Continuing Healthcare Of Gahanna

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident medical record review, review of medication regimen reviews, interview, and review of facility policy, the facility failed to complete medication regimen reviews (MRR). This affected four residents (Resident #02, #03, #93, and #99) out of five reviewed for unnecessary medication. The facility census was 91.Findings include: 1. Review of the medical record for Resident #93 revealed an admission date of 03/01/24 with diagnoses of, but not limited to, bipolar disorder, heart failure, and major depressive disorder. Review of Minimum Data Set (MDS) 3.0 dated 03/02/26 reveled Resident #93 had a Brief Interview of Mental Status (BIMS) score of 12 indicative of cognitive impairment. Review of the MRR's provided by the facility revealed no MRRs for April, May, July, and August of 2025 for Resident #93. 2. Review of the medical record for Resident #99 revealed an admission date of 06/29/23 with diagnoses of, but not limited to, epilepsy, major depressive disorder, and unspecified systolic heart failure.…

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 resident medical record, physician orders, medication administration record, interview, and policy review, the facility failed to follow physician orders for blood pressure medication. This affected one resident (Resident #93) of five reviewed for unnecessary medications. The facility census was 91.Findings include:Review of the medical record for Resident #93 revealed an admission date of 03/01/24 with diagnoses of, but not limited to hypertension, heart failure, and chronic atrial fibrillation.Review of Minimum Data Set (MDS) 3.0 dated 03/02/26 reveled Resident #93 had a Brief Interview of Mental Status (BIMS) score of 12 indicative of a moderate cognitive impairment.Review of the physician orders for Resident #93 revealed an order for metoprolol tartrate oral tablet 50 milligrams (MG) give one tablet by mouth two times a day for hypertension, with parameters to hold for a systolic blood pressure under 110 or heart rate under 60.Review of the Medication Administration Record (MAR) for January 2026 revealed the medication was administered during the following…

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, interviews and facility policy review, the facility failed to honor one resident's preference of no male caregivers. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's medical record revealed no plan of care addressing the resident's preference of no male caregivers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 10:48 A.M., an observation…

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, interview and facility policy review, the facility failed to ensure one resident's bed was bariatric in size. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 9:00 A.M., observation of Resident #17 revealed the resident was obese and was too large for the standard bed she occupied. Interview with the resident at the time of the observation revealed she had asked for a larger bed, however the room was not large enough. On 08/20/25 at 1:05 P.M., an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to notify the power of attorney (POA) of a change in condition. This affected one resident (#43) of three residents reviewed for notification. The facility census was 83. Findings Include:Review of the medical record for Resident #43 revealed an initial admission date of 07/21/23 with the latest readmission of 03/21/24 with diagnoses including human immunodeficiency virus (HIV), psoriasis, protein calorie malnutrition, dysphagia, seizures, gastro-esophageal reflux disease, asthma, major depressive disorder and anxiety disorder. Review of the plan of care dated 02/15/24 revealed the resident had a seizure disorder. Interventions included give medications as ordered, monitor/document for effectiveness and side effects, give seizure medication as ordered by doctor, monitor/document side effects and effectiveness, obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated, post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to report an allegation of abuse to the required state agency. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/20/25 at 9:00 A.M., an interview with Resident #17 revealed Licensed Practical Nurse (LPN) #116 had abused her. She revealed the LPN entered her room to apply cream to her legs and she told him she did not like men touching her and preferred female caregivers. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to investigate an allegation of abuse. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83.Findings include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment.On 08/20/25 at 9:00 A.M., an interview with Resident #17 revealed Licensed Practical Nurse (LPN) #116 had abused her. She revealed the LPN entered her room to apply cream to her legs and she told him she did not like men touching her and preferred female caregivers. The resident revealed the LPN…

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 interviews, the facility failed to identify, assess and implement care and services to prevent triggers of past trauma. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's initial social service assessment dated [DATE] revealed the resident had no Trauma Informed Care Triggers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. The resident also reported having medical conditions that had caused trauma her life like a brain aneurysm. The assessment indicated the resident reported 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 and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. The resident also reported having medical conditions that had caused trauma her life like a brain aneurysm. The assessment indicated the resident reported the development of emotional and behavioral symptoms in response to an identifiable stressor…

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, interview and facility policy review, the facility failed to ensure medications were administered as physician ordered. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83.Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the plan of care dated 10/24/24 revealed the resident had hypertension. Interventions included to administer hypertensive medications as ordered, monitor for side effects and effectiveness, obtain blood pressure readings every shift and as needed and take the blood pressure under the same condition each time. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and facility policy review, the facility failed to ensure medications were not left at bedside during medication administration. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83.Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 10:48 A.M., observation of Licensed Practical Nurse (LPN) #202 administer Resident #17's morning medications revealed the LPN removed a clear plastic cup from the top drawer of the cart with Resident #17's name written on the side. The plastic cup had one small…

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 interview, review of the facilities Self-Reported Incidents (SRI) and review of the facility abuse policy, the facility failed to timely report an allegation of staff-to-resident physical abuse to the State Survey Agency, Ohio Department of Health. This affected one (Resident #88) out of three residents reviewed for abuse. The facility census was 87.Review of the closed medical record for Resident #88 revealed an admission date of 12/31/24 and a discharge date of 06/19/25. Diagnoses included chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/19/25, revealed Resident #88 had minimal cognitive impairment. Review of the hospital documentation dated 06/19/25 revealed Resident #88 was sent out from the facility regarding a fall with injuries. While at the hospital, Resident #88 reported he was forced out of his chair by facility staff and this was the reason he fell. Resident #88 was documented as having two rib fractures, a right humerus…

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 facilities abuse policy, the facility failed to investigate an allegation of staff-to-resident physical abuse. This affected one (Resident #88) of three residents reviewed for abuse. The facility census was 87.Review of the closed medical record for Resident #88 revealed an admission date of 12/31/24 and a discharge date of 06/19/25. Diagnoses included chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had minimal cognitive impairment. The resident was assessed as having one fall with major injury, and required supervision or touching assistance from staff with toileting, bathing and the used of a wheeled walker for ambulation. Review of the hospital documentation from 06/19/25 revealed Resident #88 was sent out from the facility regarding a fall with injuries. While at the hospital, Resident #88 reported he had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's falls in the facility. This affected two (#91 and #99) out of the six residents reviewed for falls. The facility census was 87.1. Closed record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included muscle wasting and history of falling. Record review for Resident #99 revealed the resident had a fall on 06/18/25 in which he scraped his elbow, had a fall on 06/22/25 in which he sustained an abrasion to the left side of his nose, and had a fall on 06/24/25 which resulted in two fractures of the lumbar spine, a closed head injury, a hematoma to the left thigh, and a laceration to the right side of his eye. Additionally, the resident had a fall on 06/26/25 and was admitted to the hospital with acute blood loss anemia. Review of the discharge Minimum Data Set (MDS) assessment, dated 06/26/25, 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 reviews and staff interviews, the facility failed to ensure new interventions to prevent falls were added to the care plan timely. This affected one (#99) of six residents whose care plans were reviewed for falls. The facility census was 87.Closed record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included difficulty walking and history of falling. The resident was discharged from the facility on 06/26/25. Review of the comprehensive care plan, dated 06/06/25, revealed Resident #99 was at risk for falls and injuries as evidenced by history of, may not always recognize own needs or limitations, metabolic encephalopathy, Parkinson’s disease, cognitive deficits, and history of amnesia. The goal was for Resident #99 to be free from falls/injuries over the next 90 days. The interventions did not change from the baseline care plan. Interventions dated 06/06/25 included to anticipate needs – provide prompt assistance, ensure lighting 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 4. Record review of Resident #11 revealed an admission date with 04/13/22 with pertinent diagnoses of: cerebral palsy, hemiplegia, protein calorie malnutrition, neuromuscular dysfunction of the bladder, hypertension, convulsions, mood disorder, depression, benign paroxysmal vertigo, schizoaffective disorder, anxiety disorder, and calculus of kidney. Review of the 01/19/25 annual Minimum Data Set (MDS) assessment revealed the Resident was cognitively intact and used a walker and wheelchair to aid in mobility. The Resident required supervision or touching assistance for personal hygiene. Review of the medical record revealed Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical records revealed on 12/09/24 Resident #11 discharged to the hospital for a nephrostomy tube removal and returned 12/12/24. Review of the Bed Hold Notice dated 12/10/24 revealed Resident #11's bed was to be held at no cost to them for up to 30 days if they went to the hospital per…

