Ayden Healthcare Of Fairfield

Based on observation, and interview, the facility failed to ensure shower room equipment was clean and in good repair. This had the potential to affect 17 residents (#2, #5, #12, #13, #16, #29, #33, #38, #42, #43, #46, #48, #55, #62, #63, #71, #72) who the facility identified a using the shower room on the second floor. The facility census was 72.Findings include:Observation on 01/05/25 at 3:50 P.M. of the second-floor shower room revealed a single shower chair with a non-movable toilet seat. Under the toilet seat was a section of polyvinyl chloride (PVC) white pipe covered with brown smeared matter. Interview on 01/15/25 at 3:55 P.M. with Licensed Practical Nurse (LPN) #28 verified the chair was cleaned and the brown smeared matter was fecal matter. LPN #28 verified that the shower room and equipment should be cleaned after each use.Observation and interview on 01/09/26 at 11:10 A.M. of the shower room with the Director of Nursing (DON) revealed the staff providing the shower are responsible to cleaning the equipment between residents. This deficiency represents non-compliance…

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 interview, resident representative interview and staff interview, the facility failed to ensure resident or resident representative received notification/invitation to participate in care conferences. This affected three residents (#12, #5, #36) of three residents reviewed for communication of care. The facility census was 72. Findings include:1. Medical record review for Resident #5 revealed an admission on [DATE] with diagnoses including but not limited to congestive obstructive pulmonary disease, anxiety, hemiplegia and hemiparesis, abnormal posture and bilateral osteoarthritis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed intact cognition. Resident #5 required set up assistance for eating, maximum assistance for toileting, transfers and bathing. Review of the plan of care for Resident #5 revealed resident is a full code. Interventions include education of the resident and responsible party as needed and review and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview the facility failed to follow physician orders for blood glucose monitoring. This affected one resident (#36) of three reviewed for glucose monitoring. The facility census was 72.Findings include: Review of the medical record for Resident #36 revealed an admission on [DATE] with diagnoses of type two diabetes mellitus, morbid obesity, depressive disorder, panic disorder and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 revealed an intact cognition. Resident #36 required set up assistance for eating, toileting, bed mobility and transfers. Resident #36 received insulin injections during the assessment period. Review of the discharging physician orders for Resident #36 dated 10/27/25 from the previous long term care facility revealed an order dated 10/01/25 for blood sugar monitoring two times a day. Review of the admission physician orders for Resident #36 dated 10/31/25 was silent for blood sugar…

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 policy review the facility failed to ensure staff offered and documented refusals to provide incontinent care to dependent residents. This affected one resident (#5) of three incontinent residents reviewed for activities of daily living. The facility census was 72.Findings include:Medical record review for Resident #5 revealed an admission on [DATE] with diagnoses including but not limited to congestive obstructive pulmonary disease, anxiety, hemiplegia and hemiparesis, abnormal posture and bilateral osteoarthritis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed intact cognition. Resident #5 required set up assistance for eating, maximum assistance for toileting, transfers and bathing. Resident #5 is incontinent of bowel and bladder. Review of the plan of care for Resident #5 revealed resident has a self-care deficit related to left sided weakness. Interventions include the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure staff followed physician orders for medication administration. This affected two (#36, #43) residents of three reviewed for medication administration. The facility census was 72. Findings include:1. Review of the medical record for Resident #36 revealed an admission on [DATE] with diagnoses of type two diabetes mellitus, morbid obesity, depressive disorder, panic disorder and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 revealed an intact cognition. Resident #36 required set up assistance for eating, toileting, bed mobility and transfers. Review of the plan of care for Resident #36 revealed resident had an alteration in mood with little interest in doing things, trouble sleeping related to anxiety and depression. Interventions include administration of medications as ordered, behavioral health consults as needed and recommend the buddy system with care. Review of the physician orders for…

