Galion Meadows Skilled Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents were was free from accident hazards. This affected one (#31) of three residents reviewed for accidents. The facility census was 55. Findings include:Review of the medical record for Resident #31 revealed an admission date of 01/27/26. Diagnoses included pulmonary embolism, emphysema, chronic obstructive pulmonary disease, and asthma.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 revealing the resident had intact cognition. Additionally, the resident was dependent for bed mobility, transfers, and activities of daily living.Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls.Review of the plan of care dated 05/15/26 revealed the resident was at risk for falls due to generalized weakness, history of falls, decreased strength and endurance, and need 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 observation, review of the medical record, interview, and policy review, the facility failed to ensure interventions were implemented for significant weight loss, failed to monitor fluid restrictions, and failed to provide nutritional supplements per physician orders. This affected three (#1, #38, #27) of three residents reviewed for nutrition. The facility identified three residents with significant weight loss, two residents with fluid restrictions, and five residents receiving nutritional supplements. The facility census was 55. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/27/26. Diagnoses included trigeminal neuralgia, atrial fibrillation, heart failure, pneumonitis, and pleural effusion.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with eating meals. Review of hospital documentation dated 04/24/26 revealed Resident #1 weighed 130 pounds prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure placement of a gastrostomy tube prior to administering a gastrostomy tube flush. This affected one (#9) of one resident reviewed for tube feeding. The facility identified one resident with a feeding tube. The facility census was 55. Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/27/25. Diagnoses included chronic pancreatitis, gastrostomy status, type two diabetes mellitus, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition.Review of the care plan initiated 08/18/25 and revised on 05/01/26 revealed the resident had a gastrostomy feeding tube with interventions to provide enteral nutrition per physician orders, flush feeding tube per physician orders, and check for tube placement and residual as indicated. Review of a physician order dated 05/28/25 revealed to check tube…

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received the necessary respiratory care and services to meet their needs. This affected one (#29) out of two residents reviewed for respiratory care. The facility census was 55.Findings include:Review of the medical record for the Resident #29 revealed an admission date of 09/24/24. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, chronic atrial fibrillation, and chronic combined systolic and diastolic heart failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Additionally, the resident experienced shortness of breath with exertion, at rest, and while lying flat.Review of the plan of care dated 01/05/25 and revised 04/27/25 revealed the resident had impaired respiratory status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure ongoing communication with the dialysis services provider. This affected one (#27) of one resident reviewed for dialysis services. The facility identified two residents as receiving dialysis services. The facility census was 55. Findings include:Review of the medical record for Resident #27 revealed an admission date of 01/10/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, end stage renal failure, chronic kidney disease, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan dated 02/07/25 revealed the resident had end stage renal disease and was receiving dialysis services. An intervention dated 02/27/26 revealed for staff to coordinate resident's care in collaboration with the dialysis center.…

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 that residents with post-traumatic stress disorder (PTSD) received necessary care and services to meet the resident's psychosocial needs. This affected two (#31 and #03) of two residents reviewed for trauma informed care. The facility census was 55.Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 01/27/26. Diagnoses included pulmonary embolism without acute cor pulmonale, chronic obstructive pulmonary disease, asthma, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition and that the resident had a diagnoses that included post-traumatic stress disorder. Review of the plan of care dated 03/19/26 and revised 05/18/26 revealed the resident had an impaired psychiatric and mood status related to anxiety, bipolar disorder, 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, interviews, record review, review of hospital records and policy review, the facility failed to facilitate guardianship and appropriate behavioral health services to meet the complex psychosocial needs of a resident with schizoaffective disorder, post-traumatic stress disorder (PTSD), depression, anxiety, and an intellectual disability, which resulted in Resident #03 continuing with behaviors that were detrimental to his psychosocial and physical well-being. This affected one resident (#03) of two residents reviewed for behaviors. The facility census was 55. Findings include:Review of the medical record for Resident #03 revealed an original admission date of 07/17/19 with a discharge to a local hospital on [DATE] and readmission of 12/09/25. Pertinent diagnoses included: Paraplegia, Type 2 diabetes mellitus, schizoaffective disorder, bipolar type; cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder, unspecified…

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, review of the medical record, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders resulting in a medication error rate exceeding five percent. 26 opportunities were observed with three medication errors, resulting in a medication error rate of 11 percent. This affected two (#27 and #52) of six residents observed for medication administration. The facility census was 55. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 11/04/24. Diagnoses included paranoid schizophrenia, vascular dementia with behavioral disturbance, bipolar disorder, dysphagia, anxiety, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 11/04/25 revealed an order for Robitussin Cough plus Chest Congestion DM (dextromethorphan) oral liquid 20 milligrams (mg)/200 mg per 20 milliliters (ml), give 10 ml…

