The Laurels Of Kettering

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interviews, and policy reviews, the facility failed to complete a discharge summary or recapitulation of a resident's stay, failed to complete a bed hold notice when resident's were transferred to the hospital and failed to notify the Ombudsman of resident's discharges. This affected four (#15, #27, #75, and #134) out of four residents reviewed for discharges. The facility census was 76. Findings include: 1. Review of the medical record for Resident #134 revealed an admission date of 09/12/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertensive heart disease, and malignant neoplasm of kidney. Review of the medical record revealed a discharge date of 01/23/25. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MD'S) assessment, dated 12/20/24, which indicated Resident #134 was cognitively intact and was independent with activities of daily living. Review of the medical record for Resident #134…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and facility policy review, the facility failed to provide a homelike environment when meal trays were delivered to the residents with plasticware in place of silverware. This affected three Residents (#05, #67, and #129) out of three residents reviewed for home-like environment. The facility census was 76. Findings include: 1. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included hyperlipidemia, gastro-esophageal reflux disease, spinal stenosis, insomnia, essential hypertension, major depressive disorder, anorexia, anemia, and pruritus. Review of the Minimum Data Set (MDS) assessment, dated 05/12/25, revealed Resident #05 was cognitively intact. Further review of the MDS assessment revealed she was independent with eating. Review of the progress notes for Resident #05, 06/09/25 at 1:02 P.M. revealed Resident #05's daughter notified the staff that Resident #05's teeth were broken while eating pork…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate coded. This affected one (#53) out of three residents reviewed for MDS accuracy. The facility census was 76. Findings include: Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism. Review of the Minimum Data Set (MDS) for a Significant Change, dated 05/15/25, revealed Resident #53 required Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication administration and personal hygiene. Resident #53 required staff set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing.…

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 and resident interviews, and policy review, the facility failed to ensure a comprehensive skin assessment was completed upon admission. This affected one (#126) out of six residents reviewed for skin breakdown. The facility census was 76. Findings include: Review of the medical record for Resident #126 revealed an admission date of 06/07/25 with medical diagnoses of cystitis, hypothyroidism, anemia, congestive heart failure, and chronic obstructive pulmonary disease. Review of the medical record for Resident #126 revealed a nursing comprehensive evaluation, dated 06/07/25, which indicated Resident #126 had a surgical incision to her back which measured 20 centimeters (cm) and had 58 staples. Further review of the evaluation revealed Resident #126 had bruising to right and left iliac crests and left antecubital, and a scab to right deltoid. Review of the medical record for Resident #126 revealed a Brief Interview for Mental Status (BIMS), dated 06/09/25, which indicated Resident #126 had moderately impaired cognition. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure fall interventions were in place as care planned. This affected one (#31) out of one resident reviewed for falls. The facility census was 76.Findings include:Medical record review for Resident #31 revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, cellulitis of left lower limb, heart failure, essential primary hypertension, hyperlipidemia, and anemia. Review of the Minimum Data Set (MDS) assessment for Resident #31, dated 03/12/25, revealed she was cognitively intact. Resident #31 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, personal hygiene, dressing, and transfers. She required moderate assistance from staff with eating. Resident #31 required the use of a wheelchair for mobility. Review of the, Fall Care Plan, initiated on 05/28/25, for Resident #31 revealed she was care planned to have 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 3. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the medical record for weights for Resident #2 revealed the following: - 02/28/25: 221.1 pounds - 03/01/25: 289.4 pounds - 03/02/25: 289.4 pounds - 03/11/25: 388.2 pounds - 03/18/25: 388.1 pounds - 03/25/25: 387.2 pounds - 03/26/25: 244 pounds - 04/01/25: 285.6 pounds - 04/04/25: 285.5 pounds - 05/05/25: 285.5 pounds - 06/11/25: 237.6 pounds Review of the medical record for Resident #2 since admission revealed weights were inconsistent with no notification to the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, interviews, and policy review, the facility failed to timely implement appropriate interventions to manage a resident's pain. This affected one (#2) of five reviewed for pain management. The facility census was 76. Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 02/28/25 revealed Resident #2 was at risk for pain related to decreased mobility, chronic pain, MS, and generalized pain. Interventions included anticipate need for pain relief, notify…

