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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure the resident's menu followed the nutritional needs of the resident. This affected one (Resident #45) of 11 residents reviewed for nutrition. The facility census was 121. Findings include:Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with diabetic chronic kidney disease, type II diabetes mellitus with diabetic retinopathy without macular edema, and morbid (severe) obesity due to excess calorie.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact, received a therapeutic diet and required supervision with meals.Review of the physician orders dated 02/07/26 revealed an order for a renal/diabetic diet with regular texture and thin consistency.During an observation and interview on 03/11/26 at 9:56 A.M., Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, policy review, staff interviews and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure proper hand hygiene and infection control procedures were followed during incontinence care and ensure staff were aware to follow enhanced barrier precautions (EBP) for a resident with an indwelling medical device. This affected two residents (#14 and #18). The facility census was 121.Findings include:1. Review of the medical record for Resident #14 revealed an admission date of 08/07/25. Diagnoses included dementia, anxiety, major depressive disorder, chronic respiratory failure with hypoxia, panic disorder, arthritis, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition and was dependent on staff for toileting hygiene. Review of the care plan dated 08/07/25 revealed Resident #14 required enhanced barrier precautions (EBP) related to history of multi-drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, pharmacy and staff interview, the facility failed to follow an antibiotic stewardship program and ensure antibiotics were not prescribed without adequate clinical indication. This affected two (#6 and #13) of four residents reviewed for antibiotic stewardship practices. The facility census was 121.Findings include: 1. Review of Resident # 13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, intestinal obstruction unspecified as to partial versus complete obstruction, partial intestinal obstruction, acquired absence of the digestive tract, and malignant neoplasm of the endometrium. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderate cognitive impairment and required partial/moderate assistance with toileting. The care plan dated 05/27/25 revealed Resident #13 was at risk for an alteration in gastro-intestinal status related to history of intestinal obstruction,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident representative interview, medical record review, and policy review, the facility failed to provide a dignified experience when alternate communication methods were not utilized to promote and enhance a resident's quality of life. This affected one (#220) of one residents reviewed for dignity. The census was 111.Findings include:Review of Resident #220's medical record revealed an admission date of 12/29/22 with diagnoses including but not limited to Alzheimer's disease, pancreatitis, type two diabetes mellitus, hypotension, depression, gastro-esophageal reflux disease, and anxiety disorder.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #220 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Resident #220 required moderate assistance with showering, putting on and off footwear, and personal hygiene. Review of Resident #220's care plan dated 08/01/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital documentation review, review of an incident report, review of staff training documentation, staff interview, and policy review, the facility failed to ensure residents were administered antibiotic medications and insulin as ordered and within scheduled time frames which resulted in significant medication errors. This affected two (#299 and #45) of six residents reviewed for medication administration. The census was 111.Findings include: 1. Review of the medical record for Resident #299 revealed an admission date of 09/12/25 with diagnoses including pseudomonas as the cause of diseases, gastrointestinal hemorrhage, acute pyelonephritis, and presence of urogenital implants. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #299 was cognitively intact, required setup or clean-up assistance with eating, and was taking an antibiotic and intravenous (IV) medication.Review of a hospital hard script copy dated 09/08/25 and signed by a…

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

Based on medical record review, staff interview, family interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported to Ohio Department of Health (ODH) in a timely manner. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 11/06/24 with diagnoses including moderate dementia with behavioral disturbance, anxiety disorder, acquired absence of kidney, and atherosclerotic heart disease. Review of the (Minimum Data Set) MDS assessment for Resident #77 dated 02/13/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #77 dated 01/29/25 timed at 7:23 P.M. per by Licensed Practical Nurse (LPN) #101 revealed the nurse heard a scream from a resident's room and upon arrival found an altercation had taken place between Resident #77 and Resident #78 with both residents sustaining bruises and…

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

Based on medical record review, resident representative interview, staff interview, hospice staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to investigate allegations of staff to resident physical abuse. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents. Finding Include: Review of the medical record for Resident #77 revealed an admission date of 11/06/24 with diagnoses including moderate dementia with behavioral disturbance, anxiety disorder, acquired absence of kidney, and atherosclerotic heart disease. Review of the (Minimum Data Set) MDS assessment for Resident #77 dated 02/13/25 revealed the resident had severe cognitive impairment. Review of the medical record for Resident #78 revealed an admission date of 03/25/23 with diagnoses including Lewy body disease, anxiety disorder, macular degeneration, and depression. Interview on 02/25/25 at 12:23 P.M. with Resident #77's representative confirmed that on 02/11/25 two staff members came in…