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 5. Record review of Resident #74 revealed an admission date of 10/11/24 with pertinent diagnosis of: traumatic brain injury, dysarthria following cerebral infarction, type two diabetes mellitus, seizures, post traumatic stress disorder, history of falling, presence of cerebrospinal fluid drainage device, gastro-esophageal reflux disease, dementia without behaviors, noninfective gastroenteritis, anxiety disorder, and major depressive disorder. Review of the 01/16/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired and used a wheelchair to aid in mobility. The Resident had a coded diagnosis of post traumatic stress disorder. Review of the 12/17/24 Notice of Level II PASSR outcome revealed Resident #74 is approved for six months in the Nursing facility and is required services to include: A behavior management safety plan to decrease inappropriate behaviors and ensure safety. Ongoing evaluation of the effectiveness of current psychotropic medications on target…

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 4. Record review of Resident #63 revealed an admission date of 06/29/23 with pertinent diagnoses of: hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, epilepsy, human immunodeficiency virus, unspecified asthma, muscle wasting and atrophy, abnormalities of gait and mobility, anemia, autoimmune hepatitis, low back pain, congestive heart failure, and personal history of sudden cardiac arrest. Review of the 01/03/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and uses a wheelchair to aid in mobility. Review of the 01/31/25 smoking assessment revealed that staff will store Resident #63 smoking materials. Observation on 03/03/25 at 1:33 P.M. revealed Resident #63 had a lighter in her room. Interview with the Director of Nursing (DON) on 03/06/25 at 2:33 P.M. revealed she did the smoking assessment and the resident should not have cigarettes or smoking supplies in her room. That way she does not smoke in her room. Observation 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 4. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses that included heart failure, chronic respiratory failure, type II diabetes, anxiety disorder, major depressive disorder, bipolar disorder, and mood disorder. The quarterly MDS dated [DATE] revealed Resident #30 was cognitively intact. The MDS also revealed Resident #30 had a mood score of 10 which typically indicated a moderate level of depression. Resident #30 had no delusions during the assessment time period. Review of the pharmacy monthly reviews from June 2024 through February 2025 revealed no documentation if Resident #30 had any recommendations. A recommendation dated 06/12/24 was provided that revealed Resident #30 was ordered Invega Sustenna (antipsychotic) one milliliter intramuscularly every 28 days for bipolar. The recommendation revealed a supportive diagnosis including target behaviors that were continuously occurring needed to be in the order. On 06/12/24 the physician added the diagnosis of bipolar…

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

Based on observation, interview, and review of facility policy the facility failed to ensure foods that did not meet hot holding temperature were reheated. This had the potential to affect 79 of 79 residents who consumed food from the kitchen. The facility identified two residents (#69 and #80) who consumed nothing from the kitchen. The facility census was 81. Findings include: Observation on 03/05/25 beginning at 11:00 A.M. of the lunch meal revealed [NAME] #196 taking the temperature of food on the hot holding unit. The ground chicken for residents on a mechanical soft diet was 122 degrees Fahrenheit (F) and the gravy was 102 degrees F. [NAME] #196 noted that these items needed heated back up, but began tray line anyway. [NAME] #196 noted the gravy was for residents who did not like sweet potatoes and received mashed potatoes instead. At the end of meal service [NAME] #196 verified she had not reheated the food items. Interview on 03/05/25 at 12:40 P.M. with Dietary Manager #115 revealed he expected foods on the steamtable to be 160 degrees F, and if they did not reach that…

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

Based on interview and review of documents the facility failed to ensure the arbitration agreement allowed the resident/responsible party to communicate with federal, state, or local officials . This had the potential to affect 23 residents (#2, #6, #8, #17, #26, #40, #45, #49, #72, #76, #78, #80, #82, #83, #84, #188, #189, #190, #191, #192, #193, #194, #196) who had admitted since 08/01/24. The total facility census was 81. Findings include: Review of the 'Voluntary Arbitration Agreement' undated, revealed it did not address the resident/responsible party's right to communicate with federal, state, or local officials. Interview on 03/10/25 at 10:04 A.M. and 12:42 P.M. with the Administrator revealed he was unable to find evidence the arbitration agreement allowed for communication with officials. Interview on 03/10/25 at 12:42 P.M. with the Administrator revealed the current company took over in August 2024, and all residents admitted since then had signed the arbitration agreement.

Based on interview and review of documents the facility failed to ensure the arbitration agreement allowed for a convenient venue and neutral arbitrator. This had the potential to affect 23 residents (#2, #6, #8, #17, #26, #40, #45, #49, #72, #76, #78, #80, #82, #83, #84, #188, #189, #190, #191, #192, #193, #194, #196) who had admitted since 08/01/24. The total facility census was 81. Findings include: Review of the 'Voluntary Arbitration Agreement' undated, revealed it did not address the venue for arbitration. It additionally did not allow for a neutral arbitrator. It indicated the arbitration would be administered by the American Arbitrators Associations (AAA). If the AAA does not enforce pre-dispute arbitration agreements than any other reasonably comparable arbitration association would be chosen by the facility. Interview on 03/10/25 at 10:04 A.M. and 12:42 P.M. with the Administrator revealed he was unable to find evidence the arbitration agreement allowed for a convenient venue or neutral arbitrator. Interview on 03/10/25 at 12:42 P.M. with the Administrator revealed the…

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

Based on observation, interview, and review of resident medical records, the facility failed to ensure Resident #192's dignity was maintained when his catheter bag was uncovered. This affected one Resident #192 of one resident reviewed for catheters. The facility census was 81. Findings include: Observation on 03/05/25 at 12:30 P.M. and 12:48 P.M. revealed Resident #192 sitting in the common area with other residents. His catheter bag was observed uncovered and with urine observed in the bag. Interview on 03/05/25 at 12:48 P.M. with the Director of Nursing (DON) verified the catheter bag was uncovered. Interview on 03/10/25 at 12:25 P.M. with the Administrator revealed an uncovered catheter bag was a dignity issue. Review of Resident #192's medical record revealed an admission date of 02/16/25 with diagnoses including metabolic encephalopathy, type two diabetes mellitus, severe protein-calorie malnutrition, cognitive communication deficit, dysphagia, aphasia, contracture of right knee, psychosis, and heart failure. Review of Resident #192's comprehensive Minimum Data Set (MDS) 3.0…

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 interview, and facility policy the facility failed to ensure that Resident #84 and #8 had appropriate diagnoses for the psychotropic medications they were prescribed. This affected two (Resident's #84 and #8 ) out of three residents reviewed for psychotropic medications. The facility census was 83. Findings include: 1.Review of the medical record for Resident #84 revealed an admission date of 08/04/25 with diagnoses including Malignant neoplasm of unspecified part of unspecified bronchus or lung, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus without complications, transient cerebral ischemic attack unspecified, essential primary hypertension, hyperlipidemia unspecified, other nonspecific abnormal finding of lung field, anemia unspecified, fecal impaction, type 2 diabetes mellitus with hyperglycemia, and acute kidney failure unspecified. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #84 revealed a brief interview for mental status (BIMS) score of 06 out of 15 indicating severe cognitive impairment. 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 interview and record review the facility failed to ensure Resident #85's discharge from the facility was appropriately documented. This affected one Resident #85 of five residents reviewed for hospitalization. The facility census was 81. Findings include: Review of Resident #85's medical record revealed an admission date of 01/27/25 and a discharge date of 01/28/25 diagnoses included metabolic encephalopathy, heart failure, severe protein-calorie malnutrition, type two diabetes mellitus, and chronic kidney disease. Review of Resident #85's progress note dated 01/27/25 revealed the resident admitted to the facility around 5:30 P.M. Review of Resident #85's progress note dated 01/28/25 at 11:14 A.M. revealed the resident was not administered medication because she was in the hospital. Review of Resident #85's medical record revealed no further documentation related to her discharge. Interview on 03/05/25 at 12:40 P.M. and on 03/06/25 at 11:10 A.M. with the Director of Nursing (DON) verified there was no documentation related to the resident's transfer to the hospital. She…

