Otterbein Gahanna

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected two (Resident #13 and Resident #1) of three residents reviewed for medication management. The facility census was 52.Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 12/16/25 and a readmission date of 04/25/26. Diagnoses included encephalopathy, osteomyelitis of the left ankle and foot, type one diabetes mellitus, acute kidney failure, and a non pressure chronic ulcer of the left foot with necrosis of bone.Review of hospital records dated 04/21/26 revealed Resident #13's hemoglobin A1C was 8.5 milligrams per deciliter (mg/dl).Review of Resident #13's hospital after visit summary dated 04/25/26 included an order for insulin thirty units injected once each morning.Review of Resident #13's care plan dated 04/25/26 documented a diagnosis of diabetes mellitus and interventions to administer…

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, staff interview, medical record review, review of a drug manufacturer instructions, and facility policy review, the facility failed to ensure insulin pens were appropriately stored in medication cart. This affected one (#12) of one residents reviewed for insulin storage. The facility census was 52.Findings include:Review of the medical record revealed Resident #12 was admitted on [DATE] and had diagnoses that included type II diabetes, hemiplegia, and anemia. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact.Observation of the room temperature medication cart in one of the five campus houses was conducted at 9:15 A.M. on 05/05/26. There were two Novolog FlexPen insulin aspart 100 units per milliliter (u/mL) injector pens found in the medication cart. Both pens were labeled as belonging to Resident #12 and both were labeled as being opened 02/28/26.Interview with Licensed Practical Nurse (LPN) #163 at approximately 9:15 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to ensure laboratory (lab) services were timely in reporting lab results to meet resident needs. This affected one (#42) of three residents reviewed for bowel and bladder care needs. The census was 52.Findings include: Review of the electronic medical record for Resident #42 revealed an admission date of 12/19/24. Diagnoses included parkinsonism, type II diabetes, protein-calorie malnutrition, acute kidney failure, and retention of urine.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for personal hygiene, toileting, and showering tasks.Review of nursing progress notes on 05/03/26 at 3:45 P.M. revealed Resident #42 complained of a burning sensation during urination. Vital signs were obtained and were reported to be within normal limits. The on-call physician was notified, 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, medical record review, emergency medical services run report review, hospital documentation review, staff interview, resident representative interview, and review of meal menus and food recipes, the facility failed to ensure a thorough procedure was implemented to ensure staff members did not serve food items to residents with specific food allergies and intolerances. This affected two (#64 and #23) of three residents reviewed for food allergies. The facility census was 52.Findings include: 1. Review of the medical record for Resident #64 revealed an initial admission date of 03/13/25 and discharge date of 04/04/25 with a readmission date of 06/27/25 and second discharge date of 07/12/25. Diagnoses included urinary tract infection, calculus of a kidney, type II diabetes mellitus with diabetic autonomic polyneuropathy, autoimmune thyroiditis, generalized anxiety disorder, and depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed 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 medical record review, resident and staff interview, review of the incident and accident log, and policy review, the facility failed to ensure weekly skin assessments were accurately documented in the medical record and failed to ensure the medical record was complete related to resident incident documentation. This affected one (Resident #1) of one residents reviewed for assessment accuracy. The facility census was 52.Findings include:1. Record review revealed Resident #1 was admitted on [DATE] with diagnoses including end stage renal disease, type II diabetes mellitus, morbid obesity, and acquired absence of the right leg below the knee. Review of Resident #1's physician order dated 11/04/25 revealed the resident was ordered weekly skin assessments to be completed by a licensed nurse. Review of Resident #1's care plan dated 11/05/26 identified the resident had potential impairment of skin integrity with interventions including completing weekly skin screens. Review of an assessment used to predict…

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, staff interview, and review of a Centers for Disease Control and Prevention sign, the facility failed to ensure infection control measures were utilized for residents on enhanced barrier precautions. This affected one (#13) of eight residents reviewed for infection control. The facility census was 52.Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/16/25 with diagnoses including encephalopathy, osteomyelitis of the left ankle and foot, type one diabetes mellitus, sepsis due to Escherichia coli, peripheral vascular disease, and a non pressure chronic ulcer of the left foot with necrosis of bone. Review of the care plan dated 04/26/26 revealed Resident #13 had impaired skin integrity related to a chronic vascular would of the left great toe, with interventions to utilize enhanced barrier precautions. Further review revealed staff will follow proper hand hygiene, don gloves and gown to minimize microorganism transmission,…

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 policy review, the facility failed to notify the physician and/or registered dietician when Resident #44 did not have physician ordered enteral nutrition available and failed to report Resident #48's weight loss. This affected two (Resident #44 and Resident #48) of three residents reviewed for change in condition. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia. On 03/18/25 Resident #44 weighed 228 pounds. A nutrition/dietary note dated 03/20/25 at 11:33 A.M. revealed Resident #44 was ordered nothing by mouth and received enteral support as the sole source of nutrition. Resident #44 received Osmolite (therapeutic nutrition that provided complete and balanced nutrition for tube feeding (enteral nutrition) residents) 1.5 cal (caloric density of 1.5 calories per milliliter) at 80…

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 policy review, the facility failed to provide a comprehensive and individualized pressure ulcer plan to aid in the prevention and/or treatment of pressure ulcers. This affected two (Resident #4 and #50) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnosis that included multiple fractures of pelvis, osteoporosis, and psoriasis. An admission summary dated [DATE] at 6:35 P.M. revealed Resident #4 was admitted to the facility with a pelvic fracture and open reduction and internal fixation of the left hip. Resident #4 had a pressure ulcer to the coccyx. A new skin observation form dated 04/30/25 at 11:47 P.M. revealed Resident #4 was admitted with a skin tear to the coccyx that measured two centimeters (cm) long and one cm wide and surgical incision to the left thigh. An admission screen and baseline care plan dated 05/01/25 at 1:42 A.M. revealed Resident #4 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 record review, interview, and policy review, the facility failed to ensure a comprehensive, resident centered treatment plan was implemented to support identified needs related to enteral nutrition and failed to maintain appropriate parameters to accurately assess nutritional status. This affected two (Resident #44 and Resident #60) of three residents reviewed for nutrition. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia. On 03/18/25 Resident #44 weighed 228 pounds. A nutrition/dietary note dated 03/20/25 at 11:33 A.M. revealed Resident #44 was ordered nothing by mouth and received enteral support as the sole source of nutrition. Resident #44 received Osmolite (therapeutic nutrition that provided complete and balanced nutrition for tube feeding (enteral nutrition) residents) 1.5 cal (caloric density of 1.5…

