Wesleyan Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review and review of the facility assessment to provide competent support and care for the resident population, the facility failed to ensure sufficient staff to meet the individualized needs of each specific resident. This affected three (#62, #40 and #34) of three residents reviewed for staffing. Additionally, the remaining 83 residents residing in the facility were placed at potential risk for not having their individualized needs met based on insufficient staffing resources necessary to provide competent support and care for the resident population. The facility census was 86. Findings include: 1. Record review for Resident #62 revealed an admission date of 07/27/22. Diagnoses included type two diabetes mellitus, morbid obesity, and acquired absence of right lower leg below the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Resident #62 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and review of the facility assessment, the facility failed to accurately assess and identify the needed competent nursing staff resources, based on resident acuity, to meet the individualized needs of specific residents. This affected three (#62, #40 and #34) of three residents reviewed for staffing with the potential to affect the remaining 83 residents residing in the facility who required nursing staff to meet their care needs. The facility census was 86. Findings include: 1. Record review for Resident #62 revealed an admission date of 07/27/22. Diagnoses included type two diabetes mellitus, morbid obesity, and acquired absence of right lower leg below the knee. Further review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was dependent for transfers, toileting, and required substantial/maximum assistance for personal hygiene. Resident #62 was frequently incontinent of bowel and bladder. Review of the care 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 observation, medical record review, resident interview and staff interview, the facility failed to ensure resident rooms were adequately maintained. This affected one (#67) of three residents reviewed for safe and homelike environment. Additionally, the facility failed to ensure common areas, accessible to residents, was free from mold. This had the potential to affect three (#49, #75 and #86) of three male residents identified by the facility as being independent with mobility and toileting. The facility census was 86. Findings include: 1. Record review for Resident #67 revealed an admission date of 03/05/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had a Brief Interview of Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. Resident #67 had no impairment of the upper or lower extremities, used a walker and or a wheelchair 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, medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide routine dressing changes to a central line for one (#62) of one resident reviewed for the care and treatment of a central line. The facility identified one resident with a central line. The facility census was 86. Findings include: Record review for Resident #62 revealed an admission date of 07/27/22 and a readmission date of 01/14/24. Diagnoses included type two diabetes mellitus and acquired absence of right lower leg below the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Resident #62 had no impairment of the upper extremities and impairment on both sides of the lower extremities. Resident #62 required substantial/maximum assistance for personal hygiene and bed mobility. Resident #62 was at risk for pressure ulcers, had an unhealed pressure ulcer, one stage two and a diabetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, policy review, review of the Ohio Department of Health's Certification and Licensure System website, and review of a local police report, the facility failed to ensure an incident of alleged resident-to-resident physical abuse between Resident #99 and Resident #101 was reported. This affected two (Residents #99 and #101) of three residents reviewed for abuse. The facility census was 90. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of [DATE]. Medical diagnoses included delusional disorder, cognitive communication deficit, and atrial fibrillation. Resident #99 was transferred to a local hospital on [DATE] and did not return to the facility. Review of Resident #99's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. Resident #99 was noted to have delusions, verbal behaviors directed towards others on 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 staff interview, record review, policy review, review of the Ohio Department of Health's Certification and Licensure System website, and review of a local police report, the facility failed to ensure an incident of alleged resident-to-resident physical abuse between Resident #99 and Resident #101 was investigated. This affected two (Residents #99 and #101) of three residents reviewed for abuse. The facility census was 90. