Dublin Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility policy review the facility failed to provide a safe and homelike environment for residents including unsecured medications, fall prevention interventions, and functionality of facility doors. This affected five residents (#5, #10, #19, #31, #37) of five residents reviewed. The facility census was 65.Findings include: 1. Medical record review for Resident #31 revealed he was admitted to the facility on [DATE]. His diagnoses included obstructive sleep apnea, asthma, depression, allergic rhinitis, diabetes mellitus (DM), hypothyroidism, peripheral vascular disease, anxiety disorder, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 was dependent on staff for medication administration. Resident #31 required set up assistance from staff with eating, oral hygiene, toilet use, lower body dressing, putting on shoes, and personal hygiene. He required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility policy, the facility failed to store and label oxygen and nebulizer equipment properly for eight residents (#5, #7, #8, #14, #26, #27, #61, #68) of 27 residents who utilizes oxygen or nebulizers. The facility census was 65. Findings include: 1.Review of the medical record for Resident #5 revealed an admission date on 09/01/23 with diagnoses that included, but not limited to, respiratory failure, centrilobular emphysema, chronic diastolic congestive heart failure, severe dementia, dysphagia, convulsions, and atherosclerotic heart disease. The resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a BIMS score of 2, reflecting severe cognitive impairment. The resident required extensive to total assistance with most activities of daily living and utilized a wheelchair for mobility. Review of the physician orders revealed an order dated 01/08/25 for oxygen at 1–2 liters per minute via nasal cannula every 12 hours as needed 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, staff interview, and policy review, the facility failed to ensure all medications, including tuberculin solution, were accurately labeled and discarded upon expiration. This affected seven residents (#7, #19, #24, #57, #61, #64, #68) of 65 residents. The facility census was 65.Findings include: 1.Review of the medication carts and medication storage room on [DATE] at 3:04 PM by Licensed Practical Nurse (LPN) #224 revealed multiple opened medications without documentation of the date they were opened, in violation of safe medication storage standards. Two medication carts and one medication room were reviewed. Observations included: Resident #7's insulin pen with no open date; Resident #64's Lotan eye drops open with no date; Resident #68's Albuterol open with no date; Resident #7's Tiotropium (Spiriva) open with no date; Resident #24 Advair inhaler (fluticasone/salmeterol) open with no date; Resident #19's Albuterol inhaler open with no date; Resident #61's Tiotropium open with no date;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Medicare beneficiary notices and staff interview, the facility failed to notify two residents (#1, #49) of three Medicare beneficiary notices reviewed. The census was 65. Findings include:1. Review of Resident #1's Medicare beneficiary discontinuation of services letter revealed Resident #1 was notified on 08/05/25 of skilled services being discontinued on 08/08/25. The notification only identified skilled services were being cut on 08/08/25 and failed to identify the actual service. 2. Review of Resident #49's Medicare beneficiary discontinuation of services letter revealed Resident #49 was notified on 08/27/25 of skilled services being discontinued on 08/29/25. The notification is only identified skilled services were being cut on 08/29/25 and failed to identify the actual service. On 01/21/26 at 10:32 A.M. interview of the Social Service Director verified the Medicare beneficiary discontinuation of services letters for Residents #1, #49 were not specific to the service being discontinued.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to document a resident's discharge and develop a discharge plan for one Resident #74. This affected one resident (#74) of two residents reviewed for discharge. The facility census is 65.Findings include:Medical record review for Resident #74 revealed she admitted to the facility on [DATE] for a respite stay and discharged from the facility on 12/31/25 with Heartland Hospice. Her diagnoses included, gastro -intestinal hemorrhage, protein-calorie malnutrition, intestinal malabsorption, pulmonary hypertension, congestive heart failure (CHF), and hyperlipidemia. Resident #74 required a hospice stay. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #74 revealed she had moderately impaired cognition. She was dependent on staff for medication administration. Resident #74 required set up assistance from staff with eating. She required maximum assistance from staff with oral hygiene, toilet use, bathing, upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to provide a resident with a proper discharge including a discharge plan or summary. This affected one resident (#74) of two residents reviewed for discharge from the facility. The facility census is 65. Findings include:Medical record review for Resident #74 revealed she admitted to the facility on [DATE] for a respite stay and discharged from the facility on 12/31/25 with Heartland Hospice. Her diagnoses included, gastro -intestinal hemorrhage, protein-calorie malnutrition, intestinal malabsorption, pulmonary hypertension, congestive heart failure (CHF), and hyperlipidemia. Resident #74 required a hospice stay. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #74 revealed she had moderately impaired cognition. She was dependent on staff for medication administration. Resident #74 required set up assistance from staff with eating. She required maximum assistance from staff with oral hygiene, toilet use, bathing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy and procedure review, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) were updated after receiving new diagnoses. This affected three residents (#6, #12 and #65) of three residents reviewed for PASARR screening. The census was 65. Findings include:1.Review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, bipolar disorder, depression, anxiety, peripheral vascular disease, diabetes and chronic kidney disease. Review of the quarterly minimum data set assessment (MDS) dated [DATE] revealed her cognition was not intact, she was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene and turning and repositioning. She was incontinent of bowel and bladder. Review of the Preadmission Screening and Resident Review (PASARR) dated 09/03/23 revealed a diagnosis of dementia. Further review revealed new diagnoses on 11/01/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and facility policy, the facility failed to ensure comprehensive care plans were updated to ensure residents received comprehensive care and treatment. This affected three residents (#14, #55, and #61) out of 32 records reviewed in the sample. The facility census was 65. Findings include:1.Review of the medical record for Resident #55 revealed an admission date of 10/20/25. Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure unspecified whether with hypoxia or hypercapnia, pulmonary hypertension, chronic obstructive pulmonary disease, generalized muscle weakness, cognitive communication deficit, hypothyroidism, chronic kidney disease stage 3B, gastroesophageal reflux disease without esophagitis, essential (primary) hypertension, difficulty in walking not elsewhere classified, anemia, unspecified atrial fibrillation, heart failure unspecified, chronic diastolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to ensure activities of daily living (ADL's) for dependent residents were completed. This affected three residents (#7, #26 and #65) of four residents reviewed for ADL care. The census was 65. Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included diabetes, morbid obesity, adult failure to thrive, chronic obstructive pulmonary disease, chronic resp failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder and PTSD. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance for eating, independent with oral hygiene, toileting, dressing and personal hygiene. Review of resident documented showers revealed no shower or bath documented between 11/12/25 and 11/19/25, and between 12/10/25 and 12/21/25. On 01/12/26 at 8:55 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the bowel protocol was followed for Resident #3. This affected one resident (#3) of three residents reviewed for bowel and bladder incontinence. The facility census was 65.Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact. The resident had an indwelling catheter and was always incontinent of bowel. Plan of care dated 11/13/25 revealed Resident #3 had bowel incontinence. Interventions included to check and change the resident and encourage the resident to use the call light for toileting assistance. An additional plan of care dated 11/13/25 revealed Resident #3 had an activity of daily living self-care performance deficit. Interventions included that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review the facility failed to ensure weight loss was adequately addressed for Resident #8 and proper follow up was completed after Resident #6 had significant weight loss. This affected two residents (#6, #8) of eight residents reviewed for nutrition. The facility census was 65.Findings include: 1.Review of the medical record revealed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, urogenital implants, acute kidney failure, and anxiety disorder. Review of the plan of care for nutrition dated 10/22/25 revealed Resident #8 had the potential for altered nutrition related to past medical history of left femur fracture, anemia, anxiety, with varied intakes related to vomiting, recent surgery, and significant weight loss updated on 01/06/26. Interventions included house supplements as ordered, offer snacks as indicated, and diet, supplements, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to act upon the pharmacy recommendations in a timely manner. This affected three residents (#7, #24 and #32) of five residents reviewed for unnecessary medications. The census was 65. Findings include:1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, severe protein calorie malnutrition, COPD, A FIB, depression, anxiety and weight loss. Review of the quarterly MDS dated [DATE] revealed her cognition is intact, she is independent with eating, oral hygiene, toileting, shower/bathing, dressing and personal hygiene. Is occasionally incontinent of urine and continent of bowel. Review of Pharmacy Medication Regimen review revealed on 10/21/25 a recommendation to change Air Supra two puffs every six hours as needed. On 11/20/25 the order was written to change to albuterol inhaler two puffs every six 6 hours as needed. Further review revealed this order was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, pharmacy review and staff interview, the facility failed to ensure a resident was free from unnecessary medications. This affected one resident (#7) of five residents reviewed for unnecessary medications. The census was 65. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included diabetes, morbid obesity, adult failure to thrive, Chronic obstructive pulmonary disease, chronic resp failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder and PTSD. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance for eating, independent with oral hygiene, toileting, dressing and personal hygiene. Review of the physician orders revealed an order on 10/15/25 for Budesonide (corticosteroid) suspension 0.5 milligrams (mg)/2 milliliters (ml) inhale orally via nebulizer two times a day for shortness of breath…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and manufacture instructions revealed the facility failed to prime an insulin pen for Resident #56, the facility also failed to correctly read the number of insulin units for Resident #41 and failed to administer pantoprazole granules appropriately for Resident #84. This affected three (Resident #56, #41, and #84) out of two residents with insulin pens on the first floor and four residents on the first floor that received insulin via an insulin syringe, and two residents on the first floor that received pantoprazole granules. The surveyor observed 25 opportunities for error with three actual errors resulting in a medication error rate of 12%. The facility census was 65. Findings include: 1.Review of the medical record revealed Resident #84 was admitted on [DATE] with diagnoses that included chronic kidney disease and aftercare for joint replacement.Review of physician orders revealed Resident #84 was ordered pantoprazole (proton pump inhibitor to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain ordered laboratory tests. This affected one resident (#24) of 38 residents reviewed for laboratory tests. The census was 65. Findings include; Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, severe protein calorie malnutrition, COPD, A FIB, depression, anxiety and weight loss. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition is intact, she is independent with eating, oral hygiene, toileting, shower/bathing, dressing and personal hygiene. Is occasionally incontinent of urine and continent of bowel. Review of the physician orders revealed an order dated 01/09/26 for a complete blood count (CBC), comprehensive metabolic profile (CMP), A1c (test for diabetes), thyroid stimulating hormone (TSH), vitamin B12 and vitamin D on 1/12/26. Further review revealed no evidence the blood tests were completed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure complete and accurate medical records. This affected two residents (#8, #48) of 24 residents reviewed for accuracy of medical records. The facility census was 65. Findings include: 1.Review of the medical record revealed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, urogenital implants, acute kidney failure, and anxiety disorder. Plan of care for nutrition dated 10/22/25 revealed Resident #8 had the potential for altered nutrition related to past medical history of left femur fracture, anemia, anxiety, with varied intakes related to vomiting, recent surgery, and significant weight loss updated 01/06/26. Interventions included house supplements as ordered, offer snacks as indicated, and diet, supplements, and vitamins/minerals per physician order. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain hospice communication records/documentation for residents receiving hospice services. This affected two residents (#9, #68) out of two residents reviewed for hospice services. The facility census was 65. Findings include:1. Medical record review for Resident #09 revealed she was admitted to the facility on [DATE]. Her diagnoses included, obesity, gastro-esophageal reflux disease (GERD), essential primary hypertension, obstructive sleep apnea, hyperlipidemia, gout, dysphagia, anxiety, diabetes mellitus (DM), peritonitis, insomnia, and malignant neoplasm of the neck. Resident #09 required hospice services. Review of the Minimum Data Set (MDS) assessment for Resident #09 dated 12/12/25 revealed she was mildly cognitively impaired. Resident #09 was dependent on staff for medication administration, and required supervision from staff with eating. Resident #09 required moderate assistance from staff with oral hygiene, toilet use, bathing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection surveillance records, policy review and interview, the facility failed to ensure antibiotic orders were thoroughly researched to determine if residents met the criteria for infections, failed to ensure when criteria was not met the prescriber was informed, and failed to provide education and reports regarding antibiotic use to prescribers in accordance with policies. This affected three residents (#3, #23, #56) of 11 residents reviewed for antibiotic use. The facility census was 65. Findings include: 1.Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and had an indwelling catheter. Review of the antibiotic stewardship tracking log revealed on 11/21/25 Resident #3 was ordered Macrobid (antibiotic) 100 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 flu shots were completed properly. This affected three residents (#5, #26, #61) out of five residents reviewed for vaccines. The facility census was 65.Findings include:1.Review of the medical record for Resident #26 revealed an admission date of 06/06/25. Diagnoses included acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognition (Brief Interview for Mental Status [BIMS] score of 15) and no significant impairments to upper or lower extremity function but required set-up assistance for eating and oral hygiene and maximum or dependent assistance for other activities of daily living (ADLs). Additional documentation indicated the resident rejected care 1-3 days.Review of the immunization records for Resident…

