Hudson Elms Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure individualized interventions were developed and implemented to prevent resident-to-resident physical abuse between Resident #2 and Resident #24. This finding affected two (Residents #2 and #24) of three residents reviewed for abuse. The facility census was 43.Findings include: Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder and essential hypertension.Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #24's medical record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, bipolar disorder and alcohol dependence.Review of Resident #24's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #48 was provided a notification in writing the reason for the discharge to the hospital in a language the resident understands and a bed hold policy indicating the bed hold days remaining and the process for returning to the facility. This finding affected one (Resident #48) of two residents reviewed for hospitalization. The facility census was 43.Findings include:Review of Resident #48's closed medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including unspecified dementia, hyperlipidemia and essential hypertension. Resident #48 did not return to the facility.Review of Resident #48's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #48's progress note dated 02/24/26 at 5:24 A.M. revealed during morning care, the resident had an episode of coffee ground…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #31 was provided timely incontinence care. This finding affected one resident (#31) of three residents reviewed for incontinence care. The facility census was 43. Findings include:Record review of Resident #43 revealed he was admitted on [DATE] with diagnoses included cerebral infarction, heart failure, acute respiratory failure with hypoxia, tobacco use, alcohol abuse, hypertension, chronic obstructive pulmonary disease with acute exacerbation, generalized anxiety disorder, shortness of breath, asthma and personal history of pulmonary embolism.Record review of Resident #43's care plan dated 03/05/26 revealed he was resistive to care related to refusing to shower, refusing to change clothes, refusing incontinence care, refusing wound care and refusing to sleep in his bed. Interventions were to allow the resident to make decisions about treatment regime to provide a sense of control, encourage as much participation/interaction by 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 and interview, the facility failed to ensure scheduled narcotics for pain were administered as ordered and quarterly pain assessments were completed for residents on narcotic pain medications. This finding affected three (Residents #10, #31 and #40) of eleven residents reviewed for unnecessary medications. The facility census was 43.Findings include:1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and essential hypertension.Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #10's quarterly pain assessments (admit date [DATE]) revealed a pain assessment dated [DATE]. The resident's record did not have a pain assessment for 02/2026.Review of Resident #10's pain care plans revised 04/06/26 revealed to administer analgesia as per orders, anticipate the resident's need for pain relief, identify…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were served meals to meet their individual needs. This finding affected two residents (Residents #24 and #35) of four residents reviewed for food. The facility census was 43.Findings include:1. Review of Resident #24's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, bipolar disorder and alcohol dependence.Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #24's physician orders revealed an order dated 04/26/24 for a regular diet, regular texture with a regular consistency and double portions for meals.Review of Resident #24's meal ticket dated 05/06/26 revealed the resident wanted juice and hot cereal with no pasta and double portions for all meals.Interview on 05/04/26 at 12:13 P.M. with Resident #24 revealed he did not…

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

Based on observation, record review and interview, the facility failed to maintain proper infection control practices during wound care for Resident #31. This affected one resident (Resident #31) of one resident observed for wound care. The census was 43.Findings include:Record review revealed Resident #31 was admitted to the facility 03/19/26 with diagnoses including but not limited to acquired absence of left leg below-knee amputation (BKA).Record review revealed Resident #31 had an order to cleanse the left stump with soap and water, pat dry, apply Santyl and an abdominal pad and cover with kerlix. Observation of the wound care and dressing change with the Director of Nursing (DON) on 05/06/26 at 1:31 P.M. revealed the bedside table was visibly dirty and not cleaned/wiped down with an antiseptic cloth prior to the DON putting two paper towels from Resident #31's bathroom on it, as a barrier. The DON stated she forgot her marker and scissors so started removing the old dressing by removing what tape she could get ahold of with gloves on, from the top of the dressing closest 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 observations, interviews and facility policy the facility failed to ensure residents call lights were in working order. This affected three residents (Residents #6, #9, and #41) of 56 residents reviewed for call light function. The facility census was 43. Findings include: Interview on 05/06/26 at 3:02 P.M. with Resident Council members Resident #16, Resident #11 and Resident #36 revealed call light response times at night are very long and response times are sometimes over two hours.Interview on 05/07/26 at 3:45 P.M. with Resident #41 revealed he needed a new call light and his had not worked for three weeks. The bedside call cord was pulled revealing the bedside station light was activated but the corridor dome light outside the room did not light up. Interview and observation on 05/07/26 at 3:48 P.M. with Resident #6 revealed the resident tested bedside call cord revealed the bedside station light was activated but the corridor dome light outside the room did not light up and the light was missing the cover. Interview on 05/07/26 at 3:55 P.M. with Director of Clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide restorative nursing services per the plan of care. This affected four residents (#3, #10, #17, and #37) of four reviewed for restorative nursing services. The facility census was 36.Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 05/02/24 with diagnoses including Parkinson's disease, major depressive disorder, hypertension, need for assistance with personal care, spinal stenosis in the lumbar region, spinal enthesopathy in the cervical region, and intervertebral disc disorders.Review of the activities of daily living (ADL) plan of care, dated 10/02/24, revealed Resident #3 had impaired functional abilities, mobility deficit, required staff intervention to complete self-care and mobility activities, and was at risk for decline in functional ability and usual performance associated complications. Interventions included, but were not limited to: restorative nursing to ambulate or walk resident with…

