Kettering Heights Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure a new pressure ulcer was assessed, measured, and physician notified timely. This affected one (#51) out of the three residents reviewed for wound care. The facility census was 87. Findings include: Review of the medical record for Resident #51 revealed an admission date of 10/11/24 with medical diagnoses of hypertensive heart disease, chronic kidney disease Stage III, diabetes mellitus with neuropathy, bipolar disorder, and chronic obstructive pulmonary disease. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment, dated 10/18/24, which indicated Resident #51 was cognitively intact and was dependent upon staff for toileting and transfers, required substantial/maximum for bating and bed mobility. The MDS indicated Resident #51 was incontinence of bladder and bowel, was at risk for skin breakdown, and no pressure ulcers were present upon admission. Review…

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

Based on medical record reviews, staff interviews, observations and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#04 and #14) out of the four residents reviewed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record for Resident #04 revealed an admission date of 02/07/24 with medical diagnoses of atherosclerosis of native arteries, peripheral vascular disease, left hemiplegia, and adult failure to thrive. Review of the medical record for Resident #04 revealed a significant change Minimum Data Set (MDS) assessment, dated 07/27/24, which indicated was cognitively intact and required partial/moderate staff assistance with bed mobility, was dependent upon staff for toilet hygiene and transfers, and required substantial/maximum staff assistance for bathing. Review of the medical record for Resident #04 revealed a physician order dated 06/25/24 for metoprolol 25 milligram (mg) one tablet by mouth two times per day. The order also stated to hold the medication if systolic…

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 interviews, observations, and review of facility policies, the facility failed to follow infection control procedures during wound care. This affected one (#04) out of the three reviewed for wound care. The facility also failed to follow infection control procedures during medication administration. This affected one (#24) out of the three residents observed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record for Resident #04 revealed an admission date of 02/07/24 with medical diagnoses of atherosclerosis of native arteries, peripheral vascular disease, left hemiplegia, and adult failure to thrive. Review of the medical record for Resident #04 revealed a significant change Minimum Data Set (MDS) assessment, dated 07/27/24, which indicated was cognitively intact and required partial/moderate staff assistance with bed mobility, was dependent upon staff for toilet hygiene and transfers, and required substantial/maximum staff assistance for bathing. The MDS indicated Resident #04 was at risk…

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 the facility failed to ensure medications were administered as per physician order. This affected one Resident (#10) of three reviewed. The facility census was 92. Findings include: Review of medical record for Resident #10 revealed admission date of 05/19/22. The resident was admitted with diagnoses including type two diabetes mellitus, Diabetic retinopathy, bipolar disease and peripheral vascular disease. The resident remained in the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and supervision for eating. Review of the physician orders revealed the following active orders: Combigan Ophthalmic (used to lower raised pressure in the eye) 0.2 Percent (%) - 0.5% into both eyes, two times a day for Glaucoma. The order had a start date of 12/26/23.…

