrial fibrillation or flutter) 40 (mg) twice a day; Start Carafate (peptic/duodenal ulcer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, text message communication review, incident log review, time punch review, interview, and facility policy review the facility failed to maintain comprehensive and accurate medical records. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse and one resident (Resident #30) of four residents reviewed for accidents. The census was 52. Findings include:1.Review of Resident #15's medical record revealed an admission date of 10/22/21 with diagnoses including hypertension, hemiplegia (left side) and hemiparesis following cerebral infarction, major depressive disorder, muscle weakness, chronic pain syndrome, and insomnia. Review of Resident #15's quarterly minimum data set (MDS) completed on 01/30/26 revealed Resident #15 was moderately cognitively impaired. The resident did not exhibit behaviors or indicators of psychosis during the assessment period. The resident had upper and lower extremity impairment on one side and required a wheelchair for mobility (left sided hemiparesis, required maximum assistance (from staff) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the facility failed to ensure infection control procedures were followed during a dressing change. This affected one resident (Resident #4) of one residents reviewed for dialysis. Findings include: Resident #04 admitted to the facility on [DATE] with diagnoses including heart failure, type two diabetes, malnutrition, chronic kidney disease, presence of cardiac defibrillator, chronic obstructive pulmonary disease, cellulitis of the right lower limb, chronic ulcer of the right heel. Review of Resident #04 orders revealed an order for dialysis every Monday and Friday. Review of Resident #04 orders revealed an order for enhanced barrier precautions Staff to wear gloves and a gown for high contact resident care activities: Dressing Bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, interview, review of facility Self-Reported Incidents (SRI) and associated investigations, and review of the facility's Abuse policy, the facility failed to prevent the verbal abuse of Resident #10 by a facility staff member. This affected one resident (Resident #10) of three reviewed for abuse however this had the potential to affect all 56 residents in the facility.Findings Include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included traumatic subdural hemorrhage, chronic obstructive pulmonary disease, asthma, respiratory failure, diabetes, blindness, heart failure, end stage renal disease with renal dialysis, major depressive disorder, generalized anxiety disorder, cannabis use, hypertension, hypothyroidism and traumatic brain injury.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 had intact cognition with no behaviors.Review of the Self-Reported Incident dated 12/09/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, interview, and review of the facility policy, the facility failed to knock prior to entering the room of Resident #16. This affected one resident (Resident #16) of three reviewed for privacy.Findings Include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease, peripheral vascular disease, diabetes, chronic kidney disease, bipolar disorder, generalized anxiety disorder, lymphedema, and gout.Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #16 had intact cognition.Observation and interview on 01/17/26 at 10:12 A.M. revealed Maintenance #106 opened the door of Resident #16's room without knocking prior to entering. An interview at this time with Maintenance #106 stated he was doing fire watch rounds and verified she had not knocked on the door prior to opening it.Review of the undated facility policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility in-service records, review of the resident concerns/grievances log, review of the resident council minutes, interviews with residents and staff, and review of facility policy, the facility failed to ensure resident grievances were resolved in an appropriate manner and time frame regarding the answering of call llights. This affected nine residents (#30, #33, #34, #35, #39, #41, #44, #47, and #53) of nine residents reviewed for resident rights. The facility census was 54.Findings included: Review of a facility in-service record dated 09/23/25 revealed staff were in-serviced on answering call lights in a timely manner and it was everyone's responsibility to ensure call lights were answered.Review of the resident concerns/grievances log dated September 2025 to November 2025 revealed on 10/15/25 Resident #33 indicated a concern about call lights not being answered timely.Review of the concern form dated 10/15/25 revealed that Resident #33 had her call light on for over an hour before it was answered. The resolution was education.Review of the resident council…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review the facility failed to ensure infection control standards were implemented during resident care. This affected two residents (Resident #35 and Resident #25) out of three residents observed for infection control. The census was 54.Findings included:Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 10/11/25 with diagnoses including chronic kidney disease, necrotizing fasciitis (an aggressive bacterial infection that affects soft tissues underneath the skin) and Fournier gangrene (a bacterial infection of the genitals).Review of the Minimum Data Set (MDS) 3.0 five-day assessment dated [DATE] revealed the resident was cognitively impaired, did not reject care, and required moderate to complete assistance with activities of daily living.An observation on 12/08/25 at 11:05 A.M. of wound care for Resident #35 with Wound Nurse (WN) #200 revealed the following: WN #200 touched a trash can with gloved hands, did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the test tray, review of facility policy, and review of United States Department of Agriculture (USDA) guidelines, the facility failed to maintain palatable and appetizing food temperatures. This had the potential to affect all residents in the facility. The census was 56. Findings included: Review of the resident council minutes dated 05/22/25 revealed an unidentified resident complained of cold biscuits and gravy. On 06/25/25 at 7:40 A.M. an interview with Resident #25 revealed the food was sometimes cold. On 06/25/25 at 9:13 A.M. an interview with Resident #42 revealed the food was sometimes cold, but he understood it due to how far it had to come from the kitchen. On 06/25/25 at 9:17 A.M. an interview with Resident #39 revealed the food was always cold. Observation of the meal service on 06/25/25 from 10:50 A.M. to 12:50 P.M., revealed the dietary staff prepared the lunch meal that consisted of barbeque (BBQ) chicken, mashed potatoes, a broccoli, cauliflower and carrot blend, and apple crisp. Cooking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with the staff the facility failed to ensure an orthopedic consultation was set up as ordered for Resident #57. This affected one resident (Resident #57) of three reviewed for quality of care. Findings included: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, hypertension atherosclerotic heart disease, atrial fibrillation, venous insufficiency, diabetes, spinal stenosis, hypothyroidism, and anemia. Resident #57 was discharged to the hospital on [DATE]. Review of the Nurse Progress Note dated 05/06/25 at 2:30 P.M. revealed Resident #57 was transferred from the Assisted Living to the Skilled Nursing Facility due to increased difficulty ambulating. A new order was received to refer the resident to the orthopedic physician and for Tramadol 50 milligrams twice daily for seven days. Review of the physician's orders revealed Resident #57 had an order for an orthopedic referral due…