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

Based on medical record review, staff interview, and policy review, the facility failed to assess a dialysis access site as per facility policy. This affected one (#132) out of one resident reviewed for dialysis. The facility census was 76. Findings include: Review of the medical record for Resident #132 revealed an admission date of 06/03/25 with medical diagnoses of cervical disc degeneration, end stage renal disease (ESRD), dependence on dialysis, hypertension, and diabetes mellitus. Review of the medical record for Resident #132 revealed a nursing comprehensive evaluation, dated 06/03/25, which indicated Resident #132 was alert and oriented to person and place. The evaluation also indicated Resident #132 admitted with a fistula to left forearm. Review of the medical record for Resident #132 revealed no documentation to support the facility had assessed Resident #132's dialysis fistula to his left forearm. Interview on 06/11/25 at 8:30 A.M. with Director of Nursing (DON) confirmed the facility did not have documentation to support Resident #132's fistula to left forearm had been…

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, interview, and policy review, the facility failed to provide behavioral health services for Resident #14 who had diagnoses of mental disorders. This affected one (#14) of six residents reviewed for behavior management. The facility census was 76. Findings include: Review of the medical record for Resident #14 revealed an admissions date of 05/07/25 with diagnoses including bipolar disorder, anxiety disorder, recurrent depressive disorder, opioid dependence, and schizoaffective disorder. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #14 was cognitively intact. Review of Resident #14's orders revealed the resident had a physician order on 05/07/25 for a psychiatric evaluation and treatment. Review of the care plan, dated 05/28/25, revealed that Resident #14 had a history of behavior problems. Interventions include administer medications as ordered, reporting abnormal finding to the physician, approach in a calm manner, observe behavior…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered which resulted in a significant medication error. This affected one (#135) out of six residents reviewed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #135 revealed an admission date of 02/09/25 with medical diagnoses of encounter for other orthopedic aftercare, arthrodesis, left above the knee amputation, and aftercare following joint surgery. Review of the medical record revealed a discharge date of 03/11/25. Review of the medical record for Resident #135 revealed an admission Minimum Data Set (MDS) assessment, dated 02/15/25, which indicated Resident #135 was cognitively intact and required supervision with activities of daily living. Review of the medical record for Resident #135 revealed physician orders dated 02/09/25 for oxycodone 10 milligram (mg) one tablet by mouth six times per day and oxycodone 5 mg one tablet by mouth every six hours as needed (PRN). 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 review of the medical record, interviews, observations, and policy review, the facility failed to follow up with dental services regarding a resident's missing dentures. This affected one (#2) of one resident reviewed for dental services. The facility census was 76. Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the progress note dated 10/22/24 at 12:40 P.M. revealed Resident #2 reported missing dentures. Resident #2 was notified that dental services would be in the facility on 11/13/24. 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 review of the medical record, observations, interviews, and policy review, the facility failed to maintain infection control measures during wound care and peri care. This affected three (#3, #35, and #67) of five reviewed for infection control. The facility census was 76. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 06/15/24. Diagnoses included heart failure, dementia, delusional disorders, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 02/01/25 revealed Resident #35 had an actual impaired skin integrity related to pressure injury stage three to the coccyx with excoriation noted to peri-area. Interventions included conduct skin…

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 list of medications available in emergency box, staff interview, and policy review, the facility failed to administer a medication as per resident request and physician order. The affected one (#65) out of the three residents reviewed for medications administered as ordered. The facility census was 59. Findings include: Review of the medical record for Resident #65 revealed an admission date of 12/04/24 with medical diagnoses of Coronavirus Disease 2019 (COVID-19), acute respiratory failure, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, and congestive heart failure. The medical record indicated Resident #65 discharged to a hospital on [DATE]. Review of the medical record for Resident #65 revealed a discharge Minimum Data Set (MDS) assessment, dated 12/05/24, which indicated Resident #65 was dependent upon staff for toilet hygiene, bathing, and transfers, and required partial/moderate staff assistance for bed mobility and set-up…