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

Based on resident and staff interviews and record review, the facility failed to ensure mail was delivered timely and on the weekends. This had potential to affect all facility residents. The facility census was 99. Findings include Interviews on 10/23/24 at 10:30 A.M. with Resident #1, #11, and #34 revealed resident's do not get mail passed on Saturday's. They revealed activity staff do not work on the weekends and they were the staff that pass the mail out. Interview on 10/28/24 at 1:30 P.M. with Receptionist #489 revealed facility gets mail on Monday through Saturday's. She revealed she distributes resident mail to the Activity Director who passes out the mail to the residents. She confirmed resident mail delivered on Saturday is kept either at the front desk or in the copy room until Monday. Interview on 10/28/24 at 2:48 P.M. with Activities Director #464 revealed facility did not have staff from activity department on weekends and Saturday mail is passed on Monday morning. Review of facility notice titled, Mail, dated 11/30/23 revealed residents shall be allowed to communicate…

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

Based on staff interviews and record review, facility failed to ensure the Activity Director met minimum qualifications for the position. This had potential to affect all facility residents. Facility census was 99. Findings include: Interview on 10/28/24 around 2:00 P.M. with Activity Director (AD) #464 revealed she started 07/2024 and received about a day and a half of training. She revealed she had no prior history working in long term care or with activities or recreation. Interview on 10/28/24 at 2:48 P.M. with Activities Director #464 revealed she was working on a certification course for activities. She revealed the facility paid for the course and it should take about six months to complete. AD revealed she was on module five but was unable to show any evidence of any modules being completed and was unable to show a certificate of completion. Activity Director revealed from her knowledge, her hire was not conditional related to the certificate/training's being completed. Interview on 10/28/24 at 3:30 P.M. with Human Resources #506 acknowledged Activity Director #464 should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Centers for Disease Control and Prevention (CDC) guidance, staff interviews, and observations, the facility failed to ensure a comprehensive water management plan was in place for the prevention of Legionella, failed to follow proper infection control techniques during wound dressing changes, failed to utilize Enhanced Barrier Precautions for a resident with an indwelling medical device, and failed to complete tuberculosis test per the facility assessment. This affected two residents (#4 and #102) and had the potential to affect all 99 residents residing in the facility. Findings include: 1. Review of facilities Water Management Program Plan dated 01/26/18 revealed the facility must establish a water management team. The team consists of the facility administrator, maintenance director and infection preventionist. Review of the facilities Waterborne Pathogens Plan dated 09/04/24 revealed risk factors associated with Legionella bacteria are water flow, disinfection and water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of bed hold notices, staff interviews, and facility policy review, the facility failed to include a daily room rate on bed hold notices for four residents (Residents #9, #37, #43, and #68) who were transferred to the hospital. This affected four residents (Residents #9, #37, #43, and #68) of four reviewed for hospitalizations. The facility census was 99. Findings Include: 1. Review of the medical record Resident #37 revealed an admission date on 04/22/22. Medical diagnoses included chronic respiratory failure, history of falling, repeated falls, anxiety disorder, major depressive disorder, mood (affective) disorder, and need for assistance with personal care. Review of clinical census revealed Resident #37 was hospitalized on [DATE]. Resident #37's payer source was a managed care insurance provider which supplied both Medicare and Medicaid coverage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #37 had mildly impaired cognition and scored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, resident and staff interviews, and facility policy review, the facility failed to follow physician orders for three residents (Residents #37, 43, and 51), failed to ensure medications were available for administration as ordered for one resident (Resident #62), and failed to promptly initiate timely treatment for one resident's (Resident #68) malfunctioning percutaneous endoscopic gastrostomy (PEG) tube. This affected five residents (Residents #37, 43, 51, 62, and 68) of 27 residents reviewed for quality of care concerns. The facility census was 99. Findings Include: 1. Review of the medical record Resident #37 revealed an admission date on 04/22/22. Medical diagnoses included chronic respiratory failure, history of falling, repeated falls, anxiety disorder, major depressive disorder, mood (affective) disorder, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #37 had mildly impaired cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and policy review the facility failed to enforce the smoking policy to ensure resident safety. This affected three ( Resident #92, #94, and #213) residents who were observed smoking and had the potential to affect all residents in the facility. Additionally, the facility failed to ensure fall preventions were in place for one resident ( Resident #37) and failed to obtain neurological checks as scheduled after a fall for one resident ( Resident #43) out of six residents reviewed for falls. The facility census was 99. Findings include: 1. Review of the medical record for Resident #92 revealed an admission date of 04/17/24 with mild cognitive deficits. Diagnoses included muscle abscess and muscle weakness. Review of Resident #92's care plan revealed Resident #92 is to go off the premises when he wants to smoke. Review of Resident # 92's Smoking evaluation dated 10/21/24, determined he is safe to smoke independently/unsupervised if he follows the facility's smoking rules. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, family, and staff interviews, record reviews, and review of facility policies, the facility failed to ensure the residents who were at nutrition and/or hydration risk were provided with adequate assistance with meal and fluid intake, weights were obtained and monitored, and meal and fluid intakes were consistently documented. This affected six residents (Residents #4, #15, #55, #58, #68, and #100) of 12 residents reviewed for nutrition and hydration during the annual survey. The facility census was 99. Findings include: 1. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, quadriplegia, constipation, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24 revealed Resident #15 had mildly impaired cognition. Resident #15 was totally dependent on staff for eating. The resident had a significant weight loss while not on prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, observations, and review of the facility policy, the facility failed to ensure the residents were offered snacks in the evening. This affected Resident #1, #11, and #34 and had the potential to affect 96 residents who received food from the kitchen. The facility census was 99. Findings include: Interviews with Residents #1, #11 and #34 during the Resident Council meeting on 10/23/24 at 10:30 A.M. revealed the residents were not receiving snacks. Interview on 10/23/24 at 2:00 P.M. with the Director of Dietary Services (DDS) #512 and the Regional Dietary Manager #610 stated they do not prepare a snack cart for each unit. It was the responsibility of the nurses and or the state tested nursing aides (STNA) when a resident request a snack in between meals, they were to retrieve a snack in the nutrition rooms or from the kitchenette in each units dining room. DDS #512 stated she goes to the units and dining rooms routinely to ensure there was a supply of snacks. Observation and interview on 10/23/24 at 4:09 P.M. with STNA #610 revealed the second…