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

Based on observation and interview, the facility failed to maintain a resident room in a clean, organized, and sanitary manner. This affected one resident (#15). The facility census was 62. Findings include: During the tour of the facility on 04/29/25 beginning at 4:30 P.M. with Regional Maintenance Director #100 it was noted Resident #15 had an empty medication cup on the floor, a basin on the sofa with what appeared to be a dried dark brownish red substance on the bottom of the basin, clothes lying on the floor, brown discoloration in the toilet with what appeared to be a splattered spot of stool on the toilet tank, and dried yellow substance in the bottom of the container of the suction machine sitting on the stand at his bedside. On 04/29/25 during the tour, Regional Maintenance Director #100 verified Resident #15's room was not clean, organized and sanitary. This deficiency represents non-compliance investigated under Complaint Number OH00163989.

Based on medical record review, observation, and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized during a dressing change. This affected one resident (#15) of one resident observed for a dressing change. The facility census was 62. Findings include: Review of Resident #15's medical record revealed diagnoses including malignant neoplasm of the esophagus, dysphagia (difficulty swallowing), tracheostomy status, and encounter for attention to a gastrostomy. An order dated 04/26/25 revealed the area around the J-tube (jejunostomy feeding tube) was to be cleaned with normal saline and a clean drain sponge applied three times a day. A nursing note dated 04/29/25 at 5:30 P.M. indicated Resident #15's trach was removed at the doctor's office. The trach bandage was to changed every day until healed. During the tour on 04/29/25, Resident #15 was noted to have an enhanced barrier precaution (EBP) sign posted on his doorway. On 04/30/25 at 10:57 A.M., Registered Nurse (RN) #110 was observed changing the dressing to Resident #15's J-tube site.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure meals were served at a palatable temperature. This had the potential to affect all 55 residents who received meals from the kitchen, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 55. Findings include: 1. Review of medical record for Resident #156 revealed an admission date of 11/07/24. Diagnoses included atrial fibrillation, osteoarthritis, essential hypertension, bipolar, morbid obesity, chronic pain syndrome, anxiety disorder, heart failure, tremor, gout, and gastro-esophageal reflux disease without esophagitis. Review of Resident #156's physician orders revealed an order dated 11/07/24 for a regular diet regular texture thin liquid consistency diet. Review of Resident #156's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/17/24, revealed the resident was cognitively intact, was independent for eating, had no significant weight changes, and was not on either a…

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

Based on observation, interview, record review and review of facility policy the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 55 residents who received a meal from the kitchen, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 55. Findings include: 1. Observation of the kitchen on 11/25/24 between 8:15 A.M. and 8:47 A.M. with Dietary Supervisor (DS) #378 revealed the following concerns: • Observation of the walk-in cooler revealed sitting on a top of a service cart in the cooler was a pan half-full of hamburger patties not labeled or dated, one pan that was three-fourth full of mash potatoes that had red and brown discoloration and were not labeled or dated, one pan of spaghetti sauce not labeled or dated, one pan of taco meat not labeled or dated, and one pan of carrots not dated or labeled. • Observation of the walk-in freezer revealed there was one opened factory bag with 12 rectangular hashbrown patties which was open to air and undated, and one open…