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of [DATE]. Medical diagnoses included delusional disorder, cognitive communication deficit, and atrial fibrillation. Resident #99 was transferred to a local hospital on [DATE] and did not return to the facility. Review of Resident #99's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. Resident #99 was noted to have delusions, verbal behaviors directed towards others 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 staff and resident interview, record review, and policy review, the facility failed to ensure resident showers were completed as planned. This affected three (Residents #05, #44, and #56) of three residents reviewed for activities of daily living. The facility census was 90. Findings include: 1. Review of Resident #05's medical record revealed an admission date of 05/26/21. Medical diagnoses included Alzheimer's disease, anxiety, depression, and anemia. Review of Resident #05's Minimum Data Set (MDS) 3.0 annual assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #05 was recorded to require supervision to partial/moderate assistance with activities of daily living (ADL) completion. Resident #05 was not identified as having any behaviors or rejection of care. Review of Resident #05's physician's order dated 03/15/24, revealed the resident was supposed to receive a shower twice weekly on Wednesday and Saturday 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 observation, staff and resident interview, and record review, the facility failed to ensure Resident #48 was served her physician-ordered diet which accommodated her dietary restrictions. This affected one (Resident #48) of three residents reviewed for dietary services. The facility census was 90. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/23/23. Medical diagnoses included end stage renal disease (ESRD) with dependence on renal dialysis, muscle weakness, type II diabetes mellitus, and muscle weakness. The record indicated Resident #48 was lactose intolerant. Resident #48 was hospitalized on [DATE] and re-admitted to the facility on [DATE]. Review of Resident #48's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of Resident #48's interdisciplinary progress notes revealed a note dated 03/16/24 indicating ranch and blue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to ensure colostomy care and services were in place for Resident #99. This affected one (Resident #99) of three residents reviewed for changes in condition. The facility identified no current residents with a colostomy and/or ileostomy. The facility census was 86. Findings include: Review of the medical record for Resident #99 revealed an initial admission date of 08/31/23. Resident #99 was hospitalized from [DATE] until he readmitted to the facility on [DATE]. The resident discharged to the hospital on [DATE] and did not return to the facility. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side and gastrostomy status. Review of Resident #99's care plan, initiated 08/31/23 and revised on 10/29/23, revealed the resident had an alteration in gastrointestinal status with an ostomy in place. The care plan stated to provide ostomy care as ordered. 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 record review, observations and staff interviews and resident interviews the facility to ensure there was enough staff was available to meet resident needs timely. This affected three (Resident #27, #39 and #87) of five residents reviewed for staffing This had the potential to affect all 90 residents residing in the facility. Findings include: Review of the facility staffing schedules and posted staffing information from 12/01/23 through 12/14/23 revealed on 12/07/23 and 12/08/23 revealed there was only one state tested nursing aide (STNA) on third shift for the fourth floor (27 residents). On 12/09/23 and 12/12/23, there was one STNA on the fourth floor for three hours. Interview on 12/20/23 at 4:09 A.M. with Scheduler #319 verified on 12/07/23 and 12/08/23, there were only four STNAs in the building on third shift and there was only one STNA on the fourth floor for 27 residents. Scheduler #319 verified on 12/18/23, there was one STNA on the fourth floor from 3:00 P.M. to 6:30 P.M. and on 12/19/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and resident and staff interviews, the facility failed to ensure a resident was treated with respect when her call light was not answered for greater than one hour. This affected one (Resident #27) of five residents reviewed for call lights. The facility census was 90. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. Resident #27 required substantial/maximum assistance from staff with toileting and dressing and required assistance from staff with bed mobility. Interview and observation on 12/14/23 at 10:47 A.M. with Resident #27 revealed she had to wait for three hours on 12/13/23 for the bed pan and she waited two hours again at night for her call light to be answered. Resident #27 turned her call light on at 9:48 A.M. and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure incontinence care was provided to the residents in a timely manner. This affected two (Resident #39 and #87) of three residents reviewed for incontinence care. The facility census was 90. Findings include: 1. Review of the medical record for Resident #39 revealed the resident was admitted on [DATE]. Diagnoses included heart failure, peripheral vascular disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. Resident #39 required partial to maximum assistance from two staff for toileting. Interview and observation on 12/14/23 at 10:55 A.M. with Resident #39 revealed she had had a bowel movement (BM) and had been soaked all morning. Resident #39 stated no staff had been in her room to assist her this morning and she had an accident. Her whole bed will need to be changed. At 11:00 A.M., State Tested Nursing Aide (STNA) #306…

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

