Majestic Care Of Fairfield LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, review of the Enhanced Information Dissemination and Collection (EIDC), interview with a BELTSS Representative, and staff interview, the facility governing body failed to appoint an administrator, licensed in the State of Ohio who was responsible for the management of the facility. This had the potential to affect all 150 residents residing in the facility. Findings include: On [DATE], review of the State Agency EIDC System revealed Administrator #400 was listed as the facility current and primary Administrator with an effective date of [DATE]. On [DATE], review of the BELTSS system revealed Administrator #400's license was inactive. Interview with BELTSS Representative #100 on [DATE] at 10:44 A.M. indicated their website (https://prod.beltss.age.ohio.gov/) for licensure verification was up to date and had no system issues. BELTSS #100 representative verified the Administrator was not active and the license expired…

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, resident interview, review of resident council meeting minutes, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two (#27 and #93) residents who did not receive food from the facility's kitchen. The facility census was 150. Findings include: Observation of the kitchen on 02/01/24 at 8:20 A.M. revealed a test tray went out on the 2B unit cart. All trays were retrieved from the meal cart on 07/03/23 at 8:34 A.M. The scrambled eggs, served on a Styrofoam plate and covered with an insulated lid, were 110 degrees Fahrenheit and cold to taste. Interview on 02/01/24 at 8:35 A.M., Account Manager (AM) #315 verified the scrambled eggs were cold and not palatable. AM #315 further stated the facility's dishwasher had been out since 12/22/23 and the facility often had to serve on disposable dinner ware. Interview on 02/01/24 at 10:11 A.M. Resident #69 stated the food was usually served cold. Interview on 02/01/24 at 10:21 A.M., Resident #52 stated the food was often served cold.…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, staff interview, and interview with contracted entity provider representative, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30,…

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 837 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05,…

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 interviews, the facility failed to provide a resident with appropriate behavioral health treatment and services. This affected one (#152) out of the three residents reviewed for behaviors. The facility census was 159. Findings included: Review of the medical record for Resident #152 revealed an admission date of 03/29/23 with medical diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and anxiety. Further review revealed Resident #152 went on leave of absence (LOA) with his daughter on 10/20/23 and was discharged from the facility on 10/26/23. Review of the medical record for Resident #152 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #152 had moderate cognitive impairment and required supervision with bed mobility, transfers, toileting, eating, and bathing. The MDS did not indicate Resident #152 had any behaviors. Review of the medical record for Resident #152 revealed a psychiatry progress note, dated 10/13/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, ophthalmologist interview, and policy review, the facility failed to administer eye medications (anti-glaucoma and antibiotic) as ordered resulting in significant medication errors. This affected one (#296) resident out of the three residents reviewed for medication administration. The facility census was 159. Findings included: Review of the medical record for Resident #296 revealed an admission date of 07/10/23 with medication diagnoses of osteomyelitis of vertebra and sacral region, congestive heart failure, end stage renal disease, dialysis dependent, and diabetes mellitus. Review of the medical record revealed Resident #296 discharged on 10/08/23. Review of the medical record for Resident #296 revealed an admission Minimum Data Set (MDS), dated [DATE] which indicated Resident #296 was cognitively intact and required extensive staff assistance for bed mobility, transfers, and toileting. Review of the medical record for Resident #296 revealed a Certified Nurse…

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 reviews, observations, staff interviews, and policy reviews, the facility failed to ensure infection control policies and procedures were followed. This affected two (#218 and #268) out of the four residents reviewed for infection control procedures. The facility census was 159. Findings included: 1. Review of the medical record for Resident #218 revealed an admission date of 09/02/22 with medical diagnoses of hypothyroidism, hypertensive heart disease, and dementia. Review of the medical record for Resident #218 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #218 had moderate cognitive impairment and required extensive staff assistance with bed mobility, eating, toileting and was dependent upon staff for transfers and bathing. Review of the medical record for Resident #218 revealed a care plan, dated 03/16/23, which stated resident has a history of multidrug-resistant organisms (MDRO), history of Extended Spectrum [NAME] Lactamase (ESBL) and…

