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Based on staff interview, observation, record review, and policy review, the facility failed to notify a resident representative of a new skin condition. This affected one (#15) of five residents reviewed for a change in condition. The facility census was 73.Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and Type II diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's electronic medical record (EMR) from 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck. Additional review revealed no evidence Resident #15's representative was notified of a new skin condition on Resident #15's neck.Interview on 07/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #103 revealed she observed a change in condition to 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.

Based on staff interview, record review, observation, and policy review, the facility failed to ensure timely assessments of a new skin condition. This affected one (#15) of five residents reviewed for change in condition. The facility census was 73.Findings include:Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and type 2 diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's Profile in the electronic medical record (EMR) revealed she required a mechanical lift for transfers since 06/10/22.Review of Resident #15's electronic medical record (EMR) dated 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck.Review of the late entry Incident Report, initiated 07/17/25 at 11:08 A.M., revealed Resident #15 had a bruise to her…

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 policies, the facility failed to ensure food was labeled and properly refrigerated, the kitchen was maintained in a sanitary manner, and food was not handled with contaminated gloves. This had the potential to affect all residents who consume food from the kitchen. The facility census was 81. Findings include: 1. Observation of the walk-in cooler on 03/10/25 at 8:54 A.M. revealed four quart sized containers of strawberries not dated. Three of the four quarts had a gray fuzzy substance on the strawberries. Interview with [NAME] #596 on 03/10/25 at 8:58 A.M. confirmed the observed strawberries were moldy and not dated. Observation of the deep fryer on 03/10/25 at 8:59 A.M. revealed three overcooked and oil-saturated French fries along the edge of the deep fryer and overcooked crumbs floating in the oil. Interview with Director of Food Services (DFS) #583 on 03/10/25 at 9:02 A.M. confirmed the observations of the deep fryer. Additionally, she stated the fryer was typically cleaned every Thursday, but it had been heavily used…

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, staff interview, and policy review, the facility failed to ensure medications were not prepared and stored in medication cart prior administration. This affected four (#05, #19, #42, #65) out of the fourteen residents that resided on Legacy Hall. Additionally, the facility failed to ensure an opened insulin pen was dated upon first use and was not expired. This affected one (#09) out of three resident insulin pens observed in the Legacy Hall medication cart. The facility census was 81. The findings include: Observation on 03/12/25 at 8:15 A.M. of the Legacy Hall medication cart revealed four separate clear, plastic medication cups with unidentified medications sitting in the second drawer. The observation revealed two letters were written on each plastic medication cup. The observation of the medication cart also noted Resident #09's Lantus Solostar 100 units per milliliter (ml) Insulin pen injector, opened, without an open date and with expiration date of 02/13/25. Interview with Registered Nurse (RN) #620 at 8:20 A.M. confirmed the Legacy Hall medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach of residents. This affected four residents (#15, #14, #57 and #4) of nine residents reviewed for call lights. The facility census was 81. Findings include: 1. Observation on 03/10/25 at 4:28 P.M. of Resident #15 in her room revealed she was sitting in a chair crying and her call light cord was tied to the bed handle out of her reach. Interview on 03/10/25 at 4:28 P.M. with Resident #15 confirmed she was crying due to pain and she could not reach her call light cord to alert staff she needed assistance. Interview on 03/10/25 at 4:28 P.M. with Licensed Practical Nurse (LPN) #518 confirmed Resident #15 could not reach the call light cord to alert staff that she needed assistance. 2. Review of Resident #14's medical record revealed an admission date of 06/17/20. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, anxiety disorder, aphasia 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 and staff interview, the facility failed to ensure resident beds were maintained in a safe condition. This affected one resident (#53) of nine reviewed for physical environment concerns. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admission date of 01/09/23. Diagnoses included Alzheimer's disease, stroke, type II diabetes, psychosis, altered mental status, major depressive disorder, anxiety disorder, and muscle weakness. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and rarely or never understood. Resident #53 was dependent on staff for toilet use, bed mobility and transfer. Observation on 03/10/25 at 11:27 A.M. of Resident #53's room found the headboard of the bed leaning to the left when facing the bed. When the headboard was touched it was found to have been broken free from the bed frame on the left side and was attached only by the right side to the frame 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.