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

Based on observation, staff interview, and record review the facility failed to ensure that the medication error rate was less than five percent. The facility medication error rate was 6.89 percent (%) based on 29 medication opportunities and two medication errors. This affected one (Resident #56) of three residents reviewed for medication administration. The facility census was 113 residents. Findings include: Review of the medical record for Resident #56 revealed an admission date of 11/09/24 with diagnoses including cerebrovascular disease, hypertension, benign neoplasm of colon, peripheral vascular disease, and type two diabetes mellitus. Review of the physician's orders for Resident #56 revealed an order dated 11/11/24 for Aspirin 81 milligrams (mg.) chewable, give 1 tablet by mouth one time a day and an order dated 02/11/25 for Senna-S 8.6-50 mg., give one tablet by mouth twice daily. Observation of medication administration 02/25/25 at 8:45 A.M. for Resident #56 per Licensed Practical Nurse (LPN) #18 revealed the nurse administered a Senna 8.6 mg tablet and an enteric coated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of daily staffing postings the facility failed to identify a licensed charge nurse in the facility for all tours of duty. Findings include: Review of the daily staffing postings for June 2024 and July 2024 revealed there is no designated charge nurse for the 7:00 A.M. - 7:00 P. M. shift on weekends (Saturday and Sunday) or any observed holidays (i.e. Memorial Day and the 4th of July). The sheets simply say see on call list at front desk. Interview on 07/11/24 at 7:20 A.M. with the Director of Nursing (DON) confirmed the nightshift supervisor is the charge nurse from 7:00 P.M. to 7:00 A.M. The DON confirmed the day shift charge nurse Monday through Friday is the unit manager. The DON stated on weekends and holidays the on-call manager is the day shift charge nurse and is available by phone. There is always a manager on duty scheduled and always a nurse on-call. The posting at the nurse's stations and front desk always lets them know who to call. Interview on 07/11/24 at 10:05 A.M. with state tested nursing assistant (STNA) #133 revealed if 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.

Based on review of staffing schedules and staff interview, the facility failed to ensure there was a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week as required. This has the potential to affect all 92 residents residing in the facility. The facility census was 92. Findings include: Review of the staff schedules for 2024 to the current date revealed there was no RN scheduled in the facility on 01/14/24 (Sunday), 02/25/24 (Sunday), 03/23/24 (Saturday), 03/24/24 (Sunday). 03/29/24 (Friday and RN unit manager was on vacation), 06/29/24 (Saturday), and 06/30/24 (Sunday). Interview on 07/11/24 at 7:20 A.M. with the Director of Nursing (DON) confirmed the DON and unit managers were not aware that there was a regulation that states there needs to be a RN in the facility and available for resident care eight consecutive hours a day seven days a week. Interview on 07/11/24 at 10:00 A.M. with the DON confirmed the above dates did not have a RN on duty for at least eight consecutive hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, facility failed to ensure flooring was maintained in good condition affecting all 25 residents residing on the 200 hall (#5, #7, #8, #9, #11, #13, #15, #16, #19, #21, #23, #30, #39, #43, #45, #48, #49, #50, #51, #52, #57, #64, #66, #78, and #82). The facility also failed to ensure a homelike environment for one Resident (#13) of 32 residents reviewed. Facility census was 92. Findings include 1. Observation on 07/08/24 from 9:30 A.M. to 4:00 P.M. revealed several torn and frayed sections of carpet, as well as loose and wavy carpet in the 200 hall. Observation and interview on 07/11/24 at 9:00 A.M. with Unit Manager #33 confirmed the 200 hall was getting all new flooring but she was unsure of the details or timeline. Unit Manager confirmed carpet was torn and frayed with loose wavy spots. She stated they try to trim the frayed pieces to prevent an increased tripping hazard. Review of Safety Committee Meeting Minutes dated 03/06/24 revealed carpet in memory…

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

Based on record review and staff interview, the facility failed to ensure Beneficiary notices were provided timely to resident and or resident representative. This affected one Resident (#139) of three reviewed for beneficiary notices. Facility census was 92. Findings include Review of the medical record for Resident #139 revealed an admission date of 01/06/24 and discharge date of 04/04/24. Diagnoses included congestive heart failure, non-traumatic subarachnoid hemorrhage, weakness, dysphasia, diabetes and acute respiratory failure. Review progress notes dated 02/19/24 revealed notice of medicare non-coverage (NOMNC) was given with last day of coverage on 02/21/24. Progress note dated 02/22/24 revealed resident would be staying at facility and SNF ABN was issued. Review of the NOMNC dated 02/19/24 revealed the last covered day was 02/21/24 and was signed on 02/19/24. Review of the SNF ABN was signed and dated 02/24/24. Review progress notes dated 03/25/24 revealed notice of medicare non-coverage (NOMNC) was given with last day of coverage on 03/28/24. Progress note dated 04/04/24…