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

Based on observations, staff interviews, and policy review, the facility failed to ensure the kitchen and nutrition rooms were maintained in a sanitary manner. This had the potential to affect 96 residents who the facility identified to receive food from the kitchen. The facility census was 99. Findings include: Observations of the kitchen on 10/21/24 from 9:35 A.M. to 9:50 A.M. with Dietary Director of Services (DDS) #512 and Regional Director of Dietary #600 revealed throughout the kitchen area, there were knats flying around the entry way into the kitchen and in the dry storage area. This was verified by the DDS #512. Observation of the ice machine located in the kitchen revealed the shoot where the ice cubes travel to cups contained a black speckled substance when wiped with a clean white napkin. This was verified by Regional Director of Dietary #600. In the dry storage area, the area around the baseboards behind and under the shelves were covered with a dark brown, black, spotted and specks substances like dirt in the entire parameter of the room. In the kitchen area, there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and policy review, the facility failed to treat residents with dignity and respect. This had the potential to affect one residents (Resident #22) out of two residents reviewed for dignity and respect. The facility census was 99. Findings included: 1. Review of the medical record for Resident #22 revealed an admission date of 11/09/18. Diagnoses included multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes. Review of progress note dated 02/14/22 revealed resident saw dentist with exam recommending extractions of #4, #5, #6, #7, #8, #9, 11, #12, and #13 and have dentures made. Progress note dated 08/08/22 revealed appointment for [NAME] dental clinic for 09/01/22 at 1:00 P.M. Progress note dated 09/01/22 revealed resident was seen in the hallway when he should have been at his appointment. Resident informed social services that transportation could not locate the building and blamed social services. Resident also stated they would not see him due to not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and review of the facility policy, the facility failed to ensure call lights were within the resident's reach. This affected one (Resident #15) of three residents reviewed for call lights. The facility census was 99. Findings include: Record review for Resident #15 revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, quadriplegia, schizophrenia, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24, revealed Resident #15 had mildly impaired cognition. Resident #15 was totally dependent on staff for bed mobility, transfers, toileting, and eating. Review of the care plan dated 01/12/24 revealed Resident #15 was to have a disc call button on the left side of her head within reach so she can activate it as she turns her head to push it. Observation on 10/21/24 at 11:46 A.M. revealed Resident #15 was lying in bed and the call…

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

Based on staff interview, closed record review, and facility policy review, the facility failed to ensure resident funds were returned upon discharge or account closure. This affected one resident (#363) of one reviewed for closed resident fund accounts. The facility census was 99. Findings include: Review of the medical record for Resident #363 revealed an admission date of 11/19/22. Diagnoses included unspecified dementia, diabetes, malnutrition, bipolar disorder, and delirium. Review of Resident #363's quarterly statements dated 01/23/24 revealed resident had $1,331.19 in the resident fund account. The statement reported the account was closed for this amount. Interview on 10/24/24 at 10:00 A.M. with Business Office Manager (BOM) #500 revealed she started at facility 07/2024 and revealed Resident #363 had discharged and closed the account. She revealed she had not found evidence of a check being provided to Resident #363 upon discharge. Interview on 10/24/24 at 11:45 A.M. with BOM #500 revealed facility had sent the account closure to facility administrator to approve the check…

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

Based on staff interview and record review, the facility failed to ensure residents were provided spenddown notifications as required. This affected two Residents (#6, and #74) of six reviewed for resident funds. The facility census was 99. Findings include 1. Review of the medical record for Resident #6 revealed an admission date of 03/30/15. Diagnoses included dementia, schizophrenia, nutritional anemia and diabetes. Review of resident personal fund statement dated 01/2024 revealed Resident #6 had a balance $1,987.16 and $1,953.36. Review of resident personal fund statement dated 02/2024 revealed Resident #6 had a balance $2003.82. Review of resident personal fund statement dated 03/2024 revealed Resident #6 had a balance $2053.82. Review of resident personal fund statement dated 04/2024 revealed Resident #6 had a balance $2054.82 and 2104.69. 2. Review of the medical record for Resident #74 revealed an admission date of 07/25/22. Diagnoses included hypertensive heart disease, heart failure, atrial fibrillation, pulmonary hypertension, bipolar disorder, and mood disorder. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review the facility failed to notify the physician of a change of condition for one resident . This had the potential to effect one resident (#68) out of six residents reviewed for nutrition. The census was 99. Findings include: Review of the medical record for Resident #68 revealed an admission date of 09/24/24 with no cognitive deficits. Diagnoses included diabetic II hypertension, hyperlipidemia and status post exploratory laparoscopy on 8/23/2024 with extensive lysis of additions, segmental small bowel resection with anastomosis and serosal repair of cecum. Complicated with persistent partial small bowel. Review of Resident #68 physician orders on 09/24/24 to 10/22/24 revealed she was receiving Total Parenteral Nutrition (TPN) Electrolytes Intravenous Concentrate (Parenteral Electrolytes) Use 1700 ml intravenously (IV) one time a day for TPN order. Infuse 1700 ml IV for 12 hours. Administer via central line. In addition, she was ordered a clear liquids diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, and record review, the facility failed to ensure lighting issues were addressed timely for one Resident (#34) of one reviewed for lighting concerns. Facility census was 99. Findings include: Review of the medical record for Resident #34 revealed an admission date of 05/29/19. Diagnoses included alcoholic cirrhosis of liver, diabetes, acute osteomyelitis, cellulitis, diabetes, bipolar disorder, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of maintenance log dated 07/01/24 to 10/20/24 revealed no entries or mention of the over the bed light being out. Interview on 10/23/24 at 11:10 A.M. with Resident #34 revealed his over the bed light had been out for several weeks. Resident revealed he told the Maintenance Director #514 and was informed it was $2500 for the order and was waiting on approval from corporate. Observation and interview on 10/23/24 at 11:20 A.M. with…