Based medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were free from any physical restraints. This affected two (#28 and #73) out of two residents reviewed for restraints. The facility census was 81. Findings include: 1. Review of Resident #28's medical record revealed diagnose of Alzheimer's, dementia, right hand contractures, reduced mobility, glaucoma, and cognitive communication deficit. Review of physician orders, dated 12/18/24, revealed no physician order for a standard pillow to be placed under a fitted sheet on the left side of resident when in bed. Review of Resident #28's care plan, dated 01/17/25, revealed the right side of the bed was to be against the wall. Review of the Minimum Data Set (MDS) assessment, dated 12/27/24, revealed Resident #28 required maximal assistance with bed mobility. Observation on 03/10/25 at 03:54 PM revealed Resident #28 laying in bed on her right side facing the wall. Bilateral mobility bars were in place and pulled up. A standard size pillow was placed length wise under 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 medical record review and staff interview, the facility failed to ensure the care plan was updated timely to include the development of a pressure ulcer for one (#4) out two residents reviewed for pressure ulcers. The facility census was 81. Findings include: Review of Resident #04's medical recorded revealed an admission date 12/01/21. Diagnoses included Alzheimer's disease, dementia, osteoarthritis of right hip, major depressive disorder, and scoliosis. Resident #4 enrolled in hospice care 03/04/25. Review of Resident #04's Minimum Data Set (MDS) assessment, dated 12/20/24, identified Resident #4 was at risk for pressure ulcer development but no pressure ulcer noted. Review of Resident #04 nurse's notes revealed on 02/23/25 at 10:11 P.M. an open area was found on the sacrum during care. Certified Registered Medication Aide (CRMA) #622 notified Licensed Practice Nurse (LPN) #643 at the time of the finding. Further reviewed of nurses note dated 02/27/25 at 3:27 A.M. revealed the resident's daughter was notified of the wound and a treatment was established. Review of…

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

Based on observation, medical record review, and staff interview, the facility failed to follow physician orders to apply washcloths to the hands of one (#53) of four residents reviewed for skin conditions. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admission date of 01/09/23. Diagnoses included Alzheimer's disease, stroke, type II diabetes, psychosis, major depressive disorder, anxiety disorder, muscle weakness, abnormal posture, contusion of part of the head (12/09/24), and dementia with behavioral disturbance. Review of Resident #53's Minimum Data Set (MDS) assessment, dated 11/21/24, revealed Resident #53 was severely cognitively impaired. Resident #53 was dependent on staff for eating, toilet use, bathing, dressing and mobility. Review of Resident #53's physician orders revealed an order dated 01/21/25 for wash cloths to hands change daily and as needed. Review of Resident #53's care plan, revised 03/10/25, revealed supports and interventions for risk for skin breakdown. Interventions for risk for skin breakdown included…

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 staff interview, the facility failed to accurately assess a pressure ulcer, failed to complete an assessment of a pressure ulcer when identified, and failed to obtain a treatment for a pressure ulcer. This affected two (#38 and #4) out of three residents reviewed for pressure ulcers. The current census is 81. Findings include: 1. Record review for Resident #38 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #38 include dementia, urinary tract infection, respiratory failure, and chronic kidney disease. Review of Resident #38's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had impaired cognition and was incontinent of bowel and bladder. Review of Resident #38's wound management revealed on 02/13/25 the resident was noted to have an open wound measuring 7 centimeters (cm) by 2 cm by 0.1 cm depth. Per the wound assessment the wound had a 'foul' odor with necrotic tissue, irregular edges with a dark…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of facility policy, the facility failed to document a fall in the medical record, complete post fall assessments, and investigate a fall in a timely manner. This affected one (#54) of three residents reviewed for falls. The facility census was 81. Findings include: Review of the medical record for Resident #54 revealed she was admitted on [DATE] for physical therapy following joint surgery to her left shoulder. Admitting diagnoses included presence of left artificial shoulder joint, type two diabetes mellitus, chronic kidney disease, hyperlipidemia, hypothyroidism and gout. On 03/03/25 a diagnosis of unspecified fracture of shaft of left tibia was added. Review of the admission Minimum Data Set 3.0 (MDS) assessment, dated 02/11/25, revealed she was cognitively intact, required substantial assistance with dressing, toileting and showering, and utilized a cane, walker, or wheelchair. Review of the facility fall 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.