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

Based on observation, staff interview, and policy review, the facility failed to food was stored in a manner to prevent the potential spread of foodborne illness, the facility failed to ensure kitchen equipment was maintained in a clean manner, the facility failed to ensure utensils placed on meal trays were not handled by the eating surface and the facility failed to ensure foods reached the appropriate cooking temperature prior to serving. This had the potential to affect 156 out of 156 residents in the facility who received food from the kitchen, the facility identified two residents (#06 and #108) who did not receive food from the kitchen. The facility census was 158. Findings include: 1. Observations on 09/11/23 at 9:20 A.M. during the initial tour of the kitchen revealed the following: a). In the walk-in freezer, there was a box of crab cakes, a box of vegetarian chicken nuggets, and a box of vegetarian breakfast burritos which were all left with the inside plastic bag cut open and left open to air. b). In the dry storage area, there was a large box of of rice observed 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 medical record review, observations, staff interviews, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices to potentially prevent the spread of infectious diseases such as Coronavirus Disease 2019 (COVID-19) and/or Carbapenem-Resistant Acinetobacter Baumannii (CRAB). Additionally, the facility failed to develop and follow an infection disease program to aide in the potential spread of urinary tract infections (UTI) based on the facility identified concern from January 2023 through August 2023. This had the potential to affect all 158 residents who resided in the facility. The facility census was 158. Findings include: 1. Record review for Resident #259 revealed she was admitted to the facility on [DATE]. Her diagnoses included supraventricular tachycardia, Myasthenia Gravis, and restless leg syndrome and COVID-19. Review of the New admission Minimum Data Set (MDS) assessment for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held with residents. This affected four (#03, #97, #108, and #145) of six residents reviewed for care conferences. The facility census was 158. Findings include: 1. Review of the medical record of Resident #03 revealed an admission date of 02/02/17. Diagnoses included chronic obstructive pulmonary disease (COPD), essential hypertension, hypothyroidism, bipolar disorder, peripheral vascular disease, major depressive disorder, and type 2 diabetes mellitus with diabetic neuropathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Interview on 09/11/23 at 1:00 P.M., Resident #03 stated the last time she had a care conference was approximately five years ago. Review of care conference notes revealed the resident had care conferences on 12/18/20 and 03/23/21. Interview on 09/13/23 at 12:47 P.M., Regional Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility and failed to ensure the an exterior gate on the secured unit was functioning appropriately. This affected one (#14) out of three residents reviewed for elopements and had the potential to affect 30 (#104, #39, #36, #48, #101, #27, #143, #14, #308, #58, #116, #149, #141, #62, #24, #70, #114, #94, #99, #60, #63, #28, #137, #151, #154, #133, #118, #153, #91, and #83) residents residing on the secured unit who were at risk for elopement. Additionally, the facility failed to ensure fall interventions were in place and to ensure safe transfers. This affected three (#99, #16, and #149) of eight residents reviewed for accidents. The facility census was 158. Findings include: 1. Review of the medical record of Resident #14 revealed an admission date of 09/20/19. Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately document on the Minimum Data Set (MDS) related to a residents bladder function. This affected one (#34) out of 31 residents reviewed for MDS. The facility census was 158. Findings include: Review of the medical record for Resident #34 revealed an admission date of 06/12/21. Diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, dementia, congestive heart failure, repeated falls, and history of urinary tract infections. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #34 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident was assessed to require one-person total dependence with dressing, one-person extensive assistance with eating, two-person extensive assistance with toileting, and two-person total dependence with bathing. Review of the MDS section H for bowel and bladder dated 08/12/23 revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure residents were provided with necessary care to maintain good personal hygiene. This affected three (#97, #16 and #149) of three reviewed for care of dependent residents. This census was 158. Findings included: 1. Review of the medical record for Resident #97 revealed an admission date of 08/19/20. Diagnoses included dementia, major depressive disorder, type two diabetes mellitus, chronic kidney disease stage 3B, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing, bathing, and toileting, and supervision with eating. Observations on 09/11/23, 09/12/23, and 09/13/23 during the annual survey, Resident #97 had chin hairs about…