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, review of the medical record, staff interview, and policy review, the facility failed to ensure a mechanical soft diet was provided per physician orders. This affected one resident (#38) of two residents reviewed for food. The facility census was 55. Findings include: Review of the medical record for Resident #38 revealed an admission date of 02/14/26. Diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of the care plan dated 02/20/26 and last revised 05/13/26 revealed the resident was at risk for altered nutritional status due to significant weight loss and a mechanically altered diet. One intervention noted providing meals/snacks/fluids based on resident food preferences and physician orders.Review of a physician order dated 03/02/26 revealed the resident was ordered a regular diet with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and review of the facility policy, the facility failed to ensure residents received the coronavirus (Covid-19) vaccination upon consent. This affected one (#22) of five residents reviewed for vaccinations. The facility census was 55.Findings Include: Review of the medical record for Resident #22 revealed an admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic bronchitis, and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had impaired cognition. Further review of the MDS revealed Resident #22 was not up to date on the Covid-19 vaccination. Review of the care plan dated 06/25/25 revealed Resident #22 had impaired respiratory status related to COPD, and pulmonary disease. Interventions included labs and diagnostics testing as ordered, and treatments as ordered by physician. Review of the Vaccine Informed Consent Form dated 10/31/25 revealed the facility offered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, family, and staff interviews, and record review, the facility failed to ensure a pleasant homelike environment free of frequent strong foul odors of urine on the North and South units of the facility and failed to ensure the resident's wheelchairs were clean. This had the potential to affect 38 residents residing on the North and South units and affected three (Residents #25, #40, and #43) of four residents whose wheelchairs were observed for cleanliness. The facility census was 51.Findings include: 1. Observation and interview on 12/08/25 at 2:48 P.M. revealed a strong foul odor of urine upon entering the facility. Tour of the facility confirmed the strong odor was throughout the North and South resident living areas. The Director of Nursing (DON) confirmed the odor. Observations and interviews on 12/08/25 at 3:00 P.M. with Resident #17, at 3:06 P.M. with Resident #24, at 3:24 P.M. with Resident's husband revealed the hallways had a strong foul odor of urine. Observations 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 observations, staff interviews, record review, review of manufacturer instructions, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policies, the facility failed to maintain infection control practices while administering medications to the residents, completing hand hygiene when providing care to the residents, donning proper personal protective equipment (PPE) and completing proper hand hygiene for residents on Enhanced Barrier Precautions (EBP) for indwelling devices, and disinfecting a glucometer between use for Residents #4 and #5. This affected six residents (#4, #5, #34, #37, #40, and #47) observed for infection control. The facility census was 51.Findings include:1. Observation of medication administration and staff interview on 12/09/25 at 10:28 A.M. revealed after Registered Nurse (RN) #221 exited Resident #34's room, RN #221 did not wash his hands or use hand sanitizer. RN #221 returned to the medication cart and prepared Resident #40's insulin…

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 resident representative interview, staff interviews, record review, and review of the facility policy, the facility failed to inform a resident's resident representative of a incident involving the resident. This affected one (Resident #37) of three residents reviewed for being informed of health condition. The facility census was 51.Findings include:Record review for Resident #37 revealed an admission date of 11/05/21. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and cognitive communication deficit.Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired. The medical record revealed Resident #37's son was the responsible party and Emergency Contact #1.The progress note dated 12/03/25 (Wednesday) completed by Director of Nursing (DON) revealed a Certified Nursing Assistant (CNA) reported to nurse Resident #37 had a skin tear on top of right foot. Upon…

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, and record review, the facility failed to obtain urine outputs as physician ordered for a resident and failed to ensure a resident's new areas of skin breakdown were timely assessed and treated. This affected one (Resident #37) of three residents reviewed for quality of care. The facility census was 51.Findings include:Record review for Resident #37 revealed an admission date of 11/05/21. Diagnoses included diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, muscle weakness, and lack of coordination.Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired. Resident #37 had impairment on one side to the upper and lower extremities, was dependent on staff for toileting hygiene, bed mobility, frequently incontinent bowel and bladder, and had no skin ulcer/injury treatments. a. Review of 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 observation, staff interview, and record review, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer). This affected one (Resident #37) of two residents reviewed for transfers. The facility census was 51.Findings include:Record review for Resident #37 revealed an admission date of 11/05/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid, severe obesity, cognitive communication deficit, muscle weakness, lack of coordination, and need for assistance with personal care.Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired, had impairment on one side to the upper and lower extremities, and was dependent on staff for bed mobility. Review of the care plan dated 12/03/24 revealed Resident #37 had an activity of daily living self-care performance deficit related to impaired mobility, shortness of breath, hemiplegia,…