Based on observation, record review, resident interview, staff interview and policy review, the facility failed to ensure a physician order was present to administer oxygen. This affected one (#13) of three residents viewed for oxygen. The facility census was 81. The findings include: Review of Resident #13's medical record revealed an admission date of 11/22/17. Diagnoses included heart failure, chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypercapnia, left bundle-branch block, atrial fibrillation, type two diabetes mellitus, hypoxemia and nonspecific abnormal finding of lung field. Review of the care plan, dated 02/18/25, revealed Resident #13 was oxygen dependent and to use oxygen as ordered. Review of the physician orders revealed no orders for oxygen. Observation on 03/10/25 at 02:13 P.M. revealed Resident #13 sitting in her wheelchair with oxygen concentrator on and running at three liters via nasal cannula. Coinciding interview with Resident #13 revealed she has been on oxygen since 2021. Observation on 03/12/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility policy, and staff interview, the facility failed to ensure the physician responded to pharmacy recommendations timely and included a reason for the denial of gradual dose reductions. This affected one (#48) out of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Record review for Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia, depression, post-traumatic stress disorder, and obsessive compulsive disorder. Review of Resident #48's Minimum Data Set (MDS) assessment, dated 02/21/25, revealed the resident had intact cognition and was having hallucinating behaviors during the assessment period. Review of Resident #48's care plans dated 12/05/23, and revised on 02/14/25, revealed a focus for adverse consequences for psychotropic drug use. Interventions include attempt gradual dose reduction in two separate quarters and then yearly unless…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medication was administered as ordered by a physician. This affected one (#386) of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Medical record review for Resident #386 revealed an admission date of 02/26/25 for physical and occupational therapy following hospitalization for influenza A. Diagnoses included chronic respiratory failure with hypoxia, urinary tract infection (UTI), congestive heart failure, atrial fibrillation, unspecified dementia, anxiety, depression, history of cerebral infarction with left hemiparesis, and seizure disorder. Review of the hospital discharge medication orders included one tablet of ciprofloxacin 500 milligram (mg) given by mouth twice a day for four days and one tablet hydrocodone-acetaminophen 5 mg - 325 mg given by mouth every six hours as needed. Review of the medication administration record dated February 2025 and March 2025 for Resident #386 revealed ciprofloxacin 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 resident interview, the facility failed to provide a clean and comfortable environment. This affected one (#48) resident and has the potential to affect all resident residing in the facility. The current census is 81. Findings include: Observation on 03/10/25 at 8:00 A.M. upon entry to the facility revealed a remodeling in progress. At the front entrance the desk and surrounding area cloths were covering items and there were visible markings along the posts, which appeared to be prepped for painting. No staff were observed in the area working on the front desk area. Observations along the hallway in the main dining room area revealed one room had ladders, drop cloths, and other construction tools laying in the room across from the main dining area. Dust was observed on the handrail in the main hallway across from the main dining room. Observations on 03/10/25 from 11:00 A.M. to 12:10 P.M. revealed noise levels to be elevated during the lunch meal service as contractors were observed painting, nailing, and sanding walls in the room across…

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

Based on review of facility infection control records, staff interviews, review of staff schedules, review of time punch records, review of electronic mail (e-mail) correspondence, review of facility policies and procedures, review of the Center for Disease Control and Prevention CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control practices including written policies and procedures which included when and to who potentially communicable diseases should be reported, and failed to ensure the local health department was notified in a timely manner of a facility gastrointestinal illness outbreak. This affected 29 residents (#5, #6, #10, #17, #22, #23, #28, #36, #38, #39, #42, #48, #57, #58, #59, #60, #61, #63, #66, #69, #71, #74, #75, #77, #79, #82, #90, #91, and #92), two of which (Resident #58 and #60) Norovirus was detected, who experienced symptoms of gastrointestinal illness. This had the potential to affect all residents residing in the facility. 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 dining observations and staff interview the facility failed to treat 13 residents (#03, #06, #07,#36, #37, #42, #45, #51,#56, #59, #61, #333, and #434) eating in the restorative dining room with dignity during the meal. The facility census was 78. Findings include: Observation on 07/18/22 at 11:20 A.M. revealed State Tested Nursing Assistant (STNA) #123 was in the restorative dinning room standing to the right side behind Resident #37 wheelchair attempting to feed her a spoonful of food. Resident #37 would not open her mouth. Further observation on 07/18/22 at 11:40 A.M. of dining revealed a small room behind the large main dining room. There were 12 residents ( #03, #06, #07,#36, #37, #42, #45, #56, #59, #61, #333, and #434) in the room in wheelchairs sitting at three small square tables. One Resident (#51) was sitting off to the left side of the room with an over bed table in front of her. STNA #123 stood and fed three different residents ( #03, #06, and #37) each one bite at the middle table then left the small dining room. She returned to the dining room and fed…