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 medical record review, facility investigative document review, staff interview, and facility policy review, the facility failed to report an allegation of abuse to the state agency in a timely manner. This affected one (Resident #138) of two residents reviewed for abuse. The census was 92. Findings Include: Resident #138 was admitted to the facility on [DATE]. Her diagnoses were pain in left leg, morbid obesity, difficulty walking, post traumatic stress disorder, agoraphobia, insomnia, anxiety disorder, depression, chronic pain syndrome, mood disorder, and edema. Review of her minimum data set (MDS) assessment, dated 06/05/24, revealed she was cognitively intact. Review of facility Self Reported incident (SRI) number 248352, dated 06/06/24, found that Resident #138 made an abuse allegation against a staff member on 06/05/24. It was documented that the facility receptionist reported the allegation to the administrator on 06/05/24, but the allegation was not reported to the state agency until 06/06/24.…

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 medical record review, staff interview and policy review, the facility failed to develop a comprehensive care plan to address a residents nutritional risk and significant weight loss. This affected one (#61) out of 22 residents reviewed for care plans. The facility census was 92. Findings include: Review of the medical record for Resident #61 revealed an admission date of 02/12/24. Diagnoses included myasthenia gravis, morbid obesity, severe protein calorie malnutrition, gastrostomy status, muscle weakness, chronic obstructive pulmonary disease, narcolepsy, dysphagia, acute respiratory failure, anxiety disorder. Review of the Nutrition assessment dated [DATE] revealed that Resident #61 had a past medical history of severe protein calorie malnutrition (PCM), and was at risk of malnutrition as evidenced by dysphagia and the need for alternative means of nutrition. Review of nutrition progress note from 05/08/24 revealed that Resident #61 had lost 76.8 pounds in three months, which was a 29.3% significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 podiatry schedules, observations and staff, resident and resident representative interviews, the facility failed to provide a resident with timely podiatry services. This affected one (#67) of three residents reviewed for ancillary services. The facility census was 92. Findings include: Review of Resident #67's medical record revealed an admission date of 07/12/23 with diagnoses of muscle weakness, Parkinson's disease, dementia, unsteadiness on feet, and acute kidney failure. Review of the care plan for Resident #67 dated 02/17/24 revealed the following actions: educate the resident to communicate their appointment needs with nursing and social services as required; and review resident preferences or identify responsible parties to arrange appointments. Review of Minimum Data Set (MDS) 3.0 assessment completed 07/07/24 revealed Resident #67 was cognitively intact and required a walker or wheelchair for mobility. Review of Resident #67's physician orders dated 08/17/23 revealed he may receive dental, vision, audiology, and podiatry through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of video recording, staff and resident representative interviews, review of a user manual and policy review, the facility failed to ensure a resident was provided with an adequate amount of assistance while being transferred with a sit-to-stand lift. This affected one (#14) out of one residents reviewed for assistance with sit-to-stand lifts. The facility census was 92. Findings Include: Review of Resident #14's medical record revealed admission on [DATE] with diagnoses including chronic obstructive pulmonary disease, Parkinson's disease, hemiplegia, unsteadiness on feet, visual disturbances, and heart failure. Review of Resident #14's Minimum Data Set (MDS) 3.0 assessment completed on 04/04/24 indicated the resident required a wheelchair for mobility and maximum assistance for transfers. Review of Resident #14's physician orders dated 12/06/23 included an order to use a mechanical lift for transfers. Review of Resident #14's care plan dated 07/10/24 indicated the resident requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident and staff interviews, the facility failed to re-assess, monitor and notify the physician following a resident's significant weight loss. This affected one (#21) of three residents reviewed for nutrition. The census was 92. Findings include: Resident #21 was admitted to the facility on [DATE]. Diagnoses were chronic obstructive pulmonary disease, mental disorder, type II diabetes, repeated falls, hyperlipidemia, anxiety disorder, autistic disorder, pain, seborrheic dermatitis, depression, and vitamin D deficiency. Review of his minimum data set (MDS) assessment, dated 05/21/24, revealed Resident #21 was cognitively intact. Review of Resident #21 weights, dated 01/03/24 to 07/02/24 found that he lost a total of 22.6 pounds, which equated to 16.7% loss in six months. Also, within this given time period, significant weight loss moments included: from 03/06/24 to 04/15/24, he lost 11.4 pounds (8.4% in 30 days). Review of Resident #21 nutritional and nursing notes, dated…

