Momentous Health At Franklin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely to reflect new diagnoses, new sexual behaviors, and medications to treat the new diagnoses and behaviors. This affected two (#45 and #57) of six residents reviewed for care planning. The facility census was 66. Findings include: 1. Record review for Resident #57 revealed an admissions date of 04/18/22 with diagnoses including cerebral infraction, dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Review of the medical laboratory records dated 08/19/25 revealed Resident #57 was positive for Herpes Simplex 1. Review of the physician's orders dated 08/24/25 revealed Resident #57 had a new order of Valtrex (treats Herpes) 500 milligrams (mg). Review of Resident #57's care plan on 09/10/25 revealed that the new diagnoses and medication was not included in the care plan. Interview on 09/10/25…

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, staff interview, and policy review, the facility failed to ensure residents who required assistance with activities of daily living received adequate assistance with nail care. This affected one (#22) of two residents reviewed for ADLs. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 01/25/24. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, major depressive disorder, dementia, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. The resident was independent with personal hygiene, required setup/cleanup assistance with dressing, and required supervision or touching assistance with bathing. Review of the plan of care dated 08/06/24 revealed Resident #22 was independent/supervision for ADLs except for bathing.…

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

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure activities met the needs and preferences of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 66.Findings included: Review of the medical record for Resident #77 revealed an admission date of 09/02/25 with diagnoses of paraplegia, schizophrenia, anxiety disorder, and bipolar disorder. There was no Minimum Data Set (MDS) assessment available to review due to recent admission. Interview on 09/08/25 at 12:04 P.M. with Resident #77 revealed there were no activities. Observation on 09/11/25 at 8:26 A.M. revealed the schedule of activities for September 2025 had no activities scheduled for the residents after the 2:00 P.M. everyday of the month, except for every other Tuesday when church services were scheduled at 6:00 P.M. Interview on 09/11/25 at 8:38 A.M. with Activities Director #104 confirmed there were no activities scheduled for the residents after the 2:00 P.M. scheduled activity is completed, except…

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 and staff interviews, review of U.S. Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents vaped in the facility's designated smoking area. This affected one (Resident #11) of two residents reviewed for supervision. The facility census was 66.Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/29/24 with diagnoses including centrilobular emphysema and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had moderate cognitive impairment, rejected care at times and was independent with ambulation. Review of the Smoking assessment dated [DATE] revealed Resident #11 required supervision while smoking. There was no documentation that Resident #11 was non-compliant with the facility's smoking policy. Observation and interview on 09/08/25 at 10:15 A.M. revealed Resident #11 with a cloud of smoke above her knees and a vape machine in…

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 policy review the facility failed to ensure the medication error rate did not exceed five percent (%). There were two observed errors out of 34 opportunities that resulted in a medication error rate of 5.88%. This affected one (Resident #42) out of four residents reviewed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/20/21. Review of the physician orders revealed an order dated 01/09/24 for Calcium plus Vitamin D3 Oral Tablet 500-5 milligrams (mg)- microgram (mcg) give one tablet by mouth one time a day for supplement. There was an order dated 07/17/25 for Duloxetine HCl oral capsule delayed release sprinkle 30 mg give one capsule by mouth one time a day for schizophrenia. Observations on 09/10/25 from 8:00 A.M. through 8:30 A.M. with Licensed Practical Nurse (LPN) #151 revealed LPN #155 administered 33 medications to three residents. Resident #42 was administered the following medications in error, Calcium + Vitamin D3 Oral 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate. This affected one (#3) of 23 residents reviewed medical record accuracy. The facility census was 66.Findings include: Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included end-stage renal disease (ESRD) with dependence on renal dialysis, and heart failure. Review of Resident #3's physician orders revealed orders dated 05/22/25 and 05/24/25 for Resident #3 to attend dialysis on Tuesday, Thursday, and Saturday with pickup at 5:30 A.M. On 05/27/25, there was an order to send Resident #3 to the emergency room for evaluation. Review of a progress note dated 05/27/25 at 7:23 A.M. revealed Registered Nurse (RN) #128 was notified Resident #3 was not picked up for transport for dialysis that morning (05/27/25) and may have missed dialysis on Saturday (05/24/25) due to transport. NP #301 was notified and an order was received to send 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, review of the facility menu and spreadsheet and policy review, the facility failed to ensure menus were followed. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61. Findings include: Review of the menu dated 07/03/24 revealed oatmeal or cold cereal, cheesy scrambled eggs, a sausage patty, assorted toast, whole milk or two percent milk and coffee or tea were to be served for breakfast. Review of the undated menu spreadsheet revealed regular diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast, mechanical soft diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast and pureed diets were to receive six ounces of pureed oatmeal, two ounces of pureed cheesy scrambled eggs, and two ounces of pureed toast for breakfast. Observation of the kitchen on 07/03/24 at 7:38 A.M.…