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 review of the medical record and interview with the staff the facility failed to ensure a Significant Change assessment was completed for Resident #42 after initiating hospice services. This affected one resident (Resident #42) of 24 residents reviewed for comprehensive assessments. Facility census was 81. Findings include: Review of the medical record revealed Resident #42 was admitted on [DATE], readmitted on [DATE] and expired on [DATE]. Resident #42 had diagnoses that included lumbar degeneration, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver, anxiety, chronic viral hepatitis C, seizures, and psychosis. Review of physician order dated [DATE] revealed Resident #42 was admitted to hospice. Further review of the medical record revealed there was no evidence of a Significant Change Minimum Data Set (MDS) assessment completed within 14-days of receiving hospice services for Resident #42. The annual MDS dated [DATE] revealed Resident #42 had cognitive impairment. Section J1400 of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure Resident #69 and Resident #192 had accurate Minimum Data Set (MDS) 3.0 assessments. This affected two Residents #69 and #192 of 24 medical records reviewed. The facility census was 81. Findings include: 1. Review of Resident #192's medical record revealed an admission date of 02/16/25 with diagnoses including metabolic encephalopathy, type two diabetes mellitus, severe protein-calorie malnutrition, cognitive communication deficit, dysphagia, aphasia, contracture of right knee, psychosis, and heart failure. Review of Resident #192's social service assessment dated [DATE] revealed the resident had a severe cognitive impairment but had been able to answer some questions for the brief interview of mental status (BIMS). Review of Resident #192's comprehensive MDS 3.0 dated 02/20/25 revealed he was in a persistent vegetative state (PVS) or had no discernible consciousness. Review of the Long Term Care Facility Resident Assessment Instrument 3.0…

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 and record review the facility failed to incorporate the recommendations of the pre-admission screening and resident review (PASRR) level II determination into the assessment, care planning, and transitions of care. This affected one, Resident #74, of two Residents reviewed for PASRR. The facility census was 81. Findings include: Record review of Resident #74 revealed an admission date of 10/11/24 with pertinent diagnoses of: traumatic brain injury, dysarthria following cerebral infarction, type two diabetes mellitus, seizures, post-traumatic stress disorder, history of falling, presence of cerebrospinal fluid drainage device, gastro-esophageal reflux disease, dementia without behaviors, noninfective gastroenteritis, anxiety disorder, and major depressive disorder. Review of the 01/16/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired and used a wheelchair to aid in mobility. The Resident had a coded diagnosis of post-traumatic stress disorder. Review of the 12/17/24 Notice of Level II PASRR outcome…

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 and record review the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents were accurate regarding resident current conditions and diagnoses. This affected one, Resident #11, of two residents reviewed for PASRR documents. The census was 81. Findings Include: Record review of Resident #11 revealed an admission date with 04/13/22 with pertinent diagnoses of: cerebral palsy, hemiplegia, hydronephrosis, protein calorie malnutrition, neuromuscular dysfunction of the bladder, hypertension, convulsions, mood disorder, depression, benign paroxysmal vertigo, schizoaffective disorder, anxiety disorder, and calculus of kidney. Review of the 01/19/25 annual Minimum Data Set (MDS) assessment revealed Resident #11 was cognitively intact and used a walker and wheelchair to aid in mobility. The Resident required supervision or touching assistance for personal hygiene. Review of the 05/11/22 Preadmission Screening and Resident Review identification screen (PASRR) revealed the Resident had documented diagnosis of only mood disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an accurate baseline care plan was developed and implemented within 48 hours of admission. This affected one, Resident #88, out of six residents reviewed for baseline care plans. Facility census was 81. Findings include: Review of the medical record revealed Resident #88 was admitted on [DATE] and discharged on 01/31/25 with diagnoses that included encounter for surgical aftercare, type II diabetes, Crohn's disease, severe protein-calorie malnutrition, major depressive disorder, chronic kidney disease, colostomy, malignant neoplasm of colon, and psychosis. Review of the admission assessment dated [DATE] revealed Resident #88 was alert and oriented, had a colostomy incision and bag and a percutaneous endoscopic gastrostomy (PEG) tube. Review of the baseline care plan dated 01/28/25 revealed Resident #88 was incontinent of bowel and bladder and required supervision/touch assistance for toileting hygiene. The PEG tube was the only thing marked 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 2. Review of Resident #68's medical record revealed an admission date of 02/25/24 and diagnoses including cerebral infarction, apraxia, seizures, heart failure, anxiety disorder, hypertension, end stage renal disease with dependence on renal dialysis, coagulation defect, aphasia, muscle wasting and atrophy, altered mental status, and other lack of coordination. Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #68's medical record revealed she had two care conferences on 02/26/24 and 09/10/24. Interview on 03/03/25 at 4:42 P.M. with Resident #68's responsible party revealed care conferences were far in between. Interview on 03/03/25 at 9:13 A.M. and 9:43 A.M. with Social Work Director #211 verified Resident #68 had only had two care conferences since admission, and they were supposed to occur quarterly. Review of the policy 'care plan meeting' dated June 2024 revealed care plans were to be scheduled on 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 record review, policy review, hospital record review, and interview, the facility failed to develop and implement a comprehensive, resident centered wound management program for Resident #45 who sustained an injury/area of non-pressure related skin impairment to the right lower leg. This affected one (#45) of two reviewed for skin impairments. The total facility census was 81. Findings include: 1. Review of the medical record revealed Resident #45 was admitted on [DATE] and readmitted [DATE] with diagnoses that included prepatellar bursitis of the left knee, cellulitis of the right lower limb, cerebral infarction, dependence on renal dialysis, end stage renal disease, and type II diabetes. The quarterly Minimum Data Set (MDS) Assessment, dated 01/05/25, revealed Resident #45 was cognitively intact and used a wheelchair. The resident did not receive scheduled pain medication but did receive as needed pain medication for occasional pain rated a four out of ten pain rating (on a 0-10 pain scale with zero…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure Residents #68 and #69 who had splints or braces had orders for the device and orders for monitoring for their use. This affected two residents (#68 and #69) of three residents reviewed for positioning and mobility. The facility census was 81. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 10/05/23 with diagnoses including anoxic brain damage, respiratory failure, protein-calorie malnutrition, persistent vegetative state, gastro-esophageal reflux disease, gastrostomy, tracheostomy, aphasia, and contractures to right and left knee. Review of Resident #69's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had an upper extremity impairment on both sides. Review of Resident #69's occupational therapies Discharge summary dated [DATE] revealed a discharge recommendations of splinting as tolerated to both elbows and hands. Review of Resident #69's plan of care…

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

Based on observation, interview, and medical record review, the facility failed to ensure Resident #192 had orders for an indwelling catheter. This affected one resident (#192) of three residents with an indwelling catheter. The facility census was 81. Findings include: Review of Resident #192's medical record revealed an admission date of 02/16/25 with diagnoses including metabolic encephalopathy, type two diabetes mellitus, severe protein-calorie malnutrition, cognitive communication deficit, dysphagia, aphasia, contracture of right knee, psychosis, and heart failure. Review of Resident #192's comprehensive Minimum Data Set (MDS) 3.0 dated 02/20/25 revealed he had an indwelling catheter. Review of Resident #192's physician orders revealed he had no orders for an indwelling catheter or for catheter care. Observation on 03/03/25 at 10:15 A.M. revealed Resident #192 had a catheter bag hanging from his bed. Interview on 03/05/25 at 2:50 P.M. with the Director of Nursing (DON) verified Resident #192 had a catheter in place but had no orders or documentation for care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure Resident #68's fluid restriction was followed, and her noncompliance was documented in the medical record. This affected one resident (#68) of two residents on dialysis. The facility census was 81. Findings include: Review of Resident #68's medical record revealed an admission date of 02/25/24 and diagnoses including cerebral infarction, apraxia, seizures, heart failure, anxiety disorder, hypertension, end stage renal disease with dependence on renal dialysis, coagulation defect, aphasia, muscle wasting and atrophy, altered mental status, and other lack of coordination. Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #68's active physician order started 09/08/24 revealed an order for Nepro (a renal liquid supplement) 240 milliliters (ml) three times a day. Review of Resident #68's active physician order dated 10/15/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure Resident #69's tube feeding was running at the ordered rate. This affected one resident (#69) of one resident reviewed for tube feeding. The facility census was 81. Findings include: Review of Resident #69's medical record revealed an admission date of 10/05/23 with diagnoses including anoxic brain damage, respiratory failure, protein-calorie malnutrition, persistent vegetative state, gastro-esophageal reflux disease, gastrostomy, tracheostomy, aphasia, and contractures to right and left knee. Review of Resident #69's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was receiving tube feeding that provided 51% or more of calories and 501 milliliters (ml) per day. Review of Resident #69's plan of care dated 10/10/23 revealed the resident required tube feeding via a gastrostomy tube related to dysphagia. Interventions included listening to lungs, elevating the head of bed 45 degrees, monitoring as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer oxygen to Resident #30 as ordered. This affected one (Resident #30) out of one resident reviewed of oxygen use. Facility census was 81. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses that included heart failure, chronic respiratory failure, type II diabetes, anxiety disorder, major depressive disorder, bipolar disorder, and mood disorder. Review of physician order dated 11/01/24 revealed Resident #30 was ordered oxygen at two liters continuously. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Review of the March medication administration record revealed Resident #30 was administered oxygen at two liters continuously. Observations on 03/03/25 at 8:39 A.M., 03/04/25 at 11:13 A.M., and 03/06/25 at 9:53 A.M. revealed Resident #30 had a nasal cannula in place and oxygen was being administered at four liters. Interview on 03/06/25 at 11:05…

