Ayden Healthcare Of Greenville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) for residents who were in Enhanced Barrier Precautions (EBP). This affected one (Resident #3) of two residents reviewed for EBP. The facility census was 65. Findings include: Record review revealed Resident #3 was admitted on [DATE]. Diagnoses included active primary progressive multiple sclerosis, and epilepsy (seizures). Review of the weekly wound assessment dated [DATE] revealed Resident #3 had a pressure ulcer (wound from constant pressure to the skin) stage IV (pressure ulcer with bottom extending to the muscle or bone) on the sacrum (tailbone). The active physician orders for Resident #3 for December 2025 reveled an order for EBP due to wound and indwelling catheter. Observation of Certified Nursing Assistant (CNA) #164 on 12/03/25 at 12:53 P.M. revealed CNA #164…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident's call light was in working order. This affected one (#55) of 24 residents reviewed for call lights. The facility census was 65. Findings include:Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease without dyskinesia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was moderately cognitively impaired and was dependent on staff with toileting, personal hygiene, and transfers. Review of the fall care plan dated 10/30/25 revealed Resident #55 was at risk for falls. Interventions included to ensure the call light was in reach. Observation of Resident #55's room on 12/01/25 at 10:28 A.M. revealed Resident #55's call light was not functioning or turning on in the room, hallway, or nursing station. Interview on 12/01/25 at 10:28 A.M. with Maintenance Director #155…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure the physician was updated regarding a wound change affecting Resident #10. The facility also failed to ensure wound treatments and assessments were obtained timely affecting two (#10, #13) of three reviewed for wounds. The facility census was 63.1.Review of medical record for Resident #10 revealed an admission date of 04/16/25. Diagnoses included malignant neoplasm of mouth, tracheostomy and gastrostomy tubes, and skin graft to the right forearm. The resident was discharged on 05/09/25 to the hospital and did not return.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10 indicating impaired cognition. Resident #10 was dependent on eating and required maximum assistance for toileting hygiene, bed mobility and moderate assistance for transfers. Resident #10 was documented to be frequently incontinent of bowel and occasionally incontinent of urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and policy review the facility failed to ensure proper infection control practices were followed during incontinence care. This affected one (#13) of three residents reviewed for incontinence care. The facility census was 63.Review of medical record for Resident #13 revealed an admission date of 11/14/21 with diagnoses including diabetes mellitus type II, morbid obesity, depression and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) assessment for Resident #13 dated 04/09/25 revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. Resident #13 required supervision for meals and was dependent upon staff for bed mobility, transfers and toileting hygiene.Observation on 07/01/25 at 2:42 P.M. of incontinence care by Certified Nursing Assistant (CNA) #108 for Resident #13 revealed CNA #108 donned required personal protective equipment (PPE) prior to entering the room, Resident #13 was found lying on her back in bed. CNA #108 unfastened the incontinence product 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 medical record reviews, staff interview, and policy review, the facility failed to ensure psychotropic medications had appropriate documentation for medical use and failed to ensure as needed (PRN) psychotropic medications had a date for re-evaluation of use or duration of use dates. This affected two (#05 and #16) residents out of three residents reviewed for medication administration. The facility census was 60. Findings include: 1. Review of the medical record for Resident #05 revealed an admission date of 01/15/25 with medical diagnoses of dysphagia, tremors, dementia, osteoarthritis, and adult failure to thrive. Review of the medical record for Resident #05 revealed an admission Minimum Data Set (MDS) assessment, dated 01/31/25, indicated Resident #05 was cognitively intact and required partial/moderate staff assistance for eating, substantial/maximum staff assistance for transfers, and was dependent upon staff for toilet hygiene and bathing. Review of the medical record for Resident #05 revealed a physician order dated 04/14/25 for Lorazepam (antianxiety medication)…