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

Based on medical record review, observations, staff, resident and resident representative interviews and policy review, the facility failed to manage a resident's complaints of pain. This affected one (#73) of three residents reviewed for pain management. The facility census was 92. Findings include: Review of the medical record for Resident #73 revealed an initial admission date of 07/05/23. Diagnoses included dementia unspecified severity with agitation, need for assistance with personal care, moderate protein calorie malnutrition, metabolic encephalopathy, personal history of healed traumatic fracture, anxiety disorder, unspecified hearing loss bilateral, unspecified mood disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/03/24, revealed Resident #73 had unclear speech, impaired cognition with no Brief Interview of Mental Status (BIMS) score due to the resident being rarely or never understood. Review of Resident #73's care plan dated 07/07/23 revealed the resident was at risk of impaired comfort related to surgical diagnoses and post-op care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, record review and policy review, the facility failed to ensure staff implemented the medication administration policy to administer medications for one resident at a time. This affected five residents (Residents #7, #19, #23, #39 and #51) who were incidentally observed outside of the six residents formally observed for medication administration. The facility census was 92. Findings include: 1. Observation on 07/09/24 at 12:32 P.M. of licensed practical nurse (LPN) #9 revealed the nurse brought three cups of pills stacked within each other and each labeled with a resident room number on the cup. Interview on 07/09/24 at 12:33 P.M. LPN #9 confirmed the nurse typically passed afternoon medication this way (stacking cups and bringing them all at once) due to most residents being out at the dining area for lunch. LPN #9 confirmed residents who received these cups of pills included Resident #19, #39, and #51. LPN #9 revealed she was not sure what medication was in each cup, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the policy for medication storage, the facility failed to ensure medications were secure from the time they were dispensed until the medications were administered. This affected one (#67) of one residents observed during the annual survey with medications left unattended at the bedside. The facility census was 92. Findings include: Review of the medical record for Resident #67 revealed he was admitted on [DATE] with diagnoses of Parkinson's disease, muscle weakness, cognitive communication deficit, dementia, depression, and anxiety. Review of Minimum Data Set (MDS) 3.0 quarterly assessment completed 06/07/24 revealed Resident #67 was cognitively intact. Review of baseline admission evaluation completed 07/12/23 revealed Resident #67 was unable to self-administer medication. Review of Resident #67's physician's order for citalopram hydrobromide oral tablet 10 milligrams (mg) (citalopram hydrobromide) give 0.5 tablet by mouth one time a day for depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a hospice communication book/binder and staff interviews, the facility failed to ensure timely communication was occurring between hospice staff and facility staff. This affected one (#35) out of one residents reviewed for hospice care. The facility census was 92. Findings include: Review of medical records for Resident #35 revealed the resident was admitted on [DATE]. Diagnoses include malignant neoplasm of the colon, malignant neoplasm of liver and intrahepatic bile duct, colostomy, basal cell carcinoma of skin, anxiety disorder, chronic kidney disease, atherosclerotic heart disease, chronic pain syndrome, osteoarthritis, hypotension, and history of transient ischemic attack (TIA) and cerebral infarction. Review of Minimum Data Set (MDS) 3.0 Quarterly assessment completed 06/20/24 revealed Resident #35 was cognitively intact. Resident #35 has a limited range of motion on one side of the body for both upper and lower extremities, has a colostomy present, and is 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, staff interviews, and facility policy review, the facility failed to implement their antibiotic stewardship program to ensure infections and antibiotics were ordered appropriately. This affected one (#42) of two residents reviewed to proper antibiotic usage. The facility census was 92. Findings include: Review of the medical record for Resident #42 revealed an admission date of 02/29/24 with diagnosis of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, muscle weakness, anxiety and diverticulitis. Review of Minimum Data Set (MDS) 3.0 assessment completed 03/07/24 revealed she required maximum assistance with toileting and was frequently incontinent. Review of Resident #42's care plan dated 03/01/24 outlined monitoring and documenting signs and symptoms of urinary tract infection (UTI), including pain, blood-tinged urine, cloudiness, decreased output, urine color changes, increased temperature, and altered mental status. Review of progress note dated 04/19/24…

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.

Based on observation, interview, and facility policy review, the facility failed to ensure infection control was maintained when sharps containers were not changed when full to prevent overflowing of objects which were an infection control concern. This affected four residents (#40, #59, #65 and #89) and had the potential to affect all 86 residents residing in the facility. Findings included: Interview on 09/01/23 at 3:32 P.M. with Resident #59's family member revealed a concern regarding the sharps container (a hard plastic container for the storage of used sharp items like lancets and needles for safety and infection control by placing the items in the container lid and flipping them down into the container) in the bathroom had been full and overflowing for months and everyone said they couldn't find a key. Resident #59's family member reported it just wasn't sanitary or safe. Observation on 09/01/23 at 3:32 P.M. revealed Resident #59's sharps container hanging on her bathroom wall overflowing with 10 used lancets and three used glucometer strips on top of the partially closed lid…

