Laurels Of Huber Heights The

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to complete timely and thorough investigations and failed to protect residents during an abuse investigation by suspending accused staff. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents. Findings include: 1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.) Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide the appropriate level of supervision to prevent accidents involving residents while smoking cigarettes. This affected one (Resident #3) of one resident reviewed for smoking practices. The facility identified 10 residents in the facility who smoked independently. The facility census was 85 residents. Findings included: Review of the medical record for Resident #3 revealed an admission date of 12/30/21 with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes. Review of the annual Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating and substantial/maximal assistance for toileting, bed mobility, and transfers. Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility Self-Reported Incidents (SRIs), and staff interview, the facility failed to ensure the medical record was complete and included pertinent resident information. This affected one (Resident #61) of three reviewed for medical records. The facility census was 85 residents. Findings include: Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes. Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #61 dated 01/15/25 revealed there was no documentation of a phone call from the hospital social worker to the facility social worker regarding concerns of possible resident mistreatment. Review of the facility SRI dated 01/23/25 revealed a hospital social worker called the facility Social Worker (SW) #87 on 01/15/25 and reported that former…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy, the facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) during wound care and incontinence care and failed to ensure staff practiced appropriate hand hygiene during incontinence care. This affected one (Resident #23) of three residents reviewed for incontinence care and wound care. The facility census was 85 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/04/25 with diagnoses including fracture of superior rim of left pubis, heart failure, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 01/11/25 revealed the resident had intact cognition and required partial assistance with eating and transfers, substantial assistance with toileting and bathing, and was dependent with dressing. Review of the progress note for Resident #23 dated 01/06/25 timed at 4:10 P.M. revealed the resident had an unstageable pressure ulcer to the buttock which measured 10.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility resident census, the facility failed to ensure water temperatures were comfortable for residents. This had the potential to affect 42 (#5, #6, #7, #9, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) residents residing on the 300 and 400 halls. The census was 83. Findings include: Observation of the shower room located in the 400 hall with Maintenance Director (MD) #100 on 12/23/24 at 2:48 P.M. revealed hot water temperatures in shower stalls did not reach 105 degrees Fahrenheit (F). Water temperatures in each of two shower stalls reached a maximum temperature of 90 degrees F. MD #100 confirmed hot water temperatures only reached 90 degrees F. MD #100 denied any recent hot water concerns. Review of water temperature logs revealed hot water temperatures below 105 degrees F had been documented consistently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure staff timely answered a resident's call light. This affected one (#9) of six residents reviewed for call lights. The census was 83. Findings include: Review Resident #9's medical record revealed an admission date of 08/14/24. Diagnoses listed included type two diabetes mellitus, hypertension, major depressive disorder, and acute kidney failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment, was frequently incontinent of bowel, and had a indwelling urinary catheter. Observation on 12/23/24 at 10:04 A.M. revealed the call light was on for Resident #9's room. The light above the door was illuminated and an audible beeping could be heard. At 10:12 A.M. Licensed Practical Nurse (LPN) #160 could be seen sitting at the nurse's station at the end of the hall. Resident #9's room call light remained on. At 10:25 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure a resident's call light was kept within reach. The affected one (#7) of six residents reviewed for call lights. The census was 83. Findings include: Review of Resident #7's medical record revealed an admission date of 08/04/23. Diagnoses listed included type two diabetes mellitus, vascular dementia, and glaucoma. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intake. Observation on 12/23/24 at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #170 asked Resident #7 to put on her call light so an aide could assist her with getting out of bed. Resident #7 could not find her call light. Resident #7 stated she could not find her call light all night. LPN #170 looked for Resident #7's call light and found it behind a dresser drawer cabinet located to the left and behind Resident #7's bed. LPN #170 had to move the dresser…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident representatives were notified of significant changes in residents health status. This affected one (Resident #90) of three residents reviewed for change in health condition. The facility census was 84 residents. Findings include: Review of the medical record for Resident #90 revealed an admission date of 04/22/24 and a discharge date of 04/30/24. Resident #90 returned to the facility on [DATE] and discharged to the hospital on [DATE] and did not return to the facility. Resident #90's diagnoses included gram negative sepsis, congestive heart failure, non-pressure chronic ulcer of part of left lower leg, and renal disease. Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 04/29/24 revealed the resident had intact cognition and required extensive assistance from two staff members for completion of activities of daily living (ADLs). Review of the progress note 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 medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to notify the Ohio Department of Health (ODH) of an injury of unknown origin. This affected one (Resident #10) of three residents reviewed for abuse. The census was 84 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/21/22 with diagnoses including heart disease, dementia without behavioral disturbances, mood, anxiety and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 03/23/24 revealed the resident was severely cognitively impaired and required the assistance of one staff member for bed mobility, dressing and personal hygiene and used a wheelchair for mobility. Review of the hospice visit report for Resident #10 dated 06/10/24 per Hospice Registered Nurse (RN)#600 revealed the resident had a bruise to the right cheek and the aide reported they were unaware of the origin of the bruise.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin and failed to protect the resident from potential abuse. This affected one (Resident #10) of three residents reviewed for abuse. The census was 84 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/21/22 with diagnoses including heart disease, dementia without behavioral disturbances, mood, anxiety and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 03/23/24 revealed the resident was severely cognitively impaired and required the assistance of one staff member for bed mobility, dressing and personal hygiene and used a wheelchair for mobility. Review of the hospice visit report for Resident #10 dated 06/10/24 per Hospice Registered Nurse (RN)#600 revealed the resident had a bruise to the right cheek and the aide reported they were unaware…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of Resident Assessment Instrument (RAI) Manual 3.0, and policy review, the facility failed to conduct care plan review meetings quarterly and with significant change in residents' health status. This affected two (#4 and #9) out of the four residents reviewed for care plan meetings. The facility census was 68. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 12/05/22 with medical diagnoses of chronic kidney disease Stage III, arthritis, anemia, and heart disease. Review of the medical record for Resident #4 revealed a quarterly Minimum Data Set (MDS) 3.0, dated 07/21/23, indicated Resident #4 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. Review of the medical record for Resident #4 revealed documentation the facility conducted a care conference on 02/09/23 with the resident, resident's daughter, and IDT. Further review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews, and policy review, the facility failed to provide oral hygiene care for a dependent resident. This affected one (#29) out of three residents reviewed for assistants with Activities of Daily Living (ADL). The facility census was 68. Findings include: Review of the medical record for Resident #29 revealed an admission date of 09/21/18 with medical diagnoses of right sided flaccid hemiplegia following cerebral infarction, diabetes mellitus, and hypertension. Review of the medical record for Resident #29 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #29 had moderate cognitively impairment and required extensive staff assistance for bed mobility, personal hygiene, dressing and was dependent for transfers, bathing, and toileting. The MDS indicated Resident #29 received nutrition via tube feedings and did not indicate any oral or dental issues. Review of the medical record for Resident #29 revealed ADL care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely consult psychiatric (psych) services for a resident. This affected one (#32) of five residents reviewed for unnecessary medications. The census was 68. Findings include: Review of Resident #32's medical record revealed an admission date of 01/06/23. Diagnoses listed included anxiety, major depressive disorder, schizoaffective disorder and hypertension. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was moderately cognitively impaired and was receiving a anti-psychotic medication. Review admission documents revealed Resident #32 was admitted and treated at a geriatric psychiatric facility in December 2022. Resident #32 was deemed incompetent and appointed a guardian in 2021. Review of nurse practitioner (NP) notes dated 01/09/23 revealed Resident #32 was diagnosed with schizoaffective disorder and was receiving the anti-psychotic medication Abilify. Psych services was noted to be consulted. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, and policy review, the facility failed to provide a resident with routine dental services. This affected one (#29) out of the three residents reviewed for dental services. The facility census was 68. Findings include: Review of the medical record for Resident #29 revealed an admission date of 09/21/18 with medical diagnoses of right sided flaccid hemiplegia following cerebral infarction, diabetes mellitus, and hypertension. Review of the medical record for Resident #29 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #29 had moderate cognitively impairment and required extensive staff assistance for bed mobility, personal hygiene, dressing and was dependent for transfers, bathing, and toileting. The MDS indicated Resident #29 received nutrition via tube feedings and nothing by mouth (NPO). The MDS did not indicate any oral or dental issues. Review of the medical record for Resident #29 revealed an at risk for infection,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personnel record review, staff interview and facility policy review, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 85 residents residing in the facility. Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following employees: the Director of Nursing (DON) had a hire date of 02/14/19, Assistant Director of Nursing (ADON) #38 had a hire date of 09/20/19, Licensed Practical Nurse (LPN) Unit Manager #39 had a hire date of 02/21/19, Registered Nurse (RN) #42 had a hire date of 02/12/19, RN #45 had a hire date of 11/27/19, RN #47 had a hire date of 11/27/19, LPN #49 had a hire date of 12/05/19, LPN #51 had a hire date of 07/25/19, LPN #52 had a hire date of 11/27/19, LPN #53 had a hire date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and facility policy review the facility failed to ensure residents were treated in a dignified manner when staff failed to ensure they had permission to enter a residents room. This affected one (Resident #188) of three reviewed for dignity. The census was 85. Findings include: Medical record review for Resident #188 revealed an admission date of 12/15/19. Medical diagnoses included diabetes and respiratory failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #188 was cognitively intact. During an interview with Resident #188 on 02/03/20 at 5:55 P.M., he revealed he had a concern with