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

Based on record review and interviews, the facility failed to ensure residents were properly transferred using a mechanical lift. This affected one (#44) out of three residents reviewed for transfers. The facility census was 66. Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/15/24. Diagnoses included other sequelae of cerebral infarction, human immunodeficiency virus disease, hemiplegia unspecified affecting left nondominant side, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, traumatic subdural hemorrhage without loss of consciousness sequela, nontraumatic subdural hemorrhage, osteomyelitis of vertebra lumbar region, epilepsy, hyperlipidemia, paroxysmal tachycardia, nonrheumatic tricuspid stenosis, major depressive disorder, anxiety disorder, opioid abuse with withdrawal, and unspecified viral hepatitis C without hepatic coma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/24, revealed Resident #44 was cognitively intact. This resident was assessed to require…

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 provide medication per physician orders. This affected one (#69) when the facility did not administer his prescribed Methadone (opioid) medication resulting in a significant medication error. This affected one (#69) out of three residents reviewed for medication administration. Facility census was 71. Findings include: Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses of paraplegia, opioid abuse, auditory hallucinations, delusional disorders and congestive obstructive pulmonary disease. Review of the Minimum Data Set (MDS) discharge-return anticipated assessment dated [DATE] revealed Resident #69 had moderately impaired cognition and was always continent of bowel and occasionally incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene and bed mobility, moderate assistance with toileting, dressing, bed mobility and transfers. Bathing was not…

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

Based on observations, interviews, and review of facility policy, the facility failed to ensure effective pest control was maintained throughout the facility. This had the potential to affect the 66 residents residing in the facility. The facility census was 66. Findings include: 1. Observation on 09/15/24 at 8:55 A.M. revealed Resident #13 was lying in bed asleep. The residents breakfast meal tray was on the bedside table. Three flies were observed crawling on the table and breakfast meal tray. Observation on 09/15/24 at 9:00 A.M. revealed there were two flies on the door frame of Resident #3's room. Observation on 09/15/24 at 10:43 A.M. revealed there were several gnats flying around the room of Resident #45. Interview with Resident #45 at the time of the observation confirmed flies and gnats were a problem in the facility. Interview with Resident #1 on 09/15/24 at 10:50 A.M. confirmed the facility had a problem with flies and gnats. Resident #1 confirmed it was hard to eat a meal without flies landing on the food. Observation on 09/15/24 at 11:27 A.M. revealed there were several…

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

Based on Resident Council minutes review, staff and resident interviews, and policy review, the facility failed to ensure resolutions were provided to the residents after resident council meetings. This had the potential to affect all of the residents who attended resident council. The census was 66. Findings included: Review of the Resident Council Minutes from 08/28/23 through 08/30/24 revealed there were meetings but no resolutions to the problems discussed in the meeting. Interview with Activity Director (AD) #11 on 09/16/24 at 1:57 P.M. revealed she had been the director for three weeks. She stated she couldn't find any resolutions for the past Resident Council Meetings. During a Resident Council Meeting with Residents #1 and #13 on 09/17/24 at 10:52 A.M. revealed they have resident council meetings, but nothing is done about their complaints and they don't hear a resolution about the concerns during the next meeting. Interview with the Administrator on 09/17/23 at 3:30 P.M. confirmed she had not followed-up on all the concerns from the Resident Council Meetings and didn't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure care and services were provided to prevent a decline in nutritional status. This affected five residents (#3, #20, #34, #44, and #51) out of eight residents reviewed for nutrition. The facility census was 66. Findings include: 1. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, difficulty walking, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have intact cognition. The resident was assessed to have significant weight loss and to have a mechanically altered diet. Review of the care plan revised 08/12/24 revealed the resident had potential for alteration in nutrition/hydration. Interventions included provide diet as ordered and obtain weights as ordered. Review of the active physicians order dated 03/14/24 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct proper medication regimen reviews by a licensed pharmacist as required. Additionally, the facility failed to ensure the physician responded timely to a pharmacy recommendation for Resident #51. This affected five residents (Residents #13, #27, #44, #51, and #57) out of five residents reviewed for unnecessary medications. The facility census was 66. 1. Record review of Resident #27 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: cerebral infarction, human immunodeficiency virus, hemiplegia affecting left side, traumatic subdural hematoma, osteomyelitis, epilepsy, hyperlipidemia, malignant neoplasm of the ovaries, tobacco use, osteomyelitis, convulsions, atrial flutter, gastro-esophageal reflux disease, tricuspid valve stenosis, hypertension, depression, anxiety, opioid abuse with withdrawal, viral Hepatitis C. Review of the Minimum Data Set (MDS) assessment completed on 08/02/24 revealed this…