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

Based on observation, interview, and facility policy review, the facility failed to ensure a safe environment when sharps containers were not changed when full to prevent overflowing of objects which were a safety control concern. This affected four residents (#40, #59, #65 and #89) and had the potential to affect all 86 residents residing in the facility. Findings included: Interview on 09/01/23 at 3:32 P.M. with Resident #59's family member revealed a concern regarding the sharps container (a hard plastic container for the storage of used sharp items like lancets and needles for safety and infection control by placing the items in the container lid and flipping them down into the container) in the bathroom had been full and overflowing for months and everyone said they couldn't find a key. Resident #59's family member reported it just wasn't sanitary or safe. Observation on 09/01/23 at 3:32 P.M. of Resident #59's sharps container hanging on her bathroom wall overflowing with 10 used lancets and three used glucometer strips on top of the partially closed lid and a used syringe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and review of the Centers for Medicare and Medicaid (CMS) Census and Condition form 672, the facility failed to ensure sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all 84 residents residing in the facility. Findings include: 1. On 12/18/22 at 8:00 A.M. upon entrance of the facility there were four nurses and seven State Tested Nursing Assistants (STNA's) on duty to provide care for the 84 residents residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility had no residents who were independent for activity of daily living care. The facility identified 73 residents who required the assistance of one or two staff for bathing and 11 who were dependent on staff for bathing. The facility identified 80 residents who required the assistance of one or two staff for dressing and four staff who were dependent on…

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

Based on staff interview and review of the personnel records, the facility failed to ensure State Tested Nurse Assistant's (STNA) received performance evaluations. This had the potential to affect all 84 residents residing in the facility. Findings include: Review of the personnel records for STNA #200 (date of hire 09/21/21), STNA #177 (date of hire 06/25/21), STNA #124 (date of hire 01/28/21), and STNA #210 (date of hire 10/31/18) revealed no documented evidence of annual performance evaluations. Review of personnel records for STNA #132 (date of hire 03/03/22) and STNA #227 (date of hire 09/29/22) revealed no documented evidence of 90-day performance evaluations for either STNA. Interview on 12/20/22 at 8:47 A.M., with Human Resources #117 verified the absence of performance evaluations for the six staff members.

Based on review of the facility policy, observations, staff interviews, and record review, the facility failed to follow the planned menu on two different occasions. This affected all residents residing on all units, except for Resident #71 who was identified as consuming nothing by mouth. The facility census was 84. Findings include: 1. Observation of the lunch meal on 12/20/22 revealed the menu was not followed on Unit B, Unit C, and memory care. Observations included: a. On Unit B, a side salad was served in a small white Styrofoam bowl, the observed salad included lettuce and tomato and took up less than half of the bowl. Interview at that time with Dietary Aide #144 confirmed the salad. Dietary Aide #144 reported every resident on the unit received three ounces of salad. b. The test tray from Unit B revealed a side salad, the eight-ounce bowl was less than half full of lettuce and had five small slices of tomato. c. On the memory care unit, a side salad was served in a small white bowl, it included lettuce and parmesan cheese and took up half of the bowl. Interview at that time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of the facility's policy, the facility failed to keep the kitchen clean and failed to check expiration dates of food in Resident #62's refrigerator resulting in her eating expired food. This affected one (Resident #62) of three resident refrigerators observed and had the potential to affect all residents except Resident #71 who was identified as receiving no food from the kitchen. The facility census was 84. Findings include: Observation and interview on 12/18/22 revealed the facility had one main kitchen and four kitchenettes. Observation from 9:30 A.M. to 11:12 A.M. with Dietary Director #172 revealed the following concerns: a. In the main kitchen, multiple boxes were noted to be on the freezer floor. b. In the Unit A kitchenette, a bag of hot dogs was open and undated. Additionally, there were four containers of cereals that were open and undated. Observation of the hood above the oven revealed the vents had a buildup of grease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policy, observations, staff interview, and record review the facility failed to follow a Legionella prevention plan, maintain infection control during wound care for Resident #189, and to ensure laundry was appropriately separated for Resident #17 who had an active COVID-19 infection. This had the potential to affect all 84 residents residing in the facility. Findings include: 1. Review of the facility's Legionella Precautionary Maintenance and Inspection Frequency' form revealed there was equipment and systems to be monitored weekly, monthly, quarterly, and semi-annually. The form was blank. Interview on 12/27/22 at 4:50 P.M. with the Administrator revealed the facility had a water management plan that was to be monitored through the Legionella precautionary maintenance and inspection frequency form. She reported she was unable to find evidence that it was completed at that time but would check again. Electronic communication on 01/04/23 with the Administrator revealed she was…