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

Based on medical record review, observations, staff interviews, and policy review, the facility failed to properly measure pressure ulcers and ensure treatments were completed as ordered. This affected one (#36) resident out of three residents reviewed for adequate wound care and services. The facility census was 60. Findings include: Review of the medical record for Resident #36 revealed an admission date of 08/21/2020 with medical diagnoses of multiple sclerosis (MS), myelodysplastic syndrome, quadriplegia, anxiety, and schizophrenia. Review of the medical record for Resident #36 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/17/25, which indicated Resident #36 had severely impaired cognition and was dependent for all activities of daily living. The MDS indicated Resident #36 had a Stage IV pressure ulcer which was present upon admission. Review of the medical record for Resident #36 revealed a weekly wound assessment, dated 05/01/25, which indicated Resident #36 had a pressure ulcer to her coccyx which measured 6.1 centimeters (cm) by 5.6 cm by 0.4 cm and the…

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

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure medications were available for administration. This affected one (#10) resident out of the three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #10 revealed an admission date of 02/11/25 with medical diagnoses of heart disease, diabetes mellitus, atrial fibrillation, depression, and bipolar disorder. Review of the medical record for Resident #10 revealed an admission Minimum Data Set (MDS) assessment, dated 02/11/25, which indicated Resident #10 was cognitively intact and required supervision with eating, partial/moderate staff assistance with toilet hygiene and bed mobility, and substantial/maximum staff assistance with bathing and transfers. Review of the medical record for Resident #10 revealed a physician order dated 02/12/25 for Venlafaxine (antidepressant) extended release (ER) 150 milligram (mg) one tablet by mouth daily for depression. Observation with interview on 05/06/25 at…