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

Based on observation, interviews, review of the facility kitchen sanitation audits and facility policy review, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 55. Findings include: Observation of the dumpster area on 11/26/24 at 11:09 A.M. with Dietary Supervisor #378 revealed there was a buildup of debris around the base of the two dumpsters which included one Styrofoam plate, one empty box of oatmeal cream pies, multiple blue surgical gloves, two large clear fast food plastic cups, one white carafe lid, a plastic shopping bag, several plastic drinking straws, numerous plastic utensils, two small plastic drinking cups and a medicine cup. At the time of observation Dietary Supervisor #378 confirmed the debris around the dumpsters. Review of the facility document Nutrition Services Quality Validation-Kitchen Sanitation, dated 09/27/24 and authored by Dietitian #524, revealed the area was unacceptable with trash around and behind the dumpster.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure residents requiring a mechanically altered diet were served the appropriate diet consistency. This affected four residents (#12, #42, #153, and #202) of four residents reviewed for mechanically altered diets. The facility identified eight residents (#12, #16, #22, #25, #42, #152, #153, #202) as receiving mechanically altered diets. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, major depressive disorder, hyperlipidemia, anxiety disorder, osteoporosis, mood disorder, anxiety disorder, insomnia, and weakness. Review of the November 2024 physician's orders revealed Resident #12 had an order for NAS (No Added Salt), pureed texture diet with thin liquids dated 10/03/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/23/24, revealed Resident #12 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, review of the medical record, interviews with staff, and review of facility policy, the facility failed to ensure proper hand hygiene was maintained while distributing meal tray on the unit, failed to ensure proper handling of linens in the laundry room, failed to ensure the nasal cannula was stored in a protective barrier when not in use for Resident #7, failed to utilize Enhanced Barrier Precautions (EBP) for Resident #253 while receiving an intravenous medication through a peripherally inserted central catheter, and failed to maintain proper infection control measures during wound care for resident Resident #21. This affected six residents (Resident #30, #32 #44, #156, #157, and #202) of 23 residents who received their meals in their rooms, had the potential to affect all 55 residents in the facility who used the facility's laundry, affected one resident (Resident #7) of four residents reviewed for respiratory services, and affected one resident ( Resident #21) of two reviewed for…

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

Based on observations and interviews, the facility failed to maintain a safe environment in good repair. This affected three residents (#7, #48 and #160) of 55 residents observed for physical environment. The facility census was 55. Findings include: 1. On 11/25/24 at 2:23 P.M., Resident #160 stated he had taken a shower in the bathroom adjoining his room when water soaked the bathroom floor and went out into his room and under his bed. Resident #160 stated he was told he needed a longer shower curtain, but he had not received one. The bottom of the shower curtain was approximately six inches from the floor. There was no lip on the shower floor to hold the water. During environmental observations with the Director of Nursing (DON) on 11/26/24 beginning at 1:46 P.M., the DON acknowledged Resident #160's shower curtain did not reach the floor. 2. During the environmental observations with the DON on 11/26/24 beginning at 1:46 P.M., the DON verified there were gouges and/or missing pieces to the walls in Residents #7 and #48's rooms. The DON was unaware if maintenance had been informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview with staff the facility failed to ensure call lights were within reach of Resident #7 and #8. This affected two residents (#7 and #8) of three residents reviewed for physical environment. The facility census was 55. Findings included: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, vascular dementia, hydrocephalus, chronic kidney disease, chronic respiratory failure, adjustment disorder, generalized anxiety disorder and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had severely impaired cognition. Observation on 11/25/24 at 9:38 A.M. revealed Resident #7 was sitting up in her wheelchair. She had her noninvasive Trilogy ventilator on and her call light was not within reach. The call light was across the room attached to her left grab bar on her bed. An interview 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 and interview, the facility failed to ensure there was a signed Do Not Resuscitate (DNR) form in Resident #1's medical record. This affected one resident (#1) out of 17 residents reviewed for advance directives. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. Diagnoses included intellectual disability, fatty liver, chronic obstructive pulmonary disease and essential hypertension. Review of physician orders in Resident #1's electronic medical record revealed an order dated [DATE] for DNR-CCA (do not resuscitate comfort care arrest). Review of Resident #1's care plan, dated [DATE], revealed the resident wished to be a DNR-CCA (do not resuscitate comfort care arrest) with a goal of the resident's wishes would be followed through next review. Interventions indicated the resident was a DNR-CCA with no CPR (cardiopulmonary resuscitation) and advance directives would be reviewed in care conferences quarterly…