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

Based on record review and interview, the facility failed to ensure routine medication was available for administration. This affected one (Resident #67) of 24 sampled residents. Findings include: A review of Resident #67's admission Record revealed the facility admitted the resident on 06/30/22, with diagnoses that included legal blindness, cataract extraction status right and left eyes, and bipolar disorder. Resident #67's Order Summary Report, revealed an order dated 08/14/2023, for Rocklatan Ophthalmic Solution 0.02-0.005%, instill one drop in both eyes at bedtime related to cataract extraction status right eye. Resident #67's medication administration record (MAR) for May 24 revealed staff initialed the MAR on 05/07/24, 05/08/24, 05/11/24, 05/13/24 - 05/18/24, 05/20/24, and 05/22/24 - 05/24/24 to indicate the Rocklatan Ophthalmic Solution was not available for administration. During an interview on 06/11/24 at 8:30 AM, Resident #67 stated they did have eye drops that sometimes did not get reordered on time, so the eye drops were not available for the staff to administer to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Pharmacist interviews, the facility failed to administer medications as physician ordered. This affected two (#100 and #60) of three residents reviewed for medication administration. Facility census was 101. Findings include: 1. Review of medical record for Resident #100 revealed admission date of 01/17/24. Diagnoses include cellulitis of left toe, type two Diabetes Mellitus, acute osteomyelitis left ankle and foot, Methicillin Susceptible Staphylococcus Areus (MRSA). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident remains in the facility. He was independent for eating, toileting, supervision for bed mobility and transfers. Review of the physician orders revealed an order for 12 Grams (gm) Nafcillin (antibiotic) to be given intravenously (IV) every 24 hours with a start date of 01/18/24. Record review of 01/18/24 progress note revealed Nafcillin was not available and 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, staff interview, record review, the facility failed to ensure the medication were administered as ordered resulting in three medications errors out of 30 opportunities or a ten percent (%) medication error rate. This affected one (#64) out three residents observed for medication administration. The facility census was 101. Findings include: Review of medical record for Resident #64 revealed admission date of 11/11/23. Diagnoses include Metabolic Encephalopathy, stroke, anxiety and hypertension. The resident remains in the facility. Medication observation on 02/05/24 of Licensed Practical Nurse (LPN) #100 for Resident #64 revealed Amlodipine (hypertension) five milligrams (mg), two Budesonide (steroid) three mg tablets, Buspar (antianxiety) 10 mg, Imodium (antidiarrheal) two mg, Vitamin D3 (supplement) 25 micrograms (mcg), Cholestyramine (cholesterol) four Grams, three Duloxetine (depression) 30 mg tablets, Plavix (anti platelet) 75 mg, Hydralazine (blood pressure) 10 mg, Nebivolol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and staff interviews and policy review, the facility failed to ensure proper medication storage. This affected one (#65) out of three residents observed for medication storage. The facility census was 101. Findings include: Review of medical record for Resident #67 revealed admission date of 09/27/23. Diagnoses include orthopedic aftercare, spinal stenosis and cardiomegaly. The resident remained in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #67 required extensive two-person assistance for bed mobility, transfers, one person assistance for toileting and independent for eating. Further review of Resident #67's medical record revealed there was no documentation to support the resident was permitted to self-administer medications. During an interview on 02/05/24 at 12:47 P.M. with Resident #67, State Tested Nursing Assistant (STNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff interview, the facility failed to follow proper infection control procedures during incontinence care. This affected one (#14) out of three residents reviewed for infection control. The facility census was 86. Finding include: Review of medical record for Resident #14 revealed admission date of 06/22/23. Diagnoses include age related physical debility and chronic kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating the resident had impaired cognition. Resident #14 required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. A care plan relative urinary incontinence initiated 07/03/23 revealed individualized interventions which included to provide incontinence care as needed. And the bowel incontinence initiated 10/03/23 revealed interventions which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews and record review, the facility failed to maintain a clean and homelike environment. This affected three (#03, #12 and #36) residents of the six residents reviewed for homelike environment. The total facility census was 84. Findings Include: Record review of Resident #03 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, muscle weakness and osteoarthritis of the knee. Review of the Minimum Data Set, (MDS) assessment for Resident #03 dated 09/28/23, revealed the resident had intact cognition and required supervision with activities of daily living (ADLs). Record review of Resident # 12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lack of coordination, and pain of the left and right knees. Review of the MDS assessment for Resident #12 dated 09/21/23, revealed the resident had intact cognition and was independent with locomotion. Record review of Resident # 36 revealed the resident 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.

Based on record review, policy review, resident and staff interviews, the facility failed to provide residents' access to their personal funds daily, including weekends. This affected one (#47) of three reviewed for management of resident funds and the potential to affect 41 resident's accounts the facility manages. The facility census was 78. Findings include: Interview on 11/02/21 at 1:30 P.M., during the Resident Meeting, Resident #47 revealed an ongoing concern regarding the availability of resident funds managed by the facility. Interview on 11/02/21 at 2:51 P.M., with Payroll Clerk (PC) #14 confirmed the facility only allows residents to have access to their personal funds, Monday through Friday from 8:00 A.M. through 4:30 P.M. PC#14 confirmed the limited hours is because she is the only employee that has access to Petty Cash, and this is the funding used to allow residents to have access to their petty cash needs. PC#14 stated the residents are limited to accessing $50.00 cash from their personal accounts daily due to the limited monies the facility has available. If a…