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

Based on observation, and staff and resident interviews, the facility failed to ensure residents knew what they were being fed on a daily basis. This affected six (#59, #64, #4, #38, #58 and #319) of eight reviewed for food. There was one resident identified as nothing by mouth to eat. The census was 66. Findings included: Interview with Resident #59 on 09/15/24 at 12:18 P.M. revealed he didn't receive a menu and didn't know what he was going to be served on a daily basis. Observation in the room revealed no menu. Interview with Resident #64 on 09/15/24 a 12:30 P.M. revealed she didn't receive a menu and didn't know for her three meals what she was going to receive. Observation in the room revealed no menu. Interview with Resident #4 on 09/15/24 at 2:14 P.M. revealed she didn't receive a menu and didn't know what she was going to receive for her three meals. Observation in the room revealed no menu. Interview with Resident #38 on 09/16/24 at 8:00 A.M. revealed he didn't receive a menu and didn't know what he was going to receive for his three meals. Observation in the room revealed…

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

Based on observations, interviews, and policy review, the facility failed to ensure meals were palatable and served at appropriate temperatures. This had the potential to affect 65 out of 66 residents as the facility identified one resident (#19) who did not consume food from the kitchen. The facility census was 66. Findings include: Interviews on 09/15/24 from 10:50 A.M. to 2:11 P.M. with Residents #1, #12, #13, #23, and #27 revealed the food was cold and not cooked properly. Observation on 09/16/24 at 11:30 A.M. of meal temperatures before the start of the meal service revealed the chicken thigh was 184 degrees Fahrenheit (F), the mashed potatoes were 183 degrees F, and the green beans were 181 degrees F. Observation on 09/16/24 at 12:33 P.M. of a test tray on the second floor after all resident meal trays had been passed revealed the chicken thigh was 100 degrees F, the mashed potatoes were 100 degrees F, and the green beans were 100 degrees F. Interview at the time of the observation with Dietary Supervisor #26 verified the temperatures and indicated the temperature should be 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 observation, and staff and resident interviews, the facility failed to ensure residents were able to choose an alternative meal. This affected six (#59, #64, #4, #38, #58 and #319) of eight reviewed for food alternatives. The census was 66. Findings included: 1. Observation was made on 09/15/24 at 12:15 P.M. revealed there were not any postings for meal alternatives for the residents. Interview with Resident #59 on 09/15/24 at 12:18 P.M. revealed he wasn't able to choose from an alternative menu if he didn't like his meal that was served. Observation in the room revealed no alternatives for meals. Interview with Resident #64 on 09/15/24 a 12:30 P.M. revealed she wasn't able to choose from an alternative menu if she didn't like his meal that was served. Observation in the room revealed no alternatives for meals. Interview with Resident #4 on 09/15/24 at 2:14 P.M. revealed she wasn't able to choose from an alternative menu if she didn't like his meal that was served. Observation in the room revealed no alternatives for meals. Interview with Resident #38 on 09/16/24 at 8:00…

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

Based on observations, interviews, and policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 65 out of 66 residents as the facility identified one resident (#19) that had not consumed food from the kitchen. The facility census was 66. Findings include: Observation on 09/18/24 at 8:50 A.M. of the kitchen revealed a large puddle of dirty water bubbling and pooling under the dishwasher that extended to the middle of the walkway between the side of the kitchen with the dishwasher and the other side that included the three-compartment sink. Interview at the time of the observations with Dietary Aide #21 verified the water puddle. Observations on 09/18/24 from 8:50 A.M. to 9:05 A.M. of the kitchen revealed a dusty vent above the steam table where food is served. There were also ceiling tiles near the steam table that were drooping and discolored. Interview at the time of the observations with Dietary Director #23 verified the dusty vent and the ceiling tiles. Dietary Director #23 stated the roof has been leaking, which caused the…