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 interviews, record review, review of the facility policy, and review of the insulin pen guidance, the facility failed to ensure their medication error rate did not exceed five percent (%). Two errors occurred within 27 opportunities for an error rate of 7.4%. This affected one (Resident #40) of five residents observed for medication administration. The facility census was 51.Findings include:Record review for Resident #40 revealed an admission date of 09/13/19. Diagnoses included type II diabetes mellitus (DM).Review of the care plan dated 04/27/25 revealed Resident #40 had an impaired metabolic status related to DM. Interventions included to administer medications as indicated by physician orders.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired, had a diagnosis of DM and received daily injections.Review of the physician orders for December 2025 for Resident #40 included orders for Basaglar Kwikpen subcutaneous…

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 interviews, record review, review of the facility policy, and review of the insulin pen guidance, the facility failed to ensure a resident was free from significant medication errors when nursing failed to prime insulin pens prior to insulin administration. This affected one (Resident #40) of five residents observed for medication administration. The facility census was 51.Findings include: Record review for Resident #40 revealed an admission date of 09/13/19. Diagnoses included type II diabetes mellitus (DM).Review of the care plan dated 04/27/25 revealed Resident #40 had an impaired metabolic status related to DM. Interventions included to administer medications as indicated by physician orders.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired, had a diagnosis of DM and received daily injections.Review of the physician orders for December 2025 for Resident #40 included orders for Basaglar Kwikpen subcutaneous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to timely complete nutritional assessments and requests to obtain resident weights to monitor and provide intervention for continued weight increases. This affected one (#28) of three residents reviewed for nutrition and weights. The census was 48.Findings Include:Review of the medical record for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, unspecified convulsions, hypothyroidism, morbid obesity, type II diabetes, chronic obstructive pulmonary disease, dysphagia, muscle weakness, anxiety disorder, and major depressive disorder. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of Resident #28's weights, dated April 2025 to October 2025, revealed on 04/01/25 the resident weighed 286.6 pounds and on 05/01/25 the resident weighed 302.6 pounds, which represented a 5.6 percent…

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 resident and staff interview, the facility failed to obtain ordered medications to administer to residents. This affected one (#28) of three residents reviewed for medication administration. The facility census was 48.Findings include:Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included chronic kidney disease, unspecified convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema.Review of a plan of care dated 03/24/25 revealed Resident #28 had the potential for pain. Interventions included to administer medications per physician orders, encourage the resident to request pain medication before the pain becomes too intense, and to monitor for changes in usual activities.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and did not receive opioid medication.Review of a nursing progress note dated 10/09/25 at 4:40 P.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 record review and staff interview, the facility failed to ensure Resident #44 ' s guardian was informed about the potential charges for therapy and the beginning of services, which affected one (#44) of three residents reviewed for therapy, and the facility failed to ensure informed consent was obtained prior to initiating dental services for Resident #44. This affected one resident (#44) of three residents reviewed for ancillary services. The facility census was 51. Findings Include:1.) Review of the Resident #44's medical record revealed an admission date of 03/09/17 with diagnoses including Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition, anxiety, depression, heart failure, adult antisocial behavior, adult failure to thrive, and liver disease.Review of Resident #44's guardianship paper dated 10/06/22 revealed his daughter was the court appointed guardian.Review of Resident #44's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed he was rarely or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interview, the facility failed to complete physician ordered laboratory work required prior to an appointment for Resident #17, resulting in the appointment needing to be rescheduled. The facility failed to complete neurological assessments for Resident #1, after a fall with a head injury. This affected two (#1 and #17) of three residents reviewed for quality of care and treatment. The facility census was 51.Findings include: 1. Review of Resident #17's medical record revealed an admission date of [DATE] with diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure.Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Review of Resident #17's progress note dated [DATE] revealed she returned from a nephrology appointment with a follow up appointment to take place on [DATE]. The physician requested laboratory test be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure parameters for Resident #1's midodrine (to treat low blood pressure) were entered correctly into the medical record and midodrine was administered according to the parameters ordered. This affected one (#1) of three residents reviewed for medications being administered correctly. The facility census was 51.Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE] and expired on [DATE]. Resident #1 had diagnoses that included but not limited to Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes. schizoaffective disorder/bipolar type, and depressive disorder. Review of the modification of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. Review of physician orders revealed on [DATE] Resident #1 was ordered midodrine five milligram (mg) three times a day for hypotension. Midodrine was to be held for systolic blood pressure (SBP)…