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

Based on record review, observations, and staff interviews, the facility failed to maintain kitchen equipment in an operating condition. This had the potential to affect all residents but one resident (#71) identified as eating nothing by mouth. The facility census was 84. Findings include: Observation on 12/18/22 revealed the facility had one main kitchen and four kitchenettes. During a tour of the kitchens with Dietary Director #172 and Assistant Dietary Director #141, they identified multiple essential equipment that was not operating. Observation from 9:30 A.M. to 11:12 A.M. revealed the following concerns: a. In the main kitchen, the freezer had a thick buildup of ice in the right-hand corner. The ice was covering multiple boxes that were not identifiable due to the ice. b. In the Unit A kitchen, the air conditioning was not functioning, the steam table leaked, the dishwasher was down, and the oven did not work. c. In the Unit B kitchen, the dishwasher leaked. d. In the Unit C kitchen, the air conditioning was not functioning, the sandwich station was down, and the steam table…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the resident fund documentation, the facility failed to obtain authorization to manage funds and maintain witnessed authorizations for residents. This affected four residents (#17, #19, #32, and #37) out of five residents reviewed for funds. The facility census was 84. Findings include: 1. Review of the personal fund authorization revealed Resident #19's representative authorized the facility to manage funds, however, it was undated and there was no witness. 2. Review of the personal fund authorization revealed Resident #37's representative authorized the facility to manage funds on 06/02/21, this was unwitnessed. 3. Review of the personal fund authorization revealed Resident #17 wanted to manager her own funds, this was signed by her representative on 10/16/18 and was unwitnessed. Review of the trust transaction history for Resident #17 revealed the facility was managing her funds. 4. Review of the personal fund authorization revealed Resident #32 authorized the facility to manage her funds on 12/19/22, however, it was unwitnessed. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff, resident, and family interview, review of the hospice documentation, and policy and procedure review, the facility failed to ensure dependent residents received assistance with daily care. This affected one resident (#60) reviewed for oral care, three residents (#25, #76 and #87) reviewed for showers, one resident (#42) reviewed for shaving, and one resident (#28) reviewed for meals out of seven residents reviewed residents reviewed for activities of daily living. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. Diagnoses included dysphagia, adult failure to thrive, severe protein calorie malnutrition, chronic kidney disease stage four, anorexia, depression, pneumonia, shortness of breath, falls, unsteadiness on feet, muscle weakness, benign prostatic hyperplasia, malignant bladder cancer, and need for assistance with personal care. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and review of the facility activity calendar, the facility failed to ensure activities were available to residents in isolation for COVID-19 infection, ensure group activities were available to residents, and to ensure assistance to activities was provided for residents who were unable to attend activities independently. This directly affected three residents (#13, #21, and #36) out of 26 residents reviewed for activities during the annual survey with the potential to affect 23 additional residents (#02, #08, #09, #11, #13, #15, #17, #19, #20, #26, #28, #31, #35, #40, #41, #42, #46, #49, #50, #55, #59, #64, and #69) who resided on the B unit. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses including heart failure, hypertension, and diabetes mellitus. Review of the quarterly 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 medical record review, observation, staff and resident interview, review of the facility investigations, and policy and procedure review, the facility failed to ensure Resident #44's wound was monitored routinely and the dressing was changed as ordered, failed to ensure Resident #62's wound cause was comprehensively investigated and the wound dressing was changed as ordered, failed to ensure Resident #189 had an order for a wound dressing, failed to ensure appropriate positioning for Resident #19, and failed to ensure Resident #28 had geri-sleeves on as ordered. This affected five residents (#19, #28, #44, #62, and #189) out of 22 residents reviewed for quality of care. The facility identified 23 residents with non-pressure skin impairment. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #44 revealed an admission date of 10/14/22 and 11/23/22 with diagnoses of malignant neoplasm of bladder, diabetes type two, liver cirrhosis, muscle weakness, need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff, resident, and responsible party interview, and policy review, the facility failed to ensure fluids were available and provided for residents #05 and #40 and the facility failed to provide nutritional interventions, monitor weight and intake, and provide tube feeding as ordered for Resident #05, #31, #60, #62, #71, and #76. This effected two residents (#05 and #40) out of six residents reviewed for hydration and six residents (#05, #31, #60, #62, #71, and #76) out of seven residents reviewed for nutrition. The facility census was 84. Findings include: 1. Review of the medical record for Resident #05 revealed an admission date of 02/11/18 with diagnoses including dementia, repeated falls, muscle wasting and atrophy, cognitive communication deficit, and constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severely impaired cognition. She was on a mechanically altered and therapeutic diet. Review of the plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Medscape prescribing information, staff interviews, and record reviews, the facility failed to ensure the appropriate monitoring of abnormal behaviors, failed to ensure medications were used for the appropriate indication, and failed to ensure medications were held as ordered by the physician when vital signs were outside the ordered parameters. This affected four residents (#5, #28, #49, and #73) of the 26 residents whose records were reviewed during the annual survey. The facility census was 84. Findings include: 1. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, hypertension, cardiac murmur, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/16/22, revealed Resident #28 had mildly impaired cognition. Review of the active physician's order, dated 12/02/22, revealed Resident #28 was to be administered one half of a 200 milligram…