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

Based on observations and interview, the facility failed to ensure kitchen equipment was working properly. This had the potential to affect 65 out of 66 residents as the facility identified one resident (#19) that had not consumed food from the kitchen. The facility census was 66. Findings include: Observations on 09/18/24 from 8:50 A.M. to 9:05 A.M. of the kitchen revealed the garbage disposal did not function properly, the dishwasher leaked, there was a broken oven and refrigerator, and the three-compartment sink did not fill and drain properly. Interviews on 09/18/24 from 8:50 A.M. to 9:05 A.M. with Dietary Aide #21, Dietary Supervisor #26, and Dietary Director #23 verified the malfunctioning kitchen equipment. Dietary Aide #21 stated the dishwasher had leaked for months, and a wet vacuum must be used to drain the three-compartment sink. Dietary Supervisor #26 reported rags must be placed in the three-compartment sink to keep it filled. Dietary Director #23 verified the broken oven and refrigerator still in the kitchen. Dietary Director #23 also stated the garbage disposal 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 observation, staff and resident interview, and policy review the facility failed to ensure to provide a clean and maintained environment. This affected 17 (#63, #06, #47, #21, #319, #65, #58, #64, #59, #38, #04, #66, #36, #43, #51, #20, and #26) of 17 residents reviewed for homelike environment. The census was 66. Findings included: 1. Interview and observation of Resident #63's room on 09/15/24 at 10:40 A.M. revealed the floors were sticky and the resident said they remain sticky. There was a light over the bed when she turned it on it flickered. She said it had been like that and she told the housekeeper about it. There were four scrapes on the wall behind the bed, holes in the wall behind the toilet paper, wallpaper coming off under the sink area, ceiling tiles warped in the bathroom over the shower, dust coming off the blind, frosted glass on the right side her window from improper sealing, the blind had a yellowish substance on it, cobwebs on the right side of the window, and there was water damage next to the air conditioner unit. Observation of Resident #6'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 medical record review, staff interviews, and policy review, the facility failed to ensure residents had accurate advance directives in place. This affected two (#9 and #40) out of three residents reviewed for advance directives. The facility census was 66. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 04/13/19. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, bipolar disorder current episode manic without psychotic features, hypothyroidism, and tremor. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 was assessed to require supervision for eating, partial to moderate assistance for oral hygiene, and upper body dressing, substantial to maximal assistance for bathing, lower body dressing, personal hygiene, and bed mobility, and was dependent for toileting and transfer. Review of the physician orders for Resident #40 in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, and policy review, the facility failed to hold care conferences as required. This affected one (#13) out of one resident reviewed for care conferences. The facility census was 66. Findings include: Review of the medical record for Resident #13 revealed an admission date of 02/06/17. Diagnoses included type two diabetes mellitus without complications, myasthenia gravis without acute exacerbation, cardiac murmur, psoriasis, vitamin b deficiency, syncope and collapse, anemia, vascular dementia, unspecified severity with psychotic disturbance, hyperlipidemia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderately impaired cognition. Resident #13 was assessed to require setup assistance for eating, and supervision for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Further review of the medical record for Resident #13 revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received timely and required assistance with meals. This affected one resident (#51) out of the three residents reviewed for Activities of Daily Living (ADLs) during the annual survey. The facility census was 66. Findings include: Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, serous retinal detachment of the right eye, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed to require limited assistance from one staff member for eating and to have highly impaired vision. Review of the care plan dated 09/09/21 revealed the resident was at risk for decline in ADL function. Interventions included to offer assistance with meals. Further review of the care plan dated 09/09/21 revealed the resident was at risk for 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 medical record review, observations, staff and resident interviews, review of the activity calendar, and policy review, the facility failed to ensure residents were invited and were able to participate in the activities outside of their room. This affected three residents (#38, #58 and #319) of three reviewed for activities. The census was 66. Findings include: 1. Medical record review for Resident #38 revealed an admission date of 08/01/24. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively intact. His functional status was dependent for transfers. Review of the activity preferences assessment dated [DATE] revealed Resident #38 said it was somewhat important to keep up with the news, music, doing things with groups of people, and favorite activities. Review of care plan for Resident #38 dated 08/21/24 revealed he was at risk for alteration in activity participation. The interventions was to familiarize resident with nursing home environment and activity programs on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to provide adequate supervision for residents who smoke and proper storage of smoking materials for two residents (#27 and #65), and failed to provide proper supervision and services following a fall in the facility which affected one resident (Resident #44). This affected three residents (#27, #44, and #65) out of five residents reviewed for accident hazards. The facility census was 66. Findings include: 1. Record review of Resident #27 revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: cerebral infarction, human immunodeficiency virus, hemiplegia affecting left side, traumatic subdural hematoma, osteomyelitis, epilepsy, hyperlipidemia, malignant neoplasm of the ovaries, tobacco use, osteomyelitis, convulsions, atrial flutter, gastro-esophageal reflux disease, tricuspid valve stenosis, hypertension, depression, anxiety, opioid abuse with withdrawal, viral Hepatitis C. Review of the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record reviews, staff interviews, and review of facility policy, the facility failed to ensure communication between the facility and dialysis center was maintained. This affected one resident (#18) reviewed for dialysis. The facility census was 66. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including pleural effusion, dependence on renal dialysis, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have moderately impaired cognition. The resident was assessed to have received dialysis while a resident of the facility. Review of the care plan revised 04/29/21 revealed the resident was on dialysis. Interventions included resident to attend dialysis on Tuesdays, Thursdays, and Saturdays. Review of the progress notes dated 07/01/24 through 09/17/24 revealed no documentation of the resident refusing to attend…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure accurate documentation of medications administered to residents. This affected one resident (#51) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 66. Findings include: Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, serous retinal detachment of the right eye, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have intact cognition. Review of the active physicians orders for Resident #51 revealed the resident had duplicate orders in place for the medications Guaifenesin, Glucagon, Loperamide, Omeprazole, Potassium, and Tamsulosin. Review of the Medication Administration Record (MAR) from 08/01/24 through 09/15/24 revealed the scheduled medications Potassium and Tamsulosin had been documented as being…