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.

Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one (Resident #74) of three Residents reviewed for behavior emotional. The facility census was 81. Findings include: Record review of Resident #74 revealed an admission date of 10/11/24 with pertinent diagnosis of: traumatic brain injury, dysarthria following cerebral infarction, type two diabetes mellitus, seizures, post traumatic stress disorder, history of falling, presence of cerebrospinal fluid drainage device, gastro-esophageal reflux disease, dementia without behaviors, noninfective gastroenteritis, anxiety disorder, and major depressive disorder. Review of the 01/16/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired and used a wheelchair to aid in mobility. The Resident had a coded diagnosis of post traumatic stress disorder. Interview with Resident #74's family 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 staff interview and record review the facility failed to ensure a resident with dementia received appropriate treatment and services to maintain his of highest practical physical, mental, and psychosocial well being when they failed to have a plan of care to address the resident's dementia needs and services. This affected one (Resident #74) of one reviewed for dementia care. The facility census was 81. Findings include: Record review of Resident #74 revealed an admission date of 10/11/24 with pertinent diagnoses of: traumatic brain injury, dysarthria following cerebral infarction, type two diabetes mellitus, seizures, post traumatic stress disorder, history of falling, presence of cerebrospinal fluid drainage device, gastro-esophageal reflux disease, dementia without behaviors, noninfective gastroenteritis, anxiety disorder, and major depressive disorder. Review of the 01/16/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired and used a wheelchair to aid in mobility. The Resident had a coded diagnosis of dementia.…

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 and facility staff interview and policy review the facility failed to ensure failed to ensure Resident #16 and #82 received medications as ordered. This affected two resident (Resident #16 and #82) of five reviewed for un necessary medications. The total facility census was 81. Findings Include: 1. Review of the medical record revealed Resident #16 was admitted on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, altered mental status, peripheral vascular disease, hypertension, major depressive disorder, history of transient ischemic attack, and anxiety disorder. The annual MDS dated [DATE] revealed Resident #16 was cognitively intact. Resident #16 had impairment to both lower extremities (amputation) and used a wheelchair. Resident #16 required supervision/touch assistance for rolling and transfers. Resident #16 was always incontinent of bowel and bladder. Review of current physician orders 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 and interview, the facility failed to ensure Resident #45 and #66 had parameters in place for as needed pain medication. The facility also failed to document the location of the pain and the non-pharmacological interventions that were attempted. This affected two (Resident #45 and #66) out of five residents reviewed for unnecessary medications. Facility census was 81. Findings include: 1. Review of the medical record revealed Resident #45 was admitted [DATE] and readmitted [DATE] with diagnoses that included prepatellar bursitis left knee, cellulitis of right lower limb, cerebral infarction, dependence on renal dialysis, end stage renal disease, and type II diabetes. Review of physician orders revealed on 01/02/25 Resident #45 was ordered Oxycodone (opioid for moderate to severe pain) five milligrams (mg) every eight hours as needed for pain. No pain scale parameters were included in the order. Review of the medication administration record (MAR) revealed Resident #45 was administered…

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 interview and record review the facility failed to ensure Resident #82 had appropriate diagnoses for the psychotropic medications he was prescribed. This affected one resident (#82) of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Review of Resident #82's medical record revealed an admission date of 01/14/25 with diagnoses including metabolic encephalopathy, chronic respiratory failure, protein-calorie malnutrition, cognitive communication deficit, dysphagia, anxiety disorder, heart failure, and other psychoactive substance dependence. Review of Resident #82's Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Review of Resident #82's physician order dated 03/02/25 revealed an order for Valproic acid (anticonvulsant that can also be used for bipolar disorder) solution 250 milligrams (mg) twice a day for anxiety. Review of Resident #82's physician order dated 03/02/25 revealed an order 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 staff interview and record review the facility failed to ensure resident laboratory tests (lab/labs) were completed as ordered. This affected two (Resident #63 and #82) of six resident reviewed for lab values. The facility census was 81. Findings include: 1. Record review of Resident #63 revealed an admission date of 06/29/23 with pertinent diagnoses of: hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, epilepsy, human immunodeficiency virus (HIV), unspecified asthma, muscle wasting and atrophy, abnormalities of gait and mobility, anemia, autoimmune hepatitis, low back pain, congestive heart failure, and personal history of sudden cardiac arrest. Review of the 01/03/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was cognitively intact and used a wheelchair to aid in mobility. Review of a physician order dated 02/04/25 revealed to draw a complete blood count, complete metabolic panel, human immunodeficiency virus (HIV) viral load, and a lipid…

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

Based on observation, interview, and review of the menu, the facility failed to ensure Resident #194 and Resident #196 received food according to the planned menu. This affected two residents (#194 and #196) of 79 residents who consumed food from the kitchen. The facility identified two residents (#69 and #80) who consumed nothing from the kitchen. The facility census was 81. Findings include: Review of Resident #196's medical record revealed an admission date of 02/05/25 with diagnoses including metabolic encephalopathy, protein-calorie malnutrition, chronic respiratory failure, dysphagia, hypertension, chronic kidney disease stage four, and heart failure. Review of Resident #196's physician order dated 03/09/25 revealed an order for mechanical soft diet. Review of Resident #194's medical record revealed an admission date of 02/27/25 with diagnoses including type two diabetes mellitus, dysphagia, dementia, chronic kidney disease, and protein calorie malnutrition. Review of Resident #194's physician order dated 03/07/25 revealed she was on a mechanical soft and no added salt diet.…

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, interview, and policy review, the facility failed to ensure resident discharge needs were met. This affected two residents (#22 and #33) of four residents reviewed for discharge planning. The facility census was 83. Findings include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, and unspecified injury of head. Resident #22 was discharged from the facility on 12/19/24 to home. Review of a care plan dated 11/04/24 revealed no evidence of discharge goals for Resident #22. Review of a minimum data set (MDS) dated [DATE] revealed Resident #22's cognition remained intact. Review of an order dated 12/18/24 revealed Resident #22 was to discharge home with his family on 12/19/24 with physical therapy, occupational therapy, and skilled services. Review of a Discharge Summary and Instructions assessment dated [DATE] revealed Resident #22 would receive home health services…

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, hospital record review, staff interview, and facility policy review, this facility failed to ensure appropriate care and monitoring was in place for a resident who was receiving medication for high blood pressure including the administration of blood pressure medication, personalized care plan for management of hypertension, and monitoring residents blood pressure to ensure the effectiveness of medication. This affected one (Resident #85) of the four residents reviewed for medication administration. The facility census was 79. Findings include: Review of the medical record for Resident #85 revealed an admission date of 11/01/2023. Diagnoses included alcohol abuse, dysphasia, hypertension, hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain usually caused by high blood pressure and trauma), and lack of coordination. Review of the Social Services Initial assessment dated [DATE] revealed a Brief Interview for Mental Status…