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, hospital record review, interview, and policy review, the facility failed to ensure medications were necessary prior to administration and were administered per orders, non-pharmalogical interventions were attempted prior to administration of as needed pain medication and residents did not experience adverse effects from prescribed medications that resulted in hospitalization. This affected one (Resident #60) of three residents reviewed for narcotic medication use. The facility census was 54. Findings include: Review of the hospital prescription (from the resident's hospitalization prior to admission to the facility) dated 03/19/25 revealed Resident #60 was ordered Dilaudid two milligram (mg) every four to six hours as needed for pain. Review of the medical record revealed Resident #60 was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses that included osteoarthritis of right knee, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive…

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 interviews, the facility failed to notify the physician of laboratory results for Resident #60. This affected one (Resident #60) of three residents reviewed for laboratory results. The facility census was 54. Findings include: Review of the medical record revealed Resident #60 was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses that included osteoarthritis of right knee, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and retention of urine. The Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. Review of laboratory results dated [DATE] revealed Resident #60's Blood Urea Nitrogen (BUN) was 33 milligram/deciliter (mg/dl), the normal range was 7-25 mg/dl. An elevated BUN could indicate kidneys not functioning properly or dehydration. Resident #60's carbon dioxide was 34 milliequivalent…

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

Based on observation and interview the facility failed to maintain a clean kitchen environment. This had the potential to affect all residents except Resident #1 who does not receive food from the kitchen. The facility census was 55. Findings include: Observation on 12/17/24 at 9:54 A.M. of house number four revealed kitchen cabinets were dirty with a splattered white substance on the island and the cabinet next to the stove. Observation on 12/17/24 at 10:01 A.M. of house number five revealed a broken cabinet hinge facing outward toward the resident care area. The cabinets were observed with yellow, dripping dried substance along the fronts. Observation on 12/18/24 at 8:02 A.M. of house number three revealed the front of the kitchen cabinets were dirty with splatter, and the stainless steel area around the stove looked dirty. Observation on 12/18/24 at 9:17 A.M. of house number four revealed kitchen cabinets were dirty with a splattered white substance on the island and the cabinet next to the stove. Observation on 12/19/24 at 11:15 A.M. of house five revealed the kitchen island…

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, staff interview, medical record review, manufacture's guidelines, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#47) of one resident reviewing for insulin pen priming. The facility identified two residents (#47 and #55) in House #1 who received insulin. The facility census was 55. Findings include: Review of the medical record for Resident #47 revealed an admission date of 08/05/21 with diagnoses of transient cerebral ischemic attack, type two diabetes mellitus without complications, anemia, adult failure to thrive, hypertension and dementia. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment. Review of physician orders dated 01/29/24 for Resident #47 revealed the resident was prescribed Insulin Glargine Solution 100 units, with instructions to inject 8 units subcutaneously each morning before breakfast to manage…

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, staff interview, medical record review, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#23) of one resident reviewed for insulin pen priming. The facility identified five residents (#14, #15, #18, #19 and #23) in House #2 who received insulin. The facility census was 54. Findings included: Medical record review for Resident #23 revealed an admission date of 01/20/23. Medical diagnoses included chronic obstructive pulmonary disease and diabetes. Review of physician orders dated 11/02/23 revealed Lantus to inject 35 units subcutaneously in the morning. Further review of physician orders dated 01/31/24 for Resident #23 revealed Novolog flex pen subcutaneous solution to inject per sliding scale in the morning and at bedtime. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact. During a medication administration 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 Based on medical record review, observations, staff interview and policy review the facility failed to ensure glucometers were sanitized between residents. This affected three (#14, #15, #23) of three residents reviewed for medication administration. The facility identified this had the potential to affect five residents (#14, #15, #18, #19 and #23) who received accuchecks in House #2. The facility census was 54. Findings included: 1. Review of the medical record review for Resident #14 revealed an admission date of 11/18/22. Medical diagnoses included Alzheimer's Disease and diabetes. Review of physician orders dated 11/18/23 revealed to take blood sugars in the morning. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was rarely or ever understood. During a medication administration observation on 11/04/24 at 7:38 A.M. for Resident #14 revealed after taking the blood sugar of the resident the Registered Nurse (RN) #171 revealed he didn't wipe the glucometer off 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.

Based on observation, interview, and review of facility policy the facility failed to ensure foods were stored in a sanitary manner and failed to ensure foods were labeled, dated, stored appropriately, and not kept past the expiration dates. This had the potential to affect 50 of 50 residents in the facility. Findings include: Observation on 09/09/24 from 8:28 A.M. to 9:00 A.M. revealed the following concerns: In house 403 there were hot dog buns dated 09/02/24 and 09/08/24 and a rotisserie chicken for the resident in 511 dated 08/27/24. 511 also had two unidentifiable food items that were not dated. In the refrigerator there was a bag of frozen peas that was open to air and undated. The freezer in the kitchen and the refrigerator in the pantry were full of food debris and stains. In House 401 there were two packages of cheddar slices poorly wrapped in foil and exposed to air. There was half an onion and half a tomato cut open and unwrapped, both items were in a drawer that was filled with food debris. Both refrigerators and freezers in the kitchen and pantry were unclean. In House…

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 policy review the facility failed to ensure enhanced barrier precautions (EBP) were in place for five residents (Resident #32, #52, #45, #110, #45 and #1) of seven residents reviewed for enhanced barrier precautions. The facility failed to ensure an isolation room contained appropriate bins for staff to place soiled laundry and to dispose of soiled personal protective equipment (PPE) for one resident,( Resident #10) of one reviewed for transmission-based precautions. The facility failed to provide evidence the infection control policies and procedures are reviewed annually. This had the potential to affect all 50 residents in the facility as each home of the facility had residents who were not in enhanced barrier precautions who had physician orders to have enhanced barrier precautions implemented in their care. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #32 revealed an initial admission date of 01/21/23 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.