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 and resident interview, and policy review, the facility failed to ensure residents were free of any significant medication errors. This affected one resident (#12) of three residents reviewed for medication administration. The facility census was 57. Findings included: Review of the medical record for Resident #12, revealed the resident was admitted on [DATE]. Medical diagnoses included cerebral infarction (stroke), cancer, neurogenic bladder, diabetes, and psychotic disorder. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 05/08/23 for Resident #12, revealed the resident was cognitively intact. Review of the active physician orders for Resident #12, revealed the resident was ordered to receive the following 6:00 A.M. medications: Aspirin 81 (over the counter pain relief) milligram (mg) daily in the morning, Furosemide (diuretic) 20 mg daily in the morning, Gabapentin (nerve pain) 300 mg every eight hours, and Tizanidine (muscle relaxer) 4 mg every hours…

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, review of personnel files, staff interview, and review of job descriptions, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 38 residents identified by the facility as not participating in activities (Residents #02, #03, #06, #07, #10, #11, #12, #13, #14, #16, #17, #19, #22, #23, #25, #26, #29, #30, #32, #35, #36, #37, #38, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #52, #53, #55, #56, #60). Facility census was 60. Findings include: Observation on 07/26/23 at 10:00 A.M. revealed Activities Assistant (AA) #300 was leading a group activity in the common area with multiple residents in attendance. Review of the personnel record for Activities Director (AD) #225 revealed the employee changed positions from that of Assistant Dietary Manager to AD on 04/30/23. The record indicated AD #225 had enrolled in a course to become a qualified AD on 04/25/23; however, there was no documented evidence AD #225 was a qualified AD. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to report discharges to the Ombudsman. This affected four residents (#07, #29, #52, and #62) of five residents reviewed for discharge. The facility census was 65. Findings Include: 1. Review of the medical record for Resident #62 revealed an admission date of 06/02/21 and a discharge date of 09/29/21. Resident #62 had diagnoses including heart failure and lung disease. Review of the Minimum Date Set (MDS) dated [DATE] revealed the resident had no cognitive impairments and required supervision and assist of one with all care. Review of the nurses progress note dated 09/29/21 revealed Resident #62 had a change in condition requiring an emergency transfer to the hospital. Further review of the residents chart showed no notification of the residents transfer to the ombudsman. Interview on 10/28/21 at 2:27 P.M., the Administrator verified the facility had not sent notifications to the ombudsman. 2. Review of Resident #52 medical record showed an…