Based on observation and interview, the facility failed to ensure staff cleaned the food thermometer appropriately to prevent cross contamination or food borne illness. This had the potential to affect 19 (Residents #2, #6, #12, #14, #17, #19, #20, #32, #41, #45, #50, #52, #56, #60, #63, #69, #73, #78 and #79) residents residing on the fourth floor of the facility. The facility census was 85. Findings include: During an observation on 10/04/23 at 4:50 P.M., Dietary Aide (DA) #108 was serving the residents on the fourth floor their dinner meal. DA #108 obtained the facility thermometer located in a bucket on top of the meal cart. With the thermometer cover still in place, DA #108 dipped the thermometer in the sanitizing solution and shook off the excess solution. He then attempted to obtain the temperature of the hamburger patties on the steam table without removing the thermometer cover. DA #108 removed the cover, then checked the temperature of the hamburgers. Without sanitizing the thermometer, he proceeded to check the temperature of the potatoes. During interview on 10/04/23 at…

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

Based on observations, record review, review of the facility's policy, and staff interview the facility failed to maintain a clean and sanitary kitchen and dietary areas. This had the potential to affect all residents except one resident (#35) who received nothing by mouth. The facility census was 92. Findings include: 1. Tour of the kitchen on 05/09/22 between 9:12 A.M. through approximately 9:45 A.M. with Dietary Manager (DM) #550 revealed dried reddish splashes on the wall where the commercial opener across from stove. DM #550 stated it may be minestrone soup from yesterday. The back wall near the slicer, which was not in use and covered, had several gnats or fruit flies on the wall. The bottom shelf of the prep table located back against the back wall had moderate amount of food debris and housed several long flat pans. The corner of the floor next to this prep table and corners along the wall of the back part of the kitchen had a moderate amount of debris and was dirty. The top of prep table where the robocoup and blender was housed had spilled white debris. DM #550 stated it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, and resident and staff interviews, the facility failed to ensure the licensed nurses observed the residents consumed their medications. This affected two (Resident #63 and #74) of 22 residents observed in the initial pool sample and had the potential to affect the 20 residents (Resident #4, #5, #6, #7, #14, #22, #28, #29, #34, #44, #52, #53, #66, #72, #74, #77, #79, #80, #85, and #488) whom resided on the dementia care unit on the second floor. The facility census was 92. Findings include: 1. Review of Resident #63's medical record identified the resident was admitted to the facility on [DATE] following a stoke with left sided hemiparesis, colon cancer, major depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. Interview with Resident #63 on 05/09/22 at 12:29 P.M. stated the nursing staff frequently come in and set her medications in front of her and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure residents had a choice in their medication schedule and activities to attend. This affected two (Residents #42 and #63) of 22 residents regarding choices in their care and treatment. The facility census was 92. Findings include: 1. Review of Resident #63's medical record revealed Resident #63 was admitted on [DATE] following a stroke with left sided hemiparesis, colon cancer, major depression, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. Review of Resident #63's nursing note dated 05/07/22 at 7:35 P.M. revealed the nurse took Resident #63 her evening medication. Resident #63 yelled at the nurse regarding her Zoloft, Trazodone, and melatonin medications. The nurse educated Resident #63 that it was ordered at this time and the resident then began yelling at this nurse and refused to take medication. Review of Resident #63's medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one (Resident #71) of two residents reviewed for preadmission screening and resident review (PASARR). The facility census was 92. Findings Include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included depression, chronic obstructive pulmonary disease, and hypertension. The resident was later diagnosed with unspecified psychosis while residing in the facility on 10/15/21. Review of the psychiatric consult note for Resident #71 dated 11/04/21 revealed Resident #71 was very paranoid, agitated, and irritable with exhibited anger outbursts, yelling, and physical aggression. Review of both the electronic and hard charts revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of the facility's policy, and resident and staff interview, the facility failed to ensure residents whom were dependent on staff with activities of daily living (ADL) care were assisted with nail care. This affected two (Resident #35 and #38) of two residents reviewed for ADLs. The facility identified 81 residents who required assistance from staff with hygiene. The facility census was 92. Findings include: 1. Review of Resident #35's medical record revealed an admission to the facility occurred on 02/28/22. Diagnoses included a stroke, heart attack, COVID-19, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had impaired cognition and was dependent on staff for personal hygiene. Review of Resident #35's written plan of care (POC) for activities of daily living (ADL's) revealed to check nail length and trim and clean on bath day and as necessary. Review of the shower schedule for Resident #35 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 resident and staff interviews, the facility failed to ensure physician's orders were timely implemented for a resident. This affected one (Resident #35) of 22 residents reviewed for physician orders. The facility census was 92. Findings include: Review of Resident #35's medical record revealed an admission to the facility occurred on 02/28/22. Diagnoses included stroke, heart attack, hyperglycemia (high blood sugar), and moderate protein calorie nutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had impaired cognition Review of Resident #35's physicians order dated 03/02/22 revealed blood sugar levels were to be obtained four times a day. On 04/22/22, there was an order to decrease the accu checks (blood sugars) to twice a day. Review of Resident #35's Medication Administration Records (MAR) for March 2022, April 2022, and May 2022 revealed blood sugar levels were being checked four times a day from 03/02/22 to 05/10/22.