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 ordered. This affected one (#149) out of three residents reviewed for medication administration. Facility census was 158. Findings Included: Review of medical record for Resident #142 revealed an admission date of 12/13/22. Diagnoses included open wound of abdominal wall left lower quadrant without penetration into peritoneal cavity (non-orthopedic surgery) 06/12/23, local infections of skin and subcutaneous tissue, pressure ulcer of right heel stage four, pressure ulcer of left ankle stage four, pressure ulcer of part of back stage four, pressure ulcer of left heel stage four, pressure ulcer of unspecified site stage three, pressure ulcer right hip unstageable, and carrier of suspected carrier of methicillin resistant staphylococcus aureus on 02/24/23. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #142 had a BIMS of 07/17/23 revealed resident BIMS was 15 that indicated he 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 observation, staff interviews, and review of planned menus, the facility failed to follow the planned menus which had been reviewed and approved by the Registered Dietitian (RD) in regards to portion sizes. This affected 28 (#50, 55, 99, 155, 4, 157, 35, 31, 67, 182, 19, 46, 71, 68, 169, 90, 102, 48, 126, 30, 91, 158, 49, 167, 143, 52, 51, 153) of 28 residents in the 5B/600 unit. The facility census was 196. Findings include: Observations on 01/29/20 of the meal service in the 5B/600 unit dining room began at 12:18 P.M. The food arrived to the unit at 12:18 P.M. and temperatures of the hot food were taken by Dietary Staff (DS) #92 at 12:22 P.M. The temperatures of the hot foods were all within acceptable parameters. DS #92 then began portioning food onto plates for residents in the 5B/600 unit dining room. Observation on 01/29/20 at 12:37 P.M. of the portion sizes of the food being served was checked and verified by DS #92 and Dietary Supervisor (DSP) #76 who was present throughout the observation. The portion sizes served were then checked against the planned menu 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 medical record review, staff interview and review of the Resident Assessment Instrument Manual the facility failed to comprehensively assess a residents cognitive in her native language. This affected one of one reviewed for cognitive function. The facility census is 196. Findings include: Review of the medical record for Resident #109 revealed an admission on [DATE], with diagnoses including to syncope and collapse, colostomy, protein malnutrition, abdominal abscess, abnormal heart rate, heart disease, kidney disease, pain in left leg, dizziness, depressive disorder, anxiety, anemia, perforation on the intestine, pacemaker, ulcer on left heel due to poor circulation and high blood pressure. Review of quarterly Minimum Data Assessment (MDS) assessment for Resident #109 dated 12/28/19 revealed the resident was coded as rarely or never understood and the Brief Interview for Mental Status (BIMS) was not completed. Review of quarterly MDS assessment for Resident #109 dated 12/09/19 revealed resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the Minimum Data Set (MDS) the facility failed to complete a comprehensive significant change assessment. This affected one (#109) of one resident reviewed for significant change assessments. The facility census is 196. Findings include: Medical record review for Resident #109 reveals an admission on [DATE] with diagnosis that include but not limited to syncope and collapse, colostomy, protein malnutrition, abdominal abscess, abnormal heart rate, heart disease, kidney disease, pain in left leg, dizziness, depressive disorder, anxiety, anemia, perforation on the intestine, pacemaker, ulcer on left heel due to poor circulation and high blood pressure. Review of quarterly Minimum Data Set (MDS) assessment for Resident #109 dated 12/04/19 revealed a total severity score for mood of eleven (a score indicating potential depression symptoms between 00 and 27). Resident #109 requires extensive assist with one staff member for bed mobility, transfers 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 code a MDS assessment accurately. This affected one (#109) of four residents reviewed for accurate assessments. The facility census is 196. Findings include: Review of the medical record for Resident #109 revealed an admission on [DATE], with diagnoses including to syncope and collapse, colostomy, protein malnutrition, abdominal abscess, abnormal heart rate, heart disease, kidney disease, pain in left leg, dizziness, depressive disorder, anxiety, anemia, perforation on the intestine, pacemaker, ulcer on left heel due to poor circulation and high blood pressure. Review of quarterly Minimum Data Assessment (MDS) assessment for Resident #109 dated 11/22/19 for Resident #109 was silent for falls. Review of quarterly MDS assessment dated [DATE] for Resident #109 revealed resident was silent as having a colostomy (artificial opening into the large intestine for the evacuation of fecal matter). Review of plan of care for Resident #109 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 observations, medical record review, and staff interview, the facility failed to ensure fingernails were trimmed and clean. This affected one resident (#161) of one resident reviewed for assitance with activities of daily care. The facility census was 196. Findings include: Review of the medical record for Resident #161 revealed an admission date of 01/02/20, with diagnoses including: heart attack, mild cognitive impairment, heart disease, dementia, prostate disorder, malnutrition, depression, high blood pressure, high cholesterol and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #161 revealed severly impaired cognition. Resident #161 required extensive assist for bed mobility, transfers, eating, toileting and personal hygiene. Review of the plan of care for activities of daily living (ADL) for Resident #161 revealed a performance deficit related to urinary tract infection, Alzheimer's disease (with behaviors), heart disease, leg swelling-right,…