Based on observation, interview, and medical record review the facility failed to ensure a full set of utensils and napkins was provided for all residents in houses 400 (#8, #11, #14, #18, #20, #21, #32, #34, #38) and 404 (#6, #9, #19, #22, #24, #28, #33, #35, #40, #45), additionally the facility failed to ensure a dignified dining experience for Resident #19. This affected 19 residents (#6, #8, #9, #11, #14, #18, #19, #20, #21, #22, #24, #28, #32, #33, #34, #35, #38, #40, #45) observed for dining. The facility census was 50. Findings include: 1. Interview on 09/09/24 at 11:31 A.M. with Resident #33 revealed the facility did not provide appropriate silverware for meals. She reported she in the past had been given a fork to eat applesauce with. Observation on 09/10/24 at 12:40 P.M. of the lunch meal in building 404 revealed residents were served a sandwich, a bowl of soup, and orange segments. All residents (#6, #9, #19, #22, #24, #28, #33, #35, #40, and #450 were only provided a spoon for utensils. One resident (#40) was observed using her spoon to cut up her sandwich. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure Resident #52 received assistance at meals as needed, and failed to ensure routine shaving, nail care, and/or showers were provided for Resident #25, #32, #35, and #45. This affected five residents (#25, #32, #35, #45, and #52) of six residents reviewed for activities of daily living. The facility census was 50. Findings include: 1. Review of Resident #45 revealed an admission date of 08/05/21 with diagnoses including type two diabetes mellitus, paroxysmal atrial fibrillation, adult failure to thrive, major depressive disorder, unspecified dementia, chronic kidney disease stage four, and hypertension. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Resident #45 required substantial or maximal assistance for bathing and set up or clean up assistance for personal hygiene. Review of Resident #45's plan of care dated 06/19/23 revealed she had an activity of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and observation, the facility failed to assess, implement, and deliver an individualized activity program for six residents (Resident #19. #22, #32, #34, #35, and #51) of six residents reviewed for activities. The facility census was 50. Findings include: 1. Review of the medical record revealed Resident #51 was admitted on [DATE] with diagnoses that included displaced intertrochanteric fracture of right femur, chronic obstructive pulmonary disease, major depressive disorder, and dementia. Review of Resident #51's admission Minimum Data Set (MDS) revealed she is moderately cognitively intact with a brief interview for mental status (BIMS) score of 10/15. Resident #51 has no impairment of range of motion in her upper or lower extremities and uses a wheelchair for mobility. Review of the plan of care for Resident #51 initiated on 07/29/24 revealed the plan included the need to identify the resident's preferences for individual and group activities but…

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 identify, assess and monitor skin conditions for two residents (#19 and #31) and failed to ensure one resident's (#48) wound treatments were completed as physician ordered. This affected three of three residents reviewed for skin conditions. Additionally, the facility failed to ensure one resident's (#11) Thromboembolism-Deterrent (TED) hose were applied as physician ordered. This affected one of one residents revived for edema. The facility census was 50. Findings Included: 1. Review of the medical record for Resident #11 revealed an initial admission date of [DATE] with the latest readmission of [DATE] with diagnoses including but not limited to hypertensive heart disease with heart failure, asthma, pain, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, severe morbid obesity, vitamin D deficiency, pancytopenia, obstructive sleep apnea and gastro-esophageal reflux disease. 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 observation, interview, and medical record review the facility failed to ensure fall interventions were in place for Resident #8, #19, #25, #28, and #52 and failed to ensure sufficient fall documentation and neurological checks were completed for Resident #19 and #110. Additionally, the facility failed to ensure Resident #48 was not left unsupervised. This affected seven residents (#8, #19, #25, #28, #48, #52, and #110) of nine residents reviewed for accidents. The facility census was 50. Findings include: 1. Review of Resident #52's medical record revealed an admission date of 07/22/24 with diagnoses including type two diabetes mellitus, hypertension, nontraumatic intracerebral hemorrhage, anxiety, chronic kidney disease, and gastro-esophageal reflux disease without esophagitis. Review of Resident #52's Minimum Data Set (MDS) 3.0 dated 07/26/24 revealed the resident was rarely or never understood. Review of Resident #52's plan of care dated 07/31/24 revealed she was at risk for falls 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #19, #22, and #32 had reasonable access to fluids, failed to offer Resident #34 food purchased and brought in by family, and failed to offer Resident #25 ice cream following dinner as care planned. This affected four residents (#19, #22, #32, and #34) of ten residents reviewed for nutrition and hydration. The facility census was 50. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/04/23, diagnoses included metabolic encephalopathy, dementia, mixed hyperlipidemia, type two diabetes mellitus, absence epileptic syndrome, insomnia, dysphagia, hypertension. and muscle weakness. Review of Resident #19's comprehensive Minimum Data Set assessment dated [DATE] revealed she was rarely or never understood. The resident required partial or moderate assistance with eating. Review of Resident #19's plan of care dated 08/02/24 revealed she was at risk for changes to nutrition and hydration due…

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 change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four residents (#11, #21, #31, #38) of four residents reviewed for respiratory care. The census was 50. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 04/07/23 with the latest readmission of 01/12/24, diagnoses included hypertensive heart disease with heart failure, asthma, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and obstructive sleep apnea. Review of the plan of care dated 01/12/24 revealed the resident had an alteration in respiratory status related to COPD, asthma and chronic respiratory failure. Interventions included elevate head of bed due to difficulty breathing when lying flat, monitor for shortness of breath, chest pain or change in condition, monitor oxygen saturation…