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 dining observations and staff interview the facility failed to ensure there was adequate space in the restorative dining room for 13 residents (#03, #06, #07,#36, #37, #42, #45, #51, #56, #59, #61,#333, and #434) requiring extensive assistance with eating. The facility census was 78. Findings include: Observation on 07/18/22 at 11:20 A.M. revealed State Tested Nursing Assistant (STNA) #123 was in the restorative dinning room standing to the right side behind Resident #37 wheelchair attempting to feed her a spoonful of food. Resident #37 would not open her mouth. Further observation on 07/18/22 at 11:40 A.M. revealed a small room behind the large main dining room. There were 12 residents ( #03, #06, #07,#36, #37, #42, #45, #56, #59, #61,#333, and #434) in the room in wheelchairs sitting at three small square tables. One resident (#51) was sitting off to the left side of the room with an over bed table in front of her. STNA #123 stood and fed three different residents ( #03, #06, #37) each one bite at the middle table then left the small dining room. In order to leave the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review , observation, resident and staff interviews and facility policy review the facility failed to provide one resident (#36) of one resident reviewed with an adaptive call light. The facility census was 78. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, anemia, cervical spine stenosis, hypertension, and contracture of his left wrist. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive deficits. He requires extensive assistance with all activities of daily living . He was currently receiving hospice care in the facility. Review of the plan of care dated 07/18/22 stated the resident may need adaptations to participate in activities. The only adaptive intervention was for a bingo board . There was no mention of call light use and no mention…

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 facility staff interviews, the facility failed to honor choices of two of 12 sampled residents (Resident #32 and Resident #75), regarding showers. The facility census was 78. Findings include: 1. Interview with Resident #32 occurred on 07/18/22 at 12:52 P.M., Resident #32 identified she is getting a shower about once a month. Resident #32 confirmed she is receiving bed baths, but actually wants showered. Resident #32 appeared clean and odor free at the time of the interview and observation. Interview with Resident #32 occurred again on 07/19/22 at 9:58 A.M. Resident #32 confirmed there is an issue with residents not getting showers and getting bed baths. Resident #32 identified she is the resident council president and wants to speak for other residents whom can not speak for themselves. Review of Resident #32's medical record identified admission to the facility occurred on 08/04/16 with medical diagnoses including; COPD (Chronic obstructive pulmonary disease),…

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 reviews, therapy, family and staff interviews, the facility failed to maintain ambulation for one (Resident #55) of one residents reviewed for activities of daily living (ADL) decline, in a total sample of 18 residents. The facility census was 78. Findings include: Review of Resident #55's medical record identified she was admitted to the facility on [DATE]. Resident #55 has medical diagnoses that include: dementia, atrial-fibrillation, anxiety and chronic pain. Review of Resident #55's admission assessment dated [DATE] identified severe impairment with cognition and under section G- requires extensive assistant of one, for ambulation, in the room and corridor. The quarterly assessment dated [DATE] identified continued severe cognitive impairment and ambulation in room with supervision only. The assessment identified Resident #55 was not walking in the corridor. Interview with Resident #55's husband occurred on 07/19/22 09:29 A.M. The interview identified two weeks prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review and staff interviews, the facility failed to prevent a delay in treatment of surgical wound and suture (stitches) removal for one (Resident #75) of two residents reviewed for hospitalization. The facility census was 78. Findings include: Observation and Interview with Resident #75 occurred on 07/18/22 01:19 P.M. Resident #75 was observed with an ace wrap and bandage on the right calf, stopping below the knee. Resident #75 was observed with sutures (stitches) located on the top of the knee and just below the knee. Resident #75 was asked about the stitches and confirmed they should have been out weeks ago; however he missed his appointment on 06/30/22 and it has never been rescheduled. Review of Resident #75's medical record identified admission to the facility occurred on 06/17/13, with medical diagnoses including; fracture of the right fibula/tibia, end stage renal disease, diabetes, morbid obesity, anxiety, major depression, anemia and poor circulation. The most…