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

Based on staff interview and record review, facility failed to ensure resident fund accounts were free from misappropriation. This affected one Resident (#22) of six reviewed for resident funds. The facility census was 99. Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/09/18. Diagnoses included multiple sclerosis, failure to thrive, muscle weakness and diabetes. Review of the Resident funds statement dated 01/2024 to 10/2024 for Resident #22, revealed resident received two separate pensions and social security income as deposits and three withdrawals which totaled all but $50 accounting for each month. Statement entry dated 09/19/24 revealed an additional $1,136.00 was removed from Resident #22's account which was the total balance leaving resident with $0.00 in the account. Review of email communication between Regional Business Office Manager (RBOM) #777 and Business Office Manager #500 acknowledged an extra withdrawal was made from Resident #22's personal fund account. RBOM #777 stated we are not allowed to withdrawal funds from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews and record review, facility failed to ensure resident had a care plan for dental care. This affected one Resident (#22) of 27 residents in the sample. Facility census was 99. Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/09/18. Diagnoses included multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes. Review of progress note dated 02/14/22 revealed resident saw dentist with exam recommending extractions of #4, #5, #6, #7, #8, #9, 11, #12, and #13 and have dentures made. Progress note dated 04/22/22 revealed a care conference was held and resident stated he wanted teeth extractions which he had declined a few weeks prior. Review of progress notes revealed no evidence of resident getting the extractions as needed. Review of physician orders for 04/22/24 revealed an order for dentist referral for two teeth extractions. Review of the Minimum Data Set (MDS) assessment dated [DATE] 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 resident and staff interviews and record review, facility failed to assist a resident in a timely manner with referrals for transfer. This affected one Resident (#22) of two reviewed for discharge. Facility census was 99. Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/09/18. Diagnoses included multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes. Review of progress note dated 02/27/23 revealed resident wanted to move closer to [NAME], Ohio. Five referrals were sent with two not taking insurance, one with no beds and two with referrals pending. Progress note dated 03/01/23 revealed resident was updated on the referral status. It was discussed to send referrals to Columbus area and he said he would think about it. Progress note dated 01/22/24 revealed social services met with resident and daughter to discuss where they wanted Columbus, OH referrals sent, and three facility were requested. Progress note dated 01/26/24 revealed medical…