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

Based on observation, record review, interview and review of facility policy the facility did not ensure Resident #1's preference to wear undersized clothing was added to her care plan. This affected one resident (#1) of 17 residents reviewed for care plans. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/14/23. Pertinent diagnoses included panic disorder, bipolar disorder, anxiety disorder, intellectual disability and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/29/24, revealed Resident #1 was cognitively intact, had not shown any signs or symptoms of delirium or behaviors, required supervision or touch assistance from staff for upper body dressing and transfers from bed to chair and substantial/maximum assistance for lower body dressing. Review of the care plan for Resident #1 revealed she did not have a care plan in place to indicate it was her preference to wear an undersized nightgown. Observation on 11/25/24 at 1:28 P.M. with Registered Nurse (RN) #320…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, and interview, the facility failed to ensure discharge summaries were completed as required for Resident #47 and #51. This affected two Residents (#47 and #51) of three residents reviewed for discharge. The facility census was 55. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 08/10/24 and discharge date of 10/15/24. Diagnoses included schizoaffective disorder, anxiety disorder, hyperlipidemia, bipolar disorder, osteoarthritis, and hypothyroidism. Review of the Discharge Assessment and Plan, dated 08/12/24, revealed Resident #51 had fair discharge potential and Resident #51 would require home health upon discharge. Resident #51's discharge plan was to return home with her husband after completion of rehabilitation services and antibiotic course. Review of Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment dated [DATE] revealed Resident #51 discharged home to the community. 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 observation, review of the medical record, interview with staff and review of facility policy the facility failed to ensure fall interventions were implemented as ordered for Resident #31. This affected one resident (Resident #31) of two residents reviewed for falls. The facility census was 55. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, fracture of nasal bones, dementia, bipolar disorder, muscle weakness, hyperlipidemia, and hypothyroidism. Review of the plan of care dated 07/19/24 revealed Resident #31 was at risk for falls and/or injury related to weakness, potential side effects of medications, bowel incontinence and impaired cognition. Interventions included Dycem (rubber gripper mat) to the wheelchair, medication review by pharmacist or physician, obtain work as needed, perimeter mattress, staff to anticipate needs, therapy services to evaluate and treat, call light within reach, encourage non…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy the facility failed to ensure reweights were obtained in a timely manner for Residents #15 and #31 and meal intakes were adequately monitored for Resident #31. This affected two residents (#15 and #31) of five residents reviewed for nutrition. The facility census was 55. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 10/25/18. Diagnoses included anemia, age related osteoporosis, hyperparathyroidism, hyperlipidemia, recurrent depressive disorders, essential hypertension, and gastro-esophageal reflux disease without esophagitis. Review of Resident #15's physician orders revealed an order dated 10/23/18 for a NAS (No Added Salt) diet, regular texture, thin liquids. An order dated 10/08/24 revealed Resident #15 was to receive a mighty shake (a nutritional supplement shake) two times a day, and an order dated 11/14/24 revealed Resident #15 also received Resource 2.0 (a calorie dense nutritional shake).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer oxygen at the prescribed dose, failed to ensure oxygen in use signage was posted and oxygen tubing was dated and not lying on the floor. This affected one resident (#153) of four residents reviewed for respiratory care. The facility census was 55. Findings include: Review of the medical record revealed Resident #153 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and dementia- unspecified severity without behavioral disturbance. Further review of the medical record revealed a physician order dated 11/19/24 for continuous oxygen at two liters per minute (2 LPM) via nasal cannula (NC). Observation on 11/25/24 at 8:58 A.M. of Resident #153 revealed a portable oxygen concentrator was lying on the resident's bed. The oxygen was being delivered at 3.5 LPM however the undated nasal cannula tubing was lying on the floor. There was no sign clearly displayed outside 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 medical record review, facility policy review, and interview, the facility failed to ensure residents on dialysis were assessed and monitored routinely. This affected one Resident (#154) of one reviewed for dialysis. The facility census was 55. Findings include: Review of the medical record for Resident #154 revealed an admission date of 11/16/24 and diagnoses including diabetes mellitus, acute kidney failure, stage four chronic kidney disease, dependence on renal dialysis, and diabetic autonomic polyneuropathy. Review of Intermediate Care Plan dated 11/16/24 revealed Resident #154 was on dialysis with interventions including to monitor site for signs and symptoms of complications and complete labs as needed. Review of nurse progress note dated 11/16/24 revealed Resident #154 admitted to the facility with a dialysis port to her right upper chest. Review of dialysis communication forms dated 11/18/24, 11/20/24, 11/22/24, and 11/24/24 revealed pre and post dialysis weights, blood pressure, and pulse were recorded by the dialysis center. Review of physician's order 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.

Based on medical record review and interview, the facility failed to ensure pharmacy recommendations were fully addressed in an acceptable manner. This affected one (Resident #32) of five residents reviewed for medication use. The facility census was 55. Findings include: Review of Resident #32's medical record revealed diagnoses including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. a. Review of Resident #32's physician orders revealed an order dated 11/30/22 for Restoril 30 milligrams (mg) one time a day for insomnia. Review of a pharmacy review dated 02/16/24 indicated Resident #32 had been receiving hypnotic therapy with Restoril 30 mg every night at bedtime for some time without a gradual dosage reduction (GDR). The pharmacist requested, in order to achieve the minimum effective dose, if an attempt could be made to reduce the Restoril to 22.5 mg every night at bedtime. If no GDR was warranted, the pharmacist requested the physician document in the medical record why a reduction might be detrimental to the residents mental 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.