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, staff and resident interview, and observations the facility failed to ensure one resident ( #43) of 18 sampled residents received her hearing aids on a consistent basis. The facility census is 78. Findings Include: Review of the medical record for Resident #43 revealed an admission date of 12/01/21. Diagnoses included, unspecified dementia without behavioral disturbance, anxiety disorder, hypokalemia, essential hypertension, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/22, revealed she was moderate cognitive impairment. The assessment, section B (Hearing) revealed moderate difficulty - speaker has to increase volume and speak distinctly, and indicated hearing appliance used. There were no behaviors indicated. Review of the Plan of Care dated 05/21/22 revealed interventions included putting hearing aids in medication cart each night. Review of the progress notes dated 05/18/22 revealed Resident #43 had hearing aid on. Review of notes dated 06/08/22 revealed daughter, came in today and brought in left hearing aid, 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, review of pharmacy recommendations and interview the facility failed to timely respond to pharmacy recommendations. This affected one resident (#05) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: Review of the medical record for Resident #05 revealed an admission date of 03/25/22. Diagnoses included Parkinson's Disease, Alzheimer's Disease, dementia, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, single episode, and anxiety. Review of the pharmacy recommendations dated 03/29/22 revealed resident has an order for Celexa 40 milligrams (mg) daily. Food and Drug Administration (FDA) says citalopram doses should not exceed 20 mg/day for most patients over age [AGE]. Higher doses of citalopram (Celexa, etc.) increases risk of QT prolongation (a heart rhythm that can potentially cause fast, chaotic heartbeats) and torsades (a specific type of ventricular tachycardia, or fast…

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, family and staff interviews the facility failed to ensure a clean sanitary environment was maintained for one resident (#07) in a total sample of 18 residents. The facility census was 78. Findings include: Review of the medical record revealed Resident #07 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory deficits and was unable to complete the Brief Interview for Mental Status. She requires extensive assistance of one staff member for all activities of daily living including toileting. She was assessed as always incontinent of bowel and bladder. Review of the plan of care dated 05/25/22 revealed the resident is incontinent of bowel and bladder. Interventions included providing incontinent care following incontinence. Observation on 07/18/22 at 10:30 A.M. revealed the trash in 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.

Based on observation, staff interview and facility policy review, the facility failed to maintain infection control in the laundry room. This affected 90 of 90 residents residing in the facility who used the facility laundry. Findings include: 1. Observation on 08/08/19 at 7:06 A.M. conducted in the facility laundry room revealed Environmental Services Assistant (ES) #200 was sorting laundry from a large laundry bin. The bin contained resident's soiled personal items. Laundry Aide (LA) #200 was wearing gloves but no gown or other personal protective equipment. Her brown polo shirt was continually draping across the dirty laundry bin and in contact with it as she leaned over the bin to remove soiled clothes for sorting. Interview at the time of the observation with LA #200 stated she was sorting the residents' soiled personal items to be washed. LA #200 verified she was not wearing a gown and stated she does not usually wear a gown. LA #200 pointed out that there was a plastic apron hanging on the wall near the entry door and stated she would wear it if things were really dirty. LA…

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 ensure proper disposal of medications. This had the potential to affect six (#12, #19, #50, #62, #83 and #84) of seven residents near the medication cart who were independently mobile with impaired cognition. The facility census was 90. Findings include: Observation on 08/06/19 at 8:13 A.M. during medication administration revealed Licensed Practical Nurse (LPN) #220 cut a tablet of Depakote (anticonvulsant medication) in half. LPN #220 placed half of the Depakote tablet in an uncovered waste container attached to the medication cart. The medication cart was located next to the dining room in the memory care unit. There were seven residents sitting in the dining room. Observation on 08/06/19 at 8:23 A.M. revealed LPN #220 continued to prepare medications for Resident #76 including one tablet of atenolol 100 milligrams (mg.) (blood pressure medication), one tablet of carbamazepine 200 mg. (anticonvulsant), one half tablet of Depakote 125 mg., one tablet of Hydrochlorothiazide 25 mg. (diuretic), one tablet…