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, family interview, and staff interview, the faciltiy failed to obtain physician ordered laboratory tests for one resident. This affected one (#17) of three residents reviewed for physician orders. the faciltiy census was 51. Findings include:Review of Resident #17's medical record revealed an admission date of 01/15/25 with diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #17's progress note dated 01/20/25 revealed she returned from a nephrology appointment with a follow up appointment to take place on 07/20/25. The physician requested laboratory tests be drawn on 07/14/25 prior to the appointment. Review of Resident #17's physician order dated 01/20/25 revealed on 07/14/25 laboratory test were to be completed. The laboratory test included a complete blood count…

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, record review, and review of wound care policy, the facility failed to follow the appropriate infection control guidelines when changing dressing for Resident #28's wound. This affected one (#28) of two residents observed for infection control practices. The facility census was 51.Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease. Review of the significant change Minimum Data Set, dated [DATE] revealed Resident #28 had severe cognitive impairment. Review of a wound evaluation note dated 09/08/25 at 2:01 P.M. revealed Resident #28 had a skin tear to the right lower leg. The skin tear measured 2.5 centimeters (cm) long and 0.8 cm wide and was 0.1 cm deep. Review of the new order, received on 09/11/25 ,to cleanse the skin tear to Resident #28's right lower leg with normal saline or wound cleanser, apply Vitamin A and…

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

Based on observation, staff interview, record review, and review of manufacturer guidelines, the facility failed to ensure the dishwasher reach the minimum temperature to sanitize dishware properly. This had the potential to affect all residents who receive food from the kitchen. The facility identified only one resident who did not receive food from the kitchen. The facility census was 46. Findings include: Observation on 12/02/24 at 9:30 A.M. of dishwasher revealed the dishwasher as model ES 2400. Wash temperature was observed to be 110 degrees Fahrenheit (F) and rinse cycle of 130 degrees F. Interview with Dietary Aide #200 verified the wash cycle was only 110 degrees F. Dietary Aide #200 stated she believed it should be at 120 degrees F. Review of the facility's Dish Machine log for November 2024 revealed there were no temperatures documented from 11/13/24 through 11/17/24 for breakfast and lunch. No documentation for 11/19/24 and 11/22/24 for any meal. All other documentation revealed temperatures of 120 degrees F. Review of the dishwasher guidelines revealed the minimum wash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review, the facility failed to provide activities of daily living care (ADL) for dependent residents who required assistance from staff with bathing/showers. This affected three of three residents (#38, #41, and #52) reviewed for showers. The facility identified all residents required assistance with showers and bathes. The facility census was 42. Findings include: 1. Review of Resident #38's medical record revealed an admission date of 07/24/24. Diagnoses included Parkinson's disease, morbid obesity, femur fracture, and acute respiratory failure. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial/maximum assistance from staff for showers and bathing. Review of Resident #38's care plan revealed she was dependent on staff for bathing and would be clean, dry, and odor free, and appropriately groomed through next review period. Interventions included to…

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

Based on observation, staff interviews, record review, and policy review, the facility failed to implement their infection control policies ensuring staff wore the proper personal protective equipment (PPE) and have PPE readily available outside the residents' rooms. This affected one (#22) of two residents reviewed for contact precautions, This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: Review of the medical record for Resident #22 revealed and admission date of 08/15/24, with diagnoses including hypoxic ischemic encephalopathy, hemiplegia, and COVID-19 acute respiratory disease. Review of the medical record for Resident #22 revealed Resident #22 tested positive for COVID on 08/24/24. A progress note dated 08/25/24 revealed Resident #22 is droplet precautions/isolation due to testing positive for COVID. Review of the Care plan for Resident #22 revealed maintain droplet/contact isolation precautions and personal protective equipment as indicated on 08/24/24. Review of Resident #22's 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.

Based on record review and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 50 residents residing in the facility. Facility census was 50. Findings include: Review of the posted nursing staff information and staff schedule revealed on 06/15/24 and 06/16/24 there was no RN present or working in the facility. Review of pay schedules/time sheets for 06/15/24 and 06/16/24 revealed there was no RN that clocked in for work on 06/15/24 and 06/16/24. Interview with the Administrator on 06/18/24 at 11:07 A.M. confirmed there was no RN who worked on 06/15/24 or 06/16/24. Interview with the Director of Nursing (DON) on 06/18/24 at 12:49 PM confirmed there was no RN scheduled to work on 06/15/24 and 06/16/24. This deficiency represents non-compliance investigated under Complaint Number OH00154558.