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

Based on medical record review, observations, resident and staff interviews, and facility policy review, the facility failed to consistently engage in effective communication with one resident (Resident #37) whose primary language was Spanish. This affected one (Resident #37) of three reviewed for language and communication. The facility census was 99. Findings Include: Review of the medical record Resident #37 revealed an admission date on 04/22/22. Medical diagnoses included chronic respiratory failure, history of falling, repeated falls, anxiety disorder, major depressive disorder, mood (affective) disorder, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #37 had mildly impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #37's primary language was Spanish. Resident #37 required supervision or touching assistance with showering/bathing and ambulation. The resident required partial assistance from staff for toileting. Review of the care plan 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, observation, and interview, the facility failed to adequately meet personal care needs which included shaving for Resident #33. This affected one (Resident #33) of two residents reviewed for shaving needs. The facility census was 99. Findings Include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus with diabetic chronic kidney disease, obesity, dislocation of lumbar vertebra, bilateral osteoarthritis, and history of transient ischemic attack. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively impaired, had bilateral impairments on upper and lower extremities, and required maximum assistance from staff for personal hygiene needs. Review of the shower log revealed Resident #33 was scheduled to receive two showers per week, specifically on Fridays and Sundays. Review of shower/bath sheets revealed Resident #33 received a shower on 10/15/24, 10/18/24, 10/23/24, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews and record review, the facility failed to ensure activities were provided daily and to meet resident interests. This affected two Residents (#55 and #100) of two reviewed for activities. Facility census was 99. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 05/06/20. Diagnoses included cerebrovascular disease, diabetes, cerebrovascular disease, cognitive communication deficit, dysphasia, muscle weakness, and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed preferences were marked as very important to listen to music, keep up on the news, and go outside to get fresh air, and somewhat important to do activities of interest. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired and required set up assistance with eating, partial moderate assistance for personal hygiene, and substantial/maximum assistance for bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and review of the facility policy, the facility failed to develop and implement a comprehensive and individualized skin integrity program to ensure identification, interventions and treatments were initiated upon identification of the wound. This affected two (Resident #40 and #4) residents. Additionally, the facility failed to change a malfunctioning mattress timely for Resident #5. This affected three residents ( Resident #40, #4, and #5) out of three residents reviewed for skin integrity. The facility census was 99. Findings Include: 1. Review of the medical record for Resident #40 revealed an admission date of 03/13/24 with diagnoses not limited to intracapsular fracture of left femur, urinary tract infection, peripheral vascular disease, metabolic encephalopathy, history of transient ischemic attack, traumatic brain injury and dementia. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had a memory problem, was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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,and policy review, the facility failed to ensure orders for indwelling urinary catheters were in place for Resident #88 and #100. This affected two Residents (#88 and #100) of two reviewed for indwelling urinary catheters. The facility census was 99. Findings include: 1. Record review of Resident #88 revealed an admission date of 06/22/24 with pertinent diagnoses of: type two diabetes mellitus with diabetic peripheral angiopathy, pressure ulcer of sacral region stage four, rheumatic mitral stenosis, anemia, peripheral vascular disease, encounter for attention to colostomy, lactose intolerance, weakness, acquired absence of right and left leg above knee, nicotine dependence, obstructive and reflux uropathy, hyperlipidemia, depression, hyperkalemia, presence of urogenital implants, and sepsis. Review of the 09/27/24 quarterly Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and does not use and mobility devices to aid in mobility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to identify and care plan residents with Post Traumatic Stress Syndrome (PTSD) to include non-pharma logical interventions to eliminate or mitigate triggers that may cause re-traumatization. This had the potential to effect one resident (#15) of one resident reviewed for diagnosis of PTSD. The census was 99. Findings include: Record review for Resident #15 revealed Resident #15 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, seizures, quadriplegia, constipation, schizophrenia, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/24, revealed Resident #15 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11/15. Resident #15 was noted to have a diagnosis of PTSD and resident assessed to be totally dependent on staff for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure pharmacy recommendations were addressed by the physician, including rational for not following recommendations. This affected two residents (Resident #11 and #15) out of five residents reviewed for un-necessary medications. The facility census was 99. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 12/29/23 with diagnoses that included: chronic obstructive pulmonary disease, pyogenic arthritis, Type 2 diabetes mellitus, bipolar disorder, chronic kidney disease, hypertension, attention-deficit hyperactivity disorder, anxiety disorder, major depressive disorder, mood disorder, presence of artificial knee joint and infection of the surgical site infection right knee, and migraines. Review or Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact and received insulin, antipsychotics, antianxiety, antidepressant, antibiotic, opioid, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, and staff interviews, the facility failed to ensure residents who received multiple as needed pain medications had parameters in place to ensure pain medications were administered appropriately. This affected two (Residents #11 and #15) of five residents reviewed for unnecessary medications. The facility census was 99. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 12/29/23. Diagnoses included chronic obstructive pulmonary disease, pyogenic arthritis, chronic kidney disease, and migraines. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact. Review of Resident #11's current pain medications dated 10/2024 revealed orders for Oxycodone (treats moderate to severe pain) 10 milligrams (mg) every four hours as needed for pain and acetaminophen (treats minor aches and pain) 325 mg tablets give two tablets every four hours as needed for pain. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility failed to ensure dental services and follow up were provided timely to a resident. This affected one (Resident #22) of one resident reviewed for dental services. The facility census was 99. Findings include Review of the medical record for Resident #22 revealed an admission date of 11/09/18. Diagnoses included multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes mellitus. Review of the progress note dated 02/14/22 revealed Resident #22 saw the dentist with exam recommending extractions of #4, #5, #6, #7, #8, #9, 11, #12, and #13 and have dentures made and a plan would be discussed with the resident once clearance from 360 dental. The progress notes revealed on 04/22/22, a care conference was held and Resident #22 stated he wanted teeth extractions, which he had declined a few weeks prior. The progress note dated 04/25/22 revealed a call was made to schedule extractions with 360 care. On 04/28/22, a follow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to follow guidance within their antibiotic stewardship program to ensure antibiotics were ordered appropriately. This affected two (Resident #10 and Resident #163) of three residents reviewed for antibiotic usage. The facility census was 99. Findings include: Review of facilities antimicrobial stewardship program mission statement dated 11/30/23 revealed the facility ensures that antibiotic medications are only used when truly necessary, and when prescribed, will be the best medication at the correct dose for the appropriate length of treatment. Our goal is to help reduce growing antibiotic resistance. 1. Review of the medical record for Resident #10 revealed an admission date of 01/15/24. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, chronic gastritis, and urinary incontinence. Review of the care plan dated 11/30/23 revealed Resident #10 had bladder incontinence due to impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, review of facility policy, and observations, the facility failed to ensure they had a functional call light system and call lights were kept within reach. This affected two (Residents #31 and #55) of three residents reviewed for call light systems. The facility census was 99. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 02/08/24. Diagnoses included chronic kidney disease, depression, bilateral osteoarthritis of knee and bed confinement status. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively impaired, had bilateral impairments in the lower extremities, was dependent on staff for all activities of daily living, and was incontinent of urine. Review of the care plan dated 02/20/24 revealed Resident #31 was at a fall risk due to impaired mobility and incontinence. Interventions included to explain and remind the resident of non-compliance with ambulation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to put treatments in place in a timely manner when Resident #21 developed three non-pressure related ulcers. This affected one (Resident #21) of three residents reviewed for skin impairment. The facility census was 104. Findings include: Closed medical record review revealed Resident #21 was admitted on [DATE] and discharged on 08/13/24. Diagnoses included cystitis, type II diabetes mellitus, chronic pain, and erythema intertrigo (skin condition). The Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 had no pressure, venous, or arterial ulcers and had no other skin problems. Review of the hospital discharge records dated 07/11/24 revealed Resident #21 had pain and redness in lower abdominal skin folds and genital area. The admission assessment dated [DATE] revealed Resident #21 had a blister to right great toe, fungal infection under left breast that measured 0.1 centimeters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy and resident rights, resident and staff interview, and observation, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. This affected one resident (#75) and had the potential to affect an additional 36 residents (Resident #2, #3, #5, #8, #9, #11, #12, #19, #22, #23, #25, #26, #30, #32, #33, #35, #36, #40, #41, #43, #48, #49, #59, #62, #64, #65, #69, #71, #74, #83, #84, #85, #86, #91, #92, and #94) who resided on the second floor. The facility census was 93. Findings include: Review of Resident #75's medical record revealed an admission date of 12/20/22. Diagnoses included depression, muscle weakness, and peripheral vascular disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 was cognitively intact and required maximum assistance from staff with bathing. Observation on 08/19/24 at 12:13 P.M. of the second-floor community shower room…