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

Based on medical record reviews, staff interview, and policy review, the facility failed to notify resident representative of a resident's change in condition. This affected one (#33) resident out of three reviewed for changes in condition. The facility census was 63. Findings include: Review of the medical record for Resident #33 revealed an admission date of 08/05/24 with medical diagnoses of left hemiparesis, congestive heart failure, diabetes mellitus, dementia, chronic obstructive pulmonary disease (COPD), and anemia. Review of the medical record for Resident #33 revealed an admission minimum data set (MDS) assessment, dated 08/12/24, which indicated Resident #33 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. No skin issues were noted on the MDS. Review of the medical record for Resident #33 revealed a physician order dated 08/07/24 to cleanse sacrum wound with soap and water, apply foam dressing, and change daily. Review of the medical record for Resident #33 revealed a wound/skin…

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, and policy review, the facility failed to ensure safe and orderly discharges. This affected two (#67 and #68) out of four residents reviewed for discharges. The facility census was 63. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 08/06/24 and a discharge date of 09/04/24. Review of the medical record for Resident #67 revealed medical diagnoses of DM, hypertensive heart disease, and chronic obstructive pulmonary disease (COPD). Review of the medical record for Resident #67 revealed an admission minimum data set (MDS) assessment, dated 08/13/24, which indicated Resident #67 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene, bathing, and transfers and required partial/moderate staff assistance for bed mobility. Review of the medical record for Resident #67 revealed a nurse progress note dated 09/04/24 at 8:30 A.M. that Resident #67 was sent to the emergency room for nausea and vomiting. Review of the medical record for Resident #67 revealed no…

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, staff interviews, and policy review, the facility failed to ensure staff completed a recapitulation of a resident's stay upon discharge. This affected two (#66 and #70) out of four residents reviewed for discharges. The facility census was 63. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 07/25/23 and a discharge date of 04/01/24. The medical record for Resident #66 revealed medical diagnoses of multiple myeloma, lumbar spinal stenosis, hypertensive heart disease, and diabetes mellitus (DM). Review of the medical record for Resident #66 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/03/24, which indicated Resident #66 was cognitively intact and was independent with bed mobility, toileting, transfers and eating. Review of the medical record for Resident #66 revealed no documentation to support the facility staff completed a discharge recapitulation of stay or discharge summary prior to Resident #66's discharge 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.

Based on medical record review, staff interview, and policy review, the facility failed to properly assess a resident's skin breakdown at the time the area was first observed. Additionally, the facility failed to complete weekly monitoring of the wound and failed to complete treatments as ordered. This affected one (#33) out of three residents reviewed for wound care and services. The facility census was 63. Findings include: Review of the medical record for Resident #33 revealed an admission date of 08/05/24 with medical diagnoses of left hemiparesis, congestive heart failure, diabetes mellitus, dementia, chronic obstructive pulmonary disease (COPD), and anemia. Review of the medical record for Resident #33 revealed an admission minimum data set (MDS) assessment, dated 08/12/24, which indicated Resident #33 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. No skin issues were noted on the MDS. Review of the medical record for Resident #33 revealed a physician order dated 08/07/24 to cleanse…