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

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure insulin injector pens were dated when opened. This affected one (#09) resident out of three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #09 revealed an admission date of 02/15/25 with medication diagnoses of gas gangrene, chronic osteomyelitis of right ankle/foot, diabetes mellitus (DM) , peripheral vascular disease, and hypertension. Review of the medical record for Resident #09 revealed an admission Minimum Data Set (MDS) assessment, dated 02/20/25, which indicated Resident #09 was cognitively intact and required set-up assistance with eating, partial/moderate staff assistance with showers, and substantial/maximum staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #09 received six days of insulin injections. Review of the medical record for Resident #09 revealed a physician order dated 04/14/25 for Insulin Lispro pen to inject 10 units…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 contractor services invoices, interview with outside contractor service, and staff interview, the facility failed to remain solvent by paying all contractors for their services. This had the potential to affect all 67 residents residing in the facility. The current census is 67. Findings include: Review of the facility's contract with the extermination services revealed the exterminators were scheduled to provide services for the facility monthly and treat for any infestations. The contract was for 12 months of service beginning February 2024. Further review revealed the facility had no invoices for the contractor after 08/20/24. Interview on 12/26/24 at 12:08 P.M., with the Receptionist #100, from the exterminator contracted service company, revealed as of August 2024, the facility had an unpaid balance and the extermination service were no longer providing any treatments to the facility due to nonpayment. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker, (LSW) #1, 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on staff interview, review of resident records, review of employee files, review of license verification via the Ohio Board of Nursing database, review of facility corrective action, and review of staffing schedules the facility failed to ensure all nurses who were providing care to resident had active licenses. This had the potential to affect all residents residing in the facility. The current census is 67. Findings include: Review of Ohio Board of Nursing License Verification database revealed Licensed Practical Nurse (LPN) #150's the nurse's licensed had expired as of [DATE]. Review of the facility's daily nursing schedules dating from [DATE] to [DATE] revealed LPN #150 had been scheduled to work on [DATE]. Review of LPN #150's employee file revealed her license had not been renewed as of [DATE], no new license verification evidence was noted in the employee file. 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 review of contractor services invoices, interview with outside contractor service, policy review, and staff interview, the facility failed to maintain a pest control program in accordance with policy. This had the potential to affect all 67 residents residing in the facility. The current census is 67. Findings include: Review of the facility's contract with the extermination services revealed the exterminators were scheduled to provide services for the facility monthly and treat for any infestations. The contract was for 12 months of service beginning February 2024. Further review revealed the facility had no invoices for the contractor after 08/20/24. Interview on 12/26/24 at 12:08 P.M., with the Receptionist #100, from the exterminator contracted service company, revealed as of August 2024, the facility had an unpaid balance and the extermination service were no longer providing any treatments to the facility due to nonpayment. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker (LSW) #1,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, staff interview, protocol review, the facility failed to ensure a resident with a prosthesis was able to use the device, when the facility failed to timely treat the device for bed bugs. This affected one (#12) of two residents reviewed for prostheses. The current census is 67. Findings include: Review of Resident #12's medical record revealed an admission date of 10/18/24. Diagnoses for Resident #12 included encephalopathy, traumatic leg amputation, failure to thrive, and pneumonia. Review of physician assistant progress note dated 10/21/24 at 8:17 A.M., revealed Resident #12 seen for readmission. Resident #12 was infested with bed bugs upon admission. Resident #12 prosthetic needed to be completely decontaminated and cleaned prior to giving it to him. This has not been returned at this time, which has him somewhat agitated. The plan included: the physician assistant spent a lot of time reassuring Resident #12 that this will be returned to him as soon 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, observations, review of the facility policy, review of the Self-Reporting Incident (SRI) database, and staff interviews, the facility failed to report an injury of unknown origin to the State Agency. This affected one (#15) out of 11 residents reviewed for abuse allegations not being reported. The current census is 68. Findings include: Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include dementia, retrograde amnesia, falls, and asthma. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a complete assist for Activities of Daily (ADL). Review of Resident #15's care plans dated 08/16/24 revealed no focus for behaviors. Further review of the care plans revised on 08/19/24 revealed a focus for actual skin impairment to skin integrity of right posterior calf. Interventions included follow protocols for treatments of injury, identify and document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, review of the facility policy, review of the Self-Reporting Incident (SRI) database, and staff interviews, the facility failed to investigate an injury of unknown origin. This affected one (#15) out of 11 residents reviewed for abuse allegations not being reported. The current census is 68. Findings include: Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include dementia, retrograde amnesia, falls, and asthma. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a complete assist for Activities of Daily (ADL). Review of Resident #15's care plans dated 08/16/24 revealed no focus for behaviors. Further review of the care plans revised on 08/19/24 revealed a focus for actual skin impairment to skin integrity of right posterior calf. Interventions included follow protocols for treatments of injury, identify and document potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to document in the resident record a medical change in condition and accurately document the care and services provided. This affected one (#75) of four resident records reviewed for accurate documentation. The facility census was 71. Findings include: Review of Resident #75's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident expired at the hospital on [DATE]. Diagnoses for Resident #75 included malignant neoplasm of the rectum with colon resection surgery on [DATE], diabetes, morbid obesity, chronic kidney disease, and heart failure. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE], revealed the resident had intact cognition and required partial assistance for mobility, and extensive assistance for toileting and bathing. Review of a handwritten nurse notes, provided by the Director of Nursing, (DON), revealed the notes…