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, medical record review, and review of facility menus the facility failed to ensure the menu was followed for Resident #19 and the facility failed to ensure a planned menu was in place for residents on a puree and mechanically altered diet. This had the potential to affect all 11 residents on a puree and mechanically altered diet (#8, #9, #17, #19, #24, #29, #34, #40, #50, #52, and #100). The facility census was 50. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/04/23, diagnoses included dementia, dysphagia, and muscle weakness. Review of Resident #19's comprehensive Minimum Data Set assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #19's physician orders dated 08/05/23 revealed an order for pureed texture diet with slightly thick liquids. Review of the menu for the lunch meal on 09/09/24 revealed residents were to receive three ounces of beans and [NAME], cornbread, tossed salad with dressing, 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 record review and staff and family interviews, the facility failed to ensure one resident (#25) was provided bathing per her preference. This affected one ( Resident #25) of six residents reviewed for activities of daily living (ADL). The facility census was 50. Findings Include: Review of the medical record for Resident #25 revealed an initial admission date of 01/17/24 with the diagnoses including but not limited to congestive heart failure, hyperlipidemia, hypothyroidism, chronic kidney disease, atrial fibrillation, hypertension, gastro-esophageal reflux disease, macular degeneration and protein calorie malnutrition. Review of the plan of care dated 03/22/24 revealed the resident had a self-care deficit and/or physical mobility performance deficit related to activity intolerance, fatigue, impaired balance and weakness. Interventions included the resident requires moderate assistance of one staff for dressing, showering and personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to ensure one resident's (#31) physician was notified of vital signs outside of the physician ordered parameters. This affected one ( Resident #31) of 24 sampled residents reviewed. The facility census was 50. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure, presence of cardiac pacemaker, anxiety disorder and major depressive disorder. Review of the plan of care dated 03/18/22 revealed the resident had an altered cardiovascular status related to CHF, hypertension, hyperlipidemia, CVA and presence of pacemaker. Interventions included administer medications 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 staff interview, the facility failed to ensure one resident's (#31) required resident information for emergency transfer was documented in the resident's medical record and provided for the receiving facility. This affected one (Resident #31) of three residents reviewed for hospitalization. The facility census was 50. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure, presence of cardiac pacemaker, anxiety disorder and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the progress note dated 09/01/24 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #7) three residents reviewed for PASARR documents. The census was 50. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. On 06/14/23 additional diagnoses of psychotic disorder with delusions and other hallucinations were added. Review of the PASARR provided on 09/10/24 revealed it was completed on 03/20/23 by the facility. The PASARR indicated there was no mental diagnoses. There have been no other PASARR forms completed since additional mental health diagnoses of psychotic disorder with delusions and other hallucinations were added on 06/14/23. Interview on 09/16/24 at 11:45 A.M. with social worker #139…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the Preadmission Screening And Resident Review (PASARR) did not reflect all mental health diagnoses for two residents (Resident #7 and #28) out of three residents reviewed for PASARR accuracy. The facility census was 50. Findings include: 1. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. Review of the PASARR provided on 09/10/24 revealed it was completed on 03/20/23 by the facility. The PASARR indicated there was no mental health diagnoses. There have been no additional PASARR forms completed. Interview on 09/16/24 at 11:45 A.M. with social worker #139 confirmed Resident #7's admission PASARR did not contain any mental health diagnoses. 2. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included senile degeneration of the brain, dementia, atherosclerotic heart disease and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #7) of three residents reviewed for PASRR documents. The census was 50. Findings Include: Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. On 06/14/23 additional diagnoses of psychotic disorder with delusions and other hallucinations were added. Review of the PASARR provided on 09/10/24 revealed it was completed on 03/20/23 by the facility. The PASARR indicated there was no mental diagnoses. There have been no other PASARR forms completed since additional mental health diagnoses of psychotic disorder with delusions and other hallucinations were added on 06/14/23. Interview on 09/16/24 at 11:45 A.M. with social worker #139 confirmed Resident #7's admission PASARR did 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, medical record review, staff interview and facility policy review, the facility failed to develop a comprehensive plan of care to address resident needs and conditions as required. This affected three (#31, #32, and #52) of 24 sampled residents reviewed for careplans. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure (CHF), presence of cardiac pacemaker, anxiety disorder and major depressive disorder. Review of the plan of care dated 03/18/22 revealed the resident has an altered respiratory status/difficulty breathing related to CHF and seasonal allergies. Interventions included administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure quarterly care conferences were conducted and the required interdisciplinary team (IDT) members were present at care conferences. This affected two residents (#25 and #34) of 24 sampled residents. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #34 revealed an initial admission date of 06/27/18 with the latest readmission of 02/09/24 with the diagnoses including but not limited to cerebrovascular accident with left sided hemiplegia, benign prostatic hyperplasia, chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), sickle cell trait, epilepsy, adjustment disorder with depressed mood, contracture of right and left knee, gastro-esophageal reflux disease, gout, allergic rhinitis, insomnia, dysphagia, vascular dementia, hypertension, hearing loss, unilateral inguinal hernia and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. This affected one resident (#54) of one resident revived for discharge. The facility census was 50. Findings Included: Review of the closed medical record for Resident #54 revealed an initial admission date of [DATE] with the diagnoses including compression fracture of T11-T12, metabolic encephalopathy, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, major depressive disorder and pressure ulcer Stage II buttocks. The resident was discharged to an assisted living facility on [DATE]. Review of the resident's admission screen and baseline care plan dated [DATE] revealed the resident was alert and oriented to person only on admission. The assessment indicated the resident was confused. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the plan of care dated [DATE] revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure the timely assessment and treatment of a urinary tract infection (UTI) for one resident (#22). This affected one of one reviewed for UTI. Additionally, the facility failed to ensure one resident (#32) had physicians orders for the use of an indwelling urinary catheter. This affected one (#32) of two residents reviewed for catheter use. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #32 revealed an initial admission date of 01/21/23 with the latest readmission of 07/06/24 diagnoses included sepsis, urinary tract infection, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, obstructive and reflux uropathy, dementia with behavioral disturbances, intellectual disabilities and hypertension. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment…