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 follow physician orders to obtain daily weights. This affected one (Resident #81) of three residents reviewed for nutrition. The facility census was 80 residents. Findings include: Review of the medical record for Resident #81 revealed an admission date of 03/27/24 with diagnoses including acute respiratory failure with hypoxia, congestive heart failure (CHF), atrial fibrillation, and generalized anxiety disorder, and a discharge date of 07/04/24 Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 05/15/24 revealed the resident had intact cognition and was independent with eating and was dependent with toileting, bathing, dressing, and transfers. Review of the physician's orders for Resident #81 revealed an order dated 05/11/24 to weigh the resident once daily and notify physician if there was a weight gain greater than two and a half pounds (lbs.) in less than 24 hours or greater than five lbs. in a week. Review of the weight record for Resident #81 dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to properly monitor resident weights and failed to implement nutritional recommendations to prevent weight loss. This affected one (Resident #83) of three residents reviewed for nutrition. The facility census was 80 residents. Findings include: Review of the medical record for Resident #83 revealed an admission date of 05/07/24 with diagnoses including type two diabetes mellitus, anxiety disorder, and cerebral infarction, and a discharge date of 07/26/24. Review of the weight record for Resident #83 revealed the following weights: 05/07/24 -284 lbs., 05/14/24-310 lbs., 05/20/24-249.2 lbs., 06/03/24-248.7 lbs. Review of the care plan for Resident #83 dated 05/09/24 revealed the resident was unable to tolerate nutritionally adequate food and/or fluids by mouth and required the use of a feeding tube related to larynx cancer. Interventions included the following: administer tube feeding as ordered, staff to obtain weight…

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 the medication error rate was less than five percent (%.) The facility medication error rate was 7.14% based on 28 medication opporunities and two medication errors. This affected two (Residents #22 and #68) of five residents reviewed for medication administration. The facility census was 80 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 08/10/22 with diagnoses including type two diabetes mellitus (DM II), peripheral vascular disease (PVD), and anxiety disorder. Review of the physician's order for Resident #22 revealed an order dated 03/30/24 for the resident to received Refresh ophthalmic gel 1% instill one drop into both eyes two times a day for dry eyes. Observation on 08/07/24 at 8:24 A.M. of medication administration for Resident #22 per Registered Nurse (RN) #30 revealed the nurse did not administer Refresh ophthalmic gel 1% eye drops because the medication was not available. 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.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow proper infection control practices when providing direct care for residents with physician's orders for enhanced barrier precautions (EBP). This affected two (Residents #9 and #55) residents of three reviewed for infection control. The facility census was 80 residents. Findings include: 1.Review of the medical record for Resident #9 revealed an admission date of 06/13/24 with diagnoses including hemiplegia affecting right dominant side, atrial fibrillation, and type two diabetes mellitus. Review of the physician's orders for Resident #9 revealed an order dated 07/05/24 for enhanced barrier precautions (EBP) due to the resident had the presence of a gastronomy tube (g-tube). Observation on 08/08/24 at 1:47 P.M. revealed State Tested Nurse Aide (STNA) #10 performed hand hygiene and applied gloves and assisted Resident #9 into bed and checked the resident's brief for signs of incontinence. STNA #10 did not don a gown during care for Resident #9. 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.

Based on staff interview, record review, and policy review, the facility failed to ensure the resident's medication administration records (MAR) and treatment administration records (TAR) were available during disruption of internet services. This affected five (Residents #12, #13, #20, #26, and #61) of five residents reviewed for medical records and the potential to affect all 87 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/11/22. Resident #12 had physician orders for medications and treatments on 06/09/24. Review of the MAR and TAR dated June 2024 revealed Resident #12 had no documentation for blood glucose monitoring and medication administration on 06/09/24 for medications including SymlinPen (insulin) at 12:00 P.M. and 5:00 P.M., Lactobacillus (probiotic) at 5:00 P.M., Humalog insulin per sliding scale at 12:00 P.M. and 5:00 P.M., Hydralazine (treats high blood pressure) at 3:00 P.M., and Gabapentin (treats nerve pain) at 12:00 P.M. and 5:00 P.M. Additional review revealed no…