Based on observations, review of activities calendars, review of resident council minutes, review of activities director job description, review of policy, family member interview, and staff interviews, the facility failed to ensure a variety of ongoing resident centered activities were offered over various times throughout the day and staff were available to implement the scheduled activities. The deficient practice had the potential to affect all 54 residents in the facility. The facility census was 54. Findings include: Review of the February 2024 Activity Calendar revealed four to five events were scheduled for each weekday of the month other than two Valentines day parties on 02/14/24. Review of the February Activity Staffing schedule revealed two activity time slots for each weekday. Activity staff were missing for the 2:00 P.M., afternoon activity on 02/14/24, 02/20/24, 02/21/24, 02/28/24, and 02/29/24. The days of 02/19/24, 02/26/24, and 02/27/24 did not show staff coverage for any activity on each day. Review of the Elder Council Meeting Minutes dated 02/23/24 revealed the…

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

Based on observation, staff interviews, review of cleaning procedure log and review of cleaning schedule, the facility failed to ensure that the kitchen ice machine is kept clean. The deficient practice had the potential to affect 53 residents who receive ice from the machine, excluding Resident #7 (who receives nothing by mouth). The facility census was 54. Findings include: Observation on 03/10/24 at 8:40 A.M., revealed a large amount of a wet black substance inside the ice machine on the top panel. This wet black substance was directly above the ice in the machine. Interview on 03/10/24 at 8:42 A.M., with Dietary Director #336 confirmed the presence of the black substance inside the ice machine. Dietary Director #336 revealed that maintenance cleans the ice machine every one and a half to two months and that the ice is taken out of the machine prior to being cleaned. Interview on 03/10/24 at 11:38 A.M., with Plant Director #259 revealed he just cleaned the ice machine. Plant Director #259 revealed the ice machine is cleaned quarterly and he did not take the ice out when he…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure physician visits were completed as required. This affected 10 (#01, #08, #15, #16, #19, #24, #34, #39, #41, and #46) of 10 residents reviewed for physician visits. The facility census was 54. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 07/24/10. Medical diagnoses included traumatic brain injury, depression, cognitive communication deficit, and chronic pain. Review of the medical record for Resident #01 revealed he was seen by Medical Director (MD) #600 on 06/19/23. Resident #01 was seen by Nurse Practitioner (NP) #625 on 02/20/24. There were no other documented physician visits for Resident #01. 2. Review of the medical record for Resident #08 revealed an admission date of 08/03/23. Medical diagnoses included Parkinson's disease, anemia, and unspecified psychosis. Review of the medical record revealed Resident #08 was seen by MD #600 on 08/04/23 and again on 01/03/24. Resident #08 was seen by NP #625 on 02/29/24. There were no other…

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

Based on record review, staff interview, and resident interview, the facility failed to ensure residents were provided clear communication on what an arbitration agreement proposes and how to accept or decline the arbitration agreement. This affected four (#46, #203, #201, and #302) of four residents reviewed for binding arbitration. The facility census was 54. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 12/14/23. The resident was admitted with diagnoses including Alzheimer's disease, spondylosis, acute kidney failure, dysphagia, depression, and dementia. Review of the arbitration agreement for Resident #46 revealed that it was unsigned and the column next to Signer refused to sign the arbitration Agreement says no. 2. Review of the medical record for Resident #201 revealed an admission date of 07/21/23. The resident was admitted with diagnoses including hydrocephalus, urinary tract infection, hypokalemia, anxiety disorder, depression, insomnia, and mild intellectual disabilities. Review of the arbitration agreement for Resident…

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

Based on observation, staff interview, and policy review, the facility failed to ensure medications were administered in a manner that a reasonable person would consider dignified. This affected two residents (#07 and #32) of five residents reviewed for medication administration and 19 residents reviewed for dignity. The facility census was 54. Findings include: 1. Review of the medical record for Resident #07 revealed an admission date of 03/09/17. Medical diagnoses included Parkinson's disease, cerebrovascular accident (stroke), dementia, adult failure to thrive, and malnutrition. The record identified Resident #07 was to have no food or medications by mouth and was dependent on his percutaneous endoscopic gastrostomy (PEG) tube for all nutritional intake and medication administration. Resident #07 was a resident on the secured memory care unit. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 02/28/24, revealed the resident was rarely/never understood. He was dependent on activities of daily living and mobility, and received greater than 51% of his 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 interview, and staff interview, the facility failed to ensure a resident's choice for showers was honored. This affected one (#22) of two residents reviewed for choices. The facility census was 54. Findings include: Review of the medical record revealed Resident #22 had an admission date of 02/14/24. Diagnoses included osteomyelitis, type two diabetes mellitus, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required partial/moderate assistance with bathing and showers. Review of the shower schedule revealed Resident #22 was scheduled for showers on second shift on Wednesdays and Sundays. Review of the care plan for activities of daily living revealed the resident requested showers on Wednesdays and Sundays. Review of shower documentation revealed the resident had not received a shower on 03/10/24 (Sunday) or 03/13/24 (Wednesday). Interview on 03/11/24 at 8:30…