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

Based on observations, staff interview, and facility policy review, the facility failed to maintain the nourishment room's refrigerators in a clean and sanitary manner. This affected two of two nourishment rooms. This had the potential to affect all 104 residents residing in the facility. Findings include: Observation on 07/12/24 at 10:45 A.M. of the first-floor nourishment room revealed the white reach in refrigerator contained a bag with various foods dated 07/01/24, several small white bowls with a white food resembling mashed potatoes not dated, several opened containers of drinks undated, and a black bowl containing beans and a brown meat undated. Housekeeping Supervisor #272 verified the outdated food in the refrigerator. Observation on 07/12/24 at 11:21 A.M. of the second-floor nourishment room revealed the white reach in refrigerator had a brown substance spilled in the bottom of the refrigerator. There were multiple containers of undated and outdated food and an expired carton of milk. Licensed Practical Nurse (LPN) #208 verified the multiple containers of undated 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 observation and staff interview, the facility failed to ensure the flooring was in good repair and safe in the second floor nourishment room for the residents to use. This affected one of two nourishment rooms. This had the potential to affect the 58 residents residing on the second floor. The facility census was 104. Findings include: Observation on 07/12/24 at 11:21 A.M. of the second floor nourishment room revealed multiple floor tiles with missing pieces resulting in raised edges. Interview with Licensed Practical Nurse (LPN) #208 at the time of the observation verified the missing pieces of tile and verified the raised edges posed a trip hazard to residents utilizing the nourishment room. This deficiency represents non-compliance investigated under Complaint Number OH00155460.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of 30-day notice, and resident and staff interview, the facility failed to ensure the 30-day discharge notice documented the location of discharge. This affected one (Resident #90) of two residents revived for 30-day discharge notice. The facility census was 104. Findings include: Review of the medical record for Resident #90 revealed an initial admission date of [DATE]. Diagnoses included fracture of left femur, displaced fracture of fourth/fifth metatarsal bone of left foot, chronic obstructive pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, obesity, anxiety disorder, peripheral vascular disease, alcohol abuse, major depressive disorder, chronic pain, and nicotine dependence psychoactive substance abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had moderate cognitive impairment. Review of the 30-day notice issued to Resident #90 dated [DATE] revealed the discharge notice was given due to the safety of…

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

Based on observations and staff interview, the facility failed to ensure resident medications not prepared ahead of administration time and failed to store over the counter (OTC) medications appropriately with name, the original manufacturer's or pharmacy-applied label indicating the medication name, strength, quantity, accessory instructions, lot number, and expiration date when applicable. Additionally, the facility failed to ensure medications were under direct observation of the person administering the medication or locked in the medication storage area/cart. This affected one of four hallways. This affected three residents (#63, #91, and #97). The facility census was 104. Findings include: Observations on 07/12/24 from 8:47 A.M. to 9:47 A.M. revealed Registered Nurse (RN) #216 had two resident's (#91 and #97) morning medications prepared in clear plastic cups sitting on top of the medication storage cart. There were two multi use bottles of Miralax (OTC medication) sitting on top of the medication storage cart. Interview with RN #216 during the time of the observation verified…

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

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were handled and distributed a sanitary manner. This affected two residents (#63 and #99) of four residents observed during medication administration. The facility census was 104. Findings include: Observation of medication administration on 07/12/24 at 9:04 A.M. revealed Registered Nurse (RN) #216 was preparing Resident #99's medication and dropped the Eliquis (blood thinner) on the top of the medication storage cart. RN #216 then picked the medication up with her bare hands and placed the medication into a clear plastic cup. RN #216 then entered Resident #99's room and administered the medication Eliquis to Resident #99. Observation of RN #216 at 9:47 A.M. revealed the RN prepared Resident #63's morning medication dropping one Zealot (antidepressant) 25 milligram (mg) tablet on the top of the medication storage cart. RN #216 picked the medication up with her bare hands and placed it into the cup. ADON #247 alerted RN #216 to remove the tablet from the cup as it touched 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, interview, and pharmacy contract review the facility failed to ensure a comprehensive medical record review was completed to identify irregularities with prescribed medications during the monthly pharmacy medication regimen review (MRR). This affected one resident (Resident #105) of five residents reviewed for anticoagulant medication use. The facility census was 103. Findings Include: Review of medical record for Resident #105 revealed an initial admission to the facility on [DATE] with diagnoses including a history of stroke, atrial fibrillation (Afib), type two diabetes mellitus, and breast cancer. Further review revealed Resident #105 was dependent on staff for activities of daily living (ADL) tasks and transfers, was non-ambulatory using a wheelchair for mobility and was verbally able to make needs known to staff. Review of Resident #105's care plan, dated 04/13/23, revealed the use of anticoagulant therapy to treat atrial fibrillation with a goal of no adverse effects 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 observation, record review, and interview the facility failed to ensure medications were handled and distributed in a sanitary manner. This affected two residents (#12, #25 and #34) out of four residents observed during medication administration. The facility census was 103. Findings Include: 1. An observation on 06/03/24 from 8:45 A.M. to 9:03 A.M. revealed Licensed Practical Nurse (LPN) #264 performing medication administration for Residents #12, and #25. LPN #264 prepared Resident #12's morning medication at the medication cart, knocked and entered Resident #12's room and administered the medication. Upon completion of Resident #12's medication administration, LPN #264 exited the room without washing or sanitizing his hands. Once LPN #264 returned to the medication cart and began preparing Resident #25's medication without sanitizing his hands. LPN #264 completed preparation of Resident #264's medication, LPN #264 knocked and entered Resident #25's room and administered the medication. LPN #264 then exited Resident #25's room without washing or sanitizing his hands. An…