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 physicians orders were followed in regard to laboratory (Lab) test. This affected two (Resident #57 and Resident #73) of four resident records reviewed. The census was 72. Findings included: 1. Review of Resident #73's medical record revealed he was admitted tot he facility on 08/02/24 and discharged [DATE]. Diagnoses included Acute pancreatic, myelodysplastic syndrome, diabetes, , high blood pressure kidney failure, paroxysmal atrial fibrillation, herpesviral infection and protein calorie malnutrition. Review of the discharge minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required partial to moderate assistance with sitting to stand, chair to bed to chair, toilet transfer and shower and tub transfer. Review of the physicians orders dated 08/02/24 revealed basic metabolic profile (BMP) and liver function test (LFT) every day shift every Monday for Chronic Anemia and complete metabolic profile…

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, policy review, and staff interview, the facility failed to properly store food items in a safe and sanitary manner. This had the potential to affect 76 of 76 residents who eat food from the kitchen. The facility census was 78. Findings include: Observation of the refrigerator in the kitchen and interview with Dietary Manager #192 on 08/05/24 at 9:30 A.M. revealed multiple items not labeled or dated and expired items. Items identified as undated and/or unlabeled included a container of sweet and sour sauce that was three-fourths full, a container of salad dressing confirmed by Dietary Manager #192 to be poppy seed dressing, a half full milk gallon, and a three-fourths full milk gallon. The following items were expired in the refrigerator: a container of ranch dressing with a use by date of 07/18/24, a container of peanut butter and jelly with a use by date of 08/03/24, and a container of sour cream with a use by date of 07/29/24. Further observation of the kitchen revealed an ice scoop sitting in the ice in the ice machine and three individual ice cream cups 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review, and staff and resident interviews, the facility failed to provide timely assistance with eating for residents who required assistance from staff with activities of daily living. This affected two (Residents #3 and #17) of three residents reviewed for eating assistance. The facility census was 78. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 01/18/18. Diagnoses included blindness in right eye and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had severe cognitive impairment and required maximum assistance from staff with eating. Review of the care plan dated 05/27/24 revealed Resident #17 was at risk for malnutrition related to vitamin D deficiency and visual impairment. An intervention included assistance with meals. Review of the facility's list of residents who required assistance with eating revealed Residents #17 was on the list. Observation on 08/05/24 at…

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

Based on nurse aide registry review, time punch detail review and staff interview, the facility failed to ensure one State Tested Nursing Assistant (STNA) nurse aide registry was in good standing. This affected one out of three personnel files reviewed and had the potential to affect all 83 residents residing in the facility. Findings Include: Review of the nurse aide registry for STNA #130 dated 02/07/24 revealed the STNA was not in good standing and was not eligible to work. Further review revealed STNA #130 had not changed her name on the nurse aide registry following a name change. Review of STNA #130's time punch card from 01/21/24 to 02/05/24 revealed the STNA was hired on 02/02/23. Further review revealed STNA #130 worked full time and last worked on 02/05/24 with the registry not in good standing and not eligible to work. On 02/07/24 at 2:32 P.M., interview with the Human Resource Director (HRD) verified STNA #130's nurse aide registry was not in good standing and she was not eligible to work. The HRD verified STNA #130 was employed full time and had been working when 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 observation, record review and interview, the facility failed to ensure Minimum Data Assessments (MDS) were coded accurately in the area of skin for two residents (#79 and #80). This affected two (Resident #79 and #80) of four sampled residents. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #80 revealed an initial admission date of 01/11/24 with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, arteriovenous malformation of cerebral vessels, cerebral infarct, adult failure to thrive, dysphagia, hypertension, abdominal aortic aneurysm, hyperlipidemia, peripheral vascular disease and disorder of thyroid. The resident discharged home on [DATE] with hospice services. Review of the resident's nursing admit/readmit care plan dated 01/11/24 revealed the resident was admitted from the local acute care hospital with pneumonia. The assessment indicated the resident was admitted to the facility with pressure to the sacrum, coccyx, 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 observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for residents in the area of skin and eating. This affected two (Resident #33 and #73) of four sampled residents. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the nursing admit/readmit care plan dated 09/21/23 revealed the resident was admitted to the facility with no skin issues. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to identify, assess, monitor and implement interventions for Resident #33 who had multiple stasis ulcers. This affected one (Resident #33) of three residents reviewed for wounds. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the nursing admit/readmit no care plan dated 09/21/23 revealed the resident was admitted to the facility with no skin issues. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews and facility policy review, the facility failed to ensure an initial comprehensive wound assessment and subsequent wound assessments were conducted as required for one resident (#79) with a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.). This affected one ( Resident #79) of three residents reviewed for wounds. The facility census was 83. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 10/05/23 with the diagnoses including anoxic brain damage, respiratory failure, disorder of the autoimmune nervous system, nondisplaced posterior arch fracture of first cervical vertebra, fracture of shaft of right fibula, fracture of shaft of left tibia, gastrostomy and tracheostomy. Review of the resident's Braden scale dated 10/05/23 revealed a score of eight indicating the 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 observation, record review and interview, the facility failed to ensure one resident (#33) received routine podiatry care. This affected one (Resident #33) of three reviewed for podiatry care. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had one venous ulcer. Review of the medical record revealed no documented evidence the resident had received podiatry care…

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, interviews and facility policy review, the facility failed to ensure one resident (#73) was not provided food inconsistent with the physician ordered diet. This affected one of thee sampled residents reviewed for special diets. The facility census was 83. Findings Include: Review of the medical record for Resident #73 revealed an initial admission date of 07/21/23 with the latest readmission of 09/22/23 with the diagnoses including encephalopathy, human immunodeficiency virus (HIV), decreased white blood cell count, generalized muscle weakness, cognitive communication deficit, dysphagia, asthma and muscle wasting and atrophy. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the monthly physician orders for February 2024 identified orders dated 12/28/23 regular pureed diet with special instructions for one on one supervision/assistance from caregivers/staff. Review of the resident's plan 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 observation, record review and staff interview, the facility failed to maintain infection control practices to prevent the potential spread of infection during wound dressing change for one resident (#33). This affected one ( Resident #33) of three residents reviewed for wounds. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the resident's admit/readmit plan of care dated 12/21/23 revealed the resident was readmitted to the facility with a vascular wound to the left lower rear leg and left lower front leg. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews and facility policy review, the facility failed to ensure one resident's (#73) call light was in working order. This affected one ( Resident #73) of three residents reviewed for call lights. The facility census was 83. Findings Include: Review of the medical record for Resident #73 revealed an initial admission date of 07/21/23 with the latest readmission of 09/22/23 with the diagnoses including encephalopathy, human immunodeficiency virus (HIV), decreased white blood cell count, generalized muscle weakness, cognitive communication deficit, dysphagia, asthma and muscle wasting and atrophy. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. On 02/07/24 at 4:12 P.M., observation of Resident #73's call light system revealed the emergency light was activated in the bathroom and the call light was not activated outside of the room. Further observation revealed the resident utilized a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy review, the facility failed to ensure the sit to stand lift was maintained in a sanitary manner for one resident (#33). This affected one ( Resident #33) of one resident who utilized the facility's sit to stand lift on the first floor. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the resident's plan of care dated 09/27/23 revealed the resident had a self-care deficit related to impaired balance. Interventions included the resident prefers…

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, medical record review, and facility policy review, the facility failed to ensure staff wore personal protective equipment appropriately, doffed PPE appropriately, and cleaned/disinfected high touch surfaces that were potentially contaminated with COVID-19. This had the potential to affect all 84 residents in the facility. The facility also failed to ensure a glucometer was appropriately cleaned/disinfected between use with residents. This affected two (#28 and #46) out of seven residents who received glucose monitoring using the glucometer from the second floor medication cart. The census was 84. Findings include: 1. Observation of State Tested Nursing Aide (STNA) #93 on 12/03/23 at 9:03 A.M. revealed she was in Resident #15's room, who was under isolation precautions for COVID-19, and delivered a breakfast tray to Resident #15. When STNA #93 came out of the room and into the hallway, she still had her isolation gown, gloves, N95 respirator, and face shield on and another facility staff told her she needed to doff the Personal Protective…