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

Based on observation, staff interview, facility policy review, and review of the planned menus approved by a Registered Dietitian (RD) #53 revealed the facility failed to follow planned menus for resident's on pureed and mechanically soft diets. This had the potential to affect 13 (#56, #43, #63, #13, #27, #35, #60, #49, #53, #20, #59, #36, #52) of 13 residents who had orders for either a pureed or mechanically soft diet. The facility census was 78. Findings include: Observations on 11/03/21 at 3:58 P.M. was started for the meal preparation and service for the evening meal. Review of the planned menu, approved by the Registered Dietitian (RD) #53, revealed that residents on a mechanically soft diet were to receive a #8 scoop (1/2 cup) of egg salad, or #8 scoop of ground hamburger if they had chosen the alternative menu item. In addition, the planned menu specified that resident's on a pureed diet were to receive a #8 scoop of pureed egg salad, and vegetable juice as an alternate for the cucumber salad being served to regular diets. Observation on 11/03/21 at approximately 4:30 P.M.,…

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

Based on observation, staff interview, and review of facility policy, revealed the facility failed to hold food prepared for service at acceptable temperatures. This had the potential to 77 of 77 residents who receive food from the kitchen with the exception of one resident (#12) who received nothing by mouth. The facility census was 78. Findings include: Meal preparation and service for the evening meal on 11/03/21 was observed beginning at 3:58 P.M. Observation on 11/03/21 at approximately 4:30 P.M., revealed [NAME] #65 making egg salad sandwiches for the evening meal. The sandwiches were for residents on a regular or mechanically soft diet. On completing the egg salad sandwiches the cook left the egg salad sandwiches setting out on trays in the kitchen, after covering the sandwiches. The sandwiches remained out on the counter, un-refrigerated, until tray assembly began at approximately 5:00 P.M. Cook #65 then took the temperatures of the food that had been prepared for the evening meal 4:53 P.M. The temperature of the egg salad on the sandwich tested was 54 degrees Fahrenheit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and staff interview, the facility failed to maintain dignity and respect for a resident when the resident was not assisted with dressing in daily clothes. This affected one ( #12) of three residents reviewed for dignity and respect. The facility census was 78. Findings include: Review of the medical record for Resident #12 revealed resident was admitted to the facility on [DATE]. Resident #12 was listed as a full code advance directive status. His diagnoses included: schizophrenia, bipolar disorder, obstructive sleep apnea, blindness in right eye, insomnia, gastro-esophageal reflux disease, retention of urine, essential primary hypertension, conversion disorder with seizures or convulsions, dysphagia, aphasia dysphagia, anoxic brain damage, Barrett's esophagus, alcohol abuse, hepatomegaly, atypical atrial flutter, schizoaffective disorder, muscle atrophy, history of Coronavirus 2019 (COVID), and sequela. Review of the Minimum Data Set (MDS) significant change…

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

Based on record review, staff and resident interview, and review of policy, the facility failed to notify the physician according to the physician's orders when a resident's blood glucose level exceeded parameters defined by the order. This affected one (#47) of five residents reviewed for unnecessary medication. The facility census was 78. Findings include: Review of Resident #47's medical record revealed an admission date of 06/27/20, with diagnoses including: end stage renal disease, diabetes mellitus type one, exocrine pancreatic insufficiency, anemia in chronic kidney disease, hydronephrosis with urethral stricture, retention of urine, cachexia, and dementia. Review of a quarterly minimum data set (MDS) assessment of the resident dated 09/24/21 revealed the resident had good cognitive skills, was independent with or required only supervision to complete all activities of daily living. The resident was documented as receiving insulin injections daily at the time of the assessment. Review of the resident's physician orders revealed an order for Novolog (a rapid-acting insulin)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, policy review and staff interview, the facility failed to ensure residents were weighed per physician order. This affected two (#58 and #430) of seven residents reviewed for weight. The facility census was 78. Findings include: 1. Medical record review for Resident #58 revealed admission date 06/24/21. Diagnoses included congestive heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease and secondary pulmonary arterial hypertension. Review of the Medicare Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of physician orders for October 2021 revealed an order dated 10/28/21 at 8:30 A.M., for daily weights one time a day for fluid overload for two weeks. Review of Resident #58's medical record and weight flowsheet revealed no evidence of a weight on 10/29/21, 10/30/21, and resident weight on 11/01/21 was disputed on 11/02/21 at 11:35 A.M. with a strike out. Daily weights resumed 11/02/21. 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 observations, record review, resident and staff interviews and policy review, the facility failed to provide physician ordered nutritional supplementation to prevent further weight loss and/or promote weight gain. This affected one (#36) of six residents reviewed for nutrition. The facility census was 78. Findings include: Review of Resident #36's medical record revealed an admission on [DATE], with diagnoses including: atherosclerotic heart disease, dysphagia, anorexia, age-related physical debility, dementia with behavioral disturbance, chronic obstructive pulmonary disease, anxiety, diabetes mellitus type two, and chronic lymphatic leukemia of B-cell type in remission. Review of a quarterly minimum data set (MDS) assessment, dated 09/09/21, revealed Resident #36 had moderate cognitive impairment, and required supervision with limited assistance from staff to completed all activities of daily living with the exception of eating for which she required set-up help only. The resident was 59 inches tall…