Based on medical record review and interview, the facility failed to ensure a resident receiving medications to treat diabetes mellitus had blood glucose levels monitored in accordance with orders to monitor effectiveness of medications. This affected one (Resident #1) of five residents reviewed for medications. The facility census was 55. Findings include: Review of Resident #1's medical record revealed diagnoses including diabetes mellitus, morbid obesity and intellectual disabilities. Resident #1 had an order for Metformin (a medication used to treat high blood glucose levels) 500 milligrams (mg) twice a day (start date 09/04/24), Trulicity (a medication used to treat high blood glucose levels) subcutaneous solution pen-injector 4.5 units subcutaneously every Friday (start date 09/06/24), and on 11/13/24 there were new orders to discontinue sliding scale insulin, Tresiba insulin 50 units every night at bedtime, Humalog insulin 26 units before meals, and glucometer check (blood glucose monitoring) every morning. Review of the care plan revealed Resident #1 had the potential for…

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

Based on medical record review and interview, the facility failed to ensure anti-anxiety medications ordered on an as necessary basis had time limits for use and failed to address why gradual dose reductions (GDR) of psychotropic medications were contraindicated. This affected one (Resident #32) of five residents reviewed for medication use. The facility census was 55. Findings include: Review of Resident #32's medical record revealed diagnoses including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. a. Review of Resident #32's physician orders revealed an order dated 11/30/22 for Restoril 30 milligrams (mg) one time a day for insomnia. Review of a pharmacy review dated 02/16/24 indicated Resident #32 had been receiving hypnotic therapy with Restoril 30 mg every night at bedtime for some time without a gradual dosage reduction (GDR). The pharmacist requested, in order to achieve the minimum effective dose, if an attempt could be made to reduce the Restoril to 22.5 mg every night at bedtime. If no GDR was warranted, the pharmacist requested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, record review, and review of manufacturer information, the facility failed to ensure medications were administered in accordance with physician orders. Three errors were identified out of 30 opportunities for error resulting in a 10% medication error rate. This affected three (Residents #10, #20, and #152) of four residents observed for medication administration. The facility census was 55. Findings include: 1. Review of Resident #10's record revealed physician orders for Mucinex 600 mg to be administered twice a day. On 11/26/24 at 7:18 A.M., Licensed Practical Nurse (LPN) #328 was observed administering multiple medications, including Mucinex 400 milligrams (mg), to Resident #10. Interview on 11/26/24 at 7:43 A.M., with LPN #328 verified she had administered the incorrect dosage of Mucinex. 2. Review of Resident #152's record revealed physician orders for Humalog Insulin to be administered prior to meals and at bed time, per sliding scale (a dosage range based on the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of medication manufacturer information, review of physician orders, policy review and interview, the facility failed to ensure multi-dose medication vials and pens were dated when opened, disposed of when expired, and stored at the appropriate temperature. This involved one of two medication carts observed for medication storage and affected Residents #33 and #252. Findings include: On [DATE] between 1:57 P.M. and 2:05 P.M., the following concerns were noted with medication storage. 1. Resident #33 had a plastic sleeve of insulin glargine insulin pens with one open and one sealed. The envelope had directions to refrigerate. At the time of the observation, Registered Nurse (RN) #320 verified the sealed insulin pen was stored at room temperature. Review of manufacturer information for insulin glargine revealed unopened insulin vials were to be stored in the refrigerator at a temperature of 36 to 46 degrees Fahrenheit. Resident #33 also had a pen of admelog insulin. The open date label…

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

Based on interview and review of the facility arbitration agreement, the facility failed to ensure the arbitration agreement allowed for a mutually agreeable arbitrator and venue. This affected all residents residing in the facility. The facility was census was 55. Findings include: Review of the facility arbitration agreement, undated, revealed the matter shall be resolved by binding arbitration administered by the National Arbitration Forum (NAF), under their rules and procedures. If the NAF process was no longer in existence at the time of the dispute, or NAF was unwilling or unable to conduct the arbitration, then the parties shall mutually agree on an alternative organization to conduct the arbitration. The agreement did not identify in what venue the arbitration would occur. Interview on 11/26/24 at 9:53 A.M. with [NAME] President (VP) of Operations #521 and Corporate Marketing #522 revealed during the admission process residents were presented the arbitration agreement by either the marketing director, administrator, social services, or the wellness director, who have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the medical record, interview with staff, information from the Pneumonia (Pneumo) Recommendations (Rec) Vaccinations (Vax) Advisor application, and policy review, the facility failed to ensure pneumonia vaccine were up-to-date for Resident #7 and #30. This affected two residents (Resident #7 and #30) of five reviewed for vaccination status. The facility census was 55. Findings included: 1. Review of the Consent to Administer Pneumonia Vaccine form dated 12/17/21 revealed Resident#7 had received the pneumococcal vaccine according to the recommended schedule Review of the Immunization record in the resident's chart revealed Resident #7 received the PPSV23 vaccine on 12/17/21. There was no documentation she received the PCV15, PCV20 or PCV21. Review of the Pneumonia Recs Vax Advisor application revealed it was recommended to give Resident #7 one dose of PCV15, PCV20 or PCV21 at least one year after the last dose of PPSV23. This was never given. On 11/27/24 at 3:10 P.M., an interview with Infection Preventionist #356 verified Resident #7 was not up to date on her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility Payroll Based Journal (PBJ) submission data, Staffing Data Report and staff interview, the facility failed to ensure submission of the Payroll Based Journal data as required. This had the potential to affect all 53 residents residing in the facility. Findings include: Review of the Staffing Data Report revealed the facility had a 1 Star Rating for fiscal year 2024 for the third quarter (April 1 to June 30). Review of the facility Payroll Based Journal (PBJ) submission data report revealed no evidence of administrator data submitted by the facility for fiscal year 2024 for the third quarter (April 1 to June 30). Interview with the facility Administrator on 10/21/24 at 1:59 P.M. revealed the facility corporate office submits the PBJ data. The Administrator verified the lack of PBJ submission data for the administrator. He indicated the absence of administrator data was not caught during review. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00158350.