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 ensure residents received adequate assistance with transfers to prevent falls. This affected one resident (#6) out of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record for Resident #6 revealed an admission date of 05/16/20 with diagnoses including cerebral palsy, spastic hemiplegia, dysphagia, cognitive communication deficit, depression, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed Resident #6 had severely impaired cognition. Resident #6 had two or more falls without injury in the lookback period and required extensive assistance of two staff for transfers. Review of the plan of care, dated 02/13/23, revealed Resident #6 was at risk for falls and potential injury related to generalized weakness, decreased strength and endurance, impaired cognition, impaired mobility, poor safety awareness,…

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, interview, self-reported incident review (SRI) , and review of facilities Inservice record, the facility failed to prevent the misappropriation of narcotic medication for Resident #50, #60, #70 and #80. This affected four residents (#50, #60, #70, and #80) of four residents reviewed for misappropriation of narcotic medication. The facility census was 84. Findings include: Review of facilities Misappropriation SRI (240769) revealed an investigation summary dated 11/01/23 to 11/08/23 that indicated Licensed Practical Nurse (LPN) #23 appeared to not log/sign in narcotic medication cards received from the pharmacy delivery on several dates from 10/06/23 to 10/29/23 on both first-floor medication carts on Sage and Lavender Halls. During the audit and investigation, it was found only Residents #50, #60, #70 and #80 had missing medication cards from when controlled substances were delivered on the Pharmacy Slip Proof of Delivery to them not being signed in on the Shift Change Substance Inventory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, self-reported incident review (SRI) , and review of facilities Inservice record, the facility failed to maintain an accurate reconciliation of all controlled medications for their first floor Sage and Lavender Hall medication carts which resulted in misappropriation of narcotic medications. This affected four Residents (#50, #60, #70, and #80) out of four residents reviewed for misappropriation. The facility census was 84. Findings include: Review of facilities Misappropriation SRI (240769) revealed an investigation summary dated 11/01/23 to 11/08/23 that indicated Licensed Practical Nurse (LPN) #23 appeared to not log/sign in narcotic medication cards received from the pharmacy delivery on several dates from 10/06/23 to 10/29/23 on both first-floor medication carts on Sage and Lavender Halls. During the audit and investigation, it was found only Residents #50, #60, #70 and #80 had missing medication cards from when controlled substances were delivered on the Pharmacy Slip…

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, interview, and policy review the facility failed to notify a responsible representative of the misappropriation of narcotic medications per facility policy. This affected one resident (Resident #80) out of the four residents reviewed for misappropriation. The facility census was 84. Findings include: Review of the medical record for Resident #80, revealed an admission date of 08/03/23. Diagnoses included: unspecified nondisplaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing and acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 06 out of 15, indicating cognitive impairment. Review of the progress notes and assessments for Resident #80 completed on 11/01/23 to 11/03/23 revealed no documentation of notification of a responsible representative of the misappropriation and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of Self Reported Incidents (SRI), interview, and policy review, the facility failed to implement their policy related to reporting allegations of abuse, protecting residents after an allegation of abuse was made, and completing a thorough investigation. This affected two residents (#57 and #84). The facility census was 80. Findings include: 1. Review of SRI (239532) submitted 09/24/23 at 12:33 P.M. revealed the Administrator was notified by State Tested Nurse Aide (STNA) #176 that Resident #84 alleged Licensed Practical Nurse (LPN) #166 pushed her in the chest while the resident was trying to come in the courtyard door from the smoking area around 8:30 P.M. on 9/23/23. Review of Resident #84's medical record revealed a 06/21/21 admission and she had a planned discharge 10/03/23. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent for daily decision making, required supervision for activities of daily living and had early Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Self-reported Incident (SRI) review, medical record review, interview and facility policy review, the facility failed to timely report an allegation of abuse. This affected one resident (#84). The facility census was 80. Findings include: Review of SRI (239532) submitted 09/24/23 at 12:33 P.M. revealed the Administrator was notified by State Tested Nurse Aide (STNA) #176 that Resident #84 alleged Licensed Practical Nurse (LPN) #166 pushed her in the chest while the resident was trying to come in the courtyard door from the smoking area around 8:30 P.M. on 9/23/23. Review of the SRI revealed management was not notified of the police being in the facility on an allegation of abuse. There was no evidence of the night shift staff on duty calling the manager on duty to report the alleged abuse. There was no evidence of night shift staff reporting to day shift staff the events of the previous evening/night involving a police response to the facility for an allegation of resident abuse. Review of the SRI…

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 Self Reported Incidents (SRI), interview and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse, and failed to prevent further potential abuse when a specified perpetrator was not removed from the facility timely. This affected two residents (#57 and #84). The facility census was 80. Findings include: 1. Review of SRI (239532) submitted 09/24/23 at 12:33 P.M. revealed the Administrator was notified by State Tested Nurse Aide (STNA) #176 that Resident #84 alleged Licensed Practical Nurse (LPN) #166 pushed her in the chest while the resident was trying to come in the courtyard door from the smoking area around 8:30 P.M. on 9/23/23. Review of the SRI revealed management was not notified of the police being in the facility on an allegation of abuse. There was no evidence of the night shift staff on duty calling the manager on duty to report the alleged abuse. There was no evidence of night shift staff reporting to day shift staff the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and record review, the facility failed to ensure a resident who required staff assistance with personal hygiene was provided nail care and showers. This affected one resident (#36) of three residents reviewed for bathing. The census was 80. Findings include: Review of Resident #36's medical record revealed a 05/27/21 admission with diagnoses including cerebral infarction, flaccid hemiplegia affecting left non dominant side, anemia, type 2 diabetes, hypertension, osteoarthritis, and muscle wasting. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent for daily decision making, and had verbal behaviors and other behaviors one to three days in the look back period. The resident required extensive assist of two for bed mobility, transfer, toilet use, and extensive assist of one for personal hygiene. The resident needed physical help in part of bathing and one person physical assist. He had upper extremity…

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 staff interview, resident interview, observations, record review, and facility policy review, the facility failed to provide sufficient staff to meet resident needs. This had the potential to affect all 84 residents residing in the facility. Findings include: Review of the facility CMS-672 (census and condition information) form revealed the facility census as 84 residents. In the area of bathing, 61 residents required assistance of 1-2 staff members and 20 residents were completely dependent on staff for this task. 1. Review of the medical record for Resident #246 revealed an admission date of 09/24/22. Diagnoses included multiple fracture of the pelvis, cannabis use, fracture of the lumbar vertebra, fracture of a right rib, right kidney injury, schizophrenia, cerebral infarction, ventral hernia without obstruction, acute respiratory failure without hypoxia, and pedestrian on foot collision with automobile. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/01/22, revealed the…