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 interviews, and policy review, the facility failed to ensure residents were free of any significant medication errors when the residents did not receive their medications as physician ordered when the electronic record was not available. This affected five (Residents #12, #13, #17, #26, and #61) of five residents reviewed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/11/22. Diagnoses included stage III chronic kidney disease, type II diabetes mellitus, and vascular disease. Review of Resident #12's physician orders revealed medications included SymlinPen 120 subcutaneous pen-injector 2,700 microgram (mcg) per 2.7 milliliter (ml) -inject 120 mcg subcutaneously with meals and Humalog Insulin 100 units per ml - inject subcutaneously as per sliding scale before meals. Review of the Medication Administration Record (MAR) dated June 2024 revealed Resident #12 had no documentation for blood glucose monitoring and medication administration 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, staff interviews, medical record review, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and/or indwelling medical devices. This affected 11 (Residents #13, #18, #20, #23, #24, #25, #30, #36, #79, #82, and #88) of 23 residents reviewed for EBP. The facility census was 87. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 05/08/24. Diagnoses included acute respiratory failure with hypoxia and stage III chronic kidney disease. Review of the wound progress note dated 06/06/24 revealed Resident #13 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed boned, tendon or muscle) to the sacrum. Review of the physician order summary dated 06/27/24 revealed Resident #13 had no physician orders for EBP related to chronic wounds. Observations on 06/27/24 at 9:24 A.M. revealed Resident #13 did not have appropriate, visible signs for EBP posted outside of their room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and policy review, the facility failed to timely identify and treat a resident's skin tear. This affected one (Resident #28) of three residents reviewed for wound care. The facility census was 87. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included non-ischemic myocardial injury, rhabdomyolysis, chronic atrial fibrillation, stage III kidney disease, and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the Nursing Comprehensive Evaluation dated 06/20/24 revealed Resident #28 had no skin conditions documented, and there was no data to trigger a baseline care plan for potential skin breakdown. There was no mention Resident #28 had any wound to her left lower leg from 06/20/24 to 06/26/24. During an…

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 interview, review of the facility policy, and record review, the facility failed to ensure residents received incontinence care in a timely manner. This affected one (Resident #61) of six residents reviewed for toileting assistance. The facility census was 87. Findings include: Review of the medical record for Resident #6 revealed an admission date of 07/22/21. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, stage III chronic kidney disease, and anxiety. Review of the care plan dated 08/11/21 revealed Resident #61 was incontinent of bowel and bladder related to immobility. Interventions included to assist with toileting upon request, provide disposable briefs, check during rounds for incontinence, and provide incontinence care as needed. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #61 was always incontinent of bowel…

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 a facility policy, the facility failed to ensure residents received appropriate assistance with bathing. This affected three (#13, #16, and #23) of four residents reviewed for bathing assistance. The census was 54. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/13/23. Medical diagnoses included diabetes mellitus type II, sleep apnea, and malignant neoplasm of the prostate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having intact cognition, and required set up assistance for eating, was dependent for toileting, bed mobility, and transfers, and required substantial to maximal assistance for showers and bathing. Record review of shower documentation revealed Resident #13's showers were scheduled twice weekly (on Tuesday and Friday) on the day shift. Further review of the shower documentation between 10/13/23 and 11/03/23 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 medical record review and staff interview, the facility failed to obtain weekly weights as ordered. This affected one (#12) of three residents reviewed for nutrition. The census was 54. Findings include: Review of the medical record for Resident #12 revealed an admission date of 10/12/23. Medical diagnoses included diabetes mellitus type two and a wedge compression fracture and fusion of the lumbar spine. Resident #12 was discharged home on [DATE]. Review of Resident #12's admission Minimum Data Set (MDS) assessment dated [DATE] the resident was assessed as cognitively intact, and required set up assistance with eating, moderate assistance for toileting, and was independent with bed mobility. Review of Resident #12's physician orders since the admission date of 10/12/23 revealed an order for weekly weights every Monday for four weeks. Review of the electronic medical record for Resident #12 revealed an admission weight on 10/12/23 of 284.7 pounds, and a weight on 10/16/23 of 268.4 pounds. There were no…