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, policy review and staff interviews, the facility failed to ensure residents oxygen tubing was dated and documented as changed weekly per facility policy. The affected two (#58 and #430) of three residents reviewed for respiratory treatments. The facility identified 16 residents who received respiratory treatments. The facility census was 78. Findings include: 1. Medical record review for Resident #58 revealed admission date 06/24/21. Diagnoses included congestive heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease, and secondary pulmonary arterial hypertension. Review of the Medicare Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed to use oxygen. Review of the plan of care dated 10/21/21 revealed Resident #58 had altered cardiovascular status related to hypertension and atrial fibrillation. Interventions included give oxygen as ordered by the physician. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and review of facility policies, revealed the facility failed to keep all medications in locked compartments except when being administered by licensed nursing staff. This affected one (#42) and an undetermined number of residents who potentially could have had accessed the medications. The facility census of 78. Findings include: Observation on 11/02/21 at 8:29 A.M., of the conference room, revealed unidentified pills and pill cups scattered on the floor, and also setting on the bottom shelf of a white computer desk. The Unit Manager, Licensed Practical Nurse (LPN) #18 was then asked to come to the conference room to observe the pills and pill cups. She verified there were pills and pill cups scattered on and around the white computer desk in the conference room at that time. On further observation there were a total eight pills and five pill cups, some pills were in the cups and some were on the floor near the cups. LPN #18 was able to identify 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 and staff interview, the facility failed to provide written copies of 48 hour (baseline) care plans to residents. This affected eight Residents (#7, #13, #31, #34, #45, #53, #63 and #67) out of ten newly admitted residents reviewed. The census was 99 residents. Findings include: 1. Review of Resident #53's medical record revealed an admission date of 07/20/18. Diagnoses included hyperlipidemia, major depressive disorder, type II diabetes mellitus, hypertension, schizophrenia, and chronic kidney stage 4. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. Further review of Resident #53's medical record revealed no documentation of Resident #53 or representative being given a written copy of a baseline care plan for admission dated 07/20/18. 2. Review of Resident #7's medical record revealed an admission date of 01/28/18. Diagnoses included hypertension, type II diabetes mellitus, neuropathy, anxiety disorder, major…