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

Based on review of the facility policy, observations, resident and staff interviews, and review of the mealtimes, the facility failed to serve meals according to the planned times and at regular mealtimes. This affected all but the 24 residents residing on Unit A. The facility census was 84. Findings include: Observation from 12/18/22 to 12/21/22 on Unit B, Unit C, and the memory care unit revealed meals were late on multiple occasions. These observations included: a. Observation of the lunch meal on 12/18/22 on Unit B revealed the first tray was served at 1:03 P.M. and the last tray was served at 2:00 P.M. Interview on 12/18/22 at 1:52 P.M. with Dietary Director #172 confirmed the meal came out late, she reported the cause was the kitchen being short staffed on that day. b. Observation of the lunch meal on 12/18/22 on the memory care unit revealed the first tray was served at 1:01 P.M. and the last tray was served at 1:37 P.M. Interview on 12/18/22 at 1:37 P.M. with State Tested Nursing Aide (STNA) #187 confirmed the late timing of the meal. STNA #187 reported the kitchen was short…

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

Based on observations, resident representative interview, and staff interview, the facility failed to ensure the memory care unit furniture was maintained in a safe, sanitary, comfortable, and functional manner and failed to maintain clean refrigerators for Resident #19 and Resident #28. This had the potential to affected the 13 residents residing in the memory care unit and affected two (Resident #19 and Resident #28) of three resident refrigerators observed. The facility census was 84. Findings include: 1. Observations on 12/18/22 at 1:23 P.M. and 4:47 P.M., and on 12/19/22 at 12:40 P.M. reveled the furniture in the memory care unit was not maintained in a safe, sanitary, functional, and comfortable manner. Three green chairs were observed with cracked plastic cushions, and one of the green chairs had a white stain. Three orange striped chairs were observed to be faded with multiple unidentifiable stains. The couch was observed with multiple tears on the cushioned seat and the fabric was frayed at the bottom. Interview on 12/19/22 at 12:40 P.M. with Environmental Director #142…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, review of the Resident [NAME] of Rights, and policy and procedure review, the facility failed to ensure privacy was maintained and residents were treated with dignity and respect during incontinence care. This affected one resident (#60) out of seven residents reviewed for pressure ulcers. The census was 84. Findings Include: Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. Diagnoses included dysphagia, adult failure to thrive, severe protein calorie malnutrition, chronic kidney disease stage four, anorexia, depression, pneumonia, shortness of breath, falls, malignant bladder cancer, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition, and the resident required extensive assistance of two 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 medical record review and staff and family interview, the facility failed to ensure the resident representatives and the physician were notified of falls. This affected two residents (#25 and #76) out of seven residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive impairment. The resident required the extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Resident #76 had one fall with injury. Review of Resident #76's medical record revealed he had family as his responsible party. Review of the progress note dated 11/18/22 at 8:11 A.M. 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 medical record review and staff interview, the facility failed to ensure all relevant mental disorders were listed on the resident Preadmission Screening and Resident Review (PASARR). This affected one resident (#76) out of two residents reviewed for PASARR. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment. Resident #76 required extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Review of the physician's note dated 08/23/22 revealed Resident #76's diagnoses included mood disorder. Review of the Certified Nurse Practitioner's (CNP) note dated 08/25/22 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 medical record review and staff interview, the facility failed to ensure resident baseline care plans were completed upon admission to the facility. This affected two residents (#28 and #42) out of 26 residents reviewed for care plans. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and a history of falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mild impaired cognition and required extensive assistance from two staff members for bed mobility, transfers, and toilet use. Further record review for Resident #28 revealed no evidence a baseline care plan was completed. 2. Review of the medical record revealed Resident #42…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans reflected the resident assessments. This affected three residents (#28, #40, and #42) out of 26 residents reviewed for care planning. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. The resident was at risk for the development of pressure ulcers. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure timely review and revision of care planned interventions. This affected one resident (#19) out of seven residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and had diagnoses including age related osteoporosis, hemiplegia and hemiparalysis, weakness, need for assistance with personal care, diabetes mellitus, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had mild impaired cognition. The resident was dependent upon two staff members for transfers, bed mobility, and toilet use. Resident #19 had one fall with injury since the previous assessment. Review of the most recently revised care plan dated 11/30/22, revealed Resident #19 had a history of falls with injuries and was at risk for further injuries related to falls. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, the facility failed to ensure physician ordered pressure ulcer interventions were implemented. This affected one resident (#28) out of six residents reviewed for pressure ulcers. The facility census was 84. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and a history of falls. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #28 had mild impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. The resident was assessed at risk for development of pressure ulcers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely follow-up of therapy recommendations to prevent the potential worsening of a residents contracture. This affected one resident (#42) out of two residents reviewed for range of motion. The facility census was 84. Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder recurrent with psychotic symptoms, hemiplegia and hemiparalysis following cerebral infarction, contracture of the right hand, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderate impaired cognition. The resident required supervision for transfers and bed mobility, extensive assistance from one staff member for toilet use and eating. The resident had a functional impairment on one side of the upper extremity. There was no restorative nursing services received. Review of the active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and policy review, the facility failed to ensure residents received timely physician ordered incontinence care and timely treatment was implemented for a resident with a urinary tract infection (UTI). This affected two residents (#16 and #28) out of five residents reviewed for bowel and bladder incontinence and UTI. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, and muscle weakness. Review of the care plan dated 03/07/22 revealed Resident #28 had incontinence episodes and/or was at risk for bladder incontinence. Occasionally incontinent. Interventions included to notify nursing if incontinent during activities, check and record bowel movement status every shift, and document and report to nurse any change in voiding pattern. Review of the care plan dated 03/07/22 and recently revised on 11/23/22 revealed Resident #28 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure documentation of appropriate dialysis port monitoring and communication between the facility and dialysis. This affected one resident (#22) out of one resident reviewed for dialysis. The facility identified two residents (#22 and #61) who received dialysis services. The census was 84. Findings Include: Review of the medical record for Resident #22 revealed an admission date of 10/28/22 and the diagnoses of end stage renal disease (ESRD), non compliance with renal dialysis, diabetes type two, morbid obesity, need for assistance with personal care, high blood pressure, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview of Mental Status (BIMS) of 15 indicating impaired cognition and the resident required extensive assistance of one staff for bed mobility, personal hygiene and toilet use and extensive assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the Medscape prescribing information, and record review, the facility failed to ensure there was an appropriate diagnosis for the use of the antipsychotic medication Seroquel for Resident #76. This affected one (Resident #76) of five residents reviewed for unnecessary medication. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 08/20/22. Diagnoses included neurocognitive disorder with lewy bodies and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had a severe cognitive impairment. He had verbal behavioral symptoms for one to three days during the lookback period. Review of the plan of care dated 11/17/22 revealed Resident #76 had behaviors possibly related to Parkinson's disease, history of alcohol abuse, neurocognitive disorder with lewy bodies along with dementia, and other comorbidities. Interventions included administering medications as…