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

Based on observation, staff interview, and review of planned menus revealed the facility failed to prepare menus for mechanically altered menus in advance, have menu changes for mechanically altered diets reviewed and approved by a Registered Dietitian prior to service, and follow menus including portion sizes for residents on mechanically altered diets. This affected four residents (#22, #464, #04, #38) of four residents with orders for a pureed diet. The facility census was 65. Findings include: Review of the planned menu for the evening meal on 10/26/21 revealed that cheese enchiladas, Spanish rice, and refried bean were to be served. The pureed diets were to receive two #10 scoops (3.25 ounces each scoop) pureed cheese enchiladas, and #8 scoop (4 ounces) of pureed Spanish rice, and a #10 scoop (3.25 ounces) of refried beans, as well as a #12 scoop (2.23 ounces) and assorted beverages. Interview with Dietary Supervisor (DS) #91 on 10/26/21 at 2:50 P.M. revealed the facility was serving tacos that evening instead of enchiladas. At that time an amended diet spread sheet for the…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure that resident food brought in from the outside was properly labeled, dated, and stored to prevent the potential spread of food borne illness. This had the potential to affect 64 residents of the facility on an oral diet, as there was one resident (#57) who received only enteral feedings. The facility census was 65. Findings include: The refrigerators on the first and second floor of the facility, designated as refrigerators for storing resident food, were observed on 10/28/21 beginning at 9:49 A.M. with Dietary Manager (DM) #12. Observation of the refrigerator in the first floor pantry revealed a sign on the door that specified the refrigerator was for resident use only - all other food will be thrown away. In the freezer there were numerous packages of frozen convenience items including pot pies and frozen apple pies that were not labeled as to who they belonged to, or when they were placed in the freezer. In the refrigerated section the following expired food items, labeled with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, review of the fall incident report, and policy review the facility failed to ensure care planned interventions were implemented to prevent falls. This affected one resident (#51) of 24 residents reviewed for falls. The facility census was 65. Findings include: Review of medical record for Resident #51 revealed admission date 08/14/21. Diagnosis included cerebral infarction, type 2 diabetes mellitus (DM), dysphasia, hemiplegia and hemiparesis, occlusion and stenosis of right middle cerebral artery, peripheral vascular disease, acute kidney failure, metabolic encephalopathy, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had moderately impaired cognition. The resident required extensive assistance of two plus person physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident had one fall since admission with no injury. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure each resident's medical record included complete and accurate information regarding residents' weight status to ensure that unusual changes in a resident's weight status would results in timely investigation/re-weights and/or nutrition interventions as indicated. This involved two residents (#22, #30) of eight residents reviewed for nutrition. The facility census was 65. Findings include: 1. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including atrial fibrillation, atherosclerotic heart disease, muscle weakness, dysphagia, congestive heart failure, Parkinson's disease, and dementia. Review of the resident's admission minimum data set assessment (MDS) dated [DATE] revealed the resident had severe cognitive impairments and required the physical assistance of one to two staff persons to complete activities of daily living, 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, record review, staff and resident interview, and review of facility policy, revealed the facility failed to keep all medications in locked compartments except when being administered by licensed nursing staff. This directly affected one resident (#465) of 21 residents located on the first floor Transitional Care Unit (TCU). The facility census was 65. Findings include: Resident #465 was admitted to the facility on [DATE] with diagnoses including cardiac arrest, acute osteomyelitis, diabetes mellitus type 2, ischemic cardiomyopathy, and cutaneous abscess of the left foot. Review of the resident's admission minimum data set assessment dated [DATE] revealed the resident had intact cognitive skills with good memory and recall. There was no assessment evident related to the resident being able to self-administer his medications. Interview and observation on 10/26/21 at 8:31 A.M. revealed the resident #465 was sitting up in his bed in his room eating breakfast. No one else was in the room, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of tray cards, revealed the facility failed to ensure each resident was provided with a therapeutic diet as order by the physician. This involved one resident (#29) of eight residents reviewed for nutrition. The facility census was 65. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including encephalopathy, protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, diabetes type 2, chronic kidney disease, dependence on renal dialysis, congestive heart failure, and Alzheimer's disease. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairments, required extensive assistance to complete activities of daily living, except for eating which she was able to complete with set-up help and supervision. Review of the resident's current physician's orders in the…