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 ensure a medication cart was locked. This had the potential to affect seven (#29, #41, #49, #67, #71, #81 and #89) of 31 residents the facility identified as independently mobile with impaired cognition residing in the three hallways near the medication cart. The facility census was 90. Findings include Observation on 08/08/19 beginning at 7:48 A.M. of the hallway revealed a medication cart was left unlocked and unattended. Interview on 08/08/19 at 7:55 A.M. with the Administrator was notified and provided verification the medication cart was left unlocked and unattended in the hallway. Interview on 08/08/19 at 2:57 P.M. the Administrator revealed there were seven residents (#29, #41, #49, #67, #71, #81 and #89) who were independently mobile with cognitive impairment residing in the three hallways near the unlocked medication cart. Review of the facility policy Medication Storage In The Facility, last revised 01/2017, revealed medication carts should be locked when not attended by persons with authorized…

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, family interview, staff interview and policy review, the facility failed to clarify the physician's order on a DNR identification form. This affected one (#85) of two resident reviewed for advanced directives. The facility identified 25 residents as full code status. The facility census was 90. Findings include: Review of the medical record revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, major depressive disorder, hypertensive heart disease without heart failure, type I diabetes mellitus with hyperglycemia, dysphagia, and anxiety disorder. Review of the electronic health record face sheet revealed Resident #85 had a full code status. Review of the DNR identification form, dated 06/03/19, revealed Resident #85 had a Do No Resuscitate- Comfort Care (DNR-CC) code status. Interview on 08/06/19 at 5:02 P.M. with Resident #85's spouse verified Resident #85 was a full code status. Interview on 08/06/19 at 3:15 P.M. 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 record review, staff interview and facility policy review, the facility failed to provide the bed hold policy to Resident #64 and Resident #79. This affected two (#64 and #79) of two residents reviewed for hospital discharges. The facility census was 90. Findings include: 1. Review of the medical record for Resident #64 revealed an admission dated of 11/29/17. Review of the progress notes revealed on 06/15/19 at 4:30 P.M. Resident #64 was sent to the emergency room (ER) for evaluation and treatment of shortness of breath. On 06/16/19 at 2:28 A.M., Resident #64 was admitted to the hospital. Further review of the medical record revealed it was silent for the bed-hold policy being provided to the resident or her representative. 2. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, dementia without behavioral disturbance, essential hypertension, muscle weakness, insomnia, and anxiety disorder. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review, the facility failed to ensure a resident received assistance with showers as scheduled. This affected one (#42) of one residents reviewed for showers. The facility census was 90. Findings include Medical record review revealed Resident #42 admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbances, anxiety, cerebral infarction, aphasia, difficulty walking and urinary incontinence. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/17/19, revealed Resident #42 had severe cognitive impairment. Resident #42 was dependent on staff for bathing and personal hygiene. Review of the shower list revealed Resident #42 was scheduled for showers on Mondays and Thursdays on second shift. Review of the Resident Bathing Chart from 07/09/19 through 08/07/19 revealed Resident #42 had received no showers. Review of the nurse's notes from 07/09/19 through 08/07/19 revealed no documentation Resident #42 had refused his…

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, resident interview, and staff interview the facility failed to monitor an open wound on the resident's right shin. This affected one (Resident #90) of six residents reviewed for skin conditions. The facility failed to ensure a bowel management program was initiated a resident. This affected one (Resident #85) of one resident reviewed for bowel management. The facility census was 90. Findings include: 1. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE]. Diagnoses included aftercare post surgery, severe sepsis, cellulitis of lower limbs, end stage renal disease, diabetes type two, neuropathy and heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/05/19, revealed the resident has intact cognition and was being treated for unhealed wounds. Review of the physician orders, dated 07/11/19, revealed Resident #90 was to have tubigrips socks applied to bilateral lower leg, monitor shins and report if 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the resident was seen by the physician for the initial visit in the facility. This affected one (Resident #50) of three resident reviewed for physician visits. The facility census was 90. Findings include: Record review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #50 include urinary tract infections, chronic kidney disease, depression, fracture of the left radius, and dementia with Lewy bodies. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/29/19, revealed the resident had impaired cognition. Further review of Resident #50's medical record from 06/22/19 through 08/06/19 revealed there was no physician assessment or progress notes in the resident's record for the initial or subsequent visits. Interview on 08/07/19 at 5:15 P.M. with MDS Registered Nurse (RN) #320 revealed the only documentation for the initial visit from the physician was 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.