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

Based on observation, staff interview, record review, the facility failed to ensure food items were stored in a sanitary manner. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61. Findings include: Observation of the kitchen on 07/03/24 at 7:45 A.M. revealed the reach in refrigerator in the kitchen was 60 degrees Fahrenheit. A package of ham, a package of hamburgers and a package of hotdog's were located in the refrigerator. There was also a gray fuzzy substance on the line that went from the ceiling to the steam table and there was a gray fuzzy on the ceiling vent located directly above the onions in the dry storage room. There were also three flies sitting on the line that went from the ceiling to the steam table in the kitchen. Interview with Dietary Supervisor (DS) #110 on 07/03/24 at 7:45 A.M. verified the reach in refrigerator was 60 degrees Fahrenheit and there was a package of ham, a package of hamburgers and a package 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, observations, staff and resident interviews and policy review, the facility failed to ensure medications were stored securely. This affected five (#18, #29, #32, #55 and #56) out of five residents reviewed for medication storage. This had the potential to affect four (#29, #48, #10 and #57) residents that the facility identified as cognitively impaired and independently mobile. The facility census was 61. Findings include: 1. Medical record review for Resident #18 revealed an admission on [DATE] with diagnoses including but not limited to schizophrenia, left female breast cancer, anxiety disorder, impaired cognition and bipolar disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed an intact cognition. Resident #18 was independent for eating and supervised toileting, bed mobility, and transfers. Resident #18 was incontinent of bowel and bladder. Resident #18 was receiving hospice services. Review of the plan of care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure a resident's admission assessments were timely completed in the electronic health record. This affected one (#300) out of three residents reviewed for medical record accuracy and completeness. The facility census was 61. Findings include: Medical record review for Resident #300's chart revealed resident admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, emphysema, congestive heart failure, chronic kidney disease and hypertension. Resident #300 discharged from the facility on 05/23/24 at approximately 9:49 A.M. Review of Resident #300's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #300 was independent with eating. Resident #300 required maximal assistance with toileting, showering, lower body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers,…

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 and policy review, the facility failed to ensure staff completed hand hygiene during during incontinence care. This affected one (#06) out of three residents reviewed for incontinent care. The facility census was 61. Findings include Medical record review for Resident #06's revealed resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hyperlipidemia, retention of urine, hypertension, anxiety disorder, peripheral vascular disease, muscle weakness and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #06 revealed the resident had severe cognitive impairment. Resident #06 required supervision with eating and rolling left and right. Resident #06 required moderate assistance with toileting, personal hygiene, and maximal assistance with toileting. Resident #06 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 record review, review of the facility's Self-Reported Incident (SRI), review of the facility policy, and staff interview, the facility failed to report resident-to-resident physical abuse to the State Survey Agency, the Ohio Department of Health. This affected two (Residents #1 and #2) of four residents reviewed for abuse. The facility census was 55. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia, depression, anxiety, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition. Review of Resident #1's progress notes dated 01/27/24 at 7:42 P.M. revealed Resident #1 walked past Resident #3's room and while standing in the hallway, Resident #3 struck Resident #1 in the mouth causing an abrasion to her lip. Resident #1 was assessed by the nurse and the resident's family representative was notified. Record review 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 record review, staff interview, and review of the facility policy, the facility failed to notify the physician and resident representative of the resident's severe weight losses. This affected two (Residents #200 and #500) of six residents reviewed for weight loss. The facility census was 54. Finding: 1. Closed record review for Resident #200 revealed an admission date of 12/09/22. Diagnoses included diabetes mellitus type two, tracheostomy, stage four decubitus ulcer (Full thickness tissue loss with exposed bone, tendon or muscle), systemic cerebral vascular accident, dysphagia, quadriplegia, and gastrostomy tube. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was cognitively impaired and no behaviors or rejection of care. Resident #200 received 51% or more total calories though tube feeding, had a five percent weight loss, and was not on a physician prescribed weight-loss regimen. Resident #200 was at a high risk for pressure ulcers with one stage four…