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

Based on staff interview and review of facility policies, the facility failed to ensure the time frames for addressing pharmacy recommendations contained time frames for completion. This had the potential to affect all 84 residents residing in the facility who received medications from the facility. The facility census was 84. Findings include: Review of the facility policy titled Medication Regimen Reviews, not dated, revealed time frames for the physician to review pharmacy recommendations and time frames for the facility to implement the physicians changes were not included in the policy. Interview with Regional Director of Clinical Services #165 on 10/04/22 at 4:20 P.M. verified the facility policy for medication regimen reviews did not include time frames for the physician to review pharmacy recommendations or time frames for the facility to implement physician changes.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner as required. This affected six residents (Resident #2, Resident #3, Resident #18, Resident #232, Resident #233, and Resident #243) of six residents reviewed for resident assessment. The facility census was 84 residents. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 03/06/22 with diagnoses including anemia, unspecified protein-calorie malnutrition, muscle weakness and malignant neoplasm of prostate. Review of census data revealed Resident #2 discharged from the facility on 05/05/22. Review of a late entry nurses' note dated 05/05/22 at 5:51 P.M. revealed Resident #2 was admitted to the hospital following doctor's appointment. Review of Resident #2's MDS assessments revealed a discharge return not anticipated assessment dated [DATE] that was marked as in progress and was not completed. A red box was at the top that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure care plans were comprehensive. This affected six Residents (Residents #14, #51, #55, #66, #68, and #233) of 29 residents reviewed for care plans. The facility census was 84. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 08/10/22. Diagnoses included cerebral infarction, non-dominant, left side (L)hemiplegia and hemiparesis following a cerebral infarction (CVA), hypertension (HTN), heart disease, and dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/17/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required limited to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's). Review of physician orders for October 2022 revealed an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure showers and nail care were completed for residents who were dependent upon staff for assistance. This affected six residents (Residents #13, #28, #52, #59, #68, and #235) out of the nine residents who were reviewed for Activities of Daily Living (ADL's) during the annual survey. The facility census was 84. Findings include: 1. Record review for Resident #68 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, ileus, hypertension, type two diabetes mellitus, dysphagia, schizophrenia, muscle weakness, difficulty walking, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/27/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to be dependent upon one 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 interviews and record reviews, the facility failed to ensure activities were provided on weekends for cognitively impaired residents. This affected four residents (Residents #28, #36, #52, and #68) out of the four residents reviewed for activities during the annual survey. The facility census was 84. Findings include: 1. Record review for Resident #68 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, ileus, hypertension, type two diabetes mellitus, dysphagia, schizophrenia, muscle weakness, difficulty walking, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/27/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting, extensive assistance from two staff members for 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 staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #30 had a way to orient to time and date and failed to ensure Resident #237 was permitted to leave the facility as he wished. This affected two (#30 and #237) of five residents reviewed for dignity. The facility census was 84. Findings include: 1.Review of the medical record for Resident #237 revealed an admission date of 09/09/22. Diagnoses included acute embolism and thrombosis of unspecified deep veins of the right lower extremity, atherosclerotic heart disease, syncope and collapse, idiopathic gout, hypertension (HTN), arthritis, sickle-cell trait, peripheral vascular disease (PVD), chronic kidney disease (CKD), alcohol dependence, tobacco use, hyperlipidemia, obstructive sleep apnea (OSA), hematemesis, and nausea. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/22/22, revealed the resident had intact cognition with a Brief Interview 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 staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #66's call light was within reach. This affected one (Resident #66) of three residents reviewed for call light access. The facility census was 84. Findings include: Review of the medical record for Resident #66 revealed an initial admission date of 06/24/22 and a re-entry date of 07/08/22. Diagnoses included Alzheimer's Disease, lumbar vertebra fracture, low back pain, muscle weakness, difficulty walking, dysphagia, unsteadiness on her feet, encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/15/22, revealed the resident had moderately impaired cognition with no Brief Interview of Mental Status (BIMS) score due to the resident being rarely or never understood. There were no documented behaviors. The resident required extensive to total assistance of one staff for all Activities of daily Living (ADL's) except eating which she required set up help and supervision. Review of the change in condition…

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, resident interview, and staff interview, the facility failed to ensure residents had the right to make choices about aspects of their life that are significant and to choose bathing schedules. This affected two of 25 sampled residents (#14 and #29). The facility census was 88. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 02/24/22 and diagnoses including diabetes and end stage renal disease. The resident went out of the facility for hemodialysis three times weekly (Monday, Wednesday, Friday, per physician's order). An annual Minimum Data Set assessment completed on 01/14/23 stated the resident had a brief interview for mental status score of 15, indicating intact cognition. The resident required extensive assistance from one staff for bathing. Interview with Resident #14 on 02/01/23 at 2:10 P.M. revealed she often missed showers because they were scheduled on her dialysis days. She stated she leaves around 6:00 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 staff interview, observations, medical record review, and facility policy review, the facility failed to allow Resident #247 visitors. This affected one of five residents reviewed for dignity (Resident #247). The facility census was 84. Findings include: Review of the medical record for Resident #247 revealed an admission date of 09/23/22. Diagnoses included enterocolitis due to clostridium difficile (C-diff) (bacterial infection of the intestines). Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/30/22, revealed the assessment was incomplete and the resident's cognition had not been assessed. Further review of the MDS revealed the resident was not on isolation/quarantine. The resident required extensive assistance of one to two staff for all Activities of Daily Living (ADL's) except eating which he required set up and supervision. Review of the plan of care dated 09/27/22 revealed the no care plan related to isolation or infectious disease. Review of physician orders for September 2022 identified an order for strict contact precautions. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure the physician was notified when a resident was out of ordered enteral feeding solution. This affected one resident (Resident #52) reviewed for tube feeding during the annual survey. The facility census was 84. Findings include: Record review for Resident #52 revealed this resident was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, unspecified dementia with behavioral disturbance, hypotension, adult failure to thrive, hypovolemia, insomnia, and depression. Review of the quarterly MDS assessment, dated 08/17/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 08. This resident was assessed to require extensive assistance from one staff member for bed mobility, to be dependent upon two staff members for transfers, and to be dependent upon one staff member for eating, toileting, and bathing. This resident was assessed 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 record review and interview, the facility failed to notify the Long-Term Care Ombudsman (LTCO) of resident transfers/discharges as required. This affected one resident (Resident #18) of three residents reviewed for admission, discharge and transfer rights. The facility census was 84 residents. Findings include: Review of Resident #18's medical record revealed an admission date of 07/07/22 and diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, type two diabetes, dysphagia, tracheostomy status and anemia. Review of Resident #18's census data revealed a discharge date of 07/28/22. Review of nurses' notes revealed on 07/28/22 at 9:27 A.M. Resident #18 continued to have emesis through his tracheostomy. Orders given to send Resident #18 to the emergency room for further monitoring. Family notified of new order. No evidence was provided regarding LTCO notification of Resident #18's discharge on [DATE]. Phone interview on 09/28/22 at 10:41 A.M. with Social Service…

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 interview, record review and policy review, the facility failed to ensure all of Resident #240's medications were available upon his discharge home. This affected one resident (Resident #240) of three residents reviewed for admission, discharge and transfer rights. The facility census was 84 residents. Findings include: Review of Resident #240's medical record revealed an admission date of 09/06/22 and diagnoses including quadriplegia, type two diabetes, morbid obesity, colostomy and anemia. Review of Resident #240's admission minimum data set (MDS) assessment dated [DATE] revealed Resident #240 was cognitively intact, did not display behaviors and had an indwelling catheter and ostomy. Resident #240 did received antibiotics during the review period. Review of census data revealed Resident #240 was discharged from the facility on 09/26/22. Review of Resident #240's physician's orders revealed an order dated 09/09/22, for ertapenem sodium solution reconstituted one gram, use one gram intravenously (IV)…

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 complete comprehensive assessments within 14 calendar days after admission. This affected two of three residents (#9 and #73) reviewed for assessment completion. The facility census was 88. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/19/23. Review of the admission Minimum Data Set (MDS) assessment revealed it was still in progress on 02/07/23. (14 days after admission would be 02/02/23). Interview with the Director of Nursing on 02/08/23 at 8:30 A.M. confirmed the comprehensive assessment for Resident #9 was not completed within 14 days after admission. 2. Review of the medical record for Resident #73 revealed an admission date of 01/18/23. Review of the admission MDS assessment revealed it was completed on 02/06/23. (14 days after admission would be 02/01/23). Interview with the Director of Nursing on 02/08/23 at 8:30 A.M. confirmed the comprehensive assessment for Resident #73 was not completed within 14 days after admission.