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

Based on observation, staff interview and policy review, the facility failed to ensure eye protection was worn into COVID-19 positive resident's rooms. This potentially could affect eight (#31, #12, #43, #34, #13, #1, #14, #30) of twelve residents who resided on the 200 hall and did not have COVID-19. The census was 48. Findings include: Observation of the rooms on the 200 halls for Resident #3, #46, #17 and #24 revealed their doors were closed and had a red sign on the door, indicating the resident was in droplet and contact isolation, due to COVID-19 positive. The sign indicated to wear eye protection, gown, gloves, and a N-95 mask. There was a cart observed outside the door with gowns, shields, gloves, and N-95 masks in them. Observation on 09/12/23 from 8:03 A.M. to 8:21 A.M., of breakfast trays being delivered to the 200 halls and lunch trays at 12:09 P.M., revealed State Tested Nursing Aides (STNA) #83 and #90 were going into the COVID-19 isolation rooms without wearing eye protection, coming out of the rooms, and doffing their Personal Protective Equipment (PPE) and then go…

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 and resident interview and policy review, the facility failed to ensure bathing/showers was provided for residents who were dependent on staff for care. This affected two (#14 and #16) of three residents reviewed for bathing. The census was 48. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/17/23, with diagnoses including cerebrovascular attack (CVA), dementia, and multiple sclerosis. Review of care plan dated 07/17/23 revealed Resident #14 had a self-care performance deficit and required assistance with Activities of Daily Living. Interventions on 07/26/23 revealed she preferred her bathing time in the morning and a shower, and she was 1-2-person assistance for the bathing. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, and toileting. She was supervision for eating and total…

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 referrals for outside services were made when requested by the family. This affected one (#16) of three residents reviewed for outside services. The census was 48. Findings include: Review of Resident #16's medical record revealed an admission date of 08/10/22, with medical diagnoses including cancer, atrial fibrillation, heart failure, peripheral vascular disease, diabetes, and dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was rarely or never understood. She was extensive assistance for bed mobility transfers, toileting and eating. Review of the physician referrals for Resident #16 revealed there wasn't any neurology referrals in the folder since 03/01/23. Review of physician notes dated 06/19/23, documented the family wanted a neurology consultation to slow the progression of dementia. Interview on 09/12/23 at 4:00 P.M., with the Director of Nursing (DON) confirmed there 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 record review, interview and policy review, the facility failed to ensure timely completion of baseline care plans and failed to ensure residents and their representatives received a copy of the baseline care plan. This affected four (Residents #21, #50, #44, and #41) of nine residents reviewed for baseline care plans. The facility census was 44. Findings include: 1. Review of the medical record of Resident #21 revealed an admission date of 11/22/22. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, essential hypertension, chronic congestive heart failure, vascular dementia without behavioral disturbance, hypothyroidism, and unspecified atrial fibrillation. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/30/22, revealed the resident had moderately impaired cognition. The resident required extensive assistance for bed mobility, transfers, and toileting, and was independent with eating. Review of the care plan dated 11/22/22 revealed care plans…

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 routine care conferences were held. This affected three (Residents #18, #41, and #42) of four residents reviewed for care planning. The facility census was 44. Findings include: 1. Review of the medical record Resident #18 revealed revealed an admission date of 11/08/21. Review of the medical record revealed the resident had care conferences on 11/23/21 and 08/02/22. During interview on 02/27/23 at 10:28 A.M., Resident #18 stated she did not recall having routine care conferences. During interview on 03/01/23 at 10:16 A.M. Social Services (SS) #530 stated care conferences should be done on admission and quarterly or with significant changes thereafter. SS #530 verified Resident #18 had not received care conferences on a quarterly basis. 2. Review of the medical record for Resident #41 revealed an admission on [DATE]. Review of the progress notes dated 01/25/23 through 02/28/23 for Resident #41 revealed no documentation related to scheduling or…