Based on observation, policy review, and interview, the facility failed to ensure infection control standards were followed regarding sanitary pericare technique. This affected one resident (#14) of three residents reviewed for infection control. Findings include: Observation on 10/23/24 at 1:45 P.M. of pericare for Resident #14 took place with State Tested Nurse Aides (STNA) #76 and #77. After both STNA's washed their hands and gloved, STNA #76 revealed the facility used moist washcloths to cleanse the resident. STNA #76 wiped the right and left groin from front to back, changing areas on the cloth and then dried with a towel. STNA #76 swiped down the front of the of the labia from front to back with a moist wash rag without spreading the residents' legs or separating the labia. She then dried from front to back down the front of the labia without separating the labia. STNA #77 rolled Resident #14 to her right side. The resident had a bowel movement. STNA #76 cleaned the bowel movement with wet washcloths from the rectal area toward the vagina/urethral opening. After cleaning 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 interview, the facility failed to ensure residents were treated with dignity and respect. This affected one (Resident #9) of three residents reviewed for dignity. The facility census was 55. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/15/24 with diagnoses including epilepsy, alcohol abuse, diabetes mellitus, chronic kidney disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #9, dated 08/13/24, revealed the Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed there were no behaviors or rejection of care. The resident required staff assistance with activities of daily living (ADLs). Review of the Self-Reported Incident (SRI) #251341, revealed on 08/29/24, Resident #9 reported that earlier in the week, State-Tested Nursing Assistant (STNA) #300 came into his room and used profanity while directing him not to use his call light. During interview on 09/11/24 at 3:45 P.M., 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of the Self-Reported Incident (SRI), review of facility investigation, review of the facility policy, and interview with staff the facility failed to prevent misappropriation of medication for Resident #40 by a staff member. This affected one resident (#40) of three residents reviewed for medication. Findings include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure dependence on a ventilator, morbid obesity, dependent of oxygen, tracheostomy, congestive heart failure, diabetes, restless leg syndrome, obstructive and reflux uropathy, and disorders of the penis. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician's order revealed Resident #40 had an order for…

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

Based on medical record review and staff interview the facility failed to complete routine respiratory assessments for residents requiring continuous supplement oxygen and aerosolized respiratory medications. This affected two (Residents #61 and #47) of three residents reviewed for oxygen use. The facility identified 14 residents (Residents #3, #5, #6, #9, #22, #25, #28, #40, #43, #46, #47, #51, #54 and #58) currently on continuous supplemental oxygen therapy. Findings include: 1. Review of Resident #61's closed medical record revealed an admission date of 03/15/24 with diagnoses that included chronic obstructive pulmonary disease and diabetes mellitus. Upon admission the physician ordered Resident #61 supplemental oxygen at three liters per minutes (lpm) via nasal cannula continuously. Additional physician's orders on 03/16/24 revealed ipratropium bromide and albuterol solution (bronchodilator medication to improve breathing) 0.5-2.5 milligram (mg) per 3 milliliter (ml) three ml every four hours as needed by nebulizer. Review of the Medication Administration Record (MAR) 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.