Based on medical record review and staff interview, the facility failed to ensure quarterly assessments were completed timely. This affected one of three residents (#67) reviewed for assessments. The facility census was 88. Findings include: Review of the medical record for Resident #67 revealed an admission date of 10/05/22. An admission Minimum Data Set assessment was completed on 10/24/22. A quarterly assessment indicated it was in progress on 02/07/23 (was due to be completed 01/24/23). Interview with the Director of Nursing on 02/08/23 at 8:30 A.M. confirmed the quarterly assessment was not completed timely for Resident #67.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #17's Pre-admission Screening and Resident Review (PASARR) was completed accurately. This affected one resident (#17) of two residents reviewed for PASARR's. Findings include: Review of the medical record for Resident #17 revealed they were admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, lymphedema, hyperlipidemia, cognitive communication deficit, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required the extensive assistance of one person for personal hygiene. Review of the PASARR dated 02/18/22 revealed Resident #17 had a mood disorder, delusional disorder, panic or severe anxiety disorder, post-traumatic stress disorder (PTSD), and paranoid disorder. Review of the psychiatric note dated 07/08/22 revealed Resident #17 had a history of bipolar disorder and anxiety, there was no documentation related 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 staff interview, resident interview, observations, and medical record review, the facility failed to ensure Resident #66 was provided the appliances needed for hearing adequately. This affected one (Resident #66) of one resident reviewed for communication sensory. The facility census was 84. Findings include: Review of the medical record for Resident #66 revealed an initial admission date of 06/24/22 and a re-entry date of 07/08/22. Diagnoses included Alzheimer's Disease, lumbar vertebra fracture, low back pain, muscle weakness, difficulty walking, dysphagia, unsteadiness on her feet, encephalopathy, and severe protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/15/22, revealed the resident had moderately impaired cognition with no Brief Interview of Mental Status (BIMS) score due to the resident being rarely or never understood. There were no documented behaviors. The resident required extensive to total assistance of one staff for all Activities of Daily Living (ADL's) except eating which she required set up 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, interview, and record review, the facility failed to provide Resident #17 and Resident #49 with foot care and refer them to podiatry. This affected two residents (Residents #17 and #49) of nine residents reviewed for activities of daily living. The facility census was 84. Findings include: 1. Interview on 09/26/22 at 4:00 P.M. with Resident #49 revealed he had asked to see the podiatrist since he admitted to the facility and had yet to see them. Observation on 10/03/22 at 1:20 P.M. of Resident #49's feet with Licensed Practical Nurse (LPN) #100 revealed both feet had skin that was observed flaking off. The skin of his feet was dry and cracked, which worsened closer to his toes. His toenails were observed to be thick and yellow, with some black areas around the edges. Multiple toenails were long and extended past the end of his toe by up to about a half an inch. Interview with Resident #49 at that time revealed his feet were sensitive and the dry skin was uncomfortable at times. Resident #49…

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 interview, record review and policy review, the facility failed to provide appropriate catheter care and monitoring. This affected one resident (Resident #240) of two residents reviewed for catheter care. The facility census was 84 residents. Findings include: Review of Resident #240's medical record revealed an admission date of 09/06/22 and diagnoses including quadriplegia, type two diabetes, morbid obesity, colostomy and anemia. Review of Resident #240's admission minimum data set (MDS) assessment dated [DATE] revealed Resident #240 was cognitively intact, did not display behaviors and had an indwelling catheter and ostomy. Review of Resident #240's physician's orders revealed no orders pertaining to changing his suprapubic catheter or providing catheter care. Review of Resident #240's September 2022 Treatment Administration Record (TAR) revealed no evidence of suprapubic catheter care or catheter changes having been completed. Review of Resident #240's nurses' notes for September 2022 revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure enteral feeding was provided as ordered for Residents #52, #232, and #243. This affected three residents (Residents #52, #232, and #243) of four residents who had a feeding tube. The facility census was 84. Findings include: 1. Review of the medical record for Resident #232 revealed an admission date of 09/22/22 and a discharge date of 10/03/22. Diagnoses included displaced intertrochanteric fracture of the right femur, atrial fibrillation (a-fib), Diabetes Mellitus II (T2DM), emphysema, dysphagia, and severe protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/22/22, revealed the assessment remained in progress (23 days since the resident's re-entry to the facility). Further review of the MDS revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of 15 (severe impairment).…

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 interview and record review the facility failed to complete pre-dialysis and post-dialysis assessments for Resident #14 and Resident #30. This affected two residents (#14 and #30) of two residents reviewed for dialysis. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #14 admitted on [DATE] with diagnoses including type two diabetes mellitus, hypertension, end stage renal disease with dependence on renal dialysis, cerebral infarction, cognitive communication deficit, gastro-esophageal reflux disease, hypothyroidism, pain in left knee, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition and received dialysis. Review of the plan of care dated 03/21/22 revealed Resident #14 received dialysis on Monday, Wednesday, and Friday related to End Stage Renal Disease (ESRD). Interventions included assisting with transfers when going to dialysis and fluid restrictions as ordered. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure appropriate spacing between bed rails and mattresses was maintained and failed to ensure assessments for the use of bed rails were completed. This affected two residents (Residents #13 and #64) out of the two residents reviewed for use of bed rails during the annual survey. The facility census was 84. Findings include: 1. Record review for Resident #64 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis affecting the left non-dominant side, depression, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 08/26/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to be dependent upon two staff members for 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 observation, record review, policy review, and staff interviews, the facility failed to ensure pharmacy recommendations were accurately reviewed by the physician, failed to ensure physician approved pharmacy recommendations were implemented, and failed to ensure medications were necessary. This affected three residents (#32, #51, and #59) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 84. Findings include: 1. Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, hyperlipidemia, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/06/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to be…

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 interview and record review the facility failed to ensure Resident #55's 'as needed' psychotropic medication did not exceed 14 days and was used with appropriate monitoring. This affected one resident (#55) of five residents reviewed for unnecessary medication. The facility census was 84. Findings include: Review of the medical record for Resident #55 revealed an admission date of 05/13/22 revealed an admission date of chronic diastolic heart failure, type two diabetes mellitus, chronic kidney disease stage two, depression, unspecified dementia, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had severely impaired cognition. Review of the plan of care dated 05/13/22 revealed Resident #55 received a psychoactive medication. Interventions included giving medications as ordered, monitoring for effectiveness, observing and reporting any changes in mental status, and a resident specific behavior intervention. Review of the…

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

Based on medical record review and staff interview, the facility failed to ensure a resident was free from significant medication errors when medications ordered for treatment of cerebral infarction, anemia, kidney disease, hypertension were not given as ordered on days the resident went out for dialysis. This affected one of three residents (#14) reviewed for dialysis. The facility census was 88. Findings include: Review of the medical record for Resident #14 revealed an admission date of 02/24/22 and a diagnosis of end stage renal disease. The resident had a physician's order for hemodialysis three times a week at an outside dialysis center. Review of physician's orders and medication administration records for January 2023 and February 2023 revealed orders for Aspirin daily at noon due to cerebral infarction, iron 325 milligrams daily at noon due to anemia, Lasix 80 milligrams daily at noon due to end stage kidney disease, miralax in the AM on Monday, Wednesday, Friday, and Sunday, and hydralazine, an antihypertensive medication at noon. Review of the medication administration…

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 staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to keep medications in locked containers and the facility failed to ensure prescription creams and ointments were not expired. This affected two residents (Resident #235 and #243). The facility census was 84. Findings include: 1. Review of the medical record for Resident #235 revealed an initial admission date of [DATE] and a re-entry date of [DATE]. Diagnoses included type 2 Diabetes without complications, asthma, gastro-esophageal reflux disease (GERD), atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, hypothyroidism, primary pulmonary hypertension, personal history of immunosuppression therapy, rheumatoid arthritis, thoracic aortic aneurysm, unsteadiness on feet, difficulty walking, muscle weakness, cognitive communication deficit, dysphagia, cerebral infarction, and COVID-19. Review of the comprehensive Minimum Data Set…

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 staff interview, resident interview, medical record review, and facility policy review, the facility failed to failed to ensure resident medical records contained complete and accurate information. This affected four of 29 residents reviewed (Residents #14, #32, #237, and #246). The facility census was 84. Findings include: 1. Review of the medical record for Resident #237 revealed an admission date of 09/09/22. Diagnoses included acute embolism and thrombosis of unspecified deep veins of the right lower extremity, atherosclerotic heart disease, syncope and collapse, idiopathic gout, hypertension (HTN), arthritis, sickle-cell trait, peripheral vascular disease (PVD), chronic kidney disease (CKD), alcohol dependence, tobacco use, hyperlipidemia, obstructive sleep apnea (OSA), hematemesis, and nausea. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/22/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment).…

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, staff and resident interviews, and record reviews, the facility failed to ensure resident call lights were in good working order. This affected one resident (#68) out of the four residents reviewed for call lights during the annual survey. The facility census was 84. Findings include: Record review for Resident #68 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, ileus, hypertension, type two diabetes mellitus, dysphagia, schizophrenia, muscle weakness, difficulty walking, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/27/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting, extensive assistance from two staff members for transfers, and supervision 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.