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 #52's tube feeding formula was appropriately labeled and dated after opening. This affected one resident of one resident reviewed for tube feeding. The facility census was 50. Findings include: Review of Resident #52's medical record revealed an admission date of 07/22/24, diagnoses included type two diabetes mellitus, hypertension, nontraumatic intracerebral hemorrhage, anxiety, chronic kidney disease, and gastro-esophageal reflux disease without esophagitis. Review of Resident #52's Minimum Data Set (MDS) 3.0 dated 07/26/24 revealed the resident was rarely or never understood. She had no significant weight changes. Resident #52 received 51% or more of her calories from her feeding tube. Review of Resident #52's physician order dated 07/22/24 revealed she had enteral feeding. With each new bottle the formula container, syringe, and administration set were to be labeled with resident's name, date, time, and nurse's inititals. Observation on 09/10/24 at 8:40 A.M. revealed on 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 staff interview the facility failed to ensure pharmacy recommendations were addressed by the physician and followed through by facility staff for one, (Resident #35) and failed to have evidence of the pharmacist's recommendations for one, (Resident #22). This affected two residents (#22 and #35) of five residents reviewed for un-necessary medications. The facility census was 50. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 09/26/22 with diagnoses including Alzheimer's disease, osteoporosis, hypertension, anxiety disorder, and major depressive disorder. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #35's pharmacist recommendation dated 02/20/24 revealed the resident was on Cholecalciferol (vitamin) daily and an annual Vitamin D laboratory test result could not be located. The pharmacist recommended obtaining a Vitamin D level on the next…

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 residents were appropriately monitored as ordered when administered medications. This affected one (Resident #38) of four residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 07/19/23 with the latest readmission of 12/16/23 with diagnoses including but not limited to chronic respiratory therapy, congestive heart failure (CHF), hypertension, atrial fibrillation and chronic pain. Review of the plan of care dated 07/31/23 revealed the resident had an altered cardiovascular status related to arrhythmia, CHF, hypertension and atrial fibrillation. Interventions included administer medications as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no cognitive impairment. Review of the resident's monthly physician orders for September 2024 identified orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to secure and store medications appropriately. This affected one (#38) of two residents observed during medication administration. The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 07/19/23 with the latest readmission of 12/16/23, diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory therapy, congestive heart failure, hypertension, atrial fibrillation and chronic pain. Review of the plan of care dated 09/14/23 revealed the resident had a physician's order for unsupervised, self-administration of the nebulizer treatments. Interventions included assess ability to safely self administer medications on admission/readmission, quarterly, with change in medication orders and with significant changes in condition, discuss medications with each supervised administration, demonstrate correct administration as required, review…

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

Based on observation and staff interview, the facility failed to ensure puree food items were cooked and brought back up to temperature following the completion of puree method. This affected two of two residents residing in the 400 house. The census was 50. Findings included: Review of the facility's menu for house 400 revealed the scheduled meal on 09/10/24 for the lunch meal was potato soup, deli sandwich with lettuce, tomato and onion, orange sections and milk. On 09/10/24 at 11:10 A.M., State Tested Nursing Assistant (STNA) #119 was observed to prepare the lunch menu for house 400. STNA #119 opened a can of carrots and placed contents into a blender and pureed the carrots to the appropriate consistency. Interview at the time of the observation revealed the house had two residents (#8 and #34) who received a pureed diet. The STNA then placed the pureed carrots into two bowls and served them to resident #8 and #34. On 09/20/24 at 11:14 A.M., interview with STNA #119 verified the carrots were not heated, seasoned or brought back to temperature after being pureed.

Based on observations, interview, medical record review, and review of diet guides the facility failed to ensure Resident #40 was served food appropriate for a soft and bite sized texture diet and Resident #52 was served food appropriate for a pureed texture diet. This affected two residents (#40 and #52) of five residents on a puree diet and three residents on a soft and bite sized diet. The facility census was 50. Findings include: 1. Review of Resident #40's medical record revealed an admission date of 12/17/21, diagnoses included diastolic heart failure, dysphagia, and nutritional anemia. Review of Resident #40's physician order dated 06/18/24 revealed an order for a soft and bite sized diet with no added salt and a half portion of dessert. Observation of on 09/10/24 at 12:40 P.M. of the lunch meal revealed Resident #40 was served a whole sandwich with lunch meat and tomato, soup, and orange segments. She was observed taking several bites of the sandwich. Interview on 09/10/24 at 12:47 P.M. with Dietitian #150 verified Resident #40 was on a soft and bite sized diet and should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure one resident (#32) was provided the physician ordered adaptive equipment for meals. This affected one of nine residents reviewed for nutrition. The facility census was 50. Findings Include: Review of the medical record for Resident #32 revealed an initial admission date of 01/21/23 with the latest readmission of 07/06/24, diagnoses included osteoarthritis, vitamin D deficiency, chronic pain syndrome, major depressive disorder, dementia with behavioral disturbances, intellectual disabilities and hypertension. Review of the plan of care dated 01/21/23 revealed the resident was at possible nutrition/dehydration risk due to health status, low total protein levels, use of therapeutic diet, elevated body mass index (BMI), oral nutritional supplement usage, currently edentulous without appliance status and history of significant weight changes. Interventions included diet as ordered, encourage to drink fluids and eat snacks between…

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 maintain a complete and accurate medical record. This affected two (#11 and #31) of 24 sampled residents. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 04/07/23 with the latest readmission of 01/12/24, diagnoses included hypertensive heart disease with heart failure, asthma, pain, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, severe morbid obesity, vitamin D deficiency, pancytopenia, obstructive sleep apnea and gastro-esophageal reflux disease. Review of the plan of care dated 01/12/24 revealed the resident had an alteration in respiratory status related to COPD, asthma and chronic respiratory failure. Interventions included elevate head of bed due to difficulty breathing when lying flat, monitor for shortness of breath, chest pain or change in condition, monitor oxygen saturation rate, monitor respiratory status, oxygen 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.

