Heritage Healthcare of Euclid

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screen was completed after a resident remained in the facility longer than 30 days as required. This affected one (#13) of two residents reviewed for PASARR. The facility census was 65. Findings Include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact and required minimum assistance for completing his activities of daily living. Review of the medical record revealed a PASARR was completed for Resident #13's stay in the facility on 04/09/24. Social Worker (SW) #922 verified Resident #13's PASARR was not completed timely as required in an interview on 06/26/24 at 1:30 P.M.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address any medication irregularities in the medical record. This affect one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. Review of a pharmacist recommendation dated 03/04/24 revealed Resident #40 had a physician's order dated 03/16/23 for the medication carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate monitoring was completed as ordered prior to the administration of a medication. This affected one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. Review of a physician order dated 03/16/23 revealed Resident #40 was ordered carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold for systolic blood pressure (SBP) below…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #1, #24 and #55 received proper, timely incontinence care. This affected three resident's (Resident's #1, #24 and #55) out of four resident's reviewed for incontinence care. Findings include: 1. Review of Resident #55's medical record revealed an admission date of 02/04/22 and diagnoses included cerebral infarction, pseudobulbar affect, and type two diabetes mellitus with ketoacidosis without coma. Review of Resident #55's Annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #55's Brief Inteview for Mental Status was not assessed. Resident #55 was always incontinent of urine and bowel. Resident #55 was dependent for all ADL's (Activity of Daily Living) including toileting and personal hygiene. Review of Resident #55's care plan revised 05/18/22 included Resident #55 experienced bowel incontinence. Resident #55's toileting needs would be met by staff, with interventions aimed at 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, interview, record review and review of the facility policy, the facility failed to ensure Resident #45 had an individualized care plan with appropriate interventions in place to manage symptoms of dementia to prevent wandering in other residents rooms. This affected one resident (Resident #45) out of three resident reviewed for dementia care. The facility census was 67. Findings include: Review of Resident #45's medical record revealed an admission date of 08/22/23 and diagnoses included dementia, major depressive disorder, and morbid obesity. Review of Resident #45's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. Resident #45 used a manual wheelchair. Resident #45 was independent for bed mobility, the ability to transfer from a bed to a wheelchair, and the ability to come to a standing position from sitting in a wheelchair or the side of the bed. Review of Resident #45's care plan revised 01/24/24 included Resident #45 had impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician orders were in place for care or treatment of a peripherally inserted central catheter (PICC) line. This affected one (Resident #11) of one facility-identified residents with a PICC line. The facility census was 65. Findings include: Review of medical record for Resident #11 revealed an admission date of 02/20/24 with diagnoses including congestive heart failure, epilepsy, cerebral infarction, and mixed hyperlipidemia. Review of progress note for Resident #11 dated 02/20/24 revealed the resident was admitted to facility with a PICC line to left arm used to administer medication to treat endocarditis. Review of physician's orders for Resident #11 revealed an order dated 02/21/24 for 100 milliliters (ml) daily of ceftriaxone sodium intravenously for 28 days. Review of the physician's orders revealed there were no orders for care and treatment of the of the PICC line site. Review of the plan of care for Resident #11…