staff barging into his room unannounced. He stated he spoke with the resident council about the problem and it stopped for a couple of days and then started back up again. During the interview, the door barged open and State Tested Nursing Aide (STNA) #89 came in the door. He started to knock on the door after opening it 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 review, event monitor education review, observation, staff and family interview, the facility failed to ensure interventions were put in place for a resident with a cardiac monitor. This affected one (Resident #185) of one resident reviewed for cardiac monitor. The census was 85. Findings include: Medical record review for Resident #185 revealed an admission date of 01/20/20. Medical diagnoses included scoliosis and hypertension. Review of Event Monitor Education paperwork dated 01/19/20 revealed instructions to change the patch and charge the sensor for the cardiac monitor on 01/24/20, 01/29/20, and 02/03/20. Review of admission summary completed on 01/20/20 revealed Resident #185 was cognitively intact. She was an extensive assistance for bed mobility, transfers, toileting, and eating. Review of nursing comprehensive evaluation for skin and cardiovascular dated 01/20/20 revealed no mention of the cardiac monitor. Review of progress notes, physician orders and care plan from 01/20/20 through 02/03/20 for Resident #185 revealed no evidence of addressing 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, observation, and staff interview, the facility failed to have respiratory care orders in place for a resident with a tracheostomy (trach). This affected one (Resident #234) of five residents reviewed for respiratory care. The census was 85. Findings include: Review of Resident #234's medical record revealed an admission date of 01/21/20. Diagnoses included malignant neoplasm of lung, acute respiratory failure with hypoxia, malignant neoplasm of left breast, and malignant neoplasm of bone. A comprehensive Minimum Data Set (MDS) had not yet been completed. Further review of Resident #234's medical record revealed she was admitted to the facility with a trach in place. Observation of Resident #234 on 02/03/20 at 11:15 A.M. revealed she had a trach in place, and was receiving humidified oxygen through that trach. Review of physician orders revealed no documentation of trach care or respiratory care orders related to a trach being entered before 02/04/20. Review of 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 and staff interview, the facility failed to timely follow-up with physician recommendations. This affected one (Resident #80) of seven residents reviewed for unnecessary medications. The census was 85. Findings include: Review of Resident #80's medical record revealed an admission date of 01/06/20. Diagnoses included radiculopathy of lumbar region, syncope and collapse, hypokalemia, major depressive disorder, anxiety disorder, hypertension, and obesity. Review of a pharmacy recommendation dated 01/08/20 revealed as needed (PRN) hydroxyzine (antihistamine) was recommended to be discontinued. Further review revealed it was signed by a physician on 01/08/20 who agreed with the recommendation to discontinue the PRN hydroxyzine. Review of physician orders revealed the PRN hydroxyzine was not discontinued until 01/31/20. Interview with the Director of Nursing (DON) on 02/04/20 at 2:09 P.M. confirmed a physician had signed a pharmacy recommendation to discontinue PRN hydroxyzine on 01/08/20 and it was not discontinued until 01/31/20.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to have clear documentation in resident medical records. This affected one (Resident #38) of two residents reviewed for urinary tract infection (UTI). The census was 85. Findings include: Review of Resident #38's medical record revealed an admission dated of of 11/07/19. Diagnoses included anxiety disorder, major depressive disorder, hypertension, type 2 diabetes mellitus, UTI with extended spectrum beta lactamase (ESBL) resistance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a multi-drug resistant organism (MDRO). Review of physician orders dated 01/05/20 revealed contact precautions for ESBL in urine. Review of treatment administration records (TARs) for January 2020 and February 2020 revealed contact precautions were signed off as being provided three times a day by nursing staff from 01/05/20 through 02/05/20. Review of nurse practitioner (NP) notes dated 02/04/20 revealed Resident…

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

Based on observation, review of a facility spreadsheet, staff interview, and review of a facility policy, the facility failed to ensure the dietitian approved spreadsheets were followed for all residents receiving meals. The facility identified six residents (#17, #43, #63, #71, #240 and #390) who did not receive anything by mouth (NPO). In addition, the facility failed to ensure the spreadsheet was followed for residents (#82 and #241) receiving a renal diet. The facility census was 93. Findings include: Observation of lunch service on 12/12/18 at 11:35 A.M.,revealed residents receiving all meal types did not receive bread or a roll with their meals. The facility did not have pureed bread prepared. Additionally, residents (#82 and #241) receiving renal diets received black forest pudding. Review of the facility spreadsheet revealed all meal types were to receive a roll or bread with their lunch meal. Residents on pureed diets were to receive a puree dinner roll or bread. Residents on renal diets were to receive two cookies in place of the black forest pudding. Interview 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 and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded. This affected one resident (#13) of 19 residents reviewed for MDS accuracy. The facility census was 93. Findings include: Review of Resident #13's medical record revealed an admission date of 04/22/11. Medical diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, diabetic neuropathy, heart failure, morbid obesity, chronic kidney disease, and depressive disorder. Review of the resident's last wound physician visit on 11/28/18 revealed the resident had an unstageable pressure ulcer to her left buttock and a stage three pressure ulcer to her sacrum. Review of the resident's MDS dated [DATE] revealed the resident had one unhealed, unstageable pressure ulcer. Interview with the Director of Nursing (DON) on 12/12/18 at 3:18 P.M., verified the resident's MDS dated [DATE] was not coded correctly, as it did not include her stage three pressure ulcer.