Based on observation and interview the facility failed to ensure Resident #45's room was maintained in a clean and homelike manner and failed to ensure appropriate water temperature and water drainage for Resident #33. The facility census was 50. Findings include: 1. Observation on 09/09/24 at 11:53 A.M. and 2:44 P.M. and on 09/16/24 at 10:35 A.M. revealed Resident #45's bed was against the wall and a couple inches below the window. The window ledge was observed to have unidentifiable splatters and was chipped in several spots. Interview on 09/16/24 at 10:35 A.M. with Agency Aide #155 verified the observation. 2. Interview on 09/09/24 at 11:00 A.M. with Resident #33 revealed her sink was not draining appropriately. She additionally reported the water did not get hot and made it difficult to wash her face. Observation on 09/09/24 at 11:00 A.M. revealed Resident #33's bathroom sink filled up quickly without draining and the water was lukewarm after running it for several minutes. Observation on 09/16/24 at 11:15 A.M. with Maintenance #157 revealed Resident #33's bathroom sink filled…

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 resident representatives were informed of all medical appointments. This affected one (Resident #32) of three residents reviewed for medical appointments. The census was 56. Findings include: Review of the medical record for Resident #32 revealed Resident #32 was admitted to the facility on [DATE]. Resident #32's medical diagnoses included but were not limited to hemiparesis and hemiplegia, chronic kidney disease (stage III), type two diabetes, chronic obstructive pulmonary disease, sickle cell trait, epilepsy, cognitive communication deficit, dysphagia, vascular dementia, and hypertension. Review of Resident #32's medical record revealed Resident #32's daughter was his power of attorney. Review of Resident #32's Minimum Data Set assessment, dated 11/27/23, revealed he had a mild cognitive impairment. Review of Resident #32's physician orders revealed a heart and vascular appointment was scheduled for 01/09/24. The order also…

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 food was dated, not kept past its use by date, thermometers were in place to monitor refrigerator and freezer temperatures, eggs were pasteurized, and that food temperatures were obtained prior to serving meals to residents. This was observed in all five kitchens. This had the potential to affect 56 of 56 residents who consumed food from the kitchen. Findings include: 1. Observation of the kitchen in building 401 on 05/15/23 at 9:30 A.M. revealed an undated and unlabeled container of an unidentified food, that Household Aide #240 reported was soup, an opened container of coleslaw dated 05/04/23, a whole rotisserie chicken dated 04/27/23, a container of vanilla yogurt dated February 2023, and two containers of Kentucky Fried Chicken's (KFC) coleslaw. Interview on 05/15/23 at 9:30 A.M. with Household Aide #240 verified the observations. She reported the dietary manager was supposed to go through the refrigerators. She reported leftovers should be kept for seven days. Observation 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 record review, staff interviews, and facility policy review, the facility failed to notify the physician and resident representatives of a significant weight change for three residents (Residents #1, #12, and #45), a new skin condition for one resident (Resident #12), and one cognitively impaired resident's (Resident #53) continued refusals for intravenous hydration and hospitalization with a critically high potassium level. The deficient practice affected four residents (Residents #1, #12, #45, and #53) of four residents reviewed for notification of change. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, diabetic chronic kidney disease Stage III, and aphasia following stroke. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop comprehensive care plans that included activities, bladder and bowel, nutrition, hydration, respiratory care, position, mobility, and behaviors. This affected six residents (#3, #12, #33, #39, #45, and #53) of 27 records reviewed. The facility census was 56. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 03/10/23 revealed the resident was at risk for dehydration due to low fluid balance. Interventions included encouraging fluids. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews and facility policy review, the facility failed to ensure personal hygiene was completed for six residents (#7,#13, #24, #31, #33, #41), who were dependent on staff. Additionally the facility failed to ensure two residents (#8, #21) received scheduled showers. This affected eight of ten residents reviewed for activities of daily living (ADLs). The facility census was 56. Findings Included: 1. Review of the medical record for Resident #7 revealed an initial admission date of 05/03/21 with the latest readmission of 11/30/22 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, chronic peripheral venous insufficiency, diabetes mellitus, hypertension, hyperlipidemia, right knee contracture, left knee contracture, gout, gastro-esophageal reflux disease and pain. Review of the plan of care dated 05/06/21 revealed the resident had a self-care deficit and/or physical mobility performance deficit 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the activities calendar, the facility failed to provide activities in the evening and on the weekends, which had the potential to affect cognitively impaired residents, additionally, the facility failed to develop an individualized activity plan for Resident's #7, #39, and #210, and provide independent activities for Resident #12 and #210. This affected four residents (#7, #12, #39, and #210) of four reviewed for activities and had the potential to affect all cognitively impaired residents in the facility. The facility census was 56. Findings include: 1. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never…