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

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) of three reviewed for safe transfers. The facility census was 65. Findings include: Review of the medical record for Resident #30 revealed admission date of 05/14/23 with diagnoses including convulsions, migraine, fatigue, anxiety disorder, hyperlipidemia, and major depressive disorder. Review of plan of care for Resident #30 dated 05/17/23 revealed the required staff assistance with activities of daily living (ADLs.) Interventions included the resident required weight-bearing assistance including holding, lifting, or supporting the trunk or limbs and required non-weight bearing assistance including steadying, contact guard assistance or guided maneuvering when transferring between surfaces. Review of the therapy progress note for Resident #30 dated 09/13/23 revealed the resident was working with the occupational therapy department at the facility and required moderate assistance to sit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide privacy during incontinence care. This affected two of three sampled residents (#13 and #35), one which was observed during a random observation. The facility census was 60. Findings include: 1. Observation from the hallway outside of Resident #13's room on 08/30/23 at 6:01 A.M. revealed State Tested Nursing Assistant (STNA) #200 providing incontinence care to Resident #13. The door to Resident #13's room was open and the privacy curtain was not pulled around the bed. Resident #13 was not interviewable. 2. Observation of incontinence care on 08/30/23 at 6:12 A.M. with STNA #200 for Resident #35 revealed STNA #200 did not close the door or pull the privacy curtain prior to beginning incontinence care. Interview with STNA #200 at time of observation revealed the door and/or the privacy curtain should have been closed prior to beginning incontinence care. Resident #35 was not interviewable. This deficiency represents non-compliance investigated under Complaint Number OH00145488.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure timely incontinence care was provided. This affected one resident (#58) of two observed for incontinence care. The facility census was 60. Findings include: Review of Resident #58's medical records revealed an admission date of 06/28/22. Diagnoses included muscle weakness and dementia. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had intact cognition, required extensive assistance with toileting and was incontinent of bowel and bladder. Review of Resident #58's care plan dated 07/19/23 revealed Resident #58 was incontinent of bowel and bladder. Interventions included provide incontinence care every two hours and as needed. Observation of incontinence care on 08/30/23 at 6:48 A.M. with State Tested Nursing Assistant (STNA) #205 and #206 for Resident #58 revealed Resident #58 was incontinent of a large of amount of urine and stool. Further observation revealed Resident #58 was wearing an incontinence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview the facility failed to ensure it was sufficiently staffed to meet the needs of the residents. This had the potential to affect all 54 residents residing in the facility. Findings include: 1. Interview with State Tested Nursing Assistant (STNA) #801 on 04/10/22 at 10:10 A.M. revealed the facility has no idea how to staff correctly and it's a struggle to get work completed. 2. Interview with Resident #47 on 04/10/22 at 12:33 P.M. revealed there is not enough staff, and staff just sits at the desk and ignores what the resident needs. 3. Interview with Resident #45 on 04/10/22 at 2:20 P.M. revealed the facility is understaffed, and call light response is poor. 4. Interview with Resident #40 on 04/10/22 at 2:34 P.M. noted Resident #40 commenting on the need for more staff, and staff often looking overwhelmed and overlooking basic aspects of care. 5. Interview with Resident #15 on 04/10/22 at 2:41 P.M. revealed there is not enough staff because it takes…

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

Based on observation, interview, record review and review of the Facility Assessment, the facility failed to ensure sufficient dietary staffing to provide residents with a dignified dining experience. This affected 52 of 54 residents who consumed meals in the facility. Two (Resident's #37 and #249) received nothing by mouth. The facility census was 54. Findings include: Observation of breakfast tray line on 04/10/22 at 7:45 A.M. revealed there was one cook and one dietary aide in the kitchen. They were serving breakfast on paper products, and no adaptive equipment was given to residents during the meal. [NAME] #815 and Dietary Aide #816 revealed they were using paper products because they were the only two dietary staff scheduled for the weekend, and they can't do what they normally do when there were three staff on duty. [NAME] #815 stated there are two dietary staff that work 12-hour shifts on the weekend. The two dietary staff had to prepare, serve, and clean up for all three meals. When they asked for more assistance, the dietary manager would say it wasn't in the budget.…