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 did not receive an unnecessary medications, when the physician ordered parameters for administration were not followed. This affected one (#37) of one residents reviewed for dialysis medication. The facility census was 196. Finding include: Review of the medical record for Resident #37 revealed an admission date of 02/18/15 with diagnoses including end stage renal disease, hypertension and heart failure. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition and required extensive assist for bed mobility and transfer. The resident was independent for eating. Review of the care plan dated 11/15/19 revealed resident was a dialysis patient and had interventions in place related to his access site, dietary, and transportation. Review of Resident #37's physician orders revealed an order was written on 01/09/20 for Midodrine HCL Tablet (a medication used to…

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

Based on observation, record review and staff interview, the facility failed to ensure infection control measures were followed during a treatment to a wound. This affected one (#49) of seven residents reviewed for infection control. The facility census was 196. Findings include: Review of Resident #49's medical record revealed an admission date of 02/20/12, with diagnoses including congestive heart failure, coronary artery disease, hypertension, peripheral vascular disease, malnutrition, anxiety, rheumatoid arthritis, muscle weakness, stage 4 pressure ulcer of the sacrum. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/07/19, identified Resident #49 as being cognitively impaired. The MDS also identified a stage 4 pressure ulcer over the resident's sacrum. Review of the physician's orders revealed that Resident #49 was to have the sacral wound cleaned with Dakins (a antibiotic solution that kills or prevents the growth of bacteria or germs in a wound), pat dry, gently pack with a Calcium Alginate (topical wound dressing ). Then apply Chamosyn (a skin protectant)…

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 accurately code the Minimum Data Set (MDS) assessment for two (#139 and #4) of 38 records reviewed during phase two of the survey. The total facility census was 180. Findings include: 1. Record review for Resident #139 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage four, weakness, venous insufficiency, carotid artery syndrome, hypotension, bipolar disorder, morbid obesity, personality and behavioral disorder, hypothyroidism, diabetes mellitus, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/17/18, revealed Resident #139 had mild cognitive impairment. The assessment was coded indicating the resident was receiving hospice services. Review of Resident #139's orders revealed the resident had no order for hospice services. Interview on 11/26/18 at 5:40 P.M., with Resident #139 denied having hospice services. Interview with Licensed…

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 interview, the facility failed to ensure activities were provided according to resident interest for three (#42, #136, and #11) of five residents reviewed for activities. The census was 180. Findings include: 1. Medical record review for Resident #42 revealed an admission date of 02/09/09. Diagnoses included non-Alzheimer's dementia. Review of annual Minimum Data Set (MDS) assessment, dated 09/05/18, revealed Resident #42 was cognitively impaired. Review of the activity assessment dated [DATE] revealed the resident preferred to stay in her room and enjoyed one to one visits. Review of the activity participation form for Resident #42 revealed from 09/03/18 to 09/12/18, from 09/16/18 to 10/02/18, from 10/09/18 to 10/17/18, and from 10/18/18 to 11/07/18 there was no documentation of activities being offered or provided. Observations of Resident #42 on 11/26/18 at 11:00 A.M. and 11/27/18 at 10:26 A.M. revealed the resident was lying in bed. On 11/28/18 at 9:01…

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.