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

Based on observation, staff interview, family interview, record review, and review of facility incident reports, the facility failed to ensure a resident's responsible party was notified of a fall and subsequent transfer to the emergency department. This affected one (#46) of two residents reviewed for notification of change in condition. The facility census was 54. Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's Minimum Data Set (MDS) 5-day assessment, dated 02/26/24, revealed the resident had a Brief Interview for Mental Status score of 08, indicating moderately impaired cognition. The resident had no recorded hallucinations or delusions, and was noted to have wandered during one to three days during the 7-day look-back period. The resident required substantial/maximum assistance with activities of daily living (ADLs) and required partial/moderate assistance with transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was accurately completed. This affected one (#8) of one resident reviewed for PASRR. The facility census was 54. Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a PASRR results dated 08/02/24 revealed the resident required a referral for a level two evaluation. Further review of the medical record revealed the facility never updated the resident's PASRR with accurate psychiatric diagnoses. Interview on 03/13/24 at 2:24 P.M., Social Worker (SW) #348 verified the resident had a diagnosis of mental health disorders when she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident was included in quarterly care planning and invited to a quarterly care plan conference. This affected one (#41) of one resident reviewed for care planning. The facility census was 54. Findings include: Review of the medical record revealed Resident #41 had an admission date of 10/10/23. Diagnoses included chronic systolic heart failure, type two diabetes mellitus, hypertension, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the progress notes revealed the resident's last care plan conference was on 10/25/23. Interview on 03/10/24 at 11:16 A.M., with Resident #41 revealed he had not been invited to care conference meeting recently. Interview on 03/12/24 at 11:10 A.M., with the Business Office Manager (BOM) #200 revealed the resident's last care conference was on 10/25/23. Interview on 03/12/24…

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.

Based on observation, staff interview, family interview, record review, and policy review, the facility failed to ensure treatment was provided to address a resident's bilateral lower extremity edema. This affected one (#15) of 19 residents reviewed for quality of care. The facility census was 54. Findings include: Review of the medical record for Resident #15 revealed an admission date of 01/15/24. Medical diagnoses included dementia without behaviors, muscle weakness, hypertension and atrial fibrillation. Review of Resident #15's Minimum Data Set (MDS) 3.0 admission assessment, dated 01/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating severely impaired cognition. The resident was not recorded to have any hallucinations or delusions, behaviors, or rejection of care. Review of Resident #15's care plan, initiated 02/07/24, revealed the resident was on diuretic therapy and had a risk for fluid volume imbalances. The care plan reflected a goal that the resident will be free from symptoms of fluid volume imbalances, with listed approaches including 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 review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure incontinence care was completed timely. This affected one (#8) of one resident reviewed for incontinence care. The facility census was 54. Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was always incontinent of bowel and bladder. Review of an incontinence assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was not on a toileting program. Review of the care plan initiated 08/20/23 revealed the resident had episodes of incontinence and required assistance with toileting needs 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 medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident's pain was timely treated and physician ordered pain medications were available. This affected one (#24) of three residents reviewed for pain management. The facility census was 54. Findings include: Review of the medical record revealed Resident #24 revealed an admission date of 12/19/18. Diagnoses included type two diabetes mellitus, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, pain in right shoulder, gluteal tendinitis right and left hip, trochanteric bursitis right and left hip, radiculopathy cervical region, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident received as needed pain medications and had frequent pain. Review of the care plan last revised 02/07/24 revealed the resident had chronic pain, muscle spasms in his shoulder, back, neck…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to provide an appropriate and timely response to a resident with suicidal ideation. This affected one (#8) of two residents reviewed for behavioral/emotional care. The facility census was 54. Findings include: Review of the medical record revealed Resident #8 had an admission date of 08/03/24. Diagnoses included Parkinson's disease, morbid obesity, cellulitis, hypertension, chronic pain syndrome, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a nurse's note dated 12/29/23 at 1:21 P.M., revealed the nurse and nursing assistant provided a bed bath for the resident. During the bed bath the resident verbalized suicidal ideation to the staff. The nurse went to remove the call light that was near the resident's neck and the resident stated, just leave it there so I can go see Jesus faster and asked the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, consultant pharmacist interview, and policy review, the facility failed to ensure a resident was free from unnecessary psychotropic medication and failed to ensure behavior monitoring was implemented. This affected one (#46) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's Minimum Data Set (MDS) 5-day assessment, dated 02/26/24, revealed the resident had a Brief Interview for Mental Status score of 08, indicating moderately impaired cognition. The resident had no recorded hallucinations or delusions, and was noted to have wandered during one to three days during the 7-day look-back period. The resident required substantial/maximum assistance with activities of daily living (ADLs)…