Based on observations and staff interviews, the facility failed to ensure food was discarded and the kitchen was clean and sanitary. This had the potential to affect all 54 residents who received food from the kitchen. The facility census was 54. Findings include: Observation of the kitchen on 12/21/23 at 10:58 A.M. revealed there was a container of egg salad in the stand up refrigerator labeled made on 12/12/23 and to be used by 12/16/23. There was also a container labeled dill chip dip made on 12/14/23 but there was not a use by date on the label. There was an opened bag of pepperoni cubes that was not labeled with the opened or use by date. Observation of the kitchen floor revealed towels under the dishwasher, towels covered with a black substance were observed around the hot water tank, and dark substances and debris were under tables, equipment, and around the cove baseboard molding throughout the kitchen. Interview on 12/21/23 at 11:06 A.M. with [NAME] #104 verified there was food undated and the egg salad should have been discarded on 12/16/23. Interview on 12/21/23 at 12:55…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview with the resident's responsible party, and interview with staff, the facility failed to accommodate a resident's responsible parties request for a WanderGuard/elopement bracelet. This affected one (Resident #2) of three residents reviewed for accomodation of needs. The facility census was 54. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including type II diabetes mellitus, dementia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Review of the nursing progress note dated 11/06/23 at 4:00 P.M. revealed Resident #2 was admitted from a memory care facility. The power-of-attorney (POA) requested a WanderGuard/elopement bracelet be put on Resident #2. Review of the elopement evaluation dated 11/06/23 revealed Resident #2 was independent with mobility and was not at risk for elopement. There was no documentation to any follow up to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview with resident's representative, and interview with staff, the facility failed to notify the responsible party when Resident #2 eloped from the facility and for the new physician order for a WanderGuard bracelet for Resident #2. This affected one (Resident #2) out of three residents reviewed for notification of change. The facility censes was 54. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including type II diabetes mellitus, dementia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Review of the nursing progress note dated 11/30/23 at 9:49 A.M. revealed on 11/28/23, Resident #2 went out the sunroom door, walked across the parking lot and got into a car. There was no documentation the resident's responsible party was notified of Resident #2's elopement. Review of the physician order dated 11/29/23 revealed an order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to safely store the resident's medications. This affected one (Resident #2) of three residents reviewed for medications. The facility census was 54. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including type II diabetes mellitus, dementia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Review of the nursing progress note dated 12/24/23 at 4:33 P.M. revealed while the nurse was doing morning rounds, the nurse discovered evening medications and another cup of medications sitting on Resident #2's bedside table. The medications were disposed of in the sharps container. Review of the medication administration record (MAR) for 12/23/23 revealed Resident #2 was ordered atorvastatin calcium (statin medication to treat high cholesterol) 10 milligram (mg), metformin (anti-diabetic) 500 mg, and acetaminophen (for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of video camera footage, and staff interview, the facility failed to ensure Resident #1's medical record had accurate documentation of times of resident fall, medication administration, and when Resident #1 was sent to the hospital. This affected one (Resident #1) of nine residents reviewed for medical records. The facility census was 54. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Review of the fall investigation dated 12/15/23 at 9:40 A.M. revealed Resident #1 had a fall and denied any pain or injuries. Resident #1 had no visible injuries and was not transported to the hospital. The certified nurse practitioner was notified of the fall on 12/15/23 at 9:50 A.M. A nurse progress note dated 12/15/23 at 9:53 A.M. revealed Resident #1 was found lying on the floor. Resident #1 had attempted to self transfer and fell. There was no documentation Resident #1 was sent to the hospital on [DATE]. However, the nursing note dated 12/15/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of social media posting, review of billing statements, review of authorization forms, review of Medicaid forms, review of bank transactions, and interviews the facility failed to ensure accounting principles were followed. This affected one resident (#2) of four residents reviewed for billing. Findings included: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, epilepsy, depression, and anxiety. Review of Resident #2's Medicaid personal liability dated [DATE] to [DATE] revealed the resident personal liability was $1406.00. Review of Resident #2's ACH authorization agreement dated [DATE] revealed Resident #2's son (Resident #1) revealed the son gave the facility permission debit the resident's personal liability only every month. The debit may not exceed the resident liability amount. Review of Resident #2's bank transaction revealed on [DATE] the facility removed $9,042.39 from the resident's checking 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 interviews, review of social media posting, and policy review the facility failed to ensure phone calls were answered and voice messages were returned promptly. This had the potential to affect all 61 residents residing in the facility. Findings included: Interview on 08/14/23 at 9:00 A.M., with the Ombudsman confirmed there was concerns regarding the facility answering the phones and returning calls. On 07/28/23 the Ombudsman office called and left a voicemail regarding resident concerns with billing and the facility never returned the call until 08/09/23. Residents have voiced similar concerns. Interview on 08/14/23 at 9:18 A.M., with the Administrator confirmed the Ombudsman had called and left a voice message that was not returned promptly due to the facility currently doesn't have a business office manager. One of the staff from a sister facility has been helping in the business office twice a week and notified him last week of the Ombudsman call. Interview on 08/15/23 from 9:24 A.M. to 10:50 A.M., with anonymous family members (FM) #188 and #189 confirmed when they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of concern log, review of self-reported incidents, interviews, and policy review the facility failed to report an allegation of misappropriation. This affected one resident (#2) of three residents reviewed. Findings included: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, epilepsy, depression, and anxiety. Review of Resident #2's nurses progress note dated 07/20/23 revealed the resident's niece was present and concerned about the whereabouts of the resident's purse. This nurse (Licensed Practical Nurse (LPN) #144 and Director of Nursing (DON) updated her that the purse was with the resident when she had visited her son in the Assisting Living. The purse was bagged and left in his room due to bed bugs. Niece stated she would go find the purse in his