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 one resident (#24) received appropriate and timely treatment for a urinary tract infection (UTI). This affected one of four residents reviewed for catheter/UTI. Also, the facility failed to ensure indwelling urinary catheter collection bag was covered with a privacy bag for four residents (#1, #24,#52, #53) reviewed for indwelling urinary catheter and one resident (#210) reviewed for bowel and bladder. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admission date of 07/05/22 with the diagnoses including senile degeneration of brain, dementia, severe protein calorie malnutrition, dysphagia, hyperlipidemia, osteoarthritis, hypertension, bipolar disorder, diverticulosis of intestine, retention of urine and disorders of bladder. Review of the admission screen and baseline care plan dated 07/05/22 revealed the resident was admitted was admitted to the facility with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to ensure nutritional supplements were administered as ordered to three residents (Residents #1, #45, and #210), failed to timely address significant weight changes for two residents (Residents #1 and #12), and failed to ensure fluids were kept within reach of two residents (Residents #12 and #53). This deficient practice affected five residents (Residents #1, #12, #45, #53, and #210) out of 12 residents reviewed for nutrition and hydration. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following stroke, Type II Diabetes Mellitus, diabetic chronic kidney disease Stage III, and major depressive disorder-recurrent. Review of the admission Minimum Data Set (MDS) 3.0 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure staff were competent to serve meals according to the menu and diet order, to obtain temperatures prior to serving food, and use appropriate serving sizes. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56. Findings include: 1. Review of the menu for the lunch meal on 05/17/23 revealed residents were to receive four ounces of a hot turkey sandwich, 0.5 cups of coleslaw, one banana, eight ounces of milk, and dessert of choice. Observation of the lunch meal in the 400 building on 05/17/23 from 11:49 A.M. to 1:41 P.M. revealed the following concerns: a. State Tested Nursing Aide (STNA) #250 prepared lunch which included hot turkey sandwiches she put turkey, cheese, tomato, spinach, and ranch dressing on bread and put it in the oven. She reported they did not have to follow a recipe for all meals, including this one. She reported there was a recipe book, however, it took her and STNA #251 several…

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

Based on observation, interview, and review of the menu, the facility failed to ensure the menu, recipes, and portion sizes were followed in all buildings. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56. Findings include: 1. Review of the facility menu for 05/15/23 revealed the breakfast meal consisted of two waffles, one cup of cold cereal or hot cereal, one egg of choice, two slices of toast, half a cup of fruit and eight ounces of milk. Observation of the breakfast meal on 05/15/23 in house 402 revealed the following: On 05/15/23 at 10:15 A.M., observation of Resident #41 revealed he was served a small bowl of oatmeal (one package of instant oatmeal), and an eight ounce of orange juice. On 05/15/23 at 11:23 A.M., observation of the resident revealed the resident consumed the oatmeal and the orange juice. State Tested Nursing Assistant (STNA) #301 picked up the empty bowl and the resident stated, don't take that. The STNA asked the resident if he wanted more food, the resident stated, yes. STNA #301 stated, I will get…

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 interviews, record review, and facility policy review, the facility failed to ensure four residents (Residents #3, #25, #41, and #44) were served the appropriate textured diet as ordered. The deficient practice affected four residents (Residents #3, #25, #41, and #44) of 12 residents reviewed for food and nutrition. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS)…

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

Based on observation and interview, the facility failed to ensure the environment was maintained in a clean, odor free, and homelike manner for Resident #1, #2, #10, #17, #12, and #39. This affected six residents (#1, #2, #10, #12, #17, and #39) of nine residents reviewed for environment. The facility census was 56. Findings include: Observation on 05/15/23 and 05/16/23 revealed the following environmental concerns: a. Observation on 05/15/23 at 9:42 A.M. revealed Resident #12 had a variety of unidentifiable stains on her carpet. b. Observation on 05/15/23 at 10:30 A.M. revealed Resident #2's carpet had multiple black stains throughout the room. His bathroom floor was observed to have multiple black marks. Interview on 05/15/23 at 10:30 A.M. with Resident #2's wife revealed she cleaned every time she visited because the staff did not clean. c. Observation on 05/15/23 at 10:56 A.M. revealed Resident #1's room had a strong odor of urine. d. Observation on 05/16/23 at 8:23 A.M. revealed Resident #39's carpet had black stains in multiple locations. e. Observation on 05/16/23 at 8:24…

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 interview and record review the facility failed to ensure Resident #19's advanced directives were in the electronic medical record and failed to ensure Resident #12 and #29's advanced directives matched the signed documents. This affected three residents (#12, #19, and #29) of seven reviewed for advanced directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 11/07/22 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, depression, hypertension, fibromyalgia, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed cognition was not assessed but staff interview revealed Resident #19 had no memory concerns and no delirium. She was independent for cognitive skills for daily decision making. Review of the physician's orders and care plan on 05/15/23 revealed no mention of Resident #19's code status. Review of Resident #19's physician's 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 record review, staff interview, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Resident #3 and #13) to address changes in status, including the need for supervision with all meals and discontinuation of a wound vac. The deficient practice affected two residents (Resident #3 and #12) of 23 residents reviewed in the final sample for care plans. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two…

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 assess and document on new skin concerns for Resident #10 and Resident #12, and failed to ensure hospice documentation in facility for Resident #210. The facility census was 56. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 06/11/16 with diagnoses including cerebral infarction, multiple sclerosis, paraplegia, anxiety disorder, contracture's of left and right hand, unspecified dementia, peripheral vascular disease, and as of 03/24/23 fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. Review of the plan of care dated 05/16/23 revealed Resident #10 had a skin tear to the left ankle and interventions included identifying potential causative factors and eliminating and resolving when possible, treat according to facility protocol and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to provide timely and necessary treatment and services to residents with pressure ulcers to prevent, promote healing and decrease the risk of decline of pressure ulcers. This affected three residents (#13, #52, and #159) of four residents reviewed for pressure ulcers. The facility census was 56. Findings Include : 1. Review of the medical record for Resident #159 revealed an admission date on 05/01/23. Medical diagnoses included nondisplaced fracture of right femur, displaced fracture of olecranon process of right ulna (forearm), congestive heart failure (CHF), hypotension (low blood pressure), anemia (low iron level), and hypertension (high blood pressure). Although there was no indication Resident #159 had a sacral wound on the diagnosis list at the time of admission, review of the hospital records…