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

Based on observation, staff interview, hospice staff interviews, physician interview, family interview, record review, and policy review, the facility failed to ensure the medical records were complete and accurate. This affected three (#46, #34, and #19) of 20 residents reviewed for accurate medical records. The facility census was 54. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 12/14/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, cognitive communication deficit, dementia, and depression. Review of Resident #46's interdisciplinary progress notes revealed a note dated 03/09/24 at 8:40 A.M., which stated the resident returned from the local emergency room. The note explained a bandage was intact to Resident #46's left forehead, and he had skin tears present to his right knee and left forearm. The note immediately prior to this progress note was dated 03/07/24. There was no mention of what incident or event led to Resident #46's emergency department visit on 03/09/24, or any recorded nursing action taken, in…

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

Based on medical record review, hospice staff interview and staff interview, and policy review, the facility failed to designate a member of the facility's interdisciplinary team to coordinate and communicate with the outside hospice provider and failed to ensure necessary hospice records were obtained by the facility and recorded in the resident's medical record. This affected one (#34) of one resident reviewed for hospice services. The facility identified 5 residents in the facility who received hospice services. The facility census was 54. Findings include: Review of the medical record for Resident #34 revealed an admission date of 04/05/21. Medical diagnoses included Alzheimer's disease, psychotic disorder with delusions, depression, and anxiety. The medical record indicated that Resident #34 signed on with a local hospice provider on 05/25/23 with a terminal diagnosis of end stage dementia. Resident #34 had a code status of Do Not Resuscitate Comfort Care (DNRCC) assigned to her profile in the electronic health record. Review of the hospice section of Resident #34's medical…

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

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure appropriate infection control practices were maintained during medication administration. This affected one (#32) of five residents reviewed for medication administration. The facility census was 54. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/06/24. Medical diagnoses included type II diabetes mellitus with hyperglycemia, cerebral infarction, muscle weakness, morbid obesity, and depression. Observation on 03/12/24 from 10:36 A.M. to 10:42 A.M., revealed Registered Nurse (RN) #257 prepared 13 tablets or capsules for oral morning medications for Resident #32. While preparing the medications, RN #257 was observed to obtain the ordered medication card or medication bottle, and place each medication into his bare, ungloved hand prior to placing the medication into Resident #32's medication cup. During the medication preparation process, RN #257 was observed to be approached by the Administrator twice at 10:38 A.M. and 10:41…

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

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were properly stored until the time of administration. This had the potential to affected 19 (#16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) of 19 residents who received medications from the North medication cart which was observed with pre-pulled medications in the cart. The facility census was 50. Findings include: Observation on 02/22/24 at 5:07 A.M. revealed Registered Nurse (RN) #30 was observed standing in front of the North hallway medication cart with a large stack of medication cups with multiple pills in each cup. The observation identified the cups had resident initials written on the cups. The observation identified there was at least five unidentified cups with resident's pills stacked on top of one another. RN #30 was observed in the process of popping resident pills into another cup. Interview with RN #30 at 5:10 A.M. confirmed she should not be pre-pulling resident medications into cups, 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility self-reported incident (SRI) and investigation review, staff interview, facility policy review, and review of facility corrective action, the facility failed to ensure residents were free from physical and verbal abuse from staff. This affected one (#61) of three residents reviewed for abuse. The census was 50. Findings include: Review of Resident #61's medical record identified admission to the facility on [DATE] with medical diagnoses including respiratory failure, urine retention, diabetes, congestive heart failure, anxiety, and depression. The resident was transferred to another facility on 02/20/24. Review of the facility admission assessment dated [DATE] revealed Resident #61 was assessed as cognitively intact. Review of an SRI dated 01/24/24 revealed State Tested Nurse Aide (STNA) #40 and STNA #50 witnessed Registered Nurse (RN) #20 screaming…

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, family member, and staff interview, review of facility self-reported incidents, and review of a facility policy, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency as required. This affected one (#43) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record for Resident #43 revealed an admission date of 08/03/23. Medical diagnoses included osteoarthritis, morbid obesity, muscle weakness, and a need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was assessed with intact cognition, and no evidence of hallucinations or delusions. Review of a progress note dated 11/06/23, written by Registered Nurse (RN) #150, revealed RN #150 entered Resident #43's room with a unnamed state tested nurse aide (STNA) as a witness and brought ordered bedtime medications to Resident #43. When RN #150 entered Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident, family member, and staff interview, review of facility self-reported incidents, and review of a facility policy, the facility failed to investigate allegations of physical abuse in a timely manner. This affected one (#43) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record for Resident #43 revealed an admission date of 08/03/23. Medical diagnoses included osteoarthritis, morbid obesity, muscle weakness, and a need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was assessed with intact cognition, and no evidence of hallucinations or delusions. Review of a progress note dated 11/06/23, written by Registered Nurse (RN) #150, revealed RN #150 entered Resident #43's room with a unnamed state tested nurse aide (STNA) as a witness and brought ordered bedtime medications to Resident #43. When RN #150 entered Resident #43's room, Resident #43…