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

Based on medical record review, review of the facility policy, observation, and staff interview, the facility failed to ensure the medication error rate was less than five percent. There were ten medication errors out of 35 opportunities observed, resulting in 28.57% (percent) medication error rate. This affected one (#31) of three residents observed for medication administration. The facility census was 84. Findings include: Review of Resident #31's medical record revealed an admission date of 08/27/21. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type II, dysphagia, and gastrostomy (an opening in the stomach to receive to receive artificial nutrition) malfunction. Review of the active physician orders for Resident #31 revealed an order for Vitamin D (vitamin) one tablet, Cymbalta (antidepressant) 50 milligrams (mg) one tablet, Prednisone (steroid) one mg one tablet, Hydroxychloroquin (antimalaria) 200 mg one tablet, Xanax (antianxiety) 0.25 mg one tablet, Oxycodone (narcotic pain medication) liquid 0.5 mg, Senna (treats constipation) 8.6 mg one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility policy, and staff interviews, the facility failed to ensure an adequate system was in place for the timely review and reporting of laboratory and diagnostic results to the physician. This affected two (Resident #16 and #40) of six residents reviewed for laboratory services. The facility census was 84. Findings include: 1. Review of the medical record for Resident #16 revealed an admission dated of 04/09/21 with diagnoses including vascular dementia and cerebral infarction with hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Review of Resident #16's physician's order dated 11/13/22 revealed an order for blood work and a urinary analysis one time only until 11/14/22. An additional order was written for 11/16/22 through 11/19/22 for blood work and urinary analysis to be drawn and collected on one of these selected dates with results to be sent to MedOne…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and review of medical records, the facility failed to ensure the resident's medical records were accurate. This affected two (#25 and #62) of 24 resident records reviewed in the annual survey. The facility census was 84. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, pain in right wrist, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the physician's orders for Resident #25 revealed an order dated 11/29/22 for Tramadol HCL 50 milligrams (mg) one tablet by mouth every six hours as needed for pain and an order dated 12/07/22 for Tramadol HCL 50 mg one tablet by mouth every eight hours for pain. Review of the Medication Administration Record (MAR) for December 2022 revealed no documented administration for Tramadol HCL Tablet 50 mg on 12/10/22 and 12/12/22 at…

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

Based on resident representative interview, staff interviews, observations, review of the facility policy, and record review, the facility failed to ensure Resident #38's room was free from pests and maintained in a manner to prevent pests. This affected one (Resident #38) of four residents reviewed for physical environment. The facility census was 84. Findings include: Interview on 12/18/22 at 10:40 A.M. with Resident #38's representative revealed she did not feel they kept Resident #38's room clean. She reported Resident #38 dropped a lot of food, that wasn't swept up and it led to ants. Observation on 12/18/22 at 11:20 A.M. revealed Resident #38 had banana chips and other food debris in her room, she additionally appeared to have ants in her room. Observation on 12/19/22 at 12:35 P.M. revealed Resident #38's representative sweeping in her room. A large number of ants were observed to be in the pile, as well as banana chips and other food debris. Interview with Resident #38's representative at that time revealed she swept every time she visited and there were always ants, she…

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