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

Based on observations and staff interview, the facility failed to post daily staffing information as required. This had the potential to affect at 73 residents residing in the facility. The facility census was 73. Findings included: Observations on 06/12/23 at 8:30 A.M., 06/13/23 at 7:30 A.M. and 06/14/23 at 7:50 A.M. revealed no evidence of daily staffing information posted in a prominent area visible to residents and visitors. Observation on 06/14/23 at 7:55 A.M. revealed a staffing schedule form posted on the back wall at the main nurse's station. The form was behind a four-foot-tall medical record chart rack, which was filled with resident charts. The form was not visible from the nurse's station counter. The form included the names of the nurses and aides working that day on each shift but did not have documentation to support the census or the total number of actual hours worked per shirt for licensed and unlicensed staff responsible for care. Interview on 06/14/23 at 7:59 A.M. with the Director of Nursing (DON) confirmed the facility did not have daily staffing information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have an order or documentation of advance directives for Resident #37. This affected one (Resident #37) of 24 residents reviewed for advanced directives. The facility census was 73. Findings: Review of the medical record for Resident #37 revealed he was admitted [DATE] with diagnoses to including Parkinson's disease, dysphasia, aphasia, chronic atrial fibrillation, major depressive disorder, dementia, mixed hyperlipidemia, personal history of transient ischemic attack and cerebral infarction, hypertension, gastro-esophageal reflux disease and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37's Brief Interview for Mental Status (BIMS) score was 14, indicating he was cognitively intact. Resident#37 required supervision with eating and extensive assistance with activities of daily living (ADL's). Review of the Physician's Orders for Resident #37 revealed no order for advanced directives. Further review 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 reviews, staff interviews, and review of Resident Assessment Instrument (RAI) manual 3.0, the facility failed to develop a comprehensive care plan for one (Resident #51) of three residents reviewed for care plan development. The facility census was 73. Findings included: 1. Review of the medical record for Resident #51 revealed an admission date of 02/25/23 with medical diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), major Depression, and chronic pain syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and bathing. Further review revealed under the section, Care Area Assessment (CAA), revealed the facility would proceed with a care plan for Activities of Daily Living (ADLs), vision, communication, urinary incontinence, psychosocial well-being, and mood. Further 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 record review, resident and staff interviews, and policy review, the facility failed to provide showers/baths as scheduled. This affected one (Resident #6) of one resident reviewed for showers/bathing. The facility census was 73. Findings included: Review of the medical record for Resident #6 revealed an admission date of 03/13/15 with medical diagnoses of hypertension, arthritis, and transient ischemic attack (TIA). Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and was dependent upon staff for bathing. Review of Resident #6's care plan revealed the resident had an ADL deficit related to physical limitations and arthritis. Interventions included assisting Resident #6 with bath/showers as needed. Further review of the medical record revealed Resident #6 was scheduled for bath/showers on Tuesdays and Fridays each week. Review of the physician progress note dated 01/30/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed ensure the physican addressed pharmacy recommendations in a timely manner. This affected two (Residents #20 and #57) of five residents reviewed for phamacy recommendations. The facility census was 73. Findings: 1. Medical record review for Resident #20 revealed an admission date of 08/01/22. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, moderate protein-calorie malnutrition, osteoarthritis, hyperlipidemia, occlusion and stenosis of carotid artery, peripheral vascular disease, gastroenteritis and colitis, major depressive disorder, anxiety disorder, and hypertension. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. Resident #20 required supervision with eating and dressing, limited assistance with personal hygiene, and extensive assistance with toileting, bed mobility and transfers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interview, and policy review, the facility failed to ensure residents were offered the pneumococcal vaccine. This affected two (Residents #4 and #51) of the five reviewed for vaccinations. The facility census was 73. Findings included: 1. Review of the medical record for Resident #4 revealed an admission date of 11/02/21 with medical diagnoses of Alzheimer's disease, hyperlipidemia, hypothyroidism, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had severe cognitive impairment and required extensive staff assistance with bed mobility, transfers, toileting, dressing, and was dependent upon staff for bathing. Further review of the medical record revealed no documentation to support Resident #4 received the pneumococcal vaccine. The medical record did not contain documentation to support the facility provided Resident #4 or the resident's representative with education regarding the pneumococcal vaccine or offered the…

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

Based on observation, staff interview, and facility policy review, the facility failed to ensure food stored in the walk in refrigerator had expiration dates, and failed to label food when opened. This had the potential for affect all resident residing in the facility with the exception of three Residents (#34, #41, and #60) identified by the facility who did not received food from the kitchen. The facility census was 66. Findings include: Observation on 04/26/21 at 2:30 P.M. of walk in cooler revealed the following food items to not have expiration dates, or a label with the date they were opened; two 46 ounce boxes of ready care thickened water, one Smucker's squeeze bottle of caramel flavored plate scrapers, one bottle of Smucker's raspberry flavored plate scrapers dessert topping, a large bag of shredded lettuce, and a bag of shredded cheese. Interview with Dietary Manager at the time of the observation confirmed the above findings. Review of the facility policy titled, Use by Date, dated 04/07/06, revealed food items will have an expiration date or use by date.