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and family and staff interviews, the facility failed to ensure fall interventions were in place for a resident. This affected one (Resident #33) of two residents reviewed for falls. The facility census was 92. Findings include: Review of the medical record for Resident #33 revealed an admission date of 02/25/22. Diagnoses included dementia, diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 03/02/22, revealed Resident #33 had impaired cognition and was dependent for transfers, locomotion, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #33 was at a high risk for falls. Review of the plan of care dated 03/03/22 revealed Resident #33 was at a risk for falls due to a decline in physical and cognitive function. Interventions on 03/24/22 included orders for Low profile mat to exit side of bed. Review of the nurse's notes dated 04/09/22, 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 observations, medical record review, review of the facility's dietitian recommendation protocol, and staff interviews, the facility failed to timely implement a registered dietitian's (RD) recommendation to increase a rate in tube feeding to increase the caloric intake of a resident. This affected one (Resident #35) of three residents reviewed for nutrition. The facility identified one resident with a feeding tube. The facility census was 92. Finding include: Review of Resident #35's medical record revealed an admission to the facility occurred on 02/28/22. Diagnoses included a stroke, heart attack, respiratory failure, moderate protein calorie malnutrition, and history of COVID-19. Resident #35 was listed at 149 pounds upon admission on [DATE]. Review of the hospital records prior to admission revealed Resident #35 was hospitalized with COVID-19 starting on 12/14/21. Resident #35 subsequently had a stroke and heart attack. The hospital records identified his weight was listed at 190 pounds on 12/14/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medscape.com guidance and staff interviews, the facility failed to ensure a resident's blood pressure medications were not administered close together. This medication has the potential to significantly drop blood pressure and was a significant medication error. This affected one (Resident #35) of six residents reviewed for blood pressure medications. The facility census was 92. Findings include: Review of Resident #35's medical record revealed an admission to the facility occurred on 02/28/22. Diagnoses included COVID-19, stroke, and heart attack. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment. Review of Resident #35's medication administration record (MAR) for April and May 2022 revealed Resident #35 was receiving Carvedilol (Coreg-Blood pressure medication), scheduled upon rising and at lunch time. The was noted to be at 8:00 A.M. and 12:00 P.M. There were no parameters to hold the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of the facility's policy, and staff interview, the facility failed to ensure a resident received adaptive equipment at meals according the physician's order. This affected two (Resident #71 and #19) of two residents who received adaptive eating equipment. The facility identified ten residents (#10, #19, #31, #57, #70, #71, #72, #76, #442 and #445) who used adaptive equipment in the facility. The facility census was 92. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 02/13/20. Diagnoses included chronic pulmonary disease, rheumatoid arthritis, vascular dementia with behavioral disturbance, and major depressive disorder. Review of the care plan dated 01/06/22 revealed Resident #71 had a potential nutritional problem related to diagnoses. Interventions included built up utensils and two handle sip cup with straw. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/02/22, revealed Resident #71 had…

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

Based on observations and staff interviews, the facility failed to maintain a clean, functional and safe environment for the residents. This affected four (Resident #10, #35, #36, and #71) of 92 residents residing in the facility. The facility census was 92. Findings include: 1. Observation of Resident #36's room on 05/09/22 at 8:04 A.M. revealed the cove molding was missing and falling off behind Resident #36's bed, with part of the dry wall missing. The observation further revealed the wall located behind a soft chair in the room was observed with a large hole in the dry wall and cracked and crumbling dry wall. 2. Observation of Resident #35's room on 05/09/22 at 10:02 A.M. revealed the room had a window behind the resident's bed that was broken. The window had a hole in the center of the window and was spider shattered from the top to the bottom. Interview with Maintenance Director #103 on 05/12/22 at 7:18 A.M. confirmed the window was broken in Resident #35's room and he was not sure when this occurred but does not have a window to replace it. Maintenance Director #103 confirmed…

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