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 review of the Medline guidance, the facility failed to provide the care and services for a resident's peripherally inserted central catheter (PICC). This affected one (Resident #200) of three residents reviewed for intravenous (IV) therapy. The facility census was 54. Findings include: Closed record review of Resident #200 revealed an admission date of 12/09/22. Diagnoses included moyamoya, tracheostomy, systemic inflammatory response syndrome, cerebral vascular accident, neurogenic bladder, and quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had impaired cognition, had no behaviors, or no rejection of care. Review of the physician orders dated 11/14/23 revealed Resident #200 received a new order for an intravenous antibiotic Meropenem one gram three times a day for urinary tract infection. The antibiotic was to be administered through a Peripherally Inserted Central Catheter (PICC) which was placed 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 on observations, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications by ensuring expired medications were not being used. This affected six residents (#2, #4, #7, #15, #34, #155) who facility identified as receiving the expired medications from two medication carts and a medication storage room in the facility. The facility census was 51. Findings include: Observations and interviews on 01/07/23 from 10:20 A.M. to 11:00 A.M. of two facility medication carts (200 and 300 halls) and one medication storage room (200/300 halls) with Licensed Practical Nurse (LPN) #140 and Registered Nurse (RN) #192 revealed the following over the counter (OTC) expired medications: Certavite multivitamins expired 01/2023, Gerilanta expired 12/2022, and Claritin 10 milligrams (mg) expired 09/2022. LPN #140 and RN #192 confirmed the outdated medications were in the medication carts and the medication storage room. Review of the facility policy titled, Medication Storage, undated, revealed the facility failed to implement the policy.…

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 facility policy, the facility failed to notify the physician of Resident #49's elevated temperature for two days. This affected one (Resident #49) of three residents reviewed for physician notification. The facility's census was 51. Findings include: Review of Resident #49's medical record revealed he was re-admitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was 101.3. 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, observations, staff interviews, and review of facility policy, the facility failed to provide activities to residents residing in the facility's Memory Care Unit (MCU). This affected three (Residents #25, #35, and #41) of three residents reviewed for activities. The facility's census was 51. Findings included: 1. Review of Resident #25's medical records, revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbances, cerebrovascular disease, psychotic disorder with delusions due to known physiological condition, diabetes, hypertension, and diverticulosis of intestine. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had extensive cognitive impairment. His functional status is listed as extensive one to two person assist to totally dependent on staff for activities of daily living. Review of the care plan dated 07/30/21 revealed Resident #25's daily activity could be affected by admission,…

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 facility policy, the faciltiy failed to assess pressure ulcers on a weekly basis to include wound measurments and description of the wounds. This affected two (Residents #30 and #37) of four residents reviewed for pressure ulcers. The facility identified four (Residents #29, #30, #37, and #39) with pressure ulcers. The facility's census was 51. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 12/09/22. Diagnoses included neuromuscular dysfunction of bladder, gastroesophageal reflux disease, type II diabetes mellitus, seizures, major depressive disorder, and pressure ulcer of the sacral region (stage IV). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 had impaired cognition. The resident required total assistance for all activities of daily living (ADLs), except bed mobility in which the resident required extensive assistance. The assessment indicated…