Based on observation, staff interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) resources, the facility failed to ensure staff completed appropriate hand hygiene during meal service. This had the potential to effect 63 of 66 residents who consumed food from the kitchen. The facility identified three Residents (#34, #41, and #60) who did not consume food from the kitchen. Findings include: Observation on 04/29/21 at 11:25 A.M. revealed Dietary Aide (DA) #800 went into dietary office, pulled her N-95 mask down with her ungloved right hand, and touching the front of the mask seam. The DA then took a drink from a soda bottle. The DA sat the bottle down and replaced her N-95 mask on her face without completing hand hygiene or the donning of gloves before returning to the steam table. The DA then placed napkins, silverware, and individual condiments on trays for the residents' meal. At 11:30 A.M. the DA pulled her N-95 mask down below her chin exposing her mouth while on a personal phone and facility walkie talkie. She then replaced 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, resident interview, and facility policy review, the facility failed to develop a care plan for a resident who received hospice services. This affected one Resident (#44) of three reviewed for hospice services. Additionally, the facility failed to update and hold a care conference for one Resident (#27) of 18 reviewed for care planning. The facility census was 66. Findings include: 1. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including amputation of right leg, anxiety, cerebral infarction, diabetes type two, and convulsions. Review of Resident #44's physician orders dated 07/14/20 revealed the resident was to receive hospice services. Review of Resident #44's care plans dated 03/2021 revealed no evidence of a care plan for hospice care. Interview on 04/29/21 at 10:10 A.M. with the Minimum Data Set Licensed Practical Nurse, (MDS-LPN) revealed Resident #44 was coded for hospice service in 07/2020. MDS-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, resident interview and staff interview, the facility failed to ensure appropriate bowel monitoring for constipation was in place for one Resident (#8) of one reviewed for constipation. The facility census was 66. Findings include: Medical record review for Resident #8 revealed an admission date on 11/22/19 with diagnoses including heart failure, chronic respiratory failure, and gastroesophageal reflex disease. Review of most recent quarterly Minimum data Set ( MDS) assessment dated [DATE] assessment for Resident #8 revealed the resident had intact cognition. Review of Resident #8's bowel and bladder elimination tracking document in the electronic health record (EHR) dated 04/16/21 through 04/29/21 revealed no evidence the resident had a bowel movement between 04/21/21 to 04/26/21 (five days). Interview on 04/27/21 at 5:45 P.M. with Resident #8 revealed the resident had complained of constipation to the nurse and requested medication for relief that morning. Interview on 04/29/21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of pharmacy recommendations, and review of facility policy, the facility failed to respond to and implement pharmacy recommendations approved by the physician. This affected one Resident (#30) of seven residents reviewed for unnecessary medications. The census was 66. Findings include: Review of the medical record for Resident #30 revealed an admission date of 08/20/20 with a diagnosis of cerebral infarction (stroke). The resident was noted to be cognitively impaired. Review of pharmacist recommendation for Resident #30 dated 03/11/21 revealed resident had been on a routine daily dose of the antihistamine loratadine since August of 2020. The recommendation revealed the facility should document reason for continued therapy with a long term antihistamine, consider changing to an as needed dose, or consider discontinuing the medication. The Nurse Practitioner responded to the recommendation on 03/19/21 and wrote to change Resident #30's loratadine to an as needed dose. Review of the March 2021 and April 2021 Medication…

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

Based on medical record review, review of hospital records, resident interview, staff interview, and review of online medication information, the facility failed to implement a physician's order to administer an oral medication to regulate blood sugar. This affected one Resident (#271) of seven residents reviewed for medications. The facility census was 66. Findings include: Review of the medical record for Resident #271 revealed an admission date of 04/22/21 with a diagnosis of diabetes mellitus. Review of the hospital record for Resident #271 dated 04/21/21 revealed the resident the resident was to continue the same oral medications taken at home and referred to the discharge medication list. Review of the hospital discharge medication list for Resident #271 dated 04/21/21 revealed orders for 20 units of insulin to be given by injection at bedtime, and the oral medication Metformin to be taken twice daily for treatment of diabetes mellitus. Review of the April 2021 Medication Administration Record (MAR) for Resident #271 revealed no evidence the ordered Metformin was transcribed…

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