Based on observation, review of resident council minutes, review of facility policy, staff and resident interviews, the facility failed to ensure resident concerns were followed up on. In addition, residents were not informed on how to file a grievance. This affected eleven (#42, #28, #31, #5, #51, #12, #39, #72, #71, #20, #59) of eleven residents interviewed. The facility census was 73. Findings include: Review of the Resident Council Minutes dated 02/14/19, 03/14/19 and 04/11/19 revealed the residents had expressed concerns with missing dentures, call lights answered timely, and two residents with complaints of no hot water in their rooms. Interview with Residents (#42, #28, #31, #5, #51, #12, #39, #72, #71, #20, #59) on 05/07/19 at 2:44 P.M. during meeting with the Resident Council Members revealed the residents did not feel the staff got back with them wherever they expressed a concern. They reported having the same issues repeatedly and nothing has changed and were not given responses to their concerns at their meetings. In addition, the residents reported not knowing where 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, review of a preferred bathing list, review of an activities of daily living verification sheet, staff interviews and policy review, the facility failed to honor a resident's choice to take a shower. This affected one (#47) of one resident reviewed for choices. The facility census was 73. Findings include Review of Resident #47's medical record revealed the resident was admitted on [DATE]. Diagnoses included anxiety disorder, depressive disorder, contractures of the left ankle, right knee and left knee, hypertension, type two diabetes mellitus, osteoarthritis and osteoporosis. Review of the Minimum Data Set (MDS) annual assessment preference for customary routine and Activities dated 03/29/19 revealed in the interview for daily preferences Resident #47 indicated it was very important for her to choose between a tub bath, shower, bed bath or sponge bath. Further review of the annual assessment revealed the resident had mild cognitive impairment. Review of the Residents Preferred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 electronic medical record face sheet, review of a Do Not Resuscitate (DNR) identification form, review of a quarterly resident review form, review of the plan of care, staff interviews and policy review, the facility failed to obtain a physician order to honor a resident's right not to receive cardiopulmonary resuscitation (CPR). This affected one (#20) of two resident reviewed for advanced directives. The facility census was 73. Findings include Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included altered mental status, muscle weakness, repeated falls, restless leg syndrome, and spinal stenosis. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #20 had intact cognition. Review of the electronic health record and review of the paper medical chart revealed no signed physician order on a DNR identification form. Review of electronic health record states face sheet resident revealed Resident #20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide written notification of transfer/discharge to the hospital or the responsible party. This affected one Resident (#76) reviewed for hospitalization. The facility census was 73. Findings include: Medical record review revealed Resident #76 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder, hyperlipidemia, anorexia, and dementia with behavioral disturbance. Review of the nursing progress note dated 02/28/19, revealed Resident #76 was transferred to the hospital. Review of the nursing progress notes dated 02/28/19, revealed no documentation of the facility providing written notification to the resident or the responsible party. Interview on 05/09/19 at 11:54 A.M., with Assistant Director of Nursing (ADON) #143 revealed they did not provide written notification regarding the reason for transfer/discharge to the hospital, 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, staff interview, and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI), the facility failed to accurately complete comprehensive Minimum Data Set (MDS) assessments. This affected two residents (#19 and #46) of 26 residents reviewed for comprehensive MDS assessments during the annual survey. The facility census was 73. Findings include: 1. Medical record review for Resident #19 revealed an admission date of 06/04/17. Diagnoses included dementia, anxiety, and hypertension. Review of Resident #19's comprehensive annual MDS assessment, dated 06/03/18, section L0200 B, did not indicate the resident had no natural teeth or tooth fragments. Review of the residents comprehensive significant change MDS assessment, dated 02/25/19, section L0200 B, also did not indicate the resident had no natural teeth or tooth fragments. L0200 B was not coded on either assessment. Observation on 05/06/19 at 8:56 P.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 and staff interview, the facility failed to submit an application to the state Pre-admission Screening Resident Review (PASRR) (determines whether or not an individual who has an active diagnosis of mental illness or intellectual/developmental disability meets the criteria for admission and/or continued stay in a nursing facility) after a resident experienced a significant mental health change. This affected on resident (#72) of two residents (#72 and #46) reviewed for PASRR. The facility census was 73. Findings include: Medical record review revealed Resident #72 admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and bowel, urinary tract infection, Diabetes, osteoporosis, anxiety, and major depressive disorder. Review of Resident #72's pre-admission review results, dated 07/10/15, revealed the resident did not have indications of serious mental illness nor a developmental disability. Review of a Resident #72's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure the discharge needs of residents were met. This affected one (Resident #74) of three