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

Based on record review, review of self-reported incident (SRI) and interviews with staff the facility failed to report an allegation of abuse in a timely manner. This affected one resident (#55) of four residents reviewed for abuse. The census was 41.Finding include:Review of the closed medical record for Resident #55 revealed an admission date of 12/26/24. Diagnoses included major depressive disorder, paranoid personality disorder, mild cognitive impairment, insomnia, and schizoid personality disorder. A diagnosis of delusion disorder was added on 05/15/25 and diagnoses of suicidal ideations (SI) and post-traumatic stress disorder (PTSD) were added on 06/13/25. Review of the progress noted dated 06/07/25 and timed 1:57 P.M. revealed Resident #55 accused the nurse of being a murderer and an abuser. Review of the hospital records for Resident #55 revealed an admitting history and physical dated 06/13/25 at 4:40 A.M., listed the chief complaint as intentional ingestion of acid and attempt to self-harm. Past medical history included paranoid psychosis, schizoaffective 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 medical record review, resident interview, and staff interview the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #39) of three residents reviewed for pain management. The facility census was 38. Findings include: Review of the medical record for Resident #39 revealed an admission date of 05/17/24 at 11:00 A.M. with diagnoses including diabetes mellitus, anxiety disorder, insomnia, hypertensive kidney disease with stage three kidney failure, heart arrhythmia, pneumonia, adult failure to thrive, prostatic hypertrophy, and a history of transient ischemic attack and cerebral infarction (stroke). Review of the physician's orders for Resident #39 revealed an order dated 05/17/24 to administer Lyrica 25 milligrams (mg) in the morning and Lyrica 50 mg orally at bedtime for pain. Review of the Medication Administration Record (MAR) for Resident #39 dated May 2024 revealed the resident missed the following doses of Lyrica due to the medication was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #9 had physician orders for BiPAP (breathing support administered through a face mask, nasal mask or helmet), and failed to ensure Resident #9's diagnostic test for obstructive sleep apnea was scheduled. This affected one resident (Resident #9) out of three reviewed for oxygen therapy. The facility census was 36. Findings include: Review of Resident #9's medical record revealed an admission date of 02/24/22, a re-entry date of 12/28/23 and diagnoses included obstructive sleep apnea, bipolar disorder, and major depressive disorder. Review of Resident #9's medical record including progress notes and the vital sign tab which included oxygen saturations from 02/20/24 through 05/01/24 did not reveal evidence oxygen saturations were checked. Review of Resident #9's progress notes dated 02/22/24 at 2:00 P.M. included Resident #9's care conference was held on 02/22/24 at 2:00 P.M. Resident #23's power of…