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, and staff interviews, the facility failed to obtain a physician's order for the use of an orthopedic back brace for one resident (Resident #3). This affected one resident (Resident #3) out of five residents reviewed for positioning and range of motion. The facility census was 56. Findings Include: Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), except eating. The resident required limited assistance from one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure oxygen nasal cannula tubing was changed weekly as physician ordered for two residents (#3, #40). Also, the facility failed to ensure respiratory equipment was stored properly to prevent infection for Resident #40. This affected two of two residents reviewed for oxygen therapy. The facility identified seven residents receiving respiratory treatments. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 08/12/20 with the latest readmission of 05/02/23 with the diagnoses including cerebrovascular accident with right sided hemiplegia, diabetes mellitus, atrial fibrillation, hypertension, gastro-esophageal reflux disease, hyperlipidemia, cardiomyopathy, anemia, chronic kidney disease and dysphagia. Review of the plan of care dated 03/28/23 revealed the resident had an altered respiratory status/difficult breathing related to cardiac difficulties. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the physician failed to date when he addressed pharmacy recommendations and failed to provide reasoning for declining a gradual dose reduction (GDR) recommendation from the pharmacist for Resident #29. This affected one resident (#29) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record revealed an admission date of 12/22/21 with diagnoses including Parkinson's disease, paranoid personality disorder, essential tremor, anxiety disorder, unspecified hearing loss, dementia, depression, dysphagia, and delusional disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had impaired cognition. During the lookback period she received antipsychotic's, antianxiety medications, and antidepressants. Review of the medication regimen review (MRR) summary dated 06/03/22 revealed the pharmacist made a recommendation related to Resident #29 to add a stop date for Enoxaparin. The physician…

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 medication parameters were monitored as ordered for Resident #12. This affected one resident (#12) of five reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/07/22 with diagnoses including chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease stage three, adult failure to thrive, acquired absence of left leg above knee, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the physician order dated 04/17/23 revealed Resident #12 was to receive Metoprolol Succinate extended release 100 milligrams (mg) one and a half tablets at bedtime. The medication had parameters to hold for systolic blood pressure less than 100 mm/hg and 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 record review and staff interview, the facility failed to ensure antipsychotics were used with a proper diagnosis for two resident (Residents #3 and #46). The deficient practice affected two (Residents #3 and #46) of five residents reviewed for unnecessary medications. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #3 requires extensive assistance from one to two 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 observation, interview, and medical record review, the facility failed to ensure Resident #19's prescribed medications were stored securely. This affected two residents (#10 and #19) of two residents reviewed for medication storage. The facility census was 56. Findings include: 1. Observation on 05/15/23 at 2:40 P.M. of Resident #19's room revealed she had seven unknown pills in a medicine cup in her room. Resident #19 reported she was unsure when it was from and did not know if she should take it. Interview on 05/15/23 at 2:45 P.M. with Agency Registered Nurse #304 verified the observation. She reported she had just done change over with the previous nurse. She did not know what the pills were or when they were supposed to be administered. Review of the medical record for Resident #19 revealed an admission date of 11/07/22 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, depression, hypertension, fibromyalgia, and mild cognitive impairment. Review of the quarterly Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to serve pureed foods in an appropriate and palatable manner. This affected one resident (#25) of two receiving a pureed diet. The facility census was 56. Findings include: Review of the medical record revealed Resident #25 admitted on [DATE] with diagnoses including dementia, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit, bell's palsy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was rarely or never understood. She was on a mechanically altered diet. Review of the diet order dated 04/08/23 revealed she was to be getting a regular diet with pureed texture. Observation on 05/22/23 at 8:52 A.M. revealed State Tested Nursing Aide (STNA) #225 feeding Resident #25 unidentifiable food out of one bowl. Interview with STNA #225 at that time revealed she was unsure what Resident #225 was eating, and thought it was eggs.…

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, review of the facility menu and facility policy review, the facility failed to ensure one resident (#41) received the requested food as scheduled on the facility menu. This affected one of 12 residents residing in house 402. The facility census was 56. Findings included: Review of the facility menu for 05/15/23 revealed the breakfast meal consisted of two waffles, one cup of cold cereal or hot cereal, one egg of choice, two slices of toast, half a cup of fruit and eight ounces of milk. On 05/15/23 at 10:15 A.M., observation of Resident #41 revealed he was served a small bowl of oatmeal (one package of instant oatmeal), and an eight ounce of orange juice. On 05/15/23 at 11:23 A.M., observation of the resident revealed the resident consumed the oatmeal and the orange juice. State Tested Nursing Assistant (STNA) #301 picked up the empty bowl and the resident stated, don't take that. The STNA asked the resident if he wanted more food, the resident stated, yes. STNA #301 stated, I will get you an ensure. The resident was provided a container of Ensure (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, interview, and policy review, the facility failed to ensure Resident #31 and #210 received timely meal assistance and that Resident #15 was served lunch without intervention. This affected three out of three people observed for timely meals. The facility census was 56. Findings include: 1. Review of the medical record for Resident #210 revealed an admission date of 04/30/23 with diagnoses including end stage renal disease, unspecified systolic heart failure, malignant neoplasm of prostate, retention of urine, type two diabetes mellitus, and chronic pulmonary edema. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #210 was rarely or never understood. He required the extensive assistance of one person for eating. 2. Review of the medical record for Resident #31 revealed an admission date of 06/27/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage…

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, and resident and staff interviews, the facility failed to accurately document the administration of nutritional supplements for two residents (Resident #1 and #45). The deficient practice affected two residents (Resident #1 and #45) of 12 residents reviewed for food and nutrition. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the physician order dated 03/01/23 to 05/17/23 revealed an order for health shake three times a day. Review of the supplement documentation revealed State Tested Nursing Aide (STNA) #251 indicated Resident #45 consumed 100% of a supplement twice on 05/17/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection in the area of wound care, incontinence care, glucometer (machine used to check blood sugar), and proper storage of catheter bags. The deficient practices had the potential to affect one (Resident #53) of four residents reviewed for catheters, one (Resident #13) of four residents reviewed for pressure ulcers, one (Resident #13) of one residents reviewed for incontinence care, and one (Resident #17) of one residents reviewed for glucometer testing. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #13 revealed an initial admission date of 12/21/15 with the latest readmission of 12/27/18 with the diagnoses including multiple sclerosis (MS), major depressive disorder, thiamine deficiency, hyperlipidemia, hypertension, nonpsychotic mental disorder, irritable bowel syndrome, dysphagia, contracture 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.