room. Review of Resident #1's (Resident #2's son's) nursing progress notes revealed the resident was removed from his room on 06/23/23 and returned 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, review of a concern log, review of self-reported incidents, interviews, and policy review the facility failed to investigate an allegation of misappropriation. This affected one resident (#2) of three residents reviewed. Findings included: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, epilepsy, depression, and anxiety. Review of Resident #2's nurses progress note dated 07/20/23 revealed the resident's niece was present and concerned about whereabouts of the resident's purse. This nurse (Licensed Practical Nurse (LPN) #144 and Director of Nursing (DON) updated her that the purse was with the resident when she had visited her son in the Assisting Living. The purse was bagged and left in his room due to bed bugs. Niece stated she would go find the purse in his room. Review of Resident #1's (Resident #2's son) nursing progress notes revealed the resident was removed from his room on 06/23/23 and returned 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 record review, facility policy and procedure review and interview the facility failed to complete comprehensive and ongoing respiratory assessments for residents who had a diagnosis of COVID-19 to ensure the residents were monitored for complications and/or respiratory problems. This affected seven residents (#47, #51, #60, #39, #27, #33 and #36) of 18 residents currently identified to be positive for COVID-19 in the facility. Findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including COVID-19, acute kidney failure, atherosclerotic heart disease, diabetes, hypertension, and hypothyroidism. Further review revealed Resident #47 tested positive for COVID-19 on 07/15/22. Record review revealed no COVID-19 respiratory assessments had been completed for the resident. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, diabetes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents who required staff assistance with activities of daily living received timely and adequate assistance with dining and/or showers. This affected four residents (#38, #51, #63 and #224) of six residents reviewed for activities of daily living (ADL) care. Findings include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, diabetes, hypertension, acute respiratory failure, disease of the pancreas, anxiety disorder, schizoaffective disorder, vascular dementia and vitamin D deficiency. Record review revealed the resident received Hospice services. Review of the plan of care, dated 05/02/22 revealed Resident #51 required assistance from the staff to meet ADL needs related to decreased mobility and impaired cognition. Interventions included to assist with eating. Review of the quarterly Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy and procedure review and interview the facility failed to ensure a timely fall risk assessment was completed for Resident #60 following an unwitnessed fall to ensure individualized and appropriate fall risk interventions and monitoring were initiated. This affected one resident (#60) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #60 revealed an admission date of 06/04/21 with diagnoses including muscle weakness, anxiety disorder, bipolar disorder and insomnia. Review of the fall risk assessment, dated 06/04/2021 revealed the resident was at moderate risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/08/22 revealed the resident had intact cognition and was assessed to be independent for bed mobility, transfers and ambulation. Review of the plan of care, dated 08/18/22 revealed the resident was at risk for falls due to impaired gait, medications and pain. Interventions included educate to always use walker for ambulation, non-skid gripper socks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a comprehensive bowel and bladder assessment was completed for Resident #50 to implement an individualized program to restore normal bowel and bladder function. This affected one resident (#50) of one resident reviewed for bowel and bladder function. Findings include: Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including COVID 19, protein calorie malnutrition, hypothyroidism depression and chronic obstructive pulmonary disease (COPD). Record review revealed no bowel and bladder assessment was completed on admission to identify the resident's toileting needs. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/28/22 revealed the resident's cognition was intact, she required staff supervision with set up help only for transfers and toilet use. The assessment revealed the resident was occasionally incontinent of urine and always incontinent of bowels with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure nutritional interventions were initiated timely for Resident #45 and failed to ensure weekly weight monitoring was completed as recommended for Resident #45 and #59 to ensure the resident's nutritional needs were being met. This affected two residents (#45 and #59) of three residents reviewed for nutrition. Findings include: 1. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, epilepsy, major depressive disorder, chronic obstructive pulmonary disease, hypertension and depression. A physician's order, dated 10/27/21 revealed an order for the nutritional supplement (oral pass) two times daily. Review of a weight change note, dated 06/13/22 at 11:13 A.M. revealed Resident #45's current body weight was 109.4 pound which reflected a significant weight loss in three months. The resident's body mass index was noted to be within normal range. The resident was on a…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure adequate and proper tracheostomy care was provided for Resident #28 to decrease the risk of infection. This affected one resident (#28) of one resident reviewed for tracheostomy care. Findings include: Review of Resident #28's medical record revealed an admission date of 10/03/20 with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, hypertension, anemia and dependence on respirator. Review of Resident #28's care plan, dated 07/11/22 revealed the resident was at risk for ineffective airway related to tracheostomy (trach) status and to provide trach care as ordered. On 08/31/22 at 7:41 A.M. Respiratory Therapist (RT) #55 was observed to complete trach care for Resident #28. RT #55 washed his hands and applied gloves. RT #55 then removed the ventilator from the resident and placed an oxygen collar over the resident's trach. He then obtained the resident's oxygen level with a pulse oximeter. With the same gloves, RT #55…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure adaptive equipment for meals were provided as ordered/planned for Resident #45 and Resident #59. This affected two residents (#45 and #59) of three residents reviewed for nutrition. Findings include: 1. 2. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, osteoarthritis, anemia, major depressive disorder, anxiety disorder, diabetes, chronic obstructive pulmonary disease, heart failure, COVID-19, essential tremor and post-concussional syndrome. A physician order, dated 04/26/22 revealed an order for a no added sweets, regular texture diet with a two handled weighted cup for meals. Review of the weight change note, dated 7/28/22 at 3:33 P.M. revealed Resident #59 utilized a two-handled weighted cup at meals. Review of the MDS 3.0 assessment, dated 08/06/22 revealed Resident #59 had intact cognition, was independent with eating, had sustained a weight…

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