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

Based on observation and interview, the facility failed to maintain a clean, safe, and sanitary environment throughout the facility. This affected 26 (Residents #3, #7, #11, #12, #14, #16, #19, #20, #21, #22, #25, #27, #31, #32, #34, #35, #38, #41, #43, #44, #45, #46, #251, #252, #253 and #254) and had the potential to affect all 54 residents in the facility. Findings include: 1. On 04/10/22 from 7:41 A.M. to 8:32 A.M., observations of the facility revealed no door thresholds in place for the main doors leading to the nursing units and no door thresholds in place for the rooms of Resident's #7, #11, #12, #14, #27, #32, #35, #41, #44, #45, #46, #252, and #253. On 04/10/22 at 3:15 P.M., interview with Maintenance Director #804 verified the missing door thresholds. He stated the door thresholds were removed for safety due to being loose. 2. On 04/10/22 from 7:41 A.M. to 10:56 A.M., observations of the facility revealed stained carpeting in the hallways, torn carpeting in the hallway on the 100-unit, a cracked tile in Resident #25's room, and dirty carpet in Resident #251's room. 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, record review, and interview the facility failed to ensure call lights were within reach and accessible. This affected five (Resident's #20, #31, #34, #35 and #43) of 54 residents reviewed for call light placement. The facility census was 54. Findings include: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, mixed hyperlipidemia, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and required extensive assistance of one staff for mobility, toilet, and personal hygiene. Observation of Resident #20 on 04/10/22 at 11:08 A.M. revealed Resident #20 was lying in bed with his eyes open. The call light was noted to be out of reach of Resident #20. Review of the care plans dated 10/28/21 with a revision date of 03/08/22 revealed Resident #20 had a potential risk for falls related to decreased mobility and incontinent of bowel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This affected seven (Resident's #8, #16, #17, #25, #29, #30 and #31) of seven residents reviewed for personal funds. This had the potential to affect 13 additional residents (Resident's #3, #6, #7, #9, #11, #12, #14, #15, #20, #27, #32, #33 and #47) who also had personal needs bank accounts at the facility. The facility census was 54. Findings include: Review of the resident funds list provided by the facility during the annual survey beginning on 04/10/22 revealed 20 (Resident's #8, #16, #17, #25, #29, #30, #31, #3, #6, #7, #9, #11, #12, #14, #15, #20, #27, #32, #33 and #47) had an account that was actively managed by the facility. Review of seven (Resident's #8, #16, #17, #25, #29, #30 and #31) of the 20 personal funds accounts revealed no documented evidence was provided by the facility indicating the residents and/or responsible parties were given a quarterly statement of transactions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facilities failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected four (Resident's #8, #29, #30 and #31) of six residents reviewed for personal funds. The facility census was 54. Findings include: 1. Review of the banking records for Resident #8 revealed she had a current balance of $5,236.13 and was over the Medicaid resource limit of $2,000 as of 02/23/22. Further review of the banking records for Resident #8 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was signed by Resident #8 on 04/12/22. 2. Review of the banking records for Resident #29 revealed she had a current balance of $2,560.73 and was over the Medicaid resource limit of $2,000 as of 02/23/22. Further review of the banking records for Resident #29 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure hospitalized residents on leave of absence from the facility were given copies of resident bed hold status as required. This affected four (Resident's #18, #34, #35 and #41) of four residents reviewed for hospitalization. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including dysphagia, type two diabetes, and muscle weakness. Review of the census records for Resident #18 revealed he was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE]. Review of the electronic medical record revealed no evidence Resident #18 was given a copy of his current bed hold status and facility bed hold information as required. 2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes, and high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure care plans were developed timely and care plan interventions were implemented. This affected four (Resident's #20, #33, #35 and #248) of 32 residents whose care plans were reviewed. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including gastroesophageal reflux disease, history of COVID-19, coronary angioplasty implant and graft, and hypotension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the plan of care dated 04/23/21 revealed Resident #20 was at risk for impaired skin integrity related to dementia, and incontinence of bowel and bladder. Interventions included: Assist resident with turning and repositioning as needed; Complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure shower/bed baths were given to residents. This affected four (Resident's #23, #38, #43, and #47) of five residents reviewed for showers. The facility census was 54. Findings Include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria, type II diabetes, heart failure, ileus, atrial fibrillation, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented times to person, place, and time. He required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. Review of the plan of care dated 07/21/21 revealed Resident #38 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility. Interventions included: assist the resident with ADL (i.e., dressing, grooming, personal hygiene, locomotion, oral care, etc.) as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Centers for Medicare and Medicaid Services (CMS) memorandums, Food and Drug Administration (FDA) Warning about drawing insulin from pens, and manufacturer's instruction on how to use insulin pens, the facility failed to ensure nurses knew how to administer insulin using an insulin pen correctly. In addition, the facility failed to ensure non-licensed nursing staff demonstrated competencies in skills and techniques necessary to care for residents needs prior to providing care and services to residents. This had the potential to affect all 54 residents residing in the facility. Findings include: Record review of Resident #19 revealed an admission date of 01/11/22 with diagnoses including diabetes mellitus and morbid obesity. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had moderately impaired cognition and required extensive assistance of two staff for activities of daily living, except eating which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure Insulin Kwik pens were dated when opened. This affected two (Resident's #3 and #29) of two residents reviewed for Lantus Kwik pens. In addition, the facility failed to ensure expired stock over-the-counter Colace and baby aspirin used for multiple residents were removed from the medication carts. This had the potential to affect six (Resident's #4, #5, #26, #32, #34 and #35) of six residents who received baby aspirin and five (Resident's #14, #31, #43, #47 and #198) of five residents who received Colace. The facility census was 54. Finding include: 1. Observation on [DATE] at 9:32 A.M. of the medication cart on the 300-hall with Licensed Practical Nurse (LPN) # 810 revealed an over-the-counter bottle of Colace (stool softener) with an expiration date of 03/2022, and an over-the-counter bottle of baby aspirin with an expiration date of 02/2022. Review of the residents receiving baby aspirin on the 300-hall included Resident's #4, #5, #26, #32, #34…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #11) of one resident reviewed for advanced directives. The facility census was 54. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dysphagia, dementia, and muscle weakness. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and required the extensive assistance of two staff for activities of daily living. Review of the physicians' orders for Resident #11 revealed an ordered dated [DATE] for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest. Review of the care plan dated [DATE] revealed Resident #11's code status was DNRCC. Review of the signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a wheelchair was in good working order for Resident #8. This affected one (Resident #8) of one resident reviewed for wheelchair condition. The facility census was 54. Findings include: Review of the medical record for Resident #8 revealed an admission date of 11/21/16 with diagnoses including unsteadiness on feet, difficulty walking, hypertension, type one diabetes mellitus, major depressive disorder, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively impaired and utilized a wheelchair for mobility. Review of the physician's orders for April 2022 identified orders for Occupational Therapy (OT) to evaluate and treat per the plan of care, including wheelchair management. On 04/10/22 at 11:18 A.M., interview with Resident #8 revealed she needed a new wheelchair. Observation at the time of interview revealed Resident #8's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to accurately and timely complete Minimum Data Set (MDS) 3.0 assessments. This affected two (Resident's #1 and #35) of 26 residents reviewed for resident assessments. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including fractured vertebra, post-traumatic stress disorder, and major depressive disorder. Review of census records revealed Resident #1 discharged home from the facility on 12/24/21. Review of the MDS 3.0 assessment records for Resident #1 revealed an admission and Medicare Five-Day MDS 3.0 assessment were completed on 11/26/21. No other assessments including a discharge assessment were completed for Resident #1. The Administrator verified the lack of the required Discharge MDS 3.0 assessment during an interview on 04/12/22 at 10:15 A.M. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessments were completed accurately. This affected three (Resident's (#250, #19 and #248) of 26 residents reviewed for accurate assessments and had the potential to affect all 54 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #250 revealed an admission date of 03/10/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, chronic obstructive pulmonary disease, anemia, hyperlipidemia, and encephalopathy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #250 was cognitively intact and did not use tobacco. Review of the assessment titled Smoking Assessment - V 1, dated 03/10/22, indicated Resident #250 was not a smoker. Review of the assessment titled admission Assessment with Baseline Care Plan - v.4 - V 3, dated 03/10/22, also indicated Resident #250 was not a smoker. Review of the nurses note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure level one screening for mental illness and a Pre-admission Screen and Resident Review (PASARR) for residents were completed as required. This affected three (Resident's #24, #37 and #40) of four residents reviewed for PASARR status. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), bipolar disorder, conversion disorder, and panic disorder. Resident #24 was discharged home on [DATE]. Review of the medical record for Resident #24 revealed a PASARR form was completed on 03/29/22. There was no documented evidence of a level one screening as required. 2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including heart attack, gout, arthritis, and type two diabetes mellitus. Review of the admission records for Resident #37 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure insulin was administered according to the physician's orders. This affected one (Resident #19) of three residents reviewed during medication administration. The facility census was 54. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hypertension, type II diabetes, gastro esophageal reflux disease, and schizophrenia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the insulin order dated 03/13/22 revealed Resident #19 was to receive Humalog Kwik Pen 100 unit/milliliter (ml) per sliding scale before meals and at bedtime. Observation of medication administration on 04/10/22 at 8:30 A. M. with Registered Nurse (RN) #809 revealed the nurse checked Resident #19's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure physician's orders for urinary catheter care and failed to ensure routine urinary catheter care was administered. This affected one (Resident #35) of two residents reviewed for urinary catheters. The facility census was 54. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including repeated falls, paranoid schizophrenia, dementia, malignant neoplasm of the prostate, and a localized mass and lump of the right lower limb. He was transferred to the hospital on [DATE] and was admitted for a change in mental status. Resident #35 was readmitted to the facility from the hospital on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment and required extensive assistance of one to two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had a urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #47 was provided fresh water daily. This affected one (Resident #47) of three residents reviewed for hydration. The facility census was 54. Findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including pain in the left hand, type II diabetes, heart failure, hypertension, hemiplegia, and malignant neoplasm of the stomach. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment and required extensive assistance of one staff for most of her activities of daily living (ADL). Observation of Resident #47 on 04/11/22 at 8:40 A.M. revealed the resident sitting up in her wheelchair yelling for someone to please get her some ice and water. Observation of Resident #47's beside table as well as her over bed table revealed no cup in place. Interview with the resident at this time revealed she never…