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

Based on medical record review, review of a Self-Reported Incident, and staff interview, the facility failed to ensure Resident #125 was treated with dignity and respect. This affected one resident (#125) of four residents reviewed for dignity and respect. The facility census was 113. Findings include: Review of the medical record for Resident #125 revealed an admission date of 01/10/24 and a discharge date of 01/26/24 with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, borderline personality disorder, and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/17/24, revealed Resident #125 had intact cognition. Review of the Self-Reported Incident (SRI) form for SRI tracking number 243250, dated 01/19/24, revealed an allegation of neglect and emotional or verbal abuse was made by Resident #125. She alleged to a third party that Former State Tested Nursing Assistant (STNA) #802 refused to clean up her spilled water and to provide her with new ice water. The allegation was reported to the Administrator and Former…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to report an incident of potential misappropriation and verbal abuse. This affected two (Resident #46 and #51) of four residents reviewed for abuse. The facility census is 113. Findings include: Review of the medical record for Resident #51 revealed an admission date of 04/13/23 with diagnoses including cerebral infarction due to embolism, human immunodeficiency virus, schizophrenia, bipolar disorder, anxiety disorder, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/31/23, revealed Resident #51 had intact cognition. Review of the progress note, dated 01/11/24, revealed Resident #51 was complaining about her former roommate, (Resident #46) and stated she had taken her green blanket. Resident #51 continued to scream at Resident #46 as caregivers prevented Resident #51 from entering Resident #46's room. Later, Resident #51 called her daughter and she stormed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of facility investigations, review of Self-Reported Incidents, staff interview, resident interview, and facility policy review, the facility failed to thoroughly investigate incidents of potential abuse. This affected four residents (#46, #51, #84, and #101) out of four residents reviewed for abuse. The facility census was 113. Findings include: 1. Review of the medical record for Resident #84 revealed an admission date of 01/04/24 with diagnoses including Chronic Obstructive Pulmonary Disorder, diaphragmatic hernia, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/11/24, revealed Resident #84 had moderately impaired cognition. Review of the Self-Reported Incident (SRI) form for SRI tracking number 242911, revealed the date of discovery was 01/09/24. The form further revealed an allegation of physician and emotional or verbal abuse was made by Resident #84. Resident #84 alleged that while providing care, two State Tested Nursing Assistant's (STNA) hurt her stomach and made her apologize 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, staff interview, and facility policy review, the facility failed to complete wound care as ordered. This affected one (Resident #120) of four residents reviewed for wound care. The facility census was 113. Findings include: Review of the medical record for Resident #120 revealed an admission date of 09/16/23 and discharge date of 12/27/23 with diagnoses including type two diabetes mellitus, non-pressure chronic ulcer of other part of right foot, open wound of right lower leg, peripheral vascular disease, venous insufficiency, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/30/23, revealed Resident #120 had intact cognition. She had a diabetic foot ulcer and moisture associated skin damage (MASD). Review of the plan of care, dated 09/19/23, revealed Resident #120 had the potential for alteration in skin integrity related to immobility, obesity, and her diagnoses. Interventions included administering medications as ordered, administering treatments as ordered, providing the diet according 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.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure medications were administered as ordered. This affected one (Resident #101) of five residents reviewed for medication administration. The facility census was 113. Findings include: Review of the medical record for Resident #101 revealed an admission date of 11/28/20. Resident #101's medical diagnoses included multiple sclerosis, muscle weakness, and depression. Review of Resident #101's physical chart on 01/30/24 at 8:10 A.M. revealed a flagged handwritten order from a psychiatric Certified Nurse Practitioner (CNP) for Melatonin three milligrams (mg) daily at bedtime and to add a diagnosis to Resident #101's medical record of hypersomnia (excessive daytime sleepiness). The order for melatonin three mg at bedtime and the diagnosis of hypersomnia were not pressent in Resident #101's electronic health record. Observation on 01/30/24 at 6:44 A.M. revealed Resident #101 in bed with the room lights off. Resident #101 appeared to be asleep. Subsequent observations the 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 and staff and resident interviews, the facility failed to provide showers as scheduled. This affected one (#81) of three residents reviewed for showers. The facility census was 96. Findings include: Review of medical record for Resident #81 revealed admission date 12/20/23 with diagnoses including but not limited to acute respiratory failure with hypoxia, malignant neoplasm of bronchus or lung, unspecified severe protein-calorie malnutrition, dysphagia, dependence on supplemental oxygen, and encounter for antineoplastic radiation therapy. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #81 had moderately impaired cognition. Resident required partial/moderate assistance for activities of daily living. Review of care plan dated 12/21/23 revealed Resident #81 preferred showers. Further review of care plan dated 12/21/23 revealed Resident #81 prefers to be washed up at sink by his wife. Provide limited assist (supervision or touching assistance) with bathing. Review of After…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure Resident #385's advance directive in the electronic medical record was accurate. This affected one (#385) of two residents reviewed for advanced directives. The facility census was 93. Findings include: Review of the medical record for Resident #385 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/02/21, revealed Resident #385 had moderately impaired cognition. Review of the care plan, dated 10/27/21, revealed Resident #385 was a Full Code. The intervention stated the staff would treat the Resident #385 as a Full Code. Review of the paper chart revealed Resident #385's Advanced Directive, dated 11/02/21, was listed as Do Not Resuscitate Comfort Care-Arrest (DNRCCA) (the protocol is activated when the patient experiences cardiac or respiratory arrest). Review of the electronic medical record, 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 record reviews, observations, and resident and staff interview, the facility failed to maintain clean floors, tables, and privacy curtains in the resident's rooms. This affected two (#48 and #64) of two residents reviewed for environmental concerns. The facility census was 93. Findings include: 1. Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 10/04/21, revealed Resident #48 was cognitively intact, had no behaviors, did not wander, and did not reject care. Observation on 11/15/21 at 11:17 A.M. revealed Resident #48's privacy curtain was dirty. Subsequent observation on 11/18/21 at 9:39 A.M. revealed Resident #48's privacy curtain had a large brown spot. Interview on 11/18/21 at 9:39 A.M. with Resident #48 stated she had complained to multiple staff a month or two ago including State…

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

Based on record review, observation, staff interview, and policy review, the facility failed to ensure medications were locked when unattended. This had the potential to affect two (#59 and #61) of 21 residents residing on second floor unit. The facility census was 93. Findings include: Observation on 11/15/21 at 11:16 A.M. revealed a medication cart on the second floor unit on the resident's hallway. The medication cart was unlocked and the keys to the cart were laying on top of the cart. No staff were observed in the hallway. Interview on 11/15/21 at 11:18 A.M. with Registered Nurse (RN) #371 confirmed she left the medication cart unlocked and unattended with the keys on top when she walked into a resident's room. RN #371 confirmed the cart should have been locked and keys secured before walking away from the cart. Review of the facility list of residents on the second floor revealed there were 21 residents residing on this unit. Resident #59 and #61 who resided on the second floor were identified by the facility to be mobile and confused. Review of the facility's policy titled…

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