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, family and resident interview, staff interview and policy review, the facility failed to have an effective activities program for the residents. This affected six (#7, #31, #36, #41, #44 and #56) of 24 residents reviewed for activities. The facility census was 24. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted on [DATE]. Diagnoses included chronic kidney disease, depression, and dependence on renal dialysis. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact and had no behaviors. Resident #7 required limited assist from staff with bed mobility and extensive assist from staff with transfers. Review of the care plan conference summary documentation dated 07/08/22 revealed the activities Resident #7 participated in include crafts, music, and movies. Review of Resident #7's care plan dated 07/25/22 revealed the resident has the potential for isolation and needs…

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

Based on record review, observation, staff interview, policy review, and review of the Center of Disease Control (CDC) guidance, the facility failed to provide care and services to reasonably prevent the spread of SARS-CoV-2 virus (COVID-19), when staff did not appropriately use Personal Protective Equipment (PPE). This had the potential to affect 11 residents (#1, #7, #15, #31, #35, #43, #44, #45, #47, #52, and #53) who resided on the north hall and were not in isolation or quarantine for COVID-19. The facility also failed to appropriately handle soiled linen and clothing for one (Resident #49) of one resident reviewed for urinary tract infection. The facility census was 59. Findings include: 1. Observation of Licensed Practical Nurse (LPN) #944 on 08/09/22 at 5:19 P.M. revealed LPN #944 had provided medication and cared for Resident #51, who was in quarantine due to close exposure to a COVID-19 positive resident and Resident #159 was in isolation due to positive for COVID-19. LPN #944 was observed to remove her gown and gloves, wash her hands and exit the room at 5:30 P.M. LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident and staff interviews, the facility failed to allow a resident to decline laboratory testing. This affected one (Resident #55) of six residents reviewed for choices. The facility census was 59. Findings include: Review of Resident #55's medical record revealed an admission to the facility occurred on 07/09/21. Diagnoses included COVID-19, depression, anxiety, and high blood pressure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact. Review of a care conference form dated 05/06/22 revealed Resident #55's daughter had requested at that time that no further laboratory testing was completed. The record does not appear to have a physician's order until 07/20/22, for Resident #55's request. Review of Resident #55's physician orders dated 07/24/22 revealed no laboratory testing should be completed. Interview with Resident #55 on 08/11/22 at 8:43 A.M. confirmed she was currently COVID-19 positive. 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 observations, medical record review, review of kitchen meal tickets, and staff interviews, the facility failed to provide nutritional supplements to a resident with a history of significant weight loss. This affected one (Resident #56) of three residents reviewed for nutrition. The facility identified three residents with significant weight loss. The facility census was 59. Findings include: Review of Resident #56's medical record revealed a re-admission to the facility occurred on 06/24/22. Diagnoses included fractured right collar bone, acute respiratory failure with hypoxia, pneumonitis, sepsis, hyponatremia, dementia and diabetes mellitus. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 required supervision for meals and had severe cognition issues. Review of a care conference meeting notes dated 06/29/22 revealed Resident #56's family had concerns Resident #56 not eating well. The meeting identified Resident #56 liked chocolate nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure Resident #41 did not have a significant medication error related to insulin administration when the facility held Resident #41's insulin without a physician order or physician notification. This affected one (Resident #41) of six residents reviewed for medication administration. Resident The facility census was 59. Findings include: Review of Resident #41's medical record revealed an admission to the facility occurred on 11/19/21. Diagnoses included diabetes mellitus. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive issues. Review of the physician's orders dated August 2022 revealed Resident #41 had physician orders for Novolog insulin 10 units twice a day with lunch and supper. The order instruction revealed to notify the physician if Resident #41's blood sugar was over 400. The physician orders did not include any parameters to hold the insulin dose 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 observations, medical record review, review of kitchen meal tickets and staff interviews, the facility failed to ensure a resident with food allergies was implemented on the resident's meal ticket. This affected one (Resident #56) of three residents reviewed with food allergies. The facility census was 59. Findings include: Review of Resident #56's medical record revealed a re-admission to the facility occurred on 06/24/22. Diagnoses including hyponatremia, dementia and diabetes mellitus. The medical record revealed Resident #56 had food allergies to fish and shellfish, among many medication allergies. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 required supervision for meals and has severe cognitive issues. Review of Resident #56's dietary progress note dated 07/06/22 revealed the note did not state if Resident #56 had a food allergy. Observations of the lunch meal services on 08/08/22 from 11:54 A.M. to 12:27 P.M., on 08/09/22 at 11:43 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.