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

Based on record review and staff interview, the facility failed to provide any documentation related to the facility's Legionella assessment, control plan and monitoring. This had the potential to affect all of the residents at the facility. The facility census was 91. Findings include: Interview on 01/16/19 at 9:44 A.M., with the Director of Nursing (DON) confirmed the facility did not have any documentation related to Legionella. Interview on 01/16/19 at 10:38 A.M., with Regional Director of Operations #500 verified the facility did not have any documentation related to Legionella.

Based on observation and staff and resident interview, the facility failed to serve dinner in a homelike environment. This affected 16 residents residing on the second floor. The facility census was 91. Findings include: Observation of dinner in second floor dining room on 01/15/19 at 5:37 P.M. revealed the following residents were served their dinner meal with the china plates left on the trays used to transport the meal from the kitchen to the dining room: Residents #4, #8, #19, #22, #23, #26, #30, #32, #40, #47, #53, #65, #70, #74, #82, #83. Interviews with State Tested Nursing Assistants (STNA) #164 and #185 on 01/15/19 at 5:38 P.M. confirmed they usually remove the china plates from the trays when serving meals, but that they did not do so on 01/15/19 in order to save time. Interview with Dietitian #171 on 01/15/19 at 5:40 P.M. confirmed the staff usually remove the china plates from the trays when serving meals. Dietitian confirmed she was unsure why STNAs had served the dinner meal on 01/15/19 in this manner. Interview with Resident #40 on 01/15/19 at 5:42 P.M. stated that…

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 staff interview, the facility failed to thoroughly investigate two falls for one resident (#46) of three reviewed for accidents. In addition, the facility failed to properly store prescription medication for one Resident (#77) of five residents reviewed for unnecessary medications. This had the potential to affect 22 residents (#4, #8, #10, #16, #19, #23, #25, #28, #29, #30, #36, #40, #46, #54, #57, #61, #63, #69, #70, #74 #76 and #82) the facility identified as cognitively impaired mobile residents on the second floor. The facility census was 91. Findings include: 1. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included psychotic disorder, hallucinations, dementia without behavioral disturbance, repeated falls, other symbolic dysfunctions, other conduct disorders, mild cognitive impairment, right hip fracture, nasal bones fracture and osteoarthritis. Review of the resident's plan of care (POC) initiated on…