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

Based on observation, interview and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 43 of 44 residents in the facility. The facility identified one resident (Resident #44) who did not receive food from the kitchen. Findings include: Observation on 02/27/23 at approximately 8:20 A.M. of the facility's walk-in cooler revealed the following: 1. A large bowl of coleslaw, covered in plastic wrap, dated 02/17 2. A container of egg salad, covered in plastic wrap, dated 2/20 3. A container of tuna salad, covered in plastic wrap, dated 02/20 4. A pan of several pieces of pork loin, covered in plastic wrap, dated 02/19. During interview at the time of the observation, Dietary Manager (DM) #320 verified the aforementioned items were present in the walk-in cooler and stated the shelf-life of the items observed was between three and five days. Review of the facility-provided Refrigeration Date Storage Chart, undated, revealed all leftovers should be discarded after three days,…

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, interview and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's current health care status. This affected one (Resident #30) of five residents reviewed for accurate MDS assessments. The facility census was 44. Findings include: Review of the medical record revealed Resident # 30 admitted to the facility on [DATE] and had diagnoses including End Stage Renal Disease (ESRD) with dependence on renal dialysis, unspecified peripheral vascular disease, type II diabetes, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 30 had moderately-impaired cognition. Resident #30 had adequate hearing and did not have hearing aids. Review of Care 360 documentation revealed Resident # 30 received audiology services on 01/09/23. Resident #30 had bilateral hearing aides but only wore the right one. The left hearing aid was at home. Resident # 30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure the accuracy of care plans. This affected two (Residents #30 and #44) of 15 residents reviewed for care plans. The facility census was 44. Findings include: 1. Review of the medical record of Resident #44 revealed an admission date of 08/10/22. Diagnoses included acute kidney failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of muscle, unspecified site, oropharyngeal dysphagia, bipolar disorder, anxiety disorder, type two diabetes mellitus, hypertensive heart disease without heart failure, hyperlipidemia, and left bundle branch block. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident was assessed as having impairment on one side of, both, upper and lower extremities. Review of 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 record review, interview, and policy review, the facility failed to ensure a discharge summary was completed for a planned discharge. This affected one (Resident #59) of three residents reviewed for discharge. The facility census was 44. Findings include: Review of the medical record revealed Resident #59 admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, unspecified scoliosis, and fusion of the cervical spine. Resident #59 discharged on 12/10/22. Review of the 72-Hour admission Conference dated 12/08/22 revealed Resident #59 planned to discharge as soon as medically possible to complete work tasks. Social Services would follow up with needs for home health services. Review of progress note dated 12/10/2022 revealed Resident #59 discharged to home with a friend. Registered Nurse (RN) #427 reviewed discharge with guest and friend. Review of the medical record revealed revealed Resident # 59 had no care plan, no physician orders, and no recapitulation of his stay.…

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, interview, and policy review, the facility failed to respond timely to recommendations from outside providers. This affected one (Resident #30) of 16 residents reviewed for ancillary services. The facility census was 44. Findings include: Review of the medical record revealed Resident # 30 admitted to the facility on [DATE] and had diagnoses including End Stage Renal Disease (ESRD) with dependence on renal dialysis, unspecified peripheral vascular disease, type II diabetes, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderately impaired cognition. Resident #30 had adequate hearing and did not have hearing aids. Review of Care 360 documentation revealed Resident # 30 received audiology services on 01/09/23. Resident #30 had bilateral hearing aides but only wore the right one. The left hearing aid was at home. Resident #30 had cerumen removed from her right ear. Recommendations for care included…

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, interview, and policy review, the facility failed to maintain complete, accurate documentation in the medical record. This affected one (Resident #57) of sixteen records reviewed for accuracy. The facility census was 44. Findings include: Review of the medical record revealed Resident #57 admitted to the facility on [DATE] and discharged on 02/03/23. Resident # 57 had diagnoses that included osteoarthritis, unspecified dementia, pulmonary hypertension, stage III chronic kidney disease, unspecified heart failure, and non-operable left femur fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 57 had severely impaired cognition, had no behaviors, did not wander, and, and did not reject care. Resident # 57 was a two-person assist, requires supervision assistance with eating, and required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and locomotion. Review of medical record revealed Resident #57 had no progress…