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 medication storage area observation and staff interview, the facility failed to properly label and store medications. The affected three (#144, #44 and #34) residents medications that were observed opened/undated and three (100 hallway, 400 hallway and Med Bridge B) of five medication storage areas observed. The census was 99. Findings include: 1. Observation on [DATE] at 11:02 A.M. of the Med Bridge B medication cart revealed expired stock bottles of the medication Vitamin B 12, Decubi Vite Three in One, and Meclizone. Review of the medication bottles revealed the Vitamin B 12 100 expired on 12/18, the Decubi Vite Three in one expired on 09/18, and the Meclizone expired on 10/18. Continued observation of the medication cart revealed a vial of Ipratropium Bromide/Albuterol Sulfate inhalation solution and a Dulera Inhalation Aerosol with no prescription label or resident identification information. Further observation of the Med Bridge B medication cart, revealed an opened and undated bottle 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 resident record review and staff interview; the facility failed to ensure advanced directives being stored in the hard chart and electronic health record (EHR) were consistent. This affected two (#31 and #49) of 32 residents reviewed for consistency of advanced directives. The census was 99. Findings include: 1. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia, bacteremia, hypertension, diabetes mellitus, insomnia, major depressive disorder, dysphagia, pain, constipation, muscle spasm, atrial fibrillation, stage four pressure ulcer of the sacral region. Review of Resident #31's EHR revealed the resident code status was do not resuscitate comfort care arrest (DNRCC-A). Review of Resident #31's hard chart revealed the residents code status was full code. There was no DNR identification form located in the residents chart. Interview on 02/26/19 at 12:16 P.M. with registered nurse (RN) #99 verified the EHR 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, observation, and resident and staff interview, the facility failed to provide a resident assistance with activities of daily living (ADL). This affected one (#21) of two resident reviewed for ADL's. The census was 99. Findings include: Review of the medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cellulitis, restlessness and agitation, benign prostatic hyperplasia, retention of urine, hypertension, anxiety disorder, major depressive disorder, anemia, diabetes mellitus, chronic kidney disease, constipation, peripheral vascular disease. Review of Resident #21's care plan revealed the resident required assistance for bathing. The residents goal was to be neat, clean, and odor free. The care plan revealed the resident preferred bathing twice a week. Review of the annual minimum data set (MDS) assessment dated [DATE], revealed Resident #21 was totally dependent of two people with physical assistance for bathing 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 resident record review and staff interview, the facility failed thoroughly assess a non-pressure skin alteration. This affected one (#31) of two resident review for alterations of the skin. The census was 99. Findings include: Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia, pressure ulcer of the right heel, bacteremia, hypertension, diabetes mellitus, insomnia, major depressive disorder, dysphagia, pain, constipation, muscle spasm, atrial fibrillation, stage four pressure ulcer of the sacral region. Review of a physician order dated 08/16/18, revealed Resident #31 was ordered wound care for an open area located on the residents coccyx. The order was to cleanse the area with IHWC (in-house wound cleanser); apply collagen matrix and cover with a foam dressing. The wound dressing was to be changed every day and as needed. Review of the medical record revealed there was no assessment of the open area located on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure a resident received the necessary care and services to promote healing of an unavoidable pressure sore to the coccyx specifically when Resident #67 was observed on three days of the survey without position changes. This affected one (#67) out of two residents reviewed for pressure ulcers. The facility census was 99 residents. Findings include: Review of Resident #67's admission record, revealed she was admitted to the facility on [DATE] with diagnoses including intraventricular hemorrhage, cerebral vascular accident with post hemorrhagic obstructive hydrocephalus status, anemia, arthritis, chronic bronchitis, chronic pain, chronic obstructive pulmonary disease, dyspnea, edema, fibromyalgia, hiatal hernia, hypertension, and emphysema. The admission minimum data set (MDS) dated [DATE], revealed the cognitively impaired resident required extensive assistance of staff with bed mobility, transferring, dressing, eating,…

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 facility policy, the facility failed to monitor a residents blood sugar including notifying a physician and implement their hypoglycemia policy when a resident's blood sugar was below ordered parameters. This affected one (#7) of five residents reviewed for unnecessary medications. The facility identified 22 residents currently receiving blood sugar checks. The facility census was 99 residents. Findings include: Review of Resident #7's medical record revealed an admission date of 01/28/18. Diagnoses included hypertension, type II diabetes mellitus, neuropathy, anxiety disorder, major depressive disorder, and weakness. Review of a comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. Review of physician orders revealed a physician order dated 02/19/18 for Humalog (insulin) per sliding scale before meals. For blood sugars less than 60 milligram per deciliter (mg/dL) and greater than 500…

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, review of a resident list, resident and staff interview and review of policy and procedures, the facility failed to ensure the resident was seen by the dentist on a yearly basis for routine dental hygiene. This affected one (#39) out of two resident reviewed for dental services. The facility census was 99. Findings include: Review of medical record for Resident #39 documented an admission date of 09/28/16 with diagnosis including hemiplegia, pluerodynia, contractures of left hand, left foot, left hip and left ankle, hypertension, hyperlipidemia, pain, dysphagia, depression and anxiety disorder. Further review documented his payer source as Medicaid Buckeye MyCare for long term care. Review of quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #39 was moderately cognitively impaired, required an extensive two person assist with personal hygiene which included brushing his teeth and there lacked any documentation of mouth or facial pain. Review of entire 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.