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 interview, the facility failed to ensure an ordered orthotic therapeutic device was applied to assist with a resident's contracture. This affected one (Resident #49) observed for application of therapeutic devices. The facility identified 25 residents with contractures. The facility's census was 51. Findings include: Review of Resident #49's medical record revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's physician orders revealed an order dated 11/09/22 for staff…

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 interview, and review of facility policy, the facility failed to provide supervision and failed to implement interventions for a resident who smoked. This affected one (Resident #45) of five residents identified to smoke. The facility's census was 51. Findings include Medical record review for Resident #45 revealed an admission date of 06/11/21. Diagnoses included encephalopathy, seizures, polyarthritis, alcohol abuse, anxiety disorder, essential primary hypertension, pseudobulbar affect, major depressive disorder, alcohol abuse with alcohol induced psychotic disorder, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had severely impaired cognition. Resident #45 required extensive assistance from staff with bed mobility, transfers, dressing, locomotion on the unit, and toilet use. Resident #45 required limited assistance from staff with personal hygiene and eating. Review of Resident #45's most recent…

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 review of facility policies, the facility failed to maintain appropriate infection control techniques during tracheostomy (trach) care. This affected one resident (#49) of the two residents identified by the facility as requiring tracheostomy care. The facility also failed to utilize proper hand hygiene during wound care. This affected one Resident (#49) of the four residents identified with wounds and requiring dressing changes. The facility census was 51. Findings include: 1. Review of Resident #49's medical record revealed resident was readmitted to the facility on [DATE]. His diagnoses included, but not limited to, diffuse traumatic brain injury (TBI), anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, trach dependent, and gastrostomy. Review of Resident #49's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed resident had impaired cognition. Further review of the MDS assessment revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to develop and/or implement each resident's plan of care related to contracture management, diabetes management and insulin use, use of an anti-platelet medication, and for medications used to managed inappropriate behaviors. This affected four (#04, #07, #52, and #63) of 20 residents' whose care plans were reviewed. The census was 66 residents. Findings include: 1. Review of the medical record revealed Resident #04 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia. The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and representative/family interview and staff interview, the facility failed to ensure that one resident received treatment and care to maintain proper and comfortable positioning while in a wheel chair. This affected one (Resident #16) of three residents reviewed for positioning/mobility. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, moderate protein calorie malnutrition (PCM), dementia with behavioral disturbance, anxiety disorder, repeated falls, dysphagia, and bilateral hearing loss. The resident was admitted to in-facility hospice services on 11/15/19 with an admitting diagnoses of PCM. The facility completed an admission minimum data set (MDS) assessment of the resident's cognitive and physical functional status on 09/18/19. The 09/18/19 assessment identified the resident as having short and long term memory problems with severely impaired cognitive…

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 interview, the facility failed to ensure that a resident with a limited range of motion received appropriate treatment to prevent further decreases in range of motion and to improve comfort. This involved one (Resident #04) of three residents reviewed for positioning/mobility. Findings include: Review of the medical record revealed Resident #04 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia. The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in her range of motion to both of her upper and lower extremities. Review of Resident #04's current…

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 ensure a resident was monitored for sexual behaviors related to the use of medication. This affected one (Resident #07) of six residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #07's medical record revealed an admission date of 09/17/15 with diagnoses including dementia with behavioral disturbance, major depressive disorder and anxiety disorder. Review of Resident #07's Minimum Data Set (MDS) dated [DATE] revealed the resident required supervision for bed mobility and transfer. The resident required extensive one-person assistance for dressing, personal hygiene and toileting. The resident was independent with eating. Resident #07's had no identified behaviors. Review of Resident #07's plan of care dated 09/05/19 revealed no focus or interventions related to inappropriate sexual behaviors or the medication Medroxyprogesterone (Provera). Review of Resident #07's physician order…

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.