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, interview and policy review, the facility failed to ensure the Medical Director attended quality assurance performance improvement (QAPI) meetings. The facility census was 44. Findings include: Review of quarterly QAPI meeting minutes dated 01/06/22, 05/19/22, 07/28/22, 12/30/22 and 01/20/23 revealed Medical Director (MD) #25 was not present during scheduled QAPI meetings. During an interview on 03/02/23 at 1:56 P.M., the Administrator stated there had not been a physician present at the January 2023 QAPI meeting. The Administrator verified there was no evidence of MD #25 attending QAPI meetings for previous 12 months. Review of policy titled Quality Assurance Performance Improvement Committee dated 01/23/22 revealed the facility had a QAPI committee whose members at minimum consisted of the Administrator, DON, Medical Director/Designee, and Infection Preventionist, and met quarterly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, review of the facility's policies, and Review of Centers for Disease Control and Prevention (CDC) toolkit assessment, the facility failed to properly cleanse the blood glucose monitoring machine. This affected Resident #7 during an observation of medication administration. This had the potential to affect Resident #85 and Resident #177 who were identified by the facility as having shared the blood glucose monitoring machine. In addition, the facility failed to ensure infection control monitoring was adequate to control the spread of communicable diseases. Also, the facility failed to ensure control measures and monitoring was in place for all potential hazardous conditions were Legionella had the potential to grow as identified by the facility. This had the potential to effect all 35 residents residing in the facility. Findings include: 1. Review of medical record for Resident #7 on 12/27/19 revealed he was admitted to the facility on [DATE]. Diagnoses…

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 the facility's Self-Reported Incidents, staff and resident interview and policy review, the facility failed to ensure the abuse policy was followed after an allegation of abuse was voiced by a resident. This affected one of one (#177) resident who triggered for abuse during the annual survey. The census was 35. Findings included: Medical record review for Resident #177 revealed an admission date of 12/04/19. Diagnoses included diabetes mellitus and cancer. Review of the admission Minimum Data Set (MDS) assessment, dated 12/11/19, revealed Resident #177 was cognitively intact. Review of the progress note, dated 12/22/19 at 6:52 P.M., revealed Resident #177 complained that a State Tested Nursing Aide (STNA) had handled her roughly when she was transferred from the bed to standing position and then walking her with assistance to the bathroom. The STNA was questioned and stated she followed the proper procedures in transferring the resident from the bed to a standing position and assisted the resident to the bathroom with her walker. The note…

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 and resident interview, review of the facility's Self-Reported Incidents and policy review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency, the Ohio Department of Health. This affected one of one (#177) resident who made an allegation of abuse during the annual survey. The facility census was 35. Findings included: Medical record review for Resident #177 revealed an admission date of 12/04/19. Diagnoses included diabetes mellitus and cancer. Review of the admission Minimum Data Set (MDS) assessment, dated 12/11/19, revealed Resident #177 was cognitively intact. Functional status was limited assistance for bed mobility and transfer. Review of the progress note, dated 12/22/19 at 6:52 P.M., revealed Resident #177 complained that a State Tested Nursing Aide (STNA) had handled her roughly when she was transferred from the bed to standing position and then walking her with assistance to the bathroom. The STNA was questioned and stated she followed the proper procedures in transferring the resident from…

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 and resident interview, review of facility's investigation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one of one (#177) resident who made an allegation of abuse during the annual survey. The census was 35. Findings included: Medical record review for Resident #177 revealed an admission date of 12/04/19. Diagnoses included diabetes mellitus and cancer. Review of the admission Minimum Data Set (MDS) assessment, dated 12/11/19, revealed Resident #177 was cognitively intact. Review of the progress note, dated 12/22/19 at 6:52 P.M., revealed Resident #177 complained that a State Tested Nursing Aide (STNA #46) had handled her roughly when she was transferred from the bed to standing position and then walking her with assistance to the bathroom. The STNA was questioned and stated she followed the proper procedures in transferring the resident from the bed to a standing position and assisted the resident to the bathroom with her walker. The note further revealed the resident stated…

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.