residents reviewed for discharge. The facility census was 74. Findings Include: Review of Former Resident (FR) #74's medical record revealed an admission date of 02/15/19 and discharged on 02/24/19. Medical diagnoses included chronic respiratory failure, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus, anxiety, depression, paraplegia, urogenital implants, and chronic pain syndrome. Review of FR #74's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function. The resident required extensive assistance in all activities of daily living except eating which he/she was independent. Review of FR #74's medical record revealed a physician order dated 02/23/19 to discharge to home on [DATE]. Review of FR #74's medical record revealed no discharge documentation was completed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents received assistance with showering and personal hygiene. This affected one resident (Resident #32) of three residents reviewed. The facility census was 73. Findings include: Medical record review revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included dementia and unspecified intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/22/19, revealed the resident was cognitively impaired. The resident required set up help, supervision, and/or oversight for grooming and bathing. Review of the most recent plan of care, dated 04/25/19, revealed the resident had a self care deficit but was fairly independent. Interventions included for staff to provide verbal cues throughout tasks to promote independence, provide instructions and directions for the resident to complete the task giving one or two steps at at time to reduce confusion, 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, review of the bathing schedule, review of the Activities of Daily Living Verification Worksheet, staff interview and policy review, the facility failed to ensure a dependent resident received scheduled bathing. This affected one (#47) of two residents reviewed for activities of daily living. The facility census was 73. Findings include Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included anxiety disorder, depressive disorder, contractures of the left ankle, right knee and left knee, hypertension, type two diabetes mellitus, osteoarthritis and osteoporosis. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #47 was dependent on staff for bathing. Further review of the annual assessment revealed the resident had mild cognitive impairment. Review of resident bath schedule, posted on a clipboard at nurses station, noted Resident #47 was bathed on Monday and Thursdays on day shift. Review of the Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review the facility failed to ensure a physician responded timely to a resident's change in condition. This affected one (Resident #24) of three residents reviewed for urinary tract infections. The facility census was 74. Findings include: Review of Resident #24's medical record revealed an admission date of 04/08/19. Diagnoses included cervical fracture, nasal bone fracture, orbital fracture, sacral fracture, vertebra fracture, atrial fibrillation, chronic kidney disease, urinary retention, and pseudobulbar effect. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderate cognitive impairment and required extensive assistance with all activities of daily living. Review of Resident #24's nurses note dated 04/22/19 revealed the resident had a change in condition. Resident #24 was noted to have increased lethargy, sleeping through the day, and refused therapy due to not feeling well. In addition the resident complained 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 record review, policy review, and staff and resident interviews, the facility failed to complete a smoking assessment to determine a resident's ability to safely smoke and manage smoking materials as identified in the facility policy. This affected one (Resident #34) of one resident reviewed for smoking. The facility census was 74. Findings include: Review of Resident #34's medical record revealed an admission date of 03/13/19. Diagnoses included cerebral vascular accident, right femur fracture, diabetes mellitus and hypertension. Review of Resident #34's Minimum Data Set (MDS) revealed the resident had a moderate cognition deficit, utilized a wheelchair and had no upper extremity limitations. Review of Resident #34's most recent care plan revealed the resident had no plans or interventions for smoking. Review of Resident #34's nurses note dated 05/04/19 revealed cigarette smoke was noted near and outside of the resident's room. Resident #34 was not noted to have smoking material in his/her room. The resident was advised to let nursing know if he/she would wish to smoke so…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interview, and review of a facility policy, the facility failed to provide physician ordered treatment for Resident #72's supra-pubic catheter. This affected one resident (#72) of four residents reviewed for catheters. The facility census was 73. Findings include: Medical record review revealed Resident #72 admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and urine retention. Review of the most recent quarterly Minimum Data Set assessment, dated 04/16/19, revealed the resident was cognitively intact and had an indwelling catheter. Review of the resident's orders revealed on 04/23/19 the physician ordered the resident's supra-pubic catheter tube to be flushed with 60 milliliters of sterile saline daily. Review of Resident #72's April and May 2019 Treatment Administration Records (TAR) revealed no evidence the resident's catheter tube was flushed on 04/25/19, 04/28/19, 05/01/19, 05/03/19,…

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