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

Based on interview, and record review, the facility failed to ensure insulin orders for residents were written with the correct method of administration. This affected three residents (Resident's #19, #37 and #98) of three residents reviewed for insulin administration. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #19 had a physician's order dated 03/13/22 to administer Humalog Kwik Pen 100 units/milliliter (ml) solution per sliding scale intradermally (a shallow or superficial injection of a substance into the dermis, which is located between the epidermis and hypodermis) before meals and at bedtime. Interview with the Director of Nursing (DON) on 04/13/22 at 10:00 A.M. revealed all the orders the facility receives from the physician are sent to the pharmacy, and the pharmacy did not correct the order to read subcutaneously (administered into the subcutis, the layer of skin directly below the dermis and epidermis). 2. Review of the medical record revealed Resident #37 had a physician's order dated 02/23/22 to administer Humalog Kwik…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interviews the facility failed to ensure residents were provided with eating equipment to maintain independence while eating. This affected two (Resident's #26 and #40) of two residents reviewed for adaptive eating equipment. The facility census was 54. Findings include: 1 Review of the medical record for Resident #26 revealed an admission date of 01/14/22 with diagnoses including diabetes mellitus, end stage renal disease, and proliferative diabetic retinopathy of the right eye. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and required supervision with set-up only for eating. Review of the physician's orders for April 2022 revealed a diet order for renal, low concentrated sweets diet, regular texture, thin liquid consistency with double portions. Resident #26 also had an order for a plate guard with meals. Review of the care plan dated 01/19/22 revealed Resident #26 was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a complete and accurate medical record for two (Resident's #41 and #11) of 28 residents reviewed for the annual survey. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, muscle weakness, and major depressive disorder. Review of the census records for Resident #41 revealed she was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE]. Further review of the medical record revealed no documentation or evidence as to why Resident #41 was sent to the hospital. The nurse's notes noted an unrelated progress note related to an appointment on 02/23/22, and the next progress note noted in the medical record was from 03/04/22 stating Resident arrived at 12:40 P.M. via stretcher with ambulance, no complaints of pain, no lumps, bumps or bruises, lung sounds clear, 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 record review, observation and interview the facility failed to ensure foods were stored under sanitary conditions in unit refrigerators. This had the potential to affect 48 of 49 residents currently residing in the facility who received foods from the kitchen. The facility identified Resident #35 as not taking anything by mouth. Findings include: An observation was conducted on 06/05/19 at 10:08 A.M. with Licensed Practical Nurse (LPN) #903 of the 100/200 unit refrigerator used to store resident foods and snacks. There was no temperature log available to review. The internal thermometer read 38 degrees Fahrenheit (F). The general appearance of the unit indicated it had not been cleaned recently. The entire inside had multiple areas of spills and dried on food substances on all shelves and storage compartments. LPN #903 verified the temperature log was missing and the unit needed to be cleaned. An observation was conducted on 06/05/19 from 10:14 A.M. to 10:18 A.M. with LPN #904 of the 300/400 unit refrigerator used to store resident foods and snacks. LPN #904 indicated 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, observation and interview the facility failed to ensure a clean and safe environment for Resident #35 and Resident #9. This affected two of 49 residents sampled residents. The facility census was 49. Findings include: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses including stroke, right side paralysis and depression. The Minimum Data Set Assessment (MDS) dated [DATE] indicated he had mild cognitive impairment, needed staff assistance for all activities of daily living and was dependent on tube feeding as his only source of nutrition and hydration. Observation on 06/03/19 at 2:01 P.M. revealed Resident #35 laying in his bed in his room. He had a tube feeding pump next to his bed with tube feeding solution infusing. All along the pole and the feet of the pole on which the tube feeding bag was hung, on the hand rail of the bed, the bed frame and an approximate two feet by two feet area of the floor around the pole was a heavy, dried, sticky, beige collection of what…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #46's meal intakes were consistently monitored per her care plan for nutrition and failed to ensure Resident #46's care plan for the use of an indwelling urinary catheter included ordered catheter care. This affected one resident (Resident #46) out of four residents reviewed for nutrition and one resident (Resident #46) of one resident reviewed for the use of a urinary catheter. Findings include: Resident #46 was admitted to this facility on 03/26/19. Her admitting diagnoses included dementia, cerebral infarction, and neurogenic bladder (lack of bladder control due to nerve damage). The resident had an indwelling urinary catheter (a tube inserted through the urethra into the bladder for the purpose of draining urine) in place due to a diagnosis of neurogenic bladder. Review of this resident's Minimum Data Set 3.0 (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. 1. Review of the plan of care dated 04/16/19…

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.