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

Based upon record review, observation, staff interview, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure undated and expired injectable medications were discarded appropriately. This affected one (B hall/first floor) of one medication room observed. The facility further failed to ensure expired insulin was discarded. This had the potential to affect one (#5) of one resident reviewed for expired medications. The facility census was 91. Findings include: 1. Observation of the medication room on the first floor of the facility on 01/15/19 at 7:30 A.M., revealed four undated vials of opened injectable tuberculin (TB) testing solution and one opened vial of injectable TB testing solution dated 11/15/18 being stored in the medication refrigerator during the survey. Interview with Registered Nurse (RN) #194 on 01/15/19 at 7:33 A.M., confirmed the four vials of undated tuberculin testing solution and the vial dated 11/15/18 were not appropriate for resident use and should be discarded 2. Observation of the 100 B Hall medication cart on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing upon the resident's transfer to the hospital. This affected two (Residents #49 and #439) of three residents reviewed for hospitalizations. The facility census was 91. Findings include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, dementia, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 11/22/18, revealed Resident #49 was cognitively intact and was totally dependent on staff for activities of daily living. Review of MDS assessment, dated 01/08/19, revealed Resident #49 was discharged from the facility with a return not expected. Review of nurse progress notes for Resident #49 revealed resident was sent to the hospital on [DATE] per physician order due to chest x-ray result and presenting signs and symptoms. Notes on 01/09/19 revealed resident was admitted to 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 and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) for Resident #46. This affected one (#46) of two residents reviewed for PASARR. The facility census was 91. Findings include: Review of Resident #46's medical record, revealed the resident was admitted to the facility on [DATE]. Diagnoses included psychotic disorder, hallucinations, dementia without behavioral disturbance, other symbolic dysfunctions, other conduct disorders, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/18, indicated Resident #46 was alert but confused at times and required extensive assistance with activities of daily living (ADLs). Review of the resident's Resident #46's two-page PASARR results dated 02/21/13, revealed Resident #46 had no indications of serious mental illness. The resident received the diagnosis of psychotic disorder on 01/09/18. The medical record contained no evidence an updated PASARR was…

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

Based on record review and staff interview, the facility failed to provide a plan of care for a resident's tracheostomy. This affected one resident (Resident #21) of twenty residents reviewed for care plans. The facility census was 91. Findings Include: Review of Resident #21's medical record revealed an admission date of 02/21/18 with diagnosis including anoxic brain injury and acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/29/18, revealed Resident #21 has a tracheostomy. Review of the plan of care dated 10/29/18 did not identify or reveal any interventions related to Resident #21's tracheostomy. Interview on 01/16/19 at 9:44 A.M. with Director of Nursing (DON) confirmed Resident #21's plan of care did not identify a tracheostomy and did not provide any interventions related to the tracheostomy care. Interview on 01/16/19 at 10:38 A.M. with Regional Director of Operations #500 confirmed Resident #21's care plan did not identify or include interventions related to the resident's tracheostomy.

Based on record review, resident and staff interview, the facility failed to ensure resident care plans were updated to reflect the residents' current code status and failed to ensure resident involvement in the care planning process. This affected two (Resident #9 and #40) of three residents reviewed for advanced directives and one (Resident #44) of four residents reviewed for care planning. The facility census was 91. Findings include: 1. Review of the record for Resident #9 revealed an admission date of 10/13/17 with diagnoses which included epilepsy and anoxic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively impaired. Review of record for Resident #9 revealed a state of Ohio Do Not Resuscitate/Comfort Care Arrest (DNRCCA) form undated signed by resident's attending physician. Review of physician orders and Medication Administration Record (MAR) dated January 2019 for Resident #9 revealed resident code status was DNRCCA. Review of care plan for Resident #9 dated 10/18/18 revealed the resident was to be a full code. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident's advance directives were accurate in the medical record. This affected one (#76) of three residents reviewed for advanced directives. The census was 91. Findings include: Review of the record for Resident #76 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance and peripheral vascular disease. Review of code status form for Resident #76 signed by the resident's physician dated 10/23/18, revealed resident was to be a do not resuscitate/comfort care (DNRCC). Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #76 revealed resident had impaired cognition. Review of care plan for Resident #76 dated 12/17/18 revealed resident was to be a DNRCC. Review of monthly physician orders for January 2019 for Resident #76 revealed Resident #76 was to be a full code. Review of Medication Administration Record (MAR) for January 2019 for Resident #76…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interviews, the facility failed to ensure a resident's wheelchair was in safe working condition. This affected one (# 19) of two residents reviewed for physical environmental concerns. The facility census was 91. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, dysphagia, heart failure, hyperlipidemia and hypothyroidism, Vitamin D and Vitamin B deficiency, and kidney failure. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with activities of daily living including bed mobility, transferring, dressing, toileting and personal hygiene. Observation on 01/16/19 at 12:47 P.M., revealed Resident #19 was sitting in her wheelchair feeding herself. The arm rest on the right side of the wheelchair was missing the arm rest pad. On 01/16/19…

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.