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

Based on record review and staff interview the facility failed to ensure a complete and thorough investigation was completed for an allegation of neglect/mistreatment/abuse of Resident #21 by a staff member. This affected one resident (#21) of three residents revealed for abuse. The facility census was 36. Findings include: Review of the medical record for Resident #21 revealed an admission date of 11/12/23 with diagnoses including chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, chronic atrial fibrillation (abnormal heart rhythm), hypertension (high blood pressure) , and hyperlipidemia (high levels of fats in the blood). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/20/24, revealed Resident #21 was cognitively intact, was independent for oral and toileting hygiene, required set up or clean up assistance for personal hygiene and eating, and supervision for showering/bathing self. Resident #21 was able to walk independently 150 feet. Review of the facility self-reported incident (SRI) dated 02/21/24 revealed Resident #21 alleged…

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

Based on review of facility billing records, invoices and past due notices, and interviews with facility staff and contracted company personnel, the facility neglected to meet financial obligations for the delivery of care and maintenance to all the residents and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the needs of all residents in the facility. The facility census was 31. Findings included: Review of the facility utility companies and vendor bills/invoices revealed the following bills were not paid timely: a. Review of the City electric/water/sewage statement dated June 2023 revealed the facility had a previous balance of $5291.45 and a current billing of $3076.52. The facility made a payment on 05/16/23 for $5291.45. The balance due was $3076.52. Review of the City electric/water/sewage statement dated July 2023 revealed the facility had a previous balance of $3076.52 and a current billing of $2695.27. The facility did not make a payment. The balance due was $5771.79. Review of the City…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and interview the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents. This had the potential to affect all residents. The facility census was 27. Findings include: Review of annual Certified Nursing Assistant (CNA) training revealed no evidence of demonstrated competency of required skills and techniques. Interview on 06/22/23 11:33 A.M. with Regional Registered Nurse (RN) #533 revealed after several attempts to provide evidence of CNA competencies, he unable to provide evidence of the training. Interview on 06/22/23 at 1:04 P.M. with Regional RN #534 stated the CNA competencies had never been completed but would be reinstated immediately.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #10 was assessed accurately for her involuntary movements. This affected one of five residents reviewed for antipsychotic medications. The facility census was 34. Findings include: Review of the medical record revealed Resident #10 was readmitted on [DATE] with diagnoses including Parkinson's disease, Huntington's disease, psychosis, depression, mild cognitive impairment, anxiety and schizoeffective disorder. An interview with Resident #10 on 01/21/20 at 3:33 P.M. revealed Resident #10 was unable to sit still and had continuous leg and tongue movements. During the interview, Resident #10 indicated she was unable to control her tongue thrusting and leg movements. A review of Resident #10's clinical assessments indicated an abnormal involuntary movement scale (AIMS) assessment dated [DATE]. The AIMS assessment indicated when a resident received antipsychotic medication an AIMS assessment would be performed. The AIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the physician ordered wound treatment was applied to Resident #24's coccyx/right buttock pressure ulcer. This affected one of two residents reviewed for pressure ulcers. The facility census was 34. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including kidney, heart and lung disease, diabetes mellitus type II, depression and chronic pain. A review of Resident #24's plan of care indicated a risk for actual impaired skin integrity related to fragile skin, impaired mobility and diabetes mellitus initiated on 09/03/19. Interventions on the plan of care indicated provide wound treatments as ordered by the physician. A review of Resident #24's wound assessment dated [DATE] indicated a stage III pressure ulcer (involves the full thickness of the skin and may extend into the subcutaneous tissue layer) was present on the right buttock/coccyx area measuring 3.5 centimeters (cm)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory tests were completed in a timely manner for Resident #8. This affected one (Resident #8) of six residents reviewed for unnecessary medications. The facility census was 34. Findings include. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with the diagnoses of acute Hepatitis C, endocarditis and post-procedural hematoma of a nervous system organ. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had severely impaired cognition and required total assistance with activities of daily living. Review of the physician's orders dated 01/14/20 revealed orders for urinalysis and culture and sensitivity on 01/15/20. Review of the progress note dated 01/19/20 revealed the facility was unable to obtain the urine due to Resident #8 was having her menstrual cycle. The physician was notified. Interview on 01/22/20 Registered Nurse (RN) #4 indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address pharmacy recommendations. This affected three residents (Resident #3, #10 and #17) of six residents reviewed for unnecessary medications. The facility census was 34. Findings include: 1. Review of a medical record revealed Resident #3 was admitted to the facility on [DATE] with the diagnoses of urinary tract infection, cerebrovascular disease, atherosclerotic heart disease, macular degeneration, diabetes, pseudobulbar affect, major depressive disorder, delirium, dementia, hypertension, chronic pain, obesity and benign prostatic hyperplasia. Review of the pharmacy recommendation dated 12/17/18 revealed Resident #3 had received 500 milligrams (mg) of Depakote (mood stabilizer and antiseizure medication) three times a day since 12/2017. Please consider a gradual dose reduction. The pharmacy recommendation was never addressed by the physician. Review of the pharmacy recommendation dated 09/25/19 revealed Resident #3 had orders 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 medical record review and staff interview, the facility failed to follow physician's orders for Resident #17. This affected one resident (Resident #17) of six reviewed for unnecessary medications. The facility census was 34. Findings include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with the diagnoses of intraspinal abscess and granuloma, cerebral infarction affecting the left non-dominant side, fracture of left femur, major depressive disorder, chronic pain, anemia, anxiety disorder, acute respiratory failure and chronic viral hepatitis C. Review of January 2020 physician's orders revealed Resident #17 had an order dated 12/17/19 for five milligrams of Midodrine HCL (blood pressure support) every 12 hours as needed for systolic blood pressure less than 100. Review of the January 2020 medication administration records revealed Resident #17's systolic blood pressure was less than 100 on: 01/01/20, 01/03/20, 01/04/20, 01/05/20, 01/08/20, 01/09/20, 01/10/20,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview, the facility failed to provide dental services to Resident #21. This affected one resident (Resident #21) of six resident's reviewed for dental services. The facility census 34. Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with the diagnoses of respiratory failure, hypertension, diabetes, major depressive disorder, seizures and traumatic subarachnoid hemorrhage. Review of the dental assessment dated [DATE] revealed Resident #21 had four or more decayed or broken teeth. Review of the 360 care of Ohio Dental summary report for visit dated 07/30/19 revealed Resident #21 needed tooth #31 extracted. Interview on 01/21/20 at 11:10 A.M. Resident #21 indicated he had a tooth that needed to be pulled, it hurt when he ate, and he had told the staff it had been bothering him too long. Interview on 01/22/20 at 12:40 P.M., the Administrator indicated it was the social workers responsibility to follow up with the dental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to honor the food preferences of Resident #20. This affected one resident (Resident #20) of six residents reviewed for food and nutrition. The facility census was 34. Findings include: Review of the medical record revealed Resident # 20 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, schizophrenias, insomnia, gastroesophageal reflux disease, convulsions, peripheral vascular disease, psychotic disorder, pain, nicotine dependence, benign prostatic hyperplasia, diabetes, dementia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had severely impaired cognition, required supervision with eating and was on a therapeutic diet. Review of the meal tickets for breakfast and lunch revealed Resident #20 was to have a two handled cup, four ounces of tomato juice, eight ounces of milk, and disliked chicken.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to provide ordered adaptive eating equipment for Resident #20. This affected one resident (Resident #20) of six residents reviewed for food and nutrition. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, schizophrenias, insomnia, gastroesophageal reflux disease, convulsions, peripheral vascular disease, psychotic disorder, pain and nicotine dependence, benign prostatic hyperplasia, diabetes, dementia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had severely impaired cognition, required supervision with eating and was on a therapeutic diet. Review of the January 2020 physician's orders revealed Resident #20 had an order dated 10/15/19 for the use of two handled cups during meal times. Review of the meal tickets for breakfast and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure Registered Nurse (RN) #8 washed her hands appropriately while performing the wound treatment for Resident #24. This affected one of two residents reviewed for pressure ulcers. The facility census was 34. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including kidney, heart and lung disease, diabetes mellitus type II, depression and chronic pain. A review of Resident #24's plan of care initiated on 09/03/19 indicated a risk for actual impaired skin integrity related to fragile skin, impaired mobility and diabetes mellitus. An intervention on the plan of care indicated to provide wound treatments as ordered by the physician. A review of Resident #24's wound assessment dated [DATE] indicated a stage II pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) was present on the coccyx/right buttock area